Critical Result Guidelines

The table below outlines appropriate means and timeframes for communication with referring physicians.

Timely, closed loop communication of serious or unexpected results is a fundamental principle of safe high quality care and is associated improved healthcare outcomes. The need to automate this process and reduce the administrative burden for radiologists and ordering clinicians lead to creation of the Radiology Communication Center (RCC) with integration into PowerScribe and Epic.

The RCC is available 24-7 to help communicate critical findings diagnosed on a radiology test and the center also oversees the follow up imaging recommendations program. RCC staff are available under the “critical results“ roles in primordial communicator, or by phone at 475-246-8135.

The system gathers data from a custom field that is assigned to every Radiology report in PowerScribe when the attending radiologist signs the report. This field contains a list of choices (see below). This field can be in the template – if it is not, a box will pop up when a report is signed.

The acuities:

	When to use	What happens	Examples cases
Routine*	Any report without significant findings.	The report is released No RCC action	Stable chest xray findings, incidental findings like benign cysts not needing further work up or follow up
Normal*	Normal examination.	The report is released A statement about exam being “normal” is added in MyChart patient portal above the radiology report	Any study deemed completely normal by the attending radiologist
Critical Result** Goal: Communication within 1 hour (old red alert)	Life/Limb threatening finding	A pop-up is added to the patient chart in Epic. The report is released The RCC immediately attempts to contact the provider to let them know there is a critical finding RCC confirms communication with the radiologist once achieved	Ruptured AAA, large PE, tension pneumothorax, new free air, torsion, ectopic pregnancy, intracranial hemorrhage. YNHH critical result policy
Urgent Result Goal: Communication within 6 hours (old orange alert)	Non-life-threatening findings, but significant enough that they need to be communicated within a short period of time (ie. Same day)	A pop-up is added to the patient chart in Epic The report is released. A header is added to the report in chart review For outpatients, the RCC staff immediately begins to try to contact the provider For inpatients/ED - If not acknowledged within 4 hours, the RCC staff will contact the provider	New DVT, new (clinically relevant) fractures, signs of non-accidental injury, unexpected abscess
Next (business) day Goal: Communication within 1-3 days as these results are not communicated after 5pm on Friday until Monday AM.	Clinically Important findings that should be communicated outside of traditional report transmission but likely won’t result in urgent change in management	The report is released An inbox message is sent to the provider, with a link to acknowledge the report A header is added to the report in chart review If no acknowledgement by the next business day, RCC staff will contact the provider	Possible osteomyelitis, small ureteral/kidney stone causing hydronephrosis, pneumonia in an outpatient, uncomplicated diverticulitis, orthopedic hardware malfunction.
Non-urgent/incidental findings Goal: Communication within 30 days (usually communicated within 1 week) (old yellow alert)	Unexpected but non-urgent findings. Incidental findings that may be clinically relevant and that you want to ensure ordering provider is aware of.	The report is released An inbox message is sent to the provider, with a link to acknowledge the report A header is added to the report in chart review If no acknowledgement after a week, the RCC will start to contact the provider.	Incidental findings that may require further work up.
New malignancy Goal: Communication within 7 days (usually communicated within 2 days) (old purple alert)	New findings that are highly suspicious for an unknown/unsuspected malignancy	The report is released A pop-up is added to the patient chart in Epic. If no acknowledgement the RCC staff will contact the provider later that day, or the next business day. The patient gets a generic certified letter informing them to contact their provider	A probable lung cancer on a CT for chest pain, pancreatic cancer on scan done for pain, carcinomatosis on a study done for abdominal distension. This should NOT be used for cancer staging studies or a study ordered for a suspected cancer.
Already communicated*** (old green alert)	A reported containing a critical/ urgent finding that has already been communicated to the ordering provider (or their delegate) by radiology team member.	The report is released. No RCC action	Any results communicated by the RA, radiology resident/fellow, or attending radiologist.
Imaging recommendation only (old follow up only)	When another follow up study is recommended and the findings are not urgent.	The report is released The recommendation is added to a database and tracked in Epic. If it is not performed and/or ordered in the recommendation time period, the RCC staff will reach out to the provider or listed PCP office.	Pulmonary nodules that likely need a follow up chest CT, indeterminate renal or hepatic lesions that could be benign or malignant that need further imaging tests

*Note that Routine and Normal can be used interchangeably at the discretion of the attending radiologist.

**Critical Result – A result where a delay in result communication could have a serious impact on patient outcome. Furthermore, critical test results often have these common elements:

The finding reveals a potentially serious clinical condition requiring intervention.
The indicated intervention should be executed in a timely manner.
The finding is possibly unexpected, and, thus, if not highlighted by the radiologist, may not be recognized by the clinical team before harm occurs.

Full critical test result policy is available here (insert link)

***For “already communicated” acuities, the radiologists are responsible for documenting in their report who they spoke with, when (date/time) and by what method (phone call, secure text messaging etc)

FAQ’s

When should I choose “…with imaging recommendation?

Any acuity can also be paired to an imaging recommendation. The “with imaging recommendation” option should be chosen if the radiologist thinks another imaging test is needed. This can include an incidental lesion that needs follow up CT or MRI (example- new pulmonary nodule in a smoker).
Two elements must be included in your report when you pick “with imaging recommendation ”:

The exact test you think that should be done (don’t say MRI, say MRI abdomen without and with contrast”)
The time frame for the follow up exam. If you don’t give a time frame the RCC will enter a due date of 3 months by default.

The name was changed from “with follow up” to clarify that currently our system can only track imaging recommendations. If you are recommending non imaging follow up (i.e “surgical consult” or “thyroid labs”) these can be communicated but will not be tracked.

What if there is more than one unexpected finding or recommendation?

The acuity should match the most severe finding. If there are multiple imaging recommendations, the RCC will create multiple tracked follow ups.

What if the resident called the team, or if I already talked to someone?

No matter how severe the finding, it should be marked “already communicated”

What happens if the RCC staff cannot find anyone?

For critical or urgent results, the RCC will reach out to the radiologist who placed the alert if no one can be found by the communication goal time. If that radiologist is unavailable, the covering radiologist for the section or site will be called.

There are a few options available to the radiologist:

Acknowledge that the alert has gone out of compliance, ask the RCC to keep trying.
Downgrade the acuity – the RCC staff will continue trying
Try calling the provider yourself. This may be useful if you have a personal number for a physician, as the RCC staff is generally limited to office numbers in Epic or in mobile heartbeat.
Call the patient directly. For critical findings, it is advisable to just call the patient and tell them to go to nearest ED.

Why is the RCC calling a Radiologist?

A few reasons that the RCC may call a radiologist:

A provider has a question about your report. When the RCC staff reaches a provider to report a result, they usually read the impression, and tell them the report is in Epic or faxed. If the provider has questions about the report, the staff will try to connect them to the dictating radiologist or someone on call.
The RCC staff cannot contact a provider within the timeframe requested and needs guidance from the radiologist for the next steps.

What about incidental findings or non-urgent alerts in the ED?

When alerts are created on ED patients, the results are generally routed to a provider pool – providers or RN’s who work on patient follow up in the ED’s at each delivery network. The ED attending’s generally do not get the messages. If the patient is admitted from the ED, the alert will be routed to the inpatient team. If you send an imaging recommendation on an ED patient (and it is not ordered by the ED or admitting teams), the RCC will generally call the PCP listed for the patient.

Oops, I didn’t mean to put that in…that should have had an acuity…

If you put in an alert that you did not mean to, or want to change a level after it was placed, you can call the RCC at 475-246-8135 or text them using the communicator. The staff can cancel an alert on a patient. If you sent a study through as routine, you can create an addendum and change the acuity. If the report is still accessible you can also adjust the acuity by going to the Insert menu and picking the option called “custom fields” (see image below). You can adjust the acuity and sign it off again.

How do I check on alerts that I have put in?

A Radiologist can check the status of the alerts that they put in through the “result tracker” app in Epic. If you do not see a link on the tool bar, type result into the Epic search box.