Critical findings mismatch may reduce efficiency, quality

Individualized lists of what constitutes a critical imaging finding can be created through a quality improvement project and may better reflect physician judgment while improving efficiency, according to an article published in the January issue of the Journal of the American College of Radiology.

The authors held up a critical results reporting project at their own institution, which increased the number of test results labeled critical that matched their department’s standardized list of critical findings, as an example for others to follow.

“The critical findings list that each institution constructs should be seen as a living document, open for revision and updating in a planned and periodical fashion,” wrote Stacey A. Trotter, MD, PhD, and colleagues from the department of radiology at Johns Hopkins Medical Institutions in Baltimore. “Furthermore, such lists should not be upheld as a hard-and-fast mandate but should instead be used as a suggestion for practicing radiologists and radiology trainees.”

Trotter and colleagues focused on neuroradiologic studies, and sought to revise their 2004 neuroradiology critical findings list based on actual utilization data. They searched for studies performed between Jan. 1 and Feb. 28, 2011, that contained critical finding notations and matched them against the existing list of 20 critical findings that may be encountered.

Results showed a total of 871 reports containing critical findings over the study period, 608 of which matched the pre-existing list, meaning nearly one-third of the findings labeled critical were not found on the list. Of the 263 unlisted findings, facial, spinal and calvarial fractures were the most frequent, representing 28.9 percent of the labeled critical findings not on the list. Neurovascular injuries were second, accounting for 14.4 percent of such findings.

Based on what physicians were labeling as critical, the list was revised to the point where 86.7 percent of all critical findings reported over the study period fell within the guideline list.

While many of the findings labeled critical met American College of Radiology guidelines based on necessity for acute intervention, the authors noted that some findings—notably thyroid and lung nodules—were being directly communicated to healthcare providers even though they did not pose an immediate life-threatening risk.

“Every time a radiologist calls a referring physician, there is an interruption in the workflow on both sides of the telephone, with potential decreasing efficiency as a result,” wrote Trotter and colleagues. “The referring healthcare provider may raise the threshold for accepting calls or returning pages labeled ‘critical finding’ if such a designation is overused, thus creating potential for patient harm.” They recommended communicating non-critical findings via a less time consuming but traceable method to ensure efficiency.