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Morris MF, Henry TS, Raptis CA, Amin AN, Auffermann WF, Hatten BW, Kelly AM, Lai AR, Martin MD, Sandler KL, Sirajuddin A, Surasi DS, Chung JH. ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease. J Am Coll Radiol 2024; 21:S343-S352. [PMID: 38823955 DOI: 10.1016/j.jacr.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Michael F Morris
- University of Arizona College of Medicine, Phoenix, Tucson, Arizona.
| | | | | | - Alpesh N Amin
- University of California, Irvine, Irvine, California; American College of Physicians
| | | | - Benjamin W Hatten
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians
| | | | - Andrew R Lai
- University of California San Francisco, San Francisco, California, Hospitalist
| | - Maria D Martin
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kim L Sandler
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Devaki Shilpa Surasi
- The University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging
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Barrett TW, Garland NM, Freeman CL, Klar K, Dahlke J, Lancaster P, Prisco L, Chang SS, Goff LW, Russ S, Jones ID. Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings. Ann Emerg Med 2022; 80:235-242. [PMID: 35752517 DOI: 10.1016/j.annemergmed.2022.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance. METHODS Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans. RESULTS Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools. CONCLUSION We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.
| | - Nicholas M Garland
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Clifford L Freeman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Katharine Klar
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Jan Dahlke
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Penny Lancaster
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Larry Prisco
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Sam S Chang
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Laura W Goff
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Ian D Jones
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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