Neuroradiology critical findings lists: survey of neuroradiology training programs

An International Survey of Quality and Safety Programs in Radiology

PURPOSE

The aim of this study was to determine the status of radiology quality improvement programs in a variety of selected nations worldwide.

METHODS

A survey was developed by select members of the International Economics Committee of the American College of Radiology on quality programs and was distributed to committee members. Members responded on behalf of their country. The 51-question survey asked about 12 different quality initiatives which were grouped into 4 themes: departments, users, equipment, and outcomes. Respondents reported whether a designated type of quality initiative was used in their country and answered subsequent questions further characterizing it.

RESULTS

The response rate was 100% and represented Australia, Canada, China, England, France, Germany, India, Israel, Japan, the Netherlands, Russia, and the United States. The most frequently reported quality initiatives were imaging appropriateness (91.7%) and disease registries (91.7%), followed by key performance indicators (83.3%) and morbidity and mortality rounds (83.3%). Peer review, equipment accreditation, radiation dose monitoring, and structured reporting were reported by 75.0% of respondents, followed by 58.3% of respondents for quality audits and critical incident reporting. The least frequently reported initiatives included Lean/Kaizen exercises and physician performance assessments, implemented by 25.0% of respondents.

CONCLUSION

There is considerable diversity in the quality programs used throughout the world, despite some influence by national and international organizations, from whom further guidance could increase uniformity and optimize patient care in radiology.

Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings

Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retrieved from the context. Critical findings detected by imaging need urgent communication to the referring physician. According to guidelines, the occurrence of this communication should be documented in the radiology reports and should contain when, to whom and how was communicated. In free-text reporting, one or more of these required items might be omitted. We developed a contextual structured reporting template to ensure complete documentation of the communication of critical findings. The WHEN and HOW items were included automatically, and the insertion of the WHO-item was facilitated by the template. A pre- and post-implementation study demonstrated a substantial improvement in guideline adherence. The template usage improved in the long-term post-implementation study compared with the short-term results. The two most often occurring categories of critical findings are “infection / inflammation” and “oncology”, corresponding to the a large part of urgency level 2 (to be reported within 6 h) and level 3 (to be reported within 6 days), respectively. We conclude that contextual structured reporting is feasible for required elements in radiology reporting and for automated insertion of context-dependent data. Contextual structured reporting improves guideline adherence for communication of critical findings.

Assessment of actionable findings in radiology reports

PURPOSE

The American College of Radiology (ACR) Actionable Reporting Work Group defined three categories of imaging findings that require additional, nonroutine communication with the referring physician because of their urgency or unexpectedness. The objective of this study was to determine the prevalence of actionable findings in radiology reports, and to assess how well radiologists agree on the categorisation of actionable findings.

METHOD

From 124,909 consecutive radiology reports stored in the electronic health record system of a large university hospital, 1000 reports were randomly selected. Two radiologists independently annotated all actionable findings according to the three categories of urgency defined by the ACR Work Group. Annotation differences were resolved in a consensus meeting and a final category was established for each report. Interannotator agreement was measured by accuracy and the kappa coefficient.

RESULTS

The prevalence of the three categories of actionable findings together was 32.5 %. Of all reports, 10.9 % were from patients seen in the emergency department. Prevalence of actionable findings for these patients (45.9 %) was considerably higher than for patients in routine clinical care (30.9 %). Interannotator agreement scores on the categorisation of actionable findings were 0.812 for accuracy and 0.616 for kappa coefficient.

CONCLUSIONS

The prevalence of actionable findings in radiology reports is high. The interannotator agreement scores are moderate, indicating that categorisation of actionable findings is a difficult task. To avoid unneeded increase in the workload of radiologists, in particular in routine practice, clinical context may need to be considered in deciding whether a finding is actionable.

Opportunities for Targeted Education: Critical Neuroradiologic Findings Missed or Misinterpreted by Residents and Fellows

OBJECTIVE

We reviewed neuroradiology cases in which a resident or fellow missed a significant finding, to identify potential areas of deficiency that could be strengthened through targeted education.

MATERIALS AND METHODS

Included in the study were all neuroradiology reports from 2011 through 2013 that were marked with an electronic flag to indicate a significant modification between the preliminary and final versions. The reports were examined to determine whether a critical finding (CF) or a non-CF was missed, with the use of a hospital-approved list of 17 neuroradiology CFs. Results were analyzed for all trainees.

RESULTS

A total of 978 modified reports were found among reports from 225,628 neuroradiology examinations. Of these modified reports, 891 (91.1%) contained an addendum that identified the discrepancy: 658 (73.8%) contained a CF,192 (21.7%) contained a non-CF, and 41 (4.6%) were changed from containing a CF to not containing a CF. A total of 725 missed CFs were found in the 658 modified reports. The CF miss rate for all trainees was 6.0% (95% CI, 5.6-6.4%), whereas that for residents was 8.6% and that for fellows was 4.8%. Residents missed hydrocephalus, intracranial pressure or edema, new hemorrhage, and new infarction more frequently than did fellows. The five most frequently missed CFs were congenital variation, infection, misplaced hardware, a new or enlarging mass, and vascular abnormality.

CONCLUSION

Our trainees' overall CF miss rate was 6.0%. Five CFs had miss rates of approximately 10% or more, and residents missed four of the CFs more frequently than did fellows. With the use of these data, our curriculum could potentially be strengthened and our trainee error rates decreased, leading to improved patient care.

Critical findings: timing of notification in neuroradiology

BACKGROUND AND PURPOSE

Timely reporting of critical findings in radiology has been identified by The Joint Commission as one of the National Patient Safety Goals. Our aim was to determine the magnitude of delays between identifying a neuroradiologic critical finding and verbally notifying the caregiver in an effort to improve clinical outcomes.

MATERIALS AND METHODS

We surveyed the time of critical finding discovery, attempted notification, and direct communication between neuroradiologists and caregivers for weekday, evening, overnight, and weekend shifts during an 8-week period. The data were collected by trained observers and/or trainees and included 13 neuroradiology attendings plus fellows and residents. Critical findings were based on a previously approved 17-item list. Summary and comparative t test statistics were calculated, and sources of delays were identified.

RESULTS

Ninety-one critical findings were recorded. The mean time from study acquisition to critical finding discovery was 62.2 minutes, from critical finding discovery to call made 3.7 minutes, and from call made to direct communication, 5.2 minutes. The overall time from critical finding discovery to caregiver notification was within 10 minutes in 72.5% (66/91) and 15 minutes in 93.4% (85/91) of cases. There were no significant differences across shifts except for daytime versus overnight and weekend shifts, when means were 2.4, 5.6, and 8.7 minutes, respectively (P < .01). If >1 physician was called, the mean notification time increased from 3.5 to 10.1 minutes (P < .01). Sources of delays included inaccurate contact information, physician unavailability (shift change/office closed), patient transfer to a different service, or lack of responsiveness from caregivers.

CONCLUSIONS

Direct communication with the responsible referring physician occurred consistently within 10-15 minutes after observation of a critical finding. These delays are less than the average interval from study acquisition to critical finding discovery (mean, 62.2 minutes).

Continuous practice quality improvement initiative for communication of critical findings in neuroradiology

The authors examined faculty's compliance with a hospital-approved neuroradiology critical findings (CFs) policy, which requires urgent verbal communication with the clinical team when 17 specific critical pathologies are identified. During June 2011 to July 2013, 50 random neuroradiology reports were sampled monthly for the presence of CFs and appropriate action. Faculty were provided ongoing feedback, and at the end of 2 years, the medical records for cases with noncommunicated CFs were reviewed to identify potential adverse outcomes. Of the 1200 reviewed reports, 195 (16.3%) had and 1005 (83.8%) did not have a CF. A total of 176 of 195 (90.3%) cases with CFs were communicated, and compliance increased from 77.4% to 85.6% (P = .027) since the monthly sampling was instituted; 1 of 19 (5.3%) noncommunicated CFs resulted in a potential adverse event. The ongoing monthly feedback resulted in improved faculty compliance with the CF policy. However, a small number of cases with CFs are still not being communicated.

Determination and communication of critical findings in neuroradiology

PURPOSE

The aims of this study were to analyze reporting of critical findings among neuroradiologists in a university setting and to revise a list of critical findings reflecting an academic clinical practice as part of a practice quality improvement project.

MATERIALS AND METHODS

Neuroradiologic studies performed between January 1 and February 28, 2011, containing "critical finding" notations were searched. Reports were matched with an institutionally approved list of critical findings. These findings and unlisted items that were labeled critical were analyzed for frequency, clinical severity, and diagnosis category. The list was revised on the basis of frequency and severity results.

RESULTS

A total of 12,607 reports contained 871 critical findings, 608 of which (69.8%) matched the preexisting list. One-third of the findings (263 of 871) labeled critical were not found on the list. Facial, spinal, and calvarial fractures (76 of 263 [28.9%]) and neurovascular injuries (38 of 263 [14.4%]) were the most frequent unlisted findings. A revised list encompassed 86.7% of all communicated neuroradiologic critical findings.

CONCLUSIONS

Clinician-approved and neuroradiologist-approved standardized sets of critical findings can facilitate the communication of important results without "overcalling" and decreasing efficiency. Physician judgment of what constitutes a critical finding supersedes any such list, as clinical scenarios are highly variable from patient to patient. Critical findings lists require intermittent revision to reflect practice patterns and changing incidence of disease. Such a review can constitute a practice quality improvement initiative.