This is Waiting to Be Seen 9 on EM Cases – EM Quality Assurance Part 1: Improving Follow up From the ED.
Written by Lucas Chartier, edited by Howard Ovens and Anton Helman September 2016
Many years ago I received a final imaging report that included an incidental finding after the patient had been discharged from the emergency department (ED). I dutifully called the family doctor listed on the chart (yes, I phoned—this might have been before fax machines!). The family doctor agreed to follow up on the finding and said he saw the patient regularly and would make a note to raise it during his next visit. About a year later the patient was diagnosed with advanced cancer, and the oncologist noted no one had acted on the earlier report. It turned out the patient had changed family doctors after his ED visit but had not notified his previous family doctor because he didn’t want to insult him. The fact that no individual in this chain of events could be “blamed” didn’t help the patient or make me feel better about the missed opportunity.
I imagine a story such as this, or similar tragic stories reported publicly and referred to in this month’s guest blog, will cause every ED director and emergency physician to lose a little sleep because they know something similar could happen anywhere, to any of us.
We all face the challenge of how to manage final reports that arrive after the patient has been admitted or discharged, but some EDs are more organized and diligent than others in systematically addressing their obligations in this area. In this two-part guest blog, Dr. Lucas Chartier, an emergency physician in Toronto, will discuss best practices in departmental organization for Quality Assurance in part one and the obligations of the individual physician in part two. No ED will ever be perfect, but there are some positive lessons to share and we likely all can do better in reducing risks related to test result follow-up.
—Dr. Howard Ovens, September 2016
Improving Follow up From the ED: EM Quality Assurance Part One
As an emergency physician, I often feel that the patients I send home after their evaluations are detached from any continuum of care. Unless they get admitted or have a specific follow-up visit scheduled, their care remains episodic and isolated. Once patients have been discharged from the emergency department (ED), communication with them or their primary care provider is at best sub-optimal and often non-existent. One important issue is that the reports of many investigations—such as microbiology results and staff radiologist reports of diagnostic imaging tests—are often available only long after patients have left the ED.
Unless a systematic process exists to follow up and act on these “final results”, the task is left to the ED clinician who saw the patient. This time-honoured strategy, however, is fraught with issues of timeliness, provider-related variability, and patient-specific concerns (e.g., patients with no fixed address). Following up on these final results, which is one of the essential components of care and of the Quality Assurance process, is not a new concept and was well established by the 1980s.1 While it can be challenging to identify best practices that fit all ED situations, two tragic and recent high-profile cases in Canada remind us of the need to continue this dialogue. One involved a newborn who died after his positive blood culture allegedly got lost in the communication chain between the lab and the treating clinicians.2 The other case involved a woman whose lung nodule on chest X-ray was not communicated to her by the ED physician until 11 months after her ED visit, at which point she had already been diagnosed with advanced lung cancer.3
This blog post contains my thoughts on the challenges afflicting final results follow-up and suggestions that should be taken into account when developing or improving your ED’s systematic Quality Assurance process.
Hurdles to following up on final results for EM Quality Assurance
Despite your best intentions, there are numerous structural, organizational, and logistical hurdles that conspire against you to prevent reliable follow-up on your patients’ final results. The following are examples that I have experienced, either first-hand or as a witness to colleagues’ situations.
- Inconsistent methodology: I have received at various times the same type of final result report by fax, snail mail, printout from our ED assistant, or email. In most settings, the process of reporting and flagging a final result is at best variable and at worst undefined. Not only is the method inconsistent, but also the timing is unpredictable, ranging from same-day arrival to a few weeks. To add to the mix there is usually no redundancy, meaning that if a piece of paper gets lost in transit nobody knows about it.
- Irregular schedules: Many of us have returned to the hospital after a few days off only to be alarmed that an important result had not been dealt with during our absence. ED clinicians have, by nature, irregular schedules that don’t always lend themselves to following up in a timely manner with patients. Follow-up calls usually need to be made from the hospital, where the patient’s chart is available for review, which only compounds the problem.
- Vague responsibilities: Countless times I have not followed up on incidentally found nodules on chest X-rays of patients who get admitted to hospital. I assumed (possibly erroneously) the admitting clinician would act on the finding and organize follow-up. Without a standardized system, responsibility and accountability for acting on abnormal results are problematic, especially when multiple providers are involved through admission or hand-over of care.
- Lack of standardized system: One skilled and dedicated emergency physician recently told me of a big scare. She had missed a relatively subtle intra-cranial bleed on a CT scan and therefore discharged the patient home. The staff radiologist who reviewed the CT scan the next morning felt the bleed was quite obvious. He therefore elected not to flag the report as “needing review” by the ED team (thinking it surely had been seen and dealt with), despite the fact that the bleed had not been noted in the preliminary ED report. Thankfully this was caught early and the patient did not suffer meaningful adverse consequences, but without a standardized system with clear expectations, similar mishaps are bound to occur.
- Clerical issues: How often is a patient’s registration information missing, incorrect, or not updated? Often! Clerical issues are surprisingly common, and we continue to list a patient’s home phone number as the primary contact information instead of asking which of home/work/cell is best for them. And what about email addresses? It is 2016, after all! With all of this, it is common not to be able to reach patients, their listed next-of-kin, or their primary care providers through any method at all. Leaving the decision of how best to handle these common situations to the individual provider on a case-by-case basis is fraught with danger.
Given the fallibility of humans and the imperfect nature of health-care systems, adding safeguards and multiple layers of redundancy is likely to decrease patient harm. This is known as the “Swiss cheese model of system accidents,”4 in which gaps in individual layers do not overlap and having several layers (or slices) creates a solid whole. For example, if a patient’s final urine culture result with antibiotic sensitivities doesn’t make its way to the ED (e.g., the fax machine is broken) and the ED clinician forgets to follow up on his patient’s results (e.g., he went on vacation) but the patient was instructed to follow up at the family health team clinic where she is known, then there is still a chance that the patient’s antibiotic will be changed to an appropriate one. Adding more layers to the system and making them more structured are reliable ways to prevent harm. With regards to Quality Assurance processes, there are structural processes that are “must-haves” for the system to function, and there are organizational processes that allow more optimal functioning.
Must-haves for your EM Quality Assurance system in Improving Follow up From the ED
There are three must-have aspects to ensure that a Quality Assurance process is reliable:
- Safe and separate procedures must be created for following up on microbiology results and diagnostic imaging reports. Following up on final microbiology and imaging reports responds to the same fundamental need—ensuring that patients are treated according to the best possible answer to the test result. However, both processes involve distinct stakeholders and often have different communication strategies, and as such they should be handled differently. Microbiology results involve a cadre of health-care professionals and support staff who must transmit important information in a reliable way. Fail-safe and redundant processes should be developed in conjunction with the lab team. For diagnostic imaging reports, information technology capacity is crucial. There should be a system in place to note discrepant results and subsequently flag them for the ED team. This would include any significant abnormality seen by the radiologist but not noted on the ED clinician’s preliminary report. The gold standard is to have all imaging studies interpreted by a staff radiologist before the patient’s disposition is determined, and both capacity and communication should be improved to the point where this is possible.
- The task of following up must be assigned to pre-determined individuals. The Quality Assurance process should occur daily to ensure timeliness of response, and therefore has to be pre-assigned to a specific individual every day who will follow up on all results on behalf of all ED clinicians. This task can be accomplished by a physician or by a trained nurse practitioner or physician assistant with physician backup. The team should have a clear policy on the transfer of accountability and medico-legal liability from the ordering clinician to the person performing the Quality Assurance duties. This ensures that the clinicians who act on preliminary results can rest assured that final or discrepant reports will be dealt with by their colleagues in cases where further action is required.
- The Quality Assurance process must include adequate medico-legal documentation. This documentation ideally should be incorporated into the patient’s chart—either dictated, typed electronically, or provided as a scan of a hard-copy follow-up note. This is crucial for continuity of care and to avoid medico-legal difficulties pertaining to the actions taken. Time tracking of the receipt of the final results and of the actions taken is also important.
Remuneration and timing of EM Quality Assurance duties in Improving Follow up From the ED
Unless Quality Assurance duties are remunerated fairly they are unlikely to be done consistently and well. The Quality Assurance process should be performed at a dedicated time that is separate from clinical responsibilities. Whether because the waiting room is full or because physicians are paid more to see patients than to phone them for follow-up, they will tend to drift toward treating the patients in front of them and the Quality Assurance process will suffer. Both activities therefore need to be distinct. Having a consistent time set aside for the Quality Assurance process will also help support staff manage workload demands and help consultants know when discrepant or abnormal results are likely to be dealt with (and therefore whether they should call the ED to facilitate earlier notification).
Optimal timing for the performance of Quality Assurance duties is late enough in the morning so that overnight diagnostic imaging studies have been read and microbiology results reviewed, but early enough in the day that patients who are asked to return to the ED can do so and benefit from the full complement of imaging tests and consultants at the hospital. At two hospitals where I work, this is done between 10 a.m. and 12 noon—and it works well that way!
Taking your EM Quality Assurance process to the next level
One characteristic that can make a Quality Assurance process extremely effective and impactful is to develop locally approved best-practice guidelines. These represent agreements between stakeholders on what to do in common situations. For example: A blood culture is reported at 9 p.m.; do we deal with it now or wait until the Quality Assurance shift in the morning? What information can and cannot be left on a voice mail (or shared with next-of-kin)? Is faxing an acceptable way to transmit time-sensitive information?
This may require additional resources, but for microbiology results it is important to have microbiology and infectious disease experts agree on recommended actions for common or challenging situations. This would include, for example, instances when only one of two blood cultures is positive, dealing with common contaminants, treating immunosuppressed patients, or even having access to up-to-date antibiograms for the ED.
The bottom line in Improving Follow up From the ED
Given the episodic nature of emergency medicine and the lack of clear and reliable follow-up for many patients, some abnormal results will fall through the cracks and patients will suffer preventable adverse events. Our job as emergency medicine clinicians is to create a redundant system that prevents as many of these as possible. The creation of a daily, structured, and remunerated Quality Assurance process to call patients back about positive microbiology or discrepant diagnostic imaging results is one part of the solution. Agreeing on local best practices is another. If your ED does not currently have a formal Quality Assurance process, now is the time to develop one—because our job doesn’t end when the patient exits the ED! In part two of this blog, I will discuss the individual responsibilities of physicians in the Quality Assurance process, practical elements to keep in mind when caring for patients, and why assessing an ED’s Quality Assurance process may be one of the most important steps you can take when assessing a prospective job in a new ED.
—Dr. Lucas Chartier is an emergency physician at the University Health Network and North York General Hospital’s emergency departments in Toronto, Ontario. He is the Director of Quality and Innovation at the University Health Network Emergency Department and completed a Master in Public Health at Harvard School of Public Health, with a focus on quality improvement.
Links to news media that this blog references:
- Levy R, Goldstein B, Trott A. Approach to quality assurance in an emergency department: A one-year review. Ann Emerg Med. 1984;13(3):166-9
- Cribb R. (2016, March 16. ) Toronto hospital admits error after being confronted by parents of dead infant. The Toronto Star. Retrieved from http://www.thestar.com. Last accessed August 20th, 2016.
- Johnson E. (2016, May 23.) B.C. hospital fails to warn woman of potential lung cancer for 11 months. CBC News. Retrieved from http://www.cbc.ca/news. Last accessed August 20th, 2016.
- Reason J. Human error: models and management. BMJ. 2000; 320(7237):768–770