OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• administrative aspects of Emergency Medicine in Australia
• Emergency Department Information Systems (EDIS) for Australia

• it is generally regarded that the responsibility for ensuring timely and appropriate follow up of investigation results such as Xrays, pathology tests and scans falls onto the shoulders of the person who orders the investigations.

• in a small ED department, these can usually be adequately managed by printed reports being returned to the ED staff and the ED staff manually checking them and signing them before they are filed in the patient's medical record.
• even in this scenario, the printing of the report, especially radiology reports results in unacceptable delays, and thus various options have been tried in the past with variable success:
  • radiologist phoning the ED doctor of serious pathology
  • ED doctor writing their interpretation of the Xray on a paper slip attached to the Xray which the radiologist can check and notify the ED doctor if there is any serious discrepancy - unfortunately, this system often failed due to low compliance of rotating ED doctors, and the paper system is no longer relevant in an electronic PACS environment although a good PACS system should allow the ED doctor to type their interpretation which would be visible to the reporting radiologist.

• in busy ED's, the sheer volume of investigation reports makes signing printed reports far too onerous and untimely that this system becomes unproductive and largely ineffective.

• most pathology and radiology departments have in place systems to contact the referring doctor ASAP of potentially life threatening results such as severe hyperkalaemia, pneumothorax, ruptured ectopic pregnancy, etc.
  • this requires recognition of the abnormality - not usually a problem with pathology, but very dependent on timely radiologist reporting which may not always be relied upon due to resource constraints in radiology departments.
  • it may be assisted by systems which allow ED doctors to annotate their perception of the Xray appearance so that the radiologist can alert them early if there is a discrepancy.
  • it is still unbelievable how often local doctors send patients for blood tests such as troponin levels and several days later when they get back to work and get the results, refer the patients into ED if they are still alive - so the system is not 100% fool proof even in the private sector.
• unfortunately, even a seemingly inocuous result such as a positive HCG can slip through unrecognised, and a patient with abdominal pain could be discharged home with a ruptured ectopic in a busy ED if the referring doctor or, the doctor the patient has been handed over to, forgets to check the HCG result.
  • system approaches to addressing this error can involve:
    • good electronic documentation of handovers including what results need following up - my preferred option is as I have created in my HASTools program - an aide memoir system that remains on this system even if the patient is discharged and that requires a specific step to remove it from the system.
    • investigation results being “pushed” to the ED staff and require ED staff to log they the result has been seen and addressed - although there is a risk that an important result may not be seen amongst the many results on a screen, or that someone just marks the result as being addressed without actually addressing it. The system should display unmanaged results of discharged patients as well.

• we have all taken these calls - blood culture or stool culture results for patients we have never seen and who have been discharged from the ED.
• characteristically, pathology dutifully takes down YOUR name to absolve them of any responsibility and you check the computer system, but the information there does not help, so you call for the medical records which may take a few hours to get to the ED.
• in the meantime, your shift ends and forgetting all about this abnormal result you go home and the medical record gets sent back to medical records as no-one knows anything about it, and if you remember on your next shift, almost certainly you will have forgotten who the patient was to follow up.
  • system approaches to addressing this error can involve:
    • an electronic aide memoir system that caters for discharged patients - see my system above
    • electronic medical records so that there is no need to wait for the physical medical record
    • ensuring all discharged patients are given a discharge letter with instructions for the local doctor to call the pathology phone number to follow up the results - unfortunately, this measure may not adequate absolve the ED doctor of the responsibility for managing the result.

• Rh negative results and positive HCG results are among these results which will often be disregarded in follow up of batch results.
• these then become the onus of the ordering doctor to ensure they are followed up appropriately
  • system approaches to addressing this error can involve:
    • patient stays in ED until results are back - contributes to ED over-crowding
    • patient to phone back for the result that day - causes confusion and excessive phone calls in the ED
    • ED doctor to phone patient - doctor may forget - perhaps use of the aide memoir will assist
    • reinforcement of the need for the local doctor to ring pathology for the results next day - patient may not be able to get an appointment to see the doctor

• the sheer volume of these mean that going through printed or even electronic reports will result in some important results being missed, even if the ED staff had the time to go through them all.
• system approaches to addressing this error can involve:
  • all results pushed to ED staff who must log them as being managed before they will disappear from the system - eg. the Alcidion Second Screen software.
    • ideally this will be integrated with the ED information system so that the checking doctor can rapidly see the patient's diagnosis, disposition, handover plan and discharge letter so they can more reliably ascertain if the result has indeed been managed appropriately, and if not, rapid access to patient contact details.
  • BUT relying on ED staff to go to a separate system to go through batches of results is not as effective and likely to fail.

• sometimes you just can't contact a patient or the GP because of erroneous, out of date or missing contact details
• it is critically important that the steps you have taken to attempt contact are documented in the patient's medical record
• this scenario is impossible to solve, but it can be partly prevented or alleviated by:
  • checking with the patient if their contact details are correct prior to discharge
  • providing the patient with an adequate discharge letter with the contact phone numbers of pathology/radiology so that a local doctor has at least a reasonable oportunity to follow up results ordered in ED.

• these are difficult patients as historically, in many busy ED's, the ED doctors when checking batched investigation results, make an assumption that any patient who is admitted or transferred to another hospital for admission will have their investigation results ordered in ED followed up by the receiving inpatient unit.
• the reason this assumption is usually made is because it is not practical to retrieve the patient's medical record for every abnormal result of admitted patients to check if the results have indeed been managed.
• unfortunately, there is no guarantee that this will occur, and theoretically the doctor who ordered the investigation will still be held to be responsible creating unmanaged risk for the ED.
• perhaps the best solution is an electronic investigation checking system (such as the Alcidion Second Screen) that is used throughout the hospital so that inpatient units become responsible for managing them.

• this is a nice software package that combines the hospital's investigation results system with the ED information system data to “push” results to the staff as soon as they become available and presents the results in a nice touch screen user interface which also can display PACS XRay images and their reports.
• it was primarily designed for pushing results to the doctors so the doctors no longer have to waste time repeatedly logging into the investigation results system to see if their patient's results are back.

• currently Alcidion have two user interfaces for managing this:
  • the main Second Screen interface:
    • allows users to click on an investigation result and “ACCEPT” result which then displays the result with a dimmed color to indicate it has been managed, and if the patient is then discharged, allows the patient to be removed from the screen assuming all results for that patient have been so managed.
    • unfortunately, the current implementation has some short comings which could be readily addressed:
      • does not record WHO accepted the result
      • does not allow recording of HOW the result was managed - this is more useful for discharged patients when it should be documented if result was just accepted, or if patient contacted or steps to attempt contact, etc.
      • results that arrive AFTER patient has been discharged from ED or from SSU are not currently displayed which then requires another system to manage these which is unfortunate but does mean the interface is a bit cleaner.
      • for discharged patients, does not display sufficient information from the ED information system to allow a doctor to decide if the result has been managed (discharge diagnosis, discharge letter, disposition status), nor contact details to assist contacting the patient.

• Alcidion Intelligent Risk Management Server Reporting web browser interface:
  • allows users to log in and browse batches of unmanaged results and mark them as managed and HOW they were managed
  • volume of results is usually too much for even the most dedictated doctor to trawl through each day and check to see if they have been managed.
  • this batch style reporting solution seems to always be a compromise and risks poor compliance and missed results.