Critical findings in Imaging – Policy and procedure

Imaging and Medical laboratory frequently come across critical results or finding of a patient’s diagnostic tests which requires immediate intervention from the doctor to bring the patient out of the criticality. Hence, a hospital must have a policy and procedure in place for identification and quick communication of such results. This posts describes critical findings in imaging (Check critical test results in laboratory –policy and procedure).

Critical findings in imaging are the findings from imaging examination of a patient, which indicates that condition of the patient may be critical or even life-threatening. Whenever such critical findings are made, it is necessary that the treating clinician of the patient is informed immediately so that required interventions can be carried out in time. To be able to do so, a hospital needs to have a well-developed process of ‘identification and urgent communication of critical findings in Imaging’. Such process should be able to achieve following objectives.

1. Critical findings are identified while carrying out (or immediately after) the imaging examination
2. Critical findings are not missed
3. Non-critical findings do not get identified as critical
4. The treating doctor of the concerned patients gets to know about the critical findings on an urgent basis

Any lapses in identification and/or communication of critical imaging findings to concerned doctor may lead to severe consequences for patient, including death. Hence, in addition to the process, hospitals/Imaging centres must have a policy that mandates compliance to this process by imaging staff. Following points shall be taken into consideration while developing a policy and process on identification and communication of critical findings in imaging.

Policy: 

Policy shall clearly state that ‘all staff involved in performance or supervision of the Imaging test must understand the process of identification and urgent communication of critical findings. The process shall compulsorily be complied with, in all routine and non-routine tests performed Imaging department.

Defining critical findings: 

Critical findings must be defined by the hospital/Imaging centres for a uniform understanding of all staff in the department. This is important also because other terminologies such as critical values, panic values, panic findings etc. are also used for the same situation. A good definition of ‘critical imaging finding’ is,

‘A finding in imaging examination that requires immediate or urgent communication with the treating doctor of the patient. These finding reflect condition of the patient that are life-threatening or can cause life-long disability.

It shall also be clarified that critical findings are not same as abnormal findings. There can be findings that are indicative of a disease or health problem but unless the condition is serious enough and needs urgent intervention, they may not be considered ‘Critical’.

List of critical test results: 

The hospital/imaging centre must specify and list the conditions, which if found during imaging examination must be considered ‘critical’. This can be done either through discussion and consensus between clinicians and radiologists, or by taking a good and relevant reference source that defines critical imaging findings and doing necessary modifications. Some example of critical findings in imaging are given below,

S.No.	Condition to be considered as critical
Central Nervous System
1.	Cerebral Haemorrhage / Haematoma
2.	Herniation Syndrome
3.	Intracranial Infection / Empyema
4.	Skull fracture – complex in nature
5.	Unstable fracture of spine
6.	Compression of spinal cord
Neck Region
7.	Airway Compromise (eg. Epiglotitis)
8.	Carotid Artery Dissection
9.	Critical carotid stenosis
Chest Region
10.	Tension Penumothorax
11.	Aortic Dissection
12.	Large or Central Pulmonary Embolism
13.	Ruptured Aneurysm
14.	Mediastinal Emphysema
Abdomen Region
15.	Unexpected free air in abdomen
16.	Ischemic bowel
17.	Appendicitis
18.	Portal Venus air
19.	Volvulus
20.	Traumatic Visceral Injury
21.	Retroperitoneal Hemorrhage
22.	Active Intra-abdominal Haemorrhage
Urogenital
23.	High grade bowel obstruction
24.	Ectopic pregnancy
25.	Placental abruption
26.	Placenta Previa in near term
27.	Testicular or ovarian torsion
28.	Fetal demise
Others
29.	Retained surgical/foreign body
30.	Significant Line/Tube mis-placement

Timely updation of critical test results: 

The hospital/imaging centre should also have a process for periodically updating the list of critical findings as and when new tests or modalities are introduced in the Imaging department.

Identification of critical findings: 

The imaging staff/doctors who carry out examination, shall be aware of the policy and the process of critical imaging findings. The list of critical findings results shall be available/accessible to each staff. While (or after) examining the patient under any imaging modality, the concerned staff should check if the findings matches any of the given critical finding in the list.

If a critical finding is identified, the examining staff should immediately inform the same to the radiologist. The radiologist should review the finding and confirm if it is critical or not.

Confirmation of critical finding:  

On the discretion of the Radiologist, the imaging examination shall be repeated to weed out any possibility of error. If the repeat examination also confirms critical finding then it should be considered as critical and immediately be informed to the treating physician of the patient. If a confirmation test is not done, the first test finding itself shall be considered critical and shall be informed to the treating physician of the patient.

Communication of critical finding: 

As soon as the finding is confirmed to be critical, the treating physician of the concerned patient shall be informed through the quickest mean possible. This communication shall preferably be done by the Radiologist, however, if the he/she is not available at the time, the junior doctor or the staff who did the examination must directly inform the physician.

In case physician is not immediately available to receive the communication, the resident doctor on duty or the nurse in-charge of the ward must be informed about the critical finding.

The verbal/telephonic communication shall be complete and incorporate following information

       ·             Name of the patient

       ·         Imaging examination performed

       ·         Finding

It shall be assured that the physician or receiver of the message has understood the communication. A written report of a imaging finding shall be prepared on priority and should be dispatched following the verbal/telephonic communication.

Documentation: 

To ensure compliance, a register shall be maintained in the Imaging department to record all critical test results that were identified. Following information shall be recorded

       ·         Date

       ·         Patient name and UID

       ·         Examination performed - Modality

       ·         Time of obtaining the finding

       ·         Description of critical finding

       ·         Whether repeat examination was done for confirmation

       ·         Communication sent to (treating physician/resident doctor/nurse in-charge)

       ·         Time at which communication was sent

       ·         Any other remark

  

References:

Reporting of Critical and Unexpected Exam Results procedure – Radiology; Dartmouth-Hitchcock

Guidelines for documentation of special verbally communicated imaging findings