Applied Radiology

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

Allow me to present a brief hypothetical clinical situation. You are a staff radiologist covering an academic medical center (it could be a private practice without the resident) at night. A middle-aged man is admitted to the Emergency Department (ED) following a crush injury. The patient is initially hemodynamically stable with a Glasgow Coma Scale of 15. He has some mild anterior pelvic pain on manual pelvic compression and a comminuted right femur fracture. A STAT CT of the head, chest, abdomen, and pelvis is requested to exclude injury. The clinical indication is "trauma in MVC." The radiology resident reviews the CT images and finds an open-book pelvic injury without other significant pathology. This information is conveyed to the ED resident by an electronic "preliminary report." At that point, the patient is transferred to orthopedic surgery for fixation of the femur. At no time does any ED or orthopedic physician consult with or review the study with either the radiology resident or attending radiologist.

You arrive at the ED reading room 45 minutes after the preliminary report was sent to "check-out" the resident. When you reach this particular CT, you observe active bleeding in the pelvis that was not appreciated by the resident. You tell the resident to amend the preliminary report and notify the team of this important correction. After you depart to perform other duties, the resident tries to reach the on-call team, but keeps getting other residents who "don't know the patient." He contacts the operating rooms, but is put on "terminal hold." He decides to try again in a few minutes, but gets swamped with other cases and forgets. After surgery, the patient is anemic and has a mild coagulopathy, but is stable. Several hours later, the patient has required multiple transfusions and is taken to angiography. Soon after successful embolization of his pelvic bleeding he suffers cardiac arrest and cannot be resuscitated.

Did the radiology resident do something wrong? Did the radiology staff do something wrong? Did the ED or orthopedic physicians do something wrong? Did the hospital or hospital staff do something wrong? Are these questions best answered by a jury?

The issue of adequate communication of radiologic findings has grown in prominence in recent years, driven, unfortunately, by medical-legal claims centered on this issue. Dr. Leonard Berlin points out that a breakdown in communication is a factor in up to 80% of malpractice lawsuits and that a delay or failure to communicate important imaging findings is the fourth most common primary claim lodged against radiologists. ¹ While radiologists spend most of their training learning how to interpret studies accurately, almost no time is devoted to the equally important task of communicating that information in a timely fashion. ² All of us know that waiting for the arrival of the written report to "the chart" is like waiting for the "snail" mail compared with e-mail. While most of us know either by common sense or a written list of policy-generated "trigger findings" what pieces of information should be directly communicated to the physicians who are caring for patients. As part of this communication, one also needs to ensure that the information is also received, understood, and acknowledged, which has been described as "closing the loop."

Currently, the obligation of imaging result transfer seems to have fallen disproportionately on the radiologist rather than on the physician who requested the study. The need to receive the result of a study is apparently less vital than the need to send the result. That this disparity exists makes no sense. If both sender and receiver work to close the information loop, the optimal situation for success exists. To increase the challenge of communicating important imaging findings by a radiologist, many other limitations frustrate the process in daily practice. Sometimes contact information for the requesting physician is not provided. The requesting physician may not be available. The requesting physician may not be the same as the physician indicated on the request (they are often submitted by their residents). Sometimes the patient is en route to another service, but this has not been "updated" in the computer. An initial contact not infrequently responds, "That's not my patient anymore, call So-and-so…" or "I don't know him, I'm new on service." The key information may actually be relayed to a care team member, but one who is unable to act on it. Sometimes the preliminary report is taken as the gospel, or the corrected report is signed off and becomes available only after the information would have been required. Sometimes the final report is reviewed before being signed by the "attending" radiologist, who may fail to note that the "vital correction" was never included by the dictating resident. Contact may be established and the information exchanged, but this fact is not documented, a breakdown that may become quite important in a medical-legal matter. There are many other opportunities for failure.

While difficulties in medical communication are many and complex, approaches to ameliorate them are also being aggressively sought. The importance of timely communication is being increasingly emphasized in formal sessions given to staff by administrators, risk managers, radiologists, and technologists. Guidelines for communication are more available on paper and online for quick review where and when needed. Order-entry systems are requiring more precise contact information on who is responsible to receive preliminary and final study interpretations. Automated systems are coming online to contact key clinical staff with urgent and emergent findings without requiring excessive amounts of the radiologist's time.

Other concepts might be considered. There must always be clear delineation of the lines of responsibility for providing and obtaining information, particularly in emergent medical situations. A simple, fast, direct, and, optimally, a guaranteed mode of communication between radiologists and caregivers must be available. This is usually a telephone or pager, but both have limitations. An ultimate fall-back communication is a "communication facilitator," available within the institution at all times, who is responsible to ensure and document transfer of vital findings. The "contact caregiver" or designee must review and acknowledge any recent "STAT" imaging report before they can progress in a computer-based hospital system, if such a report is so designated by the interpreting radiologist.

This issue needs a great deal of attention. Radiologists and nonradiology physicians should address it with equal dedication, as they are equally involved in and responsible for the problem and, more importantly, for their patients.