HiQuiPs: Test Result Follow-up in the Emergency Department

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Introduction

Test result follow-up can be especially challenging in the Emergency Department (ED) due to its multiplicity of moving parts. ED physicians are under increasing pressure when treating patients due to the challenges of high volumes of patients, pressure for quick discharges in the face of space constraints, and complexities surrounding patient handover. Test result follow-up is a process that is complex and has several steps, each with their own potential for error. The table below is based on the work of the Agency for Healthcare Research and Quality (AHRQ) in the United States​1​, and shows the process of ordering, performing, and following up on a test in a Canadian context.​2​

Adapted from the Agency of Healthcare Research and Quality, 2013

When ordering tests for their patients, physicians have several responsibilities – these include communicating results, following up on abnormal results, and delegating responsibilities to another physician if the original physician is unable to follow up on the results themself.​3​ However, fulfilling these requirements can be challenging in the ED. There may be confusion over who is the most responsible physician, how to communicate results between the test-ordering ED physician and the patient’s treating physician, and how to respond to the urgency or severity of pending test results.​4​

There were 1,429 CMPA medico-legal cases closed between 2019 – 2021 associated with diagnostic testing. Of the cases that took place in the emergency department, 61% (126) had an unfavourable medico-legal outcome for the members. Small changes in your individual practice could help in reducing lost or unfollowed test results, while identifying or strengthening system processes can improve test result follow-up for all patients in the ED. Creating safety nets or redundancies to catch any oversights may help to ensure patients receive safe medical care. Read on for some examples of common ED scenarios where improved individual practices and system-based processes could improve patient outcomes.

Section 1: Test results ordered before you see the patient

A 25-year-old male comes to the ED on a Friday night. He is suffering from a cold and a migraine and is concerned that he took too much acetaminophen. The nurse asks how much acetaminophen was consumed in the last 24 hours and the patient says he doesn’t know, as he was taking both cold medicine and pain relievers. Your hospital has a protocol to order tests for patients in the waiting room to improve ED throughput times. The triage nurse orders basic blood work and an acetaminophen level and assigns the test results to you before you have met the patient.
 
The patient grows tired of waiting and leaves the waiting room without having been seen by you.
 
The blood tests come back after you have finished your shift with an acetaminophen level above the zone of possible toxicity. This value is recorded in a follow-up book for the next day, and the result is not acted on by the overnight team. Due to the busyness of the ED on Saturday morning, it is not noticed until the afternoon. Attempts to reach the patient were unsuccessful until Sunday morning; on his return to the ED he is showing signs of hepatic toxicity.

Emergency departments are under incredible strain. Between increased capacity issues, human resource factors, and systems issues, physicians face multiple challenges while trying to provide safe medical care. Departments or hospital administrators may implement new rules or initiatives in an effort to alleviate these stressors, which unfortunately may create other unintended consequences. Implementing appropriate Quality Improvement processes at the department level is one way to identify problems with any new initiatives and refine the process to improve patient care. Ensure that your emergency department has built-in redundancy systems for following up on waiting room tests so that important time-sensitive results are noticed.

Section 2: Test results that come back after you leave

You are a locum physician working in a small community ED. A 75-year-old man with a history of dementia is brought into the ED by ambulance from a long-term care home. The patient apparently had a fever earlier in the day, and some increased confusion from his baseline. On examination you identify a diabetic foot ulcer, but he is afebrile in the ED and his cognition seems to be back to the patient’s baseline, according to a family member who is accompanying him. You order routine bloodwork including blood cultures. You initiate an oral antibiotic regimen, clean and dress the wound and review his normal bloodwork. Several hours later the patient is sent back to his long-term care home with a prescription and instructions to the family and care workers to watch for any signs of deterioration.
 
You work in this department infrequently and are working in another community over the next two weeks. When the initial blood culture results come back positive for gram positive cocci, and subsequently as MRSA, they go undetected because you do not sign into the portal and therefore missed the results. The patient is subsequently diagnosed with osteomyelitis and MRSA endocarditis.

Emergency physicians have busy schedules and may work at more than one hospital. This can make it challenging to ensure there is adequate coverage for test results that may come back when they are off shift. It is important to remember that even if ED physicians are not in the department when the test results they order come back, they are still ultimately responsible for following up on abnormal results.

If you are going to be away, out-of-office, or unavailable and you have pending test results, ensure that there is a process in place to review any test results that may come back in your absence. Be sure to document any outstanding results for your own records as well as the plan for who is going to review and follow up on them.​5​ Remember that the patient is part of the care team. Consider including a plan for tests pending at discharge in your discharge summary. This can help patients feel informed and empowered about what tests are still outstanding and can help them if they want to follow up on results.​6​

Section 3: Incidental findings

A 45-year-old woman is brought to the emergency department after a multi-vehicle accident. You order x-rays, which indicate a thoracic compression fracture and a small nodule on her lung. You manage the pain from the spinal fracture, and she is eventually discharged with outpatient follow-up in spine clinic. She recovers uneventfully. A year later she goes to her family physician complaining of a persistent cough and her family physician discovers she has advanced lung cancer.

Physicians may uncover underlying or unknown medical conditions when treating patients. While this incidental finding may be unrelated to your primary focus with your patient, you are still responsible for following up on the test result. Colleges have made it clear that ordering physicians are responsible for following up on test results even if they fall outside of their scope of practice. If you notice something on the test results but feel that it falls outside of your investigation, you must still take the time to follow up on it.

What can physicians do?

When trying to improve processes for testing, consider efforts that you can implement on both an individual and systems level. For example, within your own practice, ask yourself the following questions:

  • Have you communicated to the patient the significance of the test?​7​
  • Have you documented what results you have received and reviewed? And what the next steps will be, including referrals?​5​

Within your own department, Quality Assurance team, or hospital system, consider the following:

  • Does your department have a process for tracking the follow-up of tests with abnormal results?
  • Does your department have a quality assurance process?​8​
  • Does your department share pending test information with patients, or include pending test information in the discharge summary shared with patients?​6​

Bottom Line

The process for performing tests has many parts with many hands. Unfortunately, this can result in missteps or mistakes that may lead to patient harm. Physicians are required to review the results of tests that are assigned under their name and take reasonable steps to communicate them to the patient. Small changes in your own practice and in department-wide processes can help to create safeguards that may minimize the risk of missing important results.

This article was copy-edited by George Gainham

Additional Resources

References

  1. 1.
    Agency for Healthcare Research and Quality . Improving your laboratory testing process: A step-by-step guide for rapid-cycle patient safety and quality improvement. (AHRQ). Published December 1, 2017. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
  2. 2.
    Canadian Medical Protective Association. . Closing the loop on effective follow-up in clinical practice: 8 suggested steps toward a robust follow-up system 2019. (CMPA). Published March 1, 2019. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2019/closing-the-loop-on-effective-follow-up-in-clinical-practice#ref
  3. 3.
    Lee S. s No News Good News? Build a More Reliable Follow-up System for Test Results. In: ; 2019.
  4. 4.
    Whitehead N, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med. 2018;13(9):631-636. doi:10.12788/jhm.2944
  5. 5.
    Chartier L. Waiting to Be Seen 10 [Internet]. Ovens H (Editor). Emergency Medicine Cases. Published October 1, 2016. https://emergencymedicinecases.com/em-quality-assurance-individual-responsibilities/
  6. 6.
    Darragh P, Bodley T, Orchanian-Cheff A, Shojania K, Kwan J, Cram P. A Systematic Review of Interventions to Follow-Up Test Results Pending at Discharge. J Gen Intern Med. 2018;33(5):750-758. doi:10.1007/s11606-017-4290-9
  7. 7.
    Canadian Medical Protective Association . Test results follow-up. (CMPA). Published March 1, 2021. https://www.cmpa-acpm.ca/en/education-events/good-practices/physician-patient/test-results-follow-up
  8. 8.
    Chartier L. WTBS 9 – EM Quality Assurance Part One: Improving Follow up from the ED (edited by Howard Ovens and Anton Helman). Emergency Medicine Cases. Published September 1, 2016. https://emergencymedicinecases.com/em-quality-assurance-improving-follow-up-ed/
Joanna Zaslow

Joanna Zaslow

Joanna Zaslow is a Health Services Researcher at the CMPA and holds a PhD in Philosophy from McMaster University.
Heather Murray

Heather Murray

Emergency Physician and Medical Educator at Queen's University
Heather Murray is an emergency physician with over 30 years of clinical experience. She is a Professor at Queen's University and a Physician Advisor at the CMPA.
Tricia Savoy

Tricia Savoy

Tricia Savoy is a Medical Analyst Researcher at the CMPA. She has been working as a registered nurse in the fields of Haematology and Community Care in Ottawa for over 30 years.
Tricia Savoy

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