ACR Bulletin

Covering topics relevant to the practice of radiology

Scan Surprises

Actionable incidental findings (AIFs) present unique challenges in the emergency department (ED) setting. By working together, radiologists and other ED physicians can ensure patients follow up on diagnoses they weren’t looking for or expecting.

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An accidental incidental finding is a mass or lesion that's not related to the visit for why the patient's actually there. It's probably not causing the acute symptoms in the emergency department.

—Gregory Nicola, MD, FACR
August 30, 2023

It happens all the time: A patient enters a hospital emergency room in crisis, and a radiologist finds something on the patient’s imaging exam that is unrelated to the short-term symptoms but potentially threatening in the long term. What should an emergency department (ED) doctor do with that information?

A recent white paper  published in the JACR® by a panel from the ACR and the American College of Emergency Physicians (ACEP) explores best practices in the communication and follow-up of actionable incidental findings (AIFs) to ED patients. First author Christopher L. Moore, MD, from the ACEP and co-author Gregory Nicola, MD, FACR, from the ACR sat down with Christopher Hobson for an episode  of the ACR Bulletin Podcast to discuss their research on AIFs. During their conversation, Moore and Nicola explained what AIFs are, how to communicate them to patients and how collaboration between the ACR and the ACEP bolstered their research.

Defining an AIF

“An accidental incidental finding is a mass or lesion that's not related to the visit for why the patient's actually there,” Nicola explained. “It's probably not causing the acute symptoms in the emergency department.”

The last thing on the physician’s mind is an incidental finding that could be worked up over months or years. ER doctors do not necessarily have continuity of care.

—Christopher L. Moore, MD

While AIFs often have nothing to do with a patient’s symptoms, Nicola noted that they could still be important to the patient’s long-term health.

“You have something that's concerning, and it could be cancer,” he continued, “and sometimes we make follow-up recommendations in our report. That needs to be communicated downstream to the care team so the patient has appropriate follow-up, and we catch something that could harm the patient in the long term.”

Moore suggested that AIFs may not be prioritized by emergency department physicians who are focused on the acute symptoms. He emphasized that a systems approach is needed to ensure these findings do not fall through the cracks.

“The last thing on the physician’s mind is an incidental finding that could be worked up over months or years,” he noted, adding that ED physicians often don’t treat patients for long periods of time. “ER doctors do not necessarily have continuity of care. The emergency department’s patient may be admitted to another clinical team. The discharged emergency physician and/or radiologist might never see the patient again. That lack of continuity makes following up on an incidental finding very difficult.”

Communicating to Sick Patients

“The patient is probably not in the right mindset to receive a recommendation from the doctor,” he explained. “The patient's an important aspect of follow up. We have to communicate with patients to make sure they understand why they're coming back and include them in the diagnostic process.”

Moore agreed, adding, “Sometimes even when you talk to the patient and you communicate with them, they're just not in the mental state to really hear it. They're there for an emergency or they're in a stressful time of their life. You may tell them very clearly that they have a finding that should be followed up on, and it just doesn't register at that time. That’s why it's important to think about this system-wide and long-term follow-up communication.”

In describing the multi-step nature of AIF communication and follow-up, Nicola likened the process to a recent experience he had at a tire shop.

“I brought my car in the other day for new tires,” he told listeners. “And I had multiple communication events, about how they received my tires and how they put my tires on and the payment. Then they even followed up about my car being dropped off into my garage. I live in New York City, so they actually drop your car off into your garage sometimes.”

“I think it's only appropriate that we strive to have that kind of communication with our patients,” Nicola said. “We’ve got to remember that these patients come to the emergency department for an acute event. They're potentially extremely sick. They're not going to remember a lot of what you've told them, and if that's the last time they hear about that important potential finding not related to why they came in, it may not be at the top of their mind. I think as a healthcare system, we probably need to strive toward better communication along the entire loop of incidental findings and make sure the patient follows up.”

Moore addressed what kind of time and resources are necessary to make these communication improvements. “The answer, I think, is to look at how it's going to work best at your hospital in terms of having a way to track these AIFs.”

Many EDs, even smaller ones, now have somebody who is following up with patients on their clinical care, making sure they set follow-up appointments, show up for a procedures like blood cultures, and report back to the ED team. “Building that into a systems approach for follow-up is what we're trying to advocate for here, to have the resources to do that,” Moore said.

A Thriving ACR-ACEP Partnership

Both Moore and Nicola expressed their gratitude for the support of the ACR and the ACEP.

From his vantage point with the ACEP, Moore highlighted the ACR’s contributions to the white paper: “Shout out to the ACR!” he exclaimed. “I did a lot of on the paper, but there are many people behind the scenes, particularly at the ACR, who helped with survey administration and putting the results together.”

Nicola noted the strong bond between the two colleges: “This might come as a surprise for many listeners and viewers, but the American College of Radiology and the American College of Emergency Physicians have worked together for a long time. For the last decade, I’ve been involved with the ACEP regarding quality and safety issues. We have a couple of grants that we’ve worked on with the ACEP, and this is really just a maturity of our relationship. We have common goals and very common ways to address them, so it was an easy collaboration.”

Author Corey Feuer  publications intern, ACR Press