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North Shore University Hospital closes the loop on significant unexpected clinical findings

Incidental findings are frequently identified during the complex imaging of trauma patients. Overlooking these clinically significant imaging results can put follow-up and patient outcomes at risk. After identifying process gaps in 2019, North Shore University Hospital (part of Northwell Health) began an initiative to improve the communication, documentation and follow-up of incidental clinical findings.

NSUH developed a clinical management guideline to establish a standardized process for identification, communication, documentation and follow-up of unexpected incidental findings. Acute care surgery division attending faculty, advanced care providers and residents were then educated on the new process.

The team then assigned a trauma concurrent nurse reviewer to check compliance daily for newly admitted patients and testing results. During the daily screening, clinical results undergo manual chart review in addition to a daily radiology tracking report that is triggered by keywords used to document incidental findings. The concurrent nurse reviewer tracks patients throughout their care, assuring compliance with documentation of incidental findings during discharge, including disclosure to patient and family, distribution of testing results, communication with the patient’s primary medical doctor and providing follow-up instructions.

In cases of non-compliance, the nurse communicates the ongoing need for follow-up directly with the clinical team and tracks compliance in the trauma data registry system. Data analysis is conducted at the end of each month to identify non-compliant cases; provider follow-up is then initiated post-discharge, including contacting patients and primary care doctors with findings.

Between Sept. 1, 2019, and March 31, 2021, a total of 230 trauma patients were identified to have one or more clinically significant incidental findings, for a total of 280 individual findings, or 26.3% of the total 873 patients admitted to the trauma service. After program initiation, concurrent closed-loop communication of unexpected findings achieved a 100% compliance rate.

For more information, contact Cristy Meyer, MSN, RN, CEN, TCRN, trauma program manager, at cmeyer4@northwell.edu or 516.562.2848.