A 73-year-old woman comes to the emergency department due to shortness of breath and productive cough for the past 2 weeks. The patient lives independently and is active in her retirement community. She was seen by her primary care physician last year and has no medical conditions. The patient has a history of smoking but quit 20 years ago. Temperature is 37.8 C (100 F). Lung auscultation reveals right-sided crackles. Chest x-ray reveals right lower lobe consolidation and a solitary 1-cm, round lesion in the left upper lung field, which was not seen on previous x-rays. The patient is admitted and treated for community-acquired pneumonia, becomes medically stable, and is ready to be discharged home with oral antibiotics. The physician records the pulmonary lesion finding on the discharge summary, places an outpatient radiology referral for chest CT scan, and informs the patient that she will be contacted regarding her radiology appointment after discharge. Several months later, the patient is readmitted to the hospital with dyspnea and weight loss. Records show that she was called about the scheduled appointment for the CT scan but did not attend it, so the test was not completed. Repeat imaging reveals enlargement of the pulmonary nodule, and biopsy confirms lung adenocarcinoma. Which of the following interventions by hospital providers is most appropriate for reducing future occurrences of similar errors?

Question

A 73-year-old woman comes to the emergency department due to shortness of breath and productive cough for the past 2 weeks.  The patient lives independently and is active in her retirement community.  She was seen by her primary care physician last year and has no medical conditions.  The patient has a history of smoking but quit 20 years ago.  Temperature is 37.8 C (100 F).  Lung auscultation reveals right-sided crackles.  Chest x-ray reveals right lower lobe consolidation and a solitary 1-cm, round lesion in the left upper lung field, which was not seen on previous x-rays.  The patient is admitted and treated for community-acquired pneumonia, becomes medically stable, and is ready to be discharged home with oral antibiotics.  The physician records the pulmonary lesion finding on the discharge summary, places an outpatient radiology referral for chest CT scan, and informs the patient that she will be contacted regarding her radiology appointment after discharge.  Several months later, the patient is readmitted to the hospital with dyspnea and weight loss.  Records show that she was called about the scheduled appointment for the CT scan but did not attend it, so the test was not completed.  Repeat imaging reveals enlargement of the pulmonary nodule, and biopsy confirms lung adenocarcinoma.  Which of the following interventions by hospital providers is most appropriate for reducing future occurrences of similar errors?

Quizplus · Accepted Answer

Explanation: Fewer than 20% of inpatients with incidentally detected lung nodules undergo recommended postdischarge follow-up (eg, CT scan, management based on malignancy risk), leading to preventable adverse outcomes, including delayed cancer diagnoses. A common cause is loss to follow-up after transfers of care (eg, hospital discharge), as seen in this patient. Because inpatient care focuses on acute medical conditions, patients may not recognize the importance of assessing unrelated findings (eg, incidental lung or adrenal nodule) after discharge, especially when symptoms resolve. Timely (<4 weeks) primary care follow-up promotes completion of pending studies (eg, imaging, laboratory tests) and health management (eg, new medications, diagnoses). During the discharge process, patients should receive high-quality provider communication and counseling explaining the importance of follow-up, as this increases patient likelihood of attending primary care visits and completing follow-up recommendations. High-quality communication includes the following: Face-to-face discourse, allowing responses to nonverbal cues Patient-centered interaction tailored to the patient's current motivations, goals, and ability Interactive approaches for verifying patient understanding (eg, inviting questions, encouraging teach-back that summarizes patient understanding of the conversation) Discharge summaries can be routed to primary care providers for review when patients attend their posthospitalization appointment. (Choice B) Including family members in follow-up care is useful if the patient has cognitive impairment or has consented to sharing medical information with them. However, for independent, cognitively intact patients (eg, this woman), direct engagement through counseling is preferred for building awareness and promoting follow-up. (Choice C) Monitoring results from pending appointments on all discharged patients extends beyond hospital providers' scope of responsibility (eg, inpatient management of acute health concerns) and potentially compromises patient safety by excessively increasing provider workload. Primary care providers often receive a log of their patients' abnormal outpatient tests through the electronic medical record, enabling superior systematic monitoring and follow-up. (Choice D) Postponing discharge of medically stable patients until completion of nonurgent studies and biopsy results, which may take several extra days, is not recommended because it increases nosocomial infection risk and undermines resource stewardship (eg, use of efficient health care resources). Educational objective: Loss to follow-up after hospital discharge can lead to adverse outcomes. High-quality patient counseling that encourages early (<4 weeks) primary care follow-up increases the likelihood of patient attendance, completion of pending items (eg, imaging studies), and management of patient health status (eg, new diagnoses). References: Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up. (http://www.ncbi.nlm.nih.gov/pubmed/20578046) Impact of a health information technology intervention on the follow-up management of pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/28664448) Patient and clinician characteristics associated with adherence. A cohort study of veterans with incidental pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/27144794)

A 73-Year-Old Woman Comes to the Emergency Department Due to Shortness