Article, Radiology

Prevalence, documentation, and communication of incidental findings in focused assessment with sonography for trauma (FAST) examinations

a b s t r a c t

Background: As the focused assessment with sonography for trauma examination becomes increasingly ubiquitous in the emergency department (ED), a parallel increase in incidental findings can also be expected. The purpose of this study was to determine the prevalence, documentation, and communication of incidental findings on emergency physician-performed FAST examinations.

Methods: Retrospective review at two academic EDs. adult trauma patients undergoing FAST examinations used for clinical decision-making at the bedside were identified from an ED ultrasound image archival system. Expert sonologists reviewed ultrasound images for incidental findings, as well as electronic medical records for demo- graphic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings to the patient.

Results: A total of 1,452 FAST examinations were reviewed. One hundred and thirty-seven patients with inciden- tal findings were identified (9.4%); 7 patients had an additional incidental finding. Renal cysts were most com- mon (49/144, 34.0%), followed by pelvic cysts in women (32/144, 22.2%). While 31/144 (21.5%) incidental findings were identified and documented in the ultrasound reports or medical records by ED providers, only 6/ 137 (4.4%) patients were noted to be informed of their incidental findings.

Conclusion: Incidental findings were often encountered in FAST examinations, with cysts of the kidneys and pel- vis being the most common findings. A vast majority of incidental findings were not documented or noted to be communicated to patients, which can be a barrier to Follow-up care.

(C) 2019

Introduction

The focused assessment with sonography for trauma (FAST) exami- nation has become increasingly ubiquitous in the initial evaluation of trauma patients in the emergency department (ED) [1]. While the pur- pose of this examination is to identify free fluid representing blood and requiring emergent operative intervention, sometimes this examina- tion will identify incidental findings that may necessitate further evalu- ation. Incidental findings in imaging studies are a common occurrence with variable clinical significance. When identified, these findings may lead to follow up studies and procedures that are variably cost-

? Abstract presented at American College of Emergency Physicians Research Forum, Denver, Colorado, 10/2019.

* Corresponding author at: 6200 N. La Cholla Blvd, Emergency Department, Tucson, AZ 85741, United States.

E-mail address: [email protected] (J. Valenzuela).

effective [2]. When not recognized, misidentified, or not communicated to patients, incidental findings may delay appropriate follow up care [3, 4]. One prior study in this population showed an incidence of 7.8% for in- cidental findings on ultrasound, with abnormalities in the hepatobiliary and renal systems being the most common. The FAST examinations, however, were performed by radiologists, and followed up by solid organ screening ultrasounds in the case of absence of free fluid [5]. The rates of reporting or follow up of incidental findings for computed tomography (CT) in the trauma setting have been reported at 1.4% to 27% [3,4]. To our knowledge, the prevalence of incidental findings in FAST examinations performed by emergency physicians has never been reported.

The primary goal of this study was to determine the prevalence and types of incidental findings identified in adult ED trauma patients un- dergoing FAST examinations by emergency physicians. The secondary goals were to determine whether incidental findings were documented by the provider in imaging reports or the medical record, and whether

https://doi.org/10.1016/j.ajem.2019.11.040

0735-6757/(C) 2019

patients were informed of their findings and given follow-up instruc- tions. We also reviewed other imaging studies’ findings for confirmation of the incidental findings seen on ultrasound.

Methods

Study design and study setting

We performed a retrospective review of ED patients with emergency physician-performed FAST examinations for adult trauma patients. The study took place between October 2017 and December 2018 at 2 aca- demic EDs with an approximate combined annual census of 120,000 pa- tients. This time interval was a convenience sample chosen to begin after the introduction of a new electronic medical record system. Both EDs had an emergency medicine (EM) residency and an active emer- gency ultrasound training program. The EM residents received point- of-care ultrasound (POCUS) training according to the Accreditation Council for Graduate Medical Education guidelines for emergency med- icine [6,7]. The EM core privileges included the FAST examination, and all EM attending physicians were credentialed to perform FAST. All FAST examination video clips were stored in the web-basED workflow solutions database, Qpath E (Qpath E; Telexy Healthcare, Port Coquitlam, British Columbia, Canada). This archiving system stored all POCUS examinations performed at both EDs, including both video clips and interpretation reports, which consisted of indications, findings, and final diagnoses associated with each POCUS examination. All POCUS examinations used for medical decision making were signed and sub- mitted for billing by the ED attending physicians in Qpath E system. This study was approved by the Institutional Review Board.

Study population and selection criteria

inclusion criterion were all adult trauma patients (N18 years) with FAST examination performed. Indication for FAST examination and mechanism of injury were determined by POCUS report and chart re- view. Pediatric trauma patients were excluded due to low volume at the two study hospitals. Exclusion criteria included non-trauma FAST examinations, repeat studies on the same day, and FAST examinations not used for medical decision making, determined by the POCUS report completed by the treating ED attending physician. Qpath E is a sophisti- cated ultrasound workflow solution which allows to filter the FAST ex- aminations that were used for medical decision making.

Study protocol

Eligible patients were identified through search of the ED ultrasound image archival system for all FAST examinations performed and used for medical decision making during the study period.

EM residents and attending physicians with varied POCUS experi- ence performed FAST examinations as part of routine care. All EM at- tending physicians were credentialed to perform FAST examinations per American College of Emergency Physicians guidelines. None of the examinations were performed by non-EM residents or advanced prac- tice providers. The FAST examinations were performed after initial clin- ical assessment. The examinations were performed with a Z.One Ultra (Zonare Medical Systems, Mountain View, CA) or a GE Venue (General Electric Company, Milwaukee, WI) with a low-frequency broadband curvilinear or phased array transducer. Standard teaching at our institu- tion for the FAST examination included obtaining views of the right upper quadrant, left upper quadrant, left and right pericolic gutters, pel- vis, and pericardium, with full interrogation of each region. However, the adequacy of the views obtained in the FAST examinations included in this study was determined by the treating EM physician, who then determined the need for further imaging, often in conjunction with the trauma surgery team. All ultrasound examinations performed in the ED were reviewed routinely for quality assurance by emergency

ultrasound section faculty. All ultrasound examinations that met inclu- sion criteria were reviewed by the primary investigator, an EM physi- cian and current fellow in emergency ultrasound, for incidental findings. This investigator had performed more than 700 POCUS exam- inations before this study. If a FAST examination included thoracic views, they were not reviewed for incidental findings. All studies with incidental findings and 10% of those without incidental findings were further reviewed by an expert sonologist. Interobserver disagreements were adjudicated by additional image review by a third expert emer- gency sonologist who was blinded to the two reviewers’ interpretations. Both expert sonologists had performed more than 2000 POCUS exami- nations before this study.

Medical records of these patients were then reviewed by two study investigators for demographic information, mechanism of injury, docu- mentation of the incidental finding, documentation of discussion of finding with the patient and referral to follow up care, and results of ad- ditional diagnostic testing. Data were collected independently by the two study investigators after a training session to standardize data col- lection strategies. A standardized data collection form was used for data abstraction. Internal quality assurance documentation was also reviewed for notation of incidental findings absent in the treating phy- sician’s POCUS report.

Outcome measures

The primary outcomes were the frequency and types of incidental findings. The secondary outcomes were the frequency of documenta- tion of these findings by the treating provider and quality assurance sonologist, documentation of discussion of findings with the patient and referral to follow up care by the treating physician, and confirma- tion of incidental FAST findings on other imaging modalities.

Data analysis

Continuous variables were reported as means with standard devia- tions and compared between groups using an unpaired Students t– test. Categorical variables were reported as proportions and compared using the Fishers Exact test. Inter-rater reliability was assessed using the kappa test statistic. A p-value of b 0.05 was considered statistically significant. All analyses were conducted in STATA 15 (College Station, Texas).

Results

A total of 1,836 FAST examinations were identified that were used for medical decision making over the 15-month study period. Eighteen examinations that were repeat FASTs on the same patient for the same visit or simply not a FAST examination were excluded. One hundred and sixty-seven pediatric patients were excluded. One hundred and ninety- nine patients who did not have a traumatic mechanism were excluded. A total of 1,452 studies were then analyzed (Fig. 1). Of these, 137 FAST examinations (9.4%) showed an incidental finding in our patient popu- lation. Seven of the ultrasounds with an incidental finding showed an additional, second incidental finding. The mean age for all patients was 44 years (SD 19). Five hundred and seventy patients were female (39.3%); 882 were male (60.7%). The most common incidental finding was renal cyst, followed by pelvic cyst (in females), bladder diverticula, hydronephrosis, and hepatic cyst (see Table 1, Fig. 2). There was 92% agreement between the reviewers regarding presence of incidental findings (kappa 0.84, STE 0.06).

Thirty-one of the 137 FAST examinations (22.6%) with incidental

findings were documented by the emergency physician, either in the POCUS report or in the medical record. A further 27 (19.7%) were noted on routine internal quality assurance review by ultrasound- trained emergency physicians. For most patients, FAST was the only im- aging obtained on their visit. However, 64 patients received additional

1836 FAST examinations

1452 FAST examinations included

1315 without incidental finding

137 with incidental finding

Fig. 1. FAST examinations included in our analysis.

Not a trauma patient (199)

imaging (most commonly CT of the abdomen and pelvis). Thirty-four (53%) of these further imaging studies demonstrated the same inciden- tal finding seen on FAST. Sixty-seven patients with incidental findings were admitted (49%). Of the 70 patients who were discharged from the ED, 6 (9%) had documentation of a discussion of the incidental find- ing with the patient or referral for follow-up care.

Patient < 18 years old (167)

Repeat or inaccurate exam type (18)

Discussion

The FAST examination is a commonly performed POCUS examina- tion to evaluate trauma patients in the ED. As this examination becomes increasingly widespread, incidental findings are an unavoidable atten- dant. These findings present a challenge in documentation, reporting, and arranging appropriate follow-up.

This study demonstrated that incidental findings were present in 9.4% of patients undergoing FAST examinations in our patient popula- tion. The most common findings included renal cysts, pelvic cysts in fe- male patients, bladder diverticulum, hydronephrosis, and hepatic cysts. This frequency was similar to a prior study of adult abdominal trauma patients in which FAST examinations were performed by radiologists,

Table 1

Number and type of incidental findings.

Finding

N (% of incidental findings)

Renal cyst

49 (34.0%)

Pelvic cyst in female patient

32 (22.2%)

Bladder diverticulum

13 (9.0%)

Hydronephrosis

11 (7.6%)

Hepatic cyst

10 (6.9%)

Uterine Fibroid

6 (4.2%)

Bladder sediment

6 (4.2%)

Splenic cyst

4 (2.8%)

Intrauterine collection (fluid, hematoma)

3 (2.1%)

Cholelithiasis

2 (1.4%)

Splenic calcifications

2 (1.4%)

Hepatic soft tissue mass

1 (0.7%)

Pelvic soft tissue mass in female patient

1 (0.7%)

Prostatic calcifications

1 (0.7%)

Prostate cyst

1 (0.7%)

Pelvic soft tissue mass in male patient

1 (0.7%)

Bladder mass

1 (0.7%)

then if negative, followed up by solid organ screening ultrasounds. The frequency of incidental findings in that population was reported at 7.8%, with the most common incidental findings being related to the hepatobiliary and renal systems [5]. In a study done by Weile et al, approximately 40% of patients presenting to the ED with any symptoms were noted to have abnormalities on ultrasound, and the potential clin- ical impact of these abnormalities was not clear [8].

Overall, incidental findings were poorly documented and communi- cated by emergency physicians in our study. Only 31 findings (22.6%) were documented by emergency physicians, and only 6 patients (9% of discharged patients) had documentation of either being notified of their incidental finding or referred for follow-up care. Reporting of inci- dental findings to trauma patients is similarly poor for CT imaging, rang- ing from 1.4% to 27% [3,4].

Based on our study findings, emergency physicians can expect to en- counter incidental findings during routine use of the FAST. This repre- sents a particular challenge for a POCUS examination in terms of reporting and management. A POCUS examination is intended to

Fig. 2. A well-marginated anechoic simple renal cyst with thin walls.

answer more focused clinical questions than a radiology-performed ul- trasound, and physicians performing these ultrasounds have less train- ing and familiarity with findings outside of the scope of the examination. Emergency physicians certainly should not be expected to actively seek out these findings; this is well outside of professional or- ganization guidelines for use of POCUS. In addition, incidental findings can lead to costly and unnecessary follow-up testing, to the detriment of the patient [2].

On the other hand, some incidental findings can have a significant impact on the patient’s health once their emergency condition is re- solved, particularly if a malignancy is identified. These incidental find- ings represent an opportunity to provide better care to ED patients by allowing expedited follow-up care, especially for clearly concerning findings (Table 2, discussed more below). Ultimately, we recommend that emergency physicians incorporate routine documentation, discus- sion with patients, and referral for follow-up care for the incidental find- ings that they note and are able to identify during FAST.

Further, a familiarity with the most common kinds of incidental findings will help the emergency physician identify them on FAST and select appropriate follow-up imaging and referral to provider for addi- tional care. All incidental findings in this study were safe for outpatient follow up. The most common incidental findings, renal cysts, are most often benign, but their differential includes Renal cell carcinoma. These cysts can be classified by the Bosniak criteria into risk categories for ma- lignancy. Concerning features include internal septation, calcification, or soft tissue, and thick, irregular cyst walls. If a cyst lacks these features, and the patient has never had imaging of their abdomen, an outpatient abdominal CT with contrast with a primary care physician is appropri- ate. A cyst with any concerning features will likely require outpatient abdominal MRI with contrast and follow up for possible biopsy [9]. He- patic cysts can be similarly categorized and followed up in the outpa- tient setting [10].

Pelvic cysts in women likewise are usually benign, especially in reproductive-age women, and can be categorized by degree of concern for ovarian malignancy. The International Ovarian Tumor Analysis (IOTA) group gives the following high-risk features for malignancy: solid components, ascites, multiple papillary structures, very strong Doppler flow, multilocular, irregular, or size N 10 cm [11]. If any of these are present, the patient should undergo outpatient Transvaginal ultrasound and gynecology follow up. In addition, we recommend that

Table 2

Management of common incidental findings.

Finding Concerning features Follow up

reproductive-age women with cysts N 5 cm receive outpatient gynecol- ogy follow up, as these patients are at higher risk for Ovarian torsion [12], and that post-menopausal women with any ovarian cyst likewise receive gynecology follow-up, as risk stratification for these women may involve tumor markers [13].

Bladder diverticulum, which can be congenital, but more often are the result of prostatic hypertrophy and urinary stasis, carry a 10% life- time risk for bladder cancer. These patients will need urology follow up for monitoring; no additional imaging is generally helpful [14]. Asymptomatic hydronephrosis has a number of Potential causes, and can result from intrinsic or extrinsic compression of any part of the uri- nary system. Over time, urinary outlet obstruction can lead to obstruc- tive nephropathy and permanent kidney damage. For this reason, for all patients with previously undiagnosed hydronephrosis, it is prudent to refer to a urologist for further testing [15].

In our study, 46% of patients with incidental findings underwent fur- ther Radiologic testing, such as CT of the abdomen and pelvis. In 53% of these patients, the finding noted on FAST examination was confirmed by CT. It is possible that the 30 cases of incidental findings not confirmed on follow up imaging were false positives on ultrasound; this seems un- likely, however, given the high degree of inter-rater reliability between the study reviewers. This discrepancy may also be due to the heteroge- neity of radiologists in reporting certain incidental findings [16]. In ad- dition, it is possible some of these incidental findings were only seen on ultrasound. Bladder diverticulum, for example, are much better visu- alized on ultrasound. Of the 14 patients with diverticulum seen on ultra- sound who got follow-up imaging, only 2 could be seen on CT. Thus, CT cannot be completely relied upon to identify and characterize all inci- dental findings seen on FAST.

Limitations

This study had several limitations, including its retrospective nature and relatively small sample size, which limited the conclusions that can be reached. The two study hospitals are academic institutions with EM residency programs and dedicated POCUS training, and so our data may not reflect other settings. Pediatric patients were not included in our study due to low volume at the two study sites, which might have introduced selection bias. The FAST examinations in this study were performed by residents and attending physicians with varied ultra- sound experience. We do not have information about the proportion of examinations performed by residents versus attending physicians, and we did not examine the association between the missed findings and sonographer experience. The data abstractors and reviewers were not blinded to the study hypothesis. We attempted to minimize the bias by blinding reviewers to each other’s interpretations. Dual data ex-

Renal cyst Internal septation, calcification, or soft tissue. Irregular, thickened walls.

Simple: outpatient CT if never imaged before

High risk: abdominal MR with contrast and follow up for possible biopsy [9]

traction was not performed, which would have made the study more robust. It is possible that emergency physicians may have given verbal instructions to patients to seek follow-up with a primary care physician for incidental findings without the discussion being documented in the

Pelvic cyst in female patient

Bladder diverticulum

Solid components, ascites, multiple papillary structures, very strong blood flow, multilocular, irregular,

size N 10 cm

None; require cystoscopy to evaluate. 10% associated with malignancy.

All patients: Hcg level Pregnant: Same-day ultrasound for Ectopic pregnancy

Reproductive-aged women:

If N 5 cm, gynecology follow up. If b 5 cm, no follow up needed. Post-menopausal women: Outpatient ultrasound and gynecology follow up [11,12,13] Urology follow up for all patients [14]

electronic medical record. We did not follow up with patients to deter- mine if they underwent further imaging or specialist consultation; therefore, the final diagnosis and clinical significance of their incidental findings were unknown. Future research could focus on the correlation between sonographer experience and recognition of incidental findings, large Prospective analysis of the type and kind of incidental findings in FAST and other POCUS examinations, and follow up with patients to de- termine the final diagnosis and clinical significance of their incidental finding.

Hydronephrosis None; require evaluation for

urinary outlet obstruction Hepatic cyst Septations, mural irregularity

or nodularity, debris, calcifications, fluid levels

Urology follow up for all patients [15]

Simple: Outpatient LFTs and CT if never imaged beforeHigh risk: Outpatient LFTs, MRI, and follow-up for possible biopsy [10]

Conclusion

Incidental findings were often encountered in the FAST examina- tions performed by emergency physicians for adult trauma patients. The most common findings were renal cysts, pelvic cysts in women, and bladder diverticulum. All were safe for further outpatient

evaluation, but were not documented or noted to be communicated to patients, hindering appropriate follow-up care.

CRediT authorship contribution statement

Josephine Valenzuela: Conceptualization, Methodology, Investiga- tion, Data curation, Writing – original draft, Writing – review & editing, Project administration. Bryan Stilson: Investigation. Asad Patanwala: Formal analysis. Richard Amini: Validation. Srikar Adhikari: Conceptu- alization, Methodology, Validation, Writing – review & editing, Supervision.

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