No stone unturned: Nodule Net, an intervention to reduce loss to follow-up of lung nodules.

OBJECTIVE: Inadequate lung nodule surveillance leads to diagnostic delays. We implemented a retrospective intervention program, Nodule Net, to improve surveillance in our hospital. METHODS: 9,224 Chest computed tomography (CT) scans between January 1, 2015 and December 31, 2016 were manually reviewed for lung nodules. For patients without follow-up, charts were reviewed to assess follow-up. If follow-up appeared indicated, the clinician or patient was contacted, and follow-up was tracked. RESULTS: Lung nodules were identified on 5,101 (55%) of 9,224 scans. Follow-up was potentially indicated and not completed in 1,385 (27%). 183 (13%) were excluded after imaging review. 1,202 received outreach. Of the 801 (66%) with a provider in our system, 225 (27%) returned for follow-up. Nodules were stable in 199 (88%), new or growing in 23 (11%), resolved in 3 (1%), and stage 1 lung cancer in 2 (1%). 90 (11%) had follow-up outside our system and 431 (51%) had no follow-up due to a clinical contraindication. 55 (7%) have imaging pending and 14 (2%) are awaiting pulmonary evaluation. Of the 302 (25%) patients with providers outside our system, 121 (40%) had followed-up elsewhere. 146 (48%) had no follow-up due to a clinical reason. 35 (12%) providers did not respond to outreach. CONCLUSIONS: We identified 1,202 patients with lung nodules who needed follow-up over a two-year period. Compliance was more successful with providers within our hospital system. We recommend robust surveillance for patients to ensure follow-up is completed and clinical contraindications are well documented.

Are vital sign abnormalities associated with poor outcomes after emergency department discharge?

To examine association between vital sign abnormalities in the emergency department (ED) and early death after ED discharge, we performed a matched case-control study. Conditional logistic regression showed that presence of any vital sign abnormality at ED discharge was significantly associated with over three-fold increase in likelihood of death within 15 days of ED discharge (OR: 3.06, 95%CI: 2.81-4.48). Even small changes were associated with increased risk: every additional beat increase in heart rate conferred additional risk (OR: 1.04, 95%CI: 1.02-1.06), while every additional oxygen saturation percentage point was protective (0.89, 0.80-0.98). However, none of these vital sign abnormalities was a good predictor of early death; there was poor discrimination and substantial overlap in values between cases and controls.