Relay Delays

PSRS has received reports related to clinical referrals for various procedures such as sleep studies, colonoscopies, audiology evaluations, and others. The following reports describe two common threads leading up to events: (1) long delays in outpatient scheduling tests; and (2) patients lost-to-follow-up during the procedure scheduling process. 

The excerpts below are from five different PSRS reports received from VA staff.

Sleep Study Relay Delays

Two physician reports describe events related to the scheduling of sleep studies. The first reporter states:

• Patient with [marked] sleep apnea — very symptomatic — no test done after 2 consults...This is a... system lapse...to perform tests for a patient at risk of CHF, MI, arrhythmia...

The second physician reporter describes a patient with symptoms of sleep apnea who was lost to follow-up. The reporter states there was no follow-up contact with the patient who forgot and missed the appointment.

Colonoscopy Relay Delays

Three additional reporters expressed their concern when requesting colonoscopies. The third physician reporter discussed a lengthy delay in obtaining a colonoscopy procedure for a patient. In the PSRS analyst callback, this reporter revealed that the Primary Care Physician did order the consult. It is unknown where the message was relayed. This delay could have potentially complicated the patient’s underlying condition.

A fourth physician reporter described another prolonged delay in a colonoscopy consult which appeared to be a clerical oversight as a result of the CPRS ordered consult.

A fifth physician describes a number of contributing issues when GI consults were submitted to GI Service:

• This is one example of many. Issues: 1. Subspecialty availability. 2. Failure to outsource to private sector. 3. Lack of tracking mechanism in CPRS. I have learned the hard way. You have to do this in your own paper record.   

In the PSRS analyst callback with the reporter, this reporter went on to say that there was a backlog of numerous GI consults.

These reports reveal the importance of tracking and following up on consults or referrals. A phone call from the referring physician to the consulting service often ensures a successful referral, particularly in urgent cases. 

There are relatively few articles that address being lost-to-follow-up, and the scheduling process. Frequency for how often patients are lost-to-follow-up and their causes are varied. In one study of asymptomatic patients with positive fecal occult blood test, 41% did not receive follow-up testing(1). Another study looked at women with abnormal pap tests found that 41.1% of the women were lost-to-follow-up and that communication issues were the major reason(2). Other studies show smaller percentages of patients being lost-to-follow-up. Some of the reasons cited include socioeconomic factors, psychiatric issues, work commitments, and lack of symptoms(3-9). The impact on outcomes of being lost-to-follow-up is difficult to assess. It is clear that being lost-to-follow-up is a problem, and communications issues play an important role. PSRS is preparing an analysis that will be available later this year of how communications impact patient safety.....so stay tuned!

There are many tools that can potentially be used to identify the issues and prevent relay delays such as the Root Cause Analysis (RCA) process. You can learn more about RCA’s from your Facility Patient Safety Manager. In addition, please continue to share these reports with PSRS!

(1) Etzioni, D.A., et. al. (2006). Measuring the Quality of Colorectal Cancer Screening: The Importance of Follow-Up. Dis Colon Rectum.

(2) Thinkhamrop, J., et. al. (1998). Loss to follow-up of patients with abnormal Pap smear: magnitude and reasons. J Med Assoc Thai, Nov; 81(11):862-5.

(3) Zunzunegui, M.V., et. al. (2001). Loss to follow-up in a longitudinal study on aging in Spain. J Clin Epidemiol, May; 54(5):501-10GRIS.

(4) Lim, L.E., et. al. (1995). Why patients fail to attend psychiatric outpatient follow-up: a pilot study. Singapore Med J., Aug; 36(4):403-5.

(5) Donnelly, S., et. al. (1991). Analysis of patients lost to follow up at a sarcoid clinic. Sarcoidosis, Mar; 8(1):45-50.

(6) Fischer, E.H., et. al. (2001). Characteristics of people lost to attrition in psychiatric follow-up studies. J Nerv Ment Dis., Jan; 189(1):49-55.

(7) Gladman, D.D., et. al. (2000). Lost-to-follow-up study in systemic lupus erythematosus (SLE). Lupus., 9(5):363-7.

(8) Piccoli, G.B., et. al. (2003). Lost to follow-up: the bottleneck of early referral to renal units? Med Sci Monit., Nov; 9(11):CR493-9.

(9) Korsgaard, M., (2005). Diagnostic delay, symptoms and stage of colorectal cancer. Dan Med Bull., Dec; 52(4):255.  

Did you know that PSRS encourages reporters to submit reports describing local solutions/safety ideas so that we can share them with VA staff nationwide? This physician reporter suggested a fix to CPRS that was successfully applied at their local facility:

• The order was signed by the [attending] physician today... the pharmacist goes into CPRS and looks into the detail of the order. The pharmacist realizes that the order signed and issued today was originally entered [by the same physician when this physician was a resident].

During the PSRS analyst callback, this reporter shared a local solution. The reporter states that they reviewed the CPRS situation at their facility and found other old, unsigned (unreleased or unfinished) POE med/patient orders that remained in the computer and that could be activated. The medical executive board took action to develop a policy which places a life-span limit on all unsigned med orders and authorizes pharmacy service (pharmacists) to “kill” unsigned orders exceeding this period of time.

The reporter explained that the unsigned and unreleased orders that exceed the time limitation could be electronically placed in a “separate file” or could be deleted altogether. This reporter believes a time limitation policy similar to that locally adopted would resolve this POE computer problem at other VA facilities.

A nursing assistant sent a report to PSRS describing a policy change at their facility as a result of an event. As described in the PSRS analyst callback, the reporter works on a combined locked unit with both general psych and dementia patients. The reporter stated that non-clinical staff frequently feed patients if they want food. However, in this case, the involved patient was a known “choker” and indeed did choke on food fed to them by non-clinical staff. 

The reporter stated that the local facility issued a new written policy related to this event: [non-clinical staff] may no longer give food or drink to patients. The reporter also noted that staff should be aware that even patient’s families who visit a unit may try to feed other nearby patients. The reporter is not aware of a national policy on this issue.