Incidental Findings in Trauma Patients: How Big is the Challenge?

The purpose of this study was to examine the prevalence of incidental findings (IFs) identified during workup of trauma patients and the effectiveness with which they were documented and communicated.

We performed a retrospective analysis of all trauma patients ≥15 y of age in 2018, who underwent at least one computed tomography scan. Patients' Electronic Medical Record was reviewed for the presence of IFs. IFs were classified in three categories: category 1, which includes highly significant findings requiring attention during hospitalization; category 2, which warrants attention in an outpatient basis; and category 3, which includes nonsignificant findings that require no follow-up.

836 patients were identified, of which 582 had at least one IF. Of the patients with IFs; 14 (2.4%) were category 1, 138 (23.7%) were category 2, and 569 (97.8%) met category 3 criteria. All category 1 patients received appropriate documentation of their IFs. Of patients with category 2 findings, only 13% had documentation of the IFs. Patients with IFs had longer length of stay (P: 0.04) and lower probability of being discharged to home (P < 0.01) compared to patients with no IFs. Only 12.5% of the patients admitted to trauma surgery service received an outpatient follow-up.

There was timely documentation and intervention for all patients with category 1 IFs. However, 87% of patients with category 2 IFs had inadequate documentation of the IF and outpatient follow-up. Outpatient follow-up of IFs poses a challenge for trauma patients partially due to their discharge disposition.