Perspectives and perceptions of urgent and alert values in surgical pathology and cytopathology: A survey of clinical practitioners and pathologists

Abstract

In previous editorials, Chapman and Otis in 2011 and Layfield in 2014 have summarized much of the work responsible for establishing the concept of critical diagnoses in surgical pathology and cytopathology. Both editorials end with a list of 8 key policy points needed for an effective strategy of handling and communicating critical diagnoses. We have developed and distributed a Web‐based survey to elicit clinicians’ attitudes regarding many of those key policy points, such as how, when, and to whom critical diagnoses should be reported; we have allowed some level of collaboration with the clinical staff when developing our communication policies as the Association of Directors of Anatomic and Surgical Pathology (ADASP) consensus statement recommends. We have identified important areas of disagreement between pathologists and clinicians regarding what entities should be considered critical and who should be responsible for correlating histologic findings with the larger clinical context. Identifying these discordant points of view and fostering interdepartmental agreement on the best practices in the communication of critical diagnoses is an important patient care and safety issue. Chapman and Otis have also suggested the importance of increased access to accurate patient information and the clinical history, including the level of clinical suspicion of malignancy, and of forming a periodic review and quality assurance process. Here we explore methods of increasing the ability of pathologists and cytopathologists to identify unexpected diagnoses, including optimization of their workstations for better access to the electronic medical record, and we examine the progress of quality assurance methods in surgical pathology and cytopathology since the ADASP consensus statement in 2012.

Reporting Critical/Urgent/Significant Results in Anatomic Pathology: The Devil Is in the Details

“…If an institution treats both categories exactly the same way, the addition of another category probably serves only to unnecessarily increase complexity of the communication process. Other authors have proposed different terms 21,22 . The ADASP survey found that approximately one-quarter of surveyed institutions used the term critical, another one-quarter used the CAP/ADASP terminology, and almost half of institutions surveyed used another term in their policy 6 …”

“…The ADASP survey, on the other hand, did find some areas of relative agreement 6 . As these 2 studies are the largest multi-institution surveys performed to date, our discussion will focus primarily on these articles; however, other smaller multi-institutional studies have been published with similar findings 7,15 ; in addition, a number of single-institution publications have suggested candidate urgent diagnoses in anatomic pathology or surgical pathology, 2,16,21,22 cytopathology, 9,19,23 pediatric pathology, 10 dermatopathology, 20 and ophthalmologic pathology 24 . The diagnoses typically considered fall into 4 broad categories: malignancy, infection, other diagnoses, and technical/diagnostic issues.…”

“…Other authors have proposed different terms. 21,22 The ADASP survey found that approximately one-quarter of surveyed institutions used the term critical, another one-quarter used the CAP/ADASP terminology, and almost half of institutions surveyed used another term in their policy. 6 There is limited evidence that terminology might have an impact on achieving consensus between pathologists and clinicians as to what constitutes an urgent diagnosis requiring special communication.…”

Critical value in surgical pathology: evaluating the current status in a multicenter study

“…As there were no established criteria for critical or unexpected results in the studied centers, a multiple-choice questionnaire was developed. The list of diagnoses was chosen by the authors according to previous surveys and the authors' experience to represent diagnoses that might be critical [ 3 , 6 – 10 ] (Table 1 ).…”

“…It is also known as "critical diagnosis," "urgent diagnosis," and treatable, immediately life-threatening diagnosis." Regardless of the attributed terms, an immediate report to a healthcare provider is necessary for taking the required medical actions [ 3 ].…”