Results
There were 74 cases reported as a panic diagnosis in EMGTRH between
January 2018-2021. 9 patients who had inappropriate contact information
were excluded from this study. A total of 65 patients were included in
this study (Figure 1). The distribution of panic diagnosis of the 65
cases, demographic data, verbally notification status, and reaction time
were presented in supplement data 1.
Of these 65 cases, 23 were males, and 42 were females; the median age
was 52 years [range, 10-85]. One patient had leukocytoclastic
vasculitis, 10 patients had uterine contents without villi or
trophoblasts, and 54 patients had unexpected malignancy. The
distribution of cases that had unexpected malignancy according to
diagnosis was presented in Figures 2-3.
There were 55 cases in the pre-COVID group. Thirty cases’ hospital
admission times were five days or fewer when cases were recruited into
FG, and 25 cases’ hospital admission time was longer than five days when
cases were recruited into SG. The average length of admission to the
hospital was 2.2 days in FG and was 99 days in SG (7-360). The average
age was 47 years in FG and 59 years in SG. The average distance of the
patient’s living area to the hospital was 11 km (1-52) in the FG and 59
km in SG (4-390 km).
There was a statistically significant difference in the average distance
of the patient’s living area to the hospital, age, and notification
status between FG and SG in the pre-COVID group. There was no
statistically significant difference in gender between FG and SG. The
summary of distribution and statistical comparison of age and distance
between patient home and hospital among FG and SG are presented in Table
2.
Among pre-pandemic group cases, forty were verbally informed about panic
diagnosis by phone call, 15 were not able to inform due to wrong phone
number records. The mean time (day) of admission to the hospital of
verbally informed and not verbally informed cases were five days and 156
days, respectively. Our results revealed that receiving verbal phone
notification was significantly associated with patients’ admission to
the hospital time (Table 3). Admission times were on mean about 151 days
longer in a patient in the not verbally informed cases compared to
verbally informed cases in pre-COVID group.
There were 10 cases in the COVID pandemic group. Four cases admission
times were five days or fewer (1-5) and six cases admission time was
longer than five days (16-40). We ascertained that four cases in the
COVID pandemic group were receiving treatment in the home due to
COVID-19 infection at the time of diagnosis.
All cases in the COVID pandemic group were verbally informed about panic
diagnosis by phone call. The mean time (day) of admission to the
hospital was 18.3 days (1-40). Admission times were on mean about 13.3
days longer in verbally informed cases in the COVID pandemic group
compared to verbally informed cases in the pre-COVID group.
Discussion
The concept of critical value in clinical pathology was first described
by Lundberg in 1972 as “Pathophysiological derangements at such
variance with normal as to be life-threatening if therapy is not
instituted immediately.”.12 The critical values in
surgical pathology handled by Pereira et al. approximately thirty years
from this, and they described possible surgical pathology critical value
cases that need immediate communication.1 Over the
years, the concept of critical diagnosis has been adopted by
pathologists, and communication checklists have been added to Laboratory
Accreditation Programs by National Pathology
Societies.2 National pathology societies recommend
that each pathology department should identify potential panic
(unexpected) diagnosis lists and draw up a communication
policy.2
Our panic diagnosis policy has been created according to the national
pathology societies recommend; when a panic diagnosis is detected,
verbal communication provides with the patient’s responsible clinicians
as soon as possible. The information of the clinicians and the
notification time are noted on the panic diagnosis form. When we
sign-out a panic diagnosis report, we indicate the patient as a panic
diagnosed patient over the hospital information processing system
(HIPS). Subsequently, the HIPS sends a notification message to the
system and cell phone of the responsible clinician. The HIPS also sends
an information message to the patient’s phone. We attach importance to
informing the responsible clinicians as well as informing the patients
verbally in the panic diagnosis notification. The patient is only
informed about the pathology report is ready and to admission to the
hospital as soon as possible. No information is given about the
diagnosis.
Most of the panic diagnosis cases were detected in materials sent from
the surgical services department and these clinicians devote most of
their employment period to surgical procedures. If clinicians receive
the panic diagnosis notification during surgical procedures, reaching a
patient’s contact information may take a long time. For this reason, we
prefer to provide verbal information to the patient.
The annual average number of cases in our department was approximately
12000 and panic diagnosis cases accounted for approximately 0.25% of
them. We recorded a significant decrease in the number of cases during
the COVID pandemic. Studies showed that panic diagnosis rates accounted
for 0.5-20% of all cases.13,14 This rate may differ
according to the specific institutional factors, such as the bed
capacity, the organ transplantation unit, and case types. Informing
patients verbally about the diagnosis can cause a serious increase in
the daily workload in centers with a high panic diagnosis reporting
rate.
Several studies indicated that well-timed effective verbal communication
had a beneficial impact on patient’s outcome and treatment
management.5,13 Staats et al. revealed that pathology
laboratories had different approaches to time limitation, such as within
1-hour, same day, or no specific time frame, for communicating with the
clinician.15 We do not have a strict time frame
policy. Most of our cases had unexpected malignancy diagnoses and the
information content is more important than the time of communication.
Therefore, we provide communication between clinicians and pathologists
as soon as possible. Our findings showed that the duration of admission
to the hospital of panic diagnosed patients varied between 1 and 360
days. The prolonged admission time indicates that patients are not
adequately informed about following up pathology reports, even if only
indirectly.
The most important findings of our study were taking a phone
notification has a beneficial impact on admission time. Admission times
were on mean about 151 days longer in the patient in the not verbally
informed group compared to the verbally informed group in the pre-COVID
period. We observed that even if the patients were verbally informed
during the COVID pandemic, they applied to the hospital for a longer
period compared to the pre-pandemic period, five days and 18.3 days,
respectively.
We could not make a notification to fifteen patients since the contact
information in HIPS belonged to different people or was not up to date.
We believe that Informing patients about the process of pathology
reports and reminding them to keep their phone numbers in hospital
records up to date to communicate in possible panic diagnosis situations
may help shorten the admission time.
Many studies revealed that hospital admission for acute medical
illnesses, including stroke and acute myocardial infarction, fell
dramatically with the onset of the COVID-19
pandemic.9-11 The most reasonable explanation for
patients’ attitude is that the limitation of elective surgical
procedures and non-critical health care services and quarantine
procedure made it difficult for patients to access healthcare services
for non- COVID-19 conditions or patients avoided seeking hospital care,
perhaps in response to the fear of COVID-19 infection. Transportation of
patients with COVID-19 to the hospital is provided only through the 112
Emergency Ambulance Service (EAS) in Turkey. EAS evaluates the patient’s
complaints related to infection and decides for the transportation of
patients with COVID-19 to the hospital. Informing the EAS about the
provision of transportation to the hospital in cases of COVID-19
positive panic diagnosed patients may be effective in shortening the
admission time.
In Turkey, doctors and patients can access health data collected from
the health institution, regardless of where the examinations and
treatments are held, via e-nabız that is an application developed by the
Ministry of Health. Cell phone applications such as e-nabız that provide
communication between patients and the health care system, contribute
positively to the country’s health care system. In our country, primary
care can also reach patients in a brief time via e-nabız. Therefore, we
believe that sending automatic messages to family medicine units, which
are primarily responsible for patients with applications such as
e-nabız, can increase the chance of success in reaching the patient in
cases of panic diagnosis. Our hospital has been integrated into this
system in 2020. Due to the small sample size, the effect of this system
on the application period cannot be evaluated clearly.
So far, a limited number of studies have been published on panic
diagnosis. Most of the previous studies focused on the general
recommendation of critical value policy, effective communication of
critical diagnosis, or documentation of possible diagnostic list
considered a critical diagnosis by pathologist or
clinician.13,14,16-20 To the best of our knowledge,
this study is the first attempt at a comprehensive evaluation of factors
that may affect the time of admission to the hospital who reach a panic
diagnosis. Our study has some limitations. This study has retrospective
character in one single center and only provides information about the
duration of hospital admission and trends of patients living around
Erzincan. Therefore, our findings cannot be generalized to the other
population. Nevertheless, we believe that the findings of this study may
be helpful to review the panic diagnosis communication policies of
pathology laboratories. Further research with well-planned multi-centric
studies in larger patient groups may be helpful to contribute to the
development of panic diagnosis policy.