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.