Antipsychotics are frequently used for inpatients with alcohol withdrawal syndromes (AWS). While there is evidence on the effects of these medications in other settings there is little data on the mortality rate associated with these drugs for the treatment of AWS) We utilized the national COSMOS Epic database to identify inpatients with AWS. We then assessed the mortality rate for adult patients with or without the use of anti-psychotics along with subsets of patients based on age, gender, race, and ethnicity. We identified 233,821 patients of whom 26% received antipsychotic agents. The mortality rate was 1.5%. Patients aged 60 or over and those who received typical antipsychotic agents had a higher mortality rate. The use of typical antipsychotic agents is associated with a higher mortality rate. The use of any antipsychotic agent in patients aged 60 or over is associated with an increased mortality rate. Further study of this effect is warranted.

Introduction: Prescribing of buprenorphine and naloxone in the emergency department (ED) has been shown to be an effective intervention. The purpose of this study was to determine the frequency of prescribing of naloxone and buprenorphine and the sub-groups that may be more or less likely to receive treatment. Methods: We used a national electronic health record database to identify patients with opioid poisoning or overdose presenting between January 2019-December 2021. Patients who were prescribed naloxone or buprenorphine were identified in this dataset and then further segmented based on self-identified gender, age, racial and ethnic identity, income categories, and social vulnerability index in order to identify sub-groups that may be less likely to be prescribed treatment. Results: We found 74,004 patients in the database whom we identified as presenting to the ED with an opioid poisoning or overdose. Overall, 22.8% were discharged with a prescription for naloxone, while 0.9% of patients were discharged with buprenorphine products. Patients were less likely to receive naloxone prescriptions if they were female, White or Pacific Islander, non-Hispanic, not between the ages of 18-65, and non-English speaking. We found the same pattern for buprenorphine prescriptions except that the results were not significant for ethnicity and English-speaking. Conclusion: Despite evidence supporting its use, buprenorphine is not prescribed from the ED in a substantial proportion of patients. Naloxone is prescribed to a higher percentage, although still a minority of patients receive it. Some sub-groups are disadvantaged in the prescribing of these products. Further study may assist in improving the prescribing of these therapies.

A 66-year-old, right-handed man presented to the emergency department (ED) reporting the perception of hearing speech “in fast forward.” The perception was intermittent; episodes lasted for a few minutes and occurred without clear triggers.

Introduction: Patients with opioid use disorder (OUD) are commonly admitted to various inpatient services where treatment can be started. The typical initiation of buprenorphine involves delay of treatment until withdrawal symptoms occur, however, those symptoms may interfere with other medical therapy. The purpose of this study was to evaluate the safety and efficacy of initiation of buprenorphine for inpatients with OUD. Methods: We reviewed the charts of 99 patients for whom the inpatient addiction medicine consult service was contacted over a 15-month period from January 2020 to identify those patients started on buprenorphine. We abstracted data on toxicology results, prior use of buprenorphine, and Clinical Opioid Withdrawal Scale (COWS) and pain scores before and after the administration of buprenorphine. Results: There was no significant difference in COWS classification post treatment based on ancillary or non use of full agonist therapy. There was no significant change in COWS scores based on prior buprenorphine or methadone use. 5% of patients developed moderate withdrawal (COWS score 12-24) after the initiation of buprenorphine. Twenty of the study patients (20%) developed a 2-point increase in pain scores after the initiation of buprenorphine. The initiation of buprenorphine for inpatients rarely results in a significant increase in withdrawal symptoms. A larger percent of patients may have an increase in pain scores which would need to be managed. Further prospective work on this subject is warranted.

OBJECTIVE:Medications for alcohol use disorder (MAUD) are thought to be underused in the United States. This study reviewed data from a national database to determine the frequency of prescribing MAUD for patients admitted to the hospital or discharged with alcohol withdrawal syndromes (AWS). METHOD:We searched for hospital admissions from 2019 to 2021 in the Epic Cosmos database associated with an active diagnosis of AWS. We then searched for patients prescribed medications approved for therapy. We reviewed 197,375 admissions with an active diagnosis of AWS. RESULTS:There was an increasing percentage of admissions for AWS from 2019 to 2021. Overall, only 7% of patients were prescribed MAUD at discharge. Naltrexone was the most prescribed MAUD. Women, non-African Americans, Latinos, and patients under 65 were more likely to be prescribed MAUD. CONCLUSIONS:Many patients with AWS during admission are not prescribed MAUD at the time of discharge.

OBJECTIVES: Results of pre-post intervention studies of sepsis early warning systems have been mixed, and randomized clinical trials showing efficacy in the emergency department setting are lacking. Additionally, early warning systems can be resource-intensive and may cause unintended consequences such as antibiotic or IV fluid overuse. We assessed the impact of a pharmacist and provider facing sepsis early warning systems on timeliness of antibiotic administration and sepsis-related clinical outcomes in our setting. DESIGN: A randomized, controlled quality improvement initiative. SETTING: The main emergency department of an academic, safety-net healthcare system from August to December 2019. PATIENTS: Adults presenting to the emergency department. INTERVENTION: Patients were randomized to standard sepsis care or standard care augmented by the display of a sepsis early warning system–triggered flag in the electronic health record combined with electronic health record–based emergency department pharmacist notification. MEASUREMENTS AND MAIN RESULTS: The primary process measure was time to antibiotic administration from arrival. A total of 598 patients were included in the study over a 5-month period (285 in the intervention group and 313 in the standard care group). Time to antibiotic administration from emergency department arrival was shorter in the augmented care group than that in the standard care group (median, 2.3 hr [interquartile range, 1.4–4.7 hr] vs 3.0 hr [interquartile range, 1.6–5.5 hr]; p = 0.039). The hierarchical composite clinical outcome measure of days alive and out of hospital at 28 days was greater in the augmented care group than that in the standard care group (median, 24.1 vs 22.5 d; p = 0.011). Rates of fluid resuscitation and antibiotic utilization did not differ. CONCLUSIONS: In this single-center randomized quality improvement initiative, the display of an electronic health record–based sepsis early warning system–triggered flag combined with electronic health record–based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions.

It is estimated that about 8% of patients with alcohol use disorder develop withdrawal symptoms when admitted to the hospital. There are a variety of medications typically used for alcohol withdrawal syndrome (AWS) and the purpose of this study was to assess patterns of medication use for inpatients with an AWS. We searched the Explorys IBM Watson Health Database for patients coded with AWS and an inpatient encounter from the years 2016 to 2019. We then searched for medication use associated with the admission focusing on benzodiazepines, barbiturates, antiepileptics, haloperidol, clonidine, and baclofen. During the 4-year study analysis, we identified 96,050 inpatients. Benzodiazepines were used in a number greater than the number of inpatients suggesting the use of multiple agents. The antiepileptics were used sparingly varying from 2% to 14% by an agent. Clonidine was used in 42% of patients and haloperidol in 44% of patients. Phenobarbital was rarely used. Baclofen was used in the same frequency as some of the antiepileptics. In summary, adjunctive agents with literature support such as carbamazepine were used sparingly. Many patients receive clonidine and haloperidol. Opportunities seem to exist to expand the use of adjunctive agents.

Introduction Smoking cessation has significant health benefits, and the emergency department (ED) can be an important venue for smoking cessation counseling. Nicotine replacement therapy with transdermal patches has been shown to be associated with smoking cessation in a variety of studies. This study evaluated fulfillment rates for prescriptions for nicotine replacement transdermal patches (NRT-P) from the ED. Methods We conducted a retrospective review of all patients receiving a prescription for a NRT-P product from January 2018–October 2019. Charts were reviewed to gather data including age, gender, presence of chronic heart or lung problems, and health insurance. We assessed the fulfillment rate of prescriptions using the Surescripts system, which is a functionality within our electronic health record system that queries participating pharmacies. Statistical analysis was conducted to determine associations between fill rates and the other variables collected from charts. Results We had follow-up on 500 patients prescribed nicotine patches. Of those patients, 44% filled their prescriptions. Those who filled their prescriptions were more likely to be female and have a history of chronic lung disease. Self-pay patients were least likely to fill their prescriptions. Overall, we had evidence of smoking cessation in 13% of patients. Conclusion This study found that a substantial proportion of patients fail to fill their NRT-P prescriptions. Further work on means of enhancing fulfillment rates is warranted.

A 58-year-old woman presented with gum bleeding, hematuria, and cutaneous ecchymoses. Left hip replacement had been performed five years prior. The overall findings of our work-up were consistent with ongoing DIC triggered by the presence of an arterio-venous left femoral fistula. The patient was treated successfully with fresh frozen plasma, the fistula was surgically repaired and a stent was placed. On the second day, bleeding had resolved and laboratory values reverted to normal. This uncommon scenario is reminiscent of the Kasabach–Merritt syndrome and well illustrates that patients with an arterio-venous fistula can sometimes present with atypical features. The Kasabach-Merritt syndrome is reported in pediatric and adult patients with giant hemangiomas and angiosarcomas. Adult cases are described also in association with hematomas and large vascular aneurysms. The underlying pathophysiology is the sequestration and consumption of platelets and clotting factors with uncontrolled formation of microthrombi within the vascular lesion. DIC and a microangiopathic hemolytic anemia can subsequently develop. Mechanistic pathways of the Kasabach-Merritt syndrome in the context of a vascular fistula are shared with the more common causes of the syndrome. We speculate that the endothelial dysfunction and injury caused by the flow shear were the pivotal triggers of the aberrant trapping of platelets, the consumptive coagulopathy, and the formation of microthrombi within the fistula. Mortality rate can be as high as up to 40%. The Kasabach-Merritt syndrome could represent the only clinical feature of an otherwise occult vascular fistula. Emergency physicians should be aware of this condition.

Previous studies have shown that thoracic ultrasound is both highly sensitive and specific for the diagnosis of pneumothorax. In the out-of-hospital setting, the ability to auscultate the lungs is frequently limited due to the presence of ambient noise. The decision to perform a thoracic procedure will therefore be based on limited information. The effect of thoracic ultrasound on medical decisionmaking in the out-of-hospital setting is unknown. In this study, we sought to evaluate the effect of thoracic ultrasound on medical decisionmaking during helicopter scene runs.

Study Objectives: The American College of Radiology lists oral contrast as an institution-specific option in the evaluation of right lower quadrant pain. Previous literature indicates that an accurate assessment for appendicitis can be made by CT using IV contrast alone, with significant time savings from withholding oral contrast. Before 2010, the protocol for CT use in the evaluation of possible appendicitis or undifferentiated abdominal pain routinely included oral contrast. The purpose of this study was to determine the incidence of repeat CT scans with oral contrast for the purpose of arriving at a final disposition in patients undergoing evaluation for abdominal pain. This analysis was also to determine if the general surgery service was willing and able to make accurate clinical determinations to operate without the use of oral contrast.Methods: Consecutive abdominal CTs for nontraumatic abdominal pain were evaluated retrospectively over a 7-month period from January through July 2010. CT scans performed for evaluation of trauma were eliminated, as were cases in patients with known previous appendectomy or in cases in which appendicitis was not a consideration. Follow-up was by chart review over the ensuing 30 days for complications or need for surgery, which was not detected after the initial CT scan. The study was conducted at a teaching hospital, level I trauma center with an annual ED census of 99,000 visits.Results: A total of 311 CT scans met the study criteria. No cases of appendicitis were missed. Two patients were operated on based upon inflammatory findings in the right lower quadrant, one with typhlitis, the second with possible inflammatory bowel disease versus typhlitis. In each case, the diagnosis was made by CT, but the surgery service chose to operate based on clinical findings. Sixteen (5.14%; 95% CI, 3.2%-8.2%) cases of acute appendicitis were accurately identified. A normal appendix was visualized in 125 (40.2 %; 95% CI, 34.9-45.7) patients. No patients (0%; 95% CI, 0%-1.2%) required a repeat CT scan with oral contrast as part of the workup. On 30-day follow-up by chart review, no (0%; 95% CI, 0%-1.2%) significant surgical problems were identified, and no cases of missed appendicitis were identified.Conclusions: Abdominal CT scan without the use of oral contrast is accurate to allow for appropriate decision making by emergency physicians and general surgeons. In our series, no patients required repeat scanning. Further assessment by larger studies is appropriate.

Objective: To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.Methods: The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 - 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).Results: Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P <=.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P,. 001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.Conclusions: A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

Background Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition. Objective Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements. Discussion Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode—regardless of severity—is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as "possible anaphylaxis," it is generally better to err on the side of caution and administer epinephrine. Conclusion We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.

Evidence indicates that there is a substantial inflammatory component associated with COPD and that this inflammation is increased during the acute exacerbation. The role of inhaled steroids in COPD has been established through a variety of studies. Inhaled steroids are most effective when given in conjunction with long-acting beta agonists. In those circumstances, patients have an improvement in quality of life, lessening of dyspnea, reduced use of rescue medications, and, in some studies, fewer exacerbations. The side effects associated with inhaled steroid use include an increase in the incidence of pneumonia and cataracts. National recommendations are for the use of inhaled steroids only in conjunction with a long-acting beta agonist.

Background Morphine and fentanyl are both frequently used in prehospital trauma patients, but due to limited formulary size, we sought to study whether both drugs should be included. Objectives The purpose of this study was to evaluate the effectiveness and safety of fentanyl as compared to morphine for patients requiring analgesic medications for a traumatic injury during transport via a physician-staffed air medical service. Methods Trauma patients were grouped by even and odd days (even - morphine 4 mg, odd - fentanyl 50 μg). Patients were excluded based on age (< 18 or > 64 years), hypotension, inability to communicate a pain score (intubated), or known allergy to the study drugs. During the flight, medical crew assessed numeric pain score, vital signs, and incidence of pruritis or nausea. Results There were 103 patients enrolled in the morphine arm and 97 patients in the fentanyl arm. The mean pain score at the beginning of enrollment was 8.0 ± 2.0 in the morphine arm and 8.0 ± 1.8 in the fentanyl arm. The mean final pain score was 5.8 ± 2.7 in the morphine arm and 5.5 ± 2.4 in the fentanyl arm (n.s. by either t-test or non-parametric testing). There was no significant difference in analgesia between fentanyl and morphine. There were no significant differences in the incidence of pruritis or vomiting between the two groups. Average transport time was 37 ± 8 min in the morphine group, and 43 ± 11 min in the fentanyl group. Average number of morphine doses was 3 ± 1.2. For fentanyl, average number of doses was 3 ± 1.3. Conclusion In our study, there was not a significant difference in analgesic effectiveness between morphine and fentanyl. There was no significant difference in the incidence of adverse effects between the two drugs. Our study suggests that either drug can be used safely with equivalent effectiveness.

BACKGROUND:Controversy exists regarding the need for contrast agents for emergency abdominal computed tomography (CT).OBJECTIVES:We surveyed United States (US) academic Emergency Departments (EDs) to document national practice. We hypothesized variable contrast use for abdominal/pelvic CT, including variance from the American College of Radiology's (ACR) Appropriateness Criteria(®), an evidence-based guideline.METHODS:A survey was sent to physician leaders of US academic EDs, defined as primary site of an Emergency Medicine residency program. Respondents were asked about their institutions' use of oral, intravenous (i.v.), and rectal contrast for various abdominal/pelvic CT indications. Responses were compared with the approach given the highest appropriateness rating by the American College of Radiology.RESULTS:One hundred and six of 152 (70%) surveys were completed. Intravenous contrast was the most frequently cited contrast. At least 90% of respondents reported using i.v. contrast in 12 of 18 indications. Oral contrast use was more variable. In no indication did ≥90% of respondents indicate use of oral contrast, and in only two indications did ≥90% avoid its use. Rectal contrast was rarely used. The most common indications for which no contrast agent was used were suspected renal colic (79%), viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%).CONCLUSIONS:Contrast practices for abdominal/pelvic CT vary nationally, according to a survey of US academic EDs. For multiple indications, the contrast practices of a substantial number of respondents deviated from those recommendations given the highest clinical appropriateness rating by the American College of Radiology.

IN THIS ISSUE OF JAMA, FEE AND COLLEAGUES 1 REPORT data from the 2008 National Hospital Ambulatory Medical Care Survey evaluating the ability of emergency departments at safety-net hospitals to comply with parameters for time to disposition for both admitted and discharged patients. Based on analysis of nearly 25 000 patient visits, including 11 065 visits at safety-net hospitals and 13 654 visits to non–safety-net emergency departments, there were no significant differences for compliance with proposed length-of-stay measures for admitted patients (median, 269 minutes vs 281 minutes) or discharged patients (median, 156 minutes vs 148 minutes) for safety-net emergency departments and non–safety-net emergency departments, respectively. However, there were associations between longer emergency department length of stay and several subgroups examined, including patients of nonwhite race, those with lower triage acuity, and type of treating clinician (eg, resident/intern). The question of length of stay as a performance measure is important because of concerns about disparity of care because safety-net hospitals serve a disproportionate share of minority, uninsured, or underinsured patients. The authors indicate that their aim was to evaluate the performance of emergency departments in meeting length of stay criteria. But it is here that concerns among emergency physicians begin. A common mantra among the emergency medicine community is that length of stay is a hospital problem and not an emergency department problem. There is evidence that this is partially true. The modern emergency department faces challenges that exceed those of past years. On the one hand, beneficial improvements in medical knowledge have led to life-saving or life-changing therapies and interventions to treat patients with myocardial infarction, stroke, and trauma, and other acute disease processes. Some treatments are time dependent, leading to pressure on already-busy clinicians to prioritize the care of some complex patients over others. Public disclosure of time to treatment has led to improvements in some of these parameters but at a cost of hurried decision making. The pay for performance measures provide incentives for hospitals to improve services and demand rapid action by their emergency department staff. Yet some of these efforts may have unintended consequences. For instance, the increased use of antibiotics for pulmonary conditions other than pneumonia was hypothesized to have occurred so that clinicians could meet the time-to-treatment performance measure for pneumonia reported to Centers for Medicare & Medicaid Services. Both structural and clinical issues contribute to the complexity of measuring quality in the emergency department. Emergency department visits have continued to increase by an estimated 25% over a 10-year period, along with an estimated 5.6% increase more in 2008, the latest year for which estimates are available. The largest increase in emergency department visits occurred among middle-aged adults and patients insured by Medicaid. At the same time, the number of emergency departments has decreased by 27% over the 20-year period up to 2009. Although the proportion of patients requiring admission has remained stable, the absolute number of patients who require admission has increased, yet the number of staffed inpatient beds decreased by 1.2% from 2004-2009. Among the more challenging patients for whom emergency physicians must find a disposition are those patients with mental health symptoms, who now account for almost 12.5% of all visits. Pressures on throughput come from complex critically ill or injured patients who require extensive testing that is most expeditiously performed out of the emergency department. Additionally, the proposed financial penalties associated with readmissions will lead hospitals to expect greater efforts in the emergency department to avoid placing these patients back on the inpatient units. As noted by Fee et al, efforts in other countries to address emergency department overcrowding and length of stay have had mixed effects. The United Kingdom had failed experiments in reducing volumes through the use of nurse

IN THIS ISSUE OF JAMA, FEE AND COLLEAGUES 1 REPORT data from the 2008 National Hospital Ambulatory Medical Care Survey evaluating the ability of emergency departments at safety-net hospitals to comply with parameters for time to disposition for both admitted and discharged patients. Based on analysis of nearly 25 000 patient visits, including 11 065 visits at safety-net hospitals and 13 654 visits to non–safety-net emergency departments, there were no significant differences for compliance with proposed length-of-stay measures for admitted patients (median, 269 minutes vs 281 minutes) or discharged patients (median, 156 minutes vs 148 minutes) for safety-net emergency departments and non–safety-net emergency departments, respectively. However, there were associations between longer emergency department length of stay and several subgroups examined, including patients of nonwhite race, those with lower triage acuity, and type of treating clinician (eg, resident/intern). The question of length of stay as a performance measure is important because of concerns about disparity of care because safety-net hospitals serve a disproportionate share of minority, uninsured, or underinsured patients. The authors indicate that their aim was to evaluate the performance of emergency departments in meeting length of stay criteria. But it is here that concerns among emergency physicians begin. A common mantra among the emergency medicine community is that length of stay is a hospital problem and not an emergency department problem. There is evidence that this is partially true. The modern emergency department faces challenges that exceed those of past years. On the one hand, beneficial improvements in medical knowledge have led to life-saving or life-changing therapies and interventions to treat patients with myocardial infarction, stroke, and trauma, and other acute disease processes. Some treatments are time dependent, leading to pressure on already-busy clinicians to prioritize the care of some complex patients over others. Public disclosure of time to treatment has led to improvements in some of these parameters but at a cost of hurried decision making. The pay for performance measures provide incentives for hospitals to improve services and demand rapid action by their emergency department staff. Yet some of these efforts may have unintended consequences. For instance, the increased use of antibiotics for pulmonary conditions other than pneumonia was hypothesized to have occurred so that clinicians could meet the time-to-treatment performance measure for pneumonia reported to Centers for Medicare & Medicaid Services. Both structural and clinical issues contribute to the complexity of measuring quality in the emergency department. Emergency department visits have continued to increase by an estimated 25% over a 10-year period, along with an estimated 5.6% increase more in 2008, the latest year for which estimates are available. The largest increase in emergency department visits occurred among middle-aged adults and patients insured by Medicaid. At the same time, the number of emergency departments has decreased by 27% over the 20-year period up to 2009. Although the proportion of patients requiring admission has remained stable, the absolute number of patients who require admission has increased, yet the number of staffed inpatient beds decreased by 1.2% from 2004-2009. Among the more challenging patients for whom emergency physicians must find a disposition are those patients with mental health symptoms, who now account for almost 12.5% of all visits. Pressures on throughput come from complex critically ill or injured patients who require extensive testing that is most expeditiously performed out of the emergency department. Additionally, the proposed financial penalties associated with readmissions will lead hospitals to expect greater efforts in the emergency department to avoid placing these patients back on the inpatient units. As noted by Fee et al, efforts in other countries to address emergency department overcrowding and length of stay have had mixed effects. The United Kingdom had failed experiments in reducing volumes through the use of nurse

Vol. 19, No. 3 March 2012 JCOM 111 AbstrAct • Objective: To report on a quality assurance program to improve communication with regard to radiologic findings. • Methods: Quality improvement report. • Results: Incidental findings requiring follow-up are common occurrences, particularly for thoracoabdominal CT scans. We found that many of these findings do not have a follow-up plan documented in the medical record. We significantly improved the rate of documented communication using technology that recognizes text strings in the radiology report. • Conclusion: An automated system of recognizing incidental findings notations in the radiology reports through an electronic medical records system that generated reports to clinicians and letters to patients improves patient safety.