Effective tracking and consistent follow-up on lung nodules and pathology results, including biopsy specimens, are vital components of quality patient care, especially within our medical institution. Given the frequent staff turnover and long rotations of fellows, it’s essential to maintain a standardized and reliable system for tracking these elements. Nodule tracking assists in monitoring patient progression over time and ensuring continuous care, despite healthcare provider changes. Similarly, pathology results and biopsy specimens offer crucial information about a patient’s health conditions, aiding in accurate diagnosis and effective treatment planning. Timely follow-ups on these results determine the success of a patient’s ongoing treatment and management plans. Thus, a robust tracking system and diligent follow-up routines are indispensable to uphold the highest standards of patient care and ensure no patient is overlooked, regardless of staff changes or rotations.

NMCSD Pulmonary Clinic Nodule Tracking Standard Operating Procedure (SOP):

Pulmonary Nodule Tracking is performed through an access database named “The Beast”. This program is used to track nodules and other abnormalities found in imaging, to ensure procedural pathology follow-ups, and generally to streamline and monitor patient care. The SOP defines distinct roles for fellows, staff physicians, nodule coordinators, and clinic corpsman in operating this system. With the help of guidelines provided herein, the SOP aims to make the process of tracking, following up, and administrating the required procedures efficient and effective.

Nodule Tracker/BEAST Overview:

The System is an access database designed for several purposes:

1. Track department procedures: All procedures conducted at NMCSD in the Clinic, Ward, CEC, Operating Rooms, or ICU should be recorded in the System. 
2. Track pathology from procedures: It also tracks the results from the procedures to ensure appropriate progression of patient workups. Some procedures, such as central lines, will not have associated pathology, but most will (BAL, bronchoscopic biopsies, thoracentesis, etc.). The System facilitates tracking to ensure timely and appropriate patient care.
3. Track lung nodules and other abnormal imaging requiring follow-up: This was primarily done by a recently retired civilian and has been in flux since 2022. The aim was to allow providers to input nodule data from CT scans with target dates for repeat imaging; our clinic support staff would then ensure the CT scans were ordered correctly and in time for surveillance imaging.

Rules of The Beast:

1. As an Access Database, only one copy of the beast can be open at once. Do not update the Beast if you receive any error or warning in opening it. Just close it and wait until later.
2. Do not leave the beast open for longer than you need it. When you are done updating whatever needs to be updated, save it and close it to ensure there are no issues.
3. There are multiple versions saved as backups; always work off the version saved most recently.
4. Enter all imaging required dates as the first date of the target month due. For instance, if a patient had a low dose CT done on December 12th 2022 and it was normal, enter the next interval imaging to be obtained on December 1st, 2023. This allows the nodule coordinators to easily generate a batch of monthly due items for action in the nodule messaging pool.

Accessing The Beast:

Accessing The Beast is done through the share drive and it is currently stored in the Pulmonary Department folder.  Notably, Dr. Miller does have to add your CAC certificates for you to gain access.

Nodule/Imaging Tracker User Roles:

Fellows

• Responsibilities: Fellows, along with nodule coordinators, will be the primary persons involved in entering data into The Beast and will have two primary responsibilities:
• Entering their procedures at NMCSD into The Beast.
• Updating and discussing their pending pathology at Friday Conference. This will primarily be the role of the Consult Fellow. Understandably, the consult fellow is not responsible for all pathology from every procedure done as there may be pending pathology from other physicians. However, the overarching goal of the Friday pathology review is to add transparency and a backup mechanism to ensure things are not missed. With that, the Friday pending path review may also simply serve as a reminder to reach out to the responsible physician if there is any pending path that has not been followed up or otherwise actioned.
• Logging completion of Friday Pending Path review in the provided sheet  in the conference room.
• Fellows will also likely add patients for required follow up imaging, however there are other mechanisms to go about doing this as well. This component generally falls more on the “Nodule Tracking” side of The Beast which is not a primary responsibility of fellows (aside from Dr. Foley, who, with Dr. Miller, is the departmental POC for all concerns related to Nodule Tracking).

Staff Physicians

• Responsibilities: As staff physicians are not as involved with procedural data entry, it is likely that they will have far less familiarity with data entry into The Beast. With that, it is generally encouraged that Staff do not attempt data entry or manipulation unless they are familiar with the quirks associated with The Beast (as with everyone who may not be familiar). Primary responsibilities will generally revolve around:
• Ensuring Friday Pending Path review is complete and logged appropriately for oversight.
• Determining next interval imaging for studies obtained by the nodule tracker in lieu of physicians who are not available (rotations, leave, PCS, retirement, etc).

Nodule Coordinators

• Responsibilities: Nodule Coordinators are the primary backbone of the nodule tracking function of the beast. As personnel changes are inevitable, ideally, we will have at least 3 nodule coordinators. HM2 Amaro is currently the only Nodule Coordinator, but it is anticipated that the assigned clinic Nurse will be able to do this as well along with another clinic support staff member. Primary responsibilities revolve around managing nodule tracking workflow:
• Ensuring monthly exams are ordered with patient messages to nodule pool being generated for action.
• Ensuring the nodule pool is calling patients and ensuring the need for required exams are relayed appropriately.
• Supervising the nodule pool to ensure the nodule pool messaging traffic flows in an orderly fashion.
• Monitoring for results when they become available and forwarding the results to the responsible Pulmonologist (or the consult staff if the primary Pulmonologist is unavailable).
• Entering recommended action into The Beast once the imaging has been reviewed by a physician to ensure the monitoring cycle continues.
• Entering new patients into The Beast for required future imaging from Physician messages to the Nodule Messaging Pool.
• Appropriately triaging any issues that arise from our Clinic Corpsman contacting patients in the nodule pool (examples: Inability to contact patient, patient with further questions or confusion, etc).

Clinic Corpsmen

• Responsibilities: Our general clinic corpsman are the primary mechanism by which patients are contacted and made aware of the need to obtain repeat imaging. Primary responsibilities include:
• Calling patients labeled as “A” messages in the nodule pool, ensuring they are made aware of the ordered imaging.
• Changing the Subject of the pertinent message from an “A” Category to a “B” Category once the patient has been contacted. This allows the Nodule Coordinators to easily identify patients that have been contacted and are pending imaging for eventual physician review.
• Bringing any issues with patient contact to the Nodule Coordinators for further action. Examples may be patients who do not answer sequential phone calls and require a certified letter with possible follow-on disenrollment, patients who have questions or who are otherwise confused about why they are being called.

Nodule/Imaging Tracker Workflow Overview:

This is a complex process and will evolve as we find more efficient ways to do things. This section will attempt to outline the SOP for monthly imaging tracking. This section is very granular and is desgned mostly for those involved in nodule workflow as a guide for our clinic operations.

1. A monthly list of due imaging is generated from the “Upcoming Action” button in the beast.
   • This is currently performed by Dr. Foley, but ideally will eventually be transitioned to the Nodule Coordinators once we gain familiarity with the process.
2. Using this monthly list from the best, Nodule Pool Genesis messages are created for each patient who has imaging due.
   • A message is opened for the patient with the Nodule Pool asthe recipicient.
   • The message subject is entered as:  “Month: A. Please contact patient”
     • Example: “August: A. Please contact patient. “
     • Using this standardized subject message, the Nodule Coordinators can easily sort patients by where they are in the process of obtaining imaging.
   • A template is entered into the message with the dot phrase. This template serves to facilitate documentation and ease of communication.  
   • The patient information from the above dot phrase is copied and pasted into the order for the CT (from the “launch orders” tab).
   • The primary responsible pulmonologist is entered for the ordering provider.
   • The order is submitted and the message is sent to the nodule pool.
   • A message titled as “August: A. Please contact patient” arrives in the nodule messaging pool.
3. The clinic Corpsmen will then initiate patient contact with all Nodule Pool Messages that are coded with “A”.
   • The clinic Corpsman will call the patients. A script is available in the dot phrase text to guide them through what to communicate to patients.
   • Another dot phrase is available to our clinic corpsmen. This dot phrase is used to document the results of the patient contact attempt.
     • If the patient answered and the information was successfully communicated to the patient, the Corpsmen documents this with the above dot phrase. The Corpsmen will then forward the message back to the nodule pool, but will change the subject to the following: “Month: B: Patient successfully contacted, pending results”
     • If the patient does not answer, the dot phrase is used to document the contact attempt. The subject is also kept as an “A” code, to signify that the patient has not yet been contacted successfully.
       • If a patient is contacted 3 times unsuccessfully by the information available in the demographics tab, the Corpsmen will bring this to the attention of the Nodule Coordinators for further action (looking for further contact information or progressing to certified letter stating need for imaging).
4. Patient’s complete exams.
5. Nodule Coordinators review all “B” coded exams for the current month.
   • When patient results are available, they forward the message string to the responsible pulmonologist for review.
     • The Nodule Coordinator will change the subject from “B” (Pending imaging) to “C” Imaging completed, pending pulmonologist recs.
     • If the responsible pulmonologist is not available, this is forwarded to the consult staff.
   • The Nodule Messaging Pool is cc’ed on the message to ensure continued visibility.
   • A dot phrase is utilized to standardize the communication. It offers the following three suggested responses:    
     • Resolve and remove from nodule tracker.
     • Continue
     • Schedule for appt.
   • The responsible pulmonologist or consult staff will review the imaging and reply all to the Nodule Pool with the recommendation.    
6. Once the responsible pulmonologist has made their recommendation, the nodule coordinators will:
   • Update the beast as applicable for the next required imaging.
   • Remove the patient from active nodule tracking if applicable.
   • Work to schedule the patient with the responsible provider for determination of the next step in the workup.
     • If the results warrant an appointment, the consult staff may also direct the patient to be scheduled with the consult fellow as the patient may require a procedure for further diagnosis.
   • After completion of step 6, the patient message is deleted from the nodule pool as the entire messaging string has now been saved in their genesis record.

Target goals for nodule tracking on a monthly basis:

• 1st day of the month: The list of exams required for the upcoming month will be ready for action.
  • The list of due imaging from the beast is exported into a stripped down excel sheet for streamlined processing.
• 7^th day of the month: All required genesis messages will be generated for and placed in an “A” status by the nodule coordinators.
• 14^th day of the month: Contact will have been initiated by nodule pool for all patients requiring imaging.

Adding patients for future imaging:

How to add a patient for future imaging:

1. Generate a message to the NMC San Diego Nodule Messaging Pool under the patient’s chart.
2. For Subject, please label the message:
   • “Z. New Patient Who Requires Future Imaging Follow-up”
   • Using the “Z” Designator Code will flag the messages as separate from the general nodule pool tracking messages and allow the Nodule Coordinators to easily locate the message.
3. In the body of the message please state:
   • Month and Year for repeat imaging.
   • Type of imaging required (Low Dose Lung CT, Regular Non-Con CT for repeat nodule assessment, PET CT).
   • Reason for imaging: Lung Cancer Screening
   • If this imaging has been ordered by the primary pulmonologist.