- Email: [email protected]
Accident and emergency reporting in UK teaching departments
Clinical Radiology (1990) 41, 264-267
Accident and Emergency Reporting in UK Teaching Departments I. BEGGS and J. K. DAVIDSON*
Departments of Radiology, Royal Infirmary, Edinburgh and * Western Infirmary, Glasgow A survey of 44 UK training departments shows that trainee radiologists commence accident and emergency (A & E) reporting after an average of 10.2 months in radiology and perform a considerable proportion of the A & E reporting workload. Most respondents consider that they supervise junior staff but only 11 departments directiy check their work and only two departments offer supervision to staff with more than 2 years' experience. AH A & E radiographs are reported in 79.9% of hospitals and the other hospitals operate selective reporting policies. The delay between the radiographic examination and the radiology report reaching the A & E department is less than 48 hours in about twothirds of departments when the examination is performed Monday to Friday, but exceeds 48 hours in two-thirds of departments when it is performed at weekends. Misinterpretation of radiographs is one of the commonest errors in A & E. Improved supervision of less experienced trainees is required. Consultants should contribute and one should be responsible for this area. Radiological conferences are important and the secretarial services require major improvement.
Accident and Emergency (A & E) reporting is a major part of the workload of many radiology departments. Craig (1985, 1989) underlined the need to provide an adequate A & E reporting service. Nearly 9% of all medical litigation cases involve radiology, although radiologists may not be directly involved, and nearly 80% of these cases relate to trauma. Almost 40% of medical negligence cases, which directly involve radiologists, relate to trauma. Difficulties with A & E reporting are not new (Aberdour, 1976; de Lacey et al., 1980: Wardrope and Chennells, 1985; Gleadhill et al., 1987) and must be set against a background of inadequate radiological staffing (Brindle, 1986), a workload which is increasing inexorably at a faster rate than the expansion of radiological staffing (Ross and Craig, 1984) and the introduction of new techniques which often consume much radiological time. Berman et al. (1985) recently surveyed A & E reporting and suggested that many patients are at risk from mistakes which can be attributed to staffing problems. They excluded radiology teaching departments from consideration because they did not consider the A & E reporting workload to be a problem in such departments. We considered that teaching and non teaching departments are subjected to the same pressures and decided to survey the former. MATERIALS AND METHODS We sent a questionnaire to 77 British radiology training departments. The questionnaire asked: Correspondence to: Ian Beggs, Department of Radiology, Royal Infirmary, Edinburgh EH3 9YW.
The total annual numbers ofA & E attendances and A & E radiographic examinations. The proportion of A & E reporting undertaken by registrars, senior registrars and consultants. The radiological experience before starting A & E reporting. The nature of junior staff supervision. The requirements to provide an adequate A & E reporting service. If a comprehensive A & E reporting service is provided and, if not, what selection criteria are used. Time intervals between radiographic examination, dictation of radiologist's report and receipt of report by A & E department. RESULTS Fifty-three departments (68.8%) responded. Four declined to complete the questionnaire because they lacked junior staff or an A & E department. Four completed the questionnaire but had no junior staff and were therefore excluded as was another department which returned a substantially incomplete questionnaire. We therefore had 44 questionnaires (57.1%) for analysis. (We included some questionnaires which had minor omissions, grouped different categories together or supplied information in a different form to that requested.) The annual number of A & E attendances ranged from 21 000 to 132 000, mean 56 000. The annual number of radiographic examinations varied from 12 000 to 73 000, mean 28 000. The proportion ofA & E attenders who had a radiographic examination ranged from 30-72%, mean 48%. Radiological Experience Needed to Start A & E Reporting
Trainees start A & E reporting after an average of 10.2
Table 1 - Radiological experience (in months) required to start A & E reporting (* = one department requires 4 months in radiology and success in a test of A & E reporting) .__..-
Months
Number
0 13 3-6 6-9 9-12 12-18 18 24 24-36 36 'depends'
3 3 5* 7 3 13 5 2 1 2
265
A & E REPORTING IN UK TEACHING DEPARTMENTS
Table 2 - A & E reporting workload and supervision Experience in radiologY in months
Number
Work checked by more experienced radiologist
Table 3 - Time interval from radiographic examination to receipt of radiology report in A & E
A & E workload Range
Mean
10-20% 3 45% 5-95% 5 100% 5 40% 5-90% 5-80%
17.5% 36% 49% 30% 26%
Mon-Fri 0900-1700
Mon Fri 1700 0900
Weekend 1700 Fri-O9OO Mon
Immediate Under 24 hours 24-48 hours 2-7 days Over 1 week Not known
3 10 11 11 1 0
1 7 14 12 1 1
1 2 9 21 1 2
Total
36
36
36
f
0 1-6 6-12 12-24 24-36 36/SR Consultant
3 7 18 29 23 33 33
3 .7 6 4 2 0 0
months in radiology. In about two-thirds of departments they start between 3 and 18 months (Table 1). Only two departments take previous experience into account. Nine departments would prefer their ti'ainees to have more experience in radiology and four departments would prefer less.
Radiological Experience and Proportion of A & E Reporting Many respondents grouped categories together and some questionnaires were incomplete. Where we have information about a particular grade we have calculated the amount of work done by that grade. The percentages we give apply only to the departments which provided information about that particular grade and are not valid as overall percentages (Table 2).
Supervision Twenty-seven departments consider that they supervise junior staff, 15 do not and two did not answer. In 11 departments the work is checked by a more experienced radiologist. In the other 16 departments, supervision consists of help with 'problem' films. The supervising radiologist ranges in experience from a consultant to one having a few more months radiological training than the supervised radiologist. Forty-two respondents believe that A & E reporting by junior staff should be supervised. One considers this to be unnecessary and another believes that it depends upon the trainee's experience. Eight departments consider that all A & E radiographs should be double reported but none practise this and several consider it to be impractical or a counsel of perfection,
Reporting Policy Thirty-five departments (79.5%) attempt to report all A & E examinations but several report difficulty in maintaining this policy, especially during holiday periods. Nine departments (20.5%) do not attempt to report all A & E radiographs: three report only those examinations considered to be normal by the A & E clinician; five do not report if the patient is admitted or referred to a follow-up clinic; and one reports only when specifically requested to do so by the A & E department. Forty-one departments Consider that all A & E radiographs should be reported. One respondent suggested that 'trained radiographers Couldtake some of the load'. Three departments advocate Selectivereporting of examinations considered normal by
the A & E clinician and one of these departments would also report chest and abdominal radiographs.
Delays in Reporting (Table 3) Thirty-six departments provided information about delays in reporting. In several departments, A & E radiographs are reported immediately but typing is delayed. In others, reporting is delayed but typing is immediate or both reporting and typing are delayed. Three departments (8.3%) provide immediate typed radiological reports during 'normal working hours' (0900-1700 Monday to Friday) and one (2.7%) also provides this service overnight and at weekends. In seven departments reports are dictated immediately, but typing and returning the report to the A & E department then takes 24 hours in four hospitals. For examinations performed between 0900 and 1700 h Monday to Friday, the radiological report reaches the A & E department immediately in 8.3% of hospitals, within 48 h in 58.2% but in 30.5% can take 2-7 days. The position is much the same for overnight weekday examinations. At weekends, the report reaches A & E immediately in one hospital, within 48 hours in 30.5% and within 2 7 days in 58.3%. In one hospital the time interval can be more than 7 days. DISCUSSION Many patients who attend A & E departments have a radiographic examination. In this survey, 30 72% of patients were examined radiologically, mean 48%, which is similar to the 54% reported by Tachakra and Beckett (1985) and the 48-60% reported by Gleadhill et al. (1987). The number of new A & E attendances tends to increase annually. Gleadhill et al. (1987) reported an 8% increase over 4 years and also an increase in the proportion of patients who had a radiographic examination. However, the introduction of clinical guidelines resulted in a significant reduction in the number of patients referred for radiographic examination. Misinterpretation of radiographs by casualty officers is one of the commonest mistakes in A & E work, and the reported error rate has varied between 3.9% and 7% (de Lacey et al., 1980; Wardrope and Chennells, 1985; Swain, 1986; Gleadhill et al., 1987). Tachakra and Beckett (1985) analysed errors made by casualty officers and found that the abnormalities most frequently missed involved pulmonary consolidation, soft tissue swelling, 'fat pad' signs and fractures of short tubular bones of the hand. Errors
266
CLINICAL RADIOLOGY
were likely to occur because of subtle abnormalities, unfamiliarity with normal variants, tenderness not corresponding with the fracture site, presence of nontraumatic abnormalities and at changeover of duties when the radiograph might be interpreted by a casualty officer who had not examined the patient. Most important errors are made by senior house officers or by doctors doing occasional sessional work (Wardrope and Chennells, 1985). Guly (1984) pointed out that many errors could be avoided by paying more attention to clinical assessment and radiographic interpretation. Radiographers have the same error rate as casualty officers in interpreting A & E radiographs (Berman et al., 1985). The two groups make different mistakes and about half of the clinically significant abnormalities missed by casualty officers are recognised by radiographers. Radiographers could have a valuable initial role in signalling abnormalities at the time of the radiographic examination and, as one of our respondents and others (Swinburne, 1971; Aberdour, 1976), have suggested could take some of the reporting workload. Most reports strongly recommend that all A & E radiographs should be reviewed by an experienced radiologist (de Lacey et al., 1980; Mucci, 1983; Guly, 1984; Wardrope and Chennells, 1985; Robson et al., 1985; Gleadhill et al., 1987) but 20.5% of our respondents do not report all A & E radiographs, de Lacey et al. (1980) and Robson et al. (1985) showed that radiology registrars are about 95% accurate in A & E reporting compared with consultant radiologists although neither report indicated the radiological experience of the registrars. In a study of emergency radiology in the Massachussetts General Hospital, Rhea et al. (1979) reported that first year radiology residents are more likely to misinterpret radiographs than those in second year but that second and third year residents still make a significant number of errors. In a study o f ' o u t of hours' reporting, Seltzer et al. (1981) found that 6.3% of the junior radiologists' reports were altered by a staff radiologist and that about twothirds of corrections were important enough to influence patient care. These error rates also declined significantly between the first and second/third years of residency. Seltzer et al. (1981) also commented that the film review session between staff and trainee radiologists provided an opportunity for teaching and making an appropriate final report and Gleadhill et al. (1987) introduced a radiology review a.s part of their package of measures which improved the performance of casualty officers. The experience of Rhea et al. (1979), de Lacey et al. (1980), Seltzer et al. (1981) and Robson et al. (1985) suggests that a significant number of undetected but clinically important errors will be made in those departments where junior radiologists report A & E radiographs unsupervised. Supervision usually means help with problem films but this, of course, assumes that the inexperienced radiologist recognises that there is a problem. Most respondents (95%) believe that junior staff should be supervised and 61% consider that they do so although only 25% actually check the work. Galasko and Monahan (1971) have shown that 'triple checking' is more accurate than 'double checking'. It is not practised although advocated by eight respondents. The additional yield from triple checking is, however, very low. Galasko and Monahan (1971) found an additional 0.2% of cases and de Lacey et al. (1980) found that 0.75% of all those examined radiographically had a clinically significant
abnormality which was missed by both casualty officer and radiology registrar. Most departments (79.5%) attempt to report all A & radiographs although even more (93%) would like to do so. However, several departments clearly have problenas in maintaining a comprehensive reporting policy during holiday periods. When selective reporting is practised or advocated it usually consists of reporting only 'casualty officer normals' or not reporting if the patient is admitted or referred to a follow up clinic. One department reports only when specifically requested to do so by the A & E clinicians. In comparison, Berman et al. (1985), in a survey of non-teaching hospitals, reported that there is no or selective reporting or reporting is delayed for more than one week in 7% of hospitals. The radiological report should reach the A & E clinician as soon as possible, de Lacey et al. (1980) reported that there are clinical and economic benefits when the radiology report is available before the patient leaves the A & E department: misinterpretation of radiographs and unnecessary return visits are reduced. In this survey only seven departments report A & E radiographs immediately during normal weekday working hours and an immediate typed report is provided in only three. One department provides immediate typed reports at nights and weekends. Most departments report A & E radiographs within 24 h except at weekends when most report within 48 h. The report reaches the A & E department within 48 h of the examination in 66% of weekday examinations, 60% of weeknight examinations and 33 % of weekend examinations. In our view the delay, particularly at weekends is unacceptable. With the current problems in medical records, and especially secretarial services, the position could have deteriorated since this survey was carried out. Our results are open to criticism on a number of points such as the wording of the questionnaire, the relatively low response rate and the way in which several respondents grouped together information about different categories or failed to answer some questions. However, we have acquired sufficient information to show that there is considerable variation in the way in which radiology teaching departments deal with A & E reporting. So what conclusions can we draw? Almost all reports agree that all A & E radiographs should be reported, yet in 20% of 44 teaching hospitals only selective reporting is carried out, and in others, arrangements come under pressure during the holiday period. Moreover relatively inexperienced radiologists, within their first year of training, do a significant proportion of the work in half the departments. Supervision tends to be unsatisfactory often relying on help with problem films, which assumes that problems are recognised. Another cause for concern is the lengthy delay in communicating the report to the A & E clinician especially at weekends. Clearly the situation in U K teaching hospitals is far from satisfactory. The recent advances in imaging demand experienced time and consequently attention is drawn from the more 'humdrum' areas such as A & E reporting. However, A & E is an important area, the 'front door' of the hospital and standards should be high. The commonest error is misinterpretation of a radio" graph. We believe that radiologists should commence A & E reporting early in their training and that their work should be properly supervised. Consultants should contribute to A & E reporting and one should be identified as
A & E REPORTING IN UK TEACHING DEPARTMENTS responsible f o r t h i s s p h e r e o f w o r k . R a d i o l o g i c a t c o n f e r ences a r e i m p o r t a n t a n d , as e l s e w h e r e i n t h e H e a l t h Service, t h e s e c r e t a r i a l s e r v i c e s r e q u i r e m a j o r i m p r o v e naent.
Acknowledgements.Our thanks to all those who took the trouble to complete the questionnaire one of many. Your help is greatly appreciated and hopefully the results will be of some help to us all. REFERENCES Aberdour, KR (1976). Must radiologists do all the reporting? British Journal of Radiology, 49, 573. Berman, L, de Lacey, G & Craig, O (1985). A survey of accident & emergency reporting: results and implication. ClinicalRadiology, 36, 483-484. Brindle, MJ (1986). Half as many radiologists again by 1995. British Medical Journal, 293, 771. Craig, O (1985). The radiologist and the c0firts. ClinicalRadiology, 36, 475-478. Craig, JOMC (1989). The Knox Lecture. Radiology and the law. Clinical Radiology, 40, 343-346. de Lacey, G, Barker, A, Harper, J & Wignall, B (1980). An assessment of the clinical effects of reporting accident & emergency radiographs. British Journal of Radiology, 53, 304 309. Galasko, CSB & Monahan, PRW (1971). Value of re-examining x-ray films of outpatients attending accident services. British Medical Journal, 1, 643-644.
267
Gleadhill, DNS, Thomson, JY & Simms, P (1987). Can more efficient use be made of x-ray examinations in the accident and emergency department? British Medical Journal, 294, 943-947. Guly, HR (1984). Missed diagnoses in an accident and emergency department. Injury, 15, 403-406. Mucci, B (1983). The selective reporting of x-ray films from the accident and emergency department. Injury, 14, 343 344. Rhea, JT, Potsaid, MS & De Luca, SA (1979). Errors of interpretation as elicited by a quality audit of an emergency radiology facility. Radiology, 132, 277 280. Robson, N, van Benthem, PP, Gan, R & Dixon, AK (1985). Casualty xray reporting; a student survey. Clinical Radiology 36, 479-481. Ross, WM & Craig, O. (1984). Manpower and workload. Royal College of Radiologists Newsletter, 17, 10. Seltzer, SE, Hessel, SJ, Herman, PG, Swensson, RG & Sheriff, CR (1981). Resident film interpretations and staff review. American Journal of Roentgenology, 137, 129-133. Swain, AH (1986). Radiological audit changes in casualty officer performance during tenure of post. British Journal of Accident and Emergency Medicine, 1, 5 9. Swinburne, K (1971). Pattern recognition for radiographers. Lancet i, 589-590. Tachakra, SS & Beckett, MW (1985). Why do casualty officers miss radiological abnormalities? Journal of the Royal Collegeof Surgeons of Edinburgh, 30, 311-313. Wardrope, J & Chennells, PM (1985). Should all casualty radiographs be reviewed? British Medical Journal, 290, 1638 1640.
Accident and Emergency Reporting in UK Teaching Departments I. BEGGS and J. K. DAVIDSON*
Departments of Radiology, Royal Infirmary, Edinburgh and * Western Infirmary, Glasgow A survey of 44 UK training departments shows that trainee radiologists commence accident and emergency (A & E) reporting after an average of 10.2 months in radiology and perform a considerable proportion of the A & E reporting workload. Most respondents consider that they supervise junior staff but only 11 departments directiy check their work and only two departments offer supervision to staff with more than 2 years' experience. AH A & E radiographs are reported in 79.9% of hospitals and the other hospitals operate selective reporting policies. The delay between the radiographic examination and the radiology report reaching the A & E department is less than 48 hours in about twothirds of departments when the examination is performed Monday to Friday, but exceeds 48 hours in two-thirds of departments when it is performed at weekends. Misinterpretation of radiographs is one of the commonest errors in A & E. Improved supervision of less experienced trainees is required. Consultants should contribute and one should be responsible for this area. Radiological conferences are important and the secretarial services require major improvement.
Accident and Emergency (A & E) reporting is a major part of the workload of many radiology departments. Craig (1985, 1989) underlined the need to provide an adequate A & E reporting service. Nearly 9% of all medical litigation cases involve radiology, although radiologists may not be directly involved, and nearly 80% of these cases relate to trauma. Almost 40% of medical negligence cases, which directly involve radiologists, relate to trauma. Difficulties with A & E reporting are not new (Aberdour, 1976; de Lacey et al., 1980: Wardrope and Chennells, 1985; Gleadhill et al., 1987) and must be set against a background of inadequate radiological staffing (Brindle, 1986), a workload which is increasing inexorably at a faster rate than the expansion of radiological staffing (Ross and Craig, 1984) and the introduction of new techniques which often consume much radiological time. Berman et al. (1985) recently surveyed A & E reporting and suggested that many patients are at risk from mistakes which can be attributed to staffing problems. They excluded radiology teaching departments from consideration because they did not consider the A & E reporting workload to be a problem in such departments. We considered that teaching and non teaching departments are subjected to the same pressures and decided to survey the former. MATERIALS AND METHODS We sent a questionnaire to 77 British radiology training departments. The questionnaire asked: Correspondence to: Ian Beggs, Department of Radiology, Royal Infirmary, Edinburgh EH3 9YW.
The total annual numbers ofA & E attendances and A & E radiographic examinations. The proportion of A & E reporting undertaken by registrars, senior registrars and consultants. The radiological experience before starting A & E reporting. The nature of junior staff supervision. The requirements to provide an adequate A & E reporting service. If a comprehensive A & E reporting service is provided and, if not, what selection criteria are used. Time intervals between radiographic examination, dictation of radiologist's report and receipt of report by A & E department. RESULTS Fifty-three departments (68.8%) responded. Four declined to complete the questionnaire because they lacked junior staff or an A & E department. Four completed the questionnaire but had no junior staff and were therefore excluded as was another department which returned a substantially incomplete questionnaire. We therefore had 44 questionnaires (57.1%) for analysis. (We included some questionnaires which had minor omissions, grouped different categories together or supplied information in a different form to that requested.) The annual number of A & E attendances ranged from 21 000 to 132 000, mean 56 000. The annual number of radiographic examinations varied from 12 000 to 73 000, mean 28 000. The proportion ofA & E attenders who had a radiographic examination ranged from 30-72%, mean 48%. Radiological Experience Needed to Start A & E Reporting
Trainees start A & E reporting after an average of 10.2
Table 1 - Radiological experience (in months) required to start A & E reporting (* = one department requires 4 months in radiology and success in a test of A & E reporting) .__..-
Months
Number
0 13 3-6 6-9 9-12 12-18 18 24 24-36 36 'depends'
3 3 5* 7 3 13 5 2 1 2
265
A & E REPORTING IN UK TEACHING DEPARTMENTS
Table 2 - A & E reporting workload and supervision Experience in radiologY in months
Number
Work checked by more experienced radiologist
Table 3 - Time interval from radiographic examination to receipt of radiology report in A & E
A & E workload Range
Mean
10-20% 3 45% 5-95% 5 100% 5 40% 5-90% 5-80%
17.5% 36% 49% 30% 26%
Mon-Fri 0900-1700
Mon Fri 1700 0900
Weekend 1700 Fri-O9OO Mon
Immediate Under 24 hours 24-48 hours 2-7 days Over 1 week Not known
3 10 11 11 1 0
1 7 14 12 1 1
1 2 9 21 1 2
Total
36
36
36
f
0 1-6 6-12 12-24 24-36 36/SR Consultant
3 7 18 29 23 33 33
3 .7 6 4 2 0 0
months in radiology. In about two-thirds of departments they start between 3 and 18 months (Table 1). Only two departments take previous experience into account. Nine departments would prefer their ti'ainees to have more experience in radiology and four departments would prefer less.
Radiological Experience and Proportion of A & E Reporting Many respondents grouped categories together and some questionnaires were incomplete. Where we have information about a particular grade we have calculated the amount of work done by that grade. The percentages we give apply only to the departments which provided information about that particular grade and are not valid as overall percentages (Table 2).
Supervision Twenty-seven departments consider that they supervise junior staff, 15 do not and two did not answer. In 11 departments the work is checked by a more experienced radiologist. In the other 16 departments, supervision consists of help with 'problem' films. The supervising radiologist ranges in experience from a consultant to one having a few more months radiological training than the supervised radiologist. Forty-two respondents believe that A & E reporting by junior staff should be supervised. One considers this to be unnecessary and another believes that it depends upon the trainee's experience. Eight departments consider that all A & E radiographs should be double reported but none practise this and several consider it to be impractical or a counsel of perfection,
Reporting Policy Thirty-five departments (79.5%) attempt to report all A & E examinations but several report difficulty in maintaining this policy, especially during holiday periods. Nine departments (20.5%) do not attempt to report all A & E radiographs: three report only those examinations considered to be normal by the A & E clinician; five do not report if the patient is admitted or referred to a follow-up clinic; and one reports only when specifically requested to do so by the A & E department. Forty-one departments Consider that all A & E radiographs should be reported. One respondent suggested that 'trained radiographers Couldtake some of the load'. Three departments advocate Selectivereporting of examinations considered normal by
the A & E clinician and one of these departments would also report chest and abdominal radiographs.
Delays in Reporting (Table 3) Thirty-six departments provided information about delays in reporting. In several departments, A & E radiographs are reported immediately but typing is delayed. In others, reporting is delayed but typing is immediate or both reporting and typing are delayed. Three departments (8.3%) provide immediate typed radiological reports during 'normal working hours' (0900-1700 Monday to Friday) and one (2.7%) also provides this service overnight and at weekends. In seven departments reports are dictated immediately, but typing and returning the report to the A & E department then takes 24 hours in four hospitals. For examinations performed between 0900 and 1700 h Monday to Friday, the radiological report reaches the A & E department immediately in 8.3% of hospitals, within 48 h in 58.2% but in 30.5% can take 2-7 days. The position is much the same for overnight weekday examinations. At weekends, the report reaches A & E immediately in one hospital, within 48 hours in 30.5% and within 2 7 days in 58.3%. In one hospital the time interval can be more than 7 days. DISCUSSION Many patients who attend A & E departments have a radiographic examination. In this survey, 30 72% of patients were examined radiologically, mean 48%, which is similar to the 54% reported by Tachakra and Beckett (1985) and the 48-60% reported by Gleadhill et al. (1987). The number of new A & E attendances tends to increase annually. Gleadhill et al. (1987) reported an 8% increase over 4 years and also an increase in the proportion of patients who had a radiographic examination. However, the introduction of clinical guidelines resulted in a significant reduction in the number of patients referred for radiographic examination. Misinterpretation of radiographs by casualty officers is one of the commonest mistakes in A & E work, and the reported error rate has varied between 3.9% and 7% (de Lacey et al., 1980; Wardrope and Chennells, 1985; Swain, 1986; Gleadhill et al., 1987). Tachakra and Beckett (1985) analysed errors made by casualty officers and found that the abnormalities most frequently missed involved pulmonary consolidation, soft tissue swelling, 'fat pad' signs and fractures of short tubular bones of the hand. Errors
266
CLINICAL RADIOLOGY
were likely to occur because of subtle abnormalities, unfamiliarity with normal variants, tenderness not corresponding with the fracture site, presence of nontraumatic abnormalities and at changeover of duties when the radiograph might be interpreted by a casualty officer who had not examined the patient. Most important errors are made by senior house officers or by doctors doing occasional sessional work (Wardrope and Chennells, 1985). Guly (1984) pointed out that many errors could be avoided by paying more attention to clinical assessment and radiographic interpretation. Radiographers have the same error rate as casualty officers in interpreting A & E radiographs (Berman et al., 1985). The two groups make different mistakes and about half of the clinically significant abnormalities missed by casualty officers are recognised by radiographers. Radiographers could have a valuable initial role in signalling abnormalities at the time of the radiographic examination and, as one of our respondents and others (Swinburne, 1971; Aberdour, 1976), have suggested could take some of the reporting workload. Most reports strongly recommend that all A & E radiographs should be reviewed by an experienced radiologist (de Lacey et al., 1980; Mucci, 1983; Guly, 1984; Wardrope and Chennells, 1985; Robson et al., 1985; Gleadhill et al., 1987) but 20.5% of our respondents do not report all A & E radiographs, de Lacey et al. (1980) and Robson et al. (1985) showed that radiology registrars are about 95% accurate in A & E reporting compared with consultant radiologists although neither report indicated the radiological experience of the registrars. In a study of emergency radiology in the Massachussetts General Hospital, Rhea et al. (1979) reported that first year radiology residents are more likely to misinterpret radiographs than those in second year but that second and third year residents still make a significant number of errors. In a study o f ' o u t of hours' reporting, Seltzer et al. (1981) found that 6.3% of the junior radiologists' reports were altered by a staff radiologist and that about twothirds of corrections were important enough to influence patient care. These error rates also declined significantly between the first and second/third years of residency. Seltzer et al. (1981) also commented that the film review session between staff and trainee radiologists provided an opportunity for teaching and making an appropriate final report and Gleadhill et al. (1987) introduced a radiology review a.s part of their package of measures which improved the performance of casualty officers. The experience of Rhea et al. (1979), de Lacey et al. (1980), Seltzer et al. (1981) and Robson et al. (1985) suggests that a significant number of undetected but clinically important errors will be made in those departments where junior radiologists report A & E radiographs unsupervised. Supervision usually means help with problem films but this, of course, assumes that the inexperienced radiologist recognises that there is a problem. Most respondents (95%) believe that junior staff should be supervised and 61% consider that they do so although only 25% actually check the work. Galasko and Monahan (1971) have shown that 'triple checking' is more accurate than 'double checking'. It is not practised although advocated by eight respondents. The additional yield from triple checking is, however, very low. Galasko and Monahan (1971) found an additional 0.2% of cases and de Lacey et al. (1980) found that 0.75% of all those examined radiographically had a clinically significant
abnormality which was missed by both casualty officer and radiology registrar. Most departments (79.5%) attempt to report all A & radiographs although even more (93%) would like to do so. However, several departments clearly have problenas in maintaining a comprehensive reporting policy during holiday periods. When selective reporting is practised or advocated it usually consists of reporting only 'casualty officer normals' or not reporting if the patient is admitted or referred to a follow up clinic. One department reports only when specifically requested to do so by the A & E clinicians. In comparison, Berman et al. (1985), in a survey of non-teaching hospitals, reported that there is no or selective reporting or reporting is delayed for more than one week in 7% of hospitals. The radiological report should reach the A & E clinician as soon as possible, de Lacey et al. (1980) reported that there are clinical and economic benefits when the radiology report is available before the patient leaves the A & E department: misinterpretation of radiographs and unnecessary return visits are reduced. In this survey only seven departments report A & E radiographs immediately during normal weekday working hours and an immediate typed report is provided in only three. One department provides immediate typed reports at nights and weekends. Most departments report A & E radiographs within 24 h except at weekends when most report within 48 h. The report reaches the A & E department within 48 h of the examination in 66% of weekday examinations, 60% of weeknight examinations and 33 % of weekend examinations. In our view the delay, particularly at weekends is unacceptable. With the current problems in medical records, and especially secretarial services, the position could have deteriorated since this survey was carried out. Our results are open to criticism on a number of points such as the wording of the questionnaire, the relatively low response rate and the way in which several respondents grouped together information about different categories or failed to answer some questions. However, we have acquired sufficient information to show that there is considerable variation in the way in which radiology teaching departments deal with A & E reporting. So what conclusions can we draw? Almost all reports agree that all A & E radiographs should be reported, yet in 20% of 44 teaching hospitals only selective reporting is carried out, and in others, arrangements come under pressure during the holiday period. Moreover relatively inexperienced radiologists, within their first year of training, do a significant proportion of the work in half the departments. Supervision tends to be unsatisfactory often relying on help with problem films, which assumes that problems are recognised. Another cause for concern is the lengthy delay in communicating the report to the A & E clinician especially at weekends. Clearly the situation in U K teaching hospitals is far from satisfactory. The recent advances in imaging demand experienced time and consequently attention is drawn from the more 'humdrum' areas such as A & E reporting. However, A & E is an important area, the 'front door' of the hospital and standards should be high. The commonest error is misinterpretation of a radio" graph. We believe that radiologists should commence A & E reporting early in their training and that their work should be properly supervised. Consultants should contribute to A & E reporting and one should be identified as
A & E REPORTING IN UK TEACHING DEPARTMENTS responsible f o r t h i s s p h e r e o f w o r k . R a d i o l o g i c a t c o n f e r ences a r e i m p o r t a n t a n d , as e l s e w h e r e i n t h e H e a l t h Service, t h e s e c r e t a r i a l s e r v i c e s r e q u i r e m a j o r i m p r o v e naent.
Acknowledgements.Our thanks to all those who took the trouble to complete the questionnaire one of many. Your help is greatly appreciated and hopefully the results will be of some help to us all. REFERENCES Aberdour, KR (1976). Must radiologists do all the reporting? British Journal of Radiology, 49, 573. Berman, L, de Lacey, G & Craig, O (1985). A survey of accident & emergency reporting: results and implication. ClinicalRadiology, 36, 483-484. Brindle, MJ (1986). Half as many radiologists again by 1995. British Medical Journal, 293, 771. Craig, O (1985). The radiologist and the c0firts. ClinicalRadiology, 36, 475-478. Craig, JOMC (1989). The Knox Lecture. Radiology and the law. Clinical Radiology, 40, 343-346. de Lacey, G, Barker, A, Harper, J & Wignall, B (1980). An assessment of the clinical effects of reporting accident & emergency radiographs. British Journal of Radiology, 53, 304 309. Galasko, CSB & Monahan, PRW (1971). Value of re-examining x-ray films of outpatients attending accident services. British Medical Journal, 1, 643-644.
267
Gleadhill, DNS, Thomson, JY & Simms, P (1987). Can more efficient use be made of x-ray examinations in the accident and emergency department? British Medical Journal, 294, 943-947. Guly, HR (1984). Missed diagnoses in an accident and emergency department. Injury, 15, 403-406. Mucci, B (1983). The selective reporting of x-ray films from the accident and emergency department. Injury, 14, 343 344. Rhea, JT, Potsaid, MS & De Luca, SA (1979). Errors of interpretation as elicited by a quality audit of an emergency radiology facility. Radiology, 132, 277 280. Robson, N, van Benthem, PP, Gan, R & Dixon, AK (1985). Casualty xray reporting; a student survey. Clinical Radiology 36, 479-481. Ross, WM & Craig, O. (1984). Manpower and workload. Royal College of Radiologists Newsletter, 17, 10. Seltzer, SE, Hessel, SJ, Herman, PG, Swensson, RG & Sheriff, CR (1981). Resident film interpretations and staff review. American Journal of Roentgenology, 137, 129-133. Swain, AH (1986). Radiological audit changes in casualty officer performance during tenure of post. British Journal of Accident and Emergency Medicine, 1, 5 9. Swinburne, K (1971). Pattern recognition for radiographers. Lancet i, 589-590. Tachakra, SS & Beckett, MW (1985). Why do casualty officers miss radiological abnormalities? Journal of the Royal Collegeof Surgeons of Edinburgh, 30, 311-313. Wardrope, J & Chennells, PM (1985). Should all casualty radiographs be reviewed? British Medical Journal, 290, 1638 1640.