- Email: [email protected]
Radiographer-performed barium enemas—results of a survey to assess progress
TH
RA ~ R
E OF AP H E RS
[.LEG
Radiography (1996) 2, 199~05
R A D I O G R A P H E R - P E R F O R M ED B A R I U M E N E M A S - - R E S U L T S OF A S U R V E Y TO ASSESS PROGRESS J. Bewell and A. H. Chapman Radiology Department, St James's University Hospital, Beckett Street, Leeds' LS9 7TF, ~K. (Received 8 December 1995," accepted 3 June 1996)
Purpose: To determine if radiographers had experienced difficulties with training or with the provision of a service or with clinical complications as a result of having been delegated to perform barium enema examinations. Method: Ninety-six questionnaires were completed by radiographers who had attended a training course. Results: All radiographers were within 2 years of their training and were on average performing two sessions a week with four patients per session. Eighty-five per cent of the radiographers had been trained to give intravenous injections. Twenty thousand examinations had been performed without mortality. The serious complication rate was 1 in 5000. Seventy-eight per cent reported an improvement in service provision. Discussion: The most common difficulties with training were in establishing a single protocol for the performance of the examination when there were multiple supervising consultant radiologists and difficulties in finding staff cover to allow radiographers the time to train. The examination complication rate was comparable to that experienced by radiologists. Conclusion: Formal training enables this form of role extension to be implemented without serious difficulty and can result in an improved service.
Keywords: skill mix; role extension; course; training; complications.
INTRODUCTION In 1991 a pilot study was undertaken at St James's University Hospital to assess the feasibility o f suitably trained radiographers performing double contrast barium enema examinations. It was f o u n d that radiographers could perform examinations o f c o m p a r able quality to those performed by radiologists [1] and it soon became apparent that the idea was being considered by other radiology departments. In order to share our experience and to help with training, a formal course was set up at the hospital in 1993 which set out to introduce radiographers to the techniques involved, the complications that can occur and the a n a t o m y and p a t h o l o g y o f the large bowel. The training course comprises a one and a half day introductory theoretical course after which the radiographers return to their base hospital for practical training under the supervision o f their o w n consultant and then return for a 1-day theoretical refresher course. Their supervising consultant is encouraged to attend the first day o f the 1078-8174/96/030199+ 07 $18.00
© 1996 The College of Radiographers 199
200
Bewell and Chapman
Table 1. Status of radiographers attending the barium enema training COUrSeS
Grade
No.
%
Basic Senior 11 Senior I Superintendent IV Superintendent Iil Superintendent II Superintendent I Unspecified
8 40 27 3 10 3 2 3
7 41 28 3 11 4 3 4
introductory course which specifically deals with training considerations. The course is open to all radiographers but we have recommended that applicants be of senior ii status or higher because of their experience and added confidence. Currently five courses have been held. In order to assess the impact of the training a survey was conducted. METHOD
All radiographers who had attended the barium enema training courses were asked to complete a questionnaire (see Appendix). These were posted to delegates who had attended the first four courses and given by hand to those attending the theoretical part of the fifth course. RESULTS
The questionnaire was completed by 96 of the 106 attending radiographers. Three reported that they had stopped performing barium enemas because they had moved to another hospital or had been promoted to a different job. One had abandoned the training because of loss of confidence of the supervising consultant following a death as a result of a barium enema performed by a radiologist colleague. Radiographers varied in grade from basic to superintendent 1, although the majority (69 per cent) were of senior I or senior II status (Table 1). Ninety-six radiographers had performed a total of 20 000 barium enema examinations. On average each radiographer performed two sessions per week (range 1 to 4) with each session comprising an average of four patients (range 2 to 9). Experienced radiographers who attended our first course were performing five examinations per session (range 4 to 6) whereas those attending the fifth course were performing four cases per session (range 3 to 8) (Table 2). A technique for performing barium enemas was described as part of the course programme. Seventy per cent (n= 64) of radiographers converted to their own consultants technique. Eighty-five per cent (n = 78) of radiographers had been trained to give an intravenous injection of an antispasmodic, which was either hyoscine butylbromide (Buscopan, Boehringer Ingelheim Ltd, U.K.) or glucagon, and 80 per cent (n=74) used an antispasmodic routinely. Eighty per cent (n = 74) screened the barium into the patient
201
Radiographer-perJormed Barium Enemas
Table 2. (a) Lists per week No. of Lists
% of Respondents (n)
1 2
37.5 (36) 44 (42)
3
5 (5)
4 Variable
5 (5) 8 (8)
(b) Patients per list No. of patients % of Respondents (n)
2 3 4 5 6 9 Unspecified
% of Respondents (n) who attended first course
3 (3) 11.5 (11) 52 (50) 24 (23) 4 (4) 1 (1) 4 (4)
54 (8) 20 (3) 20 (3) 6 (1)
Table 3. Summary of techniques used Technique employed
% (n)
Course protocol Supervising consultant's protocol Intravenous injection given Antispasmodic given as a routine Barium introduced with patient in lateral position Rectal balloon used As a routine On occasions Bowel routinely inflated with carbon dioxide
33 70 85 80 80
(32) (64) (78) (74) (74)
12 (11) 40 (37) S (7)
in the lateral position and the remainder, in the supine or prone position. Rectal balloons were used by 12 per cent (n= 11) of radiographers routinely and by 40 per cent (n= 37) on an occasional basis. Eight per cent (n= 7) used carbon dioxide to inflate the bowel instead of air (Table 3). Ten per cent (n=9) of radiographers experienced difficulties with training. Five reported t h a t there had been times when there were insufficient staff to allow radiographers to be released to perform the barium enema sessions and four had difficulties in agreeing a single protocol as they worked with more than one supervising consultant. Thirty-three per cent (n= 32) of radiographers identified that there had at times been a problem with radiol0gical supervision of their sessions. These problems related to
202
BewelI and Chapman
radiologists being otherwise occupied and not being immediately available should advice be required and cover not being available when a consultant was on leave, in which case sessions had to be cancelled. Seventy-eight per cent (n=72) of radiographers commented that there had been an improvement of service delivery, reflected by a reduction in the waiting list. Sixty-six per cent (n= 61) performed examinations on both inpatients and outpatients. Supervising consultants frequently reserved certain categories of examinations for themselves; these included children, instant enemas and colostomy enemas. There were no deaths but four serious complications were recorded and these were all due to cardiac arrhythmias. Minor complications recorded included one mild allergic reaction and four vaso-vagal attacks. Only two diagnostic errors were mentioned; one was a false positive examination in which a polyp was reported on the barium enema but no polyp could be found on colonoscopy and there was one false negative study but details of the missed pathology were not given. Thirteen per cent (n= 12) of radiographers reported that they had been regraded following their training but that this was only one of a number of factors responsible for their regrading. DISCUSSION The incidence of colonic perforation, which is believed to be the commonest of the major complications from performing a barium enema, is 1 in 10 000 with a mortality of 1 in 50 000 [1]. The 96 radiographers in this survey performed 20 000 procedures without mortality and with only four serious complications, none of which were colonic perforations or related to poor technique. This suggests that the complication rate from radiographer performed barium enemas is of the same order as that of radiologist performed procedures, although much greater numbers are needed before figures of statistical significance are achieved. Radiologists often reserve paediatric, instant and colostomy enemas for themselves as they consider them to be a difficult or high risk examination and this will need to be borne in mind when larger numbers of examinations become available for analysis, as this may bias results in favour of the radiographer performed examination. Without careful patient follow-up reliable information cannot be obtained as to the diagnostic accuracy of the radiographer performed examination although it is encouraging that only two radiographers were aware of having a false positive or false negative examination and evidence from a recent study [2] suggests that radiographer performed barium enemas are of comparable diagnostic accuracy to those performed by radiologists. However, larger studies will be required to confirm this. Radiographers currently are only performing an average of four examinations per session although the number increases as radiographers gain experience. Radiologists would be expected to perform longer lists, but nevertheless seventy-eight per cent of radiographers commented that there had been an improvement in service delivery, reflected by a reduction in the waiting list. This is likely to have been accomplished by better utilization of equipment with extra barium enema lists being performed by radiographers at times when X-ray rooms would otherwise lie empty. The barium enema technique used at St James's University Hospital was described during the course, but as the radiographers returned to their base hospital for practical
Radiographer-perJormed Barium Enemas
203
training under the supervision of their own consultant, it is perhaps not surprising that 70 per cent of radiographers reported that they followed their own consultant's technique. We advised radiographers to screen the barium into the rectum in the lateral position so that it would be immediately apparent if there were extravasation of barium due to a tear of the anterior rectal wall by the enema tube. In females this also makes it easier to recognize if the tube is misplaced and lies in the vagina. Eighty per cent of radiographers reported that they screened in the barium in the lateral position, but we were disappointed to find 20 per cent using either the prone or supine position. This again is likely to reflect their own consultant's practice. We advised that rectal balloons should not be used by radiographers as it has been suggested [3] that their use is associated with a significantly increased complication rate. We were surprised to find rectal balloons being used by 12 per cent of radiographers routinely and by as many as 40 per cent on an occasional basis. This again reflects the practice of radiologists as in another study we have found that 22 per cent of the radiologists who perform barium enemas use rectal balloons routinely (A. Blakeborough, personal communication). It is also our practice to use an intravenous antispasmodic (Buscopan or glucagon) for all barium enema examinations as it is our belief that it avoids misdiagnoses due to spasm and results in a dilatation and elongation of the colon which makes the images easier to interpret and also reduces the incidence of incontinence [4 6]. Despite the need for radiographers to obtain further training to give intravenous injections we were encouraged to find 85 per cent following our example. It was not our practice to use carbon dioxide to inflate the bowel although we did discuss this as an option that radiographers might like to consider [7]. Eight per cent of radiographers were using carbon dioxide to inflate the bowel and this again is likely to reflect their consultant's own practice. No doubt better compliance with course recommendations could be obtained if the course had also included practical training but the number of radiographers requiring training precluded this as an option. There is at present a shortage of consultant radiologists in the United Kingdom and because of this, radiologists are working well in excess of their college guidelines [8]. This is obviously one of the reasons why various forms of skill mix are of interest to radiologists but there is a risk of overloading radiographers unless extra staff can be recruited. One of the most frequent problems cited with training was lack of radiographic manpower so that radiographers found it difficult to find the time to put their new skills into practice. The next most frequent problem occurred in large departments where a radiographer was often performing a number of sessions per week with each session supervised by a different consultant and each consultant insisting on their own protocol being followed. Hopefully now that this problem has been identified it will be addressed by supervising consultants. Thirty per cent of radiographers reported that there had been a problem with the radiological supervision of their sessions. This mainly related to radiologists not being immediately available to give advice, which sometimes resulted in delays, although in general this was not considered to be a serious problem. Many radiographers expressed their frustration at having to cancel their lists when a radiologist was not available to supervise; perhaps because of sickness or annual leave. All radiographers who had been regraded since attending the barium enema course commented th.at the training helped them towards regrading. This was only one of a number of factors responsible, but it was an important one.
204
Bewell and Chapman
Overall, the response o f radiographers to this f o r m of role extension has been encouraging with 78 per cent reporting an i m p r o v e m e n t in service, indicating that this is a positive step forward towards the provision o f a quality radiology service. In view o f this, further courses have been planned.
Acknowledgement We would like to thank E-Z-EM, Inc. for their generous support for the barium enema training course.
References 1. Gore RM, Levine MS, Laufer I. Textbook o f gastrointestinal radiology Philadelphia: W.B. Saunders, 1994; 2595. 2. Mannion RAJ, Bewell J, Langan C, Robertson M, Chapman AH. A barium enema training programme for radiographers: a pilot study. Clin RadioI 1995; 50" 715 19. 3. Dodds W J, Stewart ET, Nelson JA. Rectal balloon catheters and the barium enema examination. Gastrointesti Radiol 1980; 5" 277-84. 4. Meeroff JC, Jorgens J, Isenbergh JI. The effect of glucagon on the barium enema examination. Radiology 1975; 115: 5-7. 5. Goei R, Nix M, Kessels AH, Ten Tusscher MPM. Use of antispasmodic drugs in double contrast barium enema examination: Glucagon or Buscopan. Clin Radiol 1995; 50: 553-7. 6. Lee JR. Routine use of hyoscine N butylbromide (Buscopan) in double contrast barium enema examinations. Clin Radiol 1982; 33:273 6. 7. Scullion DA, Wetton CWN, Davies C, Whitaker L, Shorven PJ. The use of air or CO2 as insufftation agents for double contrast barium enema (DCBE): Is there a qualitative difference? Clin Radiol 1995; 50: 558-61. 8. Medical staffing and workload in clinical radiology in the United Kingdom National Health Service. London: Royal College of Radiologists; 1993.
APPENDIX 1 QUESTIONNAIRE 1. 2. 3. 4. 5.
FOR R A D I O G R A P H E R S W H O H A V E A T T E N D E D T H E BARIUM ENEMA COURSE
H o w m a n y cases have y o u performed unaided? H o w m a y lists do you do a week? H o w m a y cases do you do per list? Have y o u encountered any problems with y o u r training? Whose b a r i u m enema technique do y o u follow? ours* / y o u r own* / y o u r consultants* (*please circle) 6. Have y o u been trained to give intravenous injections? If so do you use Buscopan* / glucagon* / neither* (pl. . . . . ircle) 7. In what position do you initially screen the b a r i u m in? prone* / lateral* / other (please specify) 8. D o you use rectal balloons? routinely* / occasionally* / never* (pl. . . . . . ircle) If SO do you: take a history f r o m patient o f rectal disease; do a digital rectal examination; insert a balloon catheter yourself; introduce barium to assess the rectum before inflating the balloon; inflate the balloon under screening control; obtain a post evacuation film.
Radiographer-performed Barium Enemas
205
9. Do you use carbon dioxide to inflate the bowel? 10. Do you encounter any problems with consultants being available for supervising the list? What problems have you had? 11. Has the training of radiographers to perform barium enemas resulted in any improvement in the service? yes* / unsure* / no* (*please circle) 12. Do you perform enerrias on GP cases? yes / no If so has the introduction of radiographers performing barium enemas resulted in any improvement in the GP service? 13. Are there any categories of barium enemas that are specifically referred for your consultant to perform? 14. Do you perform outpatient barium enemas / inpatient barium enemas / both inpatient and outpatient barium enemas? 15. Since running the service have you encountered any problems with errors being made in diagnosis? Please detail or instances in which, because of problems with the quality of an examination the barium enema has had to be repeated? Please detail 16. Since introducing the programme have you encountered any major complication? i.e. intraperitoneal perforation*, extraperitoneal perforation*, air embolism*, venous intravasation*, allergic reaction*, septicaemia*, cardiac arrhythmia* (pl. . . . . circle)
O t h e ~ p l e a s e specify 17. What is your grade? (i.e. Basic, Senior 2, Senior 1) Have you been regraded following your barium enema training? yes / no If so do you feel that your barium enema training helped you to obtain this regrading? 18. Any other comments?
RA ~ R
E OF AP H E RS
[.LEG
Radiography (1996) 2, 199~05
R A D I O G R A P H E R - P E R F O R M ED B A R I U M E N E M A S - - R E S U L T S OF A S U R V E Y TO ASSESS PROGRESS J. Bewell and A. H. Chapman Radiology Department, St James's University Hospital, Beckett Street, Leeds' LS9 7TF, ~K. (Received 8 December 1995," accepted 3 June 1996)
Purpose: To determine if radiographers had experienced difficulties with training or with the provision of a service or with clinical complications as a result of having been delegated to perform barium enema examinations. Method: Ninety-six questionnaires were completed by radiographers who had attended a training course. Results: All radiographers were within 2 years of their training and were on average performing two sessions a week with four patients per session. Eighty-five per cent of the radiographers had been trained to give intravenous injections. Twenty thousand examinations had been performed without mortality. The serious complication rate was 1 in 5000. Seventy-eight per cent reported an improvement in service provision. Discussion: The most common difficulties with training were in establishing a single protocol for the performance of the examination when there were multiple supervising consultant radiologists and difficulties in finding staff cover to allow radiographers the time to train. The examination complication rate was comparable to that experienced by radiologists. Conclusion: Formal training enables this form of role extension to be implemented without serious difficulty and can result in an improved service.
Keywords: skill mix; role extension; course; training; complications.
INTRODUCTION In 1991 a pilot study was undertaken at St James's University Hospital to assess the feasibility o f suitably trained radiographers performing double contrast barium enema examinations. It was f o u n d that radiographers could perform examinations o f c o m p a r able quality to those performed by radiologists [1] and it soon became apparent that the idea was being considered by other radiology departments. In order to share our experience and to help with training, a formal course was set up at the hospital in 1993 which set out to introduce radiographers to the techniques involved, the complications that can occur and the a n a t o m y and p a t h o l o g y o f the large bowel. The training course comprises a one and a half day introductory theoretical course after which the radiographers return to their base hospital for practical training under the supervision o f their o w n consultant and then return for a 1-day theoretical refresher course. Their supervising consultant is encouraged to attend the first day o f the 1078-8174/96/030199+ 07 $18.00
© 1996 The College of Radiographers 199
200
Bewell and Chapman
Table 1. Status of radiographers attending the barium enema training COUrSeS
Grade
No.
%
Basic Senior 11 Senior I Superintendent IV Superintendent Iil Superintendent II Superintendent I Unspecified
8 40 27 3 10 3 2 3
7 41 28 3 11 4 3 4
introductory course which specifically deals with training considerations. The course is open to all radiographers but we have recommended that applicants be of senior ii status or higher because of their experience and added confidence. Currently five courses have been held. In order to assess the impact of the training a survey was conducted. METHOD
All radiographers who had attended the barium enema training courses were asked to complete a questionnaire (see Appendix). These were posted to delegates who had attended the first four courses and given by hand to those attending the theoretical part of the fifth course. RESULTS
The questionnaire was completed by 96 of the 106 attending radiographers. Three reported that they had stopped performing barium enemas because they had moved to another hospital or had been promoted to a different job. One had abandoned the training because of loss of confidence of the supervising consultant following a death as a result of a barium enema performed by a radiologist colleague. Radiographers varied in grade from basic to superintendent 1, although the majority (69 per cent) were of senior I or senior II status (Table 1). Ninety-six radiographers had performed a total of 20 000 barium enema examinations. On average each radiographer performed two sessions per week (range 1 to 4) with each session comprising an average of four patients (range 2 to 9). Experienced radiographers who attended our first course were performing five examinations per session (range 4 to 6) whereas those attending the fifth course were performing four cases per session (range 3 to 8) (Table 2). A technique for performing barium enemas was described as part of the course programme. Seventy per cent (n= 64) of radiographers converted to their own consultants technique. Eighty-five per cent (n = 78) of radiographers had been trained to give an intravenous injection of an antispasmodic, which was either hyoscine butylbromide (Buscopan, Boehringer Ingelheim Ltd, U.K.) or glucagon, and 80 per cent (n=74) used an antispasmodic routinely. Eighty per cent (n = 74) screened the barium into the patient
201
Radiographer-perJormed Barium Enemas
Table 2. (a) Lists per week No. of Lists
% of Respondents (n)
1 2
37.5 (36) 44 (42)
3
5 (5)
4 Variable
5 (5) 8 (8)
(b) Patients per list No. of patients % of Respondents (n)
2 3 4 5 6 9 Unspecified
% of Respondents (n) who attended first course
3 (3) 11.5 (11) 52 (50) 24 (23) 4 (4) 1 (1) 4 (4)
54 (8) 20 (3) 20 (3) 6 (1)
Table 3. Summary of techniques used Technique employed
% (n)
Course protocol Supervising consultant's protocol Intravenous injection given Antispasmodic given as a routine Barium introduced with patient in lateral position Rectal balloon used As a routine On occasions Bowel routinely inflated with carbon dioxide
33 70 85 80 80
(32) (64) (78) (74) (74)
12 (11) 40 (37) S (7)
in the lateral position and the remainder, in the supine or prone position. Rectal balloons were used by 12 per cent (n= 11) of radiographers routinely and by 40 per cent (n= 37) on an occasional basis. Eight per cent (n= 7) used carbon dioxide to inflate the bowel instead of air (Table 3). Ten per cent (n=9) of radiographers experienced difficulties with training. Five reported t h a t there had been times when there were insufficient staff to allow radiographers to be released to perform the barium enema sessions and four had difficulties in agreeing a single protocol as they worked with more than one supervising consultant. Thirty-three per cent (n= 32) of radiographers identified that there had at times been a problem with radiol0gical supervision of their sessions. These problems related to
202
BewelI and Chapman
radiologists being otherwise occupied and not being immediately available should advice be required and cover not being available when a consultant was on leave, in which case sessions had to be cancelled. Seventy-eight per cent (n=72) of radiographers commented that there had been an improvement of service delivery, reflected by a reduction in the waiting list. Sixty-six per cent (n= 61) performed examinations on both inpatients and outpatients. Supervising consultants frequently reserved certain categories of examinations for themselves; these included children, instant enemas and colostomy enemas. There were no deaths but four serious complications were recorded and these were all due to cardiac arrhythmias. Minor complications recorded included one mild allergic reaction and four vaso-vagal attacks. Only two diagnostic errors were mentioned; one was a false positive examination in which a polyp was reported on the barium enema but no polyp could be found on colonoscopy and there was one false negative study but details of the missed pathology were not given. Thirteen per cent (n= 12) of radiographers reported that they had been regraded following their training but that this was only one of a number of factors responsible for their regrading. DISCUSSION The incidence of colonic perforation, which is believed to be the commonest of the major complications from performing a barium enema, is 1 in 10 000 with a mortality of 1 in 50 000 [1]. The 96 radiographers in this survey performed 20 000 procedures without mortality and with only four serious complications, none of which were colonic perforations or related to poor technique. This suggests that the complication rate from radiographer performed barium enemas is of the same order as that of radiologist performed procedures, although much greater numbers are needed before figures of statistical significance are achieved. Radiologists often reserve paediatric, instant and colostomy enemas for themselves as they consider them to be a difficult or high risk examination and this will need to be borne in mind when larger numbers of examinations become available for analysis, as this may bias results in favour of the radiographer performed examination. Without careful patient follow-up reliable information cannot be obtained as to the diagnostic accuracy of the radiographer performed examination although it is encouraging that only two radiographers were aware of having a false positive or false negative examination and evidence from a recent study [2] suggests that radiographer performed barium enemas are of comparable diagnostic accuracy to those performed by radiologists. However, larger studies will be required to confirm this. Radiographers currently are only performing an average of four examinations per session although the number increases as radiographers gain experience. Radiologists would be expected to perform longer lists, but nevertheless seventy-eight per cent of radiographers commented that there had been an improvement in service delivery, reflected by a reduction in the waiting list. This is likely to have been accomplished by better utilization of equipment with extra barium enema lists being performed by radiographers at times when X-ray rooms would otherwise lie empty. The barium enema technique used at St James's University Hospital was described during the course, but as the radiographers returned to their base hospital for practical
Radiographer-perJormed Barium Enemas
203
training under the supervision of their own consultant, it is perhaps not surprising that 70 per cent of radiographers reported that they followed their own consultant's technique. We advised radiographers to screen the barium into the rectum in the lateral position so that it would be immediately apparent if there were extravasation of barium due to a tear of the anterior rectal wall by the enema tube. In females this also makes it easier to recognize if the tube is misplaced and lies in the vagina. Eighty per cent of radiographers reported that they screened in the barium in the lateral position, but we were disappointed to find 20 per cent using either the prone or supine position. This again is likely to reflect their own consultant's practice. We advised that rectal balloons should not be used by radiographers as it has been suggested [3] that their use is associated with a significantly increased complication rate. We were surprised to find rectal balloons being used by 12 per cent of radiographers routinely and by as many as 40 per cent on an occasional basis. This again reflects the practice of radiologists as in another study we have found that 22 per cent of the radiologists who perform barium enemas use rectal balloons routinely (A. Blakeborough, personal communication). It is also our practice to use an intravenous antispasmodic (Buscopan or glucagon) for all barium enema examinations as it is our belief that it avoids misdiagnoses due to spasm and results in a dilatation and elongation of the colon which makes the images easier to interpret and also reduces the incidence of incontinence [4 6]. Despite the need for radiographers to obtain further training to give intravenous injections we were encouraged to find 85 per cent following our example. It was not our practice to use carbon dioxide to inflate the bowel although we did discuss this as an option that radiographers might like to consider [7]. Eight per cent of radiographers were using carbon dioxide to inflate the bowel and this again is likely to reflect their consultant's own practice. No doubt better compliance with course recommendations could be obtained if the course had also included practical training but the number of radiographers requiring training precluded this as an option. There is at present a shortage of consultant radiologists in the United Kingdom and because of this, radiologists are working well in excess of their college guidelines [8]. This is obviously one of the reasons why various forms of skill mix are of interest to radiologists but there is a risk of overloading radiographers unless extra staff can be recruited. One of the most frequent problems cited with training was lack of radiographic manpower so that radiographers found it difficult to find the time to put their new skills into practice. The next most frequent problem occurred in large departments where a radiographer was often performing a number of sessions per week with each session supervised by a different consultant and each consultant insisting on their own protocol being followed. Hopefully now that this problem has been identified it will be addressed by supervising consultants. Thirty per cent of radiographers reported that there had been a problem with the radiological supervision of their sessions. This mainly related to radiologists not being immediately available to give advice, which sometimes resulted in delays, although in general this was not considered to be a serious problem. Many radiographers expressed their frustration at having to cancel their lists when a radiologist was not available to supervise; perhaps because of sickness or annual leave. All radiographers who had been regraded since attending the barium enema course commented th.at the training helped them towards regrading. This was only one of a number of factors responsible, but it was an important one.
204
Bewell and Chapman
Overall, the response o f radiographers to this f o r m of role extension has been encouraging with 78 per cent reporting an i m p r o v e m e n t in service, indicating that this is a positive step forward towards the provision o f a quality radiology service. In view o f this, further courses have been planned.
Acknowledgement We would like to thank E-Z-EM, Inc. for their generous support for the barium enema training course.
References 1. Gore RM, Levine MS, Laufer I. Textbook o f gastrointestinal radiology Philadelphia: W.B. Saunders, 1994; 2595. 2. Mannion RAJ, Bewell J, Langan C, Robertson M, Chapman AH. A barium enema training programme for radiographers: a pilot study. Clin RadioI 1995; 50" 715 19. 3. Dodds W J, Stewart ET, Nelson JA. Rectal balloon catheters and the barium enema examination. Gastrointesti Radiol 1980; 5" 277-84. 4. Meeroff JC, Jorgens J, Isenbergh JI. The effect of glucagon on the barium enema examination. Radiology 1975; 115: 5-7. 5. Goei R, Nix M, Kessels AH, Ten Tusscher MPM. Use of antispasmodic drugs in double contrast barium enema examination: Glucagon or Buscopan. Clin Radiol 1995; 50: 553-7. 6. Lee JR. Routine use of hyoscine N butylbromide (Buscopan) in double contrast barium enema examinations. Clin Radiol 1982; 33:273 6. 7. Scullion DA, Wetton CWN, Davies C, Whitaker L, Shorven PJ. The use of air or CO2 as insufftation agents for double contrast barium enema (DCBE): Is there a qualitative difference? Clin Radiol 1995; 50: 558-61. 8. Medical staffing and workload in clinical radiology in the United Kingdom National Health Service. London: Royal College of Radiologists; 1993.
APPENDIX 1 QUESTIONNAIRE 1. 2. 3. 4. 5.
FOR R A D I O G R A P H E R S W H O H A V E A T T E N D E D T H E BARIUM ENEMA COURSE
H o w m a n y cases have y o u performed unaided? H o w m a y lists do you do a week? H o w m a y cases do you do per list? Have y o u encountered any problems with y o u r training? Whose b a r i u m enema technique do y o u follow? ours* / y o u r own* / y o u r consultants* (*please circle) 6. Have y o u been trained to give intravenous injections? If so do you use Buscopan* / glucagon* / neither* (pl. . . . . ircle) 7. In what position do you initially screen the b a r i u m in? prone* / lateral* / other (please specify) 8. D o you use rectal balloons? routinely* / occasionally* / never* (pl. . . . . . ircle) If SO do you: take a history f r o m patient o f rectal disease; do a digital rectal examination; insert a balloon catheter yourself; introduce barium to assess the rectum before inflating the balloon; inflate the balloon under screening control; obtain a post evacuation film.
Radiographer-performed Barium Enemas
205
9. Do you use carbon dioxide to inflate the bowel? 10. Do you encounter any problems with consultants being available for supervising the list? What problems have you had? 11. Has the training of radiographers to perform barium enemas resulted in any improvement in the service? yes* / unsure* / no* (*please circle) 12. Do you perform enerrias on GP cases? yes / no If so has the introduction of radiographers performing barium enemas resulted in any improvement in the GP service? 13. Are there any categories of barium enemas that are specifically referred for your consultant to perform? 14. Do you perform outpatient barium enemas / inpatient barium enemas / both inpatient and outpatient barium enemas? 15. Since running the service have you encountered any problems with errors being made in diagnosis? Please detail or instances in which, because of problems with the quality of an examination the barium enema has had to be repeated? Please detail 16. Since introducing the programme have you encountered any major complication? i.e. intraperitoneal perforation*, extraperitoneal perforation*, air embolism*, venous intravasation*, allergic reaction*, septicaemia*, cardiac arrhythmia* (pl. . . . . circle)
O t h e ~ p l e a s e specify 17. What is your grade? (i.e. Basic, Senior 2, Senior 1) Have you been regraded following your barium enema training? yes / no If so do you feel that your barium enema training helped you to obtain this regrading? 18. Any other comments?