- Email: [email protected]
Re-audit of compliance with ‘standards for radiological investigations of suspected non-accidental injury’
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Abstract / Clinical Radiology 71 (2016) S11eS25
3. Whether the severity of the fracture was stated. Results of 1st audit round: Vertebral body fractures were detected in 49 cases. Of these, a vertebral abnormality was reported in 98%, with the term ‘fracture’ being used in 79%. Severity was only stated in 35% of cases. This represents a significant improvement on the previous audit where the figures were 88.5%, 13.5% and 32.6% respectively. 1st action plan: The audit was presented at a departmental meeting. Radiologists were encouraged to use ‘fracture’ terminology. In discussion with rheumatology, a trial of a ‘vertebral fracture’ folder on the picture archive and communication system (PACS) is being undertaken. Radiologists add all detected low-impact fractures. These are reviewed by the fracture liaison service ensuring patients suspected to have osteoporosis are investigated and treated appropriately. References: 1. World Health Organization. WHO scientific group on the assessment of osteoporosis at primary care health level. Summary Meeting Report. Brussels: World Health Organization, 2004. http://www.who.int/chp/topics/ Osteoporosis.pdf An audit of the investigation of urinary tract infections in children Authors: Monique Shahid, LeeAnne Elliott Background to the audit: Urinary tract infections (UTI) are the most common cause of bacterial infection causing illness in febrile children.1 The National Institute for Health and Care Excellence (NICE) recognises that renal scarring is well documented in children, which is subsequently associated with hypertension, proteinuria and established renal failure.2 The knowledge that such complications can occur has proved a major impetus in the investigation of paediatric UTI.1 Standard: Current NICE guidelines entitled Urinary tract infection in under 16s: diagnosis and management.2 Indicator: To assess the current practice of investigation in paediatric UTI at Bradford Royal Infirmary. Target: 100% concordance with NICE guideline recommendations. Methodology: Retrospective analysis of 119 paediatric ultrasound requests for UTI between April and December 2014. As per NICE guidelines, children were divided into three categories based on age. The pathway of investigation was evaluated according to first, recurrent and/or atypical UTI. Results of 1st audit round: Overall compliance with NICE guidelines across the three age groups was 48%. Compliance with guidelines was 53% in the under six months age group, 58% in those aged between six months and three years, and 34% in children aged over three years. Non-compliance was predominantly due to a lack of assessment with dimercaptosuccinic acid (DMSA) following ultrasound in indicated cases. Of the five abnormal DMSAs, ultrasound demonstrated a corresponding abnormality in four cases. 1st action plan: 1. Information cascaded to referring clinicians, reinforcing and improving awareness of current NICE recommendations. 2. Educational posters to simplify guidelines and summarise the salient points. 3. To re-audit to close the cycle assessing whether an improvement has been made. References: 1. Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteric reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology 2010; 255(3): 890e898. 2. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management. London: National Institute for Health and Care Excellence, 2007. Re-audit of referrals to the cerebral palsy hip surveillance programme Authors: Anmol Gangi, Karen Duncan Background to the audit: Children with cerebral palsy (CP) commonly experience hip problems; hip displacement occurs in approximately one
third of CP children.1,2 This risk of hip displacement is directly related to the gross motor function in a given CP child, ranging from just 1% in spastic hemiplegia to 75% in spastic quadriplegia.3 Since hip displacement may progress causing significant damage to the acetabulum and femoral head the lasting effects can be devastating, leading to the inability to sit and stand without discomfort, hip pain and scoliosis.4 Screening patients both clinically and radiologically allows earlier detection of hip abnormalities and consequently allows preventative measures to be taken. Standard: e CP patients referred for X-ray of hips should have the gross motor function classification system (GMFSC) group stated on the referral documentation. e CP patients should be referred for X-rays at the appropriate time intervals. Indicator: Referral information: GMFCS grading Date of imaging. Target: GMFCS grading: 100% Date of imaging: 95% Methodology: Patients identified from a locally held database. Their imaging record, including referral documentation was reviewed. Results of 1st audit round: e 54% of patients had GMFCS classification stated. e 48% of cases were imaged at an appropriate interval. 1st action plan: Since the previous local audit in 2012, a national surveillance programme in Scotland has been introduced e Cerebral Palsy Integrated Pathway Scotland (CPIPS). Much of the clinical monitoring is now done by physiotherapists who now take responsibility for the ordering of X-rays at clearly defined intervals depending on the severity of the CP. Results of 2nd audit round: e 98% of patients had GMFCS classification stated, although in 22% a range was given. e 85% of cases were imaged at an appropriate interval. 2nd action plan: Share results with CPIPS team. Aim to provide clear GMFCS classification on referrals. Discuss method of recording opt outs. References: 1. Speigel DA, Flyn JM. Evaluation and treatment of hip dysplasia in cerebral palsy. Orthop Clin North Am 2006; 37(2): 185e196. 2. Robin J, Graham HK, Baker R et al. A classification system for hip disease in cerebral palsy. Developmental and Medicine Child Neurology 2009; 51(3): 183e192. 3. Miller F, et al. Complications in cerebral palsy treatment. In: Epps CH, Bowen JR (eds). Complications in pediatric orthopaedic surgery. Philadelphia: Lippincott Company, 1995. 4. Lonstein JE, Beck K. Hip dislocation and subluxation in cerebral palsy. J Pediatr Orthop 1986; 6(5): 521e526. Re-audit of compliance with ‘standards for radiological investigations of suspected non-accidental injury’ Authors: Matthew Smedley, Heiko Peschl, Kaye Platt Background to the audit: Non-accidental injury (NAI) must be considered when a child presents with a fracture with an inappropriate history or the fracture has a higher specificity for NAI. In this situation the clinicians will request a skeletal survey to assess for further skeletal injury. In 2008 The Royal College of Radiologists and the Royal College of Paediatrics and Child Health produced the report Standards for radiological investigations of suspected non-accidental injury to ensure the best care for children with suspected NAI1. Standard: Standards for radiological investigations of suspected non-accidental injury. The gold standard was for 100% compliance with these guidelines. Indicator: Are we meeting the national standards? Target: 100% compliance.
Abstract / Clinical Radiology 71 (2016) S11eS25
Methodology: A retrospective audit of all patients who underwent skeletal survey for suspected NAI in the Oxford University Hospitals (OUH) NHS Trust between January 2007 and April 2011 was performed. Patients were identified by a computerised radiology information system (CRIS) search. Each skeletal survey was assessed against guidelines from the above standards for technical quality and the radiology report. After an intervention a re-audit was performed from May 2011 to January 2015. Results of 1st audit round: At least 97% compliance with the radiographic guidelines. Fracture aging was performed in 62% of cases. Only 2.5% of cases were verbally communicated to the referrer. 1st action plan: Implementation of trust-wide policy to verbally communicate and document all important findings. Results of 2nd audit round: 30% of cases were verbally communicated and documented in the report. This increased to 43% for non post-mortem skeletal surveys. 85% of fractures were aged. 87e97% compliance with the radiographic guidelines. 2nd action plan: Reaffirm importance of documentation of communication with referrers. Ensure all skeletal surveys are booked correctly onto CRIS. All images to be reviewed by a radiologist and repeated if necessary. References: 1. The Royal College of Radiologists and the Royal College of Paediatrics and Child Health. Standards for radiological investigations of suspected nonaccidental injury. London: The Royal College of Radiologists and the Royal College of Paediatrics and Child Health, 2008. Compliance with imaging guidelines for paediatric major trauma: results of second audit cycle Authors: Tharunniya Vamadevan, T. Sarvananthan, J. Kho, D. Sander, I. Moorthy Background to the audit: UK paediatric major trauma imaging guidelines were adapted for local use in 2014, aiming to reduce radiation dose1. Standard: The local guideline must be followed for all patients presenting with major trauma before their 17th birthday. Indicator: 1. Adequacy of clinical details on request form. 2. Dose reduction by: e Targeted computed tomography (CT) instead of full-body traumagrams e Fewer X-rays before chest and pelvic CT e Correct arm position and removing scoop during CT. 3. Immediate communication of life-threatening findings to clinical teams and a verified report on the picture archiving and communication system (PACS) within an hour. Target: 100% compliance. Methodology: Data retrospectively acquired for 37 months before guideline implementation and 12 months after. Results of 1st audit round: Number of patients¼43 Traumagrams¼30 (70%) Targeted CT¼0 Adequate clinical details¼93% Pre-CT chest X-ray (CXR)¼49% Pre-CT pelvic X-ray¼33% Correct (arms up) position during CT¼49% 1st action plan: Raise awareness of guidelines (presentation at clinical governance meeting). Results of 2nd audit round: Number of patients¼10 Traumagrams¼3 (30%) Targeted CT¼7 (70%) Adequate clinical details¼60% Pre-CT CXR¼40% Pre-CT pelvic X-ray¼10% Arms up position¼67% Improvements noted in report verification, scoop usage and traumagram doses but adequacy of clinical information declined. 2nd action plan: 100% compliance with: 1) Clinical information on request forms 2) ‘Arms up’ in CT 3) Report verified within one hour, with consultant input within 24 hours. References: 1. The Royal College of Radiologists. Paediatric trauma protocols. London: The Royal College of Radiologists, 2014.
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Safe radiology for junior doctors: closed-loop audit Authors: Mahmud Saedon, Hussein Kaderbhai, Sally Lewis, Akashdeep Nijjar Background to the audit: Despite being the largest imaging requesting cohort, junior doctors’ awareness of the Ionising Radiation (Medical Exposure) Regulations (IR[ME]R) 2000 regulations and their relevance to radiology requesting is unclear.1 We aim to investigate knowledge of these regulations using a questionnaire.2 Standard: RCR IR(ME)R 2000 regulations awareness questionnaire. 2 Indicator: Foundation Year doctors’ working at St Helier Hospital understanding of the IR(ME)R guidelines. Target: 100% positive response to each questionnaire. Methodology: The ‘Foundation Doctors e Radiation Legislation Awareness Questionnaire’ was distributed within a two-week period in December 2015. An intervention was put in place and a re-audit was completed in March 2016. Results of 1st audit round: Question e % Yes Q1 Are you aware of any governmental regulations on radiation? 18% Q2 Are you aware of any legal obligation to provide accurate information when requesting imaging? 27% Q3 Are you aware that the department of radiology has the right to withdraw radiology ‘ordering’ rights? 45% Q4 Are you aware of the book ‘Making the best use of clinical radiology services’? 9% Q6 Are you able to estimate the correct radiation dose of chest X-ray? Q7 Have you been asked by a senior colleague to request imaging and been unsure of the indication? 55% Q8 Do you feel you have had adequate teaching regarding appropriate radiology referrals? 36% 1st action plan: We developed a condensed teaching resource and incorporated this into the local Foundation Doctors teaching programme Results of 2nd audit round: Question e % Yes Q1 e 80% Q2 e 80% Q3 e 80% Q4 e 20% Q6 e 40% Q7 e 60% Q8 e 40% 2nd action plan: We continue to ensure the radiology resource is being used as part of the foundation doctors’ teaching programme. Our plan is to re-audit in one year to ensure standards are maintained as junior doctors rotate through the hospital References: 1. Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER). London: Department of Health, 2012 2. www.rcr.ac.uk/audit/foundation-doctors%E2%80%99-knowledgeradiation-legislation-and-exposure (last accessed 27/05/2016) The Royal College of Radiologists. iRefer: making the best use of clinical radiology. London: The Royal College of Radiologists, 2012. The Royal College of Radiologists. Recommendations for cross-sectional imaging in cancer management, second edition. London: The Royal College of Radiologists, 2014. Can I report chest X-rays? The General Medical Council may want to know... Authors: John Laurence Oakes Background to the audit: Measuring outcomes is difficult in diagnostic radiology, but potentially important in the current climate of appraisal and revalidation. Aim is to assess strategies for assessing diagnostic accuracy in plain chest reporting. Standard: No accepted error rate for diagnostic radiology. Published data suggests a wide potential error incidence rate of 2e20%.1
Abstract / Clinical Radiology 71 (2016) S11eS25
3. Whether the severity of the fracture was stated. Results of 1st audit round: Vertebral body fractures were detected in 49 cases. Of these, a vertebral abnormality was reported in 98%, with the term ‘fracture’ being used in 79%. Severity was only stated in 35% of cases. This represents a significant improvement on the previous audit where the figures were 88.5%, 13.5% and 32.6% respectively. 1st action plan: The audit was presented at a departmental meeting. Radiologists were encouraged to use ‘fracture’ terminology. In discussion with rheumatology, a trial of a ‘vertebral fracture’ folder on the picture archive and communication system (PACS) is being undertaken. Radiologists add all detected low-impact fractures. These are reviewed by the fracture liaison service ensuring patients suspected to have osteoporosis are investigated and treated appropriately. References: 1. World Health Organization. WHO scientific group on the assessment of osteoporosis at primary care health level. Summary Meeting Report. Brussels: World Health Organization, 2004. http://www.who.int/chp/topics/ Osteoporosis.pdf An audit of the investigation of urinary tract infections in children Authors: Monique Shahid, LeeAnne Elliott Background to the audit: Urinary tract infections (UTI) are the most common cause of bacterial infection causing illness in febrile children.1 The National Institute for Health and Care Excellence (NICE) recognises that renal scarring is well documented in children, which is subsequently associated with hypertension, proteinuria and established renal failure.2 The knowledge that such complications can occur has proved a major impetus in the investigation of paediatric UTI.1 Standard: Current NICE guidelines entitled Urinary tract infection in under 16s: diagnosis and management.2 Indicator: To assess the current practice of investigation in paediatric UTI at Bradford Royal Infirmary. Target: 100% concordance with NICE guideline recommendations. Methodology: Retrospective analysis of 119 paediatric ultrasound requests for UTI between April and December 2014. As per NICE guidelines, children were divided into three categories based on age. The pathway of investigation was evaluated according to first, recurrent and/or atypical UTI. Results of 1st audit round: Overall compliance with NICE guidelines across the three age groups was 48%. Compliance with guidelines was 53% in the under six months age group, 58% in those aged between six months and three years, and 34% in children aged over three years. Non-compliance was predominantly due to a lack of assessment with dimercaptosuccinic acid (DMSA) following ultrasound in indicated cases. Of the five abnormal DMSAs, ultrasound demonstrated a corresponding abnormality in four cases. 1st action plan: 1. Information cascaded to referring clinicians, reinforcing and improving awareness of current NICE recommendations. 2. Educational posters to simplify guidelines and summarise the salient points. 3. To re-audit to close the cycle assessing whether an improvement has been made. References: 1. Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteric reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology 2010; 255(3): 890e898. 2. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management. London: National Institute for Health and Care Excellence, 2007. Re-audit of referrals to the cerebral palsy hip surveillance programme Authors: Anmol Gangi, Karen Duncan Background to the audit: Children with cerebral palsy (CP) commonly experience hip problems; hip displacement occurs in approximately one
third of CP children.1,2 This risk of hip displacement is directly related to the gross motor function in a given CP child, ranging from just 1% in spastic hemiplegia to 75% in spastic quadriplegia.3 Since hip displacement may progress causing significant damage to the acetabulum and femoral head the lasting effects can be devastating, leading to the inability to sit and stand without discomfort, hip pain and scoliosis.4 Screening patients both clinically and radiologically allows earlier detection of hip abnormalities and consequently allows preventative measures to be taken. Standard: e CP patients referred for X-ray of hips should have the gross motor function classification system (GMFSC) group stated on the referral documentation. e CP patients should be referred for X-rays at the appropriate time intervals. Indicator: Referral information: GMFCS grading Date of imaging. Target: GMFCS grading: 100% Date of imaging: 95% Methodology: Patients identified from a locally held database. Their imaging record, including referral documentation was reviewed. Results of 1st audit round: e 54% of patients had GMFCS classification stated. e 48% of cases were imaged at an appropriate interval. 1st action plan: Since the previous local audit in 2012, a national surveillance programme in Scotland has been introduced e Cerebral Palsy Integrated Pathway Scotland (CPIPS). Much of the clinical monitoring is now done by physiotherapists who now take responsibility for the ordering of X-rays at clearly defined intervals depending on the severity of the CP. Results of 2nd audit round: e 98% of patients had GMFCS classification stated, although in 22% a range was given. e 85% of cases were imaged at an appropriate interval. 2nd action plan: Share results with CPIPS team. Aim to provide clear GMFCS classification on referrals. Discuss method of recording opt outs. References: 1. Speigel DA, Flyn JM. Evaluation and treatment of hip dysplasia in cerebral palsy. Orthop Clin North Am 2006; 37(2): 185e196. 2. Robin J, Graham HK, Baker R et al. A classification system for hip disease in cerebral palsy. Developmental and Medicine Child Neurology 2009; 51(3): 183e192. 3. Miller F, et al. Complications in cerebral palsy treatment. In: Epps CH, Bowen JR (eds). Complications in pediatric orthopaedic surgery. Philadelphia: Lippincott Company, 1995. 4. Lonstein JE, Beck K. Hip dislocation and subluxation in cerebral palsy. J Pediatr Orthop 1986; 6(5): 521e526. Re-audit of compliance with ‘standards for radiological investigations of suspected non-accidental injury’ Authors: Matthew Smedley, Heiko Peschl, Kaye Platt Background to the audit: Non-accidental injury (NAI) must be considered when a child presents with a fracture with an inappropriate history or the fracture has a higher specificity for NAI. In this situation the clinicians will request a skeletal survey to assess for further skeletal injury. In 2008 The Royal College of Radiologists and the Royal College of Paediatrics and Child Health produced the report Standards for radiological investigations of suspected non-accidental injury to ensure the best care for children with suspected NAI1. Standard: Standards for radiological investigations of suspected non-accidental injury. The gold standard was for 100% compliance with these guidelines. Indicator: Are we meeting the national standards? Target: 100% compliance.
Abstract / Clinical Radiology 71 (2016) S11eS25
Methodology: A retrospective audit of all patients who underwent skeletal survey for suspected NAI in the Oxford University Hospitals (OUH) NHS Trust between January 2007 and April 2011 was performed. Patients were identified by a computerised radiology information system (CRIS) search. Each skeletal survey was assessed against guidelines from the above standards for technical quality and the radiology report. After an intervention a re-audit was performed from May 2011 to January 2015. Results of 1st audit round: At least 97% compliance with the radiographic guidelines. Fracture aging was performed in 62% of cases. Only 2.5% of cases were verbally communicated to the referrer. 1st action plan: Implementation of trust-wide policy to verbally communicate and document all important findings. Results of 2nd audit round: 30% of cases were verbally communicated and documented in the report. This increased to 43% for non post-mortem skeletal surveys. 85% of fractures were aged. 87e97% compliance with the radiographic guidelines. 2nd action plan: Reaffirm importance of documentation of communication with referrers. Ensure all skeletal surveys are booked correctly onto CRIS. All images to be reviewed by a radiologist and repeated if necessary. References: 1. The Royal College of Radiologists and the Royal College of Paediatrics and Child Health. Standards for radiological investigations of suspected nonaccidental injury. London: The Royal College of Radiologists and the Royal College of Paediatrics and Child Health, 2008. Compliance with imaging guidelines for paediatric major trauma: results of second audit cycle Authors: Tharunniya Vamadevan, T. Sarvananthan, J. Kho, D. Sander, I. Moorthy Background to the audit: UK paediatric major trauma imaging guidelines were adapted for local use in 2014, aiming to reduce radiation dose1. Standard: The local guideline must be followed for all patients presenting with major trauma before their 17th birthday. Indicator: 1. Adequacy of clinical details on request form. 2. Dose reduction by: e Targeted computed tomography (CT) instead of full-body traumagrams e Fewer X-rays before chest and pelvic CT e Correct arm position and removing scoop during CT. 3. Immediate communication of life-threatening findings to clinical teams and a verified report on the picture archiving and communication system (PACS) within an hour. Target: 100% compliance. Methodology: Data retrospectively acquired for 37 months before guideline implementation and 12 months after. Results of 1st audit round: Number of patients¼43 Traumagrams¼30 (70%) Targeted CT¼0 Adequate clinical details¼93% Pre-CT chest X-ray (CXR)¼49% Pre-CT pelvic X-ray¼33% Correct (arms up) position during CT¼49% 1st action plan: Raise awareness of guidelines (presentation at clinical governance meeting). Results of 2nd audit round: Number of patients¼10 Traumagrams¼3 (30%) Targeted CT¼7 (70%) Adequate clinical details¼60% Pre-CT CXR¼40% Pre-CT pelvic X-ray¼10% Arms up position¼67% Improvements noted in report verification, scoop usage and traumagram doses but adequacy of clinical information declined. 2nd action plan: 100% compliance with: 1) Clinical information on request forms 2) ‘Arms up’ in CT 3) Report verified within one hour, with consultant input within 24 hours. References: 1. The Royal College of Radiologists. Paediatric trauma protocols. London: The Royal College of Radiologists, 2014.
S19
Safe radiology for junior doctors: closed-loop audit Authors: Mahmud Saedon, Hussein Kaderbhai, Sally Lewis, Akashdeep Nijjar Background to the audit: Despite being the largest imaging requesting cohort, junior doctors’ awareness of the Ionising Radiation (Medical Exposure) Regulations (IR[ME]R) 2000 regulations and their relevance to radiology requesting is unclear.1 We aim to investigate knowledge of these regulations using a questionnaire.2 Standard: RCR IR(ME)R 2000 regulations awareness questionnaire. 2 Indicator: Foundation Year doctors’ working at St Helier Hospital understanding of the IR(ME)R guidelines. Target: 100% positive response to each questionnaire. Methodology: The ‘Foundation Doctors e Radiation Legislation Awareness Questionnaire’ was distributed within a two-week period in December 2015. An intervention was put in place and a re-audit was completed in March 2016. Results of 1st audit round: Question e % Yes Q1 Are you aware of any governmental regulations on radiation? 18% Q2 Are you aware of any legal obligation to provide accurate information when requesting imaging? 27% Q3 Are you aware that the department of radiology has the right to withdraw radiology ‘ordering’ rights? 45% Q4 Are you aware of the book ‘Making the best use of clinical radiology services’? 9% Q6 Are you able to estimate the correct radiation dose of chest X-ray? Q7 Have you been asked by a senior colleague to request imaging and been unsure of the indication? 55% Q8 Do you feel you have had adequate teaching regarding appropriate radiology referrals? 36% 1st action plan: We developed a condensed teaching resource and incorporated this into the local Foundation Doctors teaching programme Results of 2nd audit round: Question e % Yes Q1 e 80% Q2 e 80% Q3 e 80% Q4 e 20% Q6 e 40% Q7 e 60% Q8 e 40% 2nd action plan: We continue to ensure the radiology resource is being used as part of the foundation doctors’ teaching programme. Our plan is to re-audit in one year to ensure standards are maintained as junior doctors rotate through the hospital References: 1. Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER). London: Department of Health, 2012 2. www.rcr.ac.uk/audit/foundation-doctors%E2%80%99-knowledgeradiation-legislation-and-exposure (last accessed 27/05/2016) The Royal College of Radiologists. iRefer: making the best use of clinical radiology. London: The Royal College of Radiologists, 2012. The Royal College of Radiologists. Recommendations for cross-sectional imaging in cancer management, second edition. London: The Royal College of Radiologists, 2014. Can I report chest X-rays? The General Medical Council may want to know... Authors: John Laurence Oakes Background to the audit: Measuring outcomes is difficult in diagnostic radiology, but potentially important in the current climate of appraisal and revalidation. Aim is to assess strategies for assessing diagnostic accuracy in plain chest reporting. Standard: No accepted error rate for diagnostic radiology. Published data suggests a wide potential error incidence rate of 2e20%.1