ORIGINAL ARTICLE

Patient safety and image transfer between referring hospitals andneuroscience centres: could we do better?

MATTHEW CROCKER, WILLIAM B. CATO-ADDISON, SURESH PUSHPANANTHAN,

TIMOTHY L. JONES, JOANNA ANDERSON & B. ANTHONY BELL

Academic Neurosurgery Unit, St George’s University of London, London SW17 0RE, UK

AbstractIntroduction. District general hospital scanners have historically been linked to regional neuroscience units for specialistopinions on scans and to make decisions on transfer of patients requiring neurosurgical management. The implementation ofdigital picture archiving and communication systems (PACS) in all hospitals in the UK has disrupted these dedicated linksand technical and information governance issues have delayed reprovision of electronic transfer of images for rapid expertdecision making in this group of patients. We studied improvement in image transfer to acute neurosurgery units over a 4-year period.Methods. Four-year sequential review of national provision of image transfer facilities into neurosurgery units; observationalstudy of delays associated with image transfer modalities in one representative tertiary referral centre.Results. During the 4 years of study, all hospitals nationally have implemeted digital PACS systems for image viewing.Remote image viewing facilities have gradually changed with dedicated image links being replaced by remote PACS access.However, a minority of referrals (12%) still require images to be physically transferred between hospitals using couriers forCD-ROMs. The detailed study within our own unit shows that this adds a mean delay of 5.8 h to decision making.Conclusions. Image transfer in neuroscience has been neglected following the shift to PACS servers. The recommendationsof the 2004 Neuroscience Critical Care Report are unmet and patient safety is being threatened by a continued failure toimplement a coordinated solution to this problem.

Key words: Imaging, teleradiology, image transfer, NHS connecting for health.

Introduction

Clinical neuroscience and particularly neurosurgery

in the UK has historically been organised as a tertiary

referral service, with 33 acute adult neurosurgery

units (32 since 2009) receiving routine and emer-

gency referrals from defined regional networks. The

epidemiology of the neurosurgery caseload means

that it is not a viable alternative to have a larger

number of sub-regional neurosurgery units serving

small populations. As a result of this tertiary referral

organisation nearly all acute neurosurgery referrals

are made by non-surgical or non-neuroscience

specialties such as accident and emergency or general

medicine. Many of these referrals will be for advice

on management and not all will require inter-hospital

patient transfer.

Neurological diagnostic accuracy has been revolu-

tionised over the past four decades by the widespread

introduction of CT and subsequently MR scanning.

Specialist review of the imaging coupled with the

clinical history and examination findings secures the

diagnosis that underpins the correct management of

patients. This expert review of imaging by doctors

in the regional neurosurgical unit has become criti-

cal in the decision-making process as Figs. 1 and 2

illustrate.

Historically electronic image transfer was pio-

neered in Bristol with dedicated CT scanner links

using telephone lines and modems and was subse-

quently adopted UK wide with 56 K modem and

Integrated Services Digital Network (ISDN) con-

nections between neurosurgical units and referring

hospital scanners.1 As MRI came into clinical use,

electronic CT scan image transfer was supplemented

by couriers for photographic copies of images or

electronic copies stored on a compact disc (CD).

Since the establishment of the World Wide Web and

a standardised format (Digital Imaging and Com-

munications in Medicine: DICOM) for electronic

images, high speed broadband access to remote

patient images has become the gold standard.

Over the past decade, digital picture archiving

systems (PACS) have replaced photographic film

Correspondence: Matthew Crocker, Academic Neurosurgery Unit, St. George’s University of London, Cranmer Terrace, London SW17 0RE, UK.

Tel: þ44-0-208-725-5112. Fax: þ44-0-208-725-5139. E-mail: mjncrocker@gmail.com

Received for publication 10 March 2010. Accepted 11 July 2010.

British Journal of Neurosurgery, August 2010; 24(4): 391–395

ISSN 0268-8697 print/ISSN 1360-046X online ª The Neurosurgical Foundation

DOI: 10.3109/02688697.2010.508847

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records of patient imaging across the NHS and this

has enabled rapid electronic image transfer to the

tertiary centre via web-based software, potentially

removing the need for couriers, and reducing the

time from referral to formulation of a definitive

management plan.

There has been national and international

change in practice as a result of this technological

advance.2–6 The potential contribution of such

technology to patient care in a clinical neuroscience

setting was recognised by NHS Connecting for

Health in 2005 with recommendations that networks

should be set up to allow remote viewing of the

appropriate images to enable decision making for

neurosurgical patients.7

Prior to 2005 dedicated image transfer links from

district general hospital scanners to regional neuro-

surgical units were widely used and were reasonably

fast and reliable. The implementation of PACS

systems in referring hospitals meant that many of

these links had to be discontinued. Any computer or

scanner connected to PACS became a potential

source of entry to entire organisational IT systems.

The old arrangement of moving images from a single

computer in one organisation to a single computer in

another organisation was no longer possible in the

same way. The nearest equivalent was a DICOM

push, where a study could be ‘pushed’ from one

PACS workstation to another. A more commonly

implemented mechanism is to allow users at the

tertiary centre remote access to the referring hospital

PACS web server where images can be viewed

without being imported into the tertiary centre

system. In many cases such access has proved slow

or unreliable with potential adverse effects on patient

care. Part of the remit of the National Programme for

Information Technology in the NHS (NPfIT) was to

improve neuroscience teleradiology.7 We therefore

wanted to evaluate the provision of reliable image

transfer for neurosurgical review in an emergency

setting throughout the UK to see if our experience

was reflected nationally.

Methods

We assessed national provision for electronic transfer

of images to neurosurgery units and the ability of

consultants to review those images on call. This part

of the study was performed initially in November

2005 and repeated in November 2009 to identify

changes in provision. The on call neurosurgical

registrar at each UK neurosurgery unit was con-

tacted, and the following identified:

. PACS provision in the neurosurgery unit.

. Mode of transfer of images from referring

hospitals.

FIG. 1. A 35-year old man was referred with confusion and

headache after a head injury. The CT scan was reported locally as

showing a right-sided acute subdural haematoma, potentially a

neurosurgical emergency. The scans could not be electronically

transferred to the neurosurgery unit and were therefore sent on

CD with a courier whilst the patient was observed in the AþE

resuscitation room. On review the CT scan shows beam hardening

artifact in the right–middle cranial fossa (A, arrow) and no

pathology is demonstrated. This patient could potentially have

been intubated and transferred with an incorrect diagnosis that was

easily made with specialist review of the imaging. A comparable

image from another patient with a true-right sided acute subdural

haematoma is shown (B) for comparison.

FIG. 2. A 30-year old woman was referred with sudden onset of intermittent headaches for the past three days. She was confused at

presentation to her local hospital. The CT was reported to show subarachnoid haemorrhage with hydrocephalus and could not be transferred

electronically to the neuroscience centre. The decision was made to transfer the patient together with the CT scans and on arrival she was in

coma (GCS 4) with fixed dilated pupils. The CT scan showed lateral ventricular hydrocephalus due to a colloid cyst at the foramen of Monro

(A, arrow). The high density in the basal cisterns (B, arrow) is not subarachnoid blood but pial congestion due to raised intracranial pressure.

A CT scan of another patient with a subarachnoid haemorrhage (C, arrow) is shown for comparison.

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. Whether or not these images were routinely

reported by a radiologist at the time of referral.

. Availability of images from referring hospitals for

consultant neurosurgeon review on-call.

We also prospectively evaluated 143 referrals into

our neurosurgery unit over 6 weeks during October

and November 2009 and determined whether images

were reviewed by direct web access to the referring

hospital PACS, by a dedicated point to point

modem/ISDN connection (image link) or by cour-

iered CD-ROMs or films, and the delay associated

with each form of image transfer, defined as the time

from referral to scans being visible in the neurosur-

gical unit for review.

Results

During the period of study (November 2005 to

November 2009) PACS systems have been imple-

mented throughout UK. In November 2005, 62% of

neurosurgery units used PACS within their own

hospital and this has now increased to 100%. In

November 2005, 88% of neurosurgical referrals

relied on dedicated image links whereas 12% relied

on CD-ROMs or film copies of the images being sent

via couriers. In November 2009 image link use had

fallen from 88% to 38%, and remote web access to

PACS had risen to 51%. Somewhat surprisingly 12%

of referral pathways still relied on couriers for CD-

ROMs or films.

A marked difference was found between England

and Scotland with three of the four Scottish

neurosurgical units having reliable PACS links with

all their referring hospitals and not using couriers to

transfer images at all. It may be that lessons could be

learned from this Scottish experience to improve

arrangements in England and Wales.

To establish the quality of service in our own

region we prospectively carried out a detailed

analysis. Five of eight hospitals referring to our unit

are linked by remote PACS access, two by image link

supporting CT only, and one has no electronic link at

all. Of the 143 referrals we analysed, 66 involved

remote access to the PACS system of the referring

hospital to see the images, 38 used a dedicated image

link system and 39 used a courier to deliver CD-

ROMs of the images.

Remote access to PACS allowed rapid image

review with a median delay of 0 min and a mean

delay of 6 min. Image links were usually reliable but

there was an occasional severe delay (median delay

0 min, mean delay 84 min). Use of couriered images

was very slow with a median delay of 4 h and a mean

delay of 5 hours 48 min.

This detailed analysis from our own unit suggests

that image links are generally good when working,

but are unreliable. This is reflected nationally:

although in November 2009 the 317 hospitals

referring to acute neurosurgery units were linked

electronically in 88% of cases, 61% of the neurosur-

gery units in the UK were routinely using couriers.

This suggests that the electronic transfer systems in

place are unreliable.

In 2005, 12% of UK neurosurgery units provided

their consultants with the ability to review images at

home, but these were limited to images from the

hospital’s own PACS server and did not include

images from referring units. Mobile phones with

cameras were used in 9% of units for multimedia

messaging (MMS), a recognised form of image

transfer, although this modality transmits low resolu-

tion single images across an unsecured public

network.8 In 2009, this provision had improved

minimally with 12% of units reporting that scans

could routinely be reviewed by a consultant from

home, 33% saying they were occasionally able to be

seen but 55% reporting that scans could never be

seen by a consultant at home.

Discussion

It might be assumed that patients with a radiologi-

cally defined neurosurgical problem should auto-

matically be transferred with the imaging to the

regional neurosurgery unit. This would have appre-

ciable cost and service provision implications,

primarily of inpatient capacity, for the regional

unit.8 However our national survey found that only

24% of units said that scans of patients referred

acutely were reported by a radiologist, with 55%

saying that scans were sometimes reported and 21%

saying that scans were never reported. This is in

keeping with findings from our own study of 143

referrals in which 66% of scans were reported by a

radiologist at the time of referral and 34% were not.

Interhospital transfer of patients has been recog-

nised as a high-risk component of the care pathway

and is to be avoided where clinically unneces-

sary.9,10 Reliable teleradiology is therefore needed

not only to identify patients who need rapid transfer

but also to prevent unnecessary transfer of patients

who do not need neurosurgical intervention.

Our national survey and the findings from our own

unit allow us to make the following conclusions:

Many hospital CT scanners are linked to a neuro-

science unit by some form of electronic transfer

system, but these are now frequently unreliable. The

‘fall-back’ option of using a courier to transfer images

is employed surprisingly often, leading to lengthy

delays in offering specialist radiological interpretation

and neurosurgical opinions, and in formulating the

appropriate management plan for a patient. To put

these delays in context, the Royal College of

Surgeons in 1999 recommended a target of 4 hours

from injury to surgical intervention.11 Use of a

courier to transfer images adds a mean delay of

5.8 h to this process in our study. The RCS 4-h

target has been recognised as much more likely to be

achieved if the patient is admitted directly from

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the scene of the injury to the neurosurgery unit.12

This avoids two sources of delay: of inter-hospital

transfer of the images and subsequently transfer of

the patient.

The NHS Modernisation Agency Neuroscience

Critical Care Report in 2004 recognised that

teleradiology should be a cornerstone of an effective

acute neuroscience network.13 It also recognised that

image link systems relying on telephone modems are

unreliable. It recommended that broadband-based

teleradiology systems should be in place to facilitate

communication and decision making between refer-

ring units and neuroscience centres, and also

between these units and the consultants on call, to

enable the patient to receive consultant input to

diagnosis and decision making to ensure optimum

clinical management.

Attempts to improve remote access to PACS

systems are hampered by different manufacturers’

systems in different hospitals across the NHS,

software incompatibilities, and concerns over data

protection issues: that an employee of one NHS trust

might access confidential patient information in

another trust that they have no professional interest

in. Whilst regional image exchange systems have

been encouraged centrally by Connecting for Health

(CFH), ultimate responsibility for data sharing and

implementation has remained at a local and trust

level and as a result data protection concerns have

been given disproportionate weighting. The over-

riding concern of patient safety does not appear to

have been prioritised by those addressing this

problem nationally.

Successful implementation of a remote teleradiol-

ogy system requires the input of several people. First,

a senior radiologist (preferably a Clinical Director) at

the referring hospital must agree remote PACS

access and communicate that agreement to the

hospital’s PACS manager and IT department. The

IT departments of referring hospitals and the

neurosurgical unit must then liaise to set up remote

access through the referring hospital’s firewall.

Finally, the neurosurgical staff at the neuroscience

centre must be granted access. The security issues of

teleradiology have been discussed for many years.14

Conclusions

The teleradiology recommendations of the 2004

NHS Modernisation Agency Neuroscience Critical

Care Report have been largely ignored.15 It seems

likely that without a major change in the importance

assigned to this fundamental patient safety issue,

either as a result of threats of litigation against those

trusts where delays are considered negligent, or as a

result of persistent pressure from senior clinical

staff, that the status quo, characterised by systems

that have reached a ‘steady state’ of failure and

reimplementation, will continue. The enhanced

provision seen in Scotland may well relate to better

organisation across a smaller region and this might be

used as a solution for a better system in England.

The further progress of electronic image transfer

facilities may be driven internally from within

neuroscience units or by external regulation. Our

own attempts to improve our patient safety have been

hampered by concerns over data protection and a

lack of agreement between hospitals over the most

appropriate electronic image transfer system.

There are plans towards a much needed robust

image routing system across the NHS in England

and the Image Exchange Portal (IEP), originally

commissioned by the Department of Health for

transfer of images from Independent Sector Diag-

nostic Providers to NHS organisations, has been

scaled up to make it suitable for transferring images

between NHS organisations. Implementation is

scheduled for 2010 and is envisaged to support

emergency image transfer to tertiary centres PACS if

required. Continuing monitoring of this develop-

ment and audit of its functionality by the Connecting

for Health Safety Team and the National Patient

Safety Authority will be essential.

Acknowledgements

M.C. collected data from 2009 and designed, wrote

and revised the manuscript. W.C.-A. and S.P.

reviewed and revised the manuscript, and collected

the data from 2005 with assistance of Mary Murphy

(The Royal Free Hospital Neurosurgical Unit).

T.L.J. reviewed the manuscript and together with

J.A. collected and analysed data from 2009. B.A.B.

conceived and supervised the study from inception

and has critically reviewed and revised the manu-

script. The authors declare that they have no

competing interests. Matthew Crocker is funded by

the Neurosciences Research Foundation and the

London Deanery and Timothy Jones is funded by the

Neurosciences Research Foundation.

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