Follow-up of consolidation on chest radiographs before and after the introduction of radiology initiated follow-up.
Cliffe H, Walsh J, Kon M.
Outline
•Background•Audit population, standard and method•1st round- 2012•Change implemented- July 2013•2nd Round- 2013•Discussion
Local Context Pre July 2013
Follow-up required
Add follow-up code (AC FUP) to the report
Admin search for the AC FUP
code(8 weeks post examination)
If no follow-up is arranged a reminder sent
to clinician
Local Context
•Serious incidents
•Consideration of radiology initiated follow-up
Question: does the current system of clinician booked follow-up ensure that
patients receive the recommended follow-up?
Audit population
•New consolidation on adult chest radiographs
•Non resolving consolidation may have a sinister aetiology (Little et al 2014, Holmberg et al 1993)
•Local guidelines in place
•High volume & short follow-up period
Audit design
Standard: Local guidelines state that all adults with new consolidation require a follow-up radiograph 6-8 weeks later to ensure resolution
Indicator: dedicated follow-up film request & report on CRIS
Target: 100% dedicated follow-up
Methods• Using Computerised Radiology Information
System (CRIS)• Reviewed chest radiograph (CXR) reports for
GP and ED referrals
•Did the CXR report NEW consolidation?•Was the follow-up code added by radiologist?
•Was the follow-up CXR booked?•Did the patient attend for follow-up?•How soon after did the follow-up film occur?
Round 1 results
• GP and ED referrals to BTHFT for CXR in August 2012
• 2628 reports reviewed
• 207 chest films reporting new consolidation • Mean age 64 years, range 19-90 years• 57% male, 43% female• 48% ED referrals, 52% GP referrals
Round 1 results•‘AC FUP’ code was used in 81% of reports
•Follow-up was achieved in 62% when the ‘AC FUP’ code was used and 28% when it was not used
TOTAL
GP
ED
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
% FOLLOW-UP WITH AND WITHOUT CODE
NO CODE AC FUP USED
Round 1 results
•Attendance at booked follow-up was 97%
•Mean time to follow-up was 10 weeks
•Overall 55% of patients with new CXR consolidation obtained appropriate follow-up imaging
Implementation of change- July 2013
Follow-up required
Add ‘AC FUP’ codeDefine FU required.
Clinician informed
Partial booking of
examination
Letter to patient
asking them to confirm
Examination confirmed
Examination occurs,
results to clinician, or
GP if discharged
from ED
Round 2
Question: has the implementation of radiology initiated follow-up improved
the attainment of follow-up of consolidation on chest radiographs?
•Methods, standard and indicator: as per round 1
•Assessment Period: August 2013
Round 2 results
•GP and ED referrals for CXR in August 2013•2336 reports reviewed
•172 reports described new consolidation•Average age 66 years, range 18-97 years•45% male, 55% female•61% GP referrals 39% ED referrals
Round 2 results
TOTAL
ED
GP
0% 20% 40% 60% 80% 100%
% USE OF FOLLOWUP CODE
2013
2012
‘AC-FUP’ code use improved from 81% to 93%
Round 2 results
When ‘AC FUP’ code used FU was booked in 96% of cases versus 64% previously
TOTAL
GP
ED
0% 20% 40% 60% 80% 100%
% FOLLOW-UP BOOKED WHEN AC FUP CODE USED
2013
2012
TOTAL
ED
GP
0% 20% 40% 60% 80% 100%
% AC FUP CODE USED AND FU ATTENDED
2013
2012
Round 2 results
When ‘AC FUP’ code employed FU achieved in 72% of cases compared to 62% previously
Overall DNA rate 12% versus 3% previously
Round 2 results
A&E GP OVERALL0
2
4
6
8
10
12MEAN TIME TO FU CXR
(WEEKS)
2012
2013
Mean time to FU improved from 10 to 7 weeks (within target)
Round 2 results
Overall 69% of patients with new CXR consolidation received FU CXR versus 55% previously.TOTAL
GP
ED
0% 20% 40% 60% 80% 100%
OVERALL % FOLLOW-UP OBTAINED
2013 2012
Study limitations
• Single indication and study• Single site• No ward or outpatients• Snapshot study, soon after
implementation
Discussion
•Increase in the attainment of recommended follow-up•Multifactorial•Marked improvement in code use and rates of patients offered follow-up•A streamlined patient journey•Low cost intervention•DNA rates•How do you safety net the safety net?
Acknowledgements Dr Jonathan Barber, Clinical Director for Imaging, Bradford Teaching Hospitals Foundation Trust.
Professor Clive Kay, Chief Executive, Bradford Teaching Hospitals Foundation Trust.
References 1. National Patient Safety Agency. Early identification of failure to act on radiological imaging reports, London NPSA, February 2007.
2. Holmberg H, Kragsbjerg P. Association of pneumonia and lung cancer: the value of convalescent chest radiography and follow-up. Scandinavian Journal of Infectious Diseases 1993; 25:93-100
3. Little BP, Gilman MD, Humphrey KL, Alkasab TK, Gibbons FK, Shepard JO, Wu C. Outcome of Recommendations for Radiographic Follow-up of Pneumonia on Outpatient Chest Radiography. American Journal of Roentgenology 2014; 202:1, 54-59
4. Standards for the communication of critical, urgent and unexpected significant radiological findings, Second Edition. London: The Royal College of Radiologists, 2012.
5. Berlin LM. Failure of Radiologic Communication: An increasing cause of malpractice litigation and harm to patients. Appl Radiol 2010; 39:17-25
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