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Investigating Hospital Deaths: Radiology Investigation

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  • 1. Investigating Hospital Deaths : Radiology Investigation Dr Chris O’Donnell Radiologist June 2005
  • 2. Introduction
    • Aug 2004, Coroner convened a Radiology forum
      • response to specific death investigations
      • multiple contributors (“stakeholders”)
    • Aim
      • standardised approach to the investigation of deaths where Radiology is involved
      • benchmark for hospitals (a la “falls” protocol)
      • prevention
  • 3. Overview
    • what is radiological practice?
    • how has it worked in the past?
    • current issues/problems affecting that practice
    • what needs to be done to address those issues (risk management)
    • Coronial impact
    • outcomes
  • 4. Current/Future role of Radiology
    • increased sophistication
    • increased utilisation
    • increased clinical dependence
      • more Radiology/Radiologists
      • pressure to be quick and to be accurate
    • e.g. appendicitis
  • 5. Radiological process
    • decision to investigate
    • request issued for examination (referral)
    • examination performed
    • images “available”
    • Radiologist interprets and issues a report
    • report returned to referrer
    • appropriate practitioner takes action
  • 6. Historical
    • clinical experience of referrer
    • paper/film based (“analogue”)
    • 9 – 5 (no weekends)
    • “ low tech” radiographs
    • referring doctor reviews and awaits final report
    • management often minimally altered by that report
  • 7. Historical problems
    • junior doctors - inexperienced
    • paper/film based - gets lost
    • 9 – 5 (no weekends) – pts sick at all hours
    • “ low tech” radiographs – inadequate D x
    • referring doctor reviews and awaits final report –delayed or missed D x
    • management rarely altered – delayed treatment or †
    • all above issues before the coroner
  • 8. Issues affecting change
    • complexity of modern medical practice and sophistication of the radiological imaging
    • increased reliance on imaging to manage patients
      • radiological triage
    • desire to “sort patients out” prior to admission not “admit for observation” as in the past
    • administrative push to have patients transit through ED < 8 hrs
      • financial imperative
    • not enough radiologists for full time “access”
    • perceived need for “universality” of medical care
      • rural/remote
  • 9. The ideal
    • everyone who needs a test gets the appropriate one
    • nothing gets lost!
    • 24/7
    • sophisticated imaging techniques (multislice CT/MRI/bedside US)
    • instant Radiological report transmitted immediately to referrer
    • acute specialist management based on that report
  • 10. Solutions
    • defined imaging protocols or pathways
    • fully integrated digital system (request and images)
    • Radiologists available 24/7
      • not necessarily in Department c/o teleradiology
    • instant on line reporting
    • automated report transmission to referrer
      • specified results leading to notification of specific clinicians
    • information acted upon leading to management change
  • 11.
    • PACS
      • p icture a rchive and c ommunication s ystem
    Industry solution
  • 12. “ Digital” Radiological process
    • patient slots into a “clinical pathway”
    • request for examination – on line
    • examination performed – digital image
    • Radiologist issues a report – on line
    • report returned to referrer – electronic post-box
    • appropriate practitioner takes action – automated “traffic lights”
  • 13. Where are we now? analogue -------------------------------> digital most ↑
  • 14. What most of us are doing
    • requests based on experience of the doctor
    • mixed low tech/digital e.g. paper request, digital reporting
    • 9 – 5, M - F with reduced after-hours
    • lot of low tech imaging increasing sophisticated (CT)
    • referring doctors after hours review plain films with some help from Radiologists (interim verbal reports)
      • indecision and conflict
    • some patient's management compromised
      • Health Services Commissioner, Courts, Coroner
  • 15. “fully digital” downsides
    • too much reliance on protocol
      • excessive use of resources
    • too much reliance on imaging
      • treating the X-ray not the patient!
    • cultural change for Radiologists/clinicians
      • more on-call
      • “ soft copy” reporting i.e. computer screens not film
    • cost +++
      • getting cheaper
    • needs to be integrated (at least state based)
      • avoid the β v VHS scenario
      • DICOM (Digital Imaging and Communications in Medicine)
    • patient “privacy”
  • 16. Rural/remote
    • limited high tech
    • limited Radiologist access
    • reliance on non-specialists
    • need for a digital 2 nd opinion!
    analogue -------------------------------> digital many ↑
  • 17. Outcomes
    • efficiency (average bed stay)
    • improved diagnosis (audits)
    • less “disasters” (internal M&M Coronial review)
  • 18. Conclusion (1)
    • protocols will avoid patients falling through the net
    • “ fully digital” will greatly assist the flow from request to patient management action
    • we need help to move through the transition from analogue to digital
    • technology is available
    • money is not (need for Governmental support)
    • need to involve clinicians
      • they need to understand the benefits
      • assist in the protocol formulation
      • they need to be part of the process of implementation not to have it imposed upon them
    • measure outcomes
  • 19. Conclusion (2)
    • Coroner’s Radiology Investigation Standard
      • assist in investigation
      • help to push along the modernisation of the Radiological process