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Investigating Hospital Deaths: Radiology Investigation

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  • 1. Investigating Hospital DeathsInvestigating Hospital Deaths:: Radiology InvestigationRadiology Investigation Dr Chris O’DonnellDr Chris O’Donnell RadiologistRadiologist June 2005June 2005
  • 2. IntroductionIntroduction  Aug 2004, Coroner convened aAug 2004, Coroner convened a Radiology forumRadiology forum • response to specific death investigationsresponse to specific death investigations • multiple contributors (“stakeholders”)multiple contributors (“stakeholders”)  AimAim • standardised approach to the investigation ofstandardised approach to the investigation of deaths where Radiology is involveddeaths where Radiology is involved • benchmark for hospitals (a la “falls” protocol)benchmark for hospitals (a la “falls” protocol) • preventionprevention
  • 3. OverviewOverview  what is radiological practice?what is radiological practice?  how has it worked in the past?how has it worked in the past?  current issues/problems affecting thatcurrent issues/problems affecting that practicepractice  what needs to be done to addresswhat needs to be done to address those issues (risk management)those issues (risk management)  Coronial impactCoronial impact  outcomesoutcomes
  • 4. Current/Future role of RadiologyCurrent/Future role of Radiology increased sophisticationincreased sophistication increased utilisationincreased utilisation increased clinical dependenceincreased clinical dependence • more Radiology/Radiologistsmore Radiology/Radiologists • pressure to be quick and to bepressure to be quick and to be accurateaccurate e.g. appendicitise.g. appendicitis
  • 5. Radiological processRadiological process  decision to investigatedecision to investigate  request issued for examination (referral)request issued for examination (referral)  examination performedexamination performed  images “available”images “available”  Radiologist interprets and issues a reportRadiologist interprets and issues a report  report returned to referrerreport returned to referrer  appropriate practitioner takes actionappropriate practitioner takes action
  • 6. HistoricalHistorical  clinical experience of referrerclinical experience of referrer  paper/film based (“analogue”)paper/film based (“analogue”)  9 – 5 (no weekends)9 – 5 (no weekends)  ““low tech” radiographslow tech” radiographs  referring doctor reviews and awaits finalreferring doctor reviews and awaits final reportreport  management often minimally altered bymanagement often minimally altered by that reportthat report
  • 7. Historical problemsHistorical problems  junior doctors - inexperiencedjunior doctors - inexperienced  paper/film based - gets lostpaper/film based - gets lost  9 – 5 (no weekends) – pts sick at all hours9 – 5 (no weekends) – pts sick at all hours  ““low tech” radiographs – inadequate Dlow tech” radiographs – inadequate Dxx  referring doctor reviews and awaits final report –referring doctor reviews and awaits final report – delayed or missed Ddelayed or missed Dxx  management rarely altered – delayed treatment ormanagement rarely altered – delayed treatment or ††  all above issues before the coronerall above issues before the coroner
  • 8. Issues affecting changeIssues affecting change  complexity of modern medical practice andcomplexity of modern medical practice and sophistication of the radiological imagingsophistication of the radiological imaging  increased reliance on imaging to manage patientsincreased reliance on imaging to manage patients • radiological triageradiological triage  desire to “sort patients out” prior to admission notdesire to “sort patients out” prior to admission not “admit for observation” as in the past“admit for observation” as in the past  administrative push to have patients transit throughadministrative push to have patients transit through ED < 8 hrsED < 8 hrs • financial imperativefinancial imperative  not enough radiologists for full time “access”not enough radiologists for full time “access”  perceived need for “universality” of medical careperceived need for “universality” of medical care • rural/remoterural/remote
  • 9. The idealThe ideal  everyone who needs a test gets theeveryone who needs a test gets the appropriate oneappropriate one  nothing gets lost!nothing gets lost!  24/724/7  sophisticated imaging techniquessophisticated imaging techniques (multislice CT/MRI/bedside US)(multislice CT/MRI/bedside US)  instant Radiological report transmittedinstant Radiological report transmitted immediately to referrerimmediately to referrer  acute specialist management based onacute specialist management based on that reportthat report
  • 10. SolutionsSolutions  defined imaging protocols or pathwaysdefined imaging protocols or pathways  fully integrated digital system (request and images)fully integrated digital system (request and images)  Radiologists available 24/7Radiologists available 24/7 • not necessarily in Department c/o teleradiologynot necessarily in Department c/o teleradiology  instant on line reportinginstant on line reporting  automated report transmission to referrerautomated report transmission to referrer • specified results leading to notification of specificspecified results leading to notification of specific cliniciansclinicians  information acted upon leading to managementinformation acted upon leading to management changechange
  • 11. PACSPACS • ppictureicture aarchive andrchive and ccommunicationommunication ssystemystem Industry solutionIndustry solution
  • 12. ““Digital” Radiological processDigital” Radiological process  patient slots into a “clinical pathway”patient slots into a “clinical pathway”  request for examination – on linerequest for examination – on line  examination performed – digital imageexamination performed – digital image  Radiologist issues a report – on lineRadiologist issues a report – on line  report returned to referrer – electronic post-report returned to referrer – electronic post- boxbox  appropriate practitioner takes action –appropriate practitioner takes action – automated “traffic lights”automated “traffic lights”
  • 13. Where are we now?Where are we now? analogue -------------------------------> digital mostmost ↑↑
  • 14. What most of us are doingWhat most of us are doing  requests based on experience of the doctorrequests based on experience of the doctor  mixed low tech/digital e.g. paper request, digitalmixed low tech/digital e.g. paper request, digital reportingreporting  9 – 5, M - F with reduced after-hours9 – 5, M - F with reduced after-hours  lot of low tech imaging increasing sophisticatedlot of low tech imaging increasing sophisticated (CT)(CT)  referring doctors after hours review plain films withreferring doctors after hours review plain films with some help from Radiologists (interim verbal reports)some help from Radiologists (interim verbal reports) • indecision and conflictindecision and conflict  some patient's management compromisedsome patient's management compromised • Health Services Commissioner, Courts, CoronerHealth Services Commissioner, Courts, Coroner
  • 15. ““fully digital” downsidesfully digital” downsides  too much reliance on protocoltoo much reliance on protocol • excessive use of resourcesexcessive use of resources  too much reliance on imagingtoo much reliance on imaging • treating the X-ray not the patient!treating the X-ray not the patient!  cultural change for Radiologists/clinicianscultural change for Radiologists/clinicians • more on-callmore on-call • ““soft copy” reporting i.e. computer screens not filmsoft copy” reporting i.e. computer screens not film  cost +++cost +++ • getting cheapergetting cheaper  needs to be integrated (at least state based)needs to be integrated (at least state based) • avoid theavoid the ββ v VHS scenariov VHS scenario • DICOM (Digital Imaging and Communications inDICOM (Digital Imaging and Communications in Medicine)Medicine)  patient “privacy”patient “privacy”
  • 16. Rural/remoteRural/remote limited high techlimited high tech limited Radiologist accesslimited Radiologist access reliance on non-specialistsreliance on non-specialists need for a digital 2need for a digital 2ndnd opinion!opinion! analogue -------------------------------> digital manymany ↑↑
  • 17. OutcomesOutcomes efficiency (average bed stay)efficiency (average bed stay) improved diagnosis (audits)improved diagnosis (audits) less “disasters” (internal M&Mless “disasters” (internal M&M Coronial review)Coronial review)
  • 18. Conclusion (1)Conclusion (1)  protocols will avoid patients falling through the netprotocols will avoid patients falling through the net  ““fully digital” will greatly assist the flow from request tofully digital” will greatly assist the flow from request to patient management actionpatient management action  we need help to move through the transition fromwe need help to move through the transition from analogue to digitalanalogue to digital  technology is availabletechnology is available  money is not (need for Governmental support)money is not (need for Governmental support)  need to involve cliniciansneed to involve clinicians • they need to understand the benefitsthey need to understand the benefits • assist in the protocol formulationassist in the protocol formulation • they need to be part of the process of implementation not tothey need to be part of the process of implementation not to have it imposed upon themhave it imposed upon them  measure outcomesmeasure outcomes
  • 19. Conclusion (2)Conclusion (2) Coroner’s Radiology InvestigationCoroner’s Radiology Investigation StandardStandard • assist in investigationassist in investigation • help to push along the modernisationhelp to push along the modernisation of the Radiological processof the Radiological process