Towards best practice in interventional radiology


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Towards best practice in interventional radiology draws together the findings from visits to interventional radiology (IR) services at proposed major trauma centres in England during 2011/12. This record of their major findings provides a definitive read for trust chief executives and commissioners to help better inform IR service reviews. (June 2012)

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Towards best practice in interventional radiology

  1. 1. NHSCANCER NHS Improvement DiagnosticsDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - DiagnosticsTowards best practice ininterventional radiology British Society of Interventional RadiologyJune 2012
  2. 2. This document sets out case studies using servicedelivery models that provide benefits for patientsand staff. The clinical teams have shared theirlearning so that their experiences may be a stimulusto others to improve local interventional radiology(IR) services.
  3. 3. 3Towards best practice in interventional radiologyContentsExecutive summary 4Key messages 5Patient foreword 6Glossary of terms 7Abbreviations 8Introduction 10Networking 12Funding issues 14Facilities 15Staffing and team working 16Patient and public engagement and experience 18Leadership 20Low volume procedures 22Case studies Appendix A. Networking 24 Appendix B. Funding 32 Appendix C. Staffing and MDT working 34 Appendix D. Patient engagement and experience 45 Appendix E. Leadership 51Bibliography and suggested further reading 52Contacts 53Acknowledgements 54
  4. 4. 4 Executive summary Executive summary Towards Best Practice in Interventional Radiology draws together the major findings that came out of the visits to interventional radiology (IR) services at the proposed major Major Trauma Centres during 2011/12. Examples of best practice to provide benefits for patients and staff are described. The work by the NHS Improvement team to review IR services across England confirms that further improvements in IR are necessary to ensure equitable access to IR services for patients. The clinical teams at these centres shared their learning so their experiences may be a stimulus to Professor Erika Denton others. National Clinical Director for Imaging We urge you to read this report and to review the IR services you provide for those in your care. This report will support you to improve local IR services. Professor Erika Denton* Professor Keith Willett* Professor Keith Willett National Clinical Director for Imaging National Clinical Director for National Clinical Director Trauma Care for Trauma Care * The views of Professor Erika Denton and Professor Keith Willett are given in a clinical capacity and as national experts in the field. They do not in themselves impose any mandatory requirements on NHS organisations although commissioners are expected to take them into account.
  5. 5. Key messages 5Key messages • High quality IR services are essential for safe and effective patient care. • There is variation in provision of IR throughout England, particularly for potentially lifesaving emergency and out-of-hours procedures. • Despite this there are already many examples of good practice and service delivery across the country. • Networking will be essential to improve access to IR. There are challenges in developing effective operational delivery networks but there are already good examples of these in the UK. • A good well resourced IR service can contribute to significant savings (both financial and non-financial) along care pathways in both planned and emergency care. • The opportunity exists to use improvement techniques of standard work and visual management to create agreed standard operating procedures. This can support a network approach to providing on-call across a number of organisations.
  6. 6. 6 Patient foreword Patient foreword Provision of IR services enhances To be perceived as a world class From a patient’s perspective IR offers better outcomes for patients service, providers have to recognise the opportunity for a better patient receiving elective and non elective that patients’ groups are frustrated overall experience including reduced care for many conditions. Both that examples of best practice from length of stay and improved clinical commissioners and providers, within and outside of the UK, be it in outcome. including the medical profession and patient management, practitioner specialist IR staff need to recognise training or in communicating the that patients and their carers need value of IR are often overlooked more information and knowledge ‘because our organisation is about IR services. Communicating different.’ This is wasteful and the value of IR is vital to address the arrogant. IR has the capacity to differences of providing acute care, transform patient management, but such as when the patient arrives the benefits appear, to date, mostly unconscious and elective care which only recognised by a small group of Pat Kelly requires the patient’s consent for a highly committed, specialist and Lay Member booked procedure. personally motivated practitioners. Royal College of Radiologists Confusion about who performs IR Clinical Radiology Patients Importantly, patients and their persists - surgery, or radiology? It Liaison Group representatives want to be assured does not help the patient that this that best practice in IR is provided to debate has persisted unresolved for all service users on an equality of over twenty years. access basis across the country. This is an aspirational objective while Patients’ representatives have to be in services are being improved and a position to challenge Clive Booth evidence gathered. The challenge for commissioners and providers on the Former Chairman commissioners and providers of true role of IR including a patient Royal College of Radiologists health care will be to ensure that journey based on examples of best Clinical Radiology Patients good health care outcomes requiring practice, including adequate access Liaison Group IR are equally available wherever one to out-patient clinics, admission lives. rights and support staff.
  7. 7. Glossary of terms 7Glossary of termsA&E Accident and Emergency MR/MRI Magnetic Resonance ImagingAAA Abdominal Aortic Aneurysm MDT Multidisciplinary TeamBSIR British Society of Interventional Radiology MTC Major Trauma CentreCCG Clinical Commissioning Group NICE National Institute for Clinical ExcellenceCEO Chief Executive Officer NVD National Vascular Society DatabaseCPX Cardiopulmonary Exercise Testing OC On CallCT Computed Tomography OP OutpatientCIP Cost Improvement Programme PACS Picture Archiving Communication SystemDCC Direct Clinical Care PbR Payment by ResultsDGH District General Hospital PCI Percutaneous Coronary InterventionDOQI Disease Outcome Quality Initiative PICC Peripherally Inserted Central CatheterED Emergency Department PPM Planned Preventative MaintenanceeEVAR Emergency Endovascular Aneurysm Repair QA Quality AssuranceEPR Electronic Patient Record QIP Quality Improvement ProgrammeEVAR Endovascular Aneurysm Repair RCR Royal College of RadiologistsEWTD European Working time directive RETA Registry of Endovascular Treatment of AneurysmsHDU High Dependency Unit RIS Radiology Information SystemsHPB Hepato-biliary SLR Service Line ReportingHR Human Resources SVS Society for Vascular SurgeryHRG Healthcare Resource Group TACE Transcatheter arterial chemoembolisationIR Interventional Radiology TEVAR Thoracic Endovascular Aneurysm RepairIT Information Technology TIPS Transjugular intrahepatic portalITU Intensive Therapy Unit systemic shuntIV Intravenous UAE/UFE Uterine Artery (or Fibroid) EmbolisationIVC Inferior Vena Cava US UltrasoundMHRA Medicines and Healthcare Products Regulatory Agency
  8. 8. 8 Procedure descriptor Procedure descriptor Embolisation A minimally invasive procedure which involves the selective occlusion of blood vessels to prevent haemorrhage. EVAR Endovascular repair used to treat an abdominal aortic aneurysm A graft is placed in the aorta via the femoral arteries, without an abdominal incision, using X-rays to guide the graft into place. When this procedure is performed in an emergency setting it is called an Emergency Endovascular Aneurysm Repair (eEVAR) Fistulogram An X-ray taken of a fistula after a contrast medium has been injected. Hepatobiliary A term used to describe the liver, gallbladder and bile ducts. Nephrostomy An artificial opening created between the kidney and the skin used to drain urine from the kidney to a bag outside the body. TACE A minimally invasive procedure to restrict the blood supply to a tumour. TEVAR A minimally invasive approach to repair a thoracic aortic aneurysm. A graft is placed in the aorta via the femoral arteries, using X-rays to guide the graft into place. TIPS or TIPPS A procedure where a metal tube is passed across the liver
  9. 9. 10 Introduction Introduction The White Paper, Equity and Towards Best Practice in Excellence: Liberating the NHS1 and Interventional Radiology sets out case the Health and Social Care Act 20122 studies using service delivery models details how the improvement of that provide benefits for patients and healthcare outcomes will be staff. They are set around seven key measured using outcomes achieved themes: for patients rather than the processes by which they are achieved. • Networking • Funding Building on this aim, one of the • Facilities major purposes of The NHS • Staffing/MDT working Outcomes Framework 2011/123 was • Patient experience ‘to act as a catalyst for driving quality • Leadership improvement and outcome • Low volume procedures, measurement throughout the NHS by encouraging a change in culture and and align the case studies to the five behaviour, including a stronger focus domains (table 1) on tackling health inequalities.’ The NHS Outcomes Framework is Table 1 structured around five domains. Each of the five domains will be supported Domain 1 Preventing people from dying prematurely by a suite of NICE quality standards which will provide authoritative Domain 2 Enhancing quality of life for people with long term conditions definitions of what high-quality care looks like for a particular pathway of Domain 3 Helping people to recover from episodes of ill health or care. These quality standards are following injury currently being prepared. Domain 4 Ensuring that people have a positive experience of care Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm
  10. 10. Introduction 11The site visits and this report were Interventional radiology was felt toinspired by the two reports on be a significant challenge by many ofinterventional radiology published by the proposed Major Trauma Centresthe Department of Health in 2009 (MTCs) and a series of site visits wereand 20104,5. The 2010 report undertaken.Interventional radiology: guidance forservice delivery discussed how theNHS can improve quality, safety andproductivity while delivering Preferred acute patient pathwaycomparable or better outcomes forpatients with shorter hospital stays 24/7 network coordinator On scene triage Enhancedand fewer major complications. It in ambulance service care teamsuggests and describes how IRservices can help to ensure patientsafety whilst delivering the highest On call medical Direct Indirect consultant transfer transferquality care. (<45 mins) (geography, time critical intervention)A further driver was the 2010 reportby the NHS Clinical Advisory Group MAJOR TRAUMA CENTRE TRAUMA UNITRegional Networks for Major Trauma6 ?stated that ‘the delivery of effective Consultant led trauma team Trauma teamongoing trauma care and Immediate operating theatre Immediate CT scan All specialties Resus, assess and ? transfermanagement relies upon appropriate Immediate CT scanavailability of imaging techniques.’ Interventional radiology Specialist critical careThe key themes section within thedocument identifies ‘AcuteIntervention including...interventional radiology,’ and laid outa key recommendation: Towards Best Practice in appendix to the document and also Interventional Radiology builds on the on the NHS Improvement website atAt Major Trauma Centres work done in 2011/12 to visit all of ( radiology the agreed and proposed Major Additional case studies will be addedcapability will attend within 60 Trauma Centres in England. It draws on the website as they becomeminutes 24 hours a day. together the major findings that available and new examples of bestInterventional suites should be came out of the visits and cites practice are identified.ideally co-located with operating examples of best practice. Theserooms and/or resuscitation areas. examples are provided as
  11. 11. 12 Networking DOMAIN DOMAIN DOMAIN DOMAIN 1 3 4 5 Networking The recent Vascular Society Setting up a operational delivery Examples of good practice publication, The provision of services network can be challenging with 1.Networked on call IR services for patients with vascular diseases difficulties that may include: between several major centres 20127 emphasises the importance of around Glasgow with radiologists good clinical operational delivery • historically poor communication and nurses travelling to the patient’s networks. Whilst this document between sites; location. To overcome the issue of largely refers to vascular surgery and • possible threats to income flows; availability of specialist consumables interventional radiology (IR) related to • reluctance of staff to work on new the travelling staff carry a large box vascular surgery the same principles and unfamiliar sites; of IR equipment such as wires, apply to all forms • risks of transferring critically ill catheters and embolisation coils. This of IR. patients; good practice example is described in • bed availability if patients need to more detail in the Appendix A. In many UK hospitals there are be transferred between sites; difficulties in providing interventional • staff shortages; 2.Networked on call IR services procedures required to support the • differing practices and skill sets on between a large hospital in Coventry full range of clinical activity taking different sites; and with four interventional radiologists place within that centre. This has • standardising equipment and and a smaller hospital in a nearby city been confirmed by a recent detailed pathways across sites. (Nuneaton) with two interventional survey that shows variable and radiologists. The emergency on call patchy provision of IR throughout As with any service improvement, service is based in Coventry. In order England8. For example, many where these issues have been to overcome the issues of different hospitals admit acute medical and overcome there has been skill sets, experience and working surgical emergencies but have no engagement and good practices and the challenge of provision for emergency embolisation communication between clinicians working in an unfamiliar environment for haemorrhage. and managers on all involved the Nuneaton radiologists have locations. Examples of successful regular elective IR lists in Coventry. The areas of greatest difficulty are operational delivery networks in This good practice example is complex, low volume procedures and different geographical environments described in more detail in the the provision of emergency out-of- are given below. Appendix A. hours IR in general. This particularly applies to smaller acute hospitals where there will never be sufficient numbers of specialised staff to create a stand-alone on call rota. It is likely that effective networking between centres is the only means of achieving a sustainable solution that will enable equitable access to IR services across the country. 7Vascular Society of Great Britain and Ireland. The Provision of Services for Patients with Vascular Disease. London 2012. Interventional Radiology Service Provision Mapping 2011
  12. 12. Networking 133.Networked on call IR servicesbetween two similar sized hospitals ina rural setting (Exeter and Torbay),each with three interventionalradiologists. Week days and eveningsare covered locally with theradiologists on a 1:3 rota Monday toThursday on each site. Overweekends there is one interventionalradiologist on call for both sites,resulting in an acceptable 1:6weekend rota. The radiologist usuallytravels to the patient’s hospital andthere are interventional nurses andradiographers on call on both sites toenable this. This good practiceexample is described in more detail inthe Appendix A.4.Agreed pathways between centresfor low volume/specialist servicessuch as hepatobiliary or thoracicaortic intervention.5.Implementation of radiologynursing cross site rotation. Thesystem supports safe practice,increased knowledge base andnursing job satisfaction, plus aidsrecruitment. Cost savings can bemade by reducing two on call rotasto one. This good practice example isdescribed in more detail in theAppendix A.
  13. 13. 14 Funding issues DOMAIN DOMAIN DOMAIN DOMAIN 1 2 3 5 Funding issues Almost without exception during the Clinical coding decisions, prioritise new service site visits to the MTCs, funding issues Interventional radiology cases often developments or plan new clinical and concerns were raised by all of proceed or change once the patient investments. However where a the teams visited. The issues fell is ‘on the table’ and this is not always service costs more to deliver than the largely into five categories. reflected accurately in the notes or income it receives for delivering the on the Radiology Information System service it takes a team with foresight Getting income for referrals from (RIS). This makes accurate clinical to recognise the non financial other hospitals coding impossible. Clinical coding is incentives of delivering this service. This was a significant cost pressure most usually done by a team of for many departments. There were admin staff remote from radiology. In Examples of good practice few examples of agreed referral some centres there was little 1.Accuracy of coding for IR pathways and funding streams. recognition of why it is important to procedures is vital to reflect workload Where a referral protocol was in accurately reflect the procedure and ensures maximum income for IR place it was mostly between clinical codes and in others frustrations that departments. This ensures that specialties and the first IR knew of they felt powerless to influence the resources follow clinical activity. This the origin of the patient was when process. good practice example is described in they received the request. more detail in the Appendix B. Internal re-charging This was reported as a much more Several sites had set up a system of 2.Internal recharging was seen significant problem where DGHs internal charging. Setting up the working well in several of the sites provided an in hours or simple IR system had proved to be a lot of visited. At least two sites service but did not undertake initial work but where it was working demonstrated that it was possible to complex procedures or provide an well was felt to be hugely beneficial. reduce unit costs. out of hour’s service. The two primary reasons cited were; 3.Sites delivering an OP service or Tariffs • to influence decisions that affect post procedure telephone follow up Despite significant progress centrally the service by showing how much were working with their clinical many sites reported that the tariff did ‘income’ the service could coding teams to secure the tariff for not adequately reflect the actual cost generate; and imaging services. of delivering the service. This was • to reflect back to referrers the true particularly apparent in centres costs of an IR intervention. offering a tertiary level of care where they were asked to undertake the Service line reporting (SLR) most complex cases and often the SLR measures profitability of its out of hours work for surrounding services by monitoring cost, income, DGHs. activity and use of resources. It can enable a trust to increase its productivity by providing financial information to make informed
  14. 14. Facilities 15 DOMAIN DOMAIN 4 5FacilitiesEquipment and site guidance – Delivering an EVARTheatre design should ensure that all Service (2010)9. It should be of Examples of good practiceconsumable equipment (catheters sufficient size to permit full 1.Monthly QA checks on dose andstents, embolic material etc) is in a anaesthetic facilities, including piped image quality are recorded on asuitable equipment storage area gases, drugs and anaesthetic database and displayed graphically.immediately accessible from the IR equipment. This allows trends to be quicklytheatre. Consumable equipment identified and in one site hadshould include a full range of The theatre environment should have supported a dose reduction ofequipment suitable for embolisation a staffed recovery area to allow approximately control haemorrhage, stents and reception and onward transfer ofstent grafts suitable for major and patients to other environments. 2.Having procedure trolleys made upminor vessel repair and a ‘bail out and ready for quick access whenbox’ with everything needed for The theatre should be located as required in an emergency was incomplications. close as possible to the emergency place at several of the sites visited. CT scanner and care taken to ensureMajor Trauma Centres should be able a rehearsed rapid transfer facility. 3.IT resilience for CT scanners thatto provide Thoracic Endovascular may be required for major trauma,Aneurysm Repair (TEVAR) for IT links had been achieved by hardwiring aappropriate cases and facilities, Access to Picture Archiving & PC for each scanner separate frompathways and workforce should be in Communication Systems (PACS) PACS within the CT control to support this activity. workstations and RIS systems should be available within the IR theatre.At present, there is variation in the Teleradiology links are vital andprovision of emergency Endovascular access to a robust and rapid transferAneurysm Repair (eEVAR) for of imaging scans from hospitalsruptured abdominal aneurysms. Trial throughout the local traumadata on open surgical versus operational delivery network isendovascular repair will report in the essential. If image exchange portalsnear future and are likely to inform are required these must be testedfuture practice. Where the service is regularly and robustly to ensure thereprovided, the Interventional are no delays in image transfer andRadiology facilities should preferably should be available 24/7 at bothbe of theatre standard ventilation and sending and receiving hospitals.if being used for endovascular repairshould comply with the relevantMHRA (Medicines and Healthcareproducts Regulatory Agency)Joint Working Group to produce guidance on delivering an Endovascular Aneurysm Repair (EVAR) Service. (2010)
  15. 15. 16 Staffing and team working DOMAIN 4 Staffing and team working The provision of an IR service requires • easier separation/identification of procedures for most of their time at teamwork both within radiology and funding; work. However, even in larger units with other specialities. Planning • protection of demands from non-IR the number of trained IR radiographers service provision will relate to demand radiology; may be small and the on call may which in turn will vary depending on • autonomy for service provision; and therefore be onerous. Combining the clinical commitments locally and use of easier access to outpatient facilities. on call with radiographers from e.g. other resources (see networking Disadvantages: CT, Cardiac Labs and Neuro- above). Staffing levels will reflect this • IR radiologists will usually drop other intervention could have the advantage and will need to be tailored for radiology skills. Although this may of creating a larger pool of individual departments. The IR team mean greater individual experience, radiographers; however, careful local usually comprises radiologists, IR the workload will need to be greater planning is required as Percutaneous nurses, IR radiographers, clinical to provide the elective work and Coronary Intervention (PCI) and neuro- assistants and support staff including therefore justify enough IR intervention can use up a lot of clerical staff, porters and managerial radiologists to maintain an on-call radiographer time. Maintaining support. rota; competency across these different • maintaining a non-vascular IR service subspecialties would then be required. 24/7 availability of IR nursing staff and and on call rota; and radiographers with experience of IR • vascular surgery contributes a Interventional nurses theatre is essential. All day, every day variable proportion, often less than The RCR document Guidelines for availability of an Interventional 50%, of the IR vascular workload. Nursing Care in Interventional Radiologist with experience in Radiology (2006)10 emphasized the embolisation for haemorrhage control IR as part of the radiology service. importance of nurses in IR and treatment of vascular injuries with Advantages: departments. Effectively all radiology stent and stent grafts is essential. • IR radiologists with other departments that undertake IR subspecialty skills can be employed. procedures now have their own There are different issues relating to This can justify a greater number of nurses. However, the job description each of the groups involved in the IR radiologists and aid provision of varies widely between trusts. Almost clinical care of IR patients. on-call IR. all units with significant IR demand will Disadvantages: also provide an on-call IR nurse service. Radiologists • maintaining competency with non IR Some larger institutions even provide Interventional radiologists’ portfolios demands a fixed time commitment; two nurses on call. Pooling nurses and workload vary enormously and • identification of funding and from other departments has been there are many different IR service funding streams. introduced to facilitate this and may models across the NHS. involve cross covering of neuro- IR as part of a operational delivery intervention and cardiac theatres. IR as part of a vascular service. network service. At least two NHS trusts now provide IR Please see ‘networking’ section. Extended role of IR nurses has been services under the umbrella of vascular successfully introduced in a number of services, separated from the Imaging Interventional radiographers institutions and includes amongst Department. All IR units will have radiographers on others: Advantages: call for IR procedures. In larger units • involvement in an IR out-patient • integrated working with vascular the radiographers will all be trained in clinic; surgery; IR and probably assisting in elective IR • pre-assessment of patients; 10
  16. 16. Staffing and team working 17• insertion of central lines; Friday afternoon lists over run with 6.Patients treated by EVAR require• undertaking arterial punctures; procedures that could wait until the surveillance scans at one month, 6• ascites drainages; and following day but not over a whole months, 12 months and annually• nurse led pain control. weekend. One site has instigated thereafter to monitor aneurysm sac regular weekend daytime IR lists to size and check for the presence ofThe role of an IR nurse in the patient overcome this issue. This has helped endoleaks as per Society for Vascularpathway is variable. There is potential to relieve pressure on beds and Surgery (SVS) guidelines. Patientsfor involvement in the pre-operative, reduced length of stay. This good can be lost to follow up. One sitepre-procedural, procedural and practice example is described in has developed a robust system torecovery components. Many hospitals more detail in the Appendix C. ensure that patients are invited forhave recovery areas managed outside their surveillance scans in a timelythe radiology department. One of the 4.Historically, surgical placement of manner. This good practice exampleadvantages to this arrangement lines required an in-patient stay, is described in more detail in theincludes the flexibility in staffing a theatre time and a surgeon / Appendix C.larger unit. Having recovery ‘in-house’ anaesthetist. This service washas the advantage of protected beds identified as ideal for advanced 7.Patient selection and prioritisation ofand specialised skills. practice and several sites have elective patients requiring EVAR led moved to the placement of lines by one site to develop a database withExamples of good practice radiology nurses or radiographers. a scoring system to aid the decision1.Radiology matrons were in place at This good practice example is making process. The database tracks several of the sites visited. This role described in more detail in the elective patients through their work gave the service opportunities of Appendix C. up for EVAR and subsequent post- support and input at a senior procedural surveillance. Additionally, nursing level that was found to be 5. Where the IR out of hours workload the database allows prospective data invaluable. is insufficient to warrant a shift collection on aneurysm morphology, system a ‘light duties’ rota can be device performance and unit2.A cascade system has been introduced. At one site each IR mortality, morbidity and the established to ensure that the IR performs a week on call and full requirement for secondary response in an emergency situation week-end cover. During this week intervention. This good practice of a ruptured aortic aneurysm is no routine lists are booked for the example is described in more detail efficient and timely and that each on call IR. The diagnostic and non in the Appendix C. member of the team is aware of clinical components of an their role. This good practice interventional radiologist’s job can 8.Extending the role of the example is described in more detail still be covered during this week, radiographer has been developed in in the Appendix C. but at hours that are more flexible an IR department, underpinned by to allow sufficient rest after an protocols approved by the Trust3.Many IR departments find additional onerous night on call. This good protocols group. This good practice pressure on a Friday afternoon and practice example is described in example is described in more detail Monday morning IR lists due to more detail in the Appendix C. in the Appendix C. bottlenecks of in-patient demand.
  17. 17. 18 Patient and public engagement and experience (PPEE) Patient and public engagement DOMAIN and experience (PPEE) 4 The Government has shown an comment those that did were able to • Evidence suggests a strong link ongoing commitment to involve describe the reassurance that clinical between good communication and people in their own healthcare and in staff provided. On reflection, patient satisfaction and many of the planning, review and delivery of patients were able to identify a the sites visited invested time in health care. Equity and Excellence – number of weaknesses through their direct communication between the Liberating the NHS¹ states ‘Too often, trauma pathway including: IR team and the service user. patients are expected to fit around • the need for better pre-hospital • Almost all undertake regular services, rather than services around assessment to ensure people are patient audit review of services, patients….’ Patient and public transferred to a hospital best however it must be recognised that engagement and experience has equipped to treat their injuries; the gathering of feedback to make become a statutory requirement of all • a number of hospitals which they changes or improvements to NHS organisations. It ensures that were taken to were not equipped services, is of little use if sites then service providers have the to deal with their needs; fail to act upon the feedback opportunity to listen, understand and • in some instances ambulances within the organisation. respond to service user needs, caused great discomfort and were • All sites used a variety of perceptions and expectations. This not adequately equipped to information leaflets, both national can then be used to inform transport them; and local however it must be kept continuous improvement and service • sometimes care was perceived to in mind that studies12 show that transformation. be sub standard by professionals health information for patients and who did not have the expertise to the public is written at an above Stakeholder engagement including deal with their injuries and in some average reading ability, making it patient representation will be instances wrong treatment difficult for some service users to required in development of care resulting in prolonged and multiple understand. pathways. The Regional Trauma treatments and delayed recovery; • The British Society of Interventional Network Engagement Project11, using and Radiology (BSIR) have developed a a multi strand engagement approach, • a complete lack of co-ordination number of patient literature leaflets appeared to ensure that sufficient and support once people are these have been developed to breadth and depth of contributions discharged from acute hospital provide standard and consistent were achieved. The combination of care. messaging for patients and reduce activities facilitated both quick and the need for local IR teams to easy responses from a high volume of This is the type of structured process spend time developing their own. self selecting respondents as well as which is required to further develop supporting in-depth and considered services in ways which ensures contributions from a carefully patient confidence in service delivery. selected mix of stakeholders including patients exploring their Most of the sites visited recognised experiences and making the value of engaging with patients recommendations. Although a and service users in a variety of ways. number of patients were not able to Department of Health. Regional Trauma Networks. Engagement Strands Report (2010) London 11 Coulter A and Ellins J. (2006) The quality enhancing interventions project: patient focused interventions. London: The Health Foundation. 12
  18. 18. Patient and public engagement and experience (PPEE) 19• Patients must be made aware of the risks and benefits of IR when compared to more conventional surgical or medical procedures. This is not always possible when urgent intervention is required in trauma situations. Patients can be assured by good clinical governance that risk is minimised and managed by robust clinical protocols based on best evidence and constant review of critical incidents.Examples of good practice1.Several sites have set up new and 3.Patient feedback following 4.Several sites have introduced follow up patient clinics in imaging fistuloplasty revealed that patients dedicated written care pathways to or out-patient (OP) departments for found the procedure extremely ensure consistency of care in interventional radiologists to see, painful and traumatic and also patient needing either elective or counsel and consent new patients suggested that some patients may emergency intervention. and to see follow up patients. An refuse further interventions. This increase in patient satisfaction has poor quality experience needed to 5.An IR patient satisfaction survey been demonstrated. These good be addressed and a nurse led pain has been undertaken to gain practice examples are described in management service using an feedback about the quality of the more detail in the Appendix D. opiate analgesia was introduced. service. The aim was to determine This has had a major impact on the patient experience and2.Other sites follow up their patients effective pain management. Results highlighted any potential areas for post procedure by telephone. This from a pain audit tool showed that improvement. This good practice attracts a tariff. a large percentage of patients example is described in more detail subsequently reported a pain score in the Appendix D. of less than five and patients were happier to return for further procedures. This good practice example is described in more detail in the Appendix D.
  19. 19. 20 Leadership DOMAIN DOMAIN DOMAIN 3 4 5 Leadership A good IR service requires close team Financial solvency is clearly a key Clinical and strategic leadership is work and cross discipline co- component of the ability of the Trust vital in developing links with operation to ensure correct patient to achieve success in this field as IR is neighbouring Trusts both in terms of and procedure selection and timely an expensive modality, although IR establishing appropriate referral service delivery, particularly in the may be (and usually is) considerably pathways and protocols and in setting of acute trauma. Skilful and cheaper than other treatment creating effective clinical operational inspirational leadership at all levels in options13. Good financial leadership delivery networks. This might assist the team maintains morale under at executive level however will realise with managing demand and ensuring working conditions that are often at the potential of IR to generate that appropriate patients are referred high stress levels. Developing IR income by appropriate operational on to IR centres. teams into effective components of a delivery network arrangements, and major trauma team needs strong by ensuring that activity is correctly Leadership and support from IT executive leadership, particularly with captured and charged. services is also important to ensure the forthcoming challenges of that communications are maintained vascular reconfiguration adding to Within IR teams we have seen 24 hours 7 days a week, particularly the pressure for services. examples of good leadership from in relation to image transfer, and we clinicians, radiographers and nursing have seen several examples where Executive leadership has been seen to staff. Conversely we have seen teams have struggled to provide have an important role in the examples where elements of the optimum patient care because development and function of IR team are dispirited by a sense of lack images cannot be transferred to the teams. Where good leadership was of involvement and integration either tertiary centre in a timely manner. seen the importance of IR was owing to lack of leadership by their recognised and the teams were more professional peers or of the wider Across the country the effectiveness likely to be supported by adequate team. Good leadership supports all of leadership is very variable, notably resource in terms of equipment and members of the team to make them at executive level. Sites exhibiting manpower, and to figure in the feel useful and valued, and also good leadership are often hard strategic plans of the Trust. Where provides the possibility of professional pressed but cope with enormous this was not evident IR teams are development of team members pressures, whereas demoralisation more likely to be understaffed and within their own sphere. and stress are the hallmark of sites working with substandard or Co-operative working across where some elements of this effective outdated facilities, struggling to traditional boundaries can lead to a leadership are missing. identify the way forward. greater sense of teamwork and enhance the robustness of the service. An example of this would be non consultant led services such as line insertion developed by nursing and/or radiographic staff with the necessary support from consultant colleagues. Patients and clinicians have benefited considerably where this has been achieved.
  20. 20. Leadership 21Examples of good practice1.The introduction of a ‘radiologist of the day’ to whom all queries are directed allows other IR staff to get on with work without interruption. This system has improved productivity and made managing the workload simpler. All work is clearly displayed on a white board and this is constantly updated. It contains a list of pending cases so the team are aware of outstanding cases, priority can easily be re- ordered or if an opportunity presents the appropriate case can easily be added. The interventional radiologists cross cover for each other, vet and add cases to each other’s lists.2.A monthly diary meeting attended by all IR consultants where commitments are discussed in advance so that the team know who to approach on any given session to discuss or perform emergency interventions. Where possible absences are covered but lists are not booked if a session cannot be covered. This prevents patients having to have their procedures cancelled. This good practice example is described in more detail in the Appendix E.
  21. 21. 22 Low volume procedures Low volume DOMAIN DOMAIN DOMAIN DOMAIN DOMAIN 1 2 3 4 5 procedures Some clinical scenarios and Patient selection Procedural procedures occur sufficiently Selecting the right patient for a All members of an IR team need to infrequently that it may be difficult to particular treatment pathway requires maintain technical and clinical skills. maintain clinical and technical skills. experience. Even if the technical skills This applies equally to radiologists, Given the complexity and differences are well honed poor patient selection radiographers and nurses. However of this across organisations an exact can have disastrous consequences. within a team at any one time there definition of what constitutes a low Practitioners are encouraged to: may be different levels of experience. volume procedure is not possible. It • have a low threshold for calling For example a radiologist of limited has been suggested that, as a rule of and discussing cases with experience of bronchial embolisations thumb, a procedure should be experienced colleagues, both might be working with a nurse or considered to be of low volume if, locally and at other centres of radiographer who has experience of typically, an operator is exposed to a excellence. Teleradiology and data many bronchial embolisations. Good clinical scenario at a frequency of less transfer can play a major role here. teamwork is key to successful than once every three months. In the All IR radiologists providing outcomes in all clinical environments context of trauma, this threshold may emergency IR cover should be able but perhaps more so when dealing be reached for procedures such as to access images at home; with low volume procedures. Equally thoracic stent grafting for aortic • where possible develop written anaesthetic support is vital and allows trauma. More generally even referral criteria and appropriate the IR team to concentrate on common presentations may become treatment algorithms for all clinical procedural technical skills. low volume for an individual if he/she scenarios particularly those which is not exposed in day to day practice might be considered low volume Optimise the chances of a successful because others have a special for everyone in the department. outcome by: interest. In reality, IR practitioners will These should be updated through • good honest pre-procedural team know when skills and experience are direct experience and new briefing that MUST include all who being eroded through lack of literature; will be involved; exposure and must be expected to • set up regular morbidity and • having written procedure take steps to maintain skills especially mortality meetings both within guidelines to use as a refresher; where these skills are likely to be departments and within regions to • maintaining competency in all required in the emergency setting. share experience. Such meetings procedures that might happen as must be recognised in job plans; an emergency out of hours. Analysing the problems posed by low and Remember that many technical volume procedures, and thinking • remember that informed consent skills are transferable e.g. UAE about solutions, is best done by needs to include the information to provides perfect high volume skill considering the initial clinical the patient that the clinical scenario sets that can be transferred to the presentation, the technical skills is unusual and experience is limited occasionally performed required and the post operative care and that there is an alternative embolisation for post partum that will give the patient the best outside of IR. haemorrhage. Emergency TEVAR chance of survival. will be more familiar to those carrying out many abdominal aortic EVARs;
  22. 22. Low volume procedures 23• maintaining competencies by doubling up i.e two radiologists working together during elective or day time emergency procedures. Again it is important that the absolute need for this is recognised by hospital management and that it is built into job plans and costing of procedures;• considering external training where feasible;• using simulation techniques where Despite the above it is recognised Examples of good practice available to maintain familiarity that in the emergency setting it may 1.In Nottingham the radiologists with devices and clinical decision. be in the patient’s best interest to double up for low volume cases Such facilities exist and will become attempt a life saving procedure even such as TEVAR and TIPS and they more widely available in the future; if inexperienced in that technique. keep a record of who has done• signing up to a ‘maintenance of With use of the measures discussed what, making sure that they all competency agreement’ and clarify above it may be possible to mitigate maintain sufficient numbers of what procedures the IR team is against any potential adverse cases. happy to undertake, both in an outcomes should this scenario occur. elective and in an emergency setting. Stick to the agreement There are ways in which clinical and and review it regularly; and technical skills can be maintained to• recognising where there are cover all clinical scenarios. Patient scenarios where skills cannot be safety demands that every effort is maintained, formal pathways must made to do this on the part of be available to other hospital individuals and teams. Management clinicians, preferably published on must play their part in providing an the hospitals trust intranet. Formal environment that patients can have agreements must be made with the confidence in. All IR teams will come referral hospitals and across clinical scenarios which will commissioners involved in such present them with new challenges. decisions and pathways. An The recognition by all involved of example of a procedure that might their limitations in such situations, require such action would be TIPS seeking advice and help acutely but for uncontrollable bleeding. thinking ahead electively will ultimately provide the best possible outcomes.
  23. 23. 24 A: Networking Delivering an out of hours IR service utilising consultants from a neighbouring hospital University Hospital Coventry and Warwickshire NHS Trust Summary The two George Eliot consultants The realignment of the diagnostic Since October 2011, a full out of operate on a 1:6 rolling general on- imaging rotas demanded a hours interventional radiology service call rota at the George Eliot site and significant change for all UHCW has been provided at the University perform a dual on-call being consultant radiologists (body Hospital Coventry and Warwickshire available concurrently for the UHCW imaging 1:7, neuroimaging 1:9 and NHS Trust (UHCW) site on a 1:6 IR rota. The UHCW general and intervention 1:6). The number of basis. This has involved four neuro rotas were reconfigured to specialist registrars assigned to the consultants from UHCW with agreed release Intervention consultants for department was increased enabling contractual support from two further the IR rota who in turn dovetail with a 1:7 out of hours compliant consultant interventional radiologists the George Eliot rota. registrar rota to support the from a neighbouring Trust (George diagnostic service. Eliot Hospital, Nuneaton). UHCW is It was agreed that UHCW would pay a large 1200 bed modern teaching for one weekly in hours direct clinical The George Eliot consultants are hospital which now has major care (DCC) of intervention activity paid an agreed number of DCCs to trauma centre status. George Eliot for the two George Eliot Radiologist cover their daytime and out of hours Hospital is a smaller district general on the UHCW site for basic service IR cover. hospital. The two sites are around delivery and so that they could play a 10 miles apart. central role in the Trust’s IR activity. Results These sessions started three months Overall impact Context and background in advance of the on-call rota to The changes have been very UHCW is set up to be a Major enable familiarisation with local positively received by our clinical Trauma Centre. Vascular services for staff, rooms and equipment. colleagues. Provision of the rota the three acute Warwickshire Trusts enabled UHCW to achieve full Major had previously been reconfigured A clinical lead for IR was appointed Trauma Centre status. This has been successfully with six vascular and a specialist group formed. The a major advance in delivery of surgeons participating in a clinical lead co-ordinated all the specialist care to the patients of centralised on-call service at the arrangements and made Coventry and Warwickshire and UHCW site. A fourth consultant presentations to relevant clinical provides an excellent base for further interventional radiologist was colleagues (Emergency Department, development of IR services in the appointed in September 2010. This Anaesthesia, General Surgery and future. In the first few months of allowed the move to a full cover out Orthopaedics). operation, numerous patients have of hours IR rota for vascular and benefited from prompt percutaneous trauma services. The Trust has all What resources/ investment intervention and avoided open major medial and surgical sub were needed? surgery. specialities on site with the A sterile ultrasound (US) needle exception of specialist paediatric guide was purchased to enable US How was the change measured? surgery. guided intervention for consultants A log of out of hours interventional who required it. A document procedures has been kept along with How was the change made? detailing the agreed clinical service an hours monitoring exercise for the Informal clinical level discussions was developed following the consultants involved. In addition, between consultants from the two template provided by the Royal the impact on nursing and hospitals with subsequent discussion College of Radiologists. With this radiography staff has been logged at clinical director level. Once broad information, a review of on the shelf over the initial months in order to principles were agreed, management stents and embolisation coils was assess the service impact and meetings took place to agree precise undertaken to cover the emergency requirements for the future. operation and clinical governance workload; essentially the stock was structures. doubled.
  24. 24. 25How has good practice been Future planssustained? The rota provides an excellentAll six consultants continue their platform for further developmentsnormal update, clinical governance including acute EVAR/TEVAR andand appraisal processes. In expansion into acute colorectalparticular, the IR group has formed a stenting. A business case for uterinequarterly meeting for business and fibroid embolisation (UFE) is at anclinical case review/presentation. A advanced stage and once thesefuture specialist IR MDT and elective patients have begun tomorbidity/mortality meeting is attend the department, anplanned. All consultants now appropriately provided service forsubmit their personal data at the acute post partum haemorrhage willBSIR national registries for both be enabled.vascular and non vascular indexprocedures. We plan to develop a local specialist IR MDT with a morbidity/mortalityLessons learnt component to the meeting.The collaboration between the twohospitals has resulted in an excellent From this established base, we planworking arrangement for the to build a service which can expandprovision of a specialist IR service to and adapt to the future andthe local population. The changing needs of our localconsultants had the vision to see population adopting new techniqueshow future service configurations and technologies as they becomemight be shaped and have been available.commendably flexible in assisting alarger organisation to make the Contactnecessary advances. Patients from Dr James Harding,Coventry and Nuneaton including Consultant Radiologistthe whole catchment area for the Email: james.harding@uhcw.nhs.ukMajor Trauma Centre will benefit asa result of this.The concept of the two George Eliotconsultants being on call for bothdiagnostic and interventionalradiology appears sustainable todate.
  25. 25. 26 A: Networking Implementation of radiology nursing cross site rotation Newcastle upon Tyne Hospitals NHS Foundation Trust Summary We believed that the nursing and Although this system of working had Radiology nursing cross site rotation medical staff would provide a more been informally discussed with the was implemented in Newcastle upon efficient service when working nursing staff in previous years, a Tyne Hospitals NHS Foundation Trust together on a regular basis, thereby formal meeting was arranged out of (NuTH), in order to provide a single getting to know each other well. We hours in order to avoid any nurse on call rota, to support the felt this to be an important part of interruptions. Both registered nurses interventional radiologists. It providing a high standard, out of and health care assistants were provides registered nursing cover for hours interventional radiology invited and an agreement was made emergency out of hours radiological service, when the RVI became a level to give staff who attended, time intervention. Registered nurses 1 Major Trauma Centre in April 2012. back in lieu. A matron chaired the below band 7 are rostered to work meeting and most staff attended. in the radiology departments at the The aim was also to create a flexible Royal Victoria Infirmary and Freeman service as the registered nurses would At that time there were both positive Hospitals. Each radiology be able to cover their colleagues on and negative comments made about department performs different either site during holidays, sickness the introduction of this system. The interventional procedures, although and leave due to the European senior sisters compiled a written there is some overlap. This was working time directive. The staff survey that was completed challenging in terms of skills and experience gained would enable safe anonymously. The results showed experience and required careful and practice to occur when working on that some staff were reluctant to comprehensive planning. This system call without the presence and support make the change in practice whilst aims to provide safe practice, of other radiology nursing colleagues. others looked forward to the increased knowledge base and challenge and variety of work. nursing job satisfaction, plus aid There was also a financial incentive, recruitment. Cost savings were also as savings would be made by A nursing rota was developed to made by reducing two on call rotas, reducing two on call nursing rotas, include cross site rotation of qualified to one. to one. As only one on call rota was nurses below band 7, between both now required, changes to the skill hospital radiology departments. This Context and background mix of staff nurses and health care commenced in June 2010. The interventional radiologists at the assistants could be made, resulting Royal Victoria Infirmary (RVI) and the in further cost savings for the The two band 7 senior sisters Freeman Hospital (FH) implemented radiology directorate. permanently remain on their a single radiologist on call rota individual sites as managers, specifically aimed at providing out of This system would reduce the although work closely together and hours cover for emergency amount of on call undertaken by the frequently visit the opposite site. interventional radiological nurses from 1:5 to 1:10, thereby One of them previously worked on procedures across both sites in improving their work life balance. In the opposite site and therefore had October 2009. contrast however, it would reduce a good overview of the service on the amount of on call undertaken, both sites. This helped in Following this, there was a review of thereby reducing the amount of understanding how staff needed radiology nursing and it was decided overtime paid to staff. to be allocated on each site. that the registered nurses could mirror their system. The idea was to provide How was the change made? In October 2010, the most experienced nurses who would be Firstly, discussions between the experienced radiology nurses began knowledgeable, safe and proficient in senior sisters, matron and medical to participate in a single nurse on assisting with all types of intervention staff were made and it was agreed call rota that covered the RVI and undertaken on each site. They would that it could be advantageous to FH. The less experienced joined the also have good geographical implement cross site working for rota at a later date when they were knowledge of both sites and know qualified nurses below band 7. deemed competent. where equipment was stored.
  26. 26. 27What resources/ investment for the directorate and Trust. There A list of medical devicewere needed? was some well-established staff who competencies was compiled, trainingInitially savings were limited as were reluctant to change. We dealt given and sign off when staff wereexperienced staff (including band 7 with this by encouraging staff competent. The competencies aresenior sisters) provided on call cover involvement and asking them to undertaken on an annual basis.for the less experienced, until they discuss how they felt the rotationwere deemed competent to should be implemented. This Band 7 sisters continue to shadowundertake solo on call. In effect, this allowed staff to feel more involved in staff on call when necessary.reverted back to having two nurses the process.on call together, but for shorter Lessons learntperiods of time. Results Although the possibilities of cross Overall impact site rotation had been discussedUltimately money was saved on the Cross site rotation has given the occasionally during the previous fewnursing staff budget by reducing the registered radiology nursing staff years, the staff still did not seemnurses on call from two to one as confidence to participate in prepared for the change in practice.only one standby payment needed providing a single nurse on call rotato be made. Also, the band 7 senior that covers two hospital radiology In hindsight we feel that formal staffsisters withdrew from the on call departments. It provides a safe discussions could have been startedrota, thereby reducing the costs system of working and continuity for earlier in an effort to allow staffcreated through more expensive the radiologists on call. Staff more time to come to terms with theovertime payments. relationships have developed further changes. during cross site rotation. PatientsTime investment was required to: benefit by receiving safe care from Newly appointed staff who were• undertake extra training for staff well trained, knowledgeable and employed on the basis of working who were assessed by the senior experienced staff. across site, were very positive in sisters on an individual basis; what they could gain from working• set up quarterly cross site meetings How was the change measured? in two separate environments and that alternate across site. Initially Quarterly cross site staff meetings were excited by the learning these were arranged out of hours, were set up and minutes taken to opportunities presented. Currently but recently, with the cooperation provide an update for those who they are happy and feel as though of the medical staff, they have could not attend. their working practice is well been arranged for early in the balanced. morning to avoid minimal The staff survey was repeated after disruption to the work load; 12 months. The results were fairly After 18 months of cross site• compile new rotas, holiday and off similar to the results of the initial rotation, the established nurses have duty requests spreadsheets; survey settled down well and the whole• improve and update equipment group are sharing knowledge and lists on both sites as a learning How has good practice been best practice across site. tool and aid during call outs; and sustained?• create a medical device All new radiology nursing jobs are Future plans competency list to include medical advertised to work across both sites. Continue with the rotation. devices used across site, and use it as a training guide for staff. Cross site rotation has continued, Contact although the frequency of rotation Dr Ralph Jackson,The senior sisters invested a lot of depends on staff experience and Consultant Radiologisttime with staff as they explained training required, therefore is Email: ralph.jackson@nuth.nhs.ukregularly, the need for cross site organised on an individual basis.rotation to occur and its advantages
  27. 27. 28 A: Networking Networked on call interventional radiology across two sites South Devon Healthcare NHS Foundation Trust and Royal Devon and Exeter NHS Foundation Trust Summary How was the change made? What resources/ investment Two neighbouring DGHs, 25 miles The Torbay radiologists started their were needed? apart in a rural location each have own in-house on call service whilst There was a relatively small increase three interventional radiologists. In discussions were ongoing in Exeter. in pay costs, for the changes in job order to provide formal on call IR This was on a 1:3 rota, clearly not plans and on call frequency for the services 24/7 they have developed a sustainable in the long term. In the radiologists and for the formal on networked solution. first year of this service the cases call for the nurses and were audited and it was felt by the radiographers. (In Torbay this Context and background referring clinicians and intensive care equated to approximately an Royal Devon and Exeter has a teams that a significant minority of additional £66,000 per annum and catchment population of patients would not have been had been built into the business approximately 370,000 and Torbay’s suitable for transfer if Exeter had cases for recent general radiologist catchment resident population is been on call. appointments.) approximately 280,000. There are significant increases in transient The planned model was therefore Results population during holiday seasons. changed with the default position Overall impact being that the on call radiologist There is always interventional At each site there are three travels to the site of the patient. The radiology emergency cover at both interventional radiologists. radiologists visited each other’s sites, 24/7, providing a safe and Emergency out-of-hours IR had been departments to get to know the secure service. This is extremely well- provided on an ‘ad hoc’ basis. With layout and staff. Consumables such received by the other clinicians increasing frequency of cases there as wires and catheters were similar within the hospitals. Increased was significant risk of being unable in each department but all awareness of the service has led to a to find a willing or available staff radiologists satisfied themselves that significant increase in out-of-hours member (radiologist, radiology their preferred kit was available on cases compared to the previous ad- nurse, interventional radiographer) both sites. hoc arrangements. However, all of and staff were becoming unhappy these cases are felt to be appropriate about being called in when not on On both sites the discussion and and the frequency of call-outs is still call. planning included radiology relatively low. In order to maintain a department managers, medical degree of control and to ensure The two Torbay and three Exeter directors and senior executives, the appropriateness of referrals the on vascular surgeons have been running radiology nurses and interventional call interventional radiologists will a successful cross-site emergency on radiographers, and the general only take calls from consultants. call vascular surgical service for radiologists. several years. For this service the How was the change measured? usual approach is for the emergency On weekday evenings and nights Diaries of activity are kept and the patient to be transferred by each site covers its own emergency service audited. ambulance to the on call site if work. From Friday evening to required. The interventional Monday morning and on bank radiologists initially favoured a holidays there is one interventional similar model for an IR on call radiologist on call, covering both service, feeling unenthusiastic about sites. The radiologists’ rota is having to do urgent cases in an therefore 1:3 week days, 1:6 unfamiliar environment. weekends. For every night and weekend there are radiology nurses and interventional radiographers on call at both sites. This service has been running for 20 months.
  28. 28. 29How has good practice been The agreed portfolio of worksustained? covered on both sites on callThe radiologists from both sites meet includes nephrostomy, abscessto discuss the service and cases drainage, peripheral vascularperformed. Now that both the intervention and embolisation forvascular surgeons and the haemorrhage. Renal access work isinterventional radiologists have only done at Exeter and thereforecross-site rotas this has encouraged fistula salvage was not included.further development of formal cross- Only one of the six radiologistssite MDT working. performs TIPSS and two of the Torbay radiologists do not performLessons learnt PTCs. These procedures are thereforeAs in many radiology departments only provided on an ad hoc basis,there was reluctance from the depending on which radiologist is ongeneral radiologists regarding these call or contactable. We thought thatchanges as the interventional we had thought of everything butradiologists would come off the did not realise that the Exetergeneral on call rota. To some extent surgeons ask for urgent colonicthis was ameliorated by linking these stenting for obstruction whereas thischanges with expansion in overall is not done at Torbay. This is the oneradiologist numbers in response to procedure that was requested at thegrowing workload. Now that the weekend by an Exeter surgeon butservice is well-established the could not be performed as the onmajority of non-interventional call radiologist was from Torbay.radiologists are very happy with it;they no longer have the difficulty of Future plansbeing asked to arrange an urgent The service is working well andinterventional case at the weekend, appears sustainable. We continue toeither feeling forced to do strengthen the links between the IRsomething they are uncomfortable and vascular surgical units at bothwith or having to phone around to sites.find a colleague who is not on call. ContactAs an unexpected consequence for Dr R Seymour,two DGHs, on a few occasions at Consultant Radiologistweekends we have received patients Email: richard.seymour@nhs.nettransferred from another hospitalbecause the clinicians there areaware that we have the only formalIR on call service in the region.
  29. 29. 30 A: Networking Development of cross-site 24/7/365 interventional on-call service covering nine individual hospital units NHS Greater Glasgow & Clyde Summary The agreement for new posts was Results A case for change to work established within an overall Overall impact collaboratively across several Trusts framework that included improving • The change has provided a 24 to deliver a 24/7 IR service to cross-cover and working in hours hour IR on call service on every day patients every day of the year. between adjacent units and merging of the year with improved equity equipment and procurement to both of access to IR services. Context and background reduce costs and improve cross-site • There has been direct positive There was increasing recognition of working. feedback for the IR team. Having the importance of IR in patient developed the case for change pathways particularly for An IR on-call manual was developed. they recognised the impact they haemorrhage control with variation It included both processes and were making in acute care. in access to out of hours procedures. This allowed the clinical • Reduced referral time for out of interventional radiology across the groups to debate the detail of service hours work received very positive local areas. There was no formal IR provision prior to service introduction. feedback from all clinical staff and on call rota and the informal rota enhanced the profile of IR services was placing stress on specific points What resources/ investment across the area. of the IR team. were needed? • Consolidation of consumables • Additional staff funding was across sites was very valuable in There were nine trained required. This was not seen solely service provision and has resulted interventional radiologists across the to support out of hours but was in a cost saving. area however on-call was part of the framed to improve service • Using the separate projects of general diagnostic rota. There was provision and equality of access procurement etc did develop a no formal nurse on-call rota at the both in and out of hours. sense of identity among the units. time of inception. Equipment and • Medical staff required changes to • The IR manual was very valuable, equipment levels across the area job plans - this impacted on the particularly in the initial stages for particularly of consumables was diagnostic on-call rota. Further both external and internal groups. varied. redesign of diagnostic rota occurred. How was the change measured? How was the change made? • Medical staff had to accommodate We have published audits of our The clinical case for change was changes that meant cross-site service against the RCR guidance for established with the clinical team working both in and out of hours. 24/7 IR services. We have a research/ including nurses and radiographers • Nursing staff required significant audit interest in outcomes for IR in a series of facilitated meetings. negotiation to terms and techniques and have submitted for The managerial support was conditions - this took a publication a paper on 30 day excellent after the case for change considerable time to work outcomes after OOH intervention. was established and resource through. For a period reduced support was agreed. We did not numbers of nursing staff How has good practice been focus only on OOH services and participated and this placed sustained? accepted that we would have to pressure on this group. Nursing The on call service requires a change in hours services as well. staff also had to adapt to cross-site consistent focus and evolves as working across several hospitals. clinical requirements change. We • Most sites already had dedicated have established an Interventional radiographic staff, however there Forum that meets regularly to was concern about undertaking discuss all aspects of the service. The unfamiliar procedures. forum contains representation from radiographers, nurses and managerial structures.