1. Audit of the rejection of radiological
imaging requests in University
Hospital Limerick: completing the
cycle
Courtney, W, Kelly, P, Griffin, L, Crotty, J
2. Communication is key
Audit: Inappropriate interruptions for radiologists
• >50 interruptions per day
• >50% were inappropriate
Follow-up audit
• Increased quality of scan requests
• Decreased number interruptions
4. Audit: results
Rejectees CT-abdomen/pelvis US-abdomen US-pelvis
Interns 5.2% (28/534) 1.5% (8/534) 1.2% (4/347)
All other doctors 7.1% (38/534) 4.5% (24/534) 6.6% (23/347)
Total 12.3% (66/534) 6.0% (32/534) 7.8% (27/347)
1. CT-abdomen/pelvis rejected most
2. Interns = nearly ½ of all CT abdomen/pelvis rejections
3. ¾ of rejected CT scans required follow up imaging
5. Audit: further analysis
• Reasons for rejection:
1. Lack of detail
2. Not indicated
• Questionnaire
• Pilot trial
6.
7. CT-abdomen/pelvis: Audit Vs re-audit
Rejectees Audit Re- Audit
Interns 5.2% (28/534) 3.2% (7/218)
All other doctors 7.1% (38/534) 9.2% (20/218)
Total 12.3% (66/534) 12.4% (27/218)
1. CT-abdomen/pelvis remain the most rejected
2. Intern rejection rates fell
3. 50% of rejected CT-abdomen/pelvis requests required follow-up
8. Take home message…
• Completed audit cycle: interns can improve
• Continue intervention
• Intern handbook 2015
• Induction week lecture series
• Inappropriate interruptions for radiologists: Part II
Editor's Notes
In 2012, an audit entitled “Inappropriate interruptions for radiologists” was performed in University Hospital Limerick.
It found that, on a daily basis, each radiologist is interrupted >50 times as they try to report on their scans. >50% of these interruptions are inappropriate.
This has the potential to put strain on the relationship between those working in the radiology department and those junior doctors requesting imaging.
My aim in doing this audit was to address this shortfall by increasing the quality of imaging requests and reducing the volume of unnessescary interruptions for radiologists.
My audit aimed to answer three key questions:
What is the rate of rejection of radiological imaging requests?
What rank of doctor is most likely to have their requests’ rejected?
Why are these rejections happening?
I used the ‘NIMIS RIS’ online database to retrospectively analyse imaging requests over a 10 week period.
I focused on three, primarily, surgical scans: CT-abdomen/pelvis, US-abdomen, and US-pelvis.
In total I analysed over 1,400 requests.
Here we see the results of the first cycle of my audit.
Rejection rates for both abdominal and pelvic ultrasound were 6% and nearly 8%, respectively.
CT-abdomen/pelvis had the highest rates as 12% of all requests for CT-abdomen/pelvis were. rejected
Interns were responsible for just under half of all rejected CT-abdomen/pelvis requests.
Crucially, almost ¾ of all rejected CT-abdomen/pelvis scan requests required a follow-up scan within 3 days of initial rejection. That follow-up scan may have been a CT, PFA, or an ultrasound.
So we answered two of our initial 3 questions: we knew the rates of rejection, and we knew who gets rejected most. We then needed to understand why this was happening.
Radiological requests were rejected for two main reasons:
There was a lack of clinical detail on the scan request
The scan was not indicated.
For instance, many CT-abdomen/pelvis requests were rejected on the basis that an ultrasound would have been more appropriate.
Once we knew why scans were being rejected, we attempted a pilot intervention. Using a questionnaire which I designed with the help of a consultant radiologist we identified critical gaps in intern knowledge.
Based on the results of this, we designed an information leaflet and performed an intervention on the full intern group.
And here it is.
It highlights the problem – that intern rates of rejection are higher than other doctors – and cites the main reasons for rejection.
It also comprehensively answered the questions which our questionnaire asked.
This leaflet was distributed via hardcopy and discussed at intern teaching. It was also distributed by softcopy via email and Whataspp messenger.
Following this intervention, I performed a re-audit over a 4 week period.
Here are the results of the second cycle of the audit alongside our initial results.
Focusing on the overall rejection rate of CT-abdomen/pelvis, we can see that the rate of rejection remained the same at approximatley 12%.
However, the intern rates of rejection fell from 5% to 3%.
The take home message from this audit cycle is clear – interns can improve their rates of success when ordering radiological imaging for their patients.
Intern rejection rates fell from 42 – 26% of the total number of rejections.
As a result of this audit, we have made plans to publish the intervention leaflet in the intern handbook for the new group of interns set to join us in 2015. We have also made arrangements to introduce a radiologist-led lecture series during the intern orientation week in July 2015.
If a scan request is not initially rejected, interns will be less likely to need to go radiology department to explain why they need a scan in person, and radiologists will be less likely to be interrupted during valuable reporting time.
We await the results of “Inappropriate interruptions for radiologists: PART II” with baited breath.
My name is William Courtney, I would like to thank my co authors Dr Padraig Kelly, Dr Laoise Griffin, and Dr Jim Crotty. And, of course, I would like to thank you all for listening.
