Setti

ng S

tand

ards

for C

linic

al A

udit:

M

akin

g th

e be

st u

se o

f clin

ical

ra

diol

ogic

al s

ervi

ces

Den

is R

emed

ios

on b

ehal

f of t

he R

oyal

Col

lege

of R

adio

logi

sts

Clin

ical

Rad

iolo

gy A

udit

Sub

com

mitt

ee

Bac

kgro

und:

Wha

t mak

es a

go

od s

tand

ard?

•Th

e de

sign

of a

n au

dit i

s w

holly

re

liant

on

a sa

tisfa

ctor

y an

d ac

cept

able

sta

ndar

d •

This

sho

uld

be e

vide

nce-

base

d or

ag

reed

by

cons

ensu

s w

here

the

evid

ence

is w

eak.

Bac

kgro

und:

ne

ed fo

r gui

delin

es•

The

diag

nost

ic im

pact

and

ofte

n ec

onom

ic im

pact

of i

mag

ing

for a

ny

com

mon

clin

ical

pro

blem

relie

s on

su

ch e

vide

nce-

base

d gu

idel

ines

. •

In th

e U

K th

is n

eed

has

been

he

ight

ened

in 2

006

by th

e co

rrec

t in

clus

ion

of n

on-m

edic

ally

qua

lifie

d he

alth

pro

fess

iona

ls a

s re

ferr

ers.

Gui

delin

es a

s a

basi

s fo

r st

anda

rds

•Th

e R

oyal

Col

lege

of R

adio

logi

sts

publ

ishe

d cl

inic

al re

ferr

al g

uide

lines

si

nce

1989

and

pub

lishe

d th

e 6th

editi

on o

f “M

akin

g th

e be

st u

se o

f cl

inic

al ra

diol

ogy

serv

ices

”bo

th in

pa

per a

nd w

eb v

ersi

ons

in S

ept 2

007

•Va

lue

in re

duci

ng u

nnec

essa

ry

inve

stig

atio

ns, s

avin

g tim

e, a

bsor

bed

dose

and

cos

t

Gui

delin

e m

etho

dolo

gy:

sear

ch a

nd e

xper

t pan

els

•C

entr

alis

atio

n of

lite

ratu

re s

earc

hes

with

incl

usio

n an

d ex

clus

ion

filte

rs

•El

ectr

onic

han

d se

arch

of 7

hig

h im

pact

imag

ing

jour

nals

. •

Expe

rt p

anel

s dr

awn

from

the

Spec

ial

Inte

rest

Gro

ups:

–m

ain

syst

em b

ased

spe

cial

ties,

–

onco

logy

and

pae

diat

rics

–m

odal

ity b

ased

gro

ups

Gui

delin

e m

etho

dolo

gy:

Del

phi p

roce

ss•

e-m

ail b

ased

que

stio

nnai

res

intr

oduc

ing

the

clin

ical

pro

blem

, pr

ovid

ing

evid

ence

from

a

cent

ralis

ed s

earc

h•

Del

phi i

tera

tive

proc

ess

to a

gree

re

com

men

datio

ns a

nd th

eir g

rade

s.

Thes

e gr

oups

incl

uded

exp

erts

from

se

vera

l Eur

opea

n st

ates

.

Gui

delin

e m

etho

dolo

gy:

cons

ensu

s an

d ed

iting

•D

raft

guid

elin

es w

ere

then

put

out

for

cons

ensu

s to

ove

r 100

col

lege

s,

inst

itutio

ns a

nd le

arne

d bo

dies

acr

oss

the

UK

and

Eur

ope.

•

The

edito

rial p

roce

ss s

tren

gthe

ned

draf

t gui

delin

es w

ith fu

rthe

r evi

denc

e gl

eane

d th

roug

h co

nsul

tatio

n.

•A

n el

ectr

onic

edi

toria

l gro

up in

clud

ed

mem

bers

with

gra

phic

s an

d w

eb s

kills

.

RC

R R

efer

ral G

uide

lines

200

7

•31

5 gu

idel

ines

; 43

are

new

•67

reco

mm

enda

tions

are

now

Gra

de

A, u

p fr

om 5

2,

•O

nly

171/

647

relia

nt o

n ex

pert

op

inio

n / l

ow e

vide

nce

leve

l stu

dies

. •

280

Del

phi m

embe

rs to

ok p

art f

rom

16

exp

ert p

anel

s, re

pres

entin

g al

mos

t a te

nth

of U

K ra

diol

ogis

ts.

Gui

delin

e us

e

•B

oth

the

pape

r and

web

pub

licat

ions

w

ere

desi

gned

to b

e us

er-fr

iend

ly to

en

cour

age

thei

r eve

ryda

y us

e an

d w

hen

requ

ired

to p

rovi

de th

e st

anda

rd

agai

nst w

hich

the

mod

ality

and

in

dica

tion

of re

ferr

als

may

be

audi

ted

•R

CR

gui

delin

es a

dopt

ed n

atio

nally

an

d w

ill b

e m

ade

avai

labl

e to

all

NH

S H

ealth

Pro

fess

iona

ls

Mak

ing

the

best

use

of

clin

ical

radi

olog

y se

rvic

es 6

e

Web

-bas

e gu

idel

ines

Gui

delin

e: C

hron

ic b

ack

pain

Gui

delin

es fo

r aud

it st

anda

rds

•10

3/29

5 R

CR

Aud

it co

mpe

titio

n en

trie

s us

ed a

sta

ndar

d ba

se o

n a

Gui

delin

e•

20 A

udits

wer

e ba

ses

on R

CR

gu

idel

ines

, Mak

ing

the

best

use

of

clin

ical

radi

olog

ical

ser

vice

s or

its

pred

eces

sor

Aud

it po

ster

com

petit

ion:

R

CR

Gui

delin

es fo

r sta

ndar

ds•

Red

ucin

g th

e de

man

d fo

r lum

bar s

pine

radi

ogra

phy

from

Gen

eral

Pra

ctic

e –

DrC

hris

toph

er K

eelin

g-R

ober

ts

1st2

003

•A

n au

dit o

f une

nhan

ced

mul

tislic

e C

T (C

T K

UB

) for

inve

stig

atio

n of

acu

te re

nal c

olic

in L

eeds

DrF

UC

how

dhur

y 20

06

•A

war

enes

s of

Rad

iatio

n D

oses

Incu

rred

in D

iagn

ostic

Inve

stig

atio

nsD

rKar

en A

Dun

can

2006

•

Ultr

asou

nd re

ques

ts: A

re w

e be

ing

inap

prop

riate

ly o

verlo

aded

? -A

n au

dit.

DrA

ndre

wW

inte

rbot

tom

200

6 •

Are

abd

omin

al ra

diog

raph

s be

ing

over

used

in th

e as

sess

men

t of a

cute

abd

omin

al p

ain?

DrD

anie

l JB

ell 2

005

•M

akin

g th

e be

st u

se o

f Im

agin

g in

Str

oke

patie

nts

DrS

riram

Vund

aval

li 20

05

•A

n A

udit

of W

ater

Sol

uble

Con

tras

t Ene

ma

Ref

erra

lsD

rS D

Alle

n 20

04

•A

n au

dit o

f bod

y C

T fo

r inv

estig

atio

n of

occ

ult m

alig

nanc

yD

rS D

Alle

n 20

04

•O

ptic

ner

ve u

ltras

ound

in a

sses

smen

t of r

aise

d in

trac

rani

al p

ress

ure

-its

role

in c

linic

al p

ract

ice.

DrL

CB

amfo

rd

2003

•

Men

to-O

ccip

ital F

acia

l Rad

iogr

aphs

: A W

aste

Of T

ime?

DrL

.C.B

amfo

rd 2

003

•A

n A

udit

of a

dher

ence

to IR

MER

regu

alat

ions

in re

ques

ting

and

asse

ssin

g ch

est r

adio

grap

hs p

erm

orm

ed o

n ac

ute

med

ical

adm

issi

ons.

DrB

rend

anB

arry

200

3 •

Cur

rent

day

util

izat

ion

of a

bdom

inal

radi

ogra

phs

DrK

Gop

al 2

003

•A

n A

udit

Of C

arot

id A

rter

y D

oppl

er U

ltras

ound

Req

uest

sD

rRP

Hou

ghto

n 20

03

•Lu

mba

r spi

ne x

ray

audi

tDrL

AK

urba

n 20

03

•A

n A

udit

of a

Sca

phoi

d Fr

actu

re P

roto

col D

rJLa

rsen

200

3 •

Aud

it of

Sku

ll R

adio

grap

hy in

Pae

diat

ric H

ead

Inju

ry a

t Bla

ckpo

ol V

icto

ria H

ospi

talD

rDem

etris

A.P

atsi

os 2

003

•A

udit

of D

octo

rs' K

now

ledg

e of

Rad

iatio

n Ex

posu

reD

rJSt

eel 2

003

•In

sus

pect

ed s

ubar

achn

oid

haem

orrh

age

(SA

H) h

ow m

any

patie

nts

have

a lu

mba

r pun

ctur

e (L

P) a

fter a

neg

ativ

e C

T?D

rAB

asu

2002

•

Just

ifica

tion

in o

ut o

f hou

rs ra

diol

ogy

DrJ

DB

ircha

ll 20

02

•A

cute

Abd

omen

Imag

ing

-An

Aud

itD

rSoo

Mak

200

2

Aud

it Li

ve:

Gui

delin

es fo

r sta

ndar

dsYo

ur IV

U R

adio

grap

h Se

ries

Num

ber o

f rad

iogr

aphs

obt

aine

d du

ring

intr

aven

ous

urog

raph

y (IV

U).

IVU

Exa

min

atio

n Ti

mes

Exam

inat

ion

times

for i

ntra

veno

us u

rogr

aphy

(IVU

). R

esus

cita

tion

Skill

sR

esus

cita

tion

skill

s w

ithin

the

Dep

artm

ent o

f Clin

ical

Rad

iolo

gy. A

risk

m

anag

emen

t aud

it.

Res

usci

tatio

n A

war

enes

sA

udit

of p

ract

ical

kno

wle

dge

of a

dvan

ced

resu

scita

tion

skill

s ex

pect

ed o

f m

edic

al s

taff

in a

radi

olog

y de

part

men

t Tr

aini

ng in

Gal

l Bla

dder

Ultr

asou

ndA

dher

ence

to d

epar

tmen

tal p

roto

col d

urin

g ro

utin

e ex

amin

atio

n of

the

gall

blad

der b

y th

ose

in tr

aini

ng.

Nee

dles

tick

inju

ryC

onta

min

ated

nee

dles

tick

inju

ry to

a m

embe

r of s

taff

or th

e pu

blic

is a

se

rious

hea

lth ri

sk a

nd c

ould

lead

to li

tigat

ion.

Pr

e-O

p C

XR fo

r Ele

ctiv

e Su

rger

yPr

e-op

erat

ive

ches

t rad

iogr

aphs

prio

r to

elec

tive

surg

ery.

B

one

Scan

Imag

esIm

age

qual

ity o

f bon

e sc

ans.

G

P C

hest

Rad

iogr

aphy

App

ropr

iate

ness

of r

eque

sts

for c

hest

radi

ogra

phy

from

GPs

. Lu

mba

r Spi

neLu

mba

r spi

ne ra

diog

raph

y.

Out

-of-H

ours

Imag

ing

App

ropr

iate

ness

of o

ut-o

f-hou

rs e

xam

inat

ions

. W

aitin

g an

d A

ppoi

ntm

ent T

imes

Wai

ting

time

of p

atie

nts

prio

r to

appo

intm

ent.

Staf

f Dos

imet

ryW

earin

g of

film

bad

ges

durin

g flu

oros

copi

c pr

oced

ures

. Fi

re T

rain

ing

Atte

ndan

ce o

f sta

ff at

fire

lect

ures

. H

ead

CT

–Le

ns E

xclu

sion

Excl

usio

n of

the

lens

of t

he e

ye in

rout

ine

head

CT

exam

inat

ions

. Se

curit

y –

Staf

f ID

Dep

artm

enta

l sec

urity

–st

aff i

dent

ifica

tion

(ID).

Inve

stig

atio

n of

asy

mpt

omat

ic m

icro

scop

ic h

aem

atur

ia in

adu

ltsA

sses

smen

t of c

ompl

ianc

e w

ith a

gree

d pr

otoc

ol fo

r inv

estig

atio

n of

as

ympt

omat

ic m

icro

scop

ic h

aem

atur

ia in

adu

lts.

Con

tras

t and

Dru

g R

ecor

ding

Rec

ordi

ng o

f dos

e, m

ake,

bat

ch n

umbe

r and

exp

iry d

ate

for c

ontr

ast m

ediu

m u

sed

for

intr

aven

ous

urog

ram

s (IV

Us)

. Fo

reig

n B

ody

Rad

iogr

aphy

Pres

ence

of a

loca

lisin

g m

arke

r in

radi

ogra

phy

for p

rese

nce

of fo

reig

n bo

dies

. G

P re

ferr

als:

are

the

repo

rts

addr

essi

ng th

e qu

estio

ns p

osed

?A

udit

of g

ener

ic re

port

ing

and

effe

ctiv

e co

mm

unic

atio

n w

ith G

Ps.

Con

sent

for a

Rad

iolo

gica

l Exa

min

atio

nA

dequ

acy

of c

onse

nt fo

r rad

iolo

gica

l pro

cedu

res.

Pr

egna

ncy

Que

stio

ning

The

excl

usio

n of

pre

gnan

cy in

pat

ient

s w

ho a

re u

nder

goin

g ra

diog

raph

y (a

pplic

atio

n of

the

28 d

ay ru

le).

Rad

iolo

gy R

epor

ting

by O

ther

Doc

tors

Effe

ctiv

enes

s of

arr

ange

men

ts to

tran

sfer

the

resp

onsi

bilit

y fo

rthe

repo

rtin

g of

sp

ecifi

ed p

lain

radi

ogra

phs

to re

ferr

ing

clin

icia

ns.

Fing

er D

oses

Rad

iatio

n do

se to

the

pulp

of t

he in

dex

finge

r of s

taff

hand

ling

syrin

ges

cont

aini

ng

radi

onuc

lides

. U

rgen

t CT

Bra

in S

cans

and

LPs

Lum

bar p

unct

ure

(LP)

follo

win

g re

ques

ts fo

r urg

ent C

T br

ain

scan

s.

Rad

iogr

aphy

in A

cute

Bac

k Pa

inR

eque

sts

for l

umba

r spi

ne ra

diog

raph

y in

pat

ient

s w

ith a

cute

low

back

pai

n.

GP

Ultr

asou

nd R

eque

sts

Indi

catio

ns fo

r GP

refe

rral

s fo

r ultr

asou

nd (U

S) e

xam

inat

ion

of th

e up

per a

bdom

en.

Maj

ax C

all-I

nD

epar

tmen

t of C

linic

al R

adio

logy

cal

l-in

list f

or u

se in

cas

e of

a m

ajor

acc

iden

t (m

ajax

). A

dequ

ate

Com

plet

ion

of R

adio

logy

Req

uest

For

ms

Ade

quac

y of

com

plet

ion

of ra

diol

ogy

requ

est f

orm

s.

Gon

ad P

rote

ctio

n II

Use

of g

onad

pro

tect

ion.

Im

agin

g in

sym

ptom

atic

bre

ast d

isea

seA

n au

dit t

o as

sess

com

plia

nce

with

imag

ing

guid

elin

es w

ithin

the

sym

ptom

atic

bre

ast

clin

ic.

Can

cer S

tagi

ngSt

agin

g of

com

mon

can

cers

usi

ng C

T or

MR

I. R

epor

ting:

GP

refe

rral

s fo

r pla

in ra

diog

raph

yG

ener

al p

ract

ition

ers

depe

nd u

pon

timel

y an

d ac

cura

te re

port

s fo

r the

man

agem

ent o

f th

eir p

atie

nts.

A

n in

divi

dual

radi

olog

ist’s

wor

kloa

dTh

e nu

mbe

r of r

epor

ts is

sued

by

an in

divi

dual

radi

olog

ist.

RC

R A

udit

Com

petii

on:

Aw

aren

ess

of

Rad

iatio

n D

oses

In

curr

ed in

D

iagn

ostic

Im

agin

g

Use

of R

CR

Gui

delin

es to

in

fluen

ce G

ener

al P

ract

ice

•D

isse

min

atio

n of

the

RC

R g

uide

lines

3e

boo

klet

to G

Ps in

Sco

tland

•O

nly

a sm

all e

ffect

on

GPs

' ref

erra

ls•

No

sign

ifica

nt e

ffect

s on

the

tota

l nu

mbe

r of r

eque

sts,

or o

n re

ques

ts

for i

ndiv

idua

l exa

min

atio

ns•

Con

clud

ed o

ther

str

ateg

ies

need

edL.

Mat

owe,

C. R

. Ram

say,

J. M

. Grim

shaw

, F. J

. Gilb

ert,

M. -

J. M

acle

od a

nd G

. Nee

dham

. Effe

cts

of

Mai

led

Dis

sem

inat

ion

of th

e R

oyal

Col

lege

of R

adio

logi

sts'

Gui

delin

es o

n G

ener

al P

ract

ition

er

Ref

erra

ls fo

r Rad

iogr

aphy

: A T

ime

Serie

s A

naly

sis.

Clin

ical

Rad

iolo

gy V

olum

e 57

, Iss

ue 7

, Jul

y 20

02, P

ages

575

-578

Use

of s

elec

t Gui

delin

es to

in

fluen

ce G

ener

al P

ract

ice

•Lu

mba

r spi

ne a

nd k

nee

x-ra

ys•

6-m

onth

ly fe

edba

ck o

f aud

it da

ta is

in

effe

ctiv

e •

Rou

tine

educ

atio

nal r

emin

der

mes

sage

s to

radi

ogra

phs

is e

ffect

ive

an

d do

es n

ot a

ffect

qua

lity

of

refe

rral

s.

Effe

ct o

f aud

it an

d fe

edba

ck, a

nd re

min

der m

essa

ges

on p

rimar

y-ca

re ra

diol

ogy

refe

rral

s: a

rand

omis

ed tr

ial .

The

Lanc

et ,

Volu

me

357

,Iss

ue 9

266

,Pag

es 1

406

-140

9 M

. Ec

cles

, N

. St

een

, J .

Grim

shaw

, L

. Tho

mas

, P

. McN

amee

, J

. So

utte

r , J

. W

ilsdo

n , L

. M

atow

e , G

. N

eedh

am ,

F . G

ilber

t

Take

hom

e po

ints

•G

uide

lines

can

and

do

prov

ide

stan

dard

s fo

r cl

inic

al a

udit

•Pr

esen

tatio

n of

gui

delin

e is

im

port

ant

•Ju

dici

ous

feed

back

may

in

fluen

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ferr

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atte

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