Radiography Requests Research Articles

IRMER regulations: compliance rate of radiograph reporting by non-radiology clinicians

To assess compliance with regulation 7(8) of Ionizing Radiation Medical Exposure Regulations (IRMER) 2000 legislation amongst non-radiologists reporting radiographs in a large district general hospital. A prospective review of 100 consecutive radiography request cards from five different departments undertaking their specialty radiograph reporting were collected over 4 weeks. The requests were then traced to their respective case notes to assess documentation of radiographs. The five departments included chest, maxillo-facial, rheumatology, orthopaedics, and inpatients. Twenty-two case notes were gathered from chest clinics, 21 from maxillo-facial, 15 from rheumatology, 23 from orthopaedics fracture clinics, and 19 were taken from inpatients. Only 53% of radiographs undertaken by non-radiologists had a documented report. The specialty most compliant with IRMER was orthopaedics 17/23 (74%) and the specialty least compliant was maxilla-facial 8/21 (38%). Of the documented radiographs, the consultant grade was the largest group of doctors [36% (19/53)] that undertook documentation, and for the undocumented radiographs, they were also the largest group of clinicians that did not document radiographs [77% (36/47)]. All radiographs that were documented in the notes also had documented interpretation of the radiograph. Only 53% of plain radiographs were documented and reported by non-radiology clinicians even though IRMER legislation applies to all clinicians undertaking radiograph interpretation. All clinicians undertaking interpretation of radiographs should be made aware of this legislation and the responsibility to document their findings.

Adecuación de la petición de radiografías de tórax en urgencias hospitalarias

ObjectiveTo describe the use of chest radiography in the general emergency department of La Paz University Hospital, based on evidence-based guidelines to evaluate the degree of appropriateness of this test, and to identify the clinical factors associated with greater inappropriate use. Material and MethodsWe performed a descriptive, analytical study (univariate and multivariate) of patients presenting to the general emergency department in the week of 18-24 February 2002 who underwent chest radiography. The appropriateness of this test was evaluated according to reviewed standards (main variable: appropriateness or inappropriateness). To do this, a systematic review of evidence-based guidelines and protocols on the indication for chest radiography was performed and a data sheet was created, based on the most important articles. ResultsEighty-four percent of the requested chest radiographies reviewed were appropriate according to the selected criteria; the remaining tests (16%) were inappropriate according to these criteria. The clinical factors associated with greater inappropriate use were: costal mechanical pain after minor thoracic injury (31.4%), nonspecific symptoms (general feeling of discomfort, fever…) (27.5%), nonspecific abdominal pain (23.5%) and mechanical thoracic pain (17.6%).The age-adjusted risk of inappropriate use was 2.35 times higher at the weekend than during the rest of the week (95% CI, 1.24-4.45, p = 0.008). Adjusting by day of request (weekend versus non weekend), with each year of decreased age, the risk of inappropriate use increased by 1.02-fold (95% CI, 1.01-1.04; p < 0.001). ConclusionsSixteen percent of requests for chest radiography were deemed inappropriate, which represents an opportunity for improvement (health care quality and optimization of resource use). Inappropriate use is greater in the youngest patients, who are more demanding, which could lead to a greater number of unnecessary tests.The greater percentage of inappropriate use at the weekends could indicate insufficient supervision of duty physicians by experienced physicians or a reluctance on the part of residents to seek advice from supervisors.

Requesting and interpreting trauma radiographs: a role extension for accident & emergency nurses

Government supported expansion of the nursing role within Accident & Emergency (A&E) departments in the United Kingdom (UK) has begun to break down the traditional barriers to professional practice. Today, many nurses working within A&E departments are both requesting and interpreting radiographic examinations as part of their normal working practice. However, role expansion does not occur without increased responsibility. Unsatisfactory requests for radiography and inaccurate radiographic interpretation may result in inappropriate patient treatment, misuse of resources, patient recall and litigation. Nurses undertaking these role extensions need to ensure that their levels of knowledge and skill to perform the role are appropriate and adequately supported. This article summarises the results of a national questionnaire survey of A&E nurse managers that aimed to identify current working practices, including education, training and limitations to practice, with respect to the requesting and interpretation of trauma radiographs by A&E nurses.

THE IMPACT OF IMPLEMENTING THE OTTAWA ANKLE RULES ON ANKLE RADIOGRAPHY REQUESTS IN A&amp;E

SUMMARYThis audit was set up to quantify the effect of implementing the Ottawa ankle rules in a district general hospital that relies on both medical and nursing radiography requests. Data were collected prospectively on 207 patients who presented with an acute ankle injury between August 2001 and February 2002. The department's activity was recorded before and after a period of teaching on the Ottawa ankle rules. Before teaching, 71% of patients with an acute ankle injury were sent for radiography; teaching reduced this figure to 56% (p&lt;0.05). Auditing the activity of our department enabled us to observe a significant decrease in the number of patients sent for ankle radiography following acute ankle injury. This correlates well with research in other settings. The difficulties of rationalising radiology investigations are discussed.

Validation of the Ottawa knee rules in an emergency teaching centre.

Our objective was to determine the value of the Ottawa knee rules when applied by users with different levels of clinical training. We used a prospective patient survey by the medical students and surgery residents of a European university trauma centre. The study group consisted of 261 eligible patients who presented with acute knee trauma during a 6-month period. Radiography or follow-up was obtained for each patient. Data were separately analysed according to the degree of qualification of the initial examiner. The Ottawa knee rules had a sensitivity and a negative predictive value of 1.00. Variable degree of medical competence of the users did not alter the accuracy of the rules. Application of the rules would have reduced knee radiography requests by 25%. The Ottawa knee rules remain highly sensitive when applied by medical users with different levels of qualification, such as encountered in a teaching setting.

The use of panoramic radiography in a dental accident and emergency department.

To determine the rate of appropriate requests for panoramic radiography (PR) in a Dental Accident and Emergency Department and the implications for patient dose. Two hundred and seventy-one requests for PR during July 1998 were assessed by two dental radiologists and categorised as appropriate or inappropriate based on established selection criteria. Incidental findings that might alter patient management were also noted. One hundred and fifty-seven requests (58%) were considered appropriate and 114 (42%) inappropriate. The most common inappropriate request was to assess disease localised to one or two teeth. Dental students were involved in 186 requests and 76 of these (41%) were inappropriate. The estimated saving in collective radiation dose over the month of the study if appropriate radiographs had been taken, would have been approximately 540 microSv, a reduction of 70%. Three out of 114 (3%) inappropriate, PRS showed minor incidental findings. A considerable proportion of requests for PR were inappropriate. In most of these cases, periapical radiographs would have provided more detail with less radiation dose. The large number of inappropriate requests involving dental students has implications for educators. The use of local selection criteria based on currently accepted guidelines would have reduced the dose substantially.

Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial

We aimed to assess the care and outcome of patients with minor injuries who were managed by a nurse practitioner or a junior doctor in our accident and emergency department. 1453 eligible patients, over age 16 years, who presented at our department with minor injuries were randomly assigned care by a nurse practitioner (n=704) or by a junior doctor (n=749). Each patient was first assessed by the nurse practitioner or junior doctor who did a clinical assessment; the assessments were transcribed afterwards to maintain masked conditions. Patients were then assessed by an experienced accident and emergency physician (research registrar) who completed a research assessment, but took no part in the clinical management of the patient. A standard form was used to compare the clinical assessment of the nurse practitioner or junior doctor with the assessment of the research registrar. The primary outcome measure was the adequacy of care (history taking, examination of patient, interpretation of radiographs, treatment decision, advice, and follow-up). Compared with the rigorous standard of the experienced accident and emergency research registrar, nurse practitioners and junior doctors made clinically important errors in 65 (9.2%) of 704 patients and in 80 (10.7%) of 749 patients, respectively. This difference was not significant. The nurse practitioners were better than junior doctors at recording medical history and fewer patients seen by a nurse practitioner had to seek unplanned follow-up advice about their injury. There were no significant differences between nurse practitioners and junior doctors in the accuracy of examination, adequacy of treatment, planned follow-up, or requests for radiography. Interpretation of radiographs was similar in the two groups. Properly trained accident and emergency nurse practitioners, who work within agreed guidelines can provide care for patients with minor injuries that is equal or in some ways better than that provided by junior doctors.

Use of the Ottawa ankle rules by nurse practitioners.

OBJECTIVE: To determine the ability of nurse practitioners to use the Ottawa ankle rules by comparing their requests for radiography with those of senior house officers (SHOs). METHOD: 1365 patients...

Validation of the Ottawa Ankle Rules in France: A Study in the Surgical Emergency Department of a Teaching Hospital

Study objective: To validate the Ottawa ankle rules to predict fractures in a French clinical setting when they are used by physicians not involved in their development.Methods: We used a prospective patient survey by emergency physicians in a surgical emergency department of a university teaching hospital of the Assistance Publique-Hôpitaux de Paris. The study group consisted of 416 consecutive patients aged 18 years and older who presented with acute ankle or midfoot injuries in the surgical ED during a 4-month period. Radiography was performed in each patient after clinical evaluation findings were recorded.Results: Forty-nine ankle and 22 midfoot fractures were diagnosed. The decision rules had a sensitivity of .98, a specificity of .45, and a negative predictive value of .99 in detecting ankle fractures, a sensitivity of 1.0, a specificity of .29, and a negative predictive value of 1.0 in detecting midfoot fractures. The rules failed to predict one avulsion fracture in the ankle group. Application of these rules by emergency physicians would have reduced ankle or midfoot radiography requests by 33%.Conclusion: Use of the Ottawa ankle rules by French emergency physicians not involved in the rules’ development resulted in 99% sensitivity and had a potential of reducing radiography requests by 33%.[Auleley G-R, Kerboull L, Durieux P, Cosquer M, Courpied J-P, Ravaud P: Validation of the Ottawa ankle rules in France: A study in the surgical emergency department of a teaching hospital. Ann Emerg Med July 1998;32:14-18.]

Implementation of the Ottawa Ankle Rules in France

To assess the impact of the implementation of the Ottawa ankle rules on radiography requests in French hospitals during a 5-month intervention period and the impact of using posters alone to sustain the effect of the rules during a 5-month postintervention period. Multicenter randomized controlled trial preceded and followed by observational studies of radiological practices. The emergency departments of 5 Paris university teaching hospitals of the Assistance Publique-Hôpitaux de Paris. A total of 2218, 1911, and 851 patients-all aged 18 years and older-who were seen for acute ankle or midfoot injuries in emergency departments during preintervention, intervention, and postintervention periods, respectively. Implementation of the Ottawa ankle rules by emergency department physicians in the intervention hospitals (using meetings, posters, pocket cards, and data forms). During the postintervention period, posters alone were used to sustain the intervention effect. Percentage of patients for whom radiography was requested. During the preintervention period, 98% and 98.5% of patients were referred for radiography in the intervention and control groups, respectively. During the intervention period, the mean proportions of patients referred for radiography by physicians was 78.9% in the intervention group and 99% in the control group (P=.03). Between preintervention and intervention periods, a relative reduction of 22.4% (95% confidence interval [CI], 19.8%-24.9%) in radiography requests was observed in the intervention group, while requests increased by 0.5% (95% CI, 0%-1.4%) in the control group. During the postintervention period, the proportion of radiography requests in the intervention hospitals was lower than the proportion observed in the preintervention period (83.1% vs 98%). Implementation of the Ottawa ankle rules significantly reduced radiography requests in French hospitals. Using a minimal postintervention implementation strategy, the effect of this intervention decreased but persisted after it was discontinued.

Radiography for head trauma in children: what guidelines should we use?

OBJECTIVE: To audit the appropriateness of skill radiography in children attending an accident and emergency (A&E) department with head injuries. METHODS: 569 children presenting to a large teaching hospital A&E...

Audit of requests for preoperative chest radiography

Requests at our hospital for preoperative chest radiography were increasing but radiology staff did not know whether the increase was related to a change in workload or in clinical practice. We determined the rate of requests for preoperative radiography in patients undergoing elective surgery and the impact of such an investigation on subsequent clinical management. From 12 to 26 June 1992 we audited all admissions in all specialities of patients due to have elective surgery. We put preoperative chest radiographs in labelled envelopes, which were then sealed with staples; these envelopes were put in radiography packets, which the patients took back to the ward. The packets were returned to the radiology department after the patients had been discharged. If the staples on an envelope had been removed we concluded that the radiograph had been reviewed. We disseminated the results of this study at departmental audit meetings in surgery, anaesthetics, and radiology. After discussion among staff, revised guidelines, based on advice from the Royal College of Radiologists,1 were issued to doctors and …

A STUDY OF THE UTILISATION OF SKULL RADIOGRAPHY IN 9 ACCIDENT-AND-EMERGENCY UNITS IN THE U.K.

Over a period of ten weeks, nine accident-and-emergency units in England, Wales, and Scotland took part in an investigation into the use of skull radiography in the management of patients with head injury. 118 patients (2·0%) with linear fracture and 4 (0·07%) with depressed fracture were recorded in 5850 patients radiographed. Although only 1018 (17·4%) of these patients with head injury had significant additional injuries or pathology, they contributed just under half of the skull fractures detected. 90% of all requests for skull radiography were made by recently qualified doctors who, before radiography, classified 25·9% of their referrals as "fracture definitely absent". They were 99% accurate in this prediction. Traumatic intracranial haematoma and intracranial aerocele, conditions which the discovery of a skull fracture can help to anticipate, were recorded in 12·0 and 1·7 per 10 000 patients radiographed respectively.