Royal College Of Radiologists Research Articles

10,589 CT pulmonary angiograms: evaluating the yield of acute pulmonary embolism.

To evaluate the change in the number of CT pulmonary angiograms (CTPAs) performed and the change in the yield of acute pulmonary embolism (PE) on CTPA at a busy tertiary teaching hospital from 2016 to 2019. All CTPA examinations for both in-patients and emergency department patients performed at our busy tertiary teaching hospital between 1 January 2016 and 31 December 2019 were identified from the radiology information system. A natural language processing technique called phrase matching was employed to assign each of the examination reports a result of either positive, negative or equivocal for acute PE. This algorithm was validated on a sample of 200 reports. The number of CTPAs performed increased 59% from 2016 to 2019. The overall yield of acute PE has remained steady averaging 15.9%, ranging from 15.0% to 17.2%. Over 3 years, there has been a significant increase in the demand for CTPA examinations. The yield of acute PE has remained steady indicating a justified increase in demand. The yield of acute PE on CTPA within our centre is higher than the Royal College of Radiologists' suggested minimum of 15.4% which suggests the current guidelines used for the investigation of suspected acute PE within our centre are appropriate. The guidelines and subsequent yield of acute PE on CTPA at our tertiary teaching hospital can be used as a reference standard for other similar institutes.

Commentary on: current status of the credential “mechanical thrombectomy for acute ischaemic stroke” sponsored by the Royal College of Radiologists. What factors are preventing approval of training for non-radiologists to perform MT in the UK?

A recent commentary on behalf of UK Neurointerventional Group (UKNG) presented their concerns about the progress of a credential in mechanical thrombectomy.1 Here we consider a broader perspective about the purpose and need for this credential and the implications of further delay to its implementation.

Reducing imaging of the symptomatic male breast - Audit of compliance with national guidelines

Introduction: Male breast imaging is often over-utilised, especially in the absence of suspicious presentation. Local practice was audited against the Royal College of Radiologists (RCR) 2019 guidelines.

The first hybrid annual congress of the Royal College of Radiologists of Thailand and the Radiological Society of Thailand: How we live with COVID-19

The first hybrid annual congress of the Royal College of Radiologists of Thailand and the Radiological Society of Thailand: How we live with COVID-19

Current status of the credential “mechanical thrombectomy for acute ischaemic stroke” sponsored by the Royal College of Radiologists. What factors are preventing approval of training for non-radiologists to perform MT in the UK?

General Medical Council (GMC) Credentials are being developed to improve oversight of training in areas of practice that develop outside a GMC-recognised parent specialty, or to help address areas where clinical needs are not currently being met. This commentary describes why and how the Royal College of Radiologists (RCR)-sponsored Credential (Acute Stroke) was prepared and submitted to the GMC Curriculum Oversight Group (COG) and then substantially revised to the RCR-sponsored Credential (Mechanical Thrombectomy for Acute Ischaemic Stroke, MTAIS) in response to advice from the GMC COG.

It's not about the errors, it's about the learning: How the Royal College of Radiologists has developed a Radiology Events and Learning process in the United Kingdom.

The Royal College of Radiologists (RCR) is based in the United Kingdom but is a global organisation with members and fellows worldwide. In this invited article, the chair of the RCR Radiology Events and Learning (REAL) panel recounts his experience in looking at radiological errors. He starts with his personal work auditing his own mistakes as a junior consultant, describes what he learned in his departmental role in a large teaching hospital running a Radiology Events and Learning Meeting (REALM) and gives an overview of some of the work done over the last two decades by the RCR. This includes publishing national guidelines which set standards for running a REALM, setting up the REAL panel which produces a quarterly newsletter of cases from RCR members, and running an annual conference to share information with local radiology departments around the country. A review of the literature describing the drivers for this work and looking at the parallels with industry lies alongside the practical tips he found useful which he hopes would be helpful to anyone setting up their own departmental errors or discrepancy meeting.

210 An Audit to Evaluate Abdominal XR Requests in Surgical Patients

Abstract Abdominal x-rays (AXR) are a useful tool in investigating a number of pathologies. However, they expose the patient to up to 7 times more radiation than a standard chest x-ray1. AXR’s that are requested without appropriate indication are not an efficient use of resources. Our aim was to evaluate if requests for AXR’s being made are in line with Royal College of Radiologists (RCR) iRefer guidelines2 and try improving their adherence. Three data cycles of AXR requests made by surgical staff at Crosshouse hospital were gathered – between January & February, April, and July. Clinical history of the patients and indications in the request for the AXR were compared with guideline recommendations. In total 52 requests for AXR’s were made during January-February, of which 32 (62%) were made appropriately and 20 (38%) did not match guidelines, as the patient’s presenting complaint and clinical history did not match one of the recommended indications to perform AXR. After circulation of educational posters, 70% of requests were made in line with guidelines in April. Followed by 77% in July after a departmental presentation on the use of AXR. AXR’s requested during these time periods were not all made in line with guidelines. The most commonly noted error was the AXR being requested to rule out obstruction when the clinical history wasn't suspicious of obstruction. This QI project has demonstrated sustainable change and increased the adherence of AXR requests with RCR guidelines within the department.

A quality improvement project: Reducing the number of unnecessary plain abdominal radiographs performed in the emergency department of a London district general hospital.

Background:Inappropriate completion of abdominal radiographs results in unnecessary exposure to ionizing radiation. This quality improvement project aimed to reduce the number of inappropriate abdominal radiographs performed in the emergency department.Materials and methods:Abdominal radiograph request forms were analyzed with reference to the Royal College of Radiologists (RCR) iRefer guidance. A teaching session was then delivered to ED clinicians and posters were disseminated within the department. Post-intervention data collection followed.Results:Following the intervention, there was an increase in the proportion of abdominal radiographs meeting iRefer guidance, which was accompanied by an increased diagnostic yield of these investigations. There was a reduction in the number of requests post-intervention.Conclusions:Our interventions helped increase awareness of both the guidelines and radiation dose associated with each study. Routine education of the iRefer guidelines will help reduce inappropriate requests. This in turn will reduce unnecessary radiation exposure, whilst also reducing the financial burden.

Outcomes of male patients attending the symptomatic breast unit: adherence to local and national imaging guidelines and effectiveness of clinical examination and imaging in detecting male breast cancer

To review outcomes of male patients attending the breast unit, evaluate effectiveness of imaging and examination in detecting breast cancer and review adherence to guidelines for male breast imaging. A retrospective review was undertaken of male patients attending Cambridge Breast Unit from 1 January 2015 to 31 December 2019. Patient electronic records and imaging were reviewed to establish demographics, clinical findings, imaging, biopsy, and pathology outcomes. Of 1,362 male patients attending the breast unit, 1,028 (75%) had imaging performed. Biopsy was performed in 41 men (3%), with 14 cancers diagnosed (1%). Clinical examination showed 42.7% sensitivity, 99.6% specificity, 54.6% positive predictive value (PPV) and 99.4% negative predictive value (NPV) for detection of cancer. Mammogram demonstrated 84.6% sensitivity, 99.4% specificity, 69.8% PPV, and 99.8% NPV for detection of malignancy. Ultrasound demonstrated 78.6% sensitivity, 98.9% specificity, 73.3% PPV and 99.2% NPV for detection of cancer. Forty-one percent of patients <40 years and 51%<50 years were imaged, who according to local and Royal College of Radiologists (RCR) guidelines did not require imaging based on age and clinical score. Male patients account for a small proportion of referrals to the breast unit but generate significant workload. Imaging protocols, incorporating clinical score and age cut-off at 40 years remains robust for detecting malignancy. Clinician awareness of the imaging protocol, and close liaison with radiologists is essential to minimise additional radiology workload.

SP8.1.6 The role of staging imaging prior to neo-adjuvant chemotherapy (NACT) for breast cancer

Abstract Aims The Royal College of Radiologists (RCR) guidelines state that there is no evidence base for routine imaging in patients with early breast cancer (≤T2 and ≤N1 disease) planned for NACT. Standard practice in our unit is to routinely stage all patients scheduled for NACT with CT chest/abdomen/pelvis and MRI marrow. Our aim was to assess the utility of this practice in this group of patients. Methods All patients who received NACT for breast cancer from 2017 to 2020 were included. The imaging reports were reviewed to identify whether metastatic disease had been detected, or further investigations were required. Results 127 patients were identified. 51 patients met the current RCR criteria for imaging and were excluded. Of the remaining 76 patients with ≤T2 and ≤N1 disease, metastatic disease was found in 13. This was detected by CT in 9 patients, by MRI in 1 patient, and by both modalities in 3 patients. Indeterminate findings requiring further investigation were present in 17 with 6 patients requiring at least one further scan. Conclusion Routine staging investigations detected metastatic disease in almost one in five patients with early breast cancer about to start NACT, impacting on their treatment planning. A similar proportion of patients required further investigations due to indeterminate findings. We believe that routine staging using our current criteria for NACT patients should continue. In the absence of evidence from prospective trials, there is a need for ongoing audit of the utility of systemic staging in early breast cancer.

Are Maltese General Practitioners’ Musculoskeletal Imaging Requests Indicated for Diagnostic or Clinical Management Purposes? – A Research Study

Research Objectives: This research study aimed to determine whether the patients' exposures to ionizing radiation via plain musculoskeletal radiography are indicated for the diagnostic or clinical management purposes, according to standards defined in the European Commission (Radiation safety 118) Referral Guidelines for Imaging (2001), as well as the Royal College of Radiologists (RCR) i-Refer guidelines (2017). Research Methods: A non-experimental, exploratory research design was adopted to answer the objectives of this study. Data were collected through 694 electronic, musculoskeletal imaging requests that were selected via cluster random sampling. The data collected were quantitative in nature. The study had a 3.7 % margin of error (at a confidence level of 95 %) in relation to the analysed imaging request forms. Data were analysed using descriptive statistics. A p-value of ≤ 0.05 at a confidence level of 95 % was considered as statistically significant. Results: Only 20.5 % of plain, musculoskeletal imaging requests that are being referred by Maltese, state health centres G.Ps are classified as indicated for diagnostic or clinical management purposes. In addition, 65.3 % of plain, musculoskeletal imaging requests were classified in the not routinely indicated category. The lumbo-sacral spine is the region that has registered the highest number of cases in the not routinely indicated category; being closely followed by the knee and the cervical spine respectively. These findings indicate that there is a greater tendency for Maltese state health centres G.Ps to request plain, musculoskeletal imaging investigations which are not routinely warranted according to the European Commission RP118 (2001) or the RCR i-Refer (2017) gold-standard imaging referral guidelines. Moreover, 40.0 % of these imaging requests were also referred with insufficient clinical details. Recommendations: Based on the research findings as well as the available literature, the following recommendations are being suggested: Continuing medical education in radiation safety and imaging referral criteria for Maltese state health centres G.Ps and G.P. trainees; Issuing regular departmental memos about any related evidence-based research findings; Ensuring the availability of the imaging referral guidelines on the desktops of all workplace computers, and promoting the use of imaging referral guidelines as well as kindling the safety-net of asking for advice from senior colleagues or radiologists whenever the referrers are in doubt about the management of a particular clinical case; Promoting the development of refinements and updates of locally applicable imaging referral guidelines to address any potential gaps in the older versions; Considering the introduction of a pro-forma clinical checklist for requesting online plain imaging investigations to aid G.Ps in improving the appropriateness of their imaging requests at times of clinical controversy, as well as in providing all the relevant clinical details for reporting; Organizing a radiation protection campaign to both the Primary Health Care Department (Malta) as well as to members of the general public and considering the use of radiation protection booklets or posters that may be distributed or show-cased to the patients whilst still in the primary care clinics waiting areas.

Imaging in myeloma: a Royal College of Radiologists national survey of current imaging practice

To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites). All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed. One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (<10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training. Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning.

Meeting the new joint British Society of Gastrointestinal and Abdominal Radiology and Royal College of Radiologists CT colonography standards: a 6-year experience

To audit the performance of computed tomography colonography (CTC) at St Mark's Hospital against the joint British Society of Gastrointestinal and Abdominal Radiology (BSGAR) and Royal College of Radiologists (RCR) standards. A retrospective audit of all CTC studies between January 2012 to December 2017 was performed against the BSGAR/RCR standards along with additional data outwith the guidelines. Evidence was obtained from a central database, radiology information systems (RISs), picture archiving and communication systems (PACSs), and electronic patient records (EPRs). Over the 6 years, 13,143 CTCs were performed and 12,996 (99%) were adequate or better. Of the cases 1,867 had a >6 mm polyp or cancer reported (polyp identification rate [PIR] 14%) and the positive predictive value (PPV) was 93% (1,148/1,240). Median radiation dose was 458 mGy·cm, mean additional acquisition rate was 19% (2,505/13,143), subsequent endoscopy rate was 9% (1,222/13,143) and mean interpretation time for a negative study was 34.6 minutes. Nine perforations occurred (perforation rate of 0.068%) and one was symptomatic (symptomatic perforation rate of 0.008%). For suspected cancers, the same-day endoscopy rate was 27% (96/360) and same-day staging rate was 76% (272/360). Post-imaging colorectal cancer rates (PICRC) was 3.06 per 100 cancers detected and 0.23 per 1,000 CTCs. The service was always rated "good" or higher by patients. This audit shows the CTC service at St Mark's Hospital to be safe and of sufficiently high quality to meet the BSGAR/RCR standards with most outcomes equal to or above the aspirational target. Areas for service and individual reader improvement were also identified.

The Cheshire & Merseyside Collaborative trainee-led on-call service: a review of safety and efficiency

To assess safety and efficiency of the Cheshire & Merseyside Collaborative, the largest trainee led on-call service in the UK, based on discrepancy rates and time taken to issue reports. All studies reported by the collaborative in a 4-week period were evaluated for discrepancy and the time taken to issue a report. These figures were compared against the Royal College of Radiologists (RCR) guidelines and a recent national audit of discrepancy rates. The time taken to report was measured against the National Institute of Health and Clinical Excellence (NICE) and Trauma Audit Research Network (TARN) guidelines. The overall discrepancy rates for the collaborative were 2.5% for minor discrepancies and 2% for major discrepancies, which is within the RCR standard. The median time taken to issue a report was 30 min, which is within the NICE and TARN 1-h targets. The Cheshire & Merseyside Collaborative can be deemed a safe and efficient way of delivering an out-of-hours radiology service.

Musculoskeletal radiology training in the UK: a national survey by the British Society of Skeletal Radiologists

To identify the standard of core and subspecialist musculoskeletal (MSK) training across deaneries in the UK. An online survey of 46 questions with responses in Likert scale or dichotomous formats was distributed to members of the Society of Radiologists in training, British Society of Skeletal Radiologists (BSSR), Training Programme Directors and the Royal College of Radiologists (RCR) Junior Radiology Forum representatives for national training schemes across the country. Responses were analysed descriptively with narrative analysis of free-text comments. One hundred and seventy-eight participants completed the survey. Forty-six percent (81/178) were core trainees (ST1-3), 47% (84/178) were subspecialist trainees, and 7% (13/178) were newly qualified consultants (<2 years in post). All (178/178) of the participants had a dedicated MSK rotation, with a duration of ≥3 months in 76% (136/178). Only one-third received a dedicated period in MSK ultrasound and only 60% (107/178) had been actively involved in interventional procedures during their training. Overall, 21% (37/178) and 42% (75/178) of participants rated the quality of their MSK training as excellent and good, respectively. The majority (93%, 168/178) thought that MSK training could be improved, especially for ultrasound (62%, 110/178) and interventional computed tomography (CT) or fluoroscopy (57%, 101/178). There are inconsistencies in MSK training offered in the UK. Although the majority of trainees are satisfied, there were gaps and potential threats to the quality of training. MSK training is witnessing substantial demand from trainees and workforce strategists necessitating tactical investments to standardise and enhance its quality.

325 The Appropriate Use of Plain Film Abdomen in The Acute Surgical Assessment Unit: The Experience of a Model Three Irish Hospital

Abstract Introduction A plain film abdomen (PFA) is a useful modality of imaging if used correctly. However, when used inappropriately, it leads to unnecessary cost and increases patients’ exposure to radiation. The aim of this study is to assess the adherence to the Royal College of Radiologists (RCR) guidelines for PFA use in acute surgical patients. Method A retrospective study was conducted in the Acute Surgical Assessment Unit (ASAU) of a Model 3 Irish Hospital over a 12-day period in October 2019. Data was obtained using a Patient Census Book and the National Integrated Medical Imaging System (NIMIS). Recorded indications for the PFAs were compared against RCR guidelines. Results A total of 207 patients were reviewed, 113 males and 94 females, with a median age of 45. In 67 out of 207 patients (31.4%) a PFA was performed. A total of 31 (46.3%) were valid indications. A significant finding was present in 6 of the PFAs none related to the presenting complaint. Discussion Based on RCR guidelines regarding the indications for PFA, &amp;gt;50% of the patients had a PFA for reasons not indicated by their presenting complaint. If implemented properly, adherence to guidelines could save cost and more importantly, safeguard our patients.

P076. The indication for clinical biopsies in radiologically normal symptomatic breast disease

Introduction: The triple assessment represents the gold standard for breast diagnoses. The Royal College of Radiologists (RCR) state that a free hand core biopsy is indicated where imaging is normal, but clinical assessment is indeterminate (P3 and above). Nonetheless, clinicians are opting for clinical biopsies following normal radiological findings. Therefore, we aimed to investigate the proportion of patients with symptomatic breast disease that yielded malignant biopsy results following normal imaging; and ascertain whether biopsies are indicated.

P58 Head Injury CT scan: measuring up to NICE guidelines

IntroductionHead injury is the most common cause of death and disability in individuals between 1-40 years in the UK, with roughly 200,000 annual admissions. The aim is to evaluate how effectively CT scans following a head injury are being performed with reference to NICE guidelines 1-hour criteria1 as patient’s prognosis could potentially be improved with early detection.Standards100% of patients should be scanned within 1 hour of risk factors being identified.100% of provisional radiology reports on CT-heads should be completed within 1 hour of the scan being performed:All requests from emergency department must have clear documentation of head injury risk factors justifying scanMethodsretrospective audit collecting data from 01/01/2020 to 14/01/2020 for 1st cycle and from 14/10/2020 to 30/10/2020 for 2nd cycle.Requests were found on the electronic request system (ICE) to assess clinical information provided by ED clinicians only taking into account those scans following a head injury according to NICE guidelines.Results First cycle100 scans were examined with only 36% meeting criteria for 1 hr scan.Only 19 (52%) of those patients had received all 3 measures of the standard.In total 8 patients had positive findings with only 4 patients getting scan and report on time.Second cycle100 scans were examined with 45% meeting criteria for 1 hr scan.37 (83%) had received all 3 measures of the standard.In total 13 patients had positive findings with 11 patients getting scan and report on time.ConclusionAbout only half of the patients presenting with the risk factors got their scan done in line with NICE guidelines. Following change of ICE to include criteria patients were better categorized, eliminating any unnecessary scans, reducing waiting times and cost, improving patient flow in ED and all scans are now justifiable according to criteria.References1-National Institute for Health and Clinical Excellence. CG176. Head Injury: assessment and early management. London. January 2014. https://www.nice.org.uk/guidance/cg176: 2-irefer. The Royal College of Radiologists. Making the best use of clinical radiology services 8th edition. 2017 https://www.rcr.ac.uk/sso/irefer/v8: 3-https://www.rcr.ac.uk/audit/compliance-nice-guidelines-2014-traumatic-head-injury-regard-ct

AB134. SOH21AS031. Improving the usage of plain abdominal radiographs in emergency general surgical admissions—a closed loop audit

Background: Abdominal X-rays (AXRs) are a common admission investigation of the General Surgical (GenSurg) patient. The average cost of AXR is £27, with a radiation of 0.7 mSv. They are over requested and out with Royal College of Radiologists (RCR) guidelines. This closed loop audit was done in-order to reduce the number of inappropriate requests. We aim to achieve 70% compliance to RCR-guidelines. This will save money and reduce unnecessary radiation.

Implementation of Royal College of Radiologists Consensus Statements and National Institute for Health and Care Excellence Guidance: Breast Radiotherapy Practice in the UK

AimsBreast radiotherapy practice, driven by large randomised controls trials, is increasingly being risk adapted to the biology and stage of the cancer. The aim of this audit was to measure current breast radiotherapy practice in the UK against quality standards from the 2016 Royal College of Radiologists (RCR) consensus statements and the 2018 updated National Institute for Health and Care Excellence (NICE) guidelines. These guidelines include new recommendations for partial breast irradiation for women at lower risk of recurrence and internal mammary chain radiotherapy for those at higher risk. Materials and methodsRadiotherapy departments completed a questionnaire for all patients starting adjuvant radiotherapy for early breast cancer in a 2-week period mid-2019. ResultsEighty-one per cent of centres returned data on 958 patients, including 18 bilateral cancers. Of 976 breast cancers, 23.9% were treated with mastectomy. The dose fractionation schedule for adjuvant radiotherapy was 40 Gy in 15 fractions in 95.7% of cases. Of the 743 cases treated with breast conservation, 29.9% received an additional tumour bed boost. The boost was given sequentially in 91.9% of cases and with eight different dose fractionation schedules. Of 494 left-sided breast cancer cases, 54% (n = 267) received radiotherapy in deep inspiratory breath hold. All centres except one had a deep inspiratory breath hold technique available. Only 12% of patients who met the RCR criteria for partial breast irradiation received it. Overall, 14.7% and 9.9% of patients meeting the RCR and NICE criteria for internal mammary chain radiotherapy, respectively, received it. ConclusionsDespite established consensus statements and NICE guidelines there persists variation in breast radiotherapy practice in the UK. The results of practice-changing trials showing the benefit of cardiac-sparing radiotherapy techniques, partial breast radiotherapy and internal mammary nodal radiotherapy have not been fully implemented. This audit highlights areas for targeted quality improvement and future consensus statements.