Investigating Hospital Deaths: Radiology Investigation

1
Investigating Hospital DeathsRadiology
Investigation

• Dr Chris ODonnell
• Radiologist
• June 2005

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Introduction

• Aug 2004, Coroner convened a Radiology forum
• response to specific death investigations
• multiple contributors (stakeholders)
• Aim
• standardised approach to the investigation of
  deaths where Radiology is involved
• benchmark for hospitals (a la falls protocol)
• prevention

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Overview

• what is radiological practice?
• how has it worked in the past?
• current issues/problems affecting that practice
• what needs to be done to address those issues
  (risk management)
• Coronial impact
• outcomes

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Current/Future role of Radiology

• increased sophistication
• increased utilisation
• increased clinical dependence
• more Radiology/Radiologists
• pressure to be quick and to be accurate
• e.g. appendicitis

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Radiological process

• decision to investigate
• request issued for examination (referral)
• examination performed
• images available
• Radiologist interprets and issues a report
• report returned to referrer
• appropriate practitioner takes action

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Historical

• clinical experience of referrer
• paper/film based (analogue)
• 9 5 (no weekends)
• low tech radiographs
• referring doctor reviews and awaits final report
• management often minimally altered by that report

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Historical problems

• junior doctors - inexperienced
• paper/film based - gets lost
• 9 5 (no weekends) pts sick at all hours
• low tech radiographs inadequate Dx
• referring doctor reviews and awaits final report
  delayed or missed Dx
• management rarely altered delayed treatment or
  
• all above issues before the coroner

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Issues affecting change

• complexity of modern medical practice and
  sophistication of the radiological imaging
• increased reliance on imaging to manage patients
• radiological triage
• desire to sort patients out prior to admission
  not admit for observation as in the past
• administrative push to have patients transit
  through ED lt 8 hrs
• financial imperative
• not enough radiologists for full time access
• perceived need for universality of medical care
• rural/remote

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The ideal

• everyone who needs a test gets the appropriate
  one
• nothing gets lost!
• 24/7
• sophisticated imaging techniques (multislice
  CT/MRI/bedside US)
• instant Radiological report transmitted
  immediately to referrer
• acute specialist management based on that report

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Solutions

• defined imaging protocols or pathways
• fully integrated digital system (request and
  images)
• Radiologists available 24/7
• not necessarily in Department c/o teleradiology
• instant on line reporting
• automated report transmission to referrer
• specified results leading to notification of
  specific clinicians
• information acted upon leading to management
  change

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Industry solution

• PACS
• picture archive and communication system

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Digital Radiological process

• patient slots into a clinical pathway
• request for examination on line
• examination performed digital image
• Radiologist issues a report on line
• report returned to referrer electronic post-box
• appropriate practitioner takes action automated
  traffic lights

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Where are we now?
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What most of us are doing

• requests based on experience of the doctor
• mixed low tech/digital e.g. paper request,
  digital reporting
• 9 5, M - F with reduced after-hours
• lot of low tech imaging increasing sophisticated
  (CT)
• referring doctors after hours review plain films
  with some help from Radiologists (interim verbal
  reports)
• indecision and conflict
• some patient's management compromised
• Health Services Commissioner, Courts, Coroner

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fully digital downsides

• too much reliance on protocol
• excessive use of resources
• too much reliance on imaging
• treating the X-ray not the patient!
• cultural change for Radiologists/clinicians
• more on-call
• soft copy reporting i.e. computer screens not
  film
• cost
• getting cheaper
• needs to be integrated (at least state based)
• avoid the ß v VHS scenario
• DICOM (Digital Imaging and Communications in
  Medicine)
• patient privacy

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Rural/remote

• limited high tech
• limited Radiologist access
• reliance on non-specialists
• need for a digital 2nd opinion!

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Outcomes

• efficiency (average bed stay)
• improved diagnosis (audits)
• less disasters (internal MM Coronial review)

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Conclusion (1)

• protocols will avoid patients falling through the
  net
• fully digital will greatly assist the flow from
  request to patient management action
• we need help to move through the transition from
  analogue to digital
• technology is available
• money is not (need for Governmental support)
• need to involve clinicians
• they need to understand the benefits
• assist in the protocol formulation
• they need to be part of the process of
  implementation not to have it imposed upon them
• measure outcomes

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Conclusion (2)

• Coroners Radiology Investigation Standard
• assist in investigation
• help to push along the modernisation of the
  Radiological process