ensuring action on critical, urgent and significant

Ensuring Action on Critical, Urgent and Significant Unexpected Radiological Findings of 19

Ensuring Action on Critical, Urgent and Significant Unexpected Radiological Findings

Summary statement: How does the document support patient care?

The policy supports WSHT staff in ensuring timely receipt of radiology reports

and prevents inaction on Significant and Unexpected Radiological Findings

(SURF)

Staff/stakeholders involved in development: Job titles only

Chief Nurse

Radiology Clinical Director

Head of Clinical Governance and Patient Safety

Patient Safety Manager

Division: Core

Department: Radiology

Responsible Person: Clinical Director Radiology

Author: Radiology Manager

For use by: All Staff

Purpose: This policy describes the action to be taken when a radiological investigation

identifies unsuspected findings, unsuspected malignancy, and life threatening

findings that are deemed to be of a critical and urgent nature to ensure that

appropriate and timely treatment is instigated.

This document supports: Standards and legislation

National Patient Safety Agency. Safer practice notice 16. Early identification of

failure to act on radiological imaging reports. London: NPSA, 2007.

http://www.npsa.nhs.uk/nrls/alerts-and-directives/notices/radiological/

The Royal College of Radiologists. Standards for the communication of critical, urgent and unexpected significant radiological findings, second edition. London: The Royal College of Radiologists, 2012

https://www.rcr.ac.uk/sites/default/files/docs/radiology/pdf/BFCR%2812%2911_urgent.pdf

Key related documents: See section 5

Approved by:

Divisional Governance/Management Group

Trust Management Board

Trust Executive Committee

Approval date: July 2019

Ratified by Board of Directors/ Committee of the Board of Directors

19/07/2019

http://www.npsa.nhs.uk/nrls/alerts-and-directives/notices/radiological/




Ratification Date: 19/07/2019

Expiry Date: July 2022

Review date: July 2022

If you require this document in another format such as Braille, large print, audio or another language please contact the Trusts Communications Team

Reference Number: P19017


Version date Author Status Comment

1.0 23/05/2019 Radiology Manager Draft For Review

2.0 11/07/2019 Radiology Manager Final draft

For TEC approval

3.0

4.0

INDEX

Page No.

1.0 INTRODUCTION 4

2.0 PURPOSE 4

3.0 CLASSIFICATION OF RESULTS 5

4.0 1.0 POLICY 5-6

5.0 RELEVANT DOCUMENTATION 6

Appendix A

DOCUMENT COMPLIANCE CRIB SHEET 7-9

Appendix B SAFER PRACTICE NOTICE 10

Appendix C WSHT IN HOUSE REFFERS CONTACT SHEET 11

Appendix D WSHT REFERRERING TEAM PROCESS FLOW 12-13

EQUALITY IMPACT ASSESSMENT 14-19


Ensuring Action on Critical, Urgent and Significant and Unexpected Radiological Findings (SURF)

1.0 Introduction 1.1 The issue of the communication of radiological reports has been highlighted as an

issue for UK radiology departments over many years. Publication of Safer Practice Notice 16. Early identification of failure to act on radiological reports by the National Patient Safety Agency (NPSA) 2007 (Now NHS Improvement) recommended actions to referrers including ‘Ensure systems are in place to provide assurance that requested images are performed and the results of these are viewed, acted upon accordingly and recorded. It is the referring registered health professional’s responsibility to ensure that this is followed’.

This notice also recommended action by radiology departments, radiologists and radiographers relevant to critical or urgent findings to ensure that ‘critical findings are emphasised and obvious and that the degree of urgency for action by the referring health professional is clear’. Further recommendations were to define and develop a policy for radiological reports which require timely and reliable communication, for example, abnormal, unexpected and/or critical ranges plus to define and document ‘safety net’ procedures for example copying reports to GPs, MDTs or other identified health professionals in consultation with the referrer.

2.0 Purpose 2.1 This policy describes the action to be taken when a radiological investigation

identifies unexpected findings, e.g. unsuspected malignancy or life threatening findings that are deemed to be of a Critical or Urgent nature and to ensure that appropriate and timely management is instigated. It is also intended to act as a safety net that ensures Significant and Unexpected Radiological Findings (SURF) are communicated to and received in the most appropriate timeframe by the referring clinical team to ensure the highest standards of patient safety and care.

2.2 The policy is NOT designed to remove the responsibility of referrers from making

themselves aware of individual patient results.


3.0 Classification of results

The Royal College of Radiologists document “Standards for the Communication of critical, urgent and unexpected significant radiological findings, second edition” (2012) describes appropriate classifications of results as follows:

Critical Where emergency action is required as soon as possible

Urgent Where medical evaluation is required within 24 hours

Significant and Unexpected (Radiological) Findings (SURF)

Where the reporter has concerns that findings are significant for the patient and are unexpected

4.0 Policy 4.1 Any individual reporting on imaging examinations for Western Sussex Hospitals

Trust must follow the Critical, Urgent or SURF pathway as detailed below. 4.2 In circumstances where there is either a Critical finding (where immediate action is

required – see section 3) or Urgent finding (where medical evaluation is required within 24 hours – see section 3), communication will be triggered by the radiology team beginning with a telephone call to the appropriate clinician or team (for example, requesting consultant, oncology nurse or the on-call registrar out of hours – see appendix C)

4.3 The details of this contact will then be documented on the report and the

responsibility for the management of the patient is then transferred back to the ordering clinician or team with a copy of the result. It is the responsibility of that named clinician to act on the findings as appropriate and to ensure that they have robust mechanisms in place for accessing and following-up the results of requested tests.

4.4 In circumstances where there is a Significant and Unexpected Radiological

Finding (SURF) (Where the reporter has concerns that findings are significant for the patient and are unexpected – see section 3) then the reporter should use the coded phrase “Significant and Unexpected Radiological Finding SURF”

4.5 Responsibilities of reporters under each of the classifications are described in

Appendix A, but the interpretation of what type of result falls into which category is open to individual interpretation and professional judgement However, the examples in Appendix A are there for guidance.


4.6 An automated electronic system (Communicator) is in place that identifies SURF reports for GP and internal WSHT referrals. This system sends out results to the GP practice and the internal WSHT group mailboxes (See appendix D) within 30 minutes of the report being verified. Assurance of receipt is via an acknowledgments system and the WSHT Picture Archiving and Communication System (PACS) team have daily procedures in place to ensure that any SURF reports are followed up within two working days.

4.7 Monthly audits will be undertaken that will identify the number and type of SURF

reports issued. Results will be made available via the department’s clinical governance process.

4.8 SURF will only be raised where a significant finding is also unexpected given the

original indication for the test. It is the responsibility of the referring clinicians to ensure that radiology has the relevant minimum data set on the referral.

4.9 Where there is an addendum added to any report then this is treated electronically

as additional report and the same rules apply with regards to 4.6 4.10 Regular audit of this process is encouraged and should be fed-back via the

radiology integrated clinical governance and core governance meetings. 5. Relevant documentation 5.1 The Royal College of Radiologists. Standards for the communication of critical,

urgent and unexpected significant radiological findings, second edition. London: The Royal College of Radiologists, 2012

5.2 National Patient Safety Agency. Safer practice notice 16. Early identification of

failure to act on radiological imaging reports. London: NPSA, 2007. (See appendix B)

5.3 Care Quality Commission (CQC). Radiology Review. A National review of radiology

reporting within the NHS in England.


Appendix A (For guidance only and not an exhaustive list)

Critical Urgent SURF

Definition: (RCR)

Where emergency action is required as soon as possible.

Where medical evaluation is required within 24 hours.

Where the reporter has concerns that findings are significant for the patient and are unexpected.

Radiological Response:

Immediate and Direct communication with Referring Consultant via hospital switchboard. If no immediate response, then details to be passed to the relevant On Call team.

Prompt (within one hour) and direct communication with Referring Consultant via hospital switchboard. If no immediate response details to be passed to the relevant On Call team.

Report and verification on CRIS as soon as possible. SURF noted in report. Email communication with follow up as described in detail (see sections 4.6-4.10).

Clinician Response

Communicate findings to appropriate individual. Take IMMEDIATE action.

Communicate findings to appropriate individual. Take action within the same day and record action taken.

Read report and take possible action within 1 working day of receipt of message.

Brain:

Unexpected lesion causing hydrocephalus or significant mass effect.

Unexpected new mass lesion.

Unknown intracranial haemorrhage with significant mass effect.

Unknown intracranial haemorrhage or abscess.

Head & Neck:

Acute airway obstruction due to tumour in patient where this was not the primary concern.

Incipient airway obstruction.

Unexpected mass lesion.

Incipient erosion of tumour

into vital structure.

Unexpected jugular vein

thrombosis.

Unexpected abscess or

haemorrhage.



Chest: Unexpected tension pneumothorax.

Unexpected pneumothorax. Unexpected mass lesion.

Unexpected massive PE.

Unexpected moderate PE.

SVCO.

Severe infection compromising

respiratory function.

Unexpected large pericardial or

pleural effusion.

Abdomen:

Active extravasation from abdominal source.

Unexpected GI obstruction.


Ischaemic bowel on CT.

Unexpected abscess/collection or other acute infection.

Unexpected unilateral hydronephrosis.

Bilateral hydronephrosis or obstructed

single kidney.

Unexpected Biliary Obstruction

Unexpected portal venous thrombosis or other acute visceral vascular abnormality (e.g. hepatic or splenic infarcts).

Unexpected Fistula

IVC obstruction or thrombosis.

Pelvis: Please see abdomen (above).

Please see abdomen. Also unexpected severe bladder distension (e.g. causing hydronephrosis).


Unexpected torted structure e.g.

ovary.

Pelvic venous thrombosis.



MSK:

Fracture with haemorrhage or ischaemia.

Unexpected spinal cord compression.

Unexpected fracture which does not require urgent attention.

Unexpected discitis.


Unexpected fracture which requires

urgent attention.

DVT.

Vascular:

Bleeding from AAA or other vascular lesion.

Unexpected very large AAA (+/-) suspicious features or other large aneurysm at risk of imminent bleeding.

Unexpected AAA not at imminent risk, or other aneurysm.

Unexpected dissection or significant thrombosis.

Ischaemic limb.

DVT or other thrombosis.


Appendix B


Appendix C – WSHT Contact list for critical or urgent findings.


Appendix D – WSHT Referring Team Process Flow.

Fig 1

Fig 2


Appendix D – WSHT Referring Team’s Process Flow Continued.

Fig 3

Fig 4


EQUALITY IMPACT ASSESSMENT

Name of Policy, Service, Function, Project or Proposal

Ensuring Action on Critical, Urgent and Significant Unexpected Radiological Findings

Department

Radiology

Lead Officer for Assessment

Emma Francis

What is the main Purpose of the Policy/Service/Function/Project/Proposal?

To provide timely communication and action with critical, urgent and

significant unexpected radiological findings.

Freedom To Speak Up (FTSU) Guardian Role Staff support can also be provided by

Freedom to Speak Up (FTSU) Guardians.

The FTSU Guardians provide an impartial

service for staff to discuss concerns

confidentially. The Guardian will then

support the member of staff to raise the

concern and ensure there are no

recriminations from doing so.

List the main activities of the policy or service re-design (e.g. Manual Handling would relate to health and safety of patients; health and safety of staff; compliance with NHS and Government legislation or standards etc)

To be compliant with guidance as in section 5 of main document.

Is the policy or service relevant to: Promoting Good Relations between different people? Eliminating discrimination? Promoting Equality of Opportunity?

Yes No No

Which groups of the population do you think may be affected by this proposal? Minority Ethnic People Women and Men People in religious/faith groups Disabled people Older people Children and young people Lesbian, gay, bisexual and transgender people People of low income People with mental health problems Homeless people Staff Any other group (please detail)

No No No No No No No No No No No


Do you have any information that tells you of the current use of this service? Yes (if yes please

detail) n/a

Is it broken down by ethnicity, gender, disability, age, religion and sexual orientation? No (please detail)

Does this information reflect the proportions from the 2011 Census? No (If no, can you explain why) Not applicable

If there is no information available or if this is patchy, specify the arrangements that will make this available

Using the information above, please complete the grids below: How will the Policy etc affect Men and Women in different ways?

Gender Positive Impact

Negative Impact

Neutral Reason/Evidence Don’t know

Women

x

Men

x

How will the Policy etc affect Black and Minority ethnic people?

Race Positive Impact

Negative Impact


White

x

Mixed

x

Other Ethnic Group

x

Black/Black British

x

Asian/Asian British

x

How will the policy affect people with disabilities?

Disability Positive Impact

Negative Impact


Visually Impaired

x

Hearing Impaired

x

Physically x


Disabled

Learning Disability

x

Mental Health Related

x

How will the policy affect people of different ages?

Varying ages Positive Impact

Negative Impact


x

How will the policy affect people of different sexual orientation?

Sexual Orientation

Positive Impact

Negative Impact


x

How will the policy affect Transgender or transsexual people?

Positive Impact

Negative Impact


Transgender

x

Transsexual

x

How will the policy affect people of varying religious beliefs?

Varying beliefs

Positive Impact

Negative Impact


x

How will the policy affect those with carer responsibilities or impact on basic human rights?

Carers / Human Rights

Positive Impact

Negative Impact


x

Considering your responses above, what are the areas that are have a positive and / or negative impact?

Positive + / Negative -

Reason Given for Impact

Gender n/a

Race n/a

Disability n/a

Age n/a

Sexual Orientation n/a

Religious Belief n/a


Has there been any consultation about this Policy etc? If there has, what were the key issues identified?

Consultation Date Summary of Key Issues to be addressed

Gender n/a

Race n/a

Disability n/a

Age n/a



If consultation is planned, when will it happen and what are the key themes for consultation? How do you intend to consult staff? What does Local / Regional / National research show with regards to these groups and the likely impact?

Group Source Key Issues

Gender n/a

Race n/a

Disability n/a

Age n/a



As a result of consultation / information gathering, what changes do you intend to make to the policy etc? If ‘None’, please state as relevant: Gender

Issue Action Required Lead Officer

Timescale Outcome Measure

Review Date

Race



Review Date

Disability



Review Date


Sexual Orientation



Review Date

Religious Belief



Review Date

Age



Review Date

Please outline the monitoring and reviewing process and timescale Agreed Review Date: Signed by: Policy / Service Author ………………………………………..… Trust Equality & Diversity Lead…………………………………………………… Date:

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