Follow-up of consolidation on chest radiographs before and after the introduction of radiology initiated follow-up.

Cliffe H, Walsh J, Kon M.

Outline

•Background•Audit population, standard and method•1st round- 2012•Change implemented- July 2013•2nd Round- 2013•Discussion

Background

Local Context Pre July 2013

Follow-up required

Add follow-up code (AC FUP) to the report

Admin search for the AC FUP

code(8 weeks post examination)

If no follow-up is arranged a reminder sent

to clinician

Local Context

•Serious incidents

•Consideration of radiology initiated follow-up

Question: does the current system of clinician booked follow-up ensure that

patients receive the recommended follow-up?

Audit population

•New consolidation on adult chest radiographs

•Non resolving consolidation may have a sinister aetiology (Little et al 2014, Holmberg et al 1993)

•Local guidelines in place

•High volume & short follow-up period

Audit design

Standard: Local guidelines state that all adults with new consolidation require a follow-up radiograph 6-8 weeks later to ensure resolution

Indicator: dedicated follow-up film request & report on CRIS

Target: 100% dedicated follow-up

Methods• Using Computerised Radiology Information

System (CRIS)• Reviewed chest radiograph (CXR) reports for

GP and ED referrals

•Did the CXR report NEW consolidation?•Was the follow-up code added by radiologist?

•Was the follow-up CXR booked?•Did the patient attend for follow-up?•How soon after did the follow-up film occur?

Round 1 results

• GP and ED referrals to BTHFT for CXR in August 2012

• 2628 reports reviewed

• 207 chest films reporting new consolidation • Mean age 64 years, range 19-90 years• 57% male, 43% female• 48% ED referrals, 52% GP referrals

Round 1 results•‘AC FUP’ code was used in 81% of reports

•Follow-up was achieved in 62% when the ‘AC FUP’ code was used and 28% when it was not used

TOTAL

GP

ED

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

% FOLLOW-UP WITH AND WITHOUT CODE

NO CODE AC FUP USED

Round 1 results

•Attendance at booked follow-up was 97%

•Mean time to follow-up was 10 weeks

•Overall 55% of patients with new CXR consolidation obtained appropriate follow-up imaging

Implementation of change- July 2013

Follow-up required

Add ‘AC FUP’ codeDefine FU required.

Clinician informed

Partial booking of

examination

Letter to patient

asking them to confirm

Examination confirmed

Examination occurs,

results to clinician, or

GP if discharged

from ED

Round 2

Question: has the implementation of radiology initiated follow-up improved

the attainment of follow-up of consolidation on chest radiographs?

•Methods, standard and indicator: as per round 1

•Assessment Period: August 2013

Round 2 results

•GP and ED referrals for CXR in August 2013•2336 reports reviewed

•172 reports described new consolidation•Average age 66 years, range 18-97 years•45% male, 55% female•61% GP referrals 39% ED referrals

Round 2 results

TOTAL

ED

GP

0% 20% 40% 60% 80% 100%

% USE OF FOLLOWUP CODE

2013

2012

‘AC-FUP’ code use improved from 81% to 93%

Round 2 results

When ‘AC FUP’ code used FU was booked in 96% of cases versus 64% previously

TOTAL

GP

ED

0% 20% 40% 60% 80% 100%

% FOLLOW-UP BOOKED WHEN AC FUP CODE USED

2013

2012

TOTAL

ED

GP

0% 20% 40% 60% 80% 100%

% AC FUP CODE USED AND FU ATTENDED

2013

2012

Round 2 results

When ‘AC FUP’ code employed FU achieved in 72% of cases compared to 62% previously

Overall DNA rate 12% versus 3% previously

Round 2 results

A&E GP OVERALL0

2

4

6

8

10

12MEAN TIME TO FU CXR

(WEEKS)

2012

2013

Mean time to FU improved from 10 to 7 weeks (within target)

Round 2 results

Overall 69% of patients with new CXR consolidation received FU CXR versus 55% previously.TOTAL

GP

ED

0% 20% 40% 60% 80% 100%

OVERALL % FOLLOW-UP OBTAINED

2013 2012

Study limitations

• Single indication and study• Single site• No ward or outpatients• Snapshot study, soon after

implementation

Discussion

•Increase in the attainment of recommended follow-up•Multifactorial•Marked improvement in code use and rates of patients offered follow-up•A streamlined patient journey•Low cost intervention•DNA rates•How do you safety net the safety net?

Acknowledgements Dr Jonathan Barber, Clinical Director for Imaging, Bradford Teaching Hospitals Foundation Trust.

Professor Clive Kay, Chief Executive, Bradford Teaching Hospitals Foundation Trust.

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

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