ONE YEAR EXPERIENCE OF A “ SAFETY NET” PROTOCOL FOR ABNORMAL CHEST RADIOGRAPHS (CXR) H Singh, SCO Taggart, PM Turkington, K Peplow, R Chisholm, BR O’ Driscoll Hope Hospital, Manchester

“Missed Abnormal Chest Radiographs” Many abnormal CXR reports are not acted upon in a timely manner. “ Detection or decision errors” Turkington PM, Kennan N, Greenstone MA. Postgrad Medical J 2002, March; 78(917): Quekel LG, Kessels AG, Goei R, van Engelshoven JM. Miss rate of lung cancer on the chest radiograph in clinical practice. Chest 1999; 115(3): Potchen EJ, Bissei MA. When is it malpractice to miss lung cancer on chest radiographs? Radiology 1990; 154:

Turkington PM, Kennan N, Greenstone MA. Postgrad Medical J 2002, March; 78(917):

An example of the problem Chest Pain – Discharged “CXR normal” RADIOLOGY REPORT “Some volume loss, on the left, even allowing for rotation” RADIOLOGY REPORT “Some volume loss, on the left, even allowing for rotation” Report to wrong doctor ( similar names!) Report finally seen– Non Chest Specialist 6 months later- readmission with complete collapse Left Lung with pneumonia- died 2 days later

‘Safety Net’ Chest Team, Radiology, Risk manager Screen all abnormal CXR reports Radiologist may recommend urgent action or follow up CXR

‘Safety Net for suspicious CXR reports’ Action required for all CXR reports if….. “ suspicion of lung cancer” “ suspicion of lung cancer” or or ”recommended urgent action/follow up” All of these reports were faxed to Lung cancer team as well as the requesting clinician

Lung Cancer Nurse (LCN) Checked the electronic record for evidence of appropriate action within 2 weeks If no action was evident, she initiated it

Actions Primary Care and/or Hospital Consultant informed Referral to Chest Clinic if needed With / Without a letter to the patient

Results 1 year Abnormal CXR reports in 12 months n = 453 Abnormal CXR reports with Urgent action recommended n=269 Urgent action recommended n=269 Follow up CXR in 6 weeks n=162 Follow up CXR in 6 weeks n=162 Patients died before any action n = 22 Patients died before any action n = 22 Urgent action (n=269) Primary care n= 176 Urgent action (n=269) Primary care n= 176 Hospital n= 93 Hospital n= 93

Primary care (n=176) Urgent action recommended n =176 ( by Radiologist) This action was taken by the GP n= 149 This action had to be taken by LCN n= 27 This action had to be taken by LCN n= 27 9 out of 27 (33%)had an eventual diagnosis of Lung cancer

Hospitals films (n=93) Urgent action recommended n=93 (by radiologist) (by radiologist) This action taken by the team n=47 This action taken by the team n=47 This action taken by LCN n=46 This action taken by LCN n=46 12 patients out of these 46(26%) had an eventual diagnosis of Lung cancer

Conclusions 73 out of 269 urgent reports had to be handled by the “safety net” in 12 months 27 out of 176 (15%) of Primary care 46 out of 93 (50%) of Hospital films 21 out of 73 (28.9%)were diagnosed with Lung cancer

Conclusions “SAFETY NET” “SAFETY NET” Prevented 21 potential delayed diagnosis of lung cancer over 12 months Cost = approximately £ 2500/ year ( ½ day WTE of Nurse + secretarial time) ( ½ day WTE of Nurse + secretarial time) This is a cost effective way of reducing risk No adverse incidents over this time

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