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 1 st round Change implemented- July nd Round 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 reports reviewed 207 chest films reporting new consolidation Mean age 64 years, range years 57% male, 43% female 48% ED referrals, 52% GP referrals CXR N=2628 CONSOLIDATION ON CXR 8%, N=208 NO FU CODE 20% N=42 FU DONE 31% N=13 FU CODE 80% N=166 FU ARRANGED 70% N=117 FU ACHIEVED 97% N=114

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

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’ code Define 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 reports reviewed 172 reports described new consolidation Average age 66 years, range years 45% male, 55% female 61% GP referrals 39% ED referrals

Round 2 results ‘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

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 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.

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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