National Audit of the Accuracy of Interpretation of Emergency Abdominal CT in Adult Patients Who Present with Non-Traumatic Abdominal Pain

C Ball, SpR Radiology, Portsmouth Hospitals NHS Trust A Higginson, Consultant Radiologist, Portsmouth Hospitals NHS Trust K Drinkwater, Audit Officer, Royal college of Radiologists D Howlett, Consultant Radiologist, East Sussex Hospitals NHS Trust

In collaboration with the RCR audit committee. Special thanks to all the audit leads and those who completed the audit.

Plan BackgroundAimsMethodResults Discussion/The future

Background The NHS is experiencing a period of change with reconfiguration of local services and increasing use of outsourced reporting to external organisations to meet demand and to generate cost savings. National drive to improve quality with a strong focus on patient safety. The quality of the report must remain high whether generated by trainee radiologists, consultant trust radiologists or consultant non- trust radiologists.

Aims To assess major/minor discrepancy rates for provisional and addendum reports Assess the impact of discrepancies To evaluate correlation of provisional +/- addendum report and CT auditor report with laparotomy findings in a surgical group.

Coding Major Discrepancy – a change or potential change in diagnosis or treatment as a result of addendum/CT auditor review. Minor Discrepancy – minor differences between provisional/addendum and addendum/auditor reports, unlikely to result in a significant change in patient management. Indeterminate report – a report where a wide, or non-specific, or inappropriate differential diagnosis is given which leads to indeterminate management advice. These reports will be treated as major discrepancies.

Standards

All centres across the UK with acute abdominal CT reporting capacity were included Retrospective identification from 1/1/2013 onwards from the radiology departmental database of 50 consecutive non-traumatic adult (>16 years) emergency patients who had out of hours (6pm – 8am) abdominal/abdominopelvic CT Methods

Split cases into: 1. Non-surgically managed patients 2. Surgically managed patients Non-Surgical Group – Abdominal/abdominopelvic CT but no laparotomy subsequent to the CT. Patients who had another intervention during this admission subsequent to the CT (e.g. Colonic/JJ stent, EVAR, percutaneous drainage, laparoscopy) would be included in this category.

Surgical Group - 25 consecutive adult patients who underwent a laparotomy as an emergency for an acute abdomen (non- traumatic) and who also underwent emergency abdominal/abdominopelvic CT out of hours as part of their assessment The laparotomy may have been performed at any time following the CT if deemed relevant to the CT diagnosis

Results - Respondents

Results - Institution

Results – On call reporting by SpR

Results – On call reporting by Offsite radiologist

Standards SpR discrepancy rates Major discrepancy rate (provisional report - registrar)<10% Minor discrepancy rate (provisional report - registrar)<20% Major discrepancy rate (provisional report - trust consultant radiologist or offsite non-trust radiologist)<5% Minor discrepancy rate (provisional report - trust consultant radiologist, offsite non-trust radiologist)<10% Consultant (on and offsite) discrepancy rates

Non-surgical Discrepancies

Standards met…? Yes

Results – Surgical Discrepancies

Standards met…? Yes

Standards Correlation with laparotomy Correlation CT report with laparotomy findings (provisional report - registrar)>80% Correlation CT report with laparotomy findings (provisional report, onsite trust consultant, offsite radiologist, non-trust)>90%

Results – Correlation with laparotomy

Standards met…? Yes (Almost)

Results – Non surgical Discrepancies

Results – Surgical Discrepancies

Discussion Standards met for the majority of the parameters measured/analysed so far If discrepancies – usually a delay in treatment/surgery is the result however the impact of this/unnecessary treatment on patient outcome must be appreciated

Still a lot of data to sort through… 1. What were the discrepant cases – ischaemic bowel? Localised perforation? 2. Splitting of on and offsite radiologists and SpR reports with consultant input

References CT and appendicitis: evaluation of correlation between CT diagnosis and pathological diagnosis; Andre J et al; Postgraduate medical journal; 2008; 84; Discrepancies in interpretation of ED body CT scan reports by radiology residents; N Tieng et al; American journal of emergency medicine; 2007; 25; Evaluating the acute interpretation of emergency medicine resident interpretations of abdominal CTs in patients with non-traumatic abdominal pain; Ju Kang et al; Journal of Korean medical science; 2012; 27;

The DEPICTORS study; Discrepancies in preliminary interpretations of CT scans between on call residents and staff; J Walls et al; Emergency radiology; 2009; 16; Overnight resident preliminary interpretations on CT examinations; Should the process continue? Strub et al; Emergency radiology; 2006; 13; 19-23

Questions please…