Radiology “Dos and Don’ts” Clinical Governance Medical Division 18 July 2013

Sign of the times?? Availability of multi-slice CTs Faster turnover of acute admissions Increasing demand for cross sectional imaging Greater patient expectations Risk-averse culture in NHS

Croydon University Hospital

Consequences Delays in plain film reporting Errors in reporting of CTs Additional investigations prompted by “abnormal” reports Increased caseload of cancer MDTs Deskilling of clinical teams Escalation in healthcare costs Adverse events / SUIs Patient anxiety

Radiation Risks iRefer Guidelines: Making the best use of clinical radiology - Version (Jan 2012)

Cases discussed at MDT

“Plurality should not be posited without necessity” Ockam ( ) “Patients can have as many diseases as they damn well please” J B Hickham ( )

Incidentalomas a.k.a “VOMIT” The new medical Dilemma

Scan Symptom PositiveNegative New unexpected finding Further Scan(s) Other Ix Patient reassured Rx Referral to Specialist

If you ask the wrong questions then the answers, even if answered correctly, will lead you to the wrong conclusions “The question is not what you look at but what you see.” -Thoreau

Rule No 1 Do request a test which will give the most clinical information with the lowest acceptable radiation risk to the patient. If unsure of which test to request, do ask for advice from the radiology department or senior colleagues IRMER 2000 legislation.gov.uk No1059

Rule No 2 Do request a CT staging scan (contrast- enhanced Thorax and upper Abdomen to include both adrenals) if lung cancer is suspected NICE

Rule No 3 For patients with unexplained anaemia and weight loss, chest X-ray and CT Abdomen and Pelvis are advised in the first instance. CT Chest is only indicated if there are CXR abnormalities or when associated with respiratory symptoms (e.g. haemoptysis, shoulder pain)

Rule No 4 Do perform a pretest clinical probability assessment (2-level Wells score) before requesting a CTPA NICE

Rule No 5 Do not request a CTPA when a Doppler ultrasound has confirmed a DVT. The management for confirmed DVT / PE is the same

Rule No 6 In idiopathic DVT / VTE do perform a Chest X- ray as part of basic screening tests. CT is only indicated when there is a strong suspicion of malignancy guided by clinical features

NICE

Rule No 7 Do not ask for a CT where a less invasive investigation (e.g chest x ray or abdominal ultrasound) would answer your clinical query

Rule No 8 Do refer to the Trust urgent suspected spinal cord compression guidelines before requesting an MRI, and let the MSCC Coordinator know (Mon-Fridays)

Rule No 9 Do not copy and paste radiology reports into discharge summaries without first discussing the results with the patient (particularly if the report findings are suspicious of malignancy). If in doubt do consult speciality teams for further advice before the patient is discharged from hospital

Rule No 10 Finally requests for invasive investigations (e.g CT-guided biopsy) should be supported by advice from speciality teams. Ideally patients requiring such tests should be seen by a member of the speciality team before the test is requested. With the exception of routine drainages, aspirations, LN biopsies, most cases do benefit from discussion with the relevant radiologist - there is variation on imaging modality of choice eg CT v USS for the same lesion which is often down to personal preference.

Discussion