1. Housekeeping: PACS cleaners and sweepers Dr Nicola H Strickland Consultant Radiologist Hammersmith Hospitals Trust London, UK

2. Why this title? PACS is not like a fridge!PACS is not like a fridge! It needs looking afterIt needs looking after “a PACS nursemaid”“a PACS nursemaid” sweeper and cleaner to keep database tidysweeper and cleaner to keep database tidy

3. Jobs to be done daily housekeepingdaily housekeeping pre- and post upgrade housekeepingpre- and post upgrade housekeeping

4. Daily housekeeping 1.unspecified exams 2.exams erroneously marked dictated 3.unreported exams 4.unverify exams on request 5.CR / DR problems 6.“unfetchable exams”

5. Unspecified exams appear as, eg. “unspecified CR”appear as, eg. “unspecified CR” problem caused:problem caused: historical exams of same body part and same modality not displayed automatically action:action: exam needs to be merged with correct folder for that exam on PACS

6. Common causes of “unspecified” RIS DICOM modality worklist (on modality)RIS DICOM modality worklist (on modality) PACS “order entry” PACS “order entry” RIS updateno update to modality worklistRIS updateno update to modality worklist PACS updates correctly no DICOM modality worklistno DICOM modality worklist  typographical / demographic errors

7. later follow-up images added to same examlater follow-up images added to same exam  eg. nuclear medicine white cell scan  eg. ultrasound post micturition solution: DICOM perform procedure step (PPS) needs to be supported on the modality and on PACS. solution: DICOM perform procedure step (PPS) needs to be supported on the modality and on PACS. PPS allows a “step” of the exam to be completed without closing the whole study PPS allows a “step” of the exam to be completed without closing the whole study Common causes of “unspecified”

8. bizarre equipment malfunction!bizarre equipment malfunction!  unpredictable change of demographics eg. nuclear medicine workstation Common causes of “unspecified”

9. Daily housekeeping 1.unspecified exams 2.exams erroneously marked dictated 3.unreported exams 4.unverify exams on request 5.CR / DR problems 6.“unfetchable exams”

10. Exams erroneously marked dictated Causes: human error (by radiologist)human error (by radiologist) hit the dictated key/click dictated icon by mistake report “lost”report “lost”  tape lost / corrupted  dictation system malfunction report typed but not sent to PACSreport typed but not sent to PACS

11. Action: decide date range, eg. up to 4 weeks agodecide date range, eg. up to 4 weeks ago identify status “reported” but not “completed”identify status “reported” but not “completed” check no typed report exists on RIS / speech recognition systemcheck no typed report exists on RIS / speech recognition system  if none does...... Exams erroneously marked dictated

12. Action: restore “unreported” status so exam reappears on worklist for reportingrestore “unreported” status so exam reappears on worklist for reporting identify and alert radiologist responsible (for specials only)identify and alert radiologist responsible (for specials only) if typed report does exist on RIS / speech rec system:if typed report does exist on RIS / speech rec system:  resend to PACS  correct error sending to PACS Exams erroneously marked dictated

13. Daily housekeeping 1.unspecified exams 2.exams erroneously marked dictated 3.unreported exams 4.unverify exams on request 5.CR / DR problems 6.“unfetchable exams”

14. Unreported exams 1. very old (months ago) unreported exams ● status may change automatically: “dictated off-line” “dictated off-line” ● only a problem when you first start housekeeping ● re-instate unreported status  back on worklist ● alert appropriate radiologist (for specials)

15. Unreported exams 2. “missed” recent unreported exams (specials) ● eg. ● at session handover for CT/MR ● on call (junior radiologist) – verbal report given ● re-instate unreported status ● alert appropriate radiologist (for specials)

16. Daily housekeeping 1.unspecified exams 2.exams erroneously marked dictated 3.unreported exams 4.unverify exams on request 5.CR /DR problems 6.“unfetchable exams”

17. Unverify exams on request 1.on request by radiologist ● so that post-processed images can be sent to PACS, eg. CT reformats ● needed because PACS does not yet support DICOM perform procedure step

18. Unverify exams on request 2. on request by radiographer ● extra image taken later eg. - IVU delayed image - further view requested by radiologist ● exam already dictated and completed by radiologist before all (CT/MR) images sent to PACS by radiographer! (viewed by radiologist on 3D workstation)

19. Daily housekeeping 1.unspecified exams 2.exams erroneously marked dictated 3.unreported exams 4.unverify exams on request 5.CR / DR problems 6.“unfetchable exams”

20. CR / DR problems wrong plate put through CR readerwrong plate put through CR reader  another patient’s image assigned to the exam  unverify exam  reassign image correctly wrong processing algorithm usedwrong processing algorithm used  Reapply algorithm on plate reader / DR

21. Daily housekeeping 1.unspecified exams 2.exams erroneously marked dictated 3.unreported exams 4.unverify exams on request 5.CR / DR problems 6.“unfetchable exams”

22. “unfetchable” exams old exams not retrieved from long term archiveold exams not retrieved from long term archive a rare problema rare problem alert PACS engineer = a de-archiving problemalert PACS engineer = a de-archiving problem

23. Jobs to be done daily housekeepingdaily housekeeping pre- and post upgrade housekeepingpre- and post upgrade housekeeping

24. Upgrades housekeeping print film / CDs of critical key images requested by clinicians, eg. NNUprint film / CDs of critical key images requested by clinicians, eg. NNU merges +++ post upgrademerges +++ post upgrade  no RIS  modalities worklists  no RIS  PACS order entry

25. Policies! anything sent to PACS must have a RIS entryanything sent to PACS must have a RIS entry  digitization  CD uploading  out of hours exams (especially ultrasound!) restricted digitization / CD uploadingrestricted digitization / CD uploading  requires radiologist authorization restricted film printing / CD burningrestricted film printing / CD burning  requires radiologist / radiographer authorization

26. The “nappy changing team”!! Imaging support systems group (ISSG) 4 radiographers (2 full time posts, one at HH, other at CX)4 radiographers (2 full time posts, one at HH, other at CX) why 4?why 4?  covers annual and sick leave why radiographers?why radiographers?  understand difference between study types and body parts

27. The “nappy changing team”!! Imaging support systems group (ISSG) pattern of errors noticed early:pattern of errors noticed early:  corrected, working practices changed etc. report to the “POG” (PACS operational group)report to the “POG” (PACS operational group)  team cohesion