Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit.

AIM: To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes. MATERIALS AND METHODS: Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022. RESULTS: Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002). CONCLUSIONS: The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

Imaging in myeloma: a Royal College of Radiologists national survey of current imaging practice.

AIMS: To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites). MATERIALS AND METHODS: All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed. RESULTS: One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (<10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training. CONCLUSION: Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning.

A national audit of radiology practice in cancer multidisciplinary team meetings.

AIM: A national audit reviewing compliance of imaging departments with the Royal College of Radiologist (RCR) standards for cancer multidisciplinary team meetings (MDTMs). MATERIALS AND METHODS: The audit consisted of a generic and subspecialty component completed for breast, colorectal, and lung cancer MDTMs. RESULTS: The study achieved the highest response from a RCR national audit with 145/191 (76%) hospitals responding. Compliance with the RCR standards was suboptimal, particularly relating to MDTM attendance, documentation, and reviewing MDTM imaging. Comprehensive radiology MDTM attendance occurred in 52-65%, a supplementary report denoting staging/treatment plans happened in 15-26%, and late additions were discussed frequently without prior review of imaging (44-77%). Contributing factors maybe 13% of radiologists had no programmed activity for MDTMs in their job plan and a perceived negative impact of increasing MDTM referrals (51%). Adjuncts to improve MDTM workload, such as treatment pathways/algorithms (breast/colorectal 54%) and pro-forma (43-50%), were poorly implemented. Discrepancies with the original imaging report highlighted at MDTMs were well documented (92-94%) and frequently presented at discrepancy meetings (70-81%). Learning from involvement in MDTM was well communicated with 76-84% providing peer feedback. CONCLUSIONS: Radiologists are unable to comprehensively attain the RCR MDTM standards on providing and documenting a specialist opinion on the imaging. Increasing referrals to the MDTM appears the predominant factor and differentiating complex cases that benefit from MDTM discussion from those that can be managed via treatment pathways is required. Improved utilisation of pre-MDTMs/pro-forma and information technology in MDTMs may further aid radiologists to provide consistent high-quality contribution towards MDTMs.

Royal College of Radiologists national audit evaluating the provision of imaging in the severely injured patient and compliance with national guidelines.

AIM: To evaluate the provision of imaging in severely injured patients and com pliance with national guidelines. MATERIALS AND METHODS: Two data collection tools were sent to all Royal College of Radiologist audit leads in radiology departments with an emergency department throughout the UK. The first focused on configuration of radiology departments, number of patients scanned for major trauma and service configuration for major trauma. The second focused on reporting times for 30 patients scanned for major trauma. RESULTS: Eighty-five out of 191 (45%) eligible departments responded: 16 (19%) from major trauma centres, 52 (61%) from trauma units and 17 (20%) from other hospitals with an emergency department. Data were collected for 2,161 scans: 450 from major trauma centres, 1,400 from trauma units and 311 from emergency departments. Seven hundred and eighty-four (36%) scans were performed in hours and 1361 (63%) out of hours. Two hundred and forty (11%) scans had a primary survey report documented, of which 53 (22%) were unavailable to clinicians after 20 minutes. Time to final consultant report was within 1 hour for 1,033 (48%) scans and within 2 hours for an additional 540 (25%) scans. 34/85 (40%) departments have registrars first on call for major trauma who report scans out of hours and have a consultant final report the next day. CONCLUSIONS: This study highlights significant deficiencies in care and imaging of severely injured patients within major trauma centres and trauma units. Infrastructure and staffing have been underfunded and under resourced to meet rapidly changing best practice requirements in the management of major trauma.

The effect of routine radiological reporting of thyroid incidentalomas on rates of thyroid needle biopsy, thyroid surgery and detection of thyroid malignancy.

OBJECTIVE: This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate. CONTEXT: Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed. DESIGN: Data were collected retrospectively during a two-year period, including 12 months before and 12 months after the change in reporting policy and categorized according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion. PATIENTS: All patients undergoing ultrasound-guided fine-needle aspiration cytology or core biopsy were included. MEASUREMENTS: The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention. RESULTS: There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET)-detected cancer, two of four of the non-PET-detected malignancies were <1.5 cm. CONCLUSION: This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.

RCR audit of compliance with UK guidelines for the prevention and detection of acute kidney injury in adult patients undergoing iodinated contrast media injections for CT.

AIM: To determine radiology departmental compliance with current UK guidance on contrast-induced acute kidney injury (CI-AKI) and to provide data on the incidence of clinically significant post-contrast AKI (PC-AKI) in computed tomography (CT) practice. MATERIALS AND METHODS: A questionnaire was sent to all UK acute National Health Service (NHS) providers (NHS boards in Scotland, local health boards in Wales, NHS trusts in England and health and social care trusts in Northern Ireland) to assess compliance of provider protocols with current UK guidelines for the prevention, recognition, and management of CI-AKI. Audit data were collected for 40 consecutive fit outpatients and 40 consecutive acutely unwell patients/inpatients from hospitals within each participating provider to assess clinical compliance. RESULTS: Eighty-nine of 172 (52%) health service providers responded, and data on 7,159 contrast-enhanced CT examinations were provided. Compliance with guidelines was poor with wide variation in clinical practice. The observed incidence of clinically significant (requiring treatment or resulting in death) PC-AKI was zero in 3,590 outpatients, although two patients developed AKI due to other causes (sepsis and progressive malignancy). Fourteen out of 3,569 (0.4%) patients in the inpatient group developed clinically significant PC-AKI, and a further 17 patients were identified who met the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI (Electronic Supplementary Material Appendix S1), but did not require active treatment, giving an overall incidence of AKI of 0.9%. In patients at high risk due to impaired renal function prior to the scan, there was no difference in the median serum creatinine (SCr) before and after contrast medium administration in either group. CONCLUSION: Health service provider protocols and clinical practice demonstrate poor compliance with current UK guidance on CI-AKI. A very low incidence of PC- AKI was demonstrated.

The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit.

AIM: To evaluate major/minor discrepancy rates for provisional (initial) and addendum (supplementary senior review) emergency computed tomography (CT) reports in patients presenting with non-traumatic abdominal pain. MATERIALS AND METHODS: Ethical approval for this type of study is not required in the UK. All radiology departments with an approved lead for audit registered with the Royal College of Radiologists were invited to participate in this retrospective audit. The first 50 consecutive patients (25 surgical, 25 non-surgical) who underwent emergency abdominal CT for non-traumatic abdominal pain in 2013 were included. Statistical analyses were performed to identify organisational and report/patient-related variables that might be associated with major discrepancy. RESULTS: One hundred and nine (58%) of 188 departments supplied data to the study with a total of 4,931 patients (2,568 surgical, 2,363 non-surgical). The audit standard for provisional report major discrepancy was achieved for registrars (target <10%, achieved 4.6%), for on-site consultants (target <5%, achieved 3.1%) and consultant addendum (target <5%, achieved 2.9%). Off-site reporters failed to meet the standard target (<5%, achieved 8.7% overall and 12.7% in surgical patients). The standard for patients coming to harm was not met in the surgical group (target <1%, achieved 1.5%) and was narrowly missed overall (target <1%, achieved 1%). CONCLUSION: This study should be used to provide impetus to improve aspects of out-of-hours CT reporting. Clear benefits of CT interpretation/review by on-site and more senior (consultant) radiologists have been demonstrated.

Evaluation of paediatric radiology services in hospitals in the UK.

AIM: To compare paediatric radiology provision across the UK with national standards published by the Department of Health and the Royal College of Radiologists (RCR). MATERIALS AND METHODS: Audit standards and indicators for paediatric imaging were derived from "Delivering quality imaging services for children",1 "Standards for imaging in cases of suspected non-accidental injury"2 and "Improving paediatric interventional radiology services"3 and agreed jointly by the Clinical Radiology Audit Committee and the British Society of Paediatric Radiology. A questionnaire was sent to all hospitals and NHS trusts imaging children aged 16 or younger in the UK in October 2013. The target for all indicators was 100%. Eighty-seven of 196 (44%) eligible institutions submitted data, the size distribution of the institutions was representative when compared to data from "Facing the future: a review of paediatric services"4 published by the Royal College of Paediatrics and Child health. RESULTS: Only 65% of paediatric images were obtained by staff who had had specific training and only 60% were reported by radiographers or radiologists with appropriate training. Sixty-two percent of centres did not have access to a paediatric opinion 24 hours a day, 7 days a week all year; only 34% of radiographers who regularly imaged children had had any access to continuing professional development (CPD) in the 12 months of the audit. Although all hospitals had facilities for image transfer, only 57% had any formal funding arrangements in place for external reporting of images. CONCLUSIONS: The standards set for a network approach to paediatric radiology provision in "Delivering quality imaging services for children" are largely unmet. This failure to make the most of the workforce and resources puts vulnerable children at risk. The authors urge NHS England to work with the RCR to organise and administer a national network for paediatric imaging.

Perceptual type error in everyday practice.

Discrepancy or quality improvement meetings are good practice and are now commonplace in most Radiology Departments, with the aim of improving diagnostic accuracy, preventing recurrent and common mistakes, improving the radiological report and thereby improving patient care. A total of 122 cases were assessed from a two-year period. This review highlights some of the more common, recurrent and important issues encountered within a general hospital with an emphasis on learning points and review areas.

Audit of radiology communication systems for critical, urgent, and unexpected significant findings.

AIM: To determine the compliance of UK radiology departments and trusts/healthcare organisations with National Patient Safety Agency and Royal College of Radiologist's published guidance on the communication of critical, urgent, and unexpected significant radiological findings. MATERIALS AND METHODS: A questionnaire was sent to all UK radiology department audit leads asking for details of their current departmental policy regarding the issuing of alerts; use of automated electronic alert systems; methods of notification of clinicians of critical, urgent, and unexpected significant radiological findings; monitoring of results receipt; and examples of the more common types of serious pathologies for which alerts were issued. RESULTS: One hundred and fifty-four of 229 departments (67%) responded. Eighty-eight percent indicated that they had a policy in place for the communication of critical, urgent, and unexpected significant radiological findings. Only 34% had an automated electronic alert system in place and only 17% had a facility for service-wide electronic tracking of radiology reports. In only 11 departments with an electronic acknowledgement system was someone regularly monitoring the read rate. CONCLUSION: There is wide variation in practice across the UK with regard to the communication and monitoring of reports with many departments/trusts not fully compliant with published UK guidance. Despite the widespread use of electronic systems, only a minority of departments/trusts have and use electronic tracking to ensure reports have been read and acted upon.

Imaging submandibular pathology in the paediatric patient.

A wide range of pathologies may arise from the submandibular space (SMS) or submandibular gland (SMG) in children. We review herein the normal anatomy of the SMS and describe the role of imaging in the evaluation of SMS lesions. A schematic approach for the categorisation of SMS pathology based on imaging characteristics is provided.

Ultrasound-guided botulinum toxin injection to treat a parotid fistula following gunshot injury.

Parotid fistula is a rare but very distressing sequelum of post-operative or traumatic injuries. The management of these injuries has been reported in the literature previously and techniques employed include pressure dressings, surgery and more recently botulinum toxin A (BTA) injections. We present a patient who developed a parotid fistula as a late complication of an extensive gunshot injury to the face with subsequent successful management with ultrasound-guided intraglandular injections of BTA. This case demonstrates that the BTA injection is an effective and safe method under ultrasound guidance and should considered as a first-line treatment option for the treatment of salivary fistulas.

National audit of seven-day working care in radiology.

OBJECTIVES: To evaluate the extent to which our current provision of diagnostic and interventional radiology services matches existing clinical demand and future government proposals as set out in the Royal College of Radiologists published guidance on providing seven-day acute care. METHODS: In June 2018, all UK radiology department audit leads were sent a questionnaire designed to assess compliance for each standard of the Royal College of Radiologists published guidance on providing seven-day acute care. RESULTS: 135 hospitals (68%) responded. Of those that responded, 96% of departments have a diagnostic radiologist rota for clinicians to discuss acute cases and review imaging and 48% of departments do not have a fully staffed consultant rota 24 h a day, seven days a week for interventional radiology. There is significant variance in MRI radiographer availability within departments, ranging from 18.8% during Saturday/Sunday evening/overnight up to a maximum of 63.9% during Saturday daytime. 11% of departments participate in a regional out of hours cross-organisation reporting rota. 40% of departments have no 24/7 RIS technical support and 34% have no PACS technical support out of hours. CONCLUSION: There is a wide variation in practice across radiology departments in the UK. Although there are some standards that the majority of hospitals are achieving, there is a significant short-fall in fundamental aspects of providing acute seven-day care. The multifactorial nature in which these problems have arisen means there is no easy solution to combat these issues. There is a requirement for significant investment and political commitment to improve staffing and infrastructure in order to address the current situation. ADVANCES IN KNOWLEDGE: A UK wide evaluation of the current provision of seven-day working in radiology showing 54% of hospitals do not have a UK working-time regulations compliant Interventional radiology rota, severe lack of availability of acute MRI out of hours and significant deficiencies in providing technical support out of hours. A sustainable and efficient seven-day service is currently not being provided.