Making the most of X-ray reject analysis in the digital age.

This editorial discusses reject analysis in the digital age. It provides some recommendations that need to be considered when designing and implementing a contemporary reject analysis process.

Reducing diagnostic errors in the emergency department at the time of patient treatment.

OBJECTIVE: The purpose of the present study was to compare and combine the radiographic interpretation accuracy of emergency clinicians and radiographers in clinical practice. METHODS: A total of 838 radiographic examinations were included for analysis from 1 August to 24 August 2020. The range of examinations reviewed included the appendicular and axial skeleton, chest and abdomen. Both paediatric and adult examinations were reviewed. The emergency clinician's and radiographer's interpretations for each examination were compared to the radiologist's report. This allowed mean sensitivity, specificity and diagnostic accuracy to be calculated. RESULTS: The radiographer's interpretation demonstrated a mean sensitivity, specificity and accuracy of 80%, 98% and 92%, respectively. The emergency clinician's interpretation demonstrated a mean sensitivity, specificity and accuracy of 82%, 95% and 89%, respectively. When the radiographer's and emergency clinician's interpretations were combined, it yielded a mean sensitivity, specificity and accuracy of 90%, 93% and 92%, respectively. CONCLUSIONS: This is the first study to directly compare and combine the accuracy of an emergency clinician's radiographic interpretation with a radiographer's interpretation within clinical practice. The present study demonstrated that with the addition of a radiographer's interpretation, an emergency clinician's interpretation can be more accurate than the emergency clinician's interpretation in isolation. This highlights the value of a radiographer's interpretation that can complement an emergency clinician's interpretation when a radiologist's report is unavailable.

Is there benefit to concurrent x-ray imaging of the wrist, forearm and elbow in paediatric patients following a fall on the outstretched hand?

INTRODUCTION: Concurrent X-ray imaging of the wrist, forearm and elbow in paediatric patients following a fall on the outstretched hand (FOOSH) is intended to minimise the risk of an undetected co-occurring injury and is typically performed on patients aged 0-10 years. The purpose of this study was to explore the benefit of this strategy and to identify if age could provide evidence for imaging. METHODS: A 12-month retrospective review of all X-ray examinations of the wrist, forearm and distal humerus of patients aged 0-10 years referred from the Emergency Department of Logan Hospital, Queensland was undertaken. The frequency, type and location of radiographic abnormalities and the requested examinations region of interest (ROI), referral notation and patient's age were recorded. Analysis was made by descriptive statistics. RESULTS: Four hundred and seventy-six examinations met the studies inclusion criteria, 4.8% (n = 23) identified an abnormality outside of the documented ROI. On review of the admission and treatment notes, 1.7% (n = 8) were deemed to have detected traumatic abnormalities as a direct outcome of concurrent imaging. No age-related evidence for imaging was identified. CONCLUSION: This study demonstrates limited benefit (1.7%) to concurrent imaging following a FOOSH. The results suggest that a thorough physical evaluation of the paediatric upper limb performed by the referrer is sufficient to accurately guide X-ray imaging. These findings have the potential to positively impact a reduction in the number of X-rays performed on paediatric patients and in turn contribute to limiting radiation dose. Further studies may be beneficial in verifying the study's findings.

We can do it: Improving research culture and capacity in medical radiation sciences.

This editorial describes a number of strategies that can be employed to improve research culture and capacity in medical radiation sciences.

Digital radiography reject analysis of examinations with multiple rejects: an Australian emergency imaging department clinical audit.

INTRODUCTION: The largest source of manmade ionising radiation exposure to the public stems from diagnostic medical imaging examinations. Reject analysis, a form of quality assurance, was introduced to minimise repeat exposures. The purpose of this study was to analyse projection-specific reject rates and radiographic examinations with multiple rejects. METHODS: A retrospective audit of rejected radiographs was undertaken in a busy Australian metropolitan emergency digital X-ray room from March to June 2018. The data were collected by reject analysis software embedded within the X-ray unit. Reject rates, and reasons for rejection for each X-ray projection were analysed. RESULTS: Data from 11, 596 images showed overall reject rate was 10.3% and the overall multiple reject rate was 1.3%. The projections with both a high number and high percentage of rejects were antero-posterior (AP) chest (175, 18.1%), AP pelvis (78, 22.5%), horizontal beam hip (61, 33.5%) and horizontal beam knee (116, 30.5%). The projections with both a high frequency and multiple reject rate were horizontal beam knee (32, 8.4%) and horizontal beam hip (17, 9.3%). The top reasons for multiple rejects were positioning (67.1%) and anatomy cut-off (8.4%). CONCLUSIONS: The findings of this study demonstrated that projection-specific reject and multiple reject analysis in digital radiography is necessary in identifying areas for quality improvement which will reduce radiation exposure to patients. Projections that were frequently repeated in this study were horizontal beam knee and horizontal beam hip. Future research could involve re-auditing the department following the implementation of improvement strategies to reduce unnecessary radiation exposure.

An analysis of radiographer preliminary image evaluation - A focus on common false negatives.

INTRODUCTION: Preliminary image evaluation (PIE) is a mechanism whereby radiographers provide a preliminary evaluation of whether pathology is present in their radiographs, typically acquired within the emergency department (ED). PIE provides referrers with a timely communication of pathology prior to the availability of a radiology report. The purpose of this study was to determine the most common radiographer PIE false-negative interpretations. METHODS: Each month over a two-year period, 100 PIEs of adult and paediatric patients were randomly reviewed in a metropolitan hospital ED. The radiographer's PIE was compared with the radiologist's report and categorised into basic quality indicators; true positive, true negative, false positive and false negative. The anatomical regions which most commonly indicated a false-negative interpretation were further analysed. RESULTS: 2402 cases were reviewed which resulted in an overall PIE accuracy of 88.7%. Wrists, hands, phalanges (upper), ankles, feet and phalanges (lower) reporting the highest false-negative or false-negative/true-positive interpretations (60/116). Of the 60 false-negative PIEs, 68 pathologies were identified. 41.1% (28/68) of the pathology not identified were in the phalanges. Within these regions, examinations with multiple injuries commonly reported false negatives (17/60). CONCLUSIONS: This study demonstrated the most common false-negative radiographer PIEs were within the upper and lower distal extremities. Specifically, the phalanges and examinations demonstrating multiple injuries reported high levels of misinterpretation. The misinterpretation in multi-injury examinations could be attributed to 'Subsequent Search Miss (SSM)' error. These results provide valuable insights into areas of emphasis when providing image interpretation education.

COVID-19 Pandemic - considerations and challenges for the management of medical imaging departments in Queensland.

The purpose of this commentary was to outline several key considerations and challenges for medical imaging departments during a global pandemic. Five public hospital medical imaging departments were identified in South-East Queensland, Australia, to provide insight into their response to the COVID-19 pandemic. Common themes were identified, with the four considered most pertinent documented in this commentary. Similar operational considerations and challenges were identified amongst all sites. This commentary intends to serve as a starting point for medical imaging departments in considering the planning and implementation of services in a pandemic scenario.

Communicating traumatic pathology to ensure shared understanding: is there a recipe for the perfect preliminary image evaluation?

Medical imaging and emergency departments work collaboratively to interpret trauma radiographs. In addition to accurate radiographic interpretation, clear communication is crucial to ensure appropriate and timely management of musculoskeletal injuries. This two-step 'how to guide' provides the reviewer with a recipe for effectively evaluating trauma radiographs for traumatic pathology and succinctly documenting the findings. Step 1 is a systematic search of the radiograph: soft tissues, bones, alignment of joints and satisfaction of search (SBASS). Utilising SBASS increases reviewer confidence in identifying traumatic pathology of the appendicular and axial skeleton. Step 2 is a streamlined communication model for the documentation of pathological findings. The WWW acronym (What is it? Where is it? What is it doing?) can be adapted to describe simple or complex traumatic pathology.

Reject rate analysis in digital radiography: an Australian emergency imaging department case study.

INTRODUCTION: Reject analysis in digital radiography (DR) helps guide the education and training of staff, influences department workflow, reduces patient dose and improves department efficiency. The purpose of this study was to investigate rejected radiographs at a major metropolitan emergency imaging department to help form a benchmark of reject rates for DR and to assess what radiographs are being rejected and why. METHODS: A retrospective longitudinal study was undertaken as an in-depth clinical audit. The data were collected using automated reject analysis software from two digital x-ray systems from June 2015 to April 2017. The overall reject rate, reasons for rejection as well as the reject rates for individual radiographers, examination types and projections were analysed. RESULTS: A total of 90,298 radiographic images were acquired and included in the analysis. The average reject rate was 9%, and the most frequent reasons for image rejection were positioning error (49%) and anatomy cut-off (21%). The reject rate varied between radiographers as well as for individual examination types and projections. CONCLUSIONS: The variation in radiographer reject rates and the high reject rate for some projections indicate that reject analysis is still necessary as a quality assurance tool for DR. A feedback system between radiologists and radiographers may reduce the high percentage of positioning errors by standardising the technical factors used to assess image quality. Future reject analysis should be conducted regularly incorporating an exposure indicator analysis as well as retrospective assessment of individual rejected images.

Radiographic image interpretation by Australian radiographers: a systematic review.

INTRODUCTION: Radiographer image evaluation methods such as the preliminary image evaluation (PIE), a formal comment describing radiographers' findings in radiological images, are embedded in the contemporary radiographer role within Australia. However, perceptions surrounding both the capacity for Australian radiographers to adopt PIE and the barriers to its implementation are highly variable and seldom evidence-based. This paper systematically reviews the literature to examine radiographic image interpretation by Australian radiographers and the barriers to implementation. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used to systematically review articles via Scopus, Ovid MEDLINE, PubMed, ScienceDirect and Informit. Articles were deemed eligible for inclusion if they were English language, peer-reviewed and explored radiographic image interpretation by radiographers in the context of the Australian healthcare system. Letters to the editor, opinion pieces, reviews and reports were excluded. RESULTS: A total of 926 studies were screened for relevance, 19 articles met the inclusion criteria. The 19 articles consisted of 11 cohort studies, seven cross-sectional surveys and one randomised control trial. Studies exploring radiographers' image interpretation performance utilised a variety of methodological designs with accuracy, sensitivity and specificity values ranging from 57 to 98%, 45 to 98% and 68 to 98%, respectively. Primary barriers to radiographic image evaluation by radiographers included lack of accessible educational resources and support from both radiologists and radiographers. CONCLUSION: Australian radiographers can undertake PIE; however, educational and clinical support barriers limit implementation. Access to targeted education and a clear definition of radiographers' image evaluation role may drive a wider acceptance of radiographer image evaluation in Australia.

Reducing risk in the emergency department: a 12-month prospective longitudinal study of radiographer preliminary image evaluations.

INTRODUCTION: Innovations are necessary to accommodate the increasing demands on emergency departments whilst maintaining a high level of patient care and safety. Radiographer Preliminary Image Evaluation (PIE) is one such innovation. The purpose of this study was to determine the accuracy of radiographer PIE in clinical practice within an emergency department over 12 months. METHODS: A total of 6290 radiographic examinations were reviewed from 15 January 2016 to 15 January 2017. The range of adult and paediatric examinations incorporated in the review included the appendicular and axial skeleton including the chest and abdomen. Each examination was compared to the radiologist's report this allowed calculated mean sensitivity and specificity values to indicate if the radiographer's PIE was of a true negative/positive or false negative/positive value. Cases of no PIE participation or series' marked as unsure for pathology by the radiographer were also recorded. This allowed mean sensitivity, specificity and diagnostic accuracy to be calculated. RESULTS: The study reported a mean ± 95% confidence level (standard deviation) for sensitivity, specificity, accuracy, no participation and unsure of 71.1% ± 2.4% (6.1), 98.4% ± 0.04% (0.9), 92.0% ± 0.68% (1.9), 5.1% (1.6) and 3.6% (0.14) respectively. CONCLUSIONS: This study has demonstrated that the participating radiographers provided a consistent PIE service while maintaining a reasonably high diagnostic accuracy. This form of image interpretation can complement an emergency referrer's diagnosis when a radiologist's report is unavailable at the time of patient treatment. PIE promotes a reliable enhancement of the radiographer's role with the multi-disciplinary team.

Evaluating the effectiveness of intensive versus non-intensive image interpretation education for radiographers: a randomised controlled trial.

INTRODUCTION: The purpose of this randomised controlled trial was to compare the effectiveness of intensive and non-intensive formats of delivery of image interpretation education for radiographers. METHODS: A multi-centre, stratified (by years of experience) two group parallel arm, single blind, randomised controlled trial was conducted. Participants (n = 48) were allocated to one of two groups to receive image interpretation education: (1) intensive format (13.5 h over two consecutive days) (2) non-intensive (sequential 90-min tutorials delivered 1 week apart). Participants undertook x-ray interpretation tests before education, at 1-week post-education completion and at 12-week post-education completion. RESULTS: Image interpretation performance was not significantly different between groups at baseline. A generalised linear model indicated that participants who received intensive education format improved image interpretation performance by a greater margin than the group that received non-intensive education at 1-week (P = 0.002) and 12-week (P < 0.001) follow-up assessments. CONCLUSIONS: Although both formats of education delivery may be beneficial, the findings of this study have indicated that the intensive format of delivery was more effective at improving radiographers' ability to interpret trauma radiographs in the weeks after completion of the image interpretation program.

An investigation into the use of radiographer abnormality detection systems by Queensland public hospitals.

INTRODUCTION: A Radiographer Abnormality Detection System (RADS), such as the 'red dot system', involves radiographers highlighting the presence of potential acute abnormalities on radiographs in the emergency setting. The literature suggests little additional training is required of radiographers to participate in such a system, posing little impact on current workflow while remaining a cost-effective, easy-to-implement program. However, its use outside the United Kingdom is sporadic. The purpose of this study was to investigate the frequency of use of a RADS in Queensland public hospitals. METHODS: A cross-sectional web-based questionnaire was developed and distributed to 28 medical imaging department directors throughout metropolitan, rural and remote Queensland (Australia) public hospitals. The results of this survey were analysed using conventional descriptive statistics of response frequencies and the percentage of the sample. RESULTS: The questionnaire was completed by 25 radiography directors (89% response rate). Sixteen percent of respondents, all metropolitan-based, indicated a RADS was in operation (n = 4/25; 16%). Respondents without a RADS (n = 21/21; 100%) expressed interest in a trial. Just over half (n = 13/25; 52%) of the respondents believed their staff members were not trained appropriately to implement a RADS successfully. CONCLUSION: This study found an infrequent use of RADSs in Queensland public hospitals. This finding presents a unique opportunity for medical imaging professionals to enhance communication between the facets of a multidisciplinary emergency team via the implementation of RADS complemented by a radiographer commenting system.

Evaluating the effectiveness of intensive versus non-intensive image interpretation education for radiographers: a randomised control trial study protocol.

Radiographer commenting systems have not been successfully implemented in many Australian hospitals, despite evidence of their benefit and adoption elsewhere, such as the United Kingdom. An important contributor to the lack of widespread adoption of radiographer commenting in Australia (and likely elsewhere) is the limited availability of accessible education options for radiographers. The purpose of this randomised controlled trial is to compare the effectiveness of the same image interpretation education program delivered over an intensive 2-day period (intensive format) versus a series of shorter regular workshops (non-intensive format). The study design is a multicentre, stratified (by years of experience) two group parallel-arm single-blind (assessor blinded) randomised controlled trial. Participants will be allocated to one of the two groups: (1) intensive format of education or (2) non-intensive format of education in a 1:1 ratio. Participants will undergo assessments before education, at 1 week post-intervention completion and at 12 weeks post-intervention completion. Findings from this trial will be of relevance to radiographers seeking image interpretation training as well as organisations providing image interpretation education to prepare clinical staff for participation in a radiographer commenting system. A limitation of the trial is that the sample will be inclusive of radiographers, and findings may not be able to be directly extrapolated to other clinical disciplines (e.g. junior doctors, physiotherapists or nurse practitioners).

Radiographer commenting of trauma radiographs: a survey of the benefits, barriers and enablers to participation in an Australian healthcare setting.

INTRODUCTION: Radiographer abnormality detection systems that highlight abnormalities on trauma radiographs ('red dot' system) have been operating for more than 30 years. Recently, a number of pitfalls have been identified. These limitations initiated the evolution of a radiographer commenting system, whereby a radiographer provides a brief description of abnormalities identified in emergency healthcare settings. This study investigated radiographers' participation in abnormality detection systems, their perceptions of benefits, barriers and enablers to radiographer commenting, and perceptions of potential radiographer image interpretation services for emergency settings. METHODS: A cross-sectional survey was implemented. Participants included radiographers from four metropolitan hospitals in Queensland, Australia. Conventional descriptive statistics, histograms and thematic analysis were undertaken. RESULTS: Seventy-three surveys were completed and included in the analysis (68% response rate); 30 (41%) of respondents reported participating in abnormality detection in 20% or less of examinations, and 26(36%) reported participating in 80% or more of examinations. Five overarching perceived benefits of radiographer commenting were identified: assisting multidisciplinary teams, patient care, radiographer ability, professional benefits and quality of imaging. Frequently reported perceived barriers included 'difficulty accessing image interpretation education', 'lack of time' and 'low confidence in interpreting radiographs'. Perceived enablers included 'access to image interpretation education' and 'support from radiologist colleagues'. CONCLUSIONS: A range of factors are likely to contribute to the successful implementation of radiographer commenting in addition to abnormality detection in emergency settings. Effective image interpretation education amenable to completion by radiographers would likely prove valuable in preparing radiographers for participation in abnormality detection and commenting systems in emergency settings.

A survey of radiographers' confidence and self-perceived accuracy in frontline image interpretation and their continuing educational preferences.

INTRODUCTION: The provision of a written comment on traumatic abnormalities of the musculoskeletal system detected by radiographers can assist referrers and may improve patient management, but the practice has not been widely adopted outside the United Kingdom. The purpose of this study was to investigate Australian radiographers' perceptions of their readiness for practice in a radiographer commenting system and their educational preferences in relation to two different delivery formats of image interpretation education, intensive and non-intensive. METHODS: A cross-sectional web-based questionnaire was implemented between August and September 2012. Participants included radiographers with experience working in emergency settings at four Australian metropolitan hospitals. Conventional descriptive statistics, frequency histograms, and thematic analysis were undertaken. A Wilcoxon signed-rank test examined whether a difference in preference ratings between intensive and non-intensive education delivery was evident. RESULTS: The questionnaire was completed by 73 radiographers (68% response rate). Radiographers reported higher confidence and self-perceived accuracy to detect traumatic abnormalities than to describe traumatic abnormalities of the musculoskeletal system. Radiographers frequently reported high desirability ratings for both the intensive and the non-intensive education delivery, no difference in desirability ratings for these two formats was evident (z = 1.66, P = 0.11). CONCLUSIONS: Some Australian radiographers perceive they are not ready to practise in a frontline radiographer commenting system. Overall, radiographers indicated mixed preferences for image interpretation education delivered via intensive and non-intensive formats. Further research, preferably randomised trials, investigating the effectiveness of intensive and non-intensive education formats of image interpretation education for radiographers is warranted.