Radiology referrals achievements

By Stephen Townrow,

imaging systems manager and diagnostic radiographer, and Jack Oakes, PACS manager and diagnostic radiographer

Last November (2022), our radiology team implemented an application called MedCurrent Clinical Decisions Support (CDS) iRefer.

The application supports the decision-making for all diagnostic referrals sent to us from primary and secondary care settings.

The system recommends the most appropriate test that is required for the patient, based on the data that the clinician has entered into the system.

Background

Against the backdrop of the Covid-19 pandemic, our radiology department needed to clear a backlog of diagnostic tests, alongside increased pressure on the workforce. In order to achieve this goal, we required a dynamic and digital solution to: y Reduce inappropriate diagnostic test requests y Ensure that the correct test is carried out to avoid unnecessary ionising radiation exposure to patients y Enable a safe and quick vetting process y Increase reporting capacity y Be more cost-effective y Standardise care in line with national guidelines to reduce clinical variance

The solution PAHT is one of five trusts in the East of England Imaging Network 2 and the first to implement MedCurrent CDS iRefer. We received funding from the Digital Diagnostics Capability Programme and were supported by the network’s digital lead to successfully implement the system.

The application is based on existing iRefer guidelines that have been produced and approved by the Royal College of Radiologists. The application also supports decision-making by recommending the modality and the test that is required.

The existing test requesting system, called ICE from Clinisys, fully integrates with MedCurrent CDS iRefer without needing to open a separate programme.

When an imaging request is created, MedCurrent CDS iRefer launches automatically and presents the requested procedure, a recommended procedure and other options, with a clinical justification for each option.

The clinical detail that has been collected and whether the recommendation was accepted or not, is saved and continues through the remainder of the workflow in ICE. At the vetting stage, the radiologist can view all of the details.

The challenges

We are the first hospital trust in the region to implement the solution. As a result, the team received a high number of queries prior to the implementation.

Following the implementation, a few minor concerns were raised and this feedback helped to shape improvements within the system for users, including: y Disabling CDS for appendicular and chest X-rays. This improvement was justified as these requests do not require radiologist vetting and are relatively low-dose/low complexity procedures y Clinisys produced a script to enable the solution for large requesting groups on ICE. Completing this manually in ICE created a large strain on the database and therefore not all users had access initially y The engagement with GP colleagues has grown over time through early contact and a dynamic array of communications with practice managers, select lead GPs and transformation managers y Additional training, explanation sessions, discussions and further use of the system has reduced concerns raised by clinicians and the majority are now using the system confidently y They were unable to find a newly created patient on test ICE (which was created in an electronic patient record test). The supplier resolved this issue by undertaking a configuration update

The results

Encouraging results were visible after using the system for three weeks, including:

Primary care y 8.4% of tests (313 exams) requested by GPs were withdrawn based on the advice of CDS iRefer y 12.6% (468 exams) started with one test, but based on the recommendations they left with another test/ imaging modality

Secondary care y 2.4% (190 exams) cancelled and 7.8% (626 exams) changed to a different imaging test y The results show a 25-30% reduction in inappropriate requests that needed to be rejected by consultants. Moving forward, rejected requests will be reviewed regularly to see if any improvements can be made to the system to further reduce this number

Pictured below: Key analytics.

Sharing the learning

Since implementing the solution, our team has learnt and identified the following to share with the East of England Regional Radiology Network digital workstream teams and other hospital trusts.

Roles within ICE

We have focused on ensuring that all the roles within ICE are shown within the extract, detailing what users can and cannot request. MedCurrent utilises this information to ensure that the system does not recommend a test that a requester is not authorised to request. There is a high level of complexity when producing this

By Dr Preethi

Gopinath, director of medical education

Our medical education team has hosted a wide range of events since the last edition of Our Journal, including:

• Between January –March, each division has participated in an Active Bystander Training event. This is an innovative and award-winning training session which gives colleagues the skills to challenge unacceptable behaviours, which may have become normalised over time

• We hosted a Becoming More Assertive one day event for Specialty and extract, therefore it can be time consuming to complete.

Team work

The collaborative working and commitment from the whole radiology team has contributed to the successful implementation of the solution. It is important that radiologists are supportive of the project, as their knowledge of vetting, multi-disciplinary teams and clinical pathways is imperative to enhance and improve the system.

Next steps and sustainability

y Continue to improve and enhance the system, including protocols in line with the trust guidelines, with the support of subspecialty radiologists and MedCurrent y Utilise the MedCurrent analytics programme to identify request trends y Continue to discuss and review protocols y Contact individuals that require guidance

If you have any questions or to find out more, please email me at stownrow@nhs. net. You can also contact Jack Oakes, PACS manager, at jackoakes@nhs.net and Dr James Diss, consultant radiologist, at james.diss@ nhs.net. Well done and thank you to all involved.

Associate Specialist (SAS) and Locally Employed Doctors (LED) in the Learning and Education Centre on 6 February. The objectives of this course were to build insight into assertiveness and negotiation models, to build skills in applying these models to professional practice and to be able to apply these skills to the doctors' own real-world challenges

• We held a Human Factors Training Day for Specialty and Associate Specialist (SAS) and Locally Employed Doctors (LED) in the Learning and Education Centre on 2 March. This one day course aimed to build on existing human

Factors Knowledge Specific

to working at PAHT

Other events have included:

• Breaking Bad News Workshop - multidisciplinary (doctors/ student nurses/ occupational therapists) on 30 January

• Trauma and Orthopaedic Regional Foundation Hub on 19 January (pictured overleaf, right)

• Histopathology Regional Foundation Hub on 27 January (pictured overleaf, far right)

• Dr Andrew Ashford, GP Specialty Training (GPST) programme director, delivered in-house clinical supervisors' training on how to support trainees on hospital placements, portfolio requirements and navigation on 24 January

• International histopathology course from 20 February – 9 March

• Schwartz Round, "An act of kindness I will never forget" facilitation - 31 January

• Ongoing Freedom to Speak Up listening events

We are now looking ahead to the Planning for Emotional Intelligence EQ-i 2.0 and EQ 360 certification course on 23 May. This leading emotional intelligence assessment provides an in-depth understanding of an individual’s emotional functioning, enabling us to support our colleagues with these tools in-house.

We have weekly drop-in clinics for trainers and junior doctors at the Learning and Education Centre, please contact judith.butcher@nhs.net for more information.

We are also holding a thank you dinner and dance open to all junior doctors, physician associates and medical educators on 9 June at Harlow Rugby Club, which includes an awards ceremony.

General Medical Council (GMC) Enhanced Monitoring Programme update

In collaboration with the Junior Doctors' Committee, our junior doctors are actively contributing to the GMC Enhanced Monitoring Programme by feeding back improvements and ongoing issues with their training via a variety of platforms such as the Junior Doctors' Committee, the Medical Education Committee, the GMC Enhanced Monitoring monthly meetings, listening events with the Quality First team and the Freedom to Speak Up Guardians. This work forms part of the response to the 2022 GMC Survey and The National Education and Training Survey (NETS).

There is ongoing work towards addressing the British Medical Assocation (BMA’s) eight high impact actions for junior doctors, for example the ‘Too Tired to Drive’ policy, which is now in place. Other projects in progress are:

• Tackling work pressure

• Better engagement between trainees and the Board

• Improved access to food and drink 24/7

• Rotas that promote work/ life balance

• Clearer communication between trainees and managers

• Rewarding excellence

• Wellbeing, mentoring and support

• With the support of IT, the junior doctors completed a spot audit on computer start up times across the hospital which has helped to drive improvements in IT infrastructure

• A Clinical Escalation Standard Operating Procedure (SOP) is now in place for medicine as a result of the junior doctors' contribution to this project. Work on SOPs is progressing for the other specialties

• There is an ongoing project with the Junior Doctor Champions to improve departmental induction

• Former trainees, Mr Anoop Prasad and Dr David Ensor, have developed the ARCTERA 360 video simulation platform for clinicians to practice and develop their clinical reasoning skills in a riskfree environment, available to undergraduate and postgraduate doctors >

Read more on AlexNet >