The extending role of the radiographer in reporting plain radiographs

Kareem Magribi

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Medicine is a science of uncertainty and an art of probability Sir William Osler

Purpose of presentation
- To briefly introduce the topic - To facilitate food for thought, to generate imaginative ideas on how a sustainable model can be developed to suite the needs for our health system - To highlight the actions that the UK and US have taken in this field

- ME FOCUSED PRESENTATION - WhAT do you want to accomplish at the edn of this presentation

Why is there a need for change

An ever increasing volume of examinations - Increasing workload on radiologists primarily coming from plain x-rays (Medicare statistics shows substantial growth in the requirement for plain radiography. Between July 2000 and June 2006, the number of rebated plain radiography examinations increased by almost 16%, more than that of CT, ultrasound and MRI) 1 - also coming from ageing population Demand for more rapid access to diagnostic services to reduce waiting times. Decreased job satisfaction among radiographers - career progression needed More extensive range of procedures. - increased workload on radiologists Shortage of radiologists - rural

1. TONY N SMITH, M. B. Radiographers role in radiological reporting: a model to support future demand MED J AUST, 186, 629-631.

Manifestation of change
Role Extension/Evolution

First, who is a radiographer? Who is a radiologist?

Very clearly defined roles

Role Extension/Evolution

Suggested areas in role extension

They would produce a Radiographers opinion or preliminary report on a specified range of examinations types, depending on local requirements. This preliminary report would be provided to the Radiologist who is to report on the examination. - red dotting 1 - providing a descriptive report, not a medical report 2 Frontline reporting of appendicular and axial skeleton plain radiography images
1. COELHO, J. R., P 2011. THE RED DOT SYSTEM Emergency Diagnosis Impact and Digital
Radiology Implementation A Review.

2. DONOVAN, T. & MANNING, D. J. 2006. Successful reporting by non-medical practitioners such as radiographers, will always be task-specific and limited in scope. Radiography, 12, 712.

Suggested areas in role extension contd

Intravenous cannulation and in the administration of contrast media, as well as in initiating treatment in the case of an allergic reaction. CT Clinical Specialist Radiographers to perform minimally interventional procedures, such as biopsies and facet joint injections. Highly knowledgeable and skilled in general radiography and trauma CT scanning. Highly knowledgeable radiographer may provide valuable input into the patient care pathway beyond their core role, such as advising local GPs on patient discharge, transfer and retrieval. - more common in rural
AIR. 2009. Discussion Paper: A Model of Advanced Practice in Diagnostic Imaging and Radiation Therapy in Australia. Available: http://www.air.asn.au/cms_files/09_AdvancedPractice/APWG_Final_Report_260609.pdf.

With reference to image reporting in particular....

How can a radiographer be involved in image reporting or image interpretation? 1. 2. 3. 4. Verbal Red dotting Image reporting Image interpretation

Weve mentioned suggested roles of a radiographer, but to what extent can a radiographer go in image reporting? Who draws the line on what a radiographer can or cant do?

RANZCR official statement

Task substitution simply the handing of responsibilities to radiographers professionals taking on tasks which have been the domain of the medical profession . Creates concern among medical practitioners who want to ensure that their skills and competencies as clinical decision makers are not diminished

- relaxation of regulations which create barriers to non-medical health

Task delegation more accepted by medical professionals - they maintain their duty of responsibility and provide supervision to the nonmedical practitioners performing the task

The potential involvement of non-medical practitioners in tasks currently carried out by the radiologist must only occur in the context of delegation and under supervision by the radiologist
RANZCR. 2006. Role Evolution in Diagnostic Imaging RANZCR Response to QUDI QS3 Discussion Paper on Role Evolution.

Ability of Radiographers
Many papers show the capability of radiographers to report on images with high levels of accuracy, sensitivity and specificity
Piper K, Paterson AM. The accuracy of radiographers reports in examinations of the skeletal system. British Journal of Radiology 1997; 70(S):123.
BREALEY, S., SCALLY, A., HAHN, S., THOMAS, N., GODFREY, C. & COOMARASAMY, A. 2005. Accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis. Clinical Radiology, 60, 232-241. BUSKOV, L., ABILD, A., CHRISTENSEN, A., HOLM, O., HANSEN, C. & CHRISTENSEN, H. 2013. Radiographers and trainee radiologists reporting accident radiographs: A comparative plain film-reading performance study. Clinical Radiology, 68, 55-58. M, R. P. C. G. W. Interpretation of selected accident and emergency radiographic examinations by radiographers: a review of 11000 cases. British Journal of Radiology, 72, 546-551. Bates JA, 1994, An audit of the role of the sonographer in non obstetric ultrasound, Clinical Radiology, 49, 617-20 Loughran CF, 1994, Reporting of fracture radiographs by radiographers: the impact of a British Journal of Radiology, 67, 802, 945-50 training programme,

Suggested areas in image reporting

Trauma Mammography Intravenous Urograms Barium Enemas Unreported films

Trauma
Reporting of trauma images most needed in busy EDs where the radiologist has many other duties 1. Radiographer provides initial interpretation 2. Report sent to referring doctor 3. Referring doctor acts upon radiographers observation 4. Medical report from the radiologist comes later

Trauma
In a busy ED it may take many hours even days for a radiologist to provide an official medical report.

On average it took 2 days to receive a verbal report and 3.3 days for a written report on a trauma series radiograph. To receive a final written or verbal report it took 2.8 and 4 days respectively.
The Royal Australasian College of Surgeons Annual Scientific Congress 15-19 May 2006

These time delays can be dramatically reduced if radiographers are given the green light to record their observations. But just how accurate are radiographers in reporting trauma images?

Trauma
BREALEY SD, S. P. The effect of introducing radiographer reporting on the availability of reports for Accident and Emergency and General Practitioner examinations: a time-series analysis. British Journal of Radiology, 78, 538-542.

This study provides evidence that with appropriate training and careful supervision the introduction of radiographers in a reporting role can improve the availability of reports for A&E and GP examinations, and therefore, help X-ray departments meet quality standards

Suggested areas in image reporting

Trauma Mammography Intravenous Urograms Barium Enemas Unreported films

Mammograms
G.WIVELL et al Can Radiographers read Screening mammograms? Clinical radiology 2003, vol. 58,no1, pp. 63-67

CONCLUSION: Radiographers are able to read screening mammograms at least as well as radiologists and do not take longer to do so.

Intravenous Urograms
A.J. Bradley Volume 60, Issue 7 Clinical Radiology July 2005, Pages 807-811 ,

Accuracy of reporting of intravenous urograms: a comparison of radiographers with radiology specialist registrars
Conclusion: the uro-radiographers significantly outperformed the SpRs from years 1 to 4, achieving 92% accuracy in interpretation compared with an experienced consultant uroradiologist

Barium Enemas
A. M. Booth , R.A.J. Mannion Radiographer and radiologist perception error in reporting double contrast barium enemas. A pilot study Radiography Volume 11, Issue 4, November2005, Pages 249-254

Conclusions: The study shows that radiographers can perceive abnormalities on DCBE at similar sensitivities and specificities as radiologists.

Unreported films
PATTY, A. 2007. Hospital's hidden X-ray backlog revealed. SMH.

"We have done 72,000 examinations to date this year and 22,000 are unreported at this point," a radiology staff member said. "Most examinations involve a number of X- rays, so the number of unreported images is much bigger than that."

Can radiographers report?

YES WE CAN!!

Overseas Experience
UK and the four tier model radiographers involved in image interpretation

USA and the Radiology Assistant (RA)

The Four Tier Model - Aims

Promote new roles that will encourage lifelong learning Improve recruitment and retention of the health professions Maintain practice standards and develop the inherent potential of all clinical practitioners
DH LEARNING AND PERSONAL DEVELOPMENT DIVISION. 2003. Radiography Skills Mix.

The Four Tier Model - Structure

Assistant practitioner: performs protocol-limited clinical tasks under the direction and supervision of a State-registered practitioner Practitioner: A practitioner autonomously performs a wide-ranging and complex clinical role; is accountable for his or her own actions and for the actions of those they direct. Advanced practitioner: An advanced practitioner, autonomous in clinical practice, defines the scope of practice of others and continuously develops clinical practice within a defined field. Consultant practitioner: A consultant practitioner provides clinical leadership within a specialism, bringing strategic direction, innovation and influence through practice, research and education. DH LEARNING AND PERSONAL DEVELOPMENT DIVISION. 2003. Radiography Skills Mix.

Four Tier Model: Features

Flexible, depending on the needs of individual clinical centres. Utilises preceptorship, clinical supervision and continuing professional development to promote new and extended roles

Radiologist Assistant
- advanced-level radiologic technologist - works under the supervision of a radiologist - RA does not interpret radiological examinations or transmit observations other than to the supervising radiologist.

How can the RA improve productivity and efciency?

RA can play a role in image reporting, improves efficiency

RA can perform procedures such as fluoroscopy or paracentesis Allows radiologist to perform more complex
interventional procedures Allows radiologist to read more US, CT and MRI images

RADIOLOGISTS CAN INTERPRET MORE STUDIES!!

Objections to the RA
BERLIN, L. 2008. The Trojan Horse Once Destroyed a Nation, Could It Destroy the Specialty of Radiology? Radiology, 248, 8-11.

the RA train could well become a modern version of the Trojan horse

Advantages of image reporting

Speeds up workflow in a busy emergency department Lightens the load on radiologists Increase job satisfaction for radiographers

Objections
Radiologist Medical Staff Radiographer

Radiologist
Deskilling of radiologists Clinical experience and knowledge Duty of care and legal responsibility to patient Feel threatened by radiographers

The Royal Australian and New Zealand College of Radiologists (RANZCR) indicated that reporting cannot be effectively delegated to those who have not been specifically trained as medical practitioners and then as radiologists.

Medical Staff
Im not interested in opinion of radiographer I only want a medical report

Radiographer
I wont get a pay rise Im not interested in more education

Training
RANZCR must control the training Curriculum set by radiologists Training and assessments done at a Masters level Research Project to progress the profession of image reporting Pass mark 95% - students undergo very heavy scrutiny

The way forward

While the UK and the US progresses responding to health demands Australia is still lagging behind Limited funding for training opportunities, lack of reimbursement for the extra responsibility, unenthusiastic radiographers and poor staffing levels will only slow the process for change We must have a proactive, not a reactive response to challenges in the radiology worforce

Question Time!