Clinical Radtology (1985) 36, 483-484 0009-9260/85/548483502 00 © 1985 Royal College of Radiologists

A Survey of Accident and Emergency Results and Implications

Reporting:

LAURENCE BERMAN, GERALD de LACEY and OSCAR CRAIG*

Departments of Radiology, Northwick Park Hospital and Clinical Research Centre, Harrow, and *St Mary's Hospital, London

Surveys have shown a consistent error rate in the detec- tion of radiographically demonstrable abnormalities by casualty officers. A high incidence of medical litigation is related to casualty departments. For these reasons, a survey of hospitals in England and Wales was carried out to determine when and whether accident and emergency radiographs are reported. The practice in 146 hospitals was analysed. It was found that two-thirds of hospitals report all radiographs within 48 h. Seven per cent of hospitals either do not report any radiographs, report only radiographs of certain areas, or delay reporting for over 1 week. It is suggested that the patients attending as many as a quarter of all hospitals as casualties are at increased risk from errors which will inevitably be recog- nised late, and that these errors are directly attributable to shortage of staff.

RESULTS

Replies were obtained from 155 hospitals (97.5% of all those sent questionnaires). Nine of the hospitals do not possess a casualty department despite the record to this effect in the Hospital Year Book. The remaining 146 replies were analysed and the results are shown in Table 1. In 94 (64%) radiology departments all films are routinely reported within 48 h. A further 27 (18%) report all films within 1-4 weeks. Fifteen (10%) depart- ments provide a restricted service, most reporting only those films deemed 'normal' by the casualty officers. Ten (7%) provide no routine reporting by radiologists, but in seven of these an alternative service exists with either a clinical assistant, a casualty consultant or an orthopaedic surgeon reporting on films.

In England and Wales there has been an increase in radiological workload of 35% compared with an increase in the consultant establishment of 12% over the last 5 years. At present in the United Kingdom there are 1.8 consultant radiologists per 100 000 population, com- pared with three per 100 000 in other Western European countries (Ross and Craig, 1984) and approximately six per 100 000 in the USA.

Accident and emergency (A & E) radiographs account for 20% of all radiological examinations in a general hospital. Coping with the workload presented by A & E reporting has been a long-standing subject of correspondence (Aberdour, 1976; Bohrer, 1976). We present the results of a survey undertaken to assess the situation regarding A & E reporting in England and Wales.

PATIENTS AND METHODS

A postal questionnaire was sent to 159 hospitals with casualty departments, as indicated by the Hospital Year Book (Institute of Health Service Administrators, 1984). Radiology teaching centres were excluded as the reporting workload was not considered to be a problem in these departments. The questionnaire enquired whether A & E radiographs were routinely reported by a radiologist and, if so, what was the usual delay be- tween a radiographic examination and its being reported. In the absence of a full radiology reporting service respon- dents were asked in what way the service was limited. In those hospitals where no routine reporting by radiologists exists, the questionnaire enquired as to the nature of an alternative system of reporting (e.g. by orthopaedic surgeon or casualty consultant).

Table 1 - Accident and emergency reporting

No of hospitals

Radiologist reports all films within 48 h 94 48 h-1 week 24 1 week-1 month 3

Radiologist limits reporting Casualty officer 'normals' 10 Specific sites only (skull, spree) 5

Non-radiologist medical practmoner reports films Casualty consultant 4 Clinical assistant 2 Orthopaedic surgeon 1

No reporting at all 3 Total 146

DISCUSSION

It has been reported that casualty officers incorrectly interpret 7% of all radiological examinations, including just over 2% which are clinically significantly abnormal (de Lacey et al., 1980). A more recent study confirmed this figure (Berman et al., 1985). There are both medico- legal and clinical consequences which may result from errors in the interpretation of radiographs. Twenty- seven per cent of all medical litigation concerns accident and emergency or orthopaedic cases (Craig, 1984).

In the face of an increasing workload and time-con- suming radiological procedures, various compromises have been suggested. These include reporting only those radiographs deemed 'normal' by the casualty officer. This practice occurs in 7% of the hospitals surveyed and reduces A & E reporting by 25% (de Lacey etal., 1980).

Aberdour (1976) suggested training non-radiologists

484 CLINICAL RADIOLOGY

to report A & E films and both Aberdour (1976) and Swinburne (1971) suggested that a large part of this work might be undertaken by radiographers. A recent prospective survey found that half of the clinically sig- nificant abnormalities missed by the casualty officers were detected by the radiographers (Berman et al., 1985). The authors did not suggest that reporting by radiographers should replace reporting by radiologists and it is, of course, medico-legally unacceptable for non- qualified personnel to issue reports.

It is encouraging that two-thirds of the hospitals in this study report all radiographs within 48 h. It may appear that, since only 2% of hospitals do not provide any routine radiologist reporting, the incidence of inadequ- ate reporting cover is low. This is misleading as a further 3% report only on specific anatomical sites. There must also be concern that 2% of hospitals have reporting delays of 1-4 weeks and 17% delay reporting for up to 1 week.

One of the solutions to the difficulties experienced by these departments is an increase in radiological staffing. A Royal College of Radiologists newsletter has advised that, where a comprehensive service is not supplied, the Health

Authority should be formally notified that this is due to inadequate staffing (Craig, 1984). College recommenda- tions are for an increase of 60 consultants per year for 10 years to reach a level of three per 100 000 population.

REFERENCES

Aberdour, K. R. (1976). Must radiologists do all the reportlng~ Brit;sh Journal of Radiology, 49, 573.

Berman, L., de Lacey, G., Twomey, E., Twomey, B., Welch, T & Eban, R. (1985). Reducing errors m the accident department: a simple method using radlographers. Br;t;sh Medical Journal, 290, 421-422

Bohrer, S. P. (1976) Must radiologists do all the reporting ° Br;ti.sh Journal of Radiology, 49, 739-740

Craig, O (1984) Workload and manpower problems. Royal College of Radiologists Newsletter, 16, 11

de Lacey, G., Barker, A , Harper, J. & Wxgnall, B. (1980) An assessment of the clinical effects of reporting accident and emergency radiographs. British Journal of Rad;ology. 53,304-309

Institute of Health Service Administrators (1984) The Hosp;tal and Health Services Year Book.

Ross, W. M. & Craig, O. (1984) Manpower and workload Royal College of Ra&ologists Newsletter, 17, 10.

Swinburne, K. (1971). Pattern recognition for radlographers. La~lcet, i, 589-590