National Audit of the National Audit of the Accuracy of Interpretation Accuracy of Interpretation of Emergency Abdominal of Emergency Abdominal CT in Adult Patients Who CT in Adult Patients Who

Present with Non-Traumatic Present with Non-Traumatic Abdominal PainAbdominal Pain

C Ball, SpR Radiology, Portsmouth C Ball, SpR Radiology, Portsmouth Hospitals NHS TrustHospitals NHS TrustA Higginson, Consultant Radiologist, A Higginson, Consultant Radiologist, Portsmouth Hospitals NHS TrustPortsmouth Hospitals NHS TrustK Drinkwater, Audit Officer, Royal college K Drinkwater, Audit Officer, Royal college of Radiologistsof RadiologistsD Howlett, Consultant Radiologist, East D Howlett, Consultant Radiologist, East Sussex Hospitals NHS TrustSussex Hospitals NHS Trust

In collaboration with the RCR audit committee.

Special thanks to all the audit leads and those who completed the audit.

PlanPlan

BackgroundBackground

AimsAims

Method Method

ResultsResults

Discussion/The futureDiscussion/The future

BackgroundBackground

The NHS is experiencing a period of change The NHS is experiencing a period of change with reconfiguration of local services and with reconfiguration of local services and increasing use of outsourced reporting to increasing use of outsourced reporting to external organisations to meet demand and to external organisations to meet demand and to generate cost savings. generate cost savings. National drive to improve quality with a strong National drive to improve quality with a strong focus on patient safety. focus on patient safety. The quality of the report must remain high The quality of the report must remain high whether generated by trainee radiologists, whether generated by trainee radiologists, consultant trust radiologists or consultant non-consultant trust radiologists or consultant non-trust radiologists. trust radiologists.

AimsAims

To assess major/minor discrepancy rates for provisional To assess major/minor discrepancy rates for provisional and addendum reports and addendum reports

Assess the impact of discrepanciesAssess the impact of discrepancies

To evaluate correlation of provisional +/- addendum To evaluate correlation of provisional +/- addendum report and CT auditor report with laparotomy findings in report and CT auditor report with laparotomy findings in a surgical group. a surgical group.

CodingCoding

Major DiscrepancyMajor Discrepancy – a change or potential change – a change or potential change in diagnosis or treatment as a result of in diagnosis or treatment as a result of addendum/CT auditor review. addendum/CT auditor review.

Minor DiscrepancyMinor Discrepancy – minor differences between – minor differences between provisional/addendum and addendum/auditor provisional/addendum and addendum/auditor reports, unlikely to result in a significant change in reports, unlikely to result in a significant change in patient management. patient management.

Indeterminate report Indeterminate report – a report where a wide, or – a report where a wide, or non-specific, or inappropriate differential diagnosis non-specific, or inappropriate differential diagnosis is given which leads to indeterminate management is given which leads to indeterminate management advice. These reports will be treated as major advice. These reports will be treated as major discrepancies. discrepancies.

StandardsStandards

All centres across the UK with acute All centres across the UK with acute abdominal CT reporting capacity were abdominal CT reporting capacity were includedincluded

Retrospective identification from 1/1/2013 Retrospective identification from 1/1/2013 onwards from the radiology departmental onwards from the radiology departmental database of 50 consecutive non-traumatic database of 50 consecutive non-traumatic adult (>16 years) emergency patients who adult (>16 years) emergency patients who had out of hours (6pm – 8am) had out of hours (6pm – 8am) abdominal/abdominopelvic CTabdominal/abdominopelvic CT

MethodsMethods

Split cases into:Split cases into:1.1. Non-surgically managed patientsNon-surgically managed patients2.2. Surgically managed patientsSurgically managed patients

Non-Surgical Group Non-Surgical Group –A–Abdominal/abdominopelvic CT but no bdominal/abdominopelvic CT but no laparotomy subsequent to the CT. laparotomy subsequent to the CT.

Patients who had another intervention during Patients who had another intervention during this admission subsequent to the CT (e.g. this admission subsequent to the CT (e.g. Colonic/JJ stent, EVAR, percutaneous drainage, Colonic/JJ stent, EVAR, percutaneous drainage, laparoscopy) would be included in this category. laparoscopy) would be included in this category.

Surgical Group - Surgical Group - 25 consecutive adult 25 consecutive adult patients who underwent a laparotomy as an patients who underwent a laparotomy as an emergency for an acute abdomen (non-emergency for an acute abdomen (non-traumatic) and who also underwent emergency traumatic) and who also underwent emergency abdominal/abdominopelvic CT out of hours as abdominal/abdominopelvic CT out of hours as part of their assessment part of their assessment

The laparotomy may have been performed at The laparotomy may have been performed at any time following the CT if deemed relevant to any time following the CT if deemed relevant to the CT diagnosis the CT diagnosis

Results - RespondentsResults - Respondents

Results - InstitutionResults - Institution

Results – On call reporting by Results – On call reporting by SpRSpR

Results – On call reporting by Results – On call reporting by Offsite radiologistOffsite radiologist

StandardsStandards

SpR discrepancy ratesSpR discrepancy rates

Major discrepancy rate (provisional report - registrar) <10%

Minor discrepancy rate (provisional report - registrar) <20%

Major discrepancy rate (provisional report - trust consultant radiologist or offsite non-trust radiologist) <5%

Minor discrepancy rate (provisional report - trust consultant radiologist, offsite non-trust radiologist) <10%

Consultant (on and offsite) discrepancy Consultant (on and offsite) discrepancy ratesrates

Non-surgical DiscrepanciesNon-surgical Discrepancies

Standards met…?Standards met…?

YesYes

Results – Surgical Results – Surgical DiscrepanciesDiscrepancies

Standards met…?Standards met…?

YesYes

StandardsStandards

Correlation with laparotomy Correlation with laparotomy

Correlation CT report with laparotomy findings (provisional report - registrar) >80%

Correlation CT report with laparotomy findings (provisional report, onsite trust consultant, offsite radiologist, non-trust) >90%

Results – Correlation with Results – Correlation with laparotomylaparotomy

Standards met…?Standards met…?

Yes (Almost)Yes (Almost)

Results – Non surgical Results – Non surgical DiscrepanciesDiscrepancies

Results – Surgical DiscrepanciesResults – Surgical Discrepancies

DiscussionDiscussion

Standards met for the majority of the parameters Standards met for the majority of the parameters measured/analysed so farmeasured/analysed so far

If discrepancies – usually a delay in If discrepancies – usually a delay in treatment/surgery is the result however the treatment/surgery is the result however the impact of this/unnecessary treatment on patient impact of this/unnecessary treatment on patient outcome must be appreciatedoutcome must be appreciated

Still a lot of data to sort through… Still a lot of data to sort through…

1.1. What were the discrepant cases – What were the discrepant cases – ischaemic bowel? Localised perforation?ischaemic bowel? Localised perforation?

2.2. Splitting of on and offsite radiologists and Splitting of on and offsite radiologists and SpR SpR reports with consultant inputreports with consultant input

ReferencesReferences

CT and appendicitis: evaluation of correlation between CT and appendicitis: evaluation of correlation between CT diagnosis and pathological diagnosis; Andre J et al; CT diagnosis and pathological diagnosis; Andre J et al; Postgraduate medical journal; 2008; 84; 321-324Postgraduate medical journal; 2008; 84; 321-324

Discrepancies in interpretation of ED body CT scan Discrepancies in interpretation of ED body CT scan reports by radiology residents; N Tieng et al; American reports by radiology residents; N Tieng et al; American journal of emergency medicine; 2007; 25; 45-48journal of emergency medicine; 2007; 25; 45-48

Evaluating the acute interpretation of emergency Evaluating the acute interpretation of emergency medicine resident interpretations of abdominal CTs in medicine resident interpretations of abdominal CTs in patients with non-traumatic abdominal pain; Ju Kang et patients with non-traumatic abdominal pain; Ju Kang et al; Journal of Korean medical science; 2012; 27; 1255-al; Journal of Korean medical science; 2012; 27; 1255-12661266

The DEPICTORS study; Discrepancies in The DEPICTORS study; Discrepancies in preliminary interpretations of CT scans preliminary interpretations of CT scans between on call residents and staff; J between on call residents and staff; J Walls et al; Emergency radiology; 2009; Walls et al; Emergency radiology; 2009; 16; 303-30816; 303-308Overnight resident preliminary Overnight resident preliminary interpretations on CT examinations; interpretations on CT examinations; Should the process continue? Strub et al; Should the process continue? Strub et al; Emergency radiology; 2006; 13; 19-23Emergency radiology; 2006; 13; 19-23

Questions please…Questions please…