QUDI 2010 & 2011

In October 2009 the Department of Health and Ageing announced continued funding (under the diagnostic imaging quality projects program) for a two year program of work focused on quality and safety in diagnostic imaging. The funded projects continue previous work in this area and are managed by the RANZCR's Quality Use of Diagnostic Imaging (QUDI) Program.

The work plan in place until the end of 2011 includes projects that focus on:

InsideRadiology

InsideRadiology will continue with the aim of providing consumers and health professionals with accurate, up-to-date and easily accessible information about medical imaging tests and procedures. In addition to developing 10 consumer and 10 referrer items each year, the website will be enhanced and an evaluation of both the content and user interface will be undertaken.

The InsideRadiology Editorial Board has determined that during 2010 there will be a focus on developing information items about Interventional Radiology. New items will be published by the end of the year.

June 2010 Outcomes:

The InsideRadiology website has been redesigned with improved data management and search options.

Resources:

Visit our website: www.insideradiology.com.au

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CT Dose Optimisation

The CT Dose Optimisation Quality Improvement Activity project has commenced in Victoria, and will be undertaken in South Australia during 2011. The projects will collect dose data and scan parameters (such as average mAs, collimation, kVp, use of dose modulation) for a range of common scan protocols with the aim of:

  • Comparing the median doses delivered by each scanner
  • Identifying sources of higher dose for scanners performing at the upper end of the range
  • Assisting MITs and radiologists to reduce dose, where this is appropriate, while maintaining image quality.

This is achieved through the feedback of de-identified results at interactive workshops with education in optimisation techniques; and hands-on assistance from expert MITs and Medical Radiation Physicists.

Progress to date (October 2010):

The Victorian CT Dose Optimisation Project has involved the collection of dose related data from eight commonly performed CT examinations – non contrast brain, sinuses, CTA cerebral, high resolution chest, CT pulmonary angiography, portal venous phase abdomen and pelvis, CT urogram and lumbar spine.

The dose metric used in the project was the scanner displayed DLP (Dose Length Product) due to its accessibility and accuracy. Testing was performed using a PMMA phantom. The DLP displayed on the scanner console was within 10% of the calculated dose for all scanners. Girth and height measurements were collected from the Scout/Topogram images as girth is the major reason for justified higher radiation dose. Therefore, this could be taken into account in providing feedback about the possible reasons for higher dose.

Data was collected from 9 scanners at Southern Health and Austin Health, with variation in multidetector rows from 16 to 320 and Philips, Toshiba, and GE scanners represented. This data included all factors which could contribute to dose including kVp, effective mAs, scan length, pitch, collimation, use of dose modulation, and bismuth shielding as well as girth. The purposes of this project were to determine:

  • Median dose delivered for common CT examinations
  • Variation within and between scanners in delivered dose
  • Reasons for this variation apart from justified dose variation due to patient size
  • Whether audit – feedback – reaudit with small group face to face teaching on a single day
    could be effective in improving clinical practice in dose optimisation

Results were conveyed to each site at a Saturday workshop in a de-identified format. Only the participants knew which scanner(s) was (were) theirs. De-identifying scanners allowed sites to openly discuss how best to optimise their scanners to ensure diagnostic quality scans while at the same time, minimising the dose to the patient. The detailed nature of the data collection enabled the clear identification of the most likely reasons for higher dose when this was observed and thus where changes to scanning protocols were most likely to lead to improvement.

Post-optimisation training data collection is now nearly concluded. A similar optimisation project is planned for South Australia in 2011 and Prof John Slavotinek and Ms Stephanie Hartman will lead this project. The SA project has received enthusiastic support of private and public CT facilities within the state, with many practices wishing to audit their doses. Budgetary and time constraints will dictate the number of participants, but it is hoped that future funding for further optimisation support will be secured by RANZCR from the Federal Department of Health and Ageing for future years.

For optimisation to be successful it requires a close working partnership between radiologists and MIT’s with some assistance from medical physicists, to ensure diagnostic image quality is maintained. Sites were given 7 weeks to perform optimisation and we are currently undertaking our post-optimisation data collection. The post-optimisation data will be conveyed to sites once the data has been analysed.

Resources:

Presentations from the workshop:

Paper published in the JACR about the previous CT dose optimisation project undertaken in Queensland in 2008-09.
Full free text available from the JACR website.

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Radiology Events Register (RaER)

The increasing value of the Radiology Events Register (RaER) has also been recognised. The ongoing management and development of the RaER will continue through a two-year contract with the Australian Patient Safety Foundation (APSF) and Patient Safety International (PSI). An additional project to use the RaER as the evidence base for collaborative research with a number of research units and individual researchers will develop publishable material focusing on common sources of error in radiology is also underway. A significant outcome from this project is the convening of a major Australasian meeting on error in medical imaging.

The Radiology Events Register (RaER) has continued to grow.

RaER is a unique incident reporting database that is peer-led, online, anonymous and confidential.  It is a means of improving safety and quality in medical imaging. Established in 2006, and has grown considerably both in the number of incidents and also in the scope of activities being performed around the project.

About 10% of hospital patients suffer harm as a direct result of their healthcare, and about half of these adverse events could have been prevented.  Knowing what, how and why is critical to prevent the same incident happening again. Near-misses (i.e. no actual patient harm occurred) provide very important and valuable insights and opportunities for learning. Incident reporting is a very important way of obtaining this information and is practised in many other high risk industries such as aviation and rail, and healthcare.

Key developments in RaER are:

  1. Earning continuing professional development (CPD) points.  Submission of an incident is simple, performed via the internet and only takes a few minutes. CPD points can be claimed for every case entered. This is an important and straightforward way you can contribute towards quality improvement.
  2. Inclusion as a mandatory component of the new radiology curriculum:  RaER in now incorporated into the new training curriculum for radiologists. It forms part of the patient safety module. Instilling a safety and learning culture is a healthcare priority.
  3. A recent national survey of Diagnostic Error at the medical imaging-emergency department interface, involving radiologists and emergency medicine physicians (and the two Colleges) resulted in submission of 285 incidents, a unique repository of important information. These incidents are now included in the RaER database.  This is an example of the growing trend towards inter-professional and multidisciplinary collaboration.
  4. RaER publications: RaER recently featured in two recently published articles in the Journal of the American College of Radiology. The RaER team described incident reporting systems for medical imaging, as well as the nature of error and failures in the imaging care cycle. This has generated significant international exposure and interest in the USA and the UK.
  5. RaER has been highlighted in talks delivered at the following recent conferences  by Catherine Mandel and / or Neil Jones:
    1. RANZCR (NZ Branch) ASM, August
    2. National Forum on Safety and Quality in Health Care, October
    3. RANZCR ASM, October
    4. National Forum on Safety and Quality in Health Care, October
    5. Australasian Conference on Error in Medical Imaging: Making Imaging Safer, November
  6. Very large expansion of the number and diversity of incidents in the RaER database, now totalling approximately 4000, including new incidents from a State health department, an ionizing radiation regulatory body,  medical defence organisations, radiology and nuclear medicine trainees, referrer and nursing staff, and additional contributions from consultant radiologists.
  7. Upgrading and streamlining of online incident reporting capabilities (and associated web tutorial) including a software upgrade, the inclusion of mandatory fields, and the ability for anyone to report an incident via an anonymous, confidential login. This includes patients and al healthcare professionals.
  8. International incident submission: incidents from New Zealand can be submitted into RaER which has been declared a quality assurance activity in that country.  This means incident data is protected from use in medico-legal matters
  9. Analysis of RaER Data analysis: Three ‘hot topics’, namely “Handover”, “Diagnostic error”, and “Critical data checks” have been identified for further analysis by multidisciplinary teams. Results will be published in peer-reviewed journals.

In summary, the RaER, has continued to expand and is now entering a new phase of analysis. This unique resource is already showing its value in helping to improve how we do what we do: providing safe and effective care to all our patients.

NB: Please visit our conference website:
Australasian Conference on Error in Medical Imaging: Making Imaging Safer

Resources:

Published papers: [Available from the website of the JACR]

Jones DN, Thomas MJW, Mandel CJ, et al. Where Failures Occur in the Imaging Care Cycle: Lessons From the Radiology Events Register. JACR 2010;7(8):593-602.

Jones DN, Klee AB, Timothy JS, Catherine JM, William BR. Establishing National Medical Imaging Incident Reporting Systems: Issues and Challenges. JACR 2010;7(8):582-92.

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NHMRC Translating Research Into Practice (TRIP) Fellowship

We are very pleased about the prospect of a new NHMRC-TRIP fellowship. In association with the National Institute of Clinical Studies (NICS), the aim of this Fellowship will be to address barriers and facilitate enablers to closing the loop between logged events in the RaER and health care networks, hospitals and private practices in order to promote action as a result of incident reporting.

June 2010 Outcome:

The Fellowship will be announced during August 2010.

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Radiology Written Report Guideline Project

The final project is a continuation of the Report Writing Guidelines Project. A systematic review of the literature relating to the content and form of the written radiology report was conducted by the QUDI program in 2008-9. The results were presented at RSNA 2009 and are published in the August 2010 edition of the Journal of the American College of Radiology. This work underpins the development of a practical guideline by a multidisciplinary panel  with representation from public and private sector radiologists, RANZCR Radiology Education Board, clinician referrers, and consumers.

The anticipated outcome of this project is a standalone guideline that will provide recommendations on content, format and language of the written radiology report. It is also anticipated that a number of example reports will be developed demonstrating the application of the guidelines to a variety of imaging procedure reports.

Draft guideline available for public consultation and feedback:

December 2010: You are invited to provide feedback on the guideline document that resulted from this project. This consultation process will be open for three months.

More details about the public consultation processs are available here

Resources:

Pool F, Goergen SK. Quality of the Written Radiology Report: A Review of the Literature. JACR 2010;7(8):634-43.
[Available from the website of the JACR]

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Last updated: October 28, 2010