1. Practical Radiology for GP’s Dr Andrew Carne MSK Radiologist Deputy Medical Director CCIO

2. User Guide for GPs

3. PACS Do you want to see your patients Radiology? Quick access to reports and imaging history Fill out a PACS access form to get password & username Install web browser plugin https://webpacs.royalsurrey.nhs.uk Available from any PC within the Surrey N3

4. INSTALLING PACS To install PACS on your PC, launch internet explorer and enter https://webpacs.royalsurrey.nhs.uk The screen will look like this Click on the blue writing to install

5. Then click ‘Run’

6. As this installs the progress bar will go blue, this can take a few minutes

7. Click in the box and Close

8. Click on ‘Run ActiveX Control Then Click ‘Run’ You will need to do this twice To bring the PACS icon onto the Desktop, drag and drop the following icon from the address bar onto Desktop

9. The log in page looks like this Enter the User Name and Password as sent to you via email by the PACS team. You will be asked to change this upon first log in Ensure the remaining fields look as above. To improve the quality of the images, the “Location” can be changed from ‘Teleradiology’ to ‘Main Location’, but PACS will run significantly slower. Then press OK

10. To view Images and Reports Left click on Patient Lookup Complete the patient’s name or hospital number in the appropriate field, then press Search All patients that match that criteria will be listed – Double left click to select

11. All the patients exams will be listed below their name An exam with images shows the ‘person’ icon An exam with images and a report shows a ‘paper’ icon Highlight the exam you wish to view and double left click

12. To view the report without opening the images, highlight the exam Then right click and select ‘Show Report’ using a left click

13. To view images, highlight the exam from the list and double left click. This will open up the exam page Green No diagnostic report Blue Diagnostic report available “ | ” Image available “X” No Image available “A” Image is archived and needs retrieving from storage The exam page displays the timeline listing all the exams the patient has undergone The icons on the timeline mean the following;

14. To view the report, left click on the white clipboard with red writing To enlarge the image thumbnails, double left click. To scroll through stacked images (CT/MRI) use the arrow keys To close the patients exam page press the bullseye To log out of PACS press the yellow ‘X’ in the top right hand corner

15. Requesting guidelines Skull X-ray Nasal Bones Coccyx

16. Skull X-rays We have recently received several requests for a skull X-ray following a head injury. Under the NICE guidelines CG176 and Royal College of Radiologists (RCR) guideline T01 plain film imaging of the skull is not indicated or justified.

17. Skull X-ray The current primary investigation for detection of brain injuries is a CT brain scan after assessment in a hospital emergency department. The following guidelines have been published by NICE and are taken from CG176 published in January 2014 and available at http://www.nice.org.uk/guidance/cg176.

18. Skull X-ray NICE CG176 1.1.4 Community health services (GPs, ambulance crews, NHS walk-in centres, dental practitioners) and NHS minor injury clinics should refer patients who have sustained a head injury to a hospital emergency department, using the ambulance service if deemed necessary, if any of the following are present:

19. Skull X-ray NICE CG176 Glasgow coma scale (GCS) score of less than 15 on initial assessment. Any loss of consciousness as a result of the injury. Any focal neurological deficit since the injury.focal neurological deficit Any suspicion of a skull fracture or penetrating head injury since the injury.skull fracture or penetrating head injury Amnesia for events before or after the injury [4].4 Persistent headache since the injury. Any vomiting episodes since the injury (clinical judgement should be used regarding the cause of vomiting in those aged 12 years or younger and the need for referral).

20. Skull X-ray NICE CG176 Any seizure since the injury. Any previous brain surgery. A high-energy head injury.high-energy head injury Any history of bleeding or clotting disorders. Current anticoagulant therapy such as warfarin. Current drug or alcohol intoxication. There are any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected). Continuing concern by the professional about the diagnosis. [2003, amended 2007 and 2014]

21. Skull X-ray NICE CG176 1.1.5 In the absence of any risk factors in recommendation 1.1.4, consider referral to an emergency department if any of the following factors are present, depending on judgement of severity: Irritability or altered behaviour, particularly in infants and children aged under 5 years. Visible trauma to the head not covered in recommendation 1.1.4 but still of concern to the professional. No one is able to observe the injured person at home. Continuing concern by the injured person or their family or carer about the diagnosis. [2003, amended 2014]

22. Skull X-ray NICE CG176 Transport to hospital from community health services and NHS minor injury clinics 1.1.8 The referring professional should inform the destination hospital (by phone) of the impending transfer and in non-emergencies a letter summarising signs and symptoms should be sent with the patient. [2003]

23. Coccyx X-rays According to iRefer guideline T18 published by the RCR (2014) radiographs as a result of trauma to the coccyx are not indicated as normal appearances are often misleading and the findings do not affect management. Therefore we are not able to justify plain film imaging isolated to the coccyx as a result of injury and the request will not be undertaken.

24. Nasal bones Similarly under the RCR (2014) iRefer guideline T02: Nasal trauma; plain film imaging of the nose is not indicated as radiographs of this area are unreliable in the diagnosis of nasal fractures and even when positive do not usually affect patient management. Therefore referral for imaging will only be accepted from the ENT/Maxillofacial department.

25. iRefer The RCR iRefer guidelines are now available via the N3 (NHS) network using the following address: http://nww.irefer.nhs.uk/