1. Follow-up of consolidation on chest radiographs before and after the introduction of radiology initiated follow-up. Cliffe H, Walsh J, Kon M.

2. Outline Background Audit population, standard and method 1 st round- 2012 Change implemented- July 2013 2 nd Round- 2013 Discussion

3. Background

4. Local Context Pre July 2013 Follow-up required Add follow-up code (AC FUP) to the report Admin search for the AC FUP code (8 weeks post examination) If no follow-up is arranged a reminder sent to clinician

5. Local Context Serious incidents Consideration of radiology initiated follow-up Question: does the current system of clinician booked follow-up ensure that patients receive the recommended follow-up?

6. Audit population New consolidation on adult chest radiographs Non resolving consolidation may have a sinister aetiology (Little et al 2014, Holmberg et al 1993) Local guidelines in place High volume & short follow-up period

7. Audit design Standard: Local guidelines state that all adults with new consolidation require a follow-up radiograph 6- 8 weeks later to ensure resolution Indicator: dedicated follow-up film request & report on CRIS Target: 100% dedicated follow-up

8. Methods Using Computerised Radiology Information System (CRIS) Reviewed chest radiograph (CXR) reports for GP and ED referrals Did the CXR report NEW consolidation? Was the follow-up code added by radiologist? Was the follow-up CXR booked? Did the patient attend for follow-up? How soon after did the follow-up film occur?

9. Round 1 results GP and ED referrals to BTHFT for CXR in August 2012 2628 reports reviewed 207 chest films reporting new consolidation Mean age 64 years, range 19-90 years 57% male, 43% female 48% ED referrals, 52% GP referrals CXR N=2628 CONSOLIDATION ON CXR 8%, N=208 NO FU CODE 20% N=42 FU DONE 31% N=13 FU CODE 80% N=166 FU ARRANGED 70% N=117 FU ACHIEVED 97% N=114

10. Round 1 results ‘AC FUP’ code was used in 81% of reports Follow-up was achieved in 62% when the ‘AC FUP’ code was used and 28% when it was not used

11. Round 1 results Attendance at booked follow-up was 97% Mean time to follow-up was 10 weeks Overall 55% of patients with new CXR consolidation obtained appropriate follow-up imaging

12. Implementation of change- July 2013 Follow-up required Add ‘AC FUP’ code Define FU required. Clinician informed Partial booking of examination Letter to patient asking them to confirm Examination confirmed Examination occurs, results to clinician, or GP if discharged from ED

13. Round 2 Question: has the implementation of radiology initiated follow-up improved the attainment of follow-up of consolidation on chest radiographs? Methods, standard and indicator: as per round 1 Assessment Period: August 2013

14. Round 2 results GP and ED referrals for CXR in August 2013 2336 reports reviewed 172 reports described new consolidation Average age 66 years, range 18-97 years 45% male, 55% female 61% GP referrals 39% ED referrals

15. Round 2 results ‘AC-FUP’ code use improved from 81% to 93%

16. Round 2 results When ‘AC FUP’ code used FU was booked in 96% of cases versus 64% previously

17. Round 2 results When ‘AC FUP’ code employed FU achieved in 72% of cases compared to 62% previously Overall DNA rate 12% versus 3% previously

18. Round 2 results Mean time to FU improved from 10 to 7 weeks (within target)

19. Round 2 results Overall 69% of patients with new CXR consolidation received FU CXR versus 55% previously.

20. Study limitations Single indication and study Single site No ward or outpatients Snapshot study, soon after implementation

21. Discussion Increase in the attainment of recommended follow- up Multifactorial Marked improvement in code use and rates of patients offered follow-up A streamlined patient journey Low cost intervention DNA rates How do you safety net the safety net?

22. Acknowledgements Dr Jonathan Barber, Clinical Director for Imaging, Bradford Teaching Hospitals Foundation Trust. Professor Clive Kay, Chief Executive, Bradford Teaching Hospitals Foundation Trust.

23. References 1. National Patient Safety Agency. Early identification of failure to act on radiological imaging reports, London NPSA, February 2007. 2. Holmberg H, Kragsbjerg P. Association of pneumonia and lung cancer: the value of convalescent chest radiography and follow-up. Scandinavian Journal of Infectious Diseases 1993; 25:93-100 3. Little BP, Gilman MD, Humphrey KL, Alkasab TK, Gibbons FK, Shepard JO, Wu C. Outcome of Recommendations for Radiographic Follow-up of Pneumonia on Outpatient Chest Radiography. American Journal of Roentgenology 2014; 202:1, 54-59 4. Standards for the communication of critical, urgent and unexpected significant radiological findings, Second Edition. London: The Royal College of Radiologists, 2012. 5. Berlin LM. Failure of Radiologic Communication: An increasing cause of malpractice litigation and harm to patients. Appl Radiol 2010; 39:17-25