Board of the Faculty of Clinical Radiology. Standards for providing a 24-hour interventional radiology service

Transcription

1 Board of the Faculty of Cliical Radiology Stadards for providig a 24-hour itervetioal radiology service

2 RCR Stadards The Royal College of Radiologists (RCR), a registered charity, exists to advace the sciece ad practice of radiology ad ocology. It udertakes to produce stadards documets to provide guidace to radiologists ad others ivolved i the delivery of radiological services with the aim of defiig good practice, advacig the practice of radiology ad improvig the service for the beefit of patiets. The stadards documets cover a wide rage of topics. All have udergoe a extesive cosultatio process to esure a broad cosesus, uderpied by published evidece where applicable. Each is subject to review four years after publicatio or earlier if appropriate. The stadards are ot regulatios goverig practice but attempt to defie the aspects of radiological services ad care which promote the provisio of a high-quality service to patiets. Curret stadards documets Stadards for the commuicatio of critical, urget ad uexpected sigificat radiological fidigs Stadards for Self-assessmet of Performace Stadards for Radiology Discrepacy Meetigs Stadards i Vascular Radiology Stadards for Ultrasoud Equipmet Stadards For Iodiated Itravascular Cotrast Aget Admiistratio To Adult Patiets Stadards for Patiet Coset Particular to Radiology Stadards for the Reportig ad Iterpretatio of Imagig Ivestigatios Cacer Multidiscipliary Team Meetigs Stadards for Cliical Radiologists 360 Appraisal Good Practice for Radiologists Idividual Resposibilities A Guide to Medical Practice for Radiologists Stadards for providig a 24-hour itervetioal radiology service

3 Cotets Foreword 4 Itroductio 5 Recommedatios for idividual departmets ad trusts 6 Recommedatios for idividual radiologists 7 Implemetatio of stadards 8 Models of safe itervetioal radiology provisio 9 Refereces 10 Appedix 1. Safe itervetioal radiology service provisio 11 Appedix 2. Audit template 12 Appedix 3. Checklist for safe IR service provisio 13 Stadards for providig a 24-hour itervetioal radiology service 3

4 Foreword For the safety of patiets, it is ecessary that acute hospital trusts have formal ad robust arragemets to esure provisio of emergecy services 24 hours a day every day, of the year. The provisio of itervetioal radiology is o exceptio ad all patiets regardless of geography ad hospital size should have access to itervetioal techiques if required. Several surveys have show that this is ot curretly occurrig. The majority of radiology departmets report either o itervetioal o-call rota or iformal arragemets without adequate resource. This suggests that there is a umet eed for itervetio i may hospital trusts. I additio, oly a small umber of radiology departmets report formal lies of referral to other trusts which ca provide itervetioal radiology services o a full-time basis. Such uclear arragemets are a potetial risk to patiets ad put ufair pressure o idividual radiologists ad certai hospital trusts. There eeds to be clarity about the services that ca ad caot be offered by idividual departmets ad clear pathways for referral if we are to develop a better resourced ad collaborative atioal itervetioal radiology service. The emphasis of this documet is to ecourage trusts to: Put patiet safety first, recogisig the essetial role of itervetioal radiology i the provisio of moder medical care Recogise the resources ad mapower required to provide a itervetioal radiology service Be clear ad trasparet regardig the local provisio of itervetioal radiology services Decide what is, ad what is ot possible to provide i ad out of hours Eter ito discussios with strategic healthcare authorities, primary care trusts ad other trusts i the regio to make arragemets which esure robust ad coheret regioal itervetioal radiology service provisio 24 hours a day, seve days a week. This stadard is itetioally brief. It clarifies which services patiets should have access to ad suggest potetial solutios to esure 24-hour itervetioal radiology cover. It is stressed from the outset that the provisio of appropriate diagostic imagig is vital to the success of itervetioal radiology. 4 Stadards for providig a 24-hour itervetioal radiology service

5 Itroductio The demad for all types of radiological imagig ad itervetio o a 24-hour, seve days a week basis has icreased sigificatly i recet years. The term 24-hour radiological imagig services applies equally to elective ad acute services. Itervetioal techiques are ow at the forefrot of maagemet of may life-threateig emergecies (Table 1). Every acute trust has a duty to esure that there are formal arragemets to secure provisio of elective ad emergecy itervetioal radiology services. 1 Several surveys have show that this is ot occurrig. 3 7 Fewer tha 10% of hospitals are curretly providig 24-hour itervetioal services due to isufficiet resource. This situatio puts patiets at risk. Table 1. Maagemet of emergecies usig itervetioal techiques Situatios where urget or emergecy itervetioal radiology is idicated Stoppig haemorrhage (eg, trauma, gastroitestial (GI) bleedig, post-partum haemorrhage 8,9 ) Thoracic aortic aeurysm, traumatic dissectio ad the complicatios of Type B dissectio, ruptured peripheral aeurysms Acute peripheral ad visceral ischaemia Maagig sepsis secodary to upper uriary tract ad biliary obstructio (ofte urget though rarely a emergecy) Draiig itra-abdomial ad itra-thoracic abscess (ofte urget, though rarely a emergecy) Coloic stetig (ofte urget, though rarely a emergecy) Image-guided itervetio i subarachoid haemorrhage Situatios where emergecy itervetioal radiology might be idicated i future Emergecy maagemet of abdomial aortic aeurysm 5 Stroke Stadards for providig a 24-hour itervetioal radiology service 5

6 Recommedatios for idividual departmets ad trusts The followig issues should be addressed. 1. Recogitio that i the absece of provisio of IR services patiets will be placed at risk. 1,5 10 There should be exploratio of ways i which a comprehesive service may be offered by iteral reorgaisatio, maiteace of core skills, additioal fudig/traiig/appoitmets, or exteral etworkig. Discussio should take place with the cliical goverace departmet about the implicatios of a lack of 24-hour access. 2. There should be clarity withi the trust ad amog referrig cliicias ad service commissioers about what itervetioal radiology services are available ad whe they are available. If a service is ot available at all, withi or outside routie workig hours, for example, embolisatio for acute haemorrhage, this should be kow to the cliical goverace committee. Where there is a umet cliical eed, discussios ca take place with commissioers about purchasig appropriate services from aother trust. 3. Clear pathways should be i place for treatig patiets appropriately whe the itervetioal radiology service is ot available. The trust s cliical goverace committee ad relevat referrig cliicias eed to be aware of the situatio. This will allow discussio about plaed patiet pathways whe the service is ot available, for example, default to surgical treatmet, ad also documet a area of possible eed for service developmet. 4. Out-of-hours service provisio must be subject to a formal rota. It is ot sustaiable, safe or timely to rely o ad hoc methods of tryig to fid a suitable radiologist who is ot officially o call. Nor is it acceptable to assume that aother trust will be willig or able to provide the service without official ad agreed service level agreemets. A mechaism should be i place for iformig cliical teams i advace about whe services will ad will ot be available, so that all ivolved are clear about whe alterative o-radiological treatmets or referral will be required. 5. There should be recogitio of the resource implicatio of supportig a 24-hour itervetioal service i terms of diagostic imagig ad mapower Appropriately traied radiographers ad urses are required to support a full-time itervetioal radiology service as are CT ad ultrasoud facilities. 6. Oward referral pathways must be clear. Whe a service is ot provided o a 24-hour basis, ad whe this usually results i patiets beig trasferred to other trusts, this patter of referral requires clarificatio with the cliical goverace committees ad agreemet o the part of the receivig trust. It is ot sufficiet to assume that aother trust will accept patiets without such agreemets. Whe there is a cliical eed for a service o a routie or emergecy basis but this caot be provided locally ad patiets are trasferred elsewhere: a. Formal cotractual agreemets should be i place with ay trust to which patiets are trasferred b. Protocols should be i place describig the arragemets for trasfer c. Trasfer must be i a timely fashio d. Arragemets for appropriate fudig eed to be i place. 6 Stadards for providig a 24-hour itervetioal radiology service

7 Recommedatios for idividual radiologists 1. All doctors are boud to adhere to Geeral Medical Coucil (GMC) guidace ad must comply with the priciples ad values set out i GMC Good Medical Practice. 13 Whe a radiologist who is desigated to be o call is cosulted about a patiet, it is icumbet o that idividual to advise the cliical team appropriately, eve if they are uable to carry out the requested examiatio/procedure themselves. This may iclude advice o alterative imagig/treatmet or trasfer to the agreed alterative provider. 2. Radiologists should ot ormally carry out procedures with which they are ufamiliar. 1,12 Previous guidace from The Royal College of Radiologists (RCR) has idicated that a radiologist should ot carry out, at ight, a ivestigatio or treatmet that they do ot carry out durig the day. 15 If a service is required o a reasoably regular basis the idividual radiologists must maitai the ecessary skills. Ievitably, there will be a risk-beefit aalysis i ay idividual case. The risks of trasfer of the patiet, the presece or absece of ay alterative therapies, ad the experiece of the radiologist will all eed to be take ito accout. If it is agreed amog all the doctors ivolved that because of difficulties, or dager of trasfer or delay, it is i the best iterests of the patiet to be treated by a less experieced radiologist locally, the situatio should be made clear to the patiet (ad/or their relatives if appropriate) ad iformed coset obtaied. 3. Radiologists should recogise that ad-hoc o call rotas are ot i the best iterest of patiets. 14 This form of service provisio is usatisfactory ad may coceal a lack of safe, robust ad reliable service provisio. Formal itervetioal radiology rotas should be supported by appropriate ursig ad radiographic staff. There must be a safe eviromet for performig the procedure, icludig patiet moitorig ad aaesthetic help whe required together with liaiso with the appropriate cliical team. 4. It is the duty of the radiologist to report ay risk maagemet cocers to the trust s cliical goverace committee. 14 This applies whe a radiologist has cocers regardig ay aspect of the provisio of the radiology service. Stadards for providig a 24-hour itervetioal radiology service 7

8 Implemetatio of stadards Departmetal leads should esure the followig. 1. Local agreemet is reached amog radiologists i cliical departmets about what services are provided o call. 14 Discussio about maiteace of ad defiitio of what costitutes core radiological skills amog local radiologists ad how these may be maitaied should take place. Attedace at relevat cotiuig medical educatio (CME) courses such as those provided by the British Society of Itervetioal Radiology ad the RCR is advisable ad it may be ecessary to update practical skills by spedig time i larger departmets. 2. There is agreemet with cliicias o treatmet/alterative imagig pathways whe a particular aspect of the imagig/itervetioal service is ot available. 3. There is a mechaism for iformatio to be available to cliicias o a daily/weekly basis about whe services are/are ot available. 4. Formal cotracts exist with other trusts to which patiets are trasferred for imagig or itervetio. 5. Locally agreed protocols ad/or guidelies for referral for emergecy imagig/itervetio have the potetial to reduce cofusio ad/ or disagreemet i idividual cases. These protocols should be evidece-based ad have bee agreed with the local cliical goverace committee ad the relevat cliical teams. 6. Idividual radiologists, i cojuctio with cliical leads or their appraiser, should keep their rage of skills ad routie practice uder review, with the aim of balacig subspecialty expertise with the maiteace of core skills eeded to provide a trustwide emergecy radiology service (see 1 above). 8 Stadards for providig a 24-hour itervetioal radiology service

9 Models of safe itervetioal radiology provisio Itervetioal radiology is a small specialty ; i other words, there is isufficiet elective work i may hospitals to support the employmet of sufficiet itervetioal radiologists to provide a safe itervetioal radiology service durig or outside workig hours. The same problem pertais i may other specialties such as cardiothoracic surgery, itervetioal cardiology, eurosurgery, itesive care ad so o. For these specialties, cetralisatio or etworkig have bee the favoured solutios There is o sigle solutio for provisio of 24-hour cover, as geographical cosideratios may come ito play. Collaboratio ca occur i a variety of local, sub-regioal, regioal or supra-regioal forms. Whe cosiderig provisio of safe itervetioal radiology services, there are three potetial models of service provisio (Table 2). Table 2. Models for providig itervetioal radiology services Model Advatages Drawbacks Idividual cetres could each provide a safe itervetioal radiology service. Several cetres could collaborate to develop a etwork to provide a safe itervetioal radiology service. a. Patiet moves b. Itervetioal radiology moves Hub ad spoke arragemet: Large specialist cetres could provide services for a regio o a full- or part-time basis. Maitais the status quo i the short term. Provides local service. Utilises existig staff ad facilities across several sites. Ecoomy of scale of both staff ad equipmet. Simplifies provisio of a robust resiliet service i ad out of hours. Depedig o the model, allows maiteace ad developmet of skills for itervetioal radiologists workig i the periphery. It has bee recommeded that doctors providig a cosultat-delivered service should ot be o call o a rota more oerous tha 1:6. 20 This may ot be achievable or cost-effective. Depedig o the model either doctors or patiets trasfer. Doctors might have to provide cover for several hospitals. Most doctors prefer to work i familiar surroudigs where they uderstad the operatioal systems ad kow the equipmet ad staff. If the level of care was equivalet, most patiets would prefer to be treated locally. A additioal possibility is for services to be developed o a regioal basis ad provided from large cetres with doctors travellig to acute trusts for o-emergecy ad mior procedures but patiets comig to the cetre for emergecy ad complex procedures before returig to their local hospital to covalesce. I the cotext of a small service, this would improve provisio of a itervetioal radiology service durig periods of leave. Approved by the Board of the Faculty of Cliical Radiology 2 March 2008 Stadards for providig a 24-hour itervetioal radiology service 9

10 Refereces 1. The Royal College of Radiologists. Stadards i vascular radiology, 2d editio. Lodo: The Royal College of Radiologists, West Yorkshire Chief Executive Forum ad Strategic Health Authority. Itervetioal Radiology i North ad West Yorkshire. Leeds: West Yorkshire Chief Executive Forum ad Strategic Health Authority; Overview of Itervetioal Practice i the UK. The Royal College of Radiologists, Update of itervetioal radiology services i the Uited Kigdom The Royal College of Radiologists, cotet.aspx?pageid= Natioal Cofidetial Equiry ito Patiet Outcome ad Death. Abdomial Aortic Aeurysm: A service i eed of surgery? Lodo: NCEPOD, Natioal Cofidetial Equiry ito Patiet Outcome ad Death. Trauma: Who cares? Lodo: NCEPOD, Natioal Cofidetial Equiry ito Patiet Outcome ad Death. Emergecy Admissios: A jourey i the right directio? Lodo: NCEPOD, Healthcare Commissio. Ivestigatio ito 10 materal deaths at, or followig delivery at, Northwick Park Hospital, North West Lodo Hospitals NHS Trust, betwee April 2002 ad April Lodo: Healthcare Commissio, uk/_db/_documets/northwick_tagged.pdf 9. The role of emergecy ad elective itervetioal radiology i postpartum haemorrhage RCOG Good Practice No. 6 Jue Natioal Cofidetial Equiry ito Perioperative Deaths. Itervetioal Vascular Radiology ad Itervetioal Neurovascular Radiology. A Report of the Natioal Cofidetial Equiry ito Perioperative Deaths. Lodo: NCEPOD, The Royal College of Radiologists. Safe Sedatio, Aalgesia ad Aaesthesia withi the Radiology Departmet. Lodo: The Royal College of Radiologists, The Royal College of Radiologists, The Royal College of Nursig. Guidelies for Nursig Care i Itervetioal Radiology: The roles of the registered urse ad ursig support. Lodo: The Royal College of Radiologists, Geeral Medical Coucil. Good Medical Practice. Lodo: GMC, The Royal College of Radiologists. Advice from the Royal College of Radiologists Cocerig Traiig for Carotid Artery Stetig (CAS). Lodo: The Royal College of Radiologists, The Royal College of Radiologists. Advice to cliical radiology members ad fellows with regard to out of hours workig. Lodo: The Royal College of Radiologists, Cassar K, Godde DJ, Duca JL. Commuity mortality after ruptured abdomial aortic aeurysm is urelated to the distace from the surgical cetre. Br J Surg 2001; 88: Ham C. Recofigurig acute hospitals i Eglad. BMJ 2006; 333: Savig hospitals costs lives. Istitute for Public Policy Research December asp?id=2467&fid= The Report of the Natioal Leadership Network Local Hospitals Project. Stregtheig Local Services: The Future of the Acute Hospital. Lodo: Natioal Leadership Network, StregtheigLocalServicesMai pdf 20. The Vascular Society of Great Britai ad Irelad. The provisio of emergecy vascular services Lodo: The Vascular Society of Great Britai ad Irelad, Stadards for providig a 24-hour itervetioal radiology service

11 Appedix 1. Safe itervetioal radiology service provisio The items below idetify the elemets of a safe itervetioal radiology service. It is assumed that a departmet will be appropriately staffed for the safe performace of itervetioal procedures, icludig the availability of traied radiographers ad radiology urses. Vascular diagosis ad itervetio Arterial diagosis a. Iterpretatio of emergecy CT, MR ad ultrasoud for the detectio of vascular pathology. b. Meseteric agiography. c. Trauma agiography. d. Peripheral agiography. Arterial itervetio a. Embolisatio of haemorrhage: GI tract, uriary tract, trauma, brochial, obstetric. b. Maagemet of acute arterial ischaemia: peripheral, real, visceral by agioplasty stetig thrombolysis ad thrombus aspiratio. c. Use of stet grafts for arterial/aortic rupture. d. Stetig ad stet graftig for the complicatios of Type B aortic dissectio. Veous itervetio a. Isertio of IVC filter. b. Mechaical pulmoary thrombectomy. c. Thrombolysis for phlegmasia caerulia doles ad massive ilio femoral DVT. d. Haemodialysis access: cetral veous catheter (CVC) fistula thrombolysis ad thrombectomy.* e. TIPS for variceal haemorrhage.** No-vascular diagosis ad itervetio May of the skills required i this area are core radiological skills ad departmets should esure that there are sufficiet umbers of radiologists to provide these services i ad out of hours. a. Geeral: image-guided draiage of abscess.*** b. Urological: ephrostomy to drai ifected PC system, isertio of suprapubic catheter.*** c. Hepatobiliary: percutaeous draiage of ifected biliary tree.*** d. Gastroitestial: coloic stetig.*** * Fistula salvage is ot required as a out-of-hours itervetio but may occasioally be required over weekeds ad bak holidays. ** It is recogised that eve i large cetres ucommo procedures may ot be performed by all itervetioal radiologists hece such itervetios may ot be available 24/7. *** It would be rare for these procedures to be required at ight-time but they may be required urgetly durig the daytime at weekeds. Stadards for providig a 24-hour itervetioal radiology service 11

12 Appedix 2. Audit template Assessmet of a departmet s provisio of all aspects of a 24-hour itervetioal radiology service The audit template ca also be dowloaded from Backgroud The demad for all types of radiological imagig ad itervetio o a 24-hour, seve day a week basis has icreased sigificatly i recet years. The term 24 hour radiological imagig services applies equally to elective ad acute services. Itervetioal techiques are ow at the forefrot of maagemet of may life-threateig emergecies. Every acute trust has a duty to esure that there are formal arragemets to secure provisio of elective ad emergecy itervetioal radiology services.1 The Cycle The stadard The itervetioal radiology service should be formally available 24 hours a day, every day of the year. Service is formally supported by a o-call rota for a amed idividual for each of the followig groups: cosultat radiologist, radiographer, itervetioal radiology urse, aaesthetist whe appropriate. Diagostic imagig support such as CT is formally available 24 hours a day, every day of the year. Facilities ad cosumables are available for each of the services listed: Target Vascular: arterial diagosis, arterial itervetio, veous itervetio No-vascular: geeral, urological, biliary. 100% compliace i all areas. Assess local practice: The idicator(s) Affirmative aswer to each questio. Data items to be collected Questioaire to be completed for each aspect of the service; that is, arterial diagosis, arterial itervetio, veous itervetio, geeral, urological, biliary. Suggestios for chage if target ot met Ay deficiecy i service provisio should be brought to the attetio of the trust maagemet. Whe ot all services are available locally, departmetal leads should esure that: There is agreemet with cliicias o alterative maagemet pathways There is a mechaism for iformatio to be available to cliicias about whe services are ot available Formal cotracts exist with other trusts to which patiets are trasferred for itervetio Locally agreed protocols for referral for emergecy itervetio have the potetial to reduce cofusio i idividual cases. These protocols should be evidece-based ad agreed with relevat cliical teams Idividual radiologists should keep their rage of skills ad routie practice uder review, with the aim of balacig subspecialty expertise with the maiteace of core skills eeded to provide a trust-wide emergecy radiology service. Resources Itervetioal imagig lead oe hour to complete questioaire ad write up report ad checklist for safe IR provisio. 12 Stadards for providig a 24-hour itervetioal radiology service

13 Appedix 3. Checklist for safe IR service provisio Performig this simple audit will quickly idetify whether your IR service is safe. This should be performed for each of the services specified i Appedix Service is formally available 24 hours day every day of the year 2. If the aswer to 1 is NO, is the service formally covered uder cotract with aother trust? Yes go to Q3 No go to Q2 Yes No go to Q3 3. Service is formally supported by o-call rota for a amed idividual for each of the followig groups Cosultat radiologist Radiographer Itervetioal radiology urse Aaesthetist whe appropriate 4. Diagostic imagig support such as CT is formally available 24 hours day every day of the year 5. Facilities ad cosumables are available for each of the services listed Yes No Yes No Yes No Yes No Yes No Yes No Ay deficiecies idetified i itervetioal radiology service provisio should be ackowledged ad acted upo i accordace with the stadards provided above. Stadards for providig a 24-hour itervetioal radiology service 13

14 The Royal College of Radiologists 38 Portlad Place Lodo W1B 1JQ Tel +44 (0) Fax +44 (0) URL A Charity registered with the Charity Commissio No Citatio details: The Royal College of Radiologists. Stadards for providig a 24-hour itervetioal radiology service. Lodo: The Royal College of Radiologists, ISBN: Ref No. BFCR(08)13 The Royal College of Radiologists, September 2008 For permissio to reproduce ay of the cotet cotaied herei, please permissios@rcr.ac.uk This material has bee produced by The Royal College of Radiologists (RCR) for use iterally withi the Natioal Health Service i the Uited Kigdom. It is provided for use by appropriately qualified professioals, ad the makig of ay decisio regardig the applicability ad suitability of the material i ay particular circumstace is subject to the user s professioal judgemet. While every reasoable care has bee take to esure the accuracy of the material, RCR caot accept ay resposibility for ay actio take, or ot take, o the basis of it. As publisher, RCR shall ot be liable to ay perso for ay loss or damage, which may arise from the use of ay of the material. The RCR does ot exclude or limit liability for death or persoal ijury to the extet oly that the same arises as a result of the egligece of RCR, its employees, Officers, members ad Fellows, or ay other perso cotributig to the formulatio of the material. Desig by iov8 graphic desig: Prited by Gallpe Colour Prit. members 10 o-members 15