TELERADIOLOGY/NIGHTHAWK. IMPACT ON MRTs

Transcription

1 Document or the summary of an District Health Boards TELERADIOLOGY/NIGHTHAWK IMPACT ON MRTs MRTAC 2012 Reviewers: Amy Dunn and Mary Bull

2 EXECUTIVE SUMMARY The introduction of teleradiology has resulted in an increase in the number of scans performed, callouts required per night and hours worked by MRTs. This has cost implications that need to be considered. The increase in callouts specifically between 2200 and 0800 results in a negative impact on the workflow the following day as a result of CT MRTs taking a break. This has further cost and efficiency implications as daytime throughput is compromised. A more considered approach to the impacts the absence of a radiologist has on MRTs and service delivery is required. Efficient workflow, appropriate work practices, support for staff and patient safety have all been impacted on as a result of the lack of locally available radiologist support. The increase in scans performed is felt to be largely as a result of the absence of radiologist screening. The hospital at large needs to be more aware of the implications of teleradiology. It is not as fast, immediate or as user friendly as conventional radiology services in NZ and the IT interface not always as immediate or streamlined as we would ideally like. There are subsequent responsibilities transferred to other staff, particularly medical staff as a result of teleradiology that are not always clearly appreciated or planned for. MRTs are often working in isolation whilst delivering teleradiology services which is a particular safety risk for them and their patients. MRTs do not view teleradiology favourably due largely to the failure to deliberately consider and address the impact this technology has on their work practices and environment. The authors strongly believe that it would be of benefit to have a NZ based Teleradiology service, where on call radiologists(registrars) are shared across more than one DHB overnight. There are good IT systems already in place and a NZ based system would better meet NZ requirements such as registration, familiarity of culture, people and systems, accessibility and timeliness as well as providing a radiologist to be telephoned easily for advice as necessary. Page 2 of 12

3 INTRODUCTION The impact on MRTs of nighthawk / teleradiology needs to be considered prior to implementation in any radiology department. This paper approved by MRTAC, looks at the New Zealand experience so far, opening up discussion and identifying considerations for future best practice. The reviewers collected readily available data from 3 DHBs and further discussed impacts with one other, all (4) of whom have used Teleradiology (ITC) for a number of years, in order to identify impacts on MRTs and service delivery patterns. The paper has been divided into the following broad sections for consideration: The number, distribution and timing of scans performed and the impact this has on MRTs The interaction between MRTs and Doctors that arise as a result of teleradiology Stressors imposed on MRTs Security and Safety issues. DATA COLLECTION Information for this paper has been gathered from Lakes, Hawkes Bay and Bay of Plenty District Health Board radiology departments. Hutt Valley DHB also has Teleradiology and has contributed further insight and confirmation of trends. Lakes DHB has been using the service since 2009, operating every night and for the whole weekend. However, a Lakes radiologist on call has also covered some nights. Hawkes Bay DHB has been using a Teleradiology service provider to report afterhours CT exams since It operates from hours 7 days per week. BOPDHB introduced the service during 2011, every night and including the weekends. Hutt Valley DHB introduced teleradiology in No data has been provided from Hutt DHB however the experience from the this DHB is consistent with the other 3 DHBs. Providers: Lakes DHB is currently in the process of changing its Teleradiology provider from ITC (International Teleradiology Corporation) to IPO (Imaging Partners Online). There is a plan to re-audit after 6 months. The reasons for the change include: A reduction in processing; No reconstructions of images are required to be sent; Page 3 of 12

4 The company is based in Australia and the UK, which provides radiologists that are registered in Australia and New Zealand. There are therefore no issues with IANZ accreditation for the department or the MCNZ; Full and final reports are provided removing the need for double reporting the following day by DHB radiologists. BOPDHB currently use International Teleradiology Company (ITC). Very brief reports are provided and need to be reviewed the next morning by a BOP radiologist, hence double reporting. Hutt Valley DHB does not use Nighthawk but has used PRP (PRP Diagnostic Imaging) in Sydney and more recently, I-MED in Australia with Teleradiology reporting. All of these practices come into question with IANZ accreditation and a lot of support documentation has to be given to comply with DHB protocols and IANZ requirements. LAKES DHB At Lakes DHB, an audit was done using data gathered between December 2009 and June 2010, comparing demand between the previous scenario of (still) having a radiologist on call for CT (DHB) and the more recent use of Teleradiology (ITC or International Teleradiology Corporation) and its impact on MRTs. The number of call outs & the number of patients (from 14 Dec June 2010) DHB ITC Number of nights on call Number of nights call out made Percentage of nights called out 57% 76% number of nights on call number of nights call out made DHB ITC Conclusion: MRTs are 20% more likely to be called out when on call with ITC (as opposed to through the use of an in-house radiologist). Page 4 of 12

5 Length and timing of callouts DHB ITC Ave length of each callout 1.5hrs 1.6hrs Ave number of hours per night/period 2.7hrs 3.5hrs % of calls between hrs 8% 27% Requiring 9 hour break 7% 21% Conclusion: The length of individual callouts increased by 13% with ITC The MRT is 3 times more likely to get called between when on ITC call, and as a result, the requirement to provide a 9 hour break increased 3 fold when on call with ITC. Grouping of patients DHB ITC Ave number of calls per night / period Ave number of pts per night / period Conclusion: On call with ITC results in both an increase in the number of calls and the number of patients being scanned. BAY OF PLENTY DHB The table below demonstrates the increase in the number of overnight call outs ( ) before and after the implementation of Teleradiology at BOPDHB. CT call outs Pre Teleradiology Month (2011) No. of call outs Total hrs worked 9hr cover req (hrs) during the day. March April May June (until 26th) Total (4 months) Average(4months) Post Teleradiology Month No. of call outs Total hrs worked 9hr cover req (hrs) during the day. June (from 27th) July Page 5 of 12

6 August September Total (3months) Average(3months) Review of Tauranga Hospital MRT CT Call January 2011 to February 2012 (post telerad in red) Month All Call outs Patients Call outs Average Hrs per Patient Short Change Days Short Change Hours i.e. short staffed Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Total number of callouts, those performed overnight and number of patients between January 2011 and February 2012 at BOP DHB. ITC commenced July all callouts number of patients callouts overnight Page 6 of 12

7 NUMBER EXAMS Total number of short change days and hours short staffed in the department the day after overnight teleradiology call, January 2011 and February 2012 at BOP DHB. ITC commenced July short change days hours short staffed HAWKES BAY DHB Hours of Teleradiology operation at Hawkes Bay are between days per week. The number of scans performed per month since 2009 are tabled below. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Av CT TELERAD NUMBERS Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec MONTH Page 7 of 12

8 THE NUMBER, DISTRIBUTION AND TIMING OF SCANS PERFORMED The data confirms an increase in the number of scans, and as a result callouts performed, following the introduction of Teleradiology. In Lakes the average number of patients scanned increased from 2.7 to 3.1 per night and the number of nights MRTs were called back increased by 25%. The number of scans performed each night also increased from 1.8 to 2.2 scans per night. In BOPDHB the number of patients scanned rose from an average of 83 per month, to 106 and the number of call-backs increased from an average of 8.5 to 16.4 per month. In Hawkes Bay the number of scans performed increased by between 18% and 24% per month. The different introduction dates all saw a similar increase in demand, suggesting the introduction of the technology itself is causative of the increase. The reviewers also noted the impact external factors had on demand across all NZ departments, such as the 6 hour ED target. However the timing of the introduction of teleradiology saw a directly correlated increase in demand, regardless of the timing or degree of external demand. It is possible that the number of patents requiring urgent CT scans coincidentally increased at the same time as Teleradiology introduction; however the reviewers saw no evidence to support this and given the similar trend across departments in different parts of NZ, felt it was not a reasonable explanation. Ease of access to CT scanning was a generally accepted factor that did account for the increase. The Lakes DHB data directly suggests that the loss of a radiologist screening requests increases both the number and spread of scans performed due to the loss of the role of the in-house radiologist to discuss and prioritises cases, and to group scans together based on the level of urgency. Data confirms that MRTs are at least 20% more likely to be called out when on call with ITC (as opposed to through the use of an in-house radiologist). All 4 DHBs have confirmed this view. This impacts on MRTs in both number and distribution of call outs. When ITC is in action, the CT MRT is unable to refuse the referring doctors request; that doctor also determines the timing of the scan based on their opinion of urgency. Given the number of doctors referring and the lack of overall screening it is difficult to group patients together, and as a result call outs are more frequent. This impact itself requires consideration; the guidelines in the NZ National Radiation Laboratory C5, version 1.3 Code of Safe Practice state: 4.9 Examinations with the potential for high patient doses, such as CT Examinations, should be carried out only after there has been proper clinical justification for the examination of each individual patient by a radiologist. Page 8 of 12

9 More recently, due to issues surrounding non-radiologist vetting, changes have been made at Lakes so that referrals are required to come from the referring consultant who must call the MRT directly. The previous process for consultants to approve a referral and thereafter any doctor to call the MRT was abandoned as it was found that MRTs could be called to perform scans when the consultant had not been party to making that specific request, rather informal guidelines specific to individual consultants were being used. The average number of hours spent working by the MRT is also increased with Teleradiology. In Lakes, the time spent at work increased from 2.7 to 3.5 hours per night (13%) with ITC and BOPDHB saw an increase from 9.37 hours worked to hours per month. In Lakes the number of nights MRTs were called back increased by 25%. NON CT MRT Impacts In addition, given CT is delivered by an on call service in all the reviewed DHBs, the increase in callouts between 2200 and 0800 resulted negatively on the workflow the following day as a result of CT MRTs taking a break. In Tauranga, the number of short staffed hours per month (i.e. the number of hours during the day shift where staffing numbers were reduced as a result of breaks being taken by the overnight CT MRT on call) doubled from 16 to 32 hours and the number of days per month affected by short staffing rose from 4 to 9. In Lakes, the frequency of MRTs being absent as a result of break provisions increased 3 fold. IT Issues There are frequently long delays in image transfer due to Internet connections and bandwidth issues, requiring the MRT to stay on site longer to ensure adequate image transfer. As there is no standard time for an image to be sent, e.g. a head scan with 50 images could take anything between 6 40 minutes, it is difficult to ascertain if indeed there is a problem (as opposed to simply a time delay) and whether the MRT needs to contact the help desk. There are also problems in sending images as well as request forms adding to time delays. If a problem sending a CT exam is identified, the MRT will have to spend time identifying whether the issue is a RIS/PACS problem, Internet, or Teleradiology problem. This requires the MRT to liaise with both hospital IT support and Teleradiology IT support. In the event a CT cannot be reported the MRTs have to try and contact a local radiologist for assistance. MRTs may also be called back to do further imaging or reconstructions and may be required to re-send data. Page 9 of 12

10 DOCTOR/MRT ISSUES In addition to the workflow issues the lack of an in-house radiologist has caused a number of other issues for MRTs: There have been some concerns/frustrations at the time of a scan with respect to pregnant patients. During normal working hours a request for a pregnant patient requires discussion with a radiologist. The radiologist then approves the examination and suggests limited views if it is appropriate to go ahead. When Teleradiology is in place, any consultant can approve a request for a CT after hours, placing an MRT in a difficult position, unsure if the implications of pregnancy have been taken into account and without further instruction regarding the scan to protect the patient. MRTs feel pressured when the protocol requires contrast and the referring doctor, who is not a radiologist, is unfamiliar with such. The MRT is often relied upon to check blood results to see whether the patient is a suitable candidate for contrast. This may not be appropriate given the MRTs lack of medical training. On occasion, when contrast is requested the doctor may be delayed in getting to radiology to administer contrast / monitor and supervise the patient. STRESSORS IMPOSED ON MRTS AS A RESULT OF TELERADIOLOGY At all the DHBs, requests are sometimes vague and at times made for something that is not appropriate. MRTs find it stressful having to decide what protocol to use if the referring doctor is not a radiologist and thus is understandably unclear of the precise scan required. MRTs may have to make decisions as to oral or no oral contrast, IV or no IV contrast, depending on the clinical details provided. In these situations the MRT is often relying on their own experience and knowledge in the hope that they have made the right choice. MRTs have no mechanism to question referrals or refuse to scan. Those MRTs who seek further information or ask a doctor if they have spoken to a consultant about a scan are often perceived to be obstructive. By contrast, MRTs are quite frequently asked for their opinion regarding a scan ( is there anything you can see? ) by the requesting doctor. MRTs are however not radiologists or Medical Practitioners and find these interactions place them in a difficult position. With teleradiology, the calls are increasingly requested as being required as soon as the decision to have imaging is made e.g. an MRT might get called in for two cases overnight with an hour in between. By contrast when working with a radiologist, an effort is made to bunch the workload together to decrease the number of call-backs. Radiologists as doctors are able to schedule examinations on the basis of medical condition to reduce disruption to staff and improve efficiency. Page 10 of 12

11 Delays and technical breakdowns When there is a delay for whatever reason, it can put extra stress on the MRTs who often carry a feeling of responsibility for the delay in results and the possible effect on care / treatment of the patient. Even when everything is working well, reports can take time to get back to the hospital; more time than had the scan been done closer to the patient. Referrers often forget that the process is not happening close at hand and that the intermediary system causes time delays. They often also dislike the brief nature of some reports. Unfortunately their frustrations can be taken out on the MRTs. In the event that a CT cannot be reported despite the existence of teleradiology, the job of finding a local radiologist to help almost invariably falls to the MRT. It is unpleasant for an MRT to call someone in the middle of the night, especially when they are not on call and so understandably not expecting to be woken As one MRT put it [With Teleradiology] we have put up with so much crap for so long that the crap has just become a normal part of the job. MRTs do not view teleradiology favourably due largely to the failure to deliberately consider and address the impact this technology has on them. SECURITY AND SAFETY Images: MRTs feel uncomfortable about sending patient information overseas and would prefer for it to be New Zealand based. The MRTs concern is in respect of security of information. Personal: As radiology departments are frequently remote from other areas of the hospital, the MRT can be quite isolated. Overnight it can be daunting having to negotiate one s way to the CT area, often when most of the department is plunged into darkness. The time taken after the patient has left whilst sending images is time spent working alone. Emergency departments are often reluctant to release nursing staff to be with the patient who is attending radiology. Security staff have been sent instead of nursing staff on occasion, which from a personal safety perspective is appropriate; however it s not appropriate for the provision of adequate patient care if the patient s condition were to deteriorate while away from ED. Page 11 of 12

12 SUMMARY Teleradiology has significant scope for application in radiology departments around NZ, especially in provincial centres. The introduction of Teleradiology has however had a significant impact on MRTs. Workload has increased considerably without adequate MRT resourcing to assist. It has been only after the event and in the face of over stretched service, that consideration of the workflow and workload implications for MRTs are actively addressed. This may be as a result of the newness of this technology, however where future introduction is planned, these impacts will need to be proactively taken into account. MRTs believe that when it comes to decisions around implementing services such as Teleradiology or Nighthawk, the needs and benefits of other groups have been looked at and met ahead of the MRTs. It is the MRTs who will ultimately enable the service to be provided; however the impact and demands on this particular group resulting from such a dramatic change to the style of service provision are not well understood or taken into account. MRTs are certainly more comfortable with the traditional team consisting of a radiologist/registrar being present at the time of the scan. This provides support and reduces the responsibilities of the MRT around choosing a protocol or contrast-related issues, and removes the pressure to provide opinions. MRTs feel stuck in the middle, unable to make a comment on things that they believe may be inappropriate, yet expected to assist the referring doctors and ensure everything is been done correctly. The referring doctors are also often conflicted: they are not radiologists and therefore unfamiliar with the process required for a CT scan; they are also usually very busy and prioritise (understandably) the need to get back to the ED department. As indicated by Hutt Valley DHB, overseas practices can come into question with IANZ accreditation and MCNZ requirements for reporting. Radiologists need to be registered with the MCNZ. The authors strongly believe that it would be of benefit to have a NZ based Teleradiology service, where on call radiologists are shared across more than one DHB overnight. There are good IT systems already in place and a NZ based system would better meet NZ requirements such as registration, familiarity of culture, people and systems, accessibility and timeliness as well as providing a radiologist to be telephoned easily for advice as necessary. Page 12 of 12