Efficacy, utility, and validity in Computed Tomography head reporting by radiographers

Introduction: Demand for Computed Tomography (CT) head imaging has increased exponentially within the National Health Service (NHS) coinciding with a limited consultant radiologist workforce, resulting in time-critical CT reporting delays for patients. The safety and effectiveness of the NHS improvement initiative increasing reporting capacity with radiographers is not yet established. Aim: To establish the diagnostic accuracy (efficacy) of trained radiographers reporting CT head examinations; their role in the patient pathway (clinical utility); beneficial outcomes of radiographers’ reports (validity); and an economic assessment of the role. Methods: A literature review using validated critique frameworks assessing methodological quality (QUADAS-2, CASP, CHEERS) and reporting (STARD, StaRI) of radiographers reporting CT head examinations studies established the ‘knowledge gap’ in evidence and requirement for research rigour. A further literature review identified an efficacy framework to structure the pragmatic mixedmethod research strategy. Seven studies assessed diagnostic accuracy, radiographers’ roles within the NHS, and economic evaluation, against the same frameworks to demonstrate research rigour. Results: Radiographers trained to report CT head scans demonstrated an efficacy level (AUC 0.98) equivalent to consultant radiologists. Radiographers communicated actionable reports and advice to multidisciplinary teams aiding clinician’s decisions including medical interventions and surgical referral evidencing clinical utility. Cross-sectional surveys demonstrated radiographers’ scope of practice included all referral pathways of trauma, health screening, disease diagnosis, staging, and monitoring treatment, and patient groups. The role was cost-effective (up to £328,865 per annum, per radiographer) and contributed a cost-benefit, attesting to the validity of the role within the patient pathway and healthcare system. Conclusion: Novel findings evidence trained CT head reporting radiographers’ efficacy is equivalent to radiologists, with beneficial impact for service design and delivery of expanding the workforce safely to potentially reduce reporting delays. An emerging theme from the findings underscores the need for robust study design to generate translational evidence for clinical practice

Developing a framework of quality in radiographic service delivery in Ghana

Aim: The aim of this thesis was to develop a framework of quality in radiographic service delivery in Ghana. This aim was to fit the medico-socio-cultural context of Ghana so as to promote the radiographers with additional knowledge about quality issues in the imaging services and patient care. Methods: Mixed methods were used with a sequential explanatory design under two phases. Phase 1 was a quantitative design which employed participants’ and service perspectives. A patient satisfaction survey (questionnaire) was used to gather data from 90 adult participants who were radiographically examined and who gave voluntary consent. The service perspectives involved the basic quality assurance and quality control procedures: reject film analysis and diagnostic reference levels. Phase 2 was a qualitative design which used semi-structured interviews of six radiographers, six patients and three managers to further explore and explain the quality of service issues identified in Phase 1. Results: A reject film analysis rate of 14.55% was achieved. Diagnostic reference level values of 70 kVp and 18 mAs, and 60 kVp and 13 mAs were used to obtain images of diagnostic quality of postero-anterior (PA) chest for patients above and below average sizes. Diagnostic reference values of 75 kVp and 32 mAs, and 62 kVp and 21 mAs achieved images of diagnostic value of antero-posterior (AP) lumbar spine for patients above and below average sizes. Diagnostic values of 56 kVp and 5 mAs, and 52 kVp and 3 mAs also achieved quality images of AP knee for patients above and below average sizes. Four quality constructs were identified with diagnostic radiographic service provision both locally and nationally. The quality framework was built around the four main constructs: departmental management role, radiography workforce/staff role, quality and safety committee roles, and quality and safety outputs that would help improve efficiency and quality of radiographic service delivery in Ghana and to ensure patient satisfaction with the services delivered to them. Conclusions: The constructs contributed to service delivery theory by developing a unique quality framework that would provide policy-makers and managers a practical understanding of factors that affect quality of radiographic service delivery. Key words: Framework, quality service, reject rates, radiographic service, safety outputs

From bench to bedside : the development of a location indicating nasogastric tube

BackgroundNasogastric tubes are frequently used in clinical practice. Correct placement in the stomach must be verified on passing the tube and before every feed or administration of medicine. Current methods of confirming placement are limited and complications related to incorrect placement are well documented. The need for an easy, safe, reliable bedside method for verifying nasogastric tube placement has been identified.AimTo develop a manufactured prototype of an effective, sensitive and reliable nasogastric tube which self-indicates its position and is ready for clinical investigation in patients.MethodsA pH sensitive redox polymer, vitamin K1, was applied to the tip of 40 hand adapted nasogastric tubes (iteration 1) that were then assessed in pH solutions and clinical samples. Results were used to inform the design of manufactured prototype tubes (iteration 2). A total of 60 iteration 2 tubes were prepared and evaluated in a range of fluids, resected stomach tissue, gastric fluid and sputum. Documentation for regulatory approval of the new device was prepared and the intellectual property protected in preparation for licensing with a commercial partner. A User Network was established to inform the design and development of the device.ResultsA total of 100 prototype tubes were evaluated. One third of iteration 1 prototypes and all of iteration 2 manufactured prototypes, generated a measurable current. Variation in the size and nature of the gastric tissue samples limited definitive conclusions that could be drawn from these experiments, but guided design choices in an iterative manner. However experiments with human gastric fluid demonstrated that, using linear sweep voltammetry, zero current potential gave clearer distinction of pH than amperometry in the desired pH range. Patent protection (granted in Australia, USA and Canada and pending in Europe) of the associated intellectual property and completion of the regulatory approvals process enabled negotiations with a number of companies interested in manufacturing the novel medical device for clinical trials. A User Network was established and a range of communication strategies developed to ensure that the development of the device was informed by current experience of lay and professional users.ConclusionThis thesis documents a translational research study in which understanding of electrochemistry was applied to a current clinical problem generating new knowledge. It was demonstrated that, when a redox polymer is applied to the distal tip of a nasogastric tube, the electrochemical reaction can be measured at the proximal end and assessment of the zero current potential distinguishes fluids of different pH values. New understanding of the reality of user involvement in the development of medical devices was generated and a flexible approach of a User Network is advocated. A commercially manufactured device, with appropriate regulatory approvals was produced ready for clinical trials and patents granted or pending across the globe

Orthogeriatrics

This new open access edition supported by the Fragility Fracture Network aims at giving the widest possible dissemination on fragility fracture (especially hip fracture) management and notably in countries where this expertise is sorely needed. It has been extensively revised and updated by the experts of this network to provide a unique and reliable content in one single volume. Throughout the book, attention is given to the difficult question of how to provide best practice in countries where the discipline of geriatric medicine is not well established and resources for secondary prevention are scarce. The revised and updated chapters on the epidemiology of hip fractures, osteoporosis, sarcopenia, surgery, anaesthesia, medical management of frailty, peri-operative complications, rehabilitation and nursing are supplemented by six new chapters. These include an overview of the multidisciplinary approach to fragility fractures and new contributions on pre-hospital care, treatment in the emergency room, falls prevention, nutrition and systems for audit. The reader will have an exhaustive overview and will gain essential, practical knowledge on how best to manage fractures in elderly patients and how to develop clinical systems that do so reliably

A comparative study evaluating the performance of diagnostic radiography units and protocols for paediatric and adult chest radiography examinations

Purpose: Little is known about the variations in image quality (IQ) and radiation dose for paediatric and adult chest radiography (CXR), between and within hospitals. Large variations in IQ could influence the diagnostic accuracy, and variations in radiation dose could affect the risk to patients. This thesis aims to develop, validate and then use a novel method for comparing IQ and radiation dose for paediatric and adult CXR imaging examinations and report variation between a series of public hospitals. Method: A Figure of Merit (FOM) concept was used for the purposes of comparing IQ and radiation dose, between and within hospitals. Low contrast detail (LCD) detectability, using the CDRAD 2.0 phantom, was utilised as the main method for IQ evaluation. The validity of utilising LCD detectability, using CDRAD 2.0 phantom, for evaluating visual IQ, simulated lesion visibility (LV) and CXR optimisation studies, was investigated. This was done by determining the correlation between the LCD detectability and visual measures of IQ and LV for two lesions with different locations and visibility in the Lungman chest phantom.The CDRAD 2.0 phantom and two anthropomorphic phantoms (adult Lungman and the neonatal Gammex phantom) were used to simulate the chest region. Radiographic acquisitions were conducted on 17 X-ray units located in eight United Kingdom (UK) public hospitals within the North-west of England using their existing CXR protocols. The CDRAD 2.0 phantom was combined with different thicknesses of Polymethyl methacrylate (PMMA) slabs to simulate the chest regions of 5 different age groups: neonate, 1, 5, 10 years and adults. A Lungman phantom, with and without the fat jacket, was used to simulate average and larger sized patients. IQ was evaluated using a number of methods, including: 1) physically, by calculating LCD detectability as represented by an image quality figure inverse (IQFinv) using the CDRAD analyser software; 2) using images acquired from the anthropomorphic phantoms – for this, a relative visual grading analysis (VGA) method was used. Additionally, signal to noise ratios (SNR), contrast to noise ratios (CNR) and conspicuity indices (CI) were calculated for all phantom image data in this study. Incident air karma (IAK) was measured using a solid-state dosimeter. Results: Regarding the validation of utilising LCD detectability for evaluating visual IQ and LV, and CXR optimisation studies, a strong positive correlation (r = 0.91; p < 0.001) was observed between IQFinv and the visual IQ scores from the Lungman phantom. A good correlation was observed between IQFinv and visual LV from the Lungman phantom for both lesions (lesion 1 (with low visibility) (r = 0.79; p < 0.001); lesion 2 (with high visibility) (r =0.68; p < 0.001), respectively). Considerable variation in standard imaging protocols/techniques, radiation dose, IQ and FOM were observed between the hospitals, while within hospital variation was lower. A weak correlation between IQ and radiation dose was observed across most of the age groups studied. Conclusion: A novel method has been established to evaluate and compare IQ and radiation dose between and within hospitals based on an FOM concept. This combines IQ and radiation dose into a single factor and is the first of its kind to reported within the field of medical imaging. It can be confirmed that LCD detectability using the CDRAD 2.0 phantom is valid for evaluating visual IQ and LV and can be of use within routine quality assurance and optimisation studies in digital radiography. Further radiation dose optimisation for the paediatric age groups and adult group, especially in hospitals /X-ray machines with low IQ and high IAK, are required