Woznitza, N.

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Canterbury Research and Theses Environment

Advanced Practice in Diagnostic ImagingNick Woznitza BSc, PgD, PgC, MIR(AP)Clinical Academic Reporting Radiographer2016 CAMRT Annual General ConferenceJune 9 – 12, 2016, Halifax, NS1@xray_nickDisclosure• Research Funding: College of Radiographers (UK) & International Society of Radiographers & Radiographic Technologists23Overview What is an advanced practitioner? Why advanced practitioner radiographers? The path to advanced practice with a journey through the evidence Challenges and opportunities4Overview What is an advanced practitioner?5What is an Advanced Practitioner?“Advanced practice in Medical Radiation Technology is defined as a higher level of practice wherein clinical responsibilities routinely exceed the current principal expectations of practice.”Canadian Association of Medical Radiation Technologists 2014“Occurs when a practitioner is regularly performing beyond the core practice boundaries of the profession on a regular basis with appropriate availability of resources, educational underpinning and professional mentorship.”Australia Institute of Radiography 2014“A role, requiring a registered practitioner to have acquired an expert knowledge base, complex decision-making skills and clinical competences for expanded scope of practice, the characteristics of which are shaped by the context in which the individual practices.”Health Education England 20146What is an Advanced Practitioner?“Advanced practice in Medical Radiation Technology is defined as a higher level of practice wherein clinical responsibilities routinely exceed the current principal expectations of practice.”Canadian Association of Medical Radiation Technologists 2014“Occurs when a practitioner is regularly performing beyond the core practice boundaries of the profession on a regular basis with appropriate availability of resources, educational underpinning and professional mentorship.”Australia Institute of Radiography 2014“A role, requiring a registered practitioner to have acquired an expert knowledge base, complex decision-making skills and clinical competences for expanded scope of practice, the characteristics of which are shaped by the context in which the individual practices.Health Education England 20147What is an Advanced Practitioner?“Advanced practice in Medical Radiation Technology is defined as a higher level of practice wherein clinical responsibilities routinely exceed the current principal expectations of practice.”Canadian Association of Medical Radiation Technologists 2014“Occurs when a practitioner is regularly performing beyond the core practice boundaries of the profession on a regular basis with appropriate availability of resources, educational underpinning and professional mentorship.”Australia Institute of Radiography 2014“A role, requiring a registered practitioner to have acquired an expert knowledge base, complex decision-making skills and clinical competences for expanded scope of practice, the characteristics of which are shaped by the context in which the individual practices.Health Education England 20148Core Advanced Practice Domains Expert Practice Leadership/Service Transformation Education Service Evaluation/Research  Higher Level Practice Critical Thinking Complex Decision Making Autonomy Leadership9 Clinical Expertise Evidence-based Judgement Scholarship & Teaching Clinical LeadershipOverview Why advanced practitioner radiographers?10Why Advanced Practitioner Radiographers? Improved patient care  Radiographers fundamental to the diagnostic pathway11Overview The path to advanced practice with a journey through the evidence1213RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant Practitioner14RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant Practitioner First practitioner to see image Limited radiologist support Radiographer opinion15Evolution of Radiographer Image Interpretation Swinburne (1971) “pattern recognition” by trained radiographers Berman et al. (1985) “red dot” for MSK trauma Brealey et al. (2006) excellent accuracy; 81% sensitivity, 95% specificity for “red dot”Swinburne Lancet 1971;297:589; Berman et al. Brit Med J 1985;290:421; Brealey et al. Clin Radiol 2006;61:604 1617RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant Practitioner Radiographer advanced practice established            in the UK Opportunity (of a lifetime) to develop skills18Evidence Base – Skeletal Reporting Piper et al. (2005) Structured exam: 27 radiographers; ~2,700 X-rays; sensitivity 93%, specificity 92% and accuracy 93% Piper et al. (1999)  Multisite clinical evaluation:             10 radiographers; 7,170 reports; accuracy 97% - 99%  Brealey et al. (2005) Meta-analysis provided definitive evidence: 28,900 examinations; 92% sens 97% specPiper et al. Radiography 2014;2:94; Piper et al. 1999 NHS Executive Report; Brealey et al. Clin Radiol 2005;60:232 19 Radiographer advanced practice established            in the UK Opportunity (of a lifetime) to develop skills Was this an advanced practitioner role?2021RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant Practitioner New role, new challenges Established AP team: 4 reporting radiographers, 8 sonographers Comprehensive service developed Adult chest X-ray interpretation22Chest X-rays – Definitive Radiographer Reports Piper et al. (2014) Structured examination: 40 radiographers, 4,000 CXRs; 95% sensitivity & specificity,  89% agreement Woznitza et al. (2014) Clinical audit: 100 cases; 1 radiographer, 3 consultant radiologists; high concordance 92% (Ƙ = 0.83), 96% (Ƙ = 0.91), 96% (Ƙ = 0.91)Piper et al. Radiography 2014;20:94; Woznitza et al. Radiography 2014;20:223 2324RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant PractitionerAn Advanced Practitioner? Expert Practice Leadership/Service Transformation Education Service Evaluation/Research25Justification of Medical Exposures Radiographers act as gatekeepers Legislation in UK regarding medical radiation exposures: IR(ME)R 2000 Canada: Safety Code 35 (2008) & CAR Standards (2000) Referring clinician required to explain clinical benefit, detailed to enable exposureIonising Radiation (Medical Exposure) Regulations 2000 HMSO; Soya & Paterson Brit J Radiol 2008;81:725 ; Safety Code 35 Health Canada 2008; Standards for General Radiography CAR 200026Image Acquisition & Quality Request queries Assist/mentor junior radiographers & assistant practitioners Initial interpretation  Plain imaging queries & patient questions  Lead quality audits2728RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant PractitionerChest X-rays – Agreement of Experts Random stratified sample of CXRs Two independent expert consultant chest radiologists, blinded to clinical report Reports compared for agreement: Kappa [Ƙ ] and McNemar statistics193 cases included; 79 (41%) normal clinical report290.64 0.610.68 0.660.520.00.10.20.30.40.50.60.70.80.91.0CC1-RR CC2-RR CC1-CR CC2-CR CC1-CC2Kappa StatisticObserversObserver Agreement: Kappap < 0.001 p < 0.001 p < 0.001 p < 0.001 p < 0.00130Diagnostic Accuracy – Adult Chest X-rays 10 consultant radiologists & 11 reporting radiographers 106 adult chest x-rays with robust reference standard diagnosis Normal reporting conditions Reporting radiographers must be comparable to consultant radiologistsRoyal College of Radiologists and College of Radiographers 2012 31Diagnostic Accuracy – Figure of Merit00.10.20.30.40.50.60.70.80.91Observer PeformanceRR CRRadiologist average performance 0.79 (0.76 – 0.81)Radiographer average performance 0.83 (0.81 – 0.85)t = 11.585; p < 0.0010.1                  0.2                   0.3 0.4 0.5                   0.6                   0.7                   0.8                  0.9 1R CRLesion Localisation FractionNon-Lesion Localisation Fraction 3233RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant PractitionerContribution to Patient Care Patient focused care Rapid rise in workload Political/economic climate34Royal College of Radiologists & College of Radiographers 2012; Royal College of Radiologists 2012; Price et al. Radiography 2007;13:18Contribution to Care: Service EvaluationWoznitza et al. (2014) Service evaluation at single department Retrospective interrogation of Radiology Information Systemo Efficiency: Waiting Times, Radiographer Reportso Effectiveness: Report Turnaround Time, Discrepancies Re-audits in 2015 and 2016Woznitza et al. Radiography 2014;20:258 3536020000400006000080000100000120000140000160000180000010203040506070802010-11 2011-12 2012-13 2013-14 2014-15 2015-16DEPARTMENT ACTIVITYREPORTING TIME (HOURS)XR CT MRI ActivityContribution of Advanced Practitioners3 Consultant Radiologists6 Consultant Radiologists4.5 Consultant Radiologists2013-14 2014-15 2015-16Contribution to Care: New Services Radiographer-led immediate ED skeletal reporting service Role for radiographer-led discharge?3839RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant PractitionerConsultant Practitioner? Level 1 tertiary referral neonatal unit 14,000 cot days per annum ~3,000 x-rays annually 2010: Not reported by radiology department Implement radiographer–led plain imaging reporting service40Response to Demand: Neonatal Reporting Reporting radiographer interpreting skeletal and adult chest x-rays Bespoke, intensive training programmeBenefits? All x-rays reported, next working day 90% by radiographer Weekly MDT; radiographer deputises for consultant paediatric radiologist4142RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant Practitioner43RadiographerSenior RadiographerAustralia to UKMSK Clinical ReportingAdult Chest ReportingAdvanced PractitionerResearch & Service EvaluationConsultant PractitionerOverview Challenges and opportunities44Challenges No defined pathway/characteristics Integration Communication What are the opportunities?Where there is need!Emergency Department CIHI (2012) ED capacity an issue; overcrowding, long waits, possibility of poor care Are you making best use of the MDT? Radiographer preliminary clinical evaluation Radiographer-led discharge?46Canadian Institute for Health Information 2012; McConnell et al. Radiography 2012;18:184; Snaith Radiography 2007;13:13Health Promotion: Lung Cancer Lung cancer has a significant impact on health Most common cause of cancer death Poor 5 year survival: Canada 17%; UK 10% Byrne et al (2014): 48 day wait from abnormal imaging to biopsy for lung cancer role for AP rads to decrease waiting times?47Canadian Cancer Society’s Advisory Committee on Cancer Statistics 2015; Office of National Statistics (UK) 2016;  Cancer Research UK 2015; Byrne et al. Can Assoc Radiol J 2015;66:53Health Promotion: Lung Cancer Prevention: smoking cessation intervention Risk stratification: patient history & referral Early diagnosis: LDCT lung cancer screening48NLST N Eng J Med 2011;365:395; Canadian Partnership Against Cancer 2014; Field et al 2016 Thorax 2016;71:161Conclusions Advanced radiographer practice improves patient care Growing evidence base for radiographer advanced practice, including clinical reporting Radiographer reporting contributes to patient focused radiology service49Conclusions“professional guidelines could be changed as a result of popular pressure and published peer-reviewed audit/research”Gibbs Radiography 2013;19:16450Questions?nicholas.woznitza@nhs.net@xray_nick@MedRadJclub

Advanced practice in diagnostic imaging

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Advanced practice in diagnostic imaging

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