advanced practice in diagnostic imaging -...

Advanced Practice in Diagnostic Imaging

Nick Woznitza BSc, PgD, PgC, MIR(AP)

Clinical Academic Reporting Radiographer2016 CAMRT Annual General Conference

June 9 – 12, 2016, Halifax, NS

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@xray_nick

Disclosure

• Research Funding: College of Radiographers (UK) & International Society of

Radiographers & Radiographic Technologists

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Overview What is an advanced practitioner?

Why advanced practitioner radiographers?

The path to advanced practice with a journey through the evidence

Challenges and opportunities

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Overview What is an advanced practitioner?

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What 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 2014

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“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.


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“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.


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Core Advanced Practice Domains Expert Practice

Leadership/Service Transformation

Education

Service Evaluation/Research

Higher Level Practice

Critical Thinking

Complex Decision Making

Autonomy

Leadership

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Clinical Expertise

Evidence-based Judgement

Scholarship & Teaching

Clinical Leadership

Overview

Why advanced practitioner radiographers?

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Why Advanced Practitioner Radiographers?

Improved patient care

Radiographers fundamental to the diagnostic pathway

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Overview

The path to advanced practice with a journey through the evidence

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RadiographerSenior

RadiographerAustralia to

UKMSK Clinical

ReportingAdult Chest Reporting

Advanced Practitioner

Research & Service

Evaluation

Consultant Practitioner

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


First practitioner to see image

Limited radiologist support

Radiographer opinion

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Evolution 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 16

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


Radiographer advanced practice established in the UK

Opportunity (of a lifetime) to develop skills

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Evidence 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% spec

Piper 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?

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


New role, new challenges

Established AP team: 4 reporting radiographers, 8 sonographers

Comprehensive service developed

Adult chest X-ray interpretation

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Chest 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 23

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


An Advanced Practitioner?

Expert Practice

Leadership/Service Transformation

Education

Service Evaluation/Research

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Justification 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 exposure

Ionising 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 2000

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Image Acquisition & Quality

Request queries

Assist/mentor junior radiographers & assistant practitioners

Initial interpretation

Plain imaging queries & patient questions

Lead quality audits

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


Chest 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 report

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0.64 0.610.68 0.66

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CC1-RR CC2-RR CC1-CR CC2-CR CC1-CC2

Kap

pa

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isti

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Observers

Observer Agreement: Kappa

p < 0.001 p < 0.001 p < 0.001 p < 0.001 p < 0.001

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Diagnostic 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 radiologists

Royal College of Radiologists and College of Radiographers 2012 31

Diagnostic Accuracy – Figure of Merit

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Observer Peformance

RR CR

Radiologist average performance 0.79 (0.76 – 0.81)

Radiographer average performance 0.83 (0.81 – 0.85)

t = 11.585; p < 0.001

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

RR CR

Lesi

on

Lo

calis

atio

n F

ract

ion

Non-Lesion Localisation Fraction 32

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


Contribution to Patient Care Patient focused care

Rapid rise in workload

Political/economic climate

34Royal College of Radiologists & College of Radiographers 2012; Royal College of Radiologists 2012; Price et al. Radiography 2007;13:18

Contribution to Care: Service Evaluation

Woznitza et al. (2014) Service evaluation at single department

Retrospective interrogation of Radiology Information System

o Efficiency: Waiting Times, Radiographer Reports

o Effectiveness: Report Turnaround Time, Discrepancies

Re-audits in 2015 and 2016

Woznitza et al. Radiography 2014;20:258 35

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2010-11 2011-12 2012-13 2013-14 2014-15 2015-16

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XR CT MRI Activity

Contribution of Advanced Practitioners

3 Consultant Radiologists

6 Consultant Radiologists

4.5 Consultant Radiologists

2013-14 2014-15 2015-16

Contribution to Care: New Services Radiographer-led immediate ED skeletal reporting service

Role for radiographer-led discharge?

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


Consultant 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 service

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Response to Demand: Neonatal Reporting Reporting radiographer interpreting skeletal and adult chest x-rays

Bespoke, intensive training programme

Benefits?

All x-rays reported, next working day

90% by radiographer

Weekly MDT; radiographer deputises for consultant paediatric radiologist

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RadiographerSenior


UKMSK Clinical



Research & Service

Evaluation


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Radiographer

Senior Radiographer

Australia to UK

MSK Clinical Reporting

Adult Chest Reporting


Research & Service

Evaluation


Overview

Challenges and opportunities

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Challenges

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;13:13

Health 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;66:53

Health Promotion: Lung Cancer Prevention: smoking cessation intervention

Risk stratification: patient history & referral

Early diagnosis: LDCT lung cancer screening

48NLST N Eng J Med 2011;365:395; Canadian Partnership Against Cancer 2014; Field et al 2016 Thorax 2016;71:161

Conclusions Advanced radiographer practice improves patient care

Growing evidence base for radiographer advanced practice, including clinical reporting

Radiographer reporting contributes to patient focused radiology service

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Conclusions

“professional guidelines could be changed as a result of popular pressure and published peer-reviewed audit/research”Gibbs Radiography 2013;19:164

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Questions?

[email protected]

@xray_nick

@MedRadJclub

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