Transcript How to make the best use of clinical radiology services

How to make the best use of
clinical radiology services
Roger Laitt
Clinical Director Radiology
Salford Royal Hospitals Foundation Trust
• Guidelines
– Making the best use of clinical radiology
services 6th Ed 2007 – RCR
• Clinico-radiological dialogue
Guidelines
• A useful investigation is one in which the
result, positive or negative, will inform
clinical management and/or add
confidence to the clinician’s diagnosis
• A significant number of investigations do
not fulfill these aims and with plain films
and CT may add unecessarily to patient
irradiation
• This becomes more important with access to more
complex investigations that use increased resource AND
RADIATION
Diagnostic
Typical dose
mSv
Equivalent CXRs
Period of
background rad.
Limbs and joints
<0.01
<0.5
<1.5 days
CXR
0.02
1
3 days
Lumbar Spine
1.0
50
5 months
Hip
0.4
20
2 months
Barium meal
2.6
130
15 months
CT Brain
2
100
10 months
CT abdo/pelvis
10
500
4.5 years
• Low dose examinations are most common
• Infrequent high dose studies make the
major contribution to collective population
dose
• CT use rising and contributes at least half
the collective dose from all X-ray exams
• REQUESTS FOR CT MUST BE
JUSTIFIED
Chief causes of misuse of Radiology
• Repeating investigations that have already been done –
HAS IT BEEN DONE ALREADY?
• Investigations that are unlikely to affect patient
management – DO I NEED IT?
• Investigating too early – DO I NEED IT NOW?
• Doing the wrong investigation – IS THIS THE BEST
INVESTIGATION?
• Failing to provide adequate clinical information – HAVE I
EXPLAINED THE PROBLEM?
• Over investigating – ARE THEY ALL NEEDED?
Imaging techniques
• Computed tomography
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Multidetector (spiral) technology
Large volume of data from a single breath hold
Can review images in multiple planes
Opened up many new applications
High radiation dose
Consider MRI or US in thinner patients and children
• Applications
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Intracranial disorders particularly if acute + angiography
Chest and abdomen
CT Urography replacing IVUs
Cancer staging
As guide for biopsies and drainage procedures
• Magnetic Resonance Imaging
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No radiation and so should be used in preference to MR if similar yield
All requests require justification
Increasingly used as a surrogate for clinical exam.
Safety in first trimester unknown
Recognised contraindications
• Metallic FB in orbits
• Pacemakers
• Some implanted devices
• Applications
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Neuroimaging including Spines
MSK
Liver
Pelvis
Angiography
• Ultrasound
– Safe
– Cheap
– Accessible
• Same day service
– Operator dependant
– Compliments other modalities
– First line test
• Applications
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Obstetrics
Gynaecology
Abdominal
MSK
Vascular
Interventional
CLINICAL SCENARIOS
• NECK PAIN AND BRACHALGIA
– MRI
– Plain films only indicated in specific
circumstances
• CHRONIC BACK PAIN
– MRI
– Plain films only indicated in specific
circumstances
• SUSPECTED OSTEOPOROTIC COLLAPSE
– Lateral XR thoracic and lumbar spine
– MRI distinguishes between acute and chronic
collapse. Important with vertebroplasty
– DEXA
• Painful shoulder ? Impingement/rotator cuff
– Ultrasound
– MRI
– Plain films only in special circumstances
• Transient ischaemic attack
– MRI within 24 hours (50%) – NICE 2008
– Duplex or non invasive angiography (80%)
within 24 hours for those at high risk
– Surgery within 2 weeks where appropriate
• Dementia or memory disorders
– MRI – NICE 2007
– CT can be used
• Suspected ureteric colic
– CT urography, low dose technique
– IVU only indicated when CT not possible
– US + KUB, pregnancy
• Proven UTI in children
– US
• AXR not indicated as calculi rare
• Expert US key investigation
– Nuclear Medicine
• Acute or chronic
• DMSA and MAG3
• Palpable abdominal mass
– US
– CT if US inconclusive or with staging
– AXR
• Rarely of value
CONCLUSIONS
• Role of imaging is changing
• Increasing availability changes way imaging used
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Partly target driven
NICATS
Defensive
Surrogate for clinical examination
• Traditional pathways challenged
– Role of plain films needs to be understood
• Radiology departments important at interface between Primary and
Secondary care
• Guidelines important but they are only a guide
• Encourages good practice and avoids unnecessary waste of
resource and ionising radiation exposure
• COMMUNICATION IS EVERTHING