Benchmarking in radiology: apples and oranges?

Free AccessLetter to the EditorThe importance of safe working legislation for neuroradiologistsSanjeev Ramachandran, Robert William Foley and Harish VenkateshSanjeev RamachandranDepartment of Radiology, University Hospitals of Leicester NHS Trust, Leicester, UKSearch for more papers by this author, Robert William FoleyDepartment of Radiology, University Hospitals Bristol NHS Foundation Trust, Bristol, UKSearch for more papers by this author and Harish VenkateshDepartment of Anaesthetics, Royal Berkshire NHS Foundation Trust, Reading, UKSearch for more papers by this authorPublished Online:11 Oct 2018https://doi.org/10.1259/bjr.20180583SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations AboutWe read with interest the parallels drawn between the working patters of air-traffic controllers and neuroradiologists by Reicher and colleagues.1 We support their conclusion that more robust legislation should be established to allow safer working practices by neuroradiologists, in line with the aviation industry. From our observations, we present two further factors that underline the importance of reducing fatigue-related errors from unsafe working patterns amongst neuroradiologists.Firstly, the on-call burden of neuroradiologists in the United Kingdom is particularly onerous. Patient load and complexity from tertiary centres with large neurosurgical, stroke, neurology and neurocritical care departments mean that neuroradiologists need to be called upon frequently overnight. For example, the increasing use of the National Institute of Health and Care Excellence (NICE) guidelines on the role of mechanical thrombectomy in the management of stroke will increase demand for out-of-hours input from neuroradiologists. Sleep deprivation from the workload and frequency of such shifts will significantly affect performance.2 Secondly, in addition to spending time performing cognitively demanding tasks using data from computer screens, neuroradiologists often perform a range of practical procedures (such as myelography and angiographic procedures), train specialty registrars and lead clinico-radiological meetings. Indeed, a report on safe working by the British Society of Neuroradiologists (BSNR) has outlined the increasing time commitments required for these duties.3 This variety in work schedules may be a key difference between air-traffic controllers and neuroradiologists. Whilst the effect of task shifting on cognitive and motor performance is not entirely clear, it is reasonable to conclude that adequate rest periods may improve performances across the board.To conclude, the aforementioned report on safe working by the BSNR reflects Reicher and colleagues’ concerns but has not provided recommendations on breaks, reporting periods and shift patterns. We advocate that the publication of specific guidance on what is deemed safe practice is an important first step towards formulating adequate, specialty-specific legislation. However, stakeholders will need to be aware of the challenges in implementing such legislation in the context of ever-increasing demand from a finite pool of neuroradiologists, reflected in the recent workforce planning report by the Royal College of Radiologists.4REFERENCES1. Reicher J, Currie S, Birchall D. Safety of working patterns among UK neuroradiologists: what can we learn from the aviation industry and cognitive science? Br J Radiol 2018; 91: 20170284. doi: https://doi.org/10.1259/bjr.20170284 Link ISI, Google Scholar2. Rohatgi S, Hanna TN, Sliker CW, Abbott RM, Nicola R. After-hours radiology: challenges and strategies for the radiologist. AJR Am J Roentgenol 2015; 205: 956–61. doi: https://doi.org/10.2214/AJR.15.14605 Crossref Medline ISI, Google Scholar3. British Society of Neuroradiologists. Safe Neuroradiology. United Kingdom: The British Institute of Radiology.; 2012. Google Scholar4. The Royal College of Radiologists. Information submitted to Health Education England workforce planning and education and commissioning round - 2015/16. United Kingdom: The British Institute of Radiology.; 2016. Google ScholarResponse to letter: “The importance of safe working legislation for neuroradiologists” by Ramachandran et al1John Reicher, BA, BM, BCh, MRCP, 1Daniel Birchall, MA, MB, BChir, MRCP, FRCR, MD MBA and 2Stuart Currie, FRCR, PhD1Department of Neuroradiology, Newcastle Upon Tyne Hospitals, Newcastle Upon Tyne, UK2Department of Radiology, Leeds General Infirmary, Leeds, UKThe authors would like to thank Ramachandran and colleagues for their interesting contribution.We wholeheartedly concur with their conclusions in relation to the pressing need for official determination of guidelines for safe reporting practice. We support their points regarding the additional challenges posed by neuroradiologists’ varied workload and increasingly onerous on-call commitments.They hint that non-radiologist stakeholders might take a different view, demanding ever-greater reporting output from the limited workforce. This emphasises the necessity of developing and entrenching safe working practices in an increasingly pressurised working environment. Previous article FiguresReferencesRelatedDetails Volume 91, Issue 1091November 2018 © 2018 The Authors. Published by the British Institute of Radiology History ReceivedJune 30,2018AcceptedJuly 24,2018Published onlineOctober 11,2018 Metrics Download PDF

IntroductionAnkle trauma is a frequent presentation to the emergency department (ED) and poses a significant demand on radiology services. Efficient triage is essential to identify patients requiring urgent imaging, optimising resources, reducing waiting times, and minimising unnecessary radiation exposure. Injuries range from soft tissue damage to fractures of the distal tibia, fibula, or malleoli. Not all ankle injuries require immediate imaging, and clinical decision-making tools can guide the use of radiographs. The Ottawa Ankle Rules (OAR) are a validated tool, endorsed by the Royal College of Radiologists (RCR), designed to identify ankle injuries requiring radiographs. Imaging is indicated if the patient is unable to bear weight both immediately after injury and during examination, or if there is bone tenderness along the distal six centimetres of the posterior edge of the tibia or fibula, or over the lateral or medial malleoli. Adherence to the OAR has been shown to reduce unnecessary imaging while maintaining high sensitivity for fractures.MethodsA two-cycle retrospective review was conducted of patients presenting with traumatic ankle injuries who underwent radiography. Records were reviewed via the Picture Archiving and Communication System (PACS) until 100 patients per cycle were included. Data collected included whether the OAR were referenced in radiograph requests and whether a fracture was diagnosed. After the first cycle, educational interventions were implemented to increase guideline awareness. The second cycle evaluated the impact of these interventions. Statistical analysis assessed the significance of observed changes. Exclusions included patients aged ≤16 years or ≥55 years, those with non-traumatic or chronic ankle presentations, and those with polytrauma or high-energy mechanisms of injury. Results were compared against RCR standards, which state that 100% of all ankle plain-film requests for trauma should reference the OAR. Results were presented at departmental governance meetings, and recommendations were subsequently implemented.ResultsIn the first cycle, 37 (37%) of radiograph requests referenced the OAR. Fractures were identified in 21 (21%) patients, with 13 (61.9%) of these requests documenting the OAR and 8 (38.1%) omitting them. Following educational interventions, the second cycle demonstrated significant improvement, with 51 (51%) of requests referencing the OAR (P = 0.046). The proportion of patients with fractures increased to 31 (31%), of whom 26 (83.9%) had OAR documented, compared with 5 (16.1%) without documentation (P < 0.001). These findings reinforce that adherence to the OAR improves fracture detection, reduces unnecessary imaging, and remains a sensitive tool for ankle trauma assessment.ConclusionThis quality improvement project demonstrates that focused interventions, particularly clinician education and guideline awareness, can enhance adherence to the OAR. Increased documentation and use of the OAR were associated with a higher diagnostic yield for fractures, improved triage, and a potential reduction in unnecessary imaging. Although full compliance was not achieved, incremental improvements contribute to patient safety and alignment with national recommendations. Future strategies may include regular departmental teaching sessions and system-based interventions such as electronic prompts to sustain compliance.

EDITOR, - Linda Beecham notes that the NHS Management Executive does not believe that career grade doctors will be bound by the European Union's directive on the organisation of working time.1 The management executive believes that consultants determine their own working patterns and would therefore be covered by one of the derogations written into the directive. We suggest that consultants' intensity of work is determined by purchasers and the health of the local population. Also, for many consultants a large proportion of …

Maternal employment and overweight children

Concern for the organization of working hours was widespread among respondents to the Why do Midwives Leave study (Ball, Curtis and Kirkham, 2002). This was especially important to midwives who gave ‘family commitments’ as their main reason for leaving. Managers in the Talking to Manager study (Curtis, Ball and Kirkham 2003) reported the availability of a variety of flexible, ‘family friendly’ working patterns. However, they felt constrained to restrict their availability in order ‘to balance the needs of the service’ and to enable an adequate skill mix to be maintained. Managers were also concerned that family friendly working was exacerbating discontent within midwifery and fuelling divisions between midwives, for family friendly working hours may leave ‘unfriendly’ gaps in the staff roster that others have to fill.

'For the times they are a-changing'--or are they?

The preliminary results from the BMA's nationwide survey of junior hospital doctors shows that 300 are still contracted to work more than 83 hours a week—the ceiling that should have been achieved by 1 April 1993. The Department of Health maintains that there are only four posts in Britain over 83 hours. The survey was conducted so that comparisons could be made with the results from the regional task forces. By 31 December 1994 no junior doctor on an on call rota in a hard pressed specialty should have been working more than 72 hours. The survey shows that 22.8% of juniors are still contracted to work above 72 hours. The preliminary results are based on a random sample of 3500 responses spread across all specialties and all regions. The survey showed that 2.2% of senior registrars, 1.5% of registrars, 0.3% of senior house officers, and 1.3% of house officers were contracted to work more than 83 hours a week. Almost 60% of junior doctors are working longer than their contracted hours. The majority of these extra hours are unpaid. The department's official data do not take account of these extra hours. The results show that the take up rate of partial shifts, a working pattern introduced to help to reduce hours, has been low. Most doctors (68.5%) remain on the traditional working pattern of on call rotas; only 5.4% are on partial shifts. The survey asked about intensity of work and the results show that juniors are not receiving adequate periods of rest. …

Shortfall of consultant clinical radiologists in the UK.

Contemporary societies are characterised by new and more flexible working patterns, new family structures and widening social divisions. This book explores how these macro-level changes affect the micro organisation of daily life, with reference to working patterns and gender divisions in Northern and Western Europe and the United States.

Introduction and objectives Medical thoracoscopy, the gold standard diagnostic test in pleural disease, is only performed at experienced pleural units. Training requirements for competence are not defined in the UK,1 where there is no formalised programme. Our tertiary pleural unit provides training opportunities for ward based registrars who have general medical and specialist clinic commitments, as well as dedicated pleural clinical research fellows. Methods All medical thoracoscopies at St Thomas’ Hospital, London were reviewed. Retrospective data were collected from May 2013 to May 2018. Results 203 medical thoracoscopies were performed in this period. Registrars were involved in 101 (50%); surgical drains were inserted post procedure in 65 cases (32%). In this period, 12 registrars performed or assisted medical thoracoscopies (table 1). The median cases performed by ward registrars was 2.5 (range 1–10). Only the two clinical research fellows achieved competency to perform a level 1 thoracoscopy independently.1 33 (33%) cases involving registrars required level 2 techniques, compared to 29 (28%) by consultants. The ward registrars achieved level 1 ultrasound competence, and the clinical research fellows achieved level 2.2 Conclusions Even in a tertiary pleural unit, it is difficult for ward based registrars to acquire sufficient thoracoscopy experience. A dedicated pleural job (without general medical and ward commitments) significantly improves opportunities to achieve competency in medical thoracoscopy. This provides sufficient experience in chest drain insertion and advanced ultrasound to perform thoracoscopy safely. Medical thoracoscopies also provide training opportunities for surgical chest drain insertion. References Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British thoracic society pleural disease guideline 2010. Thorax2010;65:ii54–60. Faculty of Clinical Radiology. Ultrasound training recommendations for medical and surgical specialities 2005. London: Royal College of Radiologists.

This article raises issues about work intensity, pace, and sustainability during physical activity, focusing attention on the nature of work in labor-intensive societies, the management of exertion in habitual tasks, and the health and broad socioeconomic correlates of alternative ways to regulate work patterns. At the heart of this review are concerns to document human adaptability (in terms of the physical and behavioral management of heavy work) and to renew debate regarding the conceptualization and measurement of work intensity (variously evaluated in absolute or relative terms, as indexed by oxygen consumption, energy expenditure, percentage maximal work capacity, heart rate elevation, time and motion indicators, or physiological cost). Three questions are examined: Is heavy work primarily a matter of time or energy intensity? How is heavy work habitually sustained? What is the bigger picture relating work performance to work context and to nutritional or health status? It is argued that many arduous activities, such as carrying loads, demand endurance over time rather than intensive effort per unit time, and that work pace management lies in regulating both the rate of work and the time in rest during physical activity. Furthermore, strategies that maximize long-term endurance (adopted by "tortoises") and those that maximize short-term productivity (adopted by "hares") are appropriate to different work contexts (e.g., a subsistence or wage-labor economy) and suit individuals with different health status and ability. Thus, work intensity is an important aspect of the links between physical activity, health, productivity, and society, as noted in literature reviewing objectives for sustainable development and public health messages for disease risk management. These areas of scholarship are underresearched, partly because consensus has been slow in agreeing on which are the best measures of work pace and work intensity for use in field situations, and which are the most meaningful thresholds for evaluating absolute or relative effort across a range of populations.

The neurological basis of learning an artificial language ‘BROCANTO’, and how this is influenced by sleep wake cycle position, was investigated using fMRI. BROCANTO requires both declarative (vocabulary) and procedural (grammar) processes. Behavioural results show equivalent performance can be reached with different declarative and procedural trajectories, with peak learning at 3pm and 24 hours consolidation. Right IFG, and left BA6 are key regions responding independently of performance, at this time. Left BA6 and right thalamus respond to the interaction between consolidation and morning/evening training. During rest, the connection between the hippocampus and IFG that is stronger in the morning and negative post task, especially on the right, indicating a BROCANTO learning related disconnection. IFG connectivity is particularly responsive to the experimental conditions during rest. In a PPI task analysis, the hippocampus input to the thalamus strengthens at the second session in the morning, and its connections to right IFG and BA6 decline, when its input to IFG is negative. Connections between IFG and BA6 and thalamus and BA6 are key. The connection between left BA6 and left IFG, responds to the interaction between consolidation and sleep/wake cycle, during task and rest. Together, the results suggest a hub role for BA6, modulated by the thalamus. This could represent an essential core BROCANTO processing system, mediating between declarative and procedural learning to be investigated further. The combined results do indicate that consolidation facilitates a shift towards procedural processing, and that its functional neural pathway is influenced by the sleep wake cycle. Analysis with further temporal information, and to identify strength and direction of connections would be needed to further clarify the mechanism. These findings can inform network models of language such as the ‘dorsal and ventral’ stream, with a view to developing optimal training schedules to benefit flexible study and work patterns.

To describe methods used to estimate hospital institutional (facility) payments for providing Veterans Health Administration (VA) outpatient services. A series of audits compared the accuracy of outpatient coding at six VA medical centers in federal fiscal year 1999 with private sector standards. Outpatient records were processed through industry standard software to determine validity and remove inappropriate services. Private sector payments were estimated by applying average payment data from Medicare cost reports and Medicare outpatient prospective payment schedules to counts of VA services. Coding audits found little difference in accuracy between VA and the community. Physician visits generated the most estimated payments and deviated most from Medicare payment experience. Radiology and laboratory services were the next highest expenditure categories for both the VA and Medicare. The proportion of radiology payments in VA data was notably lower and ambulatory surgery notably higher than Medicare's experience. Within major categories, the relative rankings of VA and Medicare services were consistent. Differences in payment criteria make exact cost comparisons of hospital-based and office-based settings difficult, particularly physician visits. Two VA clinical software applications, radiology and laboratory, provide information not readily convertible to a claims format; these applications need significant changes to be used for these purposes. They understate radiology services and overstate laboratory services compared with private sector standards. In addition, the laboratory application contains inappropriate or unspecified codes that cannot be accurately valued for many reasons.

To evaluate the working patterns and facilities of the consultant orthodontist service. A cross-sectional survey. Consultant orthodontist departments in the UK. All consultant orthodontists in the UK were sent a questionnaire that gathered information on the individual consultant, the facilities available, the new patients referred and patients under current treatment. The consultant orthodontist service provided treatment to a high number of patients who were in definite need of orthodontic treatment. A marked reduction in the use of removable appliances suggests improving standards of care and provision of more complex treatment. The caseload was high and a fair proportion of patients were returned to their referring dentists with treatment plans. The consultant service has not completely evolved into a service that provides treatment at a super-specialist level alone. There has been little change in the consultant orthodontist service over the past ten years. Arguably, this is because of the wishes of the purchasers and the shortage of trained orthodontic manpower as a direct result of poor manpower planning and lack of funds for post-graduate training.

Introduction The British Geriatrics Society (BGS) Flexible Workforce Statement supports national policy such as the NHS People Plan in promoting less than full time (LTFT) working.1,2 As LTFT trainee representatives on the BGS Trainees' Council we were interested to know how consultant work patterns are advertised. We analysed job adverts for Consultants in Geriatric Medicine over a two-year period to identify how many were LTFT posts. Method A freedom of information (FOI) request was submitted to online recruitment website ‘NHS Jobs’. The request identified jobs in ‘Elderly Care Medicine’ OR those containing ‘Geriatric’ in their title between 01/04/2019 and 31/03/2021. The FOI data were filtered to only include Consultant posts, grouped by training deanery and analysed using Excel. Regional numbers of LTFT trainees were identified by emailing Training Programme Directors and a FOI request to deaneries for non-responders. The number of LTFT consultants was identified using the online Royal College of Physicians census.3 Results The FOI request returned 7589 jobs; of these 1083 were consultant posts. These ranged from 42 in Thames Valley to 171 in East of England. Twenty-one jobs (1.9%) were advertised as LTFT, the highest proportion was 10.5% in Yorkshire and Humber. Twenty-eight (2.6%) were negotiable, the highest proportion was 15.9% in the South West. On average, 33% of LTFT jobs were advertised as permanent posts. Currently, 37.7% of trainees, and 25% of consultants, work LTFT. Conclusion Number of LTFT job adverts was low compared to the number of LTFT consultants and trainees, although there is regional variation. A limitation was that details of adverts were not seen, which made it unclear whether each job was a fresh advert or readvertising an unfilled post. The latter is likely given there are 1747 consultants working in the UK.3 Further avenues of work include identifying LTFT opportunities for SAS grade doctors and allied health professionals.