Innovation Through a Pandemic – How to survive when there’s nothing to report

Dr Gareth Davies describes the massive impact the COVID 19 pandemic had on elective cross-sectional reporting, reducing output to almost zero. Here he reflects on how the drive for innovation and the motivation to think differently led to a better teleradiology service for both patients and staff.

Dr Gareth Davies

The pandemic will certainly define us as an organisation. A period of uncertainty, business survival, the protection of our staff and their livelihoods and a readiness to provide a clinical service our patients rely on.

Let’s go back to the 1 January 2020. It was a time when the UK’s radiology reporting capacity was at a tipping point, backlogs of unreported examinations were in the thousands, demand for imaging services was constantly increasing, and more and more patients were being scanned.  Just in one single day in that month, Telemedicine Clinic (TMC) reported over 1400 elective cross-sectional scans to its NHS customer base.

Wind the clock forward to May 2020, and during the midst of the Coronavirus pandemic a grand total of 11 plain films were reported in a whole week.

TMC’s business is teleradiology, a service that underpins delivery of clinical services to the customers it reports for. Take away the need for outsourcing by having to stop elective scanning and there is no need for teleradiology.  Take away elective scanning and the backlogs built up over time can be cleared.  The reset button had been pressed and no one knew what was going to happen next.

TMC employ over 300 radiologists, with over 50 radiologists working in the emergency section. The recovery for this section was quick with demand returning  to normal volumes after 3 months. The recovery of the elective service has stalled in line with countrywide lockdowns but is now about 60% and getting busier.

So how did a company that had 50% of its business disappear overnight survive? The simple answer was innovation!

Response team

The first thing TMC did was to call on its European based radiologists, staff, and management teams to team up to provide an unrivalled knowledge-share hub. Coronavirus imaging from hospitals all over the world was collated to provide real-time COVID reporting best practice as the world started to understand the virus more.  In addition, top thoracic specialist radiologists from Europe who had already experienced COVID radiology were called to report cases for NHS hospitals.  A new “24/7 COVID response” reporting team was established in less than 2 weeks. 

On the back of our experience with the 24/7 COVID Response service, the TMC Academy used our reporting experience and best practice from other nations experience to create two COVID-19 online reporting modules on the TMC Academy platform and made these free to all to view and learn from.

Platform

Our next step was the deployment of the TMC Platform for our NHS customers. Where TMC had a contract in place with a Trust who also had reporting radiologists collaborating with TMC, TMC enabled the radiologist to work for their hospital using the TMC infrastructure and IT, free of charge such that the radiologist could work remotely reporting their cases, where home reporting was not available at that time. Driving down costs to our customers in the future is a focus of TMC.

TMC is proud of its recruitment process for radiologists. Our traditional model was to invite potential colleagues to our head office in Barcelona, to undergo a series of interviews and undertake test case examinations specific to their subspecialty. What do you do when you need to recruit radiologists in a period of complete lockdown, with the inability to travel even a few miles? You challenge your teams to virtualise a 3-week induction/test period of course!  This was completed again using the online TMC Academy platform to make sure all radiologists were fully vetted, interviewed, examined and quality-assured to comply with our standards and strict working regulations required to support  the UK market and the NHS.

Hub

Prior to the pandemic, TMC were aware of a growing need for acute reporting services ranging from neuro MRI ad hoc reporting to Emergency CT daytime cover to sub-specialist short turn around reporting. One of our major ambitions during this period was to innovate more integrated clinical care and break the traditional concept of teleradiology and the clearing of backlogs and night time on call. TMC are good at elective reporting and using UK and European based radiologists. TMC are also good at UK overnight Emergency CT reporting from wide awake UK and European radiologists who have moved to Australia. However, there is a mix of requirements that TMC did not fully cater for and the NHS desperately requires. From conversations with customers, it was clear that elective reporting, although destined to return with a vengeance, was not the priority. The main driver in fact was a mixture of acute and semi-urgent work so, from this, The TMC Hub and TMC Oncology concepts were created.  

Any time of the day or night, a clinician, radiographer, or radiology manager can call TMC to discuss scanning a patient.  These can be emergency patients in the day or night, they can be acute inpatients who simply need that next step in their pathway or to be discharged safely, or perhaps just a routine scan which feels urgent. The TMC Hub can help put the patient on the right pathway for their care, anytime day or night, Monday to Friday or a weekend.  TMC’s customers love the new HUB concept, it provides a real safety net that they can contact us to get a patient scan completed, all within the hospitals set guidelines.

Artificial Intelligence

Last but not least, during the pandemic, TMC has had the opportunity to establish a dedicated team to evaluate the plethora of AI products on the market and implement products which we believe will improve patient care. Through stringent evaluation, TMC now has a number of AI products in place to assist its radiologists in making a clinical report.  For the emergency section, AI now looks at all CT PA examinations for pulmonary embolism (PE), subtle C-spine fractures in trauma scans and intracranial haemorrhage in CT brains. For elective services, the AI software looks for PEs in all CT examinations that involve the thorax as soon  as the examination arrives in the TMC PACS.  In our new low dose CT thorax reporting for the NHS lung screening / lung health check service, we are using nodule detection and automated reporting to the requirements of the NHS QA standards for such a service.  And new to TMC’s repertoire is a novel service, bringing AI to its clients without them knowing it.  Through TMC’s IT infrastructure, our AI solution can look at ALL images in a customers PACS to identify incidental PEs, assign them to a TMC radiologist for immediate reporting which is flagged to the clinician team on-site in real-time.  A scan that could have waited 3 weeks for reporting with unknown downstream costs to the Trust.    AI will not replace radiologists, but it will improve radiology workflows, something which TMC can help clients do.

Benefits

With innovation comes benefit, a benefit that can be passed on to our customers in terms of reduced costs for delivery as well as reduced costs further down the patient pathway. Innovative services such as the TMC Hub or the TMC Oncology service will give clients the confidence they need to get a scan reported first time by the most appropriate and qualified radiologists.

Teleradiology and outsourced radiology are looked upon as a cost to the NHS which needs to be removed. With over 90% of NHS services relying on overnight emergency services being delivered from the independent sector, it is hard to see how this will change any time soon.  Instead, looking at how teleradiology can help underpin service delivery, provide the AI analysis and expertise, provide the IT network to telework over international borders whilst using capacity from Europe to add to the overstretched UK workforce, the question should be how can we integrate more with our providers to deliver value-driven innovative healthcare to all people. 

About Gareth Davies

Dr Gareth Davies, UK Medical Director Head and Body Section (Full time employed)
Dr Davies has 18 years’ experience as a Consultant Radiologist in the South Wales NHS prior to joining TMC in 2019. He has a specialist interest in interventional and oncological radiology and held various national roles including the Regional Specialty advisor for training in Wales  (Royal College of Radiologists), a member of the Clinical Radiology Specialty Training committee (RCR), Lead Radiologist and Lead QA of the Wales Abdominal Aortic Aneurysm Screening Programme (WAAASP), Associate Medical Director of Cancer Diagnostics and the Clinical Lead of the Early Cancer Diagnosis Programme, Wales Cancer Network and member of the Clinical Advisory Panel for CRUK. Since Joining TMC, Dr Davies has been involved in helping form TMC Oncology as well as working within the UK Business Unit to develop a more clinically integrated approach to telemedicine with the NHS forming the TMC Hub concept.

The flu epidemic of yesteryear: the role of radiology in 1918–20

adrian thomas

Dr Adrian Thomas

100 years ago the UK was facing a fast-moving outbreak of epidemic influenza pneumonia, known as the “Spanish Flu”.

Radiology played an important part in diagnosis, although the crisis was without the scientific knowledge, strategic management and communications we have today. Here, Dr Adrian Thomas explores the six patterns of infection in this unpredictable and powerful disease.

 

 

Radiology is playing a central role in the diagnosis of COVID-19 today, and 100 years ago was also playing an important role in the diagnosis and characterisation of the outbreak of epidemic influenza pneumonia of 1918–1920. A combination of fluoroscopy and radiography was then used, with the occasional utilisation of stereoscopy. The greatest pointer to a diagnosis of epidemic influenza pneumonia in a given patient was the presence of the epidemic, although there were some specific features to indicate the diagnosis. The etiological cause of influenza was not known at the time, being first discovered in pigs by Richard Shope in 1931.

Spanish flu

The epidemic of 1918 far exceeded previous ones in its intensity. It had a high mortality in young adults with the very young and very old being comparatively immune. The associated pneumonia was particularly virulent. In the case of the troopship The Olympic (sister ship of The Titanic) there were 5,951 soldiers on board. Initially there were 571 cases of acute respiratory disease, but within 3 weeks there were 1,668 cases. Of these, 32% had pneumonia, of which 59% died. In any locality the duration of the epidemic was from between 6–8 weeks, and approximately 40% of the population was affected (Osler, 1930).

Six patterns of infection were identified, with correlation of clinical, radiological and post-mortem findings (Sante, 1930., Shanks, et al. 1938). Dr Leroy Sante, the pioneer radiologist from St Louis, described epidemic influenza pneumonia as “the most lawless of the chest infections.” Abscess formation was seen frequently, and was commonly of the small and multiple type. Radiological changes were seen developing day by day, and clinical resolution needed at least six–eight weeks since there had commonly been lung destruction and healing by fibrosis needed to occur.

The patterns were:

Type 1: Peribronchial invasion with infiltrates that enlarge and become confluent forming small areas of consolidation (figures 1 & 2, below). This was not confined to one lobe, but could appear in all lobes as a true bronchopneumonia. This was similar in appearance to ordinary bronchopneumonia.

1Type 1, Influenza bronchopneumonia

Figure 1

2Type 1, Influenza bronchopneumonia_Viewed as from behind

Figure 2

Type 2: Peribronchial invasion with infiltrates that enlarge and become confluent to form solidification of an entire lobe (figure 3, below). The changes remained confined to a single lobe. It was viewed as a true bronchopneumonia but with a lobar distribution (“pseudolobar pneumonia”). Different lobes may be invaded one after another. The pseudolobar pattern was the commonest type, and could resolve without further spread. The presence of previous isolated infiltrates would distinguish this type from common lobar pneumonia. There was a tendency to break down with extensive cavitation.

3Type 2, or pseudo-lobular

Figure 3

Type 3: This starts as blotchy infiltrates that coalesced to form a general haziness over a part of a lung, suggesting a haematogenous origin (figures 4 and 5, below). At post-mortem this was found to be an atypical lobular pneumonia, a “diffuse pneumonitis”, that was so commonly seen during the influenza outbreak. It resembled the streptococcal (septic) pneumonia that was often seen in association with septicaemia when there was no epidemic. The spread was rapid, and the prognosis was poor. Death commonly occurred within the week.

4Type 3, resembling streptococcal (septic) pneumonia

Figure 4

5Type 3, resembling streptococcal (septic) pneumonia

Figure 5

Type 4: A type starting in the hilum and spreading rapidly into the periphery, the so-called “critical pneumonia” (figure 6, below). This was attended with a high mortality. Post-mortem showed a purulent and haemorrhagic infiltration around the larger bronchi. There was often marked cyanosis.

6Type 4, the so-called “critical pneumonia

Figure 6

Type 5: This started in the dependent part of the lungs, with continuous upwards spread (figures 7a and b, below). This was an atypical lobular pneumonia, there was no associated pleural fluid, and it was usually fatal. Initial infection in the costo-phrenic angle spread within 24 hours to involve the lower lung, and death occurred within 48 hours. Clinical features included extreme prostration, high temperature, and delirium. This pattern with rapidly advancing consolidation was seldom seen in other conditions.

7a Type 5. This started in the dependent part of the lungs

Figure 7a

7b Type 5. A film taken 12 hours after 7a

Figure 7b

Type 6. A true lobar pneumonia was only seen rarely.
The prognosis of epidemic influenza pneumonia was difficult to determine. So, as an example, a patient who was resolving would suddenly have changes extend into the other lung and then die. Another patient with successive involvement of all lobes could recover completely. A patient with only minor lung involvement might die, and another with extensive consolidation would recover completely.

Radiologists continue to be in the front line in the treatment of infectious diseases, and although our modalities are now more advanced than a century ago, their contributions remain essential. It is also noteworthy that the simple CXR also remains central.

Figures:

1. Type 1, Influenza bronchopneumonia. Image seen as a positive.

2. Type 1, Influenza bronchopneumonia. Peribronchial clusters of infiltration, with no relation to lobar architecture. Viewed as from behind.

3. Type 2, or pseudo-lobular.

4. Type 3, resembling streptococcal (septic) pneumonia. Image seen as a positive.

5. Type 3, resembling streptococcal (septic) pneumonia. Blotchy ill-defined infiltrates which coalesce to form a general haziness. Viewed as from behind.

6. Type 4, the so-called “critical pneumonia.”

7a. Type 5. This started in the dependent part of the lungs, and this early film shows consolidation in the costophrenic angle (black arrow).

7b. Type 5. A film taken 12 hours after 7a. The lower right lung is consolidated, and the patient died 12 hours later. Post mortem showed a solid lung with no effusion.
Readings:

Osler, William. (1930) The Principles and Practice of Medicine. 11th Edition, Thomas McCrae (Ed.). London: D Appleton.

Sante, Leroy. (1930) The Chest, Roentgenologically Considered. New York: Paul B Hoeber.

Shanks, S Cochrane., Kerley, Peter., Twining, Edward W. (Eds). (1938) A Textbook of X-ray Diagnosis by British Authors. London: H. K. Lewis.

 

Dr Adrian Thomas FRCP FRCR FBIR, BIR Honorary Historian

About Dr Adrian Thomas

Dr Adrian Thomas is a semi-retired radiologist and a visiting professor at Canterbury Christ Church University. He has been President of the Radiology Section of the Royal Society of Medicine, and of the British Society for the History of Medicine. He is the Honorary Historian to the British Institute of Radiology. He has had a long-term interest in role development in radiography, and teaches postgraduate radiographers.

Adrian has written extensively on the history of radiology writing many papers, books and articles. He has, with a colleague, written a biography of the first female radiologist and female hospital physicist: Adrian Thomas and Francis Duck: Edith and Florence Stoney, Sisters in Radiology (Springer Biographies) Springer; 1st ed. 2019 edition (1 July 2019).

© Thomas / 2020

Review – The Unofficial Guide to Radiology: 100 Practice Chest X-Rays with Full Colour Annotations and Full X-Ray Reports

Tom Campion

The Unofficial Guide to Radiology won the BIR/Philips

Trainee award for Excellence in 2015.   Tom Campion, radiology trainee at Bart’s Hospital, London and Valandis Kostas, Senior Radiographer from Guy’s and St Thomas’ Hospital  reflect on the latest addition to the series which focuses on chest x-ray interpretation and is designed to support professionals and students.

Valandis KostasA follow-up to the Unofficial Guide to Radiology, and part of the Unofficial Guide to Medicine series, this new book The Unofficial Guide to Radiology: 100 Practice Chest X-rays, with full colour annotations and full X-ray reports  has at its heart the inspiring idea that the development of educational resources should be driven by those who use them. The result is a fantastic resource for reporting radiographers, medical students, junior doctors in any specialty, providing a comprehensive and practical approach to chest x-ray interpretation.

41Vnk61P4sL._SX352_BO1,204,203,200_Right from the start, the book’s cover is self-explanatory and is easily perceived to be about chest X-ray interpretations.   The 100 chest X-ray cases are presented in a test-yourself format, with the images and case history presented on one page and the interpretation and report on the next.

The cases are separated in three coloured divisions: Standard (orange), Intermediate (purple) and Advanced (blue). The first page provides the reader with a short clinical indication followed by the associated chest X-ray in high quality, all in one page. The second page then evaluates the technical features, again using a colour code scheme which is then diagrammatically presented on the same chest X-ray, but on a smaller scale. It may be coincidence that the orange, purple and blue technical features can also be perceived as standard, intermediate and advanced technical points to look out for from a radiographer’s perspective. Finally, there is a short but precise summary demonstrating a report of the chest X-ray followed by further management for the patient.

The image quality is excellent in comparison to most other available textbooks, with crisp full-page images allowing the detail of the images to be explored – crucial in the days of PACS when every possible abnormality can be magnified a hundredfold.

Each ‘answer’ page has a consistent format, embedding a sensible interpretation pathway, and a clear layout highlighting both normal and abnormal findings. The consistency, and the detailed and comprehensive annotations, allows the reader to build up an idea of ‘normal’ over the course of the cases, continuously reinforcing important structures to check on every radiograph.

The multidisciplinary approach to development also comes through strongly, with suggested first management steps in response to each radiograph placing the interpretation firmly in the pragmatic clinical world. However, the ‘reporting’ style employed also develops familiarity with the language of radiologists; if this can sometimes seems overly formal or formulaic, it serves a purpose in ensuring that clinicians and radiologists are on the same page.

The clinical cases provided are realistic and are what you expect to find whether in Accident and Emergency and/or outpatient, GP clinics. From pathologies to pneumothoraxes, fractures to line insertions, most scenarios are covered in this book.

Valandis Kostas strongly recommends this book to all grade and advanced radiographers. He observes that the book provides the patient pathway link from clinical presentation to radiology, to treatment and type of follow up imaging required i.e. CT and/or chest clinic referral. The layout enables understanding of the acquired chest x-ray, vital for best practice.

He particularly applauded the section on quality of the chest X-ray, using the similar 10 point image quality check radiographers use in their clearance of X-rays they undertake. Patient I.D, rotation, penetration and inspiration are a few examples. Furthermore, the case layout educates radiographers the importance of these checks to aid image interpretation for diagnosis whilst encouraging learning about chest pathologies. This will eliminate the repetitious perception of the chest X-ray and it will encourage radiographers to maintain high quality chest radiographs for accurate diagnosis and reduce false negatives and false positives.

The clinical details provided in the case vignettes are of a level of detail that surpasses most of those seen in clinical practice; hopefully, the detail provided here will also serve to demonstrate to clinicians who read the book how fundamental these details are, and serve as a resource on helpful requesting as well as interpretation of chest radiographs.

An important area for radiographers and radiologists that is not covered in as much detail is the inadequate chest x-ray, and perhaps the book could be improved by including a few examples of misses/near misses from poor quality radiographs in order to educate readers on when a repeat X-ray is required.

Tom Campion, trainee radiologist  would happily recommend the book to anyone whose job involves X-ray reporting as it delivers a solid foundation in interpretation skills and serves  as both a thoughtfully structured introduction to the beginner and a handy reference to the more experienced.

Both Valandis and Tom felt that the book would make a great app or online tool  in the future.

The Unofficial Guide to Radiology £19.99

https://www.amazon.co.uk/Unofficial-Guide-Radiology-Practice-Annotations/dp/1910399019

Images: (Top left) Tom Campion, (top right) Valandis Kostas.

AUTHORS:

by Mohammed Rashid Akhtar MBBS BSc (Hons) FRCR (Author), Na’eem Ahmed MBBS BSc (Author), Nihad Khan MBBS BSc (Author)

EDITORS:

Mark Rodrigues MBChB(Hons) BSc(Hons) FRCR (Editor), Zeshan Qureshi BM BSc (Hons) MSc MRCPCH (Editor)

 

Breaking the mould – how  radiographer reporting is better for the patient.

nigel-thomas

Professor Nigel Thomas from the University of Salford explains why allowing a radiographer to report X-rays  is not threat to the radiology profession.

 

 

 

I’ll nail my colours to the mast straight away, and state that I have been an active proponent of radiographer role extension in general, and radiographer reporting in particular, for over 20 years.

I first became involved in mid 1995 when the University of Salford (then University College Salford) asked for help in setting up a formal plain film reporting course for radiographers. The context for this was the unresolved tension between the large numbers of unreported films in most X-ray Departments and the realisation that radiographers as a group of professionals were often working below their full potential – a real untapped resource within our own departments. Becoming involved in the process seemed to me to be a very obvious thing to do, and I have never had any regrets about doing so. I don’t believe that I have contributed to the demise of my profession, and I certainly don’t feel like a “turkey voting for Christmas”.

Over the years since then, radiographers have increased the breadth of their involvement in reporting (to currently include some types of MR scanning and CT, as well as gastro-intestinal contrast studies amongst other things), as well as developing a career structure which encompasses working at Advanced Practitioner and Consultant Radiographer levels (the latter being a particular success in the world of breast imaging, where consultant radiographers can follow an entire patient journey by being able to perform and report mammograms, perform and report breast ultrasound and perform guided biopsies, as well as having counselling skills).

It was clear from the beginning that there would be opposition to the idea of radiographer reporting, both from the radiology establishment, and, to a much lesser extent, from within the radiography profession itself. In order to ensure that the process of creating reporting radiographers was as good as it could be, certain quality measures were put into place. No radiographer can report in the UK without a recognised qualification (at PgC or Pgd level) gained from a higher education institution. In the context of the workplace, reporting is done within an agreed scheme of work (signed off by the employing Trust Board), and regular audit is undertaken.

In 2017 between 15 and 20% of all plain film examinations in the UK are reported by radiographers, and there are now over 50 people in consultant radiographer grades around the country. Reporting radiographers have been “part of the furniture” in X-ray departments for over 20 years, and generations of junior doctors, nurses and physiotherapists have been familiar with using them as a port of call for advice on the interpretation of images.

And yet, despite all of the above, resistance to radiographer reporting persists. I find this particularly perplexing for several reasons:

  1. The reporting shortfall still persists, and patients are being put at risk by our failure to report their examinations in a timely and accurate way – would we rather leave them unreported?
  2. Radiologists have more than enough to do – there are too few of us, and our time is used to apply our unique skill set to report labour intensive complex examinations, undertake time-consuming interventional procedures, and provide a commitment to the support of MDTs.
  3. There is a substantial body of sound scientific evidence (published in the major UK peer-reviewed radiological journals) that radiographer reporting works, is safe, and is of a comparable standard to that provided by medical staff in many areas.
  4. Radiologists have been involved in this process from day 1 – advising on course content, giving lectures, acting as examiners and external examiners, and, most importantly, acting as mentors to radiographers in training at their places of work.

The final irony for me, as we progress into the 21st century is that, despite all the above, it is clear that some of my colleagues are much keener to gain help from computers than humans. Don’t get me wrong, I’m sure that Computer Aided Design (CAD) and Artificial Intelligence (AI)  will have a huge role to play in the routine provision of a radiology service in the near future, but reporting radiographers can help patients here and now.

References

Berman L, de Lacey G, Twomey E, Twomey B, Welch, T and Eban, R. ‘Reducing errors in the accident department: a simple method using radiographers’, British Medical Journal 1985; 290: 421-2

Loughran,C.F., Reporting of fracture radiographs by radiographers: the impact of a training programme. British Journal of Radiology, 67(802), 945 –950, 1994

Judith Kelly, Peter Hogg, Suzanne Henwood. The role of a consultant breast radiographer: A description and a reflection. Radiography, Volume 14, Supplement 1, e2-e10, 2008.

Brealey, S., Hewitt, C., Scally, A., Hahn, S., Godfrey, C., and Thomas, N.B. Bivariate meta-analysis of sensitivity and specificity of radiographers’ plain radiograph reporting in clinical practice. British Journal of Radiology, 82, (979), 600-604, 2009.

Piper, K., Buscall, K., Thomas, N.B., MRI reporting by radiographers: Findings of an accredited postgraduate programme. Radiography, Volume 16, Issue 2, 136-142, May 2010

  1. Piper, S. Cox, A. Paterson, A. Thomas, N.B. Thomas, N. Jeyagopal, N. Woznitza. Chest reporting by radiographers: Findings of an accredited postgraduate programme, Radiography, Volume 20, Issue 2, 94-99, February 2014
  1. Snaith, M. Hardy, E.F. Lewis Radiographer reporting in the UK: A longitudinal analysis

Radiography, Volume 21, Issue 2, 119-123, 2015

About Nigel Thomas

Born and raised in Cornwall, I qualified from St Bartholomew’s Hospital in London in 1981 having gained an intercalated B.Sc in Biochemistry in 1978.

My radiology training was undertaken on the North Western Training Scheme (based in Manchester), and I was appointed as Consultant Radiologist to North Manchester General Hospital in 1989.In 2005 I moved to a Consultant post at Trafford General Hospital and retired as a full-time NHS Consultant Radiologist in 2015.

I currently work as an independent Consultant Radiologist and, amongst other roles, am a mentor to Reporting Radiographers at two large Foundation Trusts in the Manchester conurbation.

I first became involved in the process of radiographer role development at the University of Salford in 1995, and was appointed as an Honorary Professor there in 2000. I have over 40 publications in scientific journals, and am a co-author of a standard textbook of Obstetric and Gynaecological Ultrasound scanning.

 

Image: Courtesy of Nottingham University Hospitals