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Abstracts / Clinical Radiology 68 (2013) S8eS15 S9

Methodology: Indications of 200 consecutive non-trauma CT head and200 MRI head requests by GPs and HN were reviewed against guidelines.Findings of scans were also noted for the diagnostic yield.1st action plan: A large number of requests from GPs and the neurologydepartment did not comply with RCR guidelines. We suggest a protocol-guided open-access to brain imaging especially for headaches to main-tain the optimal use of the service.Results of 1st round: 67% GP, 63% HN requests for CT and 58% GP, 85% HNrequests for MRI met guidelines. Majority of GP requests were for headaches(71% CT, 60% MRI). Within this group, 43% CT and 45% MRI requests failed tomeet guidelines. 51% CT, 40% MRI requests from HN were for headaches; ofthese, 42% CT, 26% MRI requests failed to comply with guidelines. Significantfindings were reported in 15% CT, 19% MRI requests by GPs; 9% CT, 12% MRIscans from HN. Infarction, demyelination and brain tumour were most com-mon findings.

Are x-rays requested appropriately in acute abdominal pain?

Authors: Laura Preston, Caroline Adams, Katy Macdonald

Background: Acute abdominal pain is a common surgical presentation.X-rays can be valuable diagnostic tools if used appropriately, but usedindiscriminately they expose patients to unnecessary ionising radiationand increase radiology department workload.Standard indicator and target: RCR referral guidelines (iRefer) forabdominal pain were used to assess the appropriateness of abdominalX-ray (AXR) and chest X-ray (CXR) requests. The target was for 100%appropriate requests.Methodology: Admissions with acute abdominal painwere identified over 1month. For thosewho hadX-rays, the indication on the requestwas recordedand compared with findings after clinical assessment from case notes. iReferwas used to assess each request as appropriate or inappropriate.1st action plan: A poster outlining the guidelines was put up in theEmergency Department and surgical wards. The audit was presented at thesurgical department meeting and at junior doctors’ teaching.Results of 1st round: 58 had AXRs; 30(52%) were appropriate. Of 56 CXRs,22(40%) were appropriate. In many cases, information on the request formdid not match with that in the case notes.2nd action plan: Results of the 2nd round suggest that X-rays are stillbeing treated as "routine" tests for abdominal pain. Meetings betweenradiologists and consultant surgeons are planned to tackle this attitude.Results of 2nd round: Of 59 AXRs, 32(54%) were appropriate. Of 72 CXRs,47(65%) were appropriate. Again, in many cases there was mismatch be-tween the information on the request form and case notes.

Unexpected pulmonary embolus on chest CT

Authors: Neil Gupta, Benjamin Winter, Kushnood Alam, Frances Aitchison

Background: Studies have shown that pulmonary embolus (PE) is acommon unexpected finding on chest CT performed for other reasons(Storto 2005, Sebastian 2006, Farrell 2010). Untreated PE is associatedwithhigh mortality. We wanted to audit our practice to determine the preva-lence of PE on standard protocol (non CTPA) contrast enhanced chest CTand whether these were diagnosed at the time of the original report.Standard indicator and target:We hoped to show that our diagnosis ratefor unexpected PE was at least equivalent to published data. 30% missed(Storto 2005 & Farrell 2010).Methodology: Consecutive chest CTs selected (200 in 1st audit cycle fromDecember2008and120 in2nd cycle fromDecember2010). ExcludedCTPAs&HRCTs. Images anonymised & randomised. Images reviewed by experiencedradiologists to assess adequacy of contrast opacification & presence of PE.1st action plan: Audit presented at local radiology clinical governancemeeting. Email to all consultant radiologists highlighting issue.Results of 1st round: 4.7% of standard protocol chest CTs had unexpected PE(rising to 7%of patientswith knownmalignancy). Allmissedon initial report.2nd action plan: Audit presented at local radiology clinical governancemeeting. Email to all consultant radiologists highlighting issue. Cases sentto discrepancy meeting for peer review. Poster in all CT reporting roomswith results of audit highlighting issue.

Results of 2nd round: 3.1% of standard protocol chest CTs had unexpected PE(rising to 5.6% of patients with knownmalignancy). All missed on initial report

An audit of CT guided methylene blue lung nodule marking pre-videoassisted thoracoscopic surgery metastectomy

Authors: James Stephenson, Amrita Bajaj

Background: VATSmetastectomy reducesmorbidity,mortality andhospitalstay, but small nodules are difficult to resect using VATS.We aim to audit theeffectiveness of a novel CT marking technique to facilitate VATS resection.Standard indicator and target: There are no set standards for this novelprocedure.Weused the British Thoracic Society RadiologicallyGuided LungNodule Biopsy guidelines, for standards of a comparable procedure.Methodology: Retrospective data collection - All markings between 07/2011-12/2012 - Patients identified from CRIS - Review of proceduredocumentation and case note review: operation note, anaesthetic chartand histology reportResults of 1st round: Successful marking - result 96% vs standard >90%-Successful VATS resection - 88% vs no standard as most patients wouldhave undergone open resection - Complete histological resection (analysisof 88% who had VATS) - 100% vs 100% - Major complications - Largepneumothorax 0% vs<3.1%; Haemorrhage 0% vs<5.3%; Reaction to dye 0%vs 0%; Death 0% vs < 0.15% - Minor complications - Small pneumothorax8% vs <20.5%; Pain 4% vs <10%1st action plan: Marking facilitated VATS resection in 88% of cases, themajority of which would have undergone open resectionwithout marking,due to nodule location. This novel technique of nodule marking is safe withcomplication rates well below accepted levels, however the small numberof procedures thus far mandates on going prospective audit.

Follow-up for consolidation on GP and emergency department (ED)chest radiographs

Authors: Jenny Walsh, Helen Cliffe, Shishir Karthik

Background: Non-resolving consolidation on chest radiographs(CXR) may indicate underlying pathology. Lung cancer rates are up to6% in inpatients diagnosed with Community Acquired Pneumonia(CAP).Standard indicator and target: Standard: Leeds Health Pathways for adultCAP state: ‘a chest radiograph should be undertaken on follow-up at about6 weeks to ensure full radiological resolution’. Indicator: If a CXR dem-onstrates new consolidation, dedicated follow-up CXR should be recom-mended and performed. Target: 100% complianceMethodology: Population: Adults referred for CXR via GP or EmergencyDepartment (ED) at a tertiary teaching hospital in January 2011. Methods:Review of initial CXR report on the Radiology Information System (CRIS). Ifnew consolidationwas reported, CRIS and request cards were reviewed fora dedicated follow-up CXR.1st action plan: -Radiologist education -Inform ED of findings -ED CXRsrequiring follow-up to be faxed to GP -Programme of engagement with GPsto assess factors affecting compliance/raise awareness. -Re-audit in 1 yearResults of 1st round: -5562 reports -Mean age 66;M:F 1:1 -41%GP referrals,59%ED-335 reports describednewconsolidation -In25%, follow-upCXRwasnot recommendedWhere follow-upwas recommended: -It was achieved in68%ofGP referrals and23%ofEDpatients (mean7weeks) Flagging the reportto the referrer -Increased GP follow-up from 68% to 70% and ED from 23% to31%. 17% of GP and 20% of ED patients had no subsequent CXR.

The use of central venous catheters for pump injection of intravenouscontrast during CT examination. Are we safe?

Authors: Annette Johnstone, Sarah Fleming, Ashley Guthrie, MichaelWeston

Background: There are currently no guidelines for pump injection ofintravenous contrast via a central venous catheter (CVC). Radiologists are