Radiographer-Led Discharge (RLD) for Accident and Emergency Patients

Lisa Jenkins

Jo Mower

Zoe Roberts

Alison Bax

Wayne Parsons

Cardiff and Vale University Health Board

This project aims to reduce the waiting time for patients attending minor injuries and paediatrics within the accident and emergency department by allowing eligible patients to be discharged directly from emergency radiology if no bony injury is demonstrated on their x-rays.

Using highly qualified and skilled Reporting Radiographers, images can be reported immediately and the patient informed of the result from the individual responsible for the report. For patients who would only require treatment if their x-rays demonstrated a fracture, this would eliminate the requirement to return to Accident and Emergency (A&E) if no fracture is demonstrated.

Where bony injuries are present, the Emergency Unit (EU) clinician will receive the official report immediately from the Reporting Radiographer, meaning the risk of potential delayed diagnosis is eliminated. This project will be trialed in Cardiff and Vale UHB at the University Hospital of Wales site.

Only adults and paediatric patients with specific minor injuries will be eligible, with inclusion criteria being applied to ensure patients receive the same level of care and treatment as using traditional pathways.

Line graph showing results pre-x-ray and post-x-ray from January to December

This Project Supports Prudent Healthcare

This project is underpinned by prudent healthcare principles; making the most effective use of skills and resources and reducing variation and duplication.

Reporting Radiographers have undertaken a PgDip in Image Interpretation, having been assessed to the same level of accuracy, sensitivity and specificity as a Consultant Radiologist in the interpretation of plain film x-rays of the skeleton.

Directly linking the skills of Reporting Radiographers with the patient ensures consistently high abnormality detection. This reduces the variation that can occur when EU staff who do not possess this further training are required to interpret x-rays.

Radiology reports are the ‘Gold Standard’, meaning every radiological report that describes a positive injury requires retrospective cross checking with the EU notes to ensure the abnormality was noted by EU staff at the time of the patient’s visit.

This requires senior staff to be taken away from clinical duties, with the whole process frequently taking at least 4 hours daily. Due to clinical demands within Radiology, it can be 2-7 days before a radiological report is generated, and a further 2-4 days before EU clinicians are available to cross check these reports. It is therefore possible for a patient who attended up to 2 weeks previously to be recalled to EU due to an injury that was undiagnosed at their initial attendance.

Radiographer Led Discharge will reduce the number of these reports that require scrutiny; any positive reports for EM/EP patients will document that the referrer was advised of the report at the time of imaging thus making the requirement for retrospective cross checking obsolete. Where a fracture or abnormality is noted, the EU clinician is informed immediately, eliminating the risk of a delayed diagnosis and the potential legal concerns and costs that may follow.

The potential for EU clinicians to misdiagnose a normal variant as an acute injury is also eliminated; thus ensuring patients do not receive unnecessary treatment or are asked to needlessly return to the trauma clinic for further follow up. Applying, for example, a plaster cast to a patient where none is required not only restricts the patient from undertaking normal daily activities, but can cause medical complications. This means this project also aligns with the prudent principle of only doing what is required, no more, no less, and doing no harm.

This project also allows for those with the greatest need to be cared for first. Patients who do not require treatment after x-ray will be given injury management advice and discharged immediately from Emergency Radiology, meaning fewer patients returning to A&E.

This allows for EU clinician’s time to be spent with patients who do require treatment, reducing their waiting times and increasing the compliance with national waiting time targets. This allows all patients within the Minor Injuries and Emergency Paediatric departments to benefit from RLD, whether directly or indirectly.

The patient is central to this project, with multidisciplinary professionals all working together to minimise waiting times whilst maximising patient care and experience. With Reporting Radiographers working in close partnership with EU junior doctors, clinicians and nurse practitioners, knowledge and skills can be shared and strong working relationships cultivated. This increases staff morale and role satisfaction as well as providing future areas for role extension.

Part of Cohort Bevan Exemplars 2015-16