Evaluation of Paediatric Radiology Services in Hospitals in the UK K

Clinical Radiology xxx (2016) 1e5

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Clinical Radiology

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Evaluation of paediatric radiology services in hospitals in the UK K. Halliday a, K. Drinkwater b,*, D.C. Howlett c a Paediatric Radiology, Queens Medical Centre, Nottingham NG7 2UH, UK b The Royal College of Radiologists, London WC2A 3JW, UK c Radiology, East Sussex Hospitals NHS Trust, Eastbourne, East Sussex BN21 2UD, UK

article information AIM: To compare paediatric radiology provision across the UK with national standards published by the Department of Health and the Royal College of Radiologists (RCR). Article history: MATERIALS AND METHODS: Audit standards and indicators for paediatric imaging were Received 11 November 2015 derived from “Delivering quality imaging services for children”,1 “Standards for imaging in Received in revised form cases of suspected non-accidental injury”2 and “Improving paediatric interventional radiology 24 March 2016 services”3 and agreed jointly by the Clinical Radiology Audit Committee and the British Society Accepted 20 May 2016 of Paediatric Radiology. A questionnaire was sent to all hospitals and NHS trusts imaging children aged 16 or younger in the UK in October 2013. The target for all indicators was 100%. Eighty-seven of 196 (44%) eligible institutions submitted data, the size distribution of the institutions was representative when compared to data from “Facing the future: a review of paediatric services”4 published by the Royal College of Paediatrics and Child health. RESULTS: Only 65% of paediatric images were obtained by staff who had had speciﬁc training and only 60% were reported by radiographers or radiologists with appropriate training. Sixty- two percent of centres did not have access to a paediatric opinion 24 hours a day, 7 days a week all year; only 34% of radiographers who regularly imaged children had had any access to continuing professional development (CPD) in the 12 months of the audit. Although all hospitals had facilities for image transfer, only 57% had any formal funding arrangements in place for external reporting of images. CONCLUSIONS: The standards set for a network approach to paediatric radiology provision in “Delivering quality imaging services for children” are largely unmet. This failure to make the most of the workforce and resources puts vulnerable children at risk. The authors urge NHS England to work with the RCR to organise and administer a national network for paediatric imaging. Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction

Making a diagnosis in sick children is often extremely challenging and frequently requires imaging. Paediatric radiology differs signiﬁcantly from adult radiology. * Guarantor and correspondent: K. Drinkwater, The Royal College of Acquiring images is heavily inﬂuenced by young children’s Radiologists, London WC2A 3JW, UK. Tel.: +44 020 7406 5945. inability to cooperate and their increased sensitivity to E-mail address: [email protected] (K. Drinkwater). http://dx.doi.org/10.1016/j.crad.2016.05.024 0009-9260/Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Halliday K, et al., Evaluation of paediatric radiology services in hospitals in the UK, Clinical Radiology (2016), http://dx.doi.org/10.1016/j.crad.2016.05.024 2 K. Halliday et al. / Clinical Radiology xxx (2016) 1e5 radiation. Image interpretation requires an in-depth Table 1 knowledge of the developmental abnormalities and dis- Audit standards. eases distinct to the paediatric population and the different Standard Indicator fi manifestations and signi cance of conditions common to 1. Children’s imaging should be % of examinations performed by both adults and children. Failure to provide this specialised performed by staff with radiographers who had received service may result in physical or psychological harm to the appropriate training1 specific training in imaging children ’ child, expensive and unnecessary investigations, and 2. Children s imaging should be % of examinations reported by 5,6 reported by staff with paediatric radiologists/ misdiagnoses. appropriate training1 radiographers appropriately The provision of a dedicated paediatric radiology service educated and trained in image is of particular importance in cases of actual or suspected interpretation physical abuse where the availability of high-quality imag- 3. Radiologists with an interest % of paediatric radiologists who ing and specialised radiological reporting is vital to protect in paediatric radiology/ have attended paediatric CPD in neuroradiology/ 2012 those at risk. Failure of radiological provision can have interventional radiology disastrous effects, not only for the child, but also their should have access to CPD2,3 family and the staff and institutions involved in their care. 4. All radiographers imaging % of radiographers who regularly children should have access to image children who have attended Poor-quality imaging was one of the many contributors to 1 fi fi CPD paediatric CPD events in 2012 the death of Peter Connelly as identi ed in the rst serious 5. Arrangements should be in % of institutions having 24/7, all year 7 case review. More recently, a serious case review by the place to access a specialist round access to paediatric radiology North East Lincolnshire local safeguarding children board paediatric radiology/ opinion described a case where failure to identify rib fractures on a neuroradiology opinion 24/ 1,3 chest X-ray had disastrous results for a child and their 7 8 6. These arrangements should be % of institutions with facilities for family. supported by facilities for image transfer to another institution In response to concerns regarding the Peter Connelly image transfer1,3 for second opinions case, and also the healthcare commission report into 7. Funding arrangements should % of institutions with facilities for interventional radiology at Birmingham children’s hospi- be in place to support access image transfer in which there is a to second opinion1,3 funding agreement in place tal,9 the former National Imaging Board commissioned a 8. Formal pathways should be in % of those institutions that transfer UK-wide document in 2010 on behalf of the Department of place for transfer of patients if patients to another institution for Health. This document, “Delivering quality imaging services appropriate3 paediatric radiology opinion/ for children”1 was intended for commissioners and treatment that have formal described a three-tier network for paediatric radiology, arrangements in place 9. Skeletal surveys should be % of surveys reviewed by where larger hospitals supported smaller units with reviewed by a consultant consultant/specialist paediatric training, imaging protocols, and reporting. By 2012, 2 years radiologist or an experienced radiographer before child left on from the publication of that document, concerns that the senior radiographer prior to department situation had not improved and that the increasing shortage the child leaving the 2 of radiologists was exacerbating the situation,10 led to this department 10. Departments that image % of surveys with initial written audit to assess the current state of paediatric radiology in children for suspected (NAI) report the UK. must be able to provide an initial report2 11. Skeletal surveys should be % of surveys double reviewed double reviewed2 12. It is recommended practice % of surveys for which there was Materials and methods that follow up imaging should follow up imaging be performed after skeletal Standards survey for NAI2 For the purpose of the audit, a paediatric radiologist was defined as a radi- Each of the audit standards in Table 1 comprises a ologist with 6 months or more training in a specialist paediatric centre. recommendation, which specifies the structure, process, or Examples given of paediatric CPD events for radiographers included Non- Accidental Injury Study Day, APR (Association of Paediatric Radiographers) outcome against which the quality of performance is to be events and UKRC (UK Radiological Congress) paediatric focussed sessions. judged; an indicator, which is a single variable that mea- CPD, continuing professional development; NAI, non-accidental injury. sures whether a recommendation is conformed with, and a target, which is the level of conformity aimed at or required. Recommendations were derived from “Delivering quality All RCR clinical radiology audit leads at institutions imaging services for children” and the Royal College of Ra- (hospitals/trusts) imaging children aged 16 years or diologists (RCR) publications “Standards for radiological younger between 1 January and 31 December 2012 were investigations of suspected non-accidental injury”2 (stan- invited to participate in October 2013. Information about dards 3 and 9e12) and “Improving paediatric interventional the audit was also circulated to lead paediatric radiogra- radiology services”3 (standards 3 and 5e8). Each standard phers via the Society and College of Radiographers and also was discussed and agreed jointly by the Clinical Radiology to paediatric radiologists via the British Society of Paediatric Audit Committee and the British Society of Paediatric Radiology. Reminders were sent to non-participating in- Radiology. The target for all standards was 100%. stitutions in November and December 2013. Data were

Compliance with audit standards Compliance with standard 2 was calculated from estimated percentages rather than counts; therefore, the value shown (60%) is the median. Table 3 shows that only one standard, “arrangements to CPD, continuing professional development. access a specialist paediatric radiology/neuroradiology

Table 2 opinion 24/7 should be supported by facilities for image Institution demographics. transfer”, was met (100%). Review of skeletal surveys by a

Home nation n%consultant radiologist or an experienced senior radiographer prior to the child leaving the department (99%), double England 68 78 Scotland 12 14 reviewing of skeletal surveys (97%), and access to CPD for Wales 5 6 radiologists with an interest in paediatric radiology/ Northern Ireland 2 2 neuroradiology/interventional radiology (95%) came close 4 Size of institution (RCPCH category) to being met. Institutions failed to meet the remaining Very small 5 6 Small 18 21 standards by a considerable margin, with compliance be- Medium 35 40 tween 34% for access to CPD for all radiographers imaging Large 27 31 children, to 74% for departments that image children for Unknown 2 2 suspected non-accidental injury (NAI) being able to provide Institutions with neonatal unit 79 92 an initial report. Reasons given by respondents for non- Institutions performing paediatric surgery 50 57 compliance with key standards are shown in Table 4. Lack Royal College of Paediatrics and Child health (RCPCH) categories based on of radiographers who had received speciﬁc training in im- Hospital Episodes Statistics (HES) data for number of paediatric emergency admissions in 2011e2012: very small <1,500, small 1,501e2,500, medium aging children, lack of access to paediatric radiologists/ 2,501e5,000, large >5,000. paediatric radiology cover, and lack of time were the most

Table 4 The results of this audit demonstrate that the blueprint Reasons for non-compliance with standards. for delivering a comprehensive paediatric imaging service Recommendations Response No. of %Of outlined by the Department of Health in its 2010 document responses respondents “Delivering quality imaging services for children” remains a a (institutions) largely unmet aspiration. This audit shows that the Children’s imaging Access to paediatric 42 60 recommendation for developing networks to allow year- should be radiologist not 24/7 round 24/7 access to a specialist opinion has only been reported by staff Paediatric radiology 42 60 with appropriate cover not always achieved in 38% of centres. Appropriate training for staff is training available not available in one-third of centres and CPD of staff is not Plain films 8 11 available in two-thirds of centres. Twenty-five percent of Other specialist, e.g., 913 centres carrying out radiological investigations for sus- neuro/ pected child abuse have no radiologist capable of issuing a musculoskeletal radiologist report on those studies and 40% are failing to carry out Not deemed 69 essential follow-up investigations. Although some chil- necessary dren’s radiology takes place in children’s hospitals or other fi Insuf cient paediatric 17 24 specialist units, 75% of paediatric imaging is performed in radiologists 13 Respondents 70 100 smaller units in the UK. The large number of vacant All radiographers Lack of funding 28 49 consultant paediatric radiology posts means that there is imaging children Lack of time 46 81 often no radiologist with specific paediatric training or should have No courses available 8 14 experience in the smaller units. Only the largest units can access to CPD Lack of interest 7 12 provide 24/7 cover and when this is not available non- Unknown 6 11 Respondents 57 100 specialist staff must do their best. This situation is confirmed by the results of this survey, and the concerns of CPD, continuing professional development. fl a The percentage of relevant respondents (institutions with <100% health professionals are re ected in their comments. compliance with given standard) providing each of the given responses. Paediatric radiography is not recognised as a specialist skill and does not attract a higher banding in agenda for change. Additionally, no postgraduate radiographic qualifi- commonly reported reasons for non-compliance with these cation is available. Most newly qualified radiographers standards. would agree that obtaining high-quality radiographs in tiny neonates or frightened toddlers requires additional com- petencies, yet only 65% of radiographers regularly obtaining Discussion such images have had any additional training beyond their basic qualification and only 34% had any access to CPD. Free- What evidence is there that specialised paediatric im- text comments received, indicating a lack of access to aging is of value? A recent study from the United States5 specialist staff and training resources, show that staff are demonstrated major errors in more than 20% of paediatric acutely aware of the deficiencies in specialised paediatric examinations reported in general hospitals. Concrete evi- imaging input and feel exposed and vulnerable as a result. dence for the adverse effects of computed tomography in The general practitioner or paediatrician requesting im- young patients has been provided by two recent large aging is usually completely dependent on the report they population studies,11,12 yet data from the UK for 2012e2013 receive and have no knowledge or control over the quality demonstrated that a child is three-times more likely to of the study or the report. They are, therefore, also undergo whole-body CT when presenting to a general extremely vulnerable to poor-quality imaging, which can trauma unit than a paediatric unit.6 have disastrous effects on the care of their patients. High-quality imaging is vital in the field of suspected There were some limitations associated with this audit. physical abuse. The first serious case review7 into the death This study only reflects the situation in the 44% of in- of Peter Connelly details several “poor-quality” radiographs stitutions that responded. Data for RCR audits are collected in the months prior to his death, and it is clear that inade- by local consultants, many of whom are compromised by quate imaging led to uncertainty and confusion. A more increasing workload and empty posts. In fact, this response recent report describes a case in which the failure to iden- rate was extremely good in comparison to other recent tify rib fractures on a chest X-ray taken in a district general audits, which reflects the strength of feeling around this hospital resulted in the child being sent back to an abusive topic. Furthermore, the size distribution of these in- environment. The child was subsequently admitted with stitutions is comparable to the picture across the UK as further fractures and a brain injury of such severity that detailed in “Facing the future”.4 Some of the respondent they will require supportive care for the remainder of their data were based on estimates (indicated in the text); life. Had the original radiograph been reported by a radi- however, this was because more accurate information was ologist with experience in paediatric imaging, it would not available or too time consuming to collect. The infor- probably have saved not only the tragedy for the child and mation presented relates to 2012 rather than the current the family, but also the considerable cost to the taxpayer of situation, but there is no reason to suppose that the situa- providing lifelong care.8 tion has improved; in fact, the increasing shortage of

Please cite this article in press as: Halliday K, et al., Evaluation of paediatric radiology services in hospitals in the UK, Clinical Radiology (2016), http://dx.doi.org/10.1016/j.crad.2016.05.024 K. Halliday et al. / Clinical Radiology xxx (2016) 1e5 5 radiologists and the increasing volume of imaging per- commissioners, and heath boards to collaborate together, to formed nationally can only be expected to exacerbate the provide the quality of care our children deserve. shortfall. The development of formal paediatric imaging networks requires participating organisations to work together to Acknowledgements ensure that existing technological solutions are optimised to facilitate rapid review and reporting of images between This study was undertaken on behalf of the Clinical centres together with effective videoconferencing. Some Radiology Audit Committee of the RCR, and the authors investment would be needed to provide administrative would like to thank all radiologists and radiographers who resource for rotas and cross-charging, but there are also collected data in different departments across the country savings. In one hospital in the East of England, paediatric and, in particular, Dr John Somers MRCP FRCR for his advice. imaging services are provided using a combination of on- site and remote support of two programmed activities References (PAs) per week. Previously, the general radiologist with an interest in paediatrics had a total of 4.5 PAs attributed to 1. Department of Health. Delivering quality imaging services for children.A children’s imaging. Expert input can decrease the number of report from the National Imaging Board. London: DoH; 2010. investigations performed15 and should reduce the high 2. Royal College of Radiologists and the Royal College of Paediatrics and Child Health. 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Please cite this article in press as: Halliday K, et al., Evaluation of paediatric radiology services in hospitals in the UK, Clinical Radiology (2016), http://dx.doi.org/10.1016/j.crad.2016.05.024