RDGY30630 Technology of Radiography: QA
Audit Coursework
PART 1: UNDERSTANDING AUDIT AND ITS SIGNIFICANCE
Briefly outline your understanding of the term “clinical audit” in the context of the radiology department and describe why it is important (guide: approx. 500-600 words, excluding references).
A clinical audit is ‘the systematic review and evaluation of current practice against research based standards with a view to improving clinical care for service users.’(Health Service Executive, 2017) In the practice of radiography, clinical audits are of great importance due to the use of ionising radiation. It is necessary to protect patients from the potential harm arising from stochastic and deterministic effects of radiation . As the field of radiography is constantly evolving with improvements in technology and radiographer role extension (Cowling, 2008,pp. 28-32), quality clinical audits are essential to ensure the standards of radiological services are being upheld. Since February 2018, clinical audits were made mandatory in every radiology department in the European Union after the European Council adopted the EURATOM directive (Council Directive, 2013). It defined audits in the radiology department as “a systematic examination or review of medical radiological procedures which seeks to improve the quality and outcome of patient care through structural review whereby radiological practices, procedures and results are examined against agreed standards for good medical radiological procedures, with modification of practices where indicated and the application of new standards if necessary.” A report on Patient Safety and Quality Assurance recognised the importance of clinical audit. It states that clinical audit is the ‘single most important method which any healthcare organisation can use to understand and ensure the quality of the service it provides.’ (Department of Health and Children, 2008). Audits allow staff to be aware of how the department is performing and also the evaluation of patient care and safety. It shows if the department is compliant to standards of good practice. Most importantly, it gives areas of improvement and recommendations. Performing re-audit checks if the expected improvement was achieved. Clinical audits in the radiology department involves many aspects such as department infrastructure, radiation safety for patients and staff, radiology equipment and clinical practice. This all must be documented and updated on a regular basis.
Literature confirms the need for healthcare providers to have the ability to perform clinical audits. Clinical audit is a professional and organisational responsibility. The burden of clinical audit should not fall on one person. Quality clinical audits make patient and staff safety a priority, set goals for the radiology service, develop a culture of openness, learn from past mistakes and develop staff skills (Pillar, 2015). Radiographers need to ‘demonstrate that they review and evaluate the quality of their work through participation in quality improvement activity.’ (The Royal College of Radiologists, 2010) Audits for accreditation certificates are not the same as clinical audits. The aim in clinical auditing is clinical good practice and ‘the results are recommendations with no inherent obligation on their implementation.’(European Commission, 2009)
When performing a clinical audit, one must follow the clinical audit cycle (HSE, 2017). This includes setting the objectives and identifying the issues to be audited, setting the criteria of good practice using evidence based practice guidelines and assessing practice according to these guidelines. Post assessment, one must give recommendations for improvement and implement these recommendations. During clinical audits in the radiology department, patient and staff confidentiality is of grave importance. An essential part of the clinical audit cycle is re-audit. Failure to re-audit undermines the effectiveness of clinical audits and leads to a waste of resources (Gnanalingham, 2001). Post audit, an audit report must be written up and made available to staff so they can see the effects the audit has had on their practice. Overall, clinical audit is an essential and efficient tool for improving standards of quality in the radiology department.
References
Council of the European Union, 2013. Council Directive 2013/59/Euratom of 5 December 2013 laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom a. [Online]
Available at: https://eur-lex.europa.eu/legal-content/en/TXT/?uri=CELEX%3A32013L0059
[Accessed 2 October 2018].
Cowling, C., 2008. A global overview of the changing roles of radiographers. International Journal of Diagnostic Imaging and Radiation Therapy, 14(1), pp. 28-32.
Health Service Executive, 2017. A Practical Guide to Clinical Audit. [Online]
Available at: https://www.hse.ie/eng/about/who/qid/measurementquality/clinical-audit/practicalguideclaudit2013.pdf
[Accessed 2 October 2018].
Department of Health & Children, 2008. Building a Culture of Patient Safety. [Online]
Available at: https://health.gov.ie/wp-content/uploads/2014/03/en_patientsafety.pdf
[Accessed 2 October 2018].
Esposito, P., Canton, A., 2014. Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology. World Journal of Nephrology, 3(4), pp. 249-255.
Faulkner, K., 2016. The role of comprehensive clinical audits in quality improvement in diagnostic radiology. Physica Medica, 32(3), p. 181.
European Commission, 2009. European Commission guidelines on clinical audit for medical radiological practices (diagnostic radiology, nuclear medicine and radiotherapy). [Online]
Available at: https://publications.europa.eu/en/publication-detail/-/publication/75688cc6-c9d3-4c43-9bfd-ce5cea0d8bcb
[Accessed 2 October 2018].
European Society of Radiology, 2016. ESR Audit Tool. [Online]
Available at: https://www.myesr.org/sites/default/files/ESR_2016_Audit-Tool.pdf
[Accessed 2 October 2018].
European Society of Radiology, 2011. European Commission guidelines on clinical audit.. [Online]
Available at: https://doi.org/10.1007/s13244-011-0065-8
[Accessed 2 October 2018].
Holmberg, O. , Malone, J., Rehania, M., McLean, D., Czarwinski, R., 2010. Current issues and actions in radiation protection of patients. European Journal of Radiology, 76(1), pp. 15-19.
Pillar, C., 2015. Clinical Audit Can Maximise Quality, Avoid Harm. Barcelona, Health in Management.
Schillebeeckx, J., 2017. The Need for Clinical Audits in Diagnostic Radiology. Health Management, 17(3), pp. 244-246.
The Royal College of Radiologists, 2018. Quality Improvement. [Online]
Available at: https://www.rcr.ac.uk/clinical-radiology/audit-and-qi/quality-improvement
[Accessed 2 October 2018].
PART 2: AUDIT TOOL
Insert your completed audit tool here. Include all parts of the tool, including methods, results and findings.
Table 1
IMAGE NO. Anatomical Marker Present* Correct Centering Patient Positioning Optimal Preventable artefacts removed Total score
1 1* 0 1 1 3
2 1 0 1 1 3
3 1 1 1 1 4
4 1 0 1 1 3
5 1 1 1 1 4
6 1 0 1 1 3
7 1 1 1 1 4
8 1 1 1 1 4
9 1 1 1 1 4
10 1 1 1 1 4
11 1* 1 0 1 3
12 1 1 1 1 4
13 1* 1 1 1 4
14 1 0 0 1 2
15 1* 1 1 1 4
16 1* 0 0 1 2
17 1* 0 0 1 2
18 1* 1 1 1 4
19 1* 1 1 1 4
20 1* 0 0 1 2
KEY: Yes=1 No= 0
*Indicate anatomical lead marker applied pre-exposure
Total score of 4 indicates that image meets all criteria
Aim
The aim of the audit was to assess plain radiographic images against the following radiographic image quality standards provided by the European Commission/Royal College of Radiologists:
1. Anatomical markers must be accurately placed on all radiographs, out of the way of the region of interest.
2. The correct centring point and limits of the examination should be adhered to.
3. Patient positioning should be optimal.
4. Artefacts should not be visible on the image where possible.
Methodology
A retrospective audit assessing x-ray images on the basis of image quality. A random set of 20 of general x-ray images were analysed to see whether they fulfilled each of the criteria of image quality listed above.
The data collected was analysed using Microsoft Excel.
Audit findings
The audit results are listed in Table 1 above. The results show that there was a 100% compliance with anatomical marker use and 45% of the images had a lead marker placed pre-exposure. Sixty percent of the images had been correctly centred. Twenty-five percent of the images did not meet the criterion of optimum patient positioning. All images had any preventable artefacts removed pre-exposure.
Figure 1: percentage of images that fulfilled the indicated image quality criteria
PART 3: ANALYSIS
Based on the results of your audit, discuss the risks (if any) associated with the findings, and root cause of any issues (if relevant).
The audit results showed a 100% compliance with use of anatomical markers placed in the primary beam and not obscuring the region of interest. This is best practice according to an article published by The Society and College of Radiographers (SCoR, 2011). However, less than 50% of the images had a lead marker. This may be due to a lack of lead marker availability in the x-ray department. (Barry et al, 2014) The low use of lead markers might also be due to the differences in radiographer training across countries, where some countries may put emphasis on lead marker use while others may not. The SCoR stresses that the application of a digital marker post-exposure should be regarded as a ‘safety net’ and not the standard of practice in radiology departments. The risk associated with reliance on digital anatomical markers is the margin for human error. The wrong digital marker can be placed on the image leading to a detrimental effect on the patient’s future management (Ringertz et al., 2002). If the x-ray image has been taken without a lead marker applied pre-exposure and the radiographer is doubtful of the anatomical side, a repeat exposure may be necessary. Subjecting patients to additional ionising radiation that could be avoided should be a concern of every radiographer. Unnecessary radiation goes against the principle of maintaining radiation exposure as low as reasonably achievable (ALARA).
Forty percent of the images evaluated in the audit were not centred correctly. This may be due to the practicing radiographer’s technique or the patient’s condition which led to the radiographer being unable to centre accurately (Woods, et al., 2016). Poor centring of an x-ray image results in unfamiliar projection of anatomy (Agthe, 2010) which may lead to a misdiagnosis by the reporting radiologist. Poor centring can also cause a reduction in image quality, making image repeats a necessity thereby increasing patient dose (Brookfield et al., 2013). When performing digital radiography using the Automatic Exposure Control (AEC) system, if the patient centring is not correct, the resulting image will have increased image noise. (Kaasalainen, et al., 2014)
Dean and Scoggins (2010) stated that proper positioning is necessary for obtaining images of diagnostic quality and also for patient safety and comfort. Good positioning technique is important to reduce the patient’s x-ray exposure (Marumaya & Yamamoto, 2008). The patient was not positioned optimally in 25% of the images. This could be due to the patient’s condition, for example if the patient has experienced severe trauma, optimal positioning may be difficult to achieve. This rate may be attributed to a lack of equipment to aid with patient positioning e.g. foam pads and straps, available in the x-ray department. Poor patient positioning could mimic pathology and cause superimposition of structures (Agthe,2010). Efficient use of the AEC system requires correct patient positioning.
Preventable artefact removal had a 100% rate of compliance in the audit. An artefact is defined as ‘a structure or an appearance that is not normally present on the radiograph and is produced by artificial means.’ (Serman, 2000). Artefact prevention in the radiology department is essential to keep with the principle of ALARA. Artefact prevention can be maintained in the department by performing regular quality assurance checks of the x-ray equipment and ensuring removal of any objects external to the patients.
References
Agthe, P., 2010. Imaging: Practice radiography: How to improve image quality: Part 1. Companion Animal, 13(8).
Barry, K., Saravana, K., Linke, R. & Dawes, E., 2016. A clinical audit of anatomical side marker use in a paediatric medical imaging department. Journal of Medical Radiation Sciences, 63(3), pp. 148-154.
Dean, E. & Scoggins, M., 2012. Essential Elements of Patient Positioning: A Review for the Radiology Nurse. Journal of Radiology Nursing, 3(1), pp. 42-52.
Finnbogason T, B. S. R. H., 2002. Side markings of the neonatal chest X-ray: two legal cases of pneumothorax side mix up.. European Journal of Radiology, 12(4), pp. 938-941.
Gnanalingha, J., Gnanalingham, M. G. & Gnanalingham, K. K., 2001. An audit of audits: are we completing the cycle?. Journal of the Royal Society of Medicine, 94(6), pp. 288-289.
Kaasalainen, T., Palmu, K., Reijonen, V. & Kortesniemi, M., 2014. Effect of Patient Centring on Patient Dose and Image Noise in Chest CT. American Journal of Roentgenology, 203(1), pp. 123-130.
Maruyama, T. & Yamamoto, H., 2008. Study of positioning techniques for radiography. [Online]
Available at: https://www.ncbi.nlm.nih.gov/pubmed/18311018
[Accessed 2 October 2018].
Serman, N., 2000. Radiographic Errors and Artefacts.[Online]
Available at: http://www.columbia.edu/itc/hs/dental/juniors/material/artifact.pdf[Accessed 2 October 2018].
Society & College of Radiographers, 2013. What is the point of centring?.[Online]
Available at: https://search.proquest.com/openview/76951f9af1397cacfece35c5622af528/1?pq-origsite=gscholar&cbl=46803
[Accessed 2 October 2018].
Woods, A. L., Miller, P. K. & Sloane, C., 2016. Patient obesity and the practical experience of the plain radiography professional: On everyday ethics, patient positioning and infelicitous equipment. Radiography, 22(2), pp. 118-123.
PART 4: RECOMMENDATIONS
Describe any actions should be taken as a result of the audit and what should be done going forward.
The audit shows that just fifty-five percent of the x-ray images assessed met all the selected image quality criteria.
Action plan
The audit results should be presented and made available to radiographers.
1. Increasing lead anatomical marker usage in the general x-ray department.
Inform radiographers of best practice of lead marker use. Ensure availability of lead markers by providing lead markers for radiographers to use in general x-ray rooms. (Johnson, 2014)
2. Inform radiographers of centring points for general examinations and explain importance of centring correctly. (Herrmann, et al., 2012)
3. Provide more supplementary equipment in the department to aid with patient positioning e.g. foam pads, straps, sandbags. Explain necessity of good patient positioning to reduce the number of repeat radiographs. (Eduwem, et al., 2011)
4. Commend radiographers for good practice of removing preventable artefacts in audit results and encourage them to keep it up (Lefroy, et al., 2015).
A re-audit is recommended in the next 6 months to review the progress after the changes have been implemented.
An audit report must be written for record-keeping purposes and for staff to see the effects the audit has had on their practice. (Shankar & Naveen, 2011)
References
Eduwem, D., Paulinus, S. & Akwa, E., 2011. A Survey of positioning and immobilization techniques adopted in Paediatric Chest Radiography in Nigeria. Journal of Radiography & Radiation Sciences, 25(1), pp. 1-7.
Herrmann, T. L. et al., 2012. Best Practices in Digital Radiography. [Online]
Available at: https://www.asrt.org/docs/default-source/publications/whitepapers/asrt12_bstpracdigradwhp_final.pdf
[Accessed 2 October 2018].
Johnson, S., 2014. Use of Anatomical Side Markers. [Online]
Available at: https://www.sor.org
[Accessed 2 October 2018].
Lefroy, J., Watling, C., Teunissen, P. W. & Brand, P., 2015. Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education. Perspectives on Medical Education, 4(6), pp. 284-299.
Shankar, A. N. & Naveen, V., 2011. The Basics in Research Methodology: The Clinical Audit. Journal of Clinical and Diagnostic Research, 5(3), pp. 679-682.
PART 5: REFLECTION
Is there anything you would change in your methodology/audit tool if you were completing this audit again?
1. Assess each projection individually.
For example, if an image had two projections of a body part e.g. anteroposterior ankle and lateral ankle on one image, each projection would be assessed individually instead of as a whole image which may have skewed the results in this audit.
2. Increase the sample size
The number of images might not have been enough to be considered the average performance of the general x-ray department as a whole.
3. Select more image quality criteria to increase the validity of the audit.
Only four image quality criteria were selected in this audit. Selecting more criteria would give a more accurate representation of overall image quality.
4. Take clinical indications on request form for x-ray image into consideration
Clinical indications would allow to assess if image quality was diagnostically acceptable in relation to the clinical request and did not warrant a repeat radiograph.
5. Include more variables
Some images contained unpreventable artefacts which could also be recorded in the audit for the purpose of assessing image quality.