Thorax | 2019
P107\u2005Designing an optimum pleural pathway: impact of one stop pleural clinic and radiographer pathway on time to diagnosis
Abstract
Introduction The ‘radiographer pathway’ was set up in 2017 at Norfolk and Norwich University Hospital to expedite access to pleural services. This pathway consists of initial radiographer review of all chest X-rays and, if the X-ray shows a significant effusion, the radiographer refers directly to the on call respiratory registrar. One stop pleural clinics were also developed, where patients undergo respiratory review and initial intervention (aspiration/ultrasound guided biopsy) at a single appointment. Aim This audit aimed to assess the time from X-ray to diagnosis for patients with a new pleural effusion referred via different pathways – GP, tertiary and radiographer and those attending a one stop pleural clinic. Methods Retrospective review of prospectively collected database of patients referred to Pleural Clinic with an undiagnosed pleural effusion from January 2018 to April 2019. Results 110 new referrals were received. The median time from X-ray to diagnosis for patients referred via the radiographer pathway was significantly less than for GP and tertiary (15, 45 and 27 days respectively, p<0.001) (Table 1). Thirty-two patients needed further biopsies (thoracoscopy/computer tomography guided) for definitive diagnosis. Sixty-four out of 110 patients came to a one stop pleural clinic. The median time from x-ray to diagnosis for patients attending a one stop pleural clinic compared to those who had separate respiratory review and intervention was 25 (IQR 15–39) and 36 days (IQR 25–53) respectively. For patients diagnosed with a malignant pleural effusion, the 62 day pathway was breached in 3/20 (15%), 6/16 (38%) and 10/22 (45%) patients referred via the radiographer, tertiary and GP pathway respectively. Discussion Referral via the radiographer pathway lead to earlier diagnosis as compared to referrals via the GP and tertiary pathways and had lesser breach of the 62 day pathway for malignant effusions.Abstract P107 Table 1 Summary of time in days through different points in the patient pathway for patients referred via GP, tertiary and radiographer pathways for patients with a final diagnosis of either malignant or non-malignant pleural effusions GP Tertiary Radiographer Number of patients 45 35 30 One stop pleural clinic 21 27 16 Median time, days (interquartile range) X-ray to referral 8 (2–13) 3 (0–16) 0 (0–0) Referral to respiratory review 13 (8–18) 7 (5–11) 0 (0–5) Respiratory review to initial intervention 3 (0–7) 0 (0–0) 0 (0–7) Initial intervention to diagnosis 14 (3–27) 4 (2–20) 7 (2–13) X-ray to diagnosis 45 (28–57) 27 (15–42) 15 (9–23) Malignant pleural effusion Number of patients 22 16 20 Median time, days (interquartile range) X-ray to referral 5 (1–12) 6 (0–17) 0 (0–0) Referral to respiratory review 11 (7–16) 6 (4–7) 0 (0–5) Respiratory review to initial intervention 0 (0–5) 0 (0–0) 2 (0–7) Initial intervention to diagnosis 16 (4–27) 8 (3–17) 7 (3–15) X-ray to diagnosis 38 (27–52) 26 (12–43) 19 (12–22) Benign pleural effusion Number of patients 23 19 10 Median time, days (interquartile range) X-ray to referral 9 (2–15) 1 (0–16) 0 (0–0) Referral to respiratory review 14 (11–21) 10 (6–16) 0 (0–4) Respiratory review to initial intervention 5 (0–9) 0 (0–5) 0 (0–4) Initial intervention to diagnosis 9 (2–24) 3 (2–16) 6 (2–9) X-ray to diagnosis 50 (35–59) 35 (17–41) 11 (9–22)