Maryann Hardy

Emergency ultrasound in the prehospital setting: the impact of environment on examination outcomes

This study aimed to compare ultrasound examinations performed within a land ambulance (stationary and moving) with those completed in a simulated emergency department (ED) to determine the feasibility of undertaking ultrasound examinations within the UK prehospital care environment. The findings suggest that abdominal aortic aneurysm and extended focused assessment with sonography in trauma emergency ultrasound examinations can be performed in the stationary or moving land ambulance environment to a standard consistent with those performed in the hospital ED.

Estimating the Effect of Nonresponse Bias in a Survey of Hospital Organizations

Nonresponse bias in survey research can result in misleading or inaccurate findings and assessment of nonresponse bias is advocated to determine response sample representativeness. Four methods of assessing nonresponse bias (analysis of known characteristics of a population, subsampling of nonresponders, wave analysis, and linear extrapolation) were applied to the results of a postal survey of U.K. hospital organizations. The purpose was to establish whether validated methods for assessing nonresponse bias at the individual level can be successfully applied to an organizational level survey. The aim of the initial survey was to investigate trends in the implementation of radiographer abnormality detection schemes, and a response rate of 63.7% (325/510) was achieved. This study identified conflicting trends in the outcomes of analysis of nonresponse bias between the different methods applied and we were unable to validate the continuum of resistance theory as applied to organizational survey data. Further work is required to ensure established nonresponse bias analysis approaches can be successfully applied to organizational survey data. Until then, it is suggested that a combination of methods should be used to enhance the rigor of survey analysis.

The impact of immediate reporting on interpretive discrepancies and patient referral pathways within the emergency department: a randomised controlled trial

OBJECTIVE To determine whether an immediate reporting service for musculoskeletal trauma reduces interpretation errors and positively impacts on patient referral pathways. METHODS A pragmatic multicentre randomised controlled trial was undertaken. 1502 patients were recruited and randomly assigned to an immediate or delayed reporting arm and treated according to group assignment. Assessment was made of concordance in image interpretation between emergency department (ED) clinicians and radiology; discharge and referral pathways; and patient journey times. RESULTS 1688 radiographic examinations were performed (1502 patients). 91 discordant interpretations were identified (n=91/1688; 5.4%) with a greater number of discordant interpretations noted in the delayed reporting arm (n=67/849, 7.9%). In the immediate reporting arm, the availability of a report reduced, but did not eliminate, discordance in interpretation (n=24/839, 2.9%). No significant difference in number of patients discharged, referred to hospital clinics or admitted was identified. However, patient ED recalls were significantly reduced (z=2.66; p=0.008) in the immediate reporting arm, as were the number of short-term inpatient bed days (5 days or less) (z=3.636; p<0.001). Patient journey time from ED arrival to discharge or admission was equivalent (z=0.79, p=0.432). CONCLUSION Immediate reporting significantly reduced ED interpretive errors and prevented errors that would require patient recall. However, immediate reporting did not eliminate ED interpretative errors or change the number of patients discharged, referred to hospital clinics or admitted overall. ADVANCES IN KNOWLEDGE This is the first study to consider the wider impact of immediate reporting on the ED patient pathway as a whole and hospital resource usage.

The Child’s Right to Consent to X-Ray and Imaging Investigations: Issues of Restraint and Immobilization from a Multidisciplinary Perspective

Children’s rights in healthcare are determined by law but strongly influenced by Piagetian theory and the related personal attitudes of healthcare professionals. While a greater priority has been given to children’s rights throughthe United Nations Convention and in the United Kingdom by means of particular legislation, this does not necessarily translate into child-centred practice. The restraint and immobilization of children are significant issues for health professionals who care for children. This paper argues that professional guidance and healthcare law are ambiguous in this regard, failing to offer direct, objective guidance to the personnel involved. A further degree of complexity is added, if when considering the child’s wishes, they differ from those of their parents. It is recommended that an effective resolution of these issues and their consequences demands that healthcare professionals familiarize themselves with the legal and ethical implications of restraining or immobilizing children, and develop a systematic approach to this aspect of practice.

Does radiography advanced practice improve patient outcomes and health service quality? A systematic review

OBJECTIVE To investigate the impact of radiographer advanced practice on patient outcomes and health service quality. METHODS Using the World Health Organization definition of quality, this review followed the Centre for Reviews and Dissemination guidance for undertaking reviews in healthcare. A range of databases were searched using a defined search strategy. Included studies were assessed for quality using a tool specifically developed for reviewing studies of diverse designs, and data were systematically extracted using electronic data extraction pro forma. RESULTS 407 articles were identified and reviewed against the inclusion/exclusion criteria. Nine studies were included in the final review, the majority (n = 7) focusing on advanced radiography practice within the UK. Advanced practice activities considered were radiographer reporting, leading patient review clinics and barium enema examinations. The articles were generally considered to be of low-to-moderate quality, with most evaluating advanced practice within a single centre. With respect to specific quality dimensions, the included studies considered cost reduction, patient morbidity, time to treatment and patient satisfaction. No articles reported data relating to time to diagnosis, time to recovery or patient mortality. CONCLUSION Radiographer advanced practice is an established activity both in the UK and internationally. However, evidence of the impact of advanced practice in terms of patient outcomes and service quality is limited. ADVANCES IN KNOWLEDGE This systematic review is the first to examine the evidence base surrounding advanced radiography practice and its impact on patient outcomes and health service quality.

Requesting and interpreting trauma radiographs: a role extension for accident & emergency nurses

Government supported expansion of the nursing role within Accident & Emergency (A&E) departments in the United Kingdom (UK) has begun to break down the traditional barriers to professional practice. Today, many nurses working within A&E departments are both requesting and interpreting radiographic examinations as part of their normal working practice. However, role expansion does not occur without increased responsibility. Unsatisfactory requests for radiography and inaccurate radiographic interpretation may result in inappropriate patient treatment, misuse of resources, patient recall and litigation. Nurses undertaking these role extensions need to ensure that their levels of knowledge and skill to perform the role are appropriate and adequately supported. This article summarises the results of a national questionnaire survey of A&E nurse managers that aimed to identify current working practices, including education, training and limitations to practice, with respect to the requesting and interpretation of trauma radiographs by A&E nurses.

Emergency department image interpretation accuracy: The influence of immediate reporting by radiology

INTRODUCTION The misinterpretation of radiographs is recognised as a key source of emergency department (ED) errors, regardless of clinician profession. This article compares ENP and medical staff accuracy in the interpretation of musculoskeletal trauma X-rays between immediate and delayed radiology reporting pathways. METHOD The data for this study was drawn from a larger pragmatic randomized controlled trial of immediate reporting. Patients were recruited and randomly assigned to immediate or delayed reporting arms and treated according to group assignment. Image interpretive accuracy between ED staff groups and arms was undertaken together with an assessment of the influence of immediate reporting on patient pathways and journey times. RESULTS Six hundred and seventy-four radiographic examinations were performed (598 patients). There was a significant reduction in the interpretive errors in the immediate reporting arm for all ED clinicians (proportional difference=4.2%; 95% CI [0.017,0.068]; p=0.001), but no significant difference in proportion of interpretive errors was evident between ENPs and medical staff. Patient journey times, discharge and referral rates were not significantly different between study arms, although admission rates varied for medical staff collectively. CONCLUSION ENP X-ray interpretation accuracy is comparable with that of medical staff, but immediate reporting was seen to reduce errors without increasing patient journey times.

The use of history to identify anterior cruciate ligament injuries in the acute trauma setting: the 'LIMP index'

Objective To identify the injury history features reported by patients with anterior cruciate ligament (ACL) injuries and determine whether history may be used to identify patients requiring follow-up appointments from acute trauma services. Methods Multisite cross-sectional service evaluation using a survey questionnaire design conducted in the UK. The four injury history features investigated were ‘leg giving way at the time of injury’, ‘inability to continue activity immediately following injury’, ‘marked effusion’ and ‘pop (heard or felt) at the time of injury’(LIMP). Results 194 patients with ACL injury were identified, of which 165 (85.5%) attended an acute trauma service. Data on delay was available for 163 (98.8%) of these patients of which 120 (73.6%) had a follow-up appointment arranged. Patients who had a follow-up appointment arranged waited significantly less time for a correct diagnosis (geometric mean 29 vs 198 days; p<0.001) and to see a specialist consultant (geometric mean 61 vs 328 days; p<0.001). Using a referral threshold of any two of the four LIMP injury history features investigated, 95.8% of patients would have had a follow-up appointment arranged. Conclusions Findings support the value of questioning patients on specific injury history features in identifying patients who may have suffered ACL injury. Using a threshold of two or more of the four LIMP history features investigated would have reduced the percentage of patients inappropriately discharged by 22.2%. Evidence presented suggests that this would significantly reduce the time to diagnosis and specialist consultation minimising the chance of secondary complications.