Allied Health Professionals with Special Interest. AHPwSI

1. Allied Health Professionals with Special Interest. AHPwSI Some experience from Diagnostic Radiography Liz Hunt - Radiology Directorate Manager Addenbrooke’s NHS Trust AHPwSI 6.11.03

2. Two examples from Diagnostic Radiography • Direct referral from GP’s for barium enemas undertaken by Radiographers. Waiting list down from 3 months to 2 weeks • Direct GP referral for women with post menopausal bleeding into ultrasound. 200-250 outpatient appointments saved per year AHPwSI 6.11.03

3. Barium Enema • Barium is inserted into the bowel via a rectal tube • Air is added to produce double contrast • The patient is rotated during the test to ensure all the bowel is visualised • Detects cancer, diverticular disease, polyps etc. AHPwSI 6.11.03

4. Diagnostic Radiographersperforming Barium Enemas • The Problem • Long waiting list for barium enemas • 2 week wait for cancer referral to diagnosis • Lists only available when Radiologist available • SpR’s in training must gain competency • Consultant Radiologists specialising, and performing more interventional work AHPwSI 6.11.03

5. The solutions • Increase the number of sessions • Vet the request forms more thoroughly • Decrease the specialist work • Train interested Radiographers in GI work and reward them for their skill AHPwSI 6.11.03

6. The method • Radiographer interested in GI work to undergo training • Leeds theory course • Practical work supervised by GI Consultant • 100 barium enemas • Exam passed and Trust authorizes Radiographer to perform the examination • Reporting done jointly with the Consultant • ( latest RCOR guidelines advise joint reporting by all staff ) AHPwSI 6.11.03

7. Radiographer assigned 2 lists per week • If waiting list rises schedule extra lists • Second Radiographer undergoes training • Back up for each other • No list cancellation • GP directly refer for barium enemas • Waiting list gone down from 3 months to 2 weeks • Quality control assessed by audit AHPwSI 6.11.03

8. Results • High patient satisfaction with excellent patient care and reduced waiting list • High job satisfaction from Radiographer with specialist skills • Recognition as an advanced practitioner in line with the 4 tier structure • High satisfaction with GP’s who get fast patient diagnosis and can refer on to appropriate specialist for treatment as necessary AHPwSI 6.11.03

9. Barriers to the process- Before introduction • “This is a teaching hospital we must enable SpR’s to get enough experience” • “How can a non medical member of staff be trained sufficiently to understand this” • “This is the beginning of the end” AHPwSI 6.11.03

10. After introduction • There is a positive impact in SpR training in that the Radiographers who have developed great expertise can contribute to training • On audit the diagnostic results for the Radiographer are better than those achieved by more junior SpR’s • Continual audit provides a standard for the service • “Can John cover my list?” AHPwSI 6.11.03

11. Post menopausal bleeding- Background • It is a common gynaecological symptom • Women with PMB should be referred to a cancer unit for gynaecological assessment • “Improving outcomes in gynaecological cancers NHS Executive 1999” • Traditionally managed by D+C and hysteroscopy • Transvaginal ultrasound can be used as a screen for endometrial cancer in symptomatic postmenopausal women AHPwSI 6.11.03

12. If the endometrial stripe is uniform and <5mm in thickness likelihood of malignancy is <1% • This group accounts for 45-50% of referrals • 50% with +ve scans have intra-uterine pathology which can be assessed at hysteroscopy • Direct referral by the GP to ultrasound would allow patients with a normal scan to return to primary care without the need for a gynae clinic appointment AHPwSI 6.11.03

13. Diagnostic radiographers trained to perform ultrasound • Background in pattern recognition and cross sectional anatomy • 12-18 month training to qualify in ultrasound (Post graduate diploma) • Supervised at every stage • On qualification can perform ultrasound and give a report • Become an advanced practitioner on proving all competencies AHPwSI 6.11.03

14. PMB • Ultrasonographers trained in the use of transvaginal scanning scan women with PMB and independently report on their diagnosis • Audit required to try and identify relevant patient group and perhaps extend the practice to patients with ? Pelvic mass. AHPwSI 6.11.03

15. Ultrasound audit • Data collected for 3 months on all referrals for pelvic ultrasound (Nov.2002-Jan 2003) • Results divided by age into PMB, pelvic mass pain, abnormal bleeding and general (330) AHPwSI 6.11.03

16. PMB About 50% PMB occurs between ages of 50-59 AHPwSI 6.11.03

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18. Peak ages for particular gynae problems as predicted. AHPwSI 6.11.03

19. Stakeholder meetings • GP cancer lead from PCT’s • Gynae Onc Consultant • Consultant Radiologist • Ultrasound Radiographer • Clerical staff from all areas • Manager from Gynae and Radiology AHPwSI 6.11.03

20. Agenda • To discuss the concept and get agreement • To discuss the paperwork required • To identify the patient pathway • To ensure a fallback for patients who did not conform to the pathway • To clear the hysteroscopy waiting list • To agree the process • To keep the referral threshold constant AHPwSI 6.11.03

21. Patient Pathway Examination by GP Patient referral proforma faxed to gynae onc and then to us Patient to GP with PMB Normal diagnosis . Patient back to GP Patient treated as required Ultrasound within 2 weeks Abnormal diagnosis Patient referred to gynae onc AHPwSI 6.11.03

22. Referral Proforma for GP AHPwSI 6.11.03

23. Scan Normal AHPwSI 6.11.03

24. Scan Abnormal AHPwSI 6.11.03

25. Conclusion • Primary and secondary care working in partnership for better patient care • GP continues to make decisions about referral based on their consultation • Diagnosis and consultation simultaneously saving patient journeys to the hospital • Fast referral for worried women • Improved use of out patient appointments • 200-250 appointments saved AHPwSI 6.11.03

26. Radiographers work independently in ultrasound to deliver the diagnosis. • Consultant Radiologist time available for other more complex work e.g. neck lump biopsy. Next steps • To audit numbers • To develop a similar pathway for pelvic masses AHPwSI 6.11.03

27. Acknowledgements • To all my colleagues in Radiology, the gynae team, the GP’s and our local PCT’s Thank you for listening AHPwSI 6.11.03