The Effect Of A Radiographer Led Discharge Service

Discharge services in Emergency Departments (ED) have been led by clinicians traditionally. Leveraging on healthcare staff would aid in providing more patient-centred care, while reducing clinical workload shouldered by clinicians. This review analyses the effect of radiographer led discharge (RLD) based on studies carried out from 2007 to 2018 in the United Kingdom, in a chronological manner. The results of pilot studies carried out in ED of hospitals would be analysed to weigh the benefits of RLD.

A four-month pilot study by Snaith (2007) evaluated the potential of RLD in reducing possible delays for patients with detailed care plans. The scope of RLD was limited to patients aged between 5 to 65 and anatomically restricted to distal extremities. Three experienced radiographers were trained and supervised in patient discharge process. Detailed care plans and instructions for discharge by ED clinicians and emergency nurse practitioners were needed before radiographers could discharge patients. The outcome of the study was measured by the duration of patients’ stay in ED and the number of unplanned returns. Out of 1760 patients who had their radiographs instantly reported, 564 assessments had normal findings and could have been discharged; but lacked written care plans. Out of 114 RLD patients, one patient had returned unplanned; but required no varied treatment. The mean length of stay for RLD patients was reduced by more than 50 percent compared to average duration prior to the study. Upon initiation of immediate reporting, a 52 percent decrease in the number of patients recalled due to misdiagnosis was observed.

Regardless of a large majority of patients having normal radiological reports, they were not discharged by radiographers due to the lack of written plans. The discharge process could not be expedited as radiographers were not given the autonomy to directly discharge patients after immediate reporting; thus, affecting results gained for duration of patients’ stay. Furthermore, a time frame for unplanned returns by patients was not set, which could have adversely affected the results gained to one of the outcome measures of this experiment.

A similar study over a period of two years by Henderson et al. (2013) assessed if RLD reduced time spent in ED without adverse effects. Unlike Snaith’s study, RLD and ED staff-led discharge, were compared simultaneously. The two participating radiographers were required to have completed specific courses. The same parameters for the scope of discharge by Snaith (2007) were used for this study; alongside with ambulant patients having to attend ED on weekdays during working hours. Patients with pathologies requiring follow-ups were excluded. The results were measured by the number of clinically significant unplanned returns, due to misdiagnosis or inexpedient treatment plans, within 28 days from discharge, diagnostic accuracy and duration of visits. Out of 639 RLD patients, 497 patients were discharged immediately. They spent an average time of 100. 9 minutes in ED, compared to an average of 122. 0 minutes spent by other patients. There were 35 significant misdiagnoses by ED staff as compared to none by RLD. There were higher chances of clinically significant same injury returns when discharged by ED staff. While Henderson et al. improved upon Snaith’s earlier study, there were no follow-ups on RLD patients like Snaith’s study to check for re-presentation of same injuries. With possibilities that patients could have sought alternative treatments, the results of re-attendance rates could have been affected. The results for the rate of significant same injury re-presentation would have been more accurate if patients were pursued after RLD. Nonetheless, the study was carried out like a randomised controlled trial (RCT) with patients being blinded, making the results mostly reliable.

A study by Hardy et al. (2013) evaluated the cost effectiveness of instant reporting of ED musculoskeletal (MSK) radiographs. RCT over four weeks was done with 1502 patients, recruited if they had sustained MSK injury within 48 hours before examinations. Those identified for participation were briefed and had to complete an EQ-5D questionnaire, a standardized measure of perceived health status. There were 752 patients randomly assigned to instant reporting group and 750 patients to delayed reporting group. The results were measured by diagnostic accuracy. Cost-effectiveness was measured by changes in utilities resulting from EQ-5D responses initially and after eight weeks. The use of resources and cost of instant reporting were examined at patient level. There were 79 out of 1688 contradictory radiographic interpretations observed between ED and radiology department, with significant misinterpretations made by ED clinicians.

Immediate reporting seemed cost-effective with no significant difference observed in patients’ perceived health status or patients’ outcomes in both groups. The average cost saving per patient in the immediate reporting group was £23. 40. Participating patients were unblinded to the details of the study; but the results were not skewered to favour RLD. Hardy et al. quantitatively measured cost-effectiveness by the EQ-5D questionnaire, which is subjective. Also, there was at least 50 percent missing data in the follow-up questionnaire. Therefore, the results obtained for this outcome measure may not have been reliable or representative of all patients. Moreover, to gain a holistic analysis of the impact of RLD, cost-effectiveness of RLD on radiographers and hospitals need to be examined.

Based upon existing studies, Rachuba et al. (2018) aimed to evaluate the effectiveness of RLD implementation with restructured minor injuries pathways, using a discrete event simulation (DES) model. A simulation model was developed by simplifying current minor injuries ED pathways at a medium-sized hospital. It was modified to create a generic DES model using Simul8, an interactive interface to increase engagement. The DES model was verified and validated to replicate current pathways and investigate pathway redesign options. RLD was added to the pathways at different degrees to assess its impact on patients’ duration of stay and the availability of qualified radiographers for trade-off analysis. A trial run of the model was conducted for 699 days. The outcome was measured by duration of stays in ED, number of RLD patients and number of clinical examinations. By using DES and RLD, patients’ duration of stay could be decreased by an average of more than 20 minutes.

The duration of stays decreased with increasing availability of RLD. RLD introduction also decreased the number of clinical examinations. The model was designed based on a historic data set, and it was assumed that a patient’s pathway is known before triaging takes place, which is not reflective of actual ED processes. As such, it would be inaccurate to generalise the model across different hospitals. Secondly, availability of RLD was quantified as the cost for trade-off analysis. The study did not analyse the extent of resources needed for training radiographers and the actual costs hospitals must bear to implement RLD, in terms of restructuring pathways. While the model proved to be effective, adopting this model across all hospitals would be impractical as it provides a generalised overview of ED pathways and may not be fully applicable to everchanging clinical settings.

RCTs were carried out by Henderson et al. (2012) and Hardy et al. (2013) without placebo effects being introduced. Rachuba et al. (2018) had a well-designed cohort studies with concurrent and historical controls for comparison of RLD. Both Snaith’s study and Hardy et al. ’s study occurred over a short period, which could have reduced the accuracy and reliability of their results. However, improved studies by Henderson et al. (2012) and Rachuba et al. (2018) provided similar outcomes of RLD. While each study had its own limitations, they built upon each other to evaluate the effects of RLD. Studies by Snaith (2007), Henderson et al. (2012) and Rachuba et al. (2018) concluded that patients benefited from RLD with reduced time spent in ED, resulting in increased patient satisfaction while reducing clinicians’ workload. This would allow ED clinicians to focus on patients with complicated pathologies.

Moreover, higher reporting accuracy, with clinically insignificant errors, was demonstrated by radiographers (Snaith 2007, Henderson et al. 2012, Hardy et al. 2013). Therefore, both patients and hospital staff benefit from RLD. Radiographers in Snaith’s (2007) study received additional training before they could be qualified to discharge patients. Moreover, there was only a handful of radiographers who were involved in the four studies. Thus, diagnostic accuracy results based on these radiographers should not be generalised to all radiographers. While Hardy et al. (2013) stated that the quality of reports done by radiographers were of similar standard to consultant radiologists, studies carried out by Snaith (2007) and Henderson et al. (2012) required participating radiographers to have significant training. This was supported by the Society and College of Radiographers (SCoR) recommended a minimum of postgraduate certificate taught at Masters level in reporting. With such prerequisites, highly skilled radiographers are required for RLD, who are more expensive than lower grade radiographers. Through the different cost-effectiveness analyses, RLD could be limited by a hospital’s finance and availability of highly trained radiographers in reporting.

Furthermore, the impact of RLD on radiographers’ current responsibilities was unexplored. According to Snaith (2007), some patients in his study had discharge plans documented; but were not discharged as radiographers were tending to other patients. This shows that RLD could be limited by radiographers’ duties and should be considered to analyse the full effects of RLD. Nonetheless, weighing the benefits of RLD against possible limitations of introducing it suggests that RLD is beneficial to patients and hospital staff. All four studies of RLD were limited to minor injuries and distal extremities. However, since these injuries account for more than 55 percent of ED attendance, the results obtained from these studies could be impactful on waiting time and patient re-attendance rates in ED, thus streamlining the care pathway.

RLD has demonstrated that the role of radiographers can extend beyond traditional parameters. With further analysis on the full costs of RLD implementation, hospitals should consider capitalising on this to improve patient management and waiting time in ED. Boundaries between roles could be blurred for optimisation of processes in hospitals, like introducing RLD.

15 July 2020
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