Radiographer abnormality flagging systems in the UK - A preliminary updated assessment of practice.

INTRODUCTION: Radiographer abnormality flagging systems have been in use in the UK for over 30 years, with the guidance of the Society and College of Radiographers indicated that the preliminary clinical evaluation (PCE), or comment, be the preferred system of choice. This study aimed to provide an updated assessment of current practice based upon a previous 2008 study. METHODS: A cross-sectional online survey was disseminated via Twitter and aimed at departmental and reporting leads. It requested information on the types of flagging and reporting systems operated, scope of the systems employed, required education of participants, and the role of audit. RESULTS: Responses were received from 31 Trusts within the UK. Red dot systems were employed in 90% (n = 28) of sites, with 26% (n = 8) undertaking PCE. Skeletal radiographs were most commonly reviewed (90%; n = 28) followed by chest (58%; n = 18) and abdomen (32%; n = 10). Only 13% (n = 4) sites indicated if the image was normal but 71% (n = 22) allowed the radiographer to indicate if they were unsure. There was marked variation in the educational requirements and use of audit. CONCLUSION: Compared to 2008 there appears to be quite minimal change in practices in the UK. There does appear to be some increase in the use of flagging systems generally and a higher proportion of PCE systems in comparison to red dot but the use of education and audit does not necessarily show much development in the past 15 years. IMPLICATIONS FOR PRACTICE: Significant conclusions cannot be drawn due to limited sample size, however, it may support further study and consideration in relation to implementation and potentially standardisation of abnormality detection systems may be justified.

The efficacy of preliminary clinical evaluation for emergency department chest radiographs with trauma presentations in pre- and post-training situations.

INTRODUCTION: The chest X-ray (CXR) is the most frequently performed radiographic examination. This study evaluates radiographers' ability to localise traumatic CXR pathology and provide a preliminary clinical evaluation (PCE) for these cases. METHODS: This observer study was performed in a district general hospital in the United Kingdom (UK). A 58-case image bank was used with 20 positive cases. Participants were awarded a maximum of three points, based on abnormality recognition and descriptive accuracy. Localisation data were recorded with ROCView. Training was delivered via short online recorded tutorials covering an introduction of a systematic search strategy for CXR, how to recognise the common abnormalities covered in the tests, how to structure a PCE and multiple practice cases to review at participants' own pace. Pre- and post-training data was recorded. RESULTS: Nine participants completed the study. Overall, pooled sensitivity remained consistent (78.9%-78.8%) following training, specificity and accuracy showed improvement of 79.0%-89.9% and 78.9%-86.0% respectively. An increase in the number of correct localisations and PCE scores were also evident. Participants performed better at correctly identifying a pneumothorax compared to skeletal abnormalities. CONCLUSION: Improvements in performance were evident for most participants' abnormality localisations and PCE scores, following the training intervention. The study highlighted areas of CXR PCE that may require further training, such as detecting superimposed or subtle abnormalities. IMPLICATIONS FOR PRACTICE: This study provides additional support for the development of PCE systems in additional areas of imaging practice.

What information is required in a preliminary clinical evaluation? A service evaluation.

INTRODUCTION: The preliminary clinical evaluation (PCE) abnormality flagging system is a progression from the red dot system. The need for a PCE service may be reduced by immediate "hot" reporting services, however, PCE can be valuable in those Trusts that do not have a "hot reporting"service, as well as in the out of hours setting. This study aimed to identify what information clinicians require within the PCE to aid decision making. METHODS: Emergency Department (ED) clinicians and Radiology reporters were approached to complete a paper survey seeking their preferences on various aspects of the What, Where, How model, regarding their usefulness. Questions were a combination of multiple choice, Likert scale, and free-text. RESULTS: Thirty participants (20 ED clinicians and 10 Radiology Reporters) provided a 100% response rate. Overall, Where was considered to be most significant (n = 18, 60%), followed by What (n = 11, 37%). Half of participants (n = 15, 50%) considered How to be least significant. ED clinicians found all aspects of the What, Where, How useful, in particular the Where, but to a slightly lesser extent regarding how much displacement was involved. Overall, the information ranked as least useful was how much movement, followed by direction of movement, and type of fracture. The preferred style for a PCE comment is a bullet format. CONCLUSION: PCE content should accommodate the preferences of ED referrers. Our findings suggest clinicians want information pertaining to what the abnormality is (i.e. the type of injury), where it was (more specific than simply which bone) and if displacement is present. IMPLICATIONS FOR PRACTICE: These findings add to the current knowledge base and provide support to the local department when implementing the PCE system.

Radiographers reporting chest X-ray images: Identifying the service enablers and challenges in England, UK.

INTRODUCTION: The chest x-ray (CXR) is the most commonly performed x-ray examination in England, UK. Reporting radiographers provide a cost-effective and safe solution for managing CXR backlogs, but not all Trusts support this service development. This study aimed to establish the service enablers and challenges associated with training and employing radiographers to report CXR images in acute hospital sites in England, UK. METHODS: Approval for this electronic survey was granted in 84 of 146 (58%) Trusts approached. The survey was open for 10 weeks during August to October 2020, comprising of qualitative and quantitative questions. Data was exported in to an Excel spreadsheet where manual thematic analysis was performed. Descriptive statistics were also generated. RESULTS: Sample size was 75 (89% response rate). Thirty-three departments (44%) had at least one trainee. Most departments (n = 53, 71%) employ at least one CXR reporting radiographer. A total of 121/160 (76%) radiographers report CXRs. Number of reporting sessions shows progression. Factors enabling training and employment arise from service improvements, financial pressures, and developing the workforce. The main challenges relate to staffing issues with a number of associated sub-themes. A small faction indicated lack of radiographer interest to report CXRs due to litigation worries; possibly uncovering a new and emerging issue. CONCLUSION: Enablers and challenges associated with radiographers reporting CXRs are similar to previous studies. The growth of CXR reporting radiographers and reporting sessions indicates a continuing reliance on radiographers to contributing to managing CXR backlogs. IMPLICATIONS FOR PRACTICE: It is recommended that potential trainees are explicitly informed of the legal protection that will be provided, to prevent accountability concerns impacting on the continuing progression in this area of advanced practice.

An analysis of the structure and brevity of preliminary clinical evaluations describing traumatic abnormalities on extremity x-ray images.

INTRODUCTION: The preliminary clinical evaluation (PCE) system involves the radiographer providing an immediate comment highlighting an abnormality on the x-ray image. This can be a valuable service development though it must be recognised that the structure of the PCE may impede its usefulness. This study aimed to assess radiographers' ability to form a concise description of radiographic abnormalities by evaluating their structure and brevity. METHOD: A convenience sampling approach was used and the study was open to all radiographers (n = 48) in a United Kingdom (UK) hospital. Participants provided a PCE for 35 abnormal appendicular cases, which were assessed for the number of words used, lexical density and Gunning-Fog index; comparisons were made with a gold standard. PCE accuracy was evaluated with a scoring system and statistical analysis was completed with SPSS. RESULTS: 21 participants took part. The mean (SD,range) words used was greater than the gold standard (9.5 (3.89,14.9) vs 5.6 (1.46,7)). The mean (SD,range) lexical density was lower than the gold standard (73.8 (4.02,20.1) vs 100 (0,0)), and the mean Gunning-Fog index was also lower (15.1 (3.79,18.3) vs 20.7 (6.82,22.6)). The mean (SD,range) PCE score was 2.8 (0.34,1.17), compared to 5 (0,0) for the gold standard, and this was a statistically significant difference (t (21) = -29,p = .001). CONCLUSION: Participants used too many words in their PCE comments with reduced descriptive content that did not match the reading level of the gold standard. Areas for suggested improvement in practice include introduction of a comment-forming model with additional education. These findings provide an interesting addition to the growing PCE knowledge base. IMPLICATIONS FOR PRACTICE: Dedicated training prior to implementation and participation, to standardise comment structure, could improve the effectiveness of the PCE system.

A survey assessment of reporting radiographers' scope of practice in the West Midlands region of the United Kingdom.

INTRODUCTION: Radiographers have been providing reporting solutions for a number of years. Given the persistent radiologist vacancies and the increased demand on imaging services, the utilisation of reporting radiographers is widespread across England. Capacity and demand issues may lead to reporting boundaries being extended. The aim was to generate an updated appraisal of participants' scopes of practice in the West Midlands of region of England. METHOD: Reporting radiographers at 11 healthcare institutions across the West Midlands region were invited to participate in an online survey. Topics covered included reporting scope of practice, onward referrals and suggestion of treatments. Descriptive statistics were generated in Microsoft Excel and free responses were analysed manually. RESULTS: Response rate was 47% (40/86). The majority (n = 34, 85%) report Emergency Department skeletal examinations, only 12 (30%) report adult chests and only three (8%) report paediatric chests. Of those permitted to refer to other modalities, 85% (n = 23/27) actively do so. Of those permitted to refer to specialist teams, 97% (n = 31/32) actively do so. Only 23% of all participants (n = 9/40) suggest treatments in their reports. CONCLUSION: An increased number of participants report chest and abdominal examinations than previously identified. Restrictions in paediatric scopes of practice and adult GP chest examinations are also evident. Participants stated they do include recommendations in their reports by referring to other modalities and for specialist opinions. Suggesting treatment is not common practice and is considered an area for further advancement.

Newly qualified radiographers' perceptions of their abnormality detection abilities and the associated training they received at undergraduate level.

INTRODUCTION: Abnormality detection system use across National Health Service (NHS) hospitals is widespread with radiographer participation considered as fundamental to the role. The "red dot" system is evolving towards the preliminary clinical evaluation (PCE) system. Newly qualified radiographers will be expected to be able to provide accurate descriptive comments. Confidence and training issues may hinder implementation of the PCE system. METHOD: An online quantitative survey approach was used. Participants were sought from 24 major trauma centres (MTC) across England. The sample frame was defined as radiographers who had been qualified less than 2 years. Approval to approach was granted by all local Research & Development departments. Cross-tabulation and correlational statistical analyses were undertaken. RESULTS: Approval to approach radiographers was granted in 17 of the 24 MTCs yielding 85 participants, 63 females and 22 males. The large majority are confident with their red dot skills. Strong correlation exists between university training and PCE confidence. However, almost a third of participants are not confident in describing abnormalities. Thirty percent of participants thought PCE training at university was not suitable, and 55% thought PCE training on placement was not suitable. CONCLUSION: While red dot training at university and placement is considered suitable as it positively affects confidence, participants' views on PCE training are more variable. At university PCE training positively influences confidence in describing abnormalities, but commenting training on placement is recognised as an area for improvement. A larger study is suggested to gain further understanding of any issues hindering widespread PCE implementation.

Electronic control of coherence in a two-dimensional array of photonic crystal surface emitting lasers.

We demonstrate a semiconductor PCSEL array that uniquely combines an in-plane waveguide structure with nano-scale patterned PCSEL elements. This novel geometry allows two-dimensional electronically controllable coherent coupling of remote vertically emitting lasers. Mutual coherence of the PCSEL elements is verified through the demonstration of a two-dimensional Young's Slits experiment. In addition to allowing the all-electronic control of the interference pattern, this type of device offers new routes to power and brightness scaling in semiconductor lasers, and opportunities for all-electronic beam steering.

Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and incision site reactions in dogs undergoing routine castration.

Post-operative pain scores and incision site reactions were compared in healthy dogs undergoing routine castration at a county animal shelter and assigned to two treatment groups, namely: (1) lidocaine/bupivacaine (1mg/kg lidocaine+1mg/kg bupivacaine mixture; n=17), or (2) placebo (0.9% saline; n=16), administered via intratesticular injection. Dogs were injected with an equivalent volume of solution based on bodyweight. Premedication, induction and anesthetic maintenance protocols were identical in all animals. Pain scores were assessed at 15min, 60min, 120min and 24h post-recovery from anesthesia. Surgical site evaluation based on swelling and bruising was evaluated at 24h. The addition of lidocaine/bupivacaine did not impact pain scores compared to the saline placebo (P>0.05). Incision site reactions were statistically similar between the two groups.

Working out the kinks: testing the feasibility of an electronic pain diary for adolescents with arthritis.

BACKGROUND: Current approaches to evaluating pain in children with chronic arthritis suffer from methodological problems. A real-time data capture approach using electronic diaries has been proposed as a new standard for pain measurement. However, there is limited information available regarding the development and feasibility of this approach in children. OBJECTIVES: The aim of the present study was to pilot test the e-Ouch electronic pain diary in terms of compliance and acceptability in adolescents with arthritis to further refine the prototype. METHODS: A descriptive study design -- with two iterative phases of testing, modifying the prototype and retesting -- was used. A purposive sample of 13 adolescents with mild to severe pain and disability was drawn from a large rheumatology clinic in a university-affiliated pediatric tertiary care centre in Canada over a four-week period in December 2004. Participants were signalled with an alarm to use the diary three times per day for a two-week period. Adolescents completed an electronic diary acceptability questionnaire. RESULTS: Overall mean compliance rates for phases 1 and 2 were 72.9% and 70.5%, respectively. Compliance was affected by the timing of data collection and technical difficulties. Children rated the diary as highly acceptable and easy to use. Phase 1 testing revealed aspects of the software program that affected compliance, which were subsequently altered and tested in phase 2. No further technical difficulties arose in phase 2 testing. CONCLUSIONS: Feasibility testing is a crucial first step in the development of electronic pain measures before use in clinical and research practice.

Assessment and management of pain in neonates.

Neonates are capable of experiencing pain from birth onwards. An impressive body of neuroanatomical, neurochemical and biobehavioural evidence, which has accumulated over the past 2 decades, supports this capability. This evidence mandates health professionals to attend to the prevention, elimination, or at the very least, control of pain for infants. This mandate is essential since pain is known to have both immediate and long term effects, especially if pain is untreated and is severe, prolonged or frequently experienced. Therefore, pain must be assessed frequently, not only to measure location, intensity and duration but also to determine the effectiveness of interventions implemented to control pain. An impressive array of measures for assessing acute pain in infants exists which incorporates valid pain indicators in this population. However, there is a need to develop new measures to assess chronic pain conditions and pain in infants in acute situations.

Factors explaining lack of response to heel stick in preterm newborns.

OBJECTIVE: To determine factors explaining lack of response by preterm newborns to heel stick for blood sampling. DESIGN: A cross-sectional design based on secondary analysis of the control session of a randomized crossover design. SETTING: Four Level III neonatal intensive-care units of university teaching hospitals. PARTICIPANTS: 120 preterm newborns with an average age of 28 weeks postconceptional age. INTERVENTION: 24 newborns who showed a "no change" response according the Premature Infant Pain Profile were compared to the remaining 96 newborns who had shown a pain response. MAIN OUTCOME MEASURES: Age (postconceptional age at birth, postnatal age at study), Apgar score at 5 minutes, severity of illness, sex, race, wake/sleep state, previous study sessions, total number of painful procedures since birth, and time since last painful procedure. RESULTS: After stepwise logistic regression analysis the variables remaining in the final model that explained the difference between the groups were postnatal age at time of study, postconceptional age at birth, time since last painful procedure, and wake/sleep state. CONCLUSIONS: Newborns who were younger, asleep, and had undergone a painful event more recently were less likely to demonstrate behavioral and physiologic indicators of pain.

Effectiveness of oral sucrose and simulated rocking on pain response in preterm neonates.

Feeding and carrying have been interventions used by caregivers throughout history in relieving distress in infants. Recent studies on the food substance sucrose have elucidated the comforting effect of the taste component of feeding while studies of rocking have examined the comforting effect of the vestibular component of carrying. The purpose of this study was to determine the effectiveness of sucrose and simulated rocking alone and in combination on diminishing pain response in preterm neonates undergoing routine heelstick procedure in the neonatal intensive care unit (NICU). Preterm infants (n = 85) between 25-34 weeks post-conceptual age (PCA) and 2-10 days postnatal age (PNA) were randomly assigned to one of four conditions for routine heelstick procedure. The conditions were (1) sucrose alone: 0.05 ml of 24% sucrose was placed on the anterior surface of the tongue just prior to the lancing of the heel; (2) simulated rocking alone: 15 min prior to and during the heelstick procedure, the infant was swaddled and put on an oscillating mattress; (3) combination of sucrose and simulated rocking; and (4) placebo: 0.05 ml sterile water administered just prior to heelstick. Physiological (heart rate) and behavioural (facial actions) responses from baseline across 90 s following heelstick were scored second-to-second. Facial actions were analysed with repeated measures MANCOVA and heart rate with repeated measures ANCOVA. Behavioural state and gestational age were covariates. The groups that received sucrose alone or in combination with simulated rocking showed less facial actions indicative of pain than the rocking alone or control group. The addition of rocking to the sucrose condition tended to further blunt the facial expression of pain, but this enhancement did not reach a significant level. Heart rate was not decreased by any intervention compared to the control condition. Although the simulated rocking did promote quiet sleep, which has been reported in earlier studies to blunt pain response, there was no difference between simulated rocking and control groups in either facial expressions indicative of pain or heart rate. The implication of these results is that sucrose, but not simulated rocking may be a means of diminishing pain from minor procedures in preterm infants. Further research is needed on the use of sucrose for more than one procedure as well as examining the contact component of natural rocking, as opposed to simulated rocking.

Experience in a neonatal intensive care unit affects pain response.

OBJECTIVE: To determine the effect of being in the neonatal intensive care unit (NICU) on pain responses in infants of 32 weeks' postconceptual age (PCA). DESIGN: A cross-sectional comparative design was used. SETTING: Two level III NICUs, each in metropolitan, university teaching hospitals. PATIENTS: Infants of 32 weeks' PCA born within the past 4 days (the newly born group; n = 53) were compared with infants of the same PCA who had been born 4 weeks earlier (the earlier-born group: n = 36) and had spent that time in an NICU. OUTCOME MEASURES: Heart rate, oxygen saturation levels, and facial actions were used as outcomes in a between-group repeated measures analysis of variance across the heel stick procedure. Background variables of Apgar, weight at birth and data collection, severity of illness, age group, and total number of invasive procedures were entered into a stepwise regression. RESULTS: The two groups responded differently to the heel stick: the earlier-born infants had less behavioral manifestations of pain than the newly born infants. The number of invasive procedures was the primary factor that explained those behavioral differences, with Apgar as a second explanatory factor. The earlier-born infants had higher heart rates and lower oxygen saturation than the newly born infants before as well as during the procedure. These physiological differences were explained by the perinatal factors of age at birth and birth weight. CONCLUSION: Preterm infants who spend PCA weeks 28 through 32 in an NICU are less mature in their pain response than newborn premature infants of 32 weeks' PCA. Greater frequency of invasive procedures is associated with behavioral immaturity, whereas birth factors are associated with physiological immaturity.

Issues of assessment of pain and discomfort in neonates.

Pain assessment in neonates often presents problems. The problem of inadequate or inaccurate assessment is complicated by issues related to the nature, consistency, and variability of the infant's physiologic and behavioral responses; the reliability, validity, specificity, sensitivity, and practicality of existing neonatal pain measures or measurement approaches; ethical questions about pain research in infants; and uncertainty about the responsibilities of health care professionals in managing pain in clinical settings. Despite these many issues, neonates need to be comfortable and as free of pain as possible to grow and develop normally. Valid and reliable assessment of pain is the major prerequisite for attaining this goal. Issues embodied in neonatal pain responses, measurement, ethical, and clinical considerations are explored. Suggestions for resolving some of these problems are presented.

Special needs of preterm infants in the management of pain and discomfort.

Most infants born preterm are admitted to hospital neonatal intensive care units, where they undergo repeated multiple diagnostic and therapeutic procedures that result in pain and discomfort. Although there is convincing evidence to support the preterm infant's neurologic capacity for pain, management of pain often is not optimal. Accurate and reliable assessment of the preterm infant's pain is an important prerequisite for effective pain management. Pain assessment is a challenge for health professionals because the preterm infant's responses are less vigorous, more variable, and less consistent than are the responses of term neonates and older infants. Few reliable and valid assessment measures exist for this age group. There also is uncertainty in implementing pain-relieving intervention because of inadequate information on their safety and effectiveness and preconceived attitudes and beliefs of health professionals. The special needs of preterm infants related to the assessment and management of pain are discussed.

Physiological responses of premature infants to a painful stimulus.

The purpose of this study was to describe the physiological responses of premature infants to an acute tissue-damaging stimulus and to determine how severity of illness and behavioral state influenced these responses. The physiological responses (heart rate, oxygen saturation, and intracranial pressure) of a convenience sample of 124 premature infants between 32 and 34 weeks gestational age were described during four phases of a routine heel stick procedure. Analysis of the results showed a significant multivariate main effect of phase on the group of physiological responses. Behavioral state was found to influence the physiological responses, but severity of illness did not.

Multidimensional pain assessment in premature neonates: a pilot study.

OBJECTIVE: To describe the physiologic and behavioral responses of premature neonates to a painful stimulus. DESIGN: Descriptive. SETTING: Secondary-level neonatal unit in a large metropolitan university teaching hospital. PARTICIPANTS: Forty neonates between 32 and 34 weeks' postconceptual age and less than 5 days' postnatal age. MAIN OUTCOME MEASURES: Physiologic (heart rate, oxygen saturation, and intracranial pressure) and behavioral (facial expression and cry) outcomes observed during a routine heel stick. RESULTS: Physiologic responses were significant, but were not specific to pain. Behavioral responses were more promising and indicated that premature neonates were capable of responding in a manner similar to full-term neonates. CONCLUSIONS: Premature neonates are capable of expressing their pain in a manner similar to healthy, full-term neonates. Factors that alter this response were not clearly delineated. Further research is needed to determine more precise patterns of response in this age group.