Implementing Diagnostic Imaging Pathways
Objectives: Evaluate compliance of diagnostic imaging requests with imaging pathways and reasons for non-compliance.
Methods: An ‘on-line’ evidence-based decision support tool called Diagnostic Imaging Pathways (DIP) was developed at Royal Perth Hospital (RPH) to assist clinicians request the most appropriate examinations and in the best sequence to achieve a diagnosis. DIP is accessed from the ‘desk-top’ and the Internet (www.imagingpathways.health.wa.gov.au). Clinicians at RPH are regularly alerted to the desirability of complying with DIP recommendations at the ‘Grand Round’, in the medical newsletter and in the orientation and induction programme of junior doctors. Retrospective audits targeting four pathways (‘Suspected Pulmonary Embolism’ N=187, ‘Ankle Injury’ N=149, ‘Suspected Renal Colic’ N=89, ‘Non-Traumatic Acute Abdominal Pain’ N=213), followed by intervention and re-audits (N=109, N=116, N=113, N=94 respectively) were carried out on all referrals from the Emergency Department (ED) over defined periods. Request forms and medical records were reviewed and the proportion of patients receiving non-compliant examinations was documented. Interventions included education of ED clinicians on DIP recommendations, introduction of request forms requiring ‘proof’ of adherence to pathways, and refusal of inappropriate requests.
Findings: In the initial audits (N=638), there were 347 (54%) incidences on non-compliance with the recommended pathway. In the re-audits (N=432), inappropriate incidences were 132 (31%). Requesters failed to follow recommendations for many reasons including; insufficient time to learn about recommendations, disbelief in their validity, and not understanding the importance of adhering to recommendations. Requesters then provided inaccurate pre-requisite information or ‘pressurised’ providers to accept a request without pre-requisites. Providers failed in their ‘gatekeeper’ function because of insufficient time to deliver education, difficulty obtaining pre-requisite information, and reluctance to resist a demand.
Discussion: Prior to the initial audits, the easy availability and active marketing of DIP within RPH had not eliminated inappropriate diagnostic imaging. Re-audits showed that targeted interventions improved compliance but did not eliminate inappropriate imaging. The delivery of decision support to clinicians must be improved. DIP needs to be embedded in the clinical decision workflow if maximum and sustained reduction of inappropriate imaging is to be achieved. It is envisaged that the best approach is to convert the current paper-based referral processes to an electronic process (Electronic Order Entry - EOE) and to progressively link EOE to decision support afforded by DIP. In the process of completing an electronic order, requesters would be alerted to the need to provide prerequisite information and would not need to access DIP as an extra step or to remember the recommendations. Providers would not need to continuously deliver education or to obtain pre-requisite information at difficult stages in the clinical workflow, and would be alerted to the need for a consultation.
The 2008 6th Biennial Joanna Briggs Colloquium was hosted by the Spanish Centre for Evidence-based Nursing in association with the 12th International Nursing Conference.
Further information from the conference may be accessed from the link provided.
Bairstow, P. J., Persaud, J., Mendelson, R., Grabinski, R., Ho, K., Low, R., Nguyen, L., & Thelander, A., (2008). Implementing diagnostic imaging pathways. Paper presented at the 6th Biennial Joanna Briggs Colloquium in association with the 12th International Nursing Research Conference. Cordoba, Spain, 12-15 November, 2008.