GIRSIG 2000

Review of GIRSIG 2000
The Legal Implications Of Extended Role
Barium Enema: The 'Down Under' Experience
Quality Issues in Barium Enema Radiology
Photographs of evening event

Review of GIRSIG 2000
Robert Law and Christine Bloor

Maclagan Hall, St Williams College, York was a fitting venue for the group to hold its first national study weekend. Sixty-nine delegates attended the weekend of the 16th-17th September 2000 from as far a field as Dundee and Truro, despite the problems of the fuel crisis.

Jane Bewell, who chaired the morning session, provided a welcome and introduction to the weekend.

The first three speakers were all from Dundee. Professor Steel and Mr Lavell-Jones are both surgeons and Dr McCullock is a consultant radiologist. They are all involved in the demonstration pilot study into faecal occult bold (FOB) testing. They gave interesting talks on the pilot study from the view point of their own speciality. This multi-centre study is also being carried out in Warwickshire and Coventry.

The aim of the pilot study is not only to test the feasibility of screening, but also to examine its impact on endoscopy and radiology workload. In their talks, they discussed the rational behind the use of FOB test, and the concern over potential morbidity caused by the colonoscopy performed following a positive FOB. They also talked about the involvement of the barium enema examination and the impact of cancers detected at screening on other imaging modalities used in staging. Only when the results of the pilot are available will a definite decision be made on a national bowel screening programme.

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The Legal Implications Of Extended Role
Sandra McDonald LL.B.(Hons), RGN, Cert MHS

Resume: I am a qualified lawyer, nurse and health service manager. I originally trained as a nurse and practised as such, attaining the status of Sister in Intensive Care. Witnessing the distress of patients and their families in this environment made me appreciate the vital importance of psychological support as a complement to the high standards of physical care. This lead to what was to be the first of several changes of direction when I took a position as a nurse counsellor, concentrating on the psychological needs of patients with breast cancer.

With the big three-o on the horizon I realised that if I did not wish to counsel breast cancer patients for the rest of my career (as stimulating and challenging as this was) I would need other skills and experience. This prompted the second major change of direction, I left nursing and, following completion of a recognised health service management course became one of the dreaded `grey suits'.

I held several health service management posts but remained less than entirely satisfied with my career. It seemed that one needed a degree to progress, I did not possess such so decided I should undertake a degree course and that this would be in law.

On qualifying in law, rather than earn big bucks as a privately practising solicitor I choose (some would say foolishly others laudably) to combine my then new found legal knowledge with the familiarity of the health service and sought work where I could utilise both sets of experiences.

For the last five years I have been employed as the in house legal advisor to Salford Royal NHS Trust where approximately 75% of my time is taken up with clinical legal matters, the other 25% with advising on other, non clinical, areas of law e.g. contract, copyright, and corporate law.

Abstract:
The Legal Implications Of Extended Role

The information I propose to give falls under two main headings: Consent and Protocols of Work. Inevitably many questions are generated so I will leave time for a question and answer session on any associated legal issues.

1) Consent
Are You Battering your Patient?
Do You Have A Lawful Consent?

o Can you accept consent?
o Who can offer you consent?
o Who is charged with ensuring consent has been obtained?
o When should consent be obtained?
o What form should it take?
o Of what risks must the patient be advised?
o How does one prove that the patient has been advised of the risks?
o How far does the patient's consent give you lawful permission to go?
o What if the patient can't consent?
o What if the patient refuses?

2) Protocols

Working Protocols
o Do you have one?
o Is it reviewed regularly?
o Can you prove this?
o Is the legitimacy of the author clear?
o Has it been authorised by the Trust?
o Is it a fools guide?
o Is it comparable?

Your Defence
o Documentation
o Protocols. Are they available?
o Are all the relevant authorisations in place?
o Your training programme. Is it available?
o Is evidence of updating available?

Questions & Answers
o 1st Question - Do You Still Wish To Continue With All Of This ?

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Barium Enema: The 'Down Under' Experience
Roger Lysaght, Wanganui River with Mt. Ruapehu, New Zealand

Why did I travel half way round the world just to learn how to do a barium enema? The answer is that there have been major health reforms within New Zealand hospitals which mean that Hospitals have been charged with operating as commercial businesses. The government have forced hospitals to make a profit, even while we still had waiting lists. Needless to say many hospitals did not achieve profitability.

Management looked at areas of expenditure and made staff cuts at all levels. My department suffered approximately 30% cuts to both Radiologists and radiographers.

What was the effect? My hospital is quite small and was continually under threat so to survive meant we had to get innovative. Our directors idea was to train me in how to do 'Barium Enema's' as a means of reducing the radiologist's workload and to bring down growing waiting lists and thereby increasing quality of care to our patients.

The Problem: No one else, to our knowledge, was doing Radiographer performed Barium Enema's in New Zealand, so it wasn't a question of enrolling on the next course! Because this was a new venture in my country the legal considerations had to be addressed.

The Solution: Obtain the necessary training! Easier said than done, I heard of the St James's Barium Enema Course for Radiographers in Leeds - but the traveling expenses were a problem. Fortunately sponsorship from Nycomed Amersham got me there!!

The Result: I attended the course and then returned home, eager to start doing barium's!! I've had great radiology support but have practised in isolation, because radiographers doing barium enema's is still a controversial topic in New Zealand!

What's happening nationally now in New Zealand? Interest in what I have been doing has grown amongst radiographers and I have had many enquires as to how I learnt and many questions on how they can learn. These many discussions were al on an informal basis so a small group of charge radiographers decided to formalise this process.

I was recently asked to give a semi provocative paper on Radiographer Role Extension at a Charge Radiographer conference. It initiated great discussion and has had the positive effect we were hoping for!! As a result I was asked to co-ordinate a committee on Role Extension and in particular to launch a programme in Barium Enema training.

The Committee: This now consists of a Charge Radiographer from NZ's largest hospital, a university course co-ordinator/ tutor (from the UK but working in New Zealand), two motivated & interested radiographers, myself and, very importantly, a well respected and enthusiastic Radiologist.

Our goals: We want to learn from the UK experience - you have already invented this wheel, so we would like to carry this momentum into New Zealand. So our goals are to develop a suitable course based on ideas from the St James's Barium Enema course and have our first 'Radiographer performed Barium Enema Training Programme' up and running in early 2001!

The end.
Haere Ra!

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Quality Issues in Barium Enema Radiology
Dr A H Chapman, Consultant Radiologist, Leeds St James Teaching Hospital.

Dr Chapman's presentation covered quality issues prior to patient attendance in the department, during their attendance and after they have left.

Prior to the Attendance

Waiting Lists
Quality of Literature
Identify & Deal with Special Problems
Diabetics
Endocarditis risk
Disabled
Vetting Requests

Targets
Waiting list time < 3 weeks in > 95%
Waiting time < 30 mins in > 95%
Room time < 30 mins in > 95%
Results received in < 2 weeks in > 95%

Antibiotic prophylaxis
Do antibiotics reduce the risk?
Antibiotics are known to fail
Many are unaware that they have had endocarditis
Incidence of Bacteraemia in the Immuno-compromised

Barium Enema 11%
Tooth Brushing 25%
Dental extraction 30-60%

During the Attendance

Staff
Environment
Equipment
Bowel Preparation
Radiation Dose
Complications & Discomfort
Consent & Dignity

Radiation Risk
In 8,300 exams we find 83 carcinomas & as sensitivity is 83% we miss 17 (1 in 500) significance of 10/12 delay - ?15% mortality - 1 in 3000
Radiation - 2 to 3 mSv (1 in 25,000 fatal Ca's / mSv) - 1 in 10,000
Ba. En. Complications - Mortality - 1 in 57,000

Safety of the radiographer performed barium enema
129,273 - 3 †'s (2 cardiac,1 perf.,1 impaction)
Mortality 1 in 43,091

Radiologists-1:56,800 14 Perforations (8 intra,6 extra)
Perf. rate 1 in 9,233 Radiologists-1:25,000

Targets
Screening time < 5 min > 95%
DAP reading < 10,000 cGy.cm2 > 95%
< 12 films /images recorded for normal examinations in > 95%

Should we be using CO2?
More trouble

The Examination
Completeness
Coating
Distension
Double Contrast
Contamination

American College of Radiology Standard (ACR 1995)
Suggested quality control programme

Correlate radiologic, endoscopic and pathologic findings.
Periodically monitor polyp >1cm and carcinoma detection rates.

Target
Completeness - caecum shown in
> 95% of examinations
Coating, distension, double contrast - too much inter and intra-observer variation
Consider asking radiographer to present best barium enema to colleagues each month/quarter

Target if FOB Positive
· 1 cm adenoma - 30%
· 10% proximal to sigmoid
Carcinoma - 10% to 17%
· 3% proximal to sigmoid
Target for Symptomatic Service
Depends on case-mix
i.e policy of endoscopy dept

Polyp Detection Rate
Computerized Search
? No. of False positives
Size is important.
Monitor rate ? twice yearly.

? Target
> 95% of examinations reported in presence of radiographer who performed the examination

After the Attendance

Report timely
Follow-up Appointment

Management Issues
Audit
Adequate staffing
Adequate training

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