The Effect Of A Radiographer Led Discharge Service

Time is of essence when providing necessary care for patients, especially in an emergency department (ED). Several studies have considered a radiographer-led discharge (RLD) service as an alternative pathway to reduce patients’ waiting time. The effects of the service are explored in this essay. A pilot study done by Snaith (2007) over a period of four months aimed to assess the possibility of radiographers providing an extended service of discharging patient to reduce ED waiting time.

A total of 114 patients who received the RLD service fulfilled the following criteria: attended the ED on normal working hours when immediate reporting by radiographers were available, were within the age range of five to 65, had musculoskeletal (MSK) examinations of the distal extremities and had a documented RLD plan by referring clinicians. Radiographers involved were trained to assess, treat and discharge patients. Outcome measured the number of RLDs, the related re-attendances to the ED for the same injury; and compared the difference in the patients’ recall rates due to radiographic misinterpretations and the average waiting time between RLD and ED-led discharges. The findings showed that 7% of patients in immediate reporting were referred for the RLD service, with 5% discharged.

There were three re-attendances of radiographer-led discharged patients, albeit, treatments were unchanged. Furthermore, patients’ recall rates were reduced by 52% and the mean journey time decreased more than 50% in RLD compared to ED discharges. Therefore, Snaith concluded that RLD reduced waiting time while maintaining the risk of patient returning. Snaith had admittedly mentioned that he excluded regions where further assessments were often necessary for RLD. However, while RLD patients were limited to those with distal limbs MSK injuries, ED discharge, included all minor injuries regardless of the different treatment pathways. Therefore, the two groups were not comparable, and the deductions made from comparing RLD and ED discharge were arguably questionable. Henderson et al. (2013) used a similar methodology as Snaith (2007) to determine the effectiveness of an RLD service in reducing discharge time after imaging. Patients were above four years old, attended the ED during normal working hours, had distal extremities examinations and did not require follow-ups. However, unlike Snaith’s (2007), it was conducted over a two-years period with simultaneous operations of RLD and ED-led discharge systems. Outcomes were measured by the number of unplanned returns to ED within 28 days, the accuracy of diagnosis and the overall waiting time. Comparison between 497 RLD patients and 2632 ED-led discharge patients found that the chance of re-attendance for the same injuries was lower in RLD by 2. 87% and the risk of misdiagnosis resulting in a change of patient’s treatment was also reduced by 1. 89%. Additionally, the overall waiting time for patients discharged by radiographers (100. 9 minutes) was significantly shortened compared to ED-led discharge (122. 0 minutes). Henderson et al. (2013) concluded that discharge times were reduced significantly without adverse effects on accuracy of diagnosis. Notably, the introduction of see-and-treat—a separate system intended to reduce waiting time by eliminating the triage stage—overlapped partially with the study period.

The results were based on overall journey time and the reduction demonstrated might have been contributed by both RLD and see-and-treat services. Hence, the results of reduced waiting time, while should not be discredited, was likely exaggerated especially considering that a large percentage (23. 1%) of RLD patients were seen-and-treated. In a nationally-funded randomised control trial study conducted by Hardy et al. (2013), a total of 1502 participants were recruited to evaluate the cost-effectiveness of prompt radiographic reporting of MSK cases in ED. These patients were randomly referred for either prompt-reporting or belated-reporting of their radiographs and must fulfil the participation criteria: attended the ED within 48 hours of sustaining the MSK injury, requiring strictly MSK X-rays, and could give informed consent. The study was carried out in five hospitals under National Health Service (NHS) that provided 24-hours ED services and practised belated-reporting. Four weeks of radiographer-led prompt reporting was then implemented in the hospitals.

Outcome measured the radiographic interpretation discrepancies between the two groups, and cost effectiveness in two parts namely through (i) EQ-5D responses, a questionnaire that quantified patients’ health gain, during ED attendance and eight weeks post-attendance, (ii) and the cost incurred per patient. The results showed 79 discrepant interpretations in total, with 57% higher diagnostic inaccuracy in belated-reporting. EQ-5D responses collected from 50. 8% of recruited participants showed comparable increase in the health gain for both groups (0. 340 in prompt-reporting and 0. 345 in belated-repoting), and average cost per patient decreased by £23. 40 in prompt-reporting. Hence, it was apparent that a prompt MSK reporting in ED was cost effective in NHS settings. However, it is important to note that the study method could only conclude the benefits of reduced time and cost-effectiveness for patients limitedly within the scope for NHS and not across different hospital settings or country. Hence, Rachuba et. al (2018) aimed to develop an ED workflow model for patients with minor injuries to evaluate waiting time reduction against associated costs induced by RLD using a discrete event simulation (DES) model. The study developed the model by acquiring a standard ED workflow of minorly injured patients through interviewing practitioners, identifying main stages in the workflow to visualise the current three ED pathways and to redesign a streamline RLD pathway; and then collecting 23 months of historic data from 2810 patients to compute in the DES model.

The outcome measured the benefits of RLD by the reduction in the length of stay (LOS), the decrease in clinical workload, and the number of discharges by radiographers against the associated costs through RLD availability. The study showed overall LOS reduction of at least 20 minutes in the RLD pathway. Furthermore, on weekends, RLD service could decrease clinical examinations by 300 and discharge 500 patients. The model analysis showed that a day of RLD service proved beneficial, especially on weekends, and increasing RLD availability would further decrease waiting time. Albeit, the results of the model should not be generalised indiscriminately across any hospital settings. Smaller institutions, particularly, should consider the disparate workload increase because they could not designate a separate radiographer for RLD from those performing X-rays and hence the effects of RLD might not reflect similarly.

Noticeably, the four studies have shown that there is evident waiting time reduction in an RLD system compared to a standard ED discharge with the diagnostic accuracy maintained. Although the first three studies could only conclude the significance of the benefits limitedly within the scope of their institution, Rachuba et al. (2018) has developed a model that could blanket the conclusion that an RLD system reduces patients’ waiting time significantly and is cost effective across different hospital settings. Hence, the study done by Rachuba et al. (2018) is especially important in convincing a change of discharge practices in the ED because of its general applicability of proven benefits to patients. Furthermore, the implementation of an RLD service is feasible and sustainable in terms of cost. The omission of a clinical assessment step after imaging in the RLD workflow would, understandably, reduce clinicians’ time catered for each patient (Rachuba et al. 2018). This translates to an increase of ED resources available, namely the practitioners’ time, that makes it possible for the ED to bear an increment of workload with constant manpower.

Arguably, there are costs incurred from the necessary training or the employment of such highly skilled radiographers (Rachuba et al. 2018). However, the costs incurred could be neutralised with how RLD could potentially reduce the ED staffing costs. Hence, the positive effects of RLD from a hospital’s standpoint could not be dismissed, especially if deliberated for the long-run. However, it should be noted that patients have been largely filtered for the service, i. e. only 114 (6. 48%) patients out of 1760 patients with radiographs reported promptly, were in the RLD system (Snaith 2007). A foreseeable problem associated with this is that patients’ waiting time to be discharged after imaging could increase if the existing framework could not cope with the number of patients referred for the service.

There is a real possibility that a fully functioning RLD system catering to minorly injured MSK patient could cause a bottleneck in waiting to be discharged because of the increased workload to radiographers. However, this problem is not reflected in the results of the four studies that showed RLD significantly reducing waiting time. Hence, it could be concluded that this problem had either not occurred during the duration of the studies or even if it had, it was insignificant when weighed against the overall time reduction. Nonetheless, taking an anticipatory stance of problem solving, hospitals should be prepared to bear the additional cost needed to provide a proper framework through training and designating more reporting radiographers. Understandably, there are limitations to the studies when determining the effects of RLD. However, the main anticipated problem areas have been addressed properly and the results of the studies have evidently showed significant benefits, namely in reduction of ED waiting time and its cost effectiveness.