Address the backlog issue or you will sink

Rinckside 2015; 26,1: 1-2.

acklogs of unread images are one of the worst nightmares in clinical routine. Unreported x-ray or MR studies older than two days start blocking the daily routine; if they are older than one week and mounting they are the beginning of a catastrophe. Any backlog has to be tackled urgently and with high priority – otherwise you will be watching helplessly as the ship sinks and sink with it.

The best recipe against backlog? Finish today what should be done today.

   Backlogs are often homegrown problems of radiological departments, and should be dealt with there. Analyze, diagnose, and find a therapy for the problem. If the department staff is unable to handle referrals and readings, if you are relying on typists who are sick or do not exist at all, if you are depending on dictation software that does not function or the radiologists cannot handle, or if there are simply not enough trained radiologists, the head of the department has to react rapidly and smoothly.

However, in many instances the department of radiology is not at fault, but rather the hospital managers or other bureaucrats well out of harm's way who are not able to understand the work flow and sequence of operations in a department of radiology, even if you prepare and show them flow-charts – diagnostic radiology is a multi-step process not a click-and-go amateur camera system. Usually, their solution is: "Head in sand and sit it out."

Thus, the ball is back in the radiologists' court: become more efficient, only perform necessary studies, and only accept examinations for which you have the personnel. However, do not allow other medical disciplines to take over and perform imaging examinations – with the following exceptions: insertion of a device under x-ray screening. Here, a physician experienced in the procedure uses x-ray imaging, commonly fluoroscopy, to place the device accurately – and places a report of the procedure in the patient's files immediately afterwards. A similar exception from the rule holds for the treatment of bone fractures and other orthopedic problems where fluoroscopy is necessary [1].

However, it doesn't hold for chest x-rays required by the surgeons or orthopedists. I know of a German hospital whose department of radiology had to hire a locum tenens to read a four-years backlog of chest x-rays recovered from the department of surgery. It was difficult to find a radiologist for this task, but Europe has open borders and one day a foreign radiologist arrived with his trailer home, settled down in the parking lot of the hospital, and after some weeks the job was done.

During the last five years, backlog scandals have also shaken Ireland and Great Britain. An Irish hospital had a backlog of more than 57,000 unread studies and, in addition, thousands of unprocessed GP referral letters. Many images could not be found any more. An investigation pointed to “problems with governance, management and administrative practice, as well as a shortage of radiology staffing at the hospital [3]”.

   A recent review of the London-based Royal College of Radiologists describes a projected national picture of about 300,000 patients who are currently waiting more than a month for their x-rays to be read and about 6,000 patients waiting more than a month for the results of CT and MRI scans.

The College asks: “What are the implications?", and answers:

• Potential to cause delays in diagnosing cancer and other serious illnesses;
• anxiety for patients waiting for test results;
• wasted journeys for patients expecting test results;
• waste of time and other resources, not just in radiology but throughout the healthcare system [3].”

   A possible “scientific” solution I found in a German radiological Dr.med. thesis: According to the statistics applied the median image reading time per patient study is 76 ± 77 seconds; as I understand this, the studies of some patients can be read in negative time which would be perfect to kill backlogs [4].

References

1. Devlin J. Health Service Executive [of the Republic of Ireland]. Report of the HSE National Radiology Survey. December 2010.
2. Hayes M. Report of the Review of Radiology Reporting and the Management of GP Referral Letters at Adelaide and Meath Hospital (Dublin), incorporating the National Children’s Hospital, (AMNCH) [Tallaght Hospital]. September 2010.
3. The Royal College of Radiologists. Patients waiting too long for test results. Press release. 14 November 2014.
4. Reference given upon request.

Citation: Rinck PA. Address the backlog issue or you will sink. Rinckside 2015; 26,1: 1-2.

A digest version of this column was published as:
Rinck PA. Address the backlog issue or you will sink.
Aunt Minnie Europe. Maverinck. 7 January 2015.