Download 2093 Safety Net Policy Template

Title: A Policy for Abnormal Chest X-rays Reported as
Suspicious of Lung Cancer (Safety Net)
Unique Identifier:
Issue Status: Draft
Issue No: 1
Issue Date: March 2006
Scope: Trust wide/Community
Classification: Policy
Replaces:
Authors Name: Janette Murray
Authors Title: Macmillan Lung Cancer Nurse
Specialist
To be read in conjunction with the following documents:
Authorised by:
Authorisation Date:
Review Date: March 2007
This document is no longer authorised for use after this date
1.
Introduction
The reporting of abnormal chest radiographs suspicious of lung cancer should
normally be acted upon by the requesting physician. However, due to a
number of adverse incidents in which abnormal chest radiographs were either
lost or not acted upon in a timely manner, potentially affecting delays in the
assessment, initiation of treatment and generating malpractice claims, the
safety net screening service was introduced at Salford Royal Health Trust in
2004. The safety net is a monitoring/screening process designed to check
that action has been taken regarding the Radiologists recommendations on
chest radiographs reported as suspicious of cancer.
1.1
The chest x-ray Safety Net does not replace the responsibility of
each individual professional requesting a chest x-ray to ensure
the result is noted and appropriate action is taken.
2.
The Purpose of This Policy
The Operational Policy formalises the purpose, service and multidisciplinary
personnel involved in the safety net service. The safety net service has been
designed as a back up screening service for abnormal chest x-rays suspicious
of lung cancer. It is however the responsibility of each professional requesting
a chest x-ray to ensure that:
(a)
(b)
(c)
Issue [ ]
[Date]
The Radiologist’s recommendations are followed
The patient is informed
The GP is informed
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3.
Aim
In the event of an unsuspected diagnosis of cancer being found when
reporting a routine imaging examination, Salford Royal Hospitals NHS Trust
policy is that all radiology reports are to be fast tracked to the referring
Clinician to enable appropriate and timely action to be taken. A hard copy of
the report must also go to the lung cancer team.
4.
Objectives
4.1
Any chest x-ray suspicious of lung cancer will be screening in order to
ensure that the radiologist recommendations have been actioned.
4.2
A multi-disciplinary approach will be adopted in order to provide a
quality service.
4.3
All chest radiographs suspicious of lung cancer will be acted upon by
the lung cancer team within 2 weeks of receipt of chest x-ray report.
4.4
Patient assessment and initiation of treatment will not be delayed as a
result of chest radiographs not being acted upon within 2 weeks.
4.5
Malpractice claims will be prevented.
5.
Scope
5.1
This policy applies to all referrals for chest x-rays from within Salford
Royal Hospitals Trust and from General Practice/community.
6.
Multi-Disciplinary Team Members
The Multi-Disciplinary Team consists of the following personnel:
6.1
6.2
6.3
6.4
6.5
6.6
6.7
The Radiologist
The Radiologist Secretary/Clerk
The Respiratory Clerk
The Lung Secretary
The Lung Cancer Nurse Specialists
The Lead Lung Cancer Clinician
Pooled Respiratory Consultants
7.
Roles and Responsibilities
7.1
Radiologist
It is the responsibility of the Radiology Department at Salford Royal Health
Trust to ensure that a local robust process is in place that notifies the referring
clinician of the findings without delay. (See appendix 1)
7.2
7.3
On reporting the image, if malignancy pathology is suspected, the
reporting Radiologist must indicate that the report is fast tracked to the
requesting physician with a copy sent to the Lung Cancer Team.
If malignant pathology is suspected, the Radiologist comments must
include one of the following:

Urgent:
“Suspected lung neoplasm”
“Requires urgent follow up”
“Requires urgent referral to a chest physician”
“Requires CT and/or bronchoscopy”

Follow Up:
“Follow up after appropriate therapy to ensure resolution”
“Repeat PA/lateral film”
7.4
Urgent fast track reports must be dictated onto a separate tape, which
is identified and passed to the Radiology secretarial staff for typing
immediately.
8.
Clerical/Secretarial Team (Radiology)
8.1 Fast tracked reports must be given priority, typed, verified and sent to the
requesting clinician and the lung cancer team within one working day of
receipt.
8.2 Requests from within the hospital
The fast tracked reports must also be entered into the iSOFT electronic
system and placed in the allocated trays in Radiology 1 and 2 for daily
collection by the respiratory clerk.
8.3 Requests from outside the hospital
8.4 In the case of GP referrals and other community staff, acknowledgement
that the report findings have been received must be obtained and stored
within the radiology department (see appendix 2).
8.5 On Friday of each week t he radiology secretaries will e-mail the names
of the patient and hospital number of all fast tracked reports to the
lung cancer secretary. This will enable the lung secretary to check that all
the reports have been received for that week.
9.
Respiratory Clerk
9.1
The respiratory clerk will collect the fast track reports daily from
dedicated trays in Radiology 1 and 2 and will write the number
collected, patients names and hospital numbers in a book within the
lung cancer team office.
9.2
The book will be signed by one of the lung cancer team on receipt.
10
Lung Cancer CNS (Process Steps)
10.1
The lung cancer CNS will take responsibility for screening all suspected
lung cancer chest x-ray reports received. If any of the reports are not
clear, the lung cancer CNS will seek advice regarding appropriate
action from a chest physician.
10.2
The screening process involves all chest x-ray reports deemed
abnormal (suspicious of lung cancer by the Radiologist).
10.3
The iSOFT and PAS systems will be checked for acknowledgement
and/or response to the recommendation. This involves reading clinical
letters and checking for respiratory appointments.
10.4
The lung cancer CNS will then check if the patient has been referred to
the lung cancer/respiratory team for further investigation of the
abnormality.
10.5
The screening process will be completed within two working weeks of
receiving the report. This will give the requesting clinician of the chest
x-ray time to act on the report.
10.6
If no action is evident the lung cancer CNS will take action as below.
10.7
A standard letter and a copy of the report will be forwarded to the
requesting clinician.
10.8
A screening sheet will be completed for every chest x-ray report
received detailing action taken by the lung cancer team. These reports
will be input into the iSOFT system and filed.
11
In Response to General Practitioner Reports (Chest Clinic
Referral)
11.1
If the recommendation on the report is referral to the chest clinic the
iSOFT system will be checked by the CNS (Cancer Nurse Specialist)
to see if this has been done.
11.2
If the patient is registered or awaiting chest clinic appointment: No
action is required.
11.3
If there is no evidence of registration the CNS will contact the
GP/Practice Manager via telephone to see if the referral has been
madeusing a 2-week wait cancer proforma.
11.4
If the referral has not been made, the GP will be advised to refer the
patient using the 2-week wait proforma and inform the patient.
12
In Response to General Practitioner Reports (Requiring repeat
chest x-ray)
12.1
If the recommendation on the chest x-ray report is repeat film, the CNS
will check iSOFT to see if the chest x-ray has been done.
12.2
If the repeat film has been done: No further action required.
12.3
If there is no evidence of this, the GP will be contacted via telephone
and advised regarding the abnormal chest x-ray and the need to repeat
the chest x-ray urgently.
13
Accident & Emergency and Emergency Admission Unit Reports
requiring chest clinic referral (patient admitted)
13.1
If the patient is under the care of/or referred to respiratory lung team:
No action required.
13.2
If the patient has not been referred to the respiratory lung cancer team,
the following action is required.
13.3
The lung cancer CNS will liaise with the requesting clinician for the
patient and ask if they have received a copy of the report.
13.4
Advice will be given regarding the recommendations and a review from
Lead Lung Cancer Clinician will be offered or alternatively referral to
the chest clinic can be activated in order to avoid a delayed discharge.
13.5
The requesting consultant must inform the patient of the abnormal
chest x-ray and the need to see a chest physician urgently.
13.6
Patients Attending Accident and Emergency / Emergency
Admissions Unit requiring repeat chest x-ray (patients who are
admitted)
13.7
If there is evidence of repeat chest x-ray/CT scan: No further action
required.
If the recommendation is repeat chest x-ray/CT scan, the requesting
consultant caring for the patient will be requested to follow this
recommendation and liaise with the lung cancer CNS if it is still
abnormal, so that the patient can be seen by the Lead Lung Cancer
Clinician or a tertiary referral can be activated. Where appropriate
direct liaision with ward staff will be made.
14
Patients Attending Accident and Emergency (A&E) and
Emergency Admissions Units (EAU) and Discharged Home
14.1
The report will be faxed to the requesting physician, GP and lung
cancer CNS.

If A&E/EAU request a film and the recommendation is referral to a
chest physician, the requesting physician must make the referral to the
chest clinic or ask the lung cancer CNS to activate a tertiary referral.
They must also contact the patient to inform them that there is an
abnormality on the chest x-ray and that they need to be seen by a
chest physician urgently within 2 weeks.
14.2
Repeat Film

If the recommendation is for a repeat film the requesting physician
must action this recommendation and inform the patient. If the
recommendation is for repeat film following appropriate therapy the GP
should be requested to undertake this action by the requesting
physician. If the patient is admitted from A&E/EAU the requesting
physician must liaise with the Consultant responsible for the patient
and advise regarding radiology recommendations. The lung cancer
CNS must also be informed.
15
In-Patients Requiring Chest Clinic Referral
15.1
If the patient is under the care of/or referred to the respiratory lung
cancer team: No action.
15.2
If the patient is not referred to the respiratory lung cancer team, the
following action is required:
The lung cancer CNS will liaise with the accountable consultant caring
for the in-patient offering review by the Lead Lung Cancer Clinician and
lung cancer CNS.
15.3
In Patients Requiring Repeat Chest X-ray.
15.4
Patients requiring repeat chest x-ray: if there is evidence of the chest
x-ray no further action.
If no evidence of the chest x-ray, the lung cancer CNS will liaise with
the consultant regarding repeat film.
16
Discharged Patients Requiring Chest Clinic Referral Who Do Not
Receive Regular Review from Hospital Consultant
16.1
The Hospital iSOFT and/or PAS system will be checked by the CNS
for evidence of the chest clinic referral and/or registration under the
care of the respiratory team.
16.2
If the patient is registered/waiting for chest clinic appointment: No
action required.
16.3
If no evidence of registration with respiratory team: The following action
is required.
16.4
Tertiary referral to the lung cancer team for suspected lung cancer will
be activated.
16.5
A standard letter with a copy of the x-ray report will be sent to the GP
and copied to the Call Centre, and Lead Lung Cancer Clinician.
16.6
The lung cancer CNS will contact the accountable physician by
telephone to inform them of the tertiary referral and request that they
inform the patient.
17
Discharged Patients Requiring Repeat Chest X-ray
17.1
If the chest x-ray has been repeated: No action.
17.2
If there is no evidence of a chest x-ray, the GP will be contacted to
request that he repeats the chest x-ray and inform the patient.
NB: It is the responsibility of the accountable physician i.e. the
consultant from the ward/unit that the patient was on prior to
discharge to action on the radiologist recommendations and
inform the patient.
18
If the patient is having regular follow up by a hospital consultant and is
due to be seen, the lung cancer CNS will liaise with them regarding the
Radiologist recommendations.
19
Designated Work Place
The Macmillan Lung Cancer Nurse Specialists are based at Salford Royal
Hospitals NHS Trust, H3 Teaching Block, 2nd floor Lung Team Office.
20
Cross Cover Arrangements
The Macmillan Lung Cancer Nurse Specialists will cover each other in times
of annual leave and sickness.
21
Audit
The screening will be audited every 6 months by the lung cancer CNS. The
audit will note the following:
Total number of chest x-rays
Break down of referral source
Percentage of reports which action was required
An estimate of the workload
whether the report was actioned within the 2 weeks.
Appendix 1
Patient
referred for
imaging
Imaging
performed
& reported
Imaging
report sent
to referrer
Imaging normal or
other abnormality
not suggestive of
cancer
Imaging suggestive of
cancer
Radiologist or reporting radiographer to
flag report as priority (following local policy)
GP
imaging
referral
Radiology report is faxed
with cover sheet within 1
working day to GP with
copy to CNS/x-ray safety net
Hospital
imaging
referral
Urgent report sent to
referrer with copy to
CNS who should
follow up/x-ray safety
net
GP to assess
report and
discuss with
their patient the
referral options.
Patient managed in
primary care
GP sends written referral through 2
week wait referral process
Appendix 2:
NOTIFICATION OF UNSUSPECTED IMAGING DIAGNOSIS OF CANCER –
FOR GP ATTENTION
GP NAME
PATIENT NAME
PATIENT
ADDRESS
PATIENT DATE OF
BIRTH
PROVISIONAL
DIAGNOSIS
See also attached
radiology report
COMMENTS
IMPORTANT
MESSAGE FOR
GP:
Please acknowledge
receipt of this fax by
signing and faxing
back to:
Fax received:
(sign)
Date:
(fax number)
IMPORTANT NOTICE: The information in this fax may be confidential and/or covered by legal professional privilege.
It must not be read, copied, disclosed or used by any person other than the above named addressee. Unauthorised
use, disclose or copying is strictly prohibited and may be unlawful. If you have received this fax in error, please
contact the above named practice immediately.
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Endorsed by:
Name of Lead Clinician/Manager or
Committee Chair
Position of Endorser or Name of
Endorsing Committee
Dr Simon Taggart
Lead Lung Cancer Clinician
Consultant Chest Physician
Dr Ronan O’Driscoll
Clinical Director
Consultant Chest Physician
Dr Peter Turkington
Consultant Chest Physician
Dr David Hughes
Clinical Director
Consultant Radiologist
Ms Fiona Noden
Directorate Manager Radiology
References
Date
DIVERSITY & EQUALITY SCREENING QUESTIONNAIRE
1.
Does the document relate to a specific group of service users (if yes,
please specify)
2.
Is there the potential for people to be affected differently by the
document because of their background (e.g. race, sex, disability)? If
yes please specify how?
3.
What data/information is collected to monitor the impact of this
document / procedure/ protocol ?
4.
Do you currently monitor the impact of the document on service users
by the following categories ?
Ethnic origin
Nationality
Gender
Age
Sexual Orientation
Disability
Religion
From this monitoring, have you identified any adverse trends, possible
discrimination for any specific groups of service users? (if yes, please
specify these)
If adverse trends have been identified, what action has been taken or is
being planned to address these?
5.
Is there the potential for this document to affect relations between
different racial groups ? (If yes, please specify how)
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6.
Is there potential for this document to damage relations between the
Trust and any particular group within the community (e.g. racial group)
If you would like to make additional comments on this document in relation to
equality and diversity please, add these below
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Changes approved in this document by Section
Amendment (shown in bold Deletion
Number
Date:
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italics)
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