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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 Insert Document Title Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Form 10(2) Policy Document Middle Pages Page 1 of 14 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. Issue [ ] [Date] Insert Document Title Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Form 10(3) Policy Document Last Page Page 10 of 14 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) Issue [ ] [Date] Insert Document Title Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Form 10(3) Policy Document Last Page Page 12 of 14 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 ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Record of Changes to Document - Issue number: Changes approved in this document by Section Amendment (shown in bold Deletion Number Date: Addition italics) Issue [ ] [Date] Insert Document Title Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Form 10(3) Policy Document Last Page Page 14 of 14 Reason