How well can radiographers triage x ray films in accident and emergency departments?

This study assessed the ability of junior doctors in accident and emergency to detect radiographic abnormalities. Their assessments of 505 radiographs taken at nights and weekends over a period of 8 months and showing abnormalities were examined. Each assessment by a senior house officer (SHO) was compared with the subsequent diagnosis of a radiologist of senior registrar or consultant status. An error rate of 35% was found. For abnormalities with clinically significant consequences the error rate was 39%. Although this error rate appears high the results are consistent with those of earlier studies in that missed positive radiographs constitute 2.8% of the total number of radiographs taken in the period. It is considered that the proportion of missed abnormalities gives a truer index of SHOs' abilities. No improvement in performance was evident over the 6-month period of the SHOs tenure of post. It is argued that it is unrealistic to expect accident and emergency SHOs to acquire this complex skill simply through experience and that more formal training and guidance is needed.

The effect on the management of patients of routine reporting of casualty radiographs by radiologists was reviewed. The overall prevalence of error by casualty doctors was 6.2%. Many of these errors, however, were trivial and did not alter treatment. In only 1.1% of the cases reviewed did the report of x ray films appreciably alter the management of the patient. A severity score was introduced to highlight those anatomical areas in which important lesions were overlooked most often. Radiologists' reports on radiographs of the chest, face, skull, and wrist had the greatest effect on management of patients, while reports on radiographs of fingers, hands, shoulders, long bones, and toes seldom altered treatment.

Clinical guidelines for the selection of patients with head injuries for skull radiography, based on those formulated by the Royal College of Radiologists, were introduced into the Accident and Emergency department at the Manchester Royal Infirmary. Before the guidelines were implemented 94 skull X-rays were obtained per 1000 new casualty attenders. After implementation the rate of skull radiography initially fell by 40%, but thereafter slowly increased so that 12 months later it had returned to the pre-implementation level. During the first and second 6 months of the study reductions of 37% and 17%, respectively, were achieved. Although the overall annual reduction was only 27% an estimated saving of almost 10,000 pounds was made. Although clinical guidelines for skull radiography can reduce the number of skull radiographs without detriment to the care of the head-injured patient, their constant use is difficult to sustain. The application of clinical guidelines needs regular monitoring. Referring clinicians and radiologists need to be strongly motivated if such guidelines are to find a useful place in clinical management.