Example 2 - Investigation and Imaging

Appraisal Toolkit for Sessional GPs Domain 2 QIA: Audit and Prescribing Review Example 2 - Investigation and Imaging

Example 2 - Investigation and Imaging (5 or 8 criterion audit)

Sessional doctors as a group generate a high rate of investigation and imaging requests. This is not necessarily a criticism, since a sessional doctor may see a case mix which includes fewer patients attending for review.

You may also feel the need to practice more defensively without the opportunity for follow up or "watchful waiting". However, it may be helpful to audit your use of investigations as a way to review their effectiveness.

For ten surgeries, note your use of investigations and imaging requests. You should keep a note of each patient, and at a later date you should

either contact the practice to find out the result
or contact the laboratory or X-ray department

You can audit against your chosen set of criteria and standards. You need to consider setting criteria such as:

A request for a laboratory test should have a clear clinical reason. Can you identify one for each of yours? (For example if checking renal function in hypertension, what reason for also ticking LFTs?)
Laboratory samples need to be correctly labelled, in the correct container and to arrive timeously. (Were all of yours?)
A laboratory investigation should be appropriate. On reflection did you ask for a test that was likely to help with managing the patient's problem? (For example it is difficult to justify checking TFTs for a young patient who complains of "tiredness all the time" whose TFTs were checked three months ago)
Investigations should expect to include a reasonable proportion of abnormal results. (What proportion do you think this should be?)
Clear directions should be included on a request form if a telephone report is required. Did you do this?
X-rays should only be requested in compliance with the guidelines of the Royal College of Radiologists (to avoid unnecessary exposure to ionising radiation). Do you know what these state or how to find out?
Guidelines now suggest alternatives to X-ray investigations in some cases: did you follow all relevant guidelines? (for example SIGN or local guidelines on dyspepsia)
Radiologists now have the right to refuse all requests which do not conform to guidelines. All requests for which the referring doctor is uncertain should be discussed before referral. Did you encounter a situation like this?
All imaging techniques have limitations. Can you show that your requests take this into account? (For example, an ultrasound scan on a "lump" can only be performed on one that you can definitely palpate)
Some imaging investigations can be dangerous or uncomfortable. Do you give patients a clear explanation and explore possible adverse events in advance? (Barium enema or colonoscopy are both uncomfortable and sometimes hazardous; allergy to injected contrast medium may be serious; diabetics who are asked to fast before an examination need special arrangements)

These are only examples of criteria which you might choose from. You are recommended to use criteria which you can justify, and you will then need to justify the standards that you set for your performance.

You may find it helpful to contact a local laboratory or X-ray department for some advice on what criteria to choose. Many departments are now able to provide you with feedback on your use of their services if you have made the request with a name or identifier which is unique to you.

You might want to consider repeating the exercise for another 10 surgeries at a later date, to complete the "audit cycle".

If you would like more information on Audits please visit the Audit section on the main toolkit.

Example 2 - Investigation and Imaging (5 or 8 criterion audit)

Example 2 - Investigation and Imaging (5 or 8 criterion audit)

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