RADIOLOGY AND IMAGING 2021 - The Offi cial HOPE Reference Book hospitalhealthcare.com - Hospital Healthcare Europe
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The Official HOPE
Reference Book
hospitalhealthcare.com
RADIOLOGY AND
IMAGING 2021
2 | HHE 2021 | hospitalhealthcare.com RADIOLOGY AND IMAGING
Contents
03 High-level dIsinfection of ultrasound probes
Sponsored by Nanosonics
05 The world of medical ultrasound:
A President’s perspective
Pamela Parker
07 Meet the Expert: Paul Sidhu
10 Meet the Expert: Neelam Dugar
13 Guideline summary: Integrating artificial intelligence
with the radiology reporting workflows
15 Guideline summary: Vetting (triaging) and cancellation
of inappropriate radiology requests
16 News roundup
3 | HHE 2021 | hospitalhealthcare.com SPONSORED
High-level disinfection
of ultrasound probes
A large population-level study has revealed an unacceptable risk of infection following endocavitary
ultrasound procedures. Nanosonics is intent on ensuring that vulnerable patients are protected from
the risk of cross-contamination.
Support for the Patients can be at risk from ultrasound patients were found to be at a 41% greater risk
development of associated infections when low-level of infection and a 26% greater risk of needing
this advertorial has disinfection (LLD) is the standard of care. an antibiotic prescription in the 30 days
been provided by In order to quantify this risk, Scotland’s National following their transvaginal ultrasound procedure
Nanosonics Health Service undertook a retrospective when compared to gynaecological patients who
analysis of microbiological and prescription data had not undergone a transvaginal ultrasound.
through linked national health databases. During the study period, 90.5% of facilities
Patient records were examined in the 30-day reported that they were performing low level
period following semi-invasive ultrasound probe disinfection for transvaginal ultrasound probes.
(SIUP) procedures. These patients were at a greater risk of infection
The study analysed almost one million patient due to inadequate reprocessing and the study
journeys that occurred during a six-year period concluded that: “Hence failure to comply with
from 2010.1 existing guidance on [high-level disinfection] of
Of the 982,911 patients followed, 330,500 SIUPs will continue to result in an unacceptable
were gynaecological patients; and 60,698 of risk of harm to patients .”1
these gynaecological patients had undergone The diverse use of ultrasound probes is now
a transvaginal (TV) ultrasound procedure. These prompting a renewed focus on correct probe
reprocessing to ensure patient safety. To ensure
best practice standards, decontamination
experts and ultrasound users need to work
together to reduce the risk of infection that
is associated with using ultrasound probes.
Ultrasound procedures are performed in
various inpatient and outpatient settings by
a wide range of health professionals. This has
increased the use of surface probes to guide
procedures such as biopsies, cell retrieval,
cannulation, catheterisation, injections,
ablations, surgical aspirations, and drainages.
Across these procedures, the probe has the
potential to contact various patient sites
– including intact skin, non-intact skin, mucous
membranes and sterile tissue. This presents
a complex challenge, as contact with these
various body sites requires differing levels of
disinfection or sterilisation between patient
uses. Failure to adequately clean and disinfect
medical devices like ultrasound probes between
patients poses a serious risk to patient safety.
In 2012, a patient in Wales died from
a hepatitis B infection – most likely caused by
a failure to appropriately decontaminate
a transoesophageal echocardiography probe
between patients. As a result of this fatality,
a Medical Device Alert was issued by the
Medicines and Healthcare Products Regulatory
Agency (UK) advising users to appropriately
decontaminate all types of reusable ultrasound
probes.2
The UK and European guidelines require
ultrasound probes that come into contact with
mucous membranes and non-intact or broken
skin to be high-level disinfected. In particular,
4 | HHE 2021 | hospitalhealthcare.com SPONSORED
Automated high-level disinfection
The trophon® system is designed to reduce properties enabling the disinfectant to kill
the risks of infection transmission through bacteria, fungi and viruses. The mist particles
automated high-level disinfection of are so small that they reach crevices,
transvaginal, transrectal and surface probes. grooves and imperfections on the probe
With over 25,000 units operating surface. Nanosonics works collaboratively
worldwide, 80,000 people each day are with probe manufacturers to carry out
protected from the risk of cross- extensive probe compatibility testing. More
contamination with trophon devices. As a than 1000 surface and intracavity probes
fully enclosed system, trophon2 can be from all major and many specialist probe
placed at the point of care to integrate with manufacturers are approved for use with
clinical workflows and maintain patient trophon devices.
throughput. trophon technology# uses # The trophon family includes the trophon
proprietary hydrogen peroxide disinfectant EPR and trophon2 devices which share the
that is sonically activated to create a mist. same core technology of sonically-activated
Free radicals in the mist have oxidative hydrogen peroxide.
automated and validated processes for This category also includes contact surfaces
ultrasound reprocessing are preferred. This is that are not intended for patient contact in
supported by a study relating to manual health settings. These devices and surfaces
disinfection methods, which found that only should be cleaned and low level disinfected.
References 1.4% of reprocessing systems were fully It is important to note the difference between
1 Scott D et al. Risk compliant when using manual methods, cleaning and low-level disinfection. Cleaning is
of infection following
semi-invasive ultrasound compared to 75.4% when using semi-automated the removal of soil and visible material until the
procedures in Scotland, disinfection methods.3 item is clean by visual inspection. Low level
2010 to 2016: A
retrospective cohort study
disinfection is the elimination of most bacteria,
using linked national The Spaulding classification system some fungi and some viruses.
datasets. Ultrasound The Spaulding classification system4 must be A final and important point for consideration
2018;26(3):168–77.
2 Medicines and Healthcare applied before a procedure commences so that is the use of probe covers.
products Regulatory information about what tissues or body sites While many ultrasound users and
Agency (MHRA). Medical
Device Alert. Reusable
may be contacted is taken into account. sonographers believe that their transvaginal
transoesophageal This classification system is a widely adopted ultrasound patients are protected from infection
echocardiography, disinfection framework for classifying medical risk by using barrier shields and/or condoms,
transvaginal and transrectal
ultrasound probes devices, based on the degree of infection research has shown that up to 13% of condoms
(transducers) Document: transmission risk, and requires the following fail and up to 5% of commercial covers fail.
MDA/2012/037. 2012.
3 Ofstead CL et al.
approaches: Probe covers may have microscopic tears or
Endoscope reprocessing • Critical devices are defined as those that breakages which can allow microorganisms to
methods: Prospective study come into contact with sterile tissue or the pass through.5
on the impact of human
factors and automation. bloodstream. Probes in this category should
Gastroenterol Nurs generally be cleaned and sterilised. Where Conclusion
2010;33(4):304–11.
4 Spaulding EH. Chemical
sterilisation is not possible, high-level Ultrasound users should work with their
disinfection of medical disinfection is acceptable with the use of decontamination colleagues to understand the
and surgical materials. a sterile cover for ultrasound probes. current UK and European guidelines for
In: Lawrence C, Block
SS, editor. Disinfection, • Semi-critical devices contact intact mucous reprocessing ultrasound probes. There are
sterilization, and membranes and do not ordinarily penetrate patient risks associated with ultrasound usage
preservation. Lea &
Febiger Philadelphia (PA);
sterile tissue. Ultrasound probes scanning over when proper disinfection procedures are not
1968:517–31. non-intact skin are also considered semi-critical. followed, as well as from ancillary products such
5 Basseal JM, Westerway Semi-critical ultrasound probes include as contaminated ultrasound gel. While the
SC, Hyett JA. Analysis of
the integrity of ultrasound endocavitary probes, which should be used with increased use of ultrasound has brought many
probe covers used for a cover in addition to being high-level benefits for patients, effective education and
transvaginal examinations.
Infect Dis Health 2020
disinfected. disinfection protocols are required to minimise
Mar;25(2):77–81. • Non-critical devices only contact intact skin. the risk of infection.
5 | HHE 2021 | hospitalhealthcare.com EXPERT OPINION
The world of medical
ultrasound – A President’s
perspective
Pamela Parker There can be no one truly unaffected by the pandemic, and difficult to consider planning in
President, British COVID-19 pandemic. This ongoing international the immediate future. This, too, has led to the
Medical Ultrasound health crisis has impacted on lives around the organisation pausing, reflecting, and
Society; Department world; arguably, none more so than those of redesigning what can be delivered. The need for
of Radiology, Hull front-line health care workers. Speaking as a support for ultrasound professionals has not
& East Yorkshire sonographer based in a large teaching hospital diminished; indeed, with increasing role
Hospitals NHS Trust, in the north of England, I have experienced development, it can be argued the need is
UK first-hand the significant impact the pandemic greater than before. A virtual webinar
has had on service delivery, my colleagues and, programme was developed by BMUS during
most of all, our patients. However, as an 2020 to provide relevant, and pertinent,
optimist, I like to believe that with every dark education and standard setting in line with the
cloud a silver lining can be sought. Therefore, objectives of the organisation; a journal club via
as an optimist, one opportunity the pandemic Twitter established, and now plans are well
presents is the opportunity to reset normal underway for a full virtual online conference.
within our clinical and professional landscapes. None of these are likely to have developed
In some instances, of course, this happened without the dark cloud of the COVID-19
rapidly and without time to pause and reflect. pandemic causing much disruption.
However, there has been an opportunity to Webinars and e-learning, in the world of
review those services that were stopped and an medical ultrasound at least, have developed at
opportunity to redesign as we move to restart a pace in the last 18 months. Having a creative
planned care. Indeed, in my own institution, and innovative team supporting an online
entire pathways have been remodelled, placing training programme has been essential and has
ultrasound imaging at the very core of where it unearthed hidden talents within the BMUS
was once an afterthought and poorly resourced administrative team as well as the multitude of
or acknowledged. This has provided an ideal professionals who have supported and
opportunity for modern ultrasound imaging to volunteered to provide the education
be showcased; those technological programme. As with many professional
developments that have gradually become charitable organisations, BMUS is reliant on
integral in diagnostic ultrasound imaging are volunteers who are willing and able to share
now being recognised as essential to providing their time and knowledge with peers. Despite
a powerful first-line core test for many patients, the difficulties we have all faced, the willingness
particularly those with delayed presentation and of our clinical colleagues to support the
for whom swift assessments and management ongoing education and professional guidance
plans are required. output of BMUS has been phenomenal, and yet,
despite this wealth of readily available material,
The British Medical Ultrasound Society attracting new members and minimising
The British Medical Ultrasound Society (BMUS) attrition of existing members remains as very
has the core objectives: “to promote the real challenge. It is pleasing to note that the
advancement of the science and technology of sonographer membership of BMUS has
ultrasonics as applied to medicine” and “to marginally increased recently, but attracting
ensure the highest standards in practice are medical colleagues, in particular radiologists,
maintained”. Coupled with the changing role of to support the organisation remains difficult.
ultrasound in patient pathways, BMUS has BMUS prides itself on being a multi-disciplinary
developed and provided education and organisation and there to support any
guidance to all professionals working in the field professional using medical ultrasound within
of medical ultrasound. For BMUS, as the premier their scope of practice. In the UK, by far the
ultrasound society in the UK, the annual largest professional group is sonographers who
scientific meeting has been the stage to present primarily use ultrasound in their everyday
developing best practice, new and emerging clinical practice. Essentially, a sonographer is
technology, and provide an opportunity to medical ultrasound! Radiologists learn
discuss research and development with ultrasound as a core skill during their training
like-minded professionals. Face to face events but, and as is common in larger establishments,
have clearly been impossible to hold during the radiologists are specialty-focused and many use
6 | HHE 2021 | hospitalhealthcare.com EXPERT OPINION
been established to promote career
development for non-medical ultrasound
practitioners and show case the very best in
ultrasound innovation. However, membership
of the society and an engaged workforce, from
whatever background, is essential to the future
success of these committees and the wider
BMUS family. BMUS upholds the highest
standards of practice and, it is with this aim,
that the society engaged with Health Education
England (HEE) in a project to increase the
sonography workforce. BMUS, in collaboration
with the Consortium for Accreditation of
Sonographic Education, the Royal College of
Radiologists and the Society of Radiographers
has been integral member of this HEE
sonographer workforce project group and
progress is slowly being made. Every arm of
health care is under pressure to increase activity,
improve turn-around-times, and deliver safe and
effective care. There is no profession that is not
struggling with workforce capacity, with
vacancy rates well documented; radiology and
sonography are no different, and solutions have
needed. While BMUS has no remit to act as a
trade union or provide workplace advice, it does
cross-sectional imaging modalities or have a remit to ensure standards of practice are
interventional suites that are now far removed optimised, safe and of high standards. The
from the hands-on image acquisition, multi-disciplinary nature of its membership
interpretation and reporting of ultrasound ensures BMUS is well-placed to offer opinion,
imaging. Increasingly, there are numerous advice and guidance as part of this collaborative
non-radiology professions using medical approach to HEE as the path of defining and
ultrasound as a tool to enhance their clinical developing an ultrasound / sonography career
practice and to guide patient management. framework emerges.
Indeed, many Royal Colleges now have specific Whilst there have been significant challenges,
ultrasound training programmes and in the workplace, professionally and personally
competency assessments that their members over the last 18 months there has been
are expected to complete to be able to deliver opportunity to reflect and set a new or revised
this point-of-care ultrasound (PoCUS). The course for the future. The publication of the
importance of PoCUS cannot be overstated. As Richards Report in 20201 and NHS Long Term
such, publications produced by our emergency Plan in 20192 has provided an opportunity for
medicine, chest, and intensive care colleagues the role of sonography, and the role of medical
About the author ensured shared learning of the signs of COVID- ultrasound within healthcare, to be established
Pamela Parker 19 on lung imaging, which became critical as as essential in first line investigations in critical,
is a consultant hospital admissions rose in the first and second acute and planned care, the improvement of
sonographer working waves. The aim of BMUS is to bring this obstetric outcomes, and in guiding interventions
within radiology of multi-disciplinary family together and recognise within an out-patient setting. Professionals
the Hull University the benefits of sharing knowledge and skills but, working with medical ultrasound, as a career
Teaching Hospitals at the same time, not alienating those for whom path or using it as a tool, have the opportunity
NHS Trust. Pamela medical ultrasound is a professional career to embrace new ways of working and new
has over 25 years’ choice; sonographers, physicists, and pathways. Supporting national organisations,
experience in the radiologists alike. such as the BMUS, provides the opportunity for
field of medical BMUS has had, as do many societies, professional societies to have a voice around
ultrasound. Her sub-committees whose roles are to ensure the the table at national discussions and highlight
specialist interests are objectives of the organisation are met. the benefits of a highly trained, well-motivated,
uro-genital ultrasound, Longstanding and hardworking committees recognised workforce. There are challenges
contrast and fusion- such as the physics and safety, publications and ahead but none that cannot be faced together.
guided imaging. She education committees have been the I am proud to represent BMUS and my
has established the workhorses of the society since its inception. multi-disciplinary ultrasound colleagues and will
first sonographer- Latterly, new committees have been set up to work hard in my tenure as President to turn
delivered fusion and reflect the changing professional landscape and, those challenges into golden opportunities as
transperineal prostate the now more diverse, users of medical we head into the new normal of 2021 and
biopsy service within ultrasound. PoCUS and obstetric clinical beyond.
radiology in the UK. imaging groups have been established to
Pamela is studying support improvements in these critical fields of References
part-time for a PhD 1 Diagnostics: Recovery and Renewal – Report of the
medical ultrasound. The professional standards
Independent Review of Diagnostic Services for NHS
investigating the role group was established to better nurture and England. www.england.nhs.uk/publication/diagnostics-
of ultrasound within enhance working relationships with like-minded recovery-and-renewal-report-of-the-independent-review-of-
diagnostic-services-for-nhs-england/ (accessed June 2021).
the active surveillance professional bodies and organisations. 2 NHS Long Term Plan. www.longtermplan.nhs.uk/
of prostate cancer. A consultant sonographer interest group has (accessed June 2021).
7 | HHE 2021 | hospitalhealthcare.com INTERVIEW
Meet the Expert: Paul Sidhu
Paul Sidhu is Professor of Imaging Sciences at King’s College London and consultant radiologist
in the Department of Radiology at King’s College Hospital. His research interests have focused on
ultrasound and interventional radiology. Here he shares his thoughts with Hospital Healthcare Europe
on ultrasound and how this technique has evolved and will continue to develop in the future.
On how radiology services are organised identify pleural effusions that need to be
at King’s drained, and rheumatologists will make use of
Professor Sidhu described how King’s is a large ultrasound to examine the small joints of the
tertiary, general hospital in southeast London hands. The evolution of ultrasound in other
serving a population of over 2.2 million people specialties has been considerable and
in a largely deprived area. King’s has several radiologists no longer have either the time or
different sites that cover various services, perhaps inclination to perform such scans.
including paediatric, neonatal, cardiothoracic, Despite these developments, as Professor Sidhu
neurosurgery, breast cancer screening, and liver described, it is safety regulations, focused on
transplantation. There is one centralised, very the patient, that keep radiology departments
large, radiology department employing around together. However, while the use of ultrasound
80 consultant radiologists and up to 700 staff. has now extended beyond the realms of the
The department is also involved in the provision radiology department, he felt that the radiology
of training for radiologists and radiographer community was not overly concerned about this
staff. Although radiologists are qualified direction of travel, especially given that in the
doctors, their path towards becoming a UK, there is a shortage of radiologists, and this
radiologist is a long one that can take up to delegation has to some extent been welcomed.
12 years. In contrast, radiographers, who are the In fact, he now believes that no single speciality
individuals responsible for taking images, still effectively “owns” ultrasound and in many
need to undergo degree level training although radiology departments, the ultrasound scanning
their role has greatly expanded in recent years. is performed by sonographers and the
At King’s for example, radiographers manage all radiologists themselves have moved on to
aspects of imaging for CT and MRI scans becoming more focused on the interpretation of
imaging in interventional radiology and some specialised scans. As a passing thought, he felt
radiographers have become sonographers that while radiologists were likely to be the most
involved in the scanning and issuing of medical competent individuals to perform and interpret
reports. All aspects require several years of scans, if an ultrasound was being used as
training to become established within these a point-of-care service for a specific indication,
roles. provided that an individual healthcare
Ultrasound is available and employed in many professional appropriately interpret a scan, he
different specialities by experienced and had no objection to these developments.
competent individuals. Professor Sidhu
explained how there remains strict controls on On the ESR subcommittee on ultrasound, his
who can perform scans that involve exposure to work as Chair, and future plans
radiation and particularly in nuclear medicine, Professor Sidhu mentioned how he had been
with the administration of radioactive isotopes. a member of the European Society of
Administrators are required to have a specific Radiologists (ESR) ultrasound subcommittee
ARSAC licence. All hospitals that undertake for several years during which time, it had
examinations with radiation exposure will have produced a number of different position papers.
a radiation protection officer. In contrast, while He cited what has become a very successful
there are no specific controls on who can position paper on infection control and
perform either an MRI and ultrasound scan, he prevention from 2017,1 highlighting the
highlighted how MRI equipment is prohibitively importance of good hygiene measures,
expensive and ultimately is best reserved for the especially with transducers and how these
radiology department. Nevertheless, according should be cleaned after each use. More recently
to Professor Sidhu, the position is rather in 2020, the group have published best practice
different with respect to ultrasound. While in recommendations and imaging use.2
the past, ultrasound has been the responsibility This latest paper was an update of an earlier
of the radiology department, as Professor Sidhu 2009 position paper on ultrasound.3
explained, things are rapidly changing with As Professor Sidhu clarified, the newer version
much ultrasound, particularly point-of-care, provides a series of recommendations on
becoming performed outside of radiology. For appropriate standards for the use of ultrasound
instance, chest physicians will use ultrasound to in radiology from the perspective of the ESR.
8 | HHE 2021 | hospitalhealthcare.com INTERVIEW
For instance, the position paper, defines the
essential requirements for equipment, practice
aspects of use, infection control, requirements
for training, certification and competence. He
noted that while not all ultrasound operators
would necessarily conform to the standards
delineated in the position paper, it did define
the professional standards which would be
expected if the service were delivered by
a radiologist. Professor Sidhu explained that an
important aim of the position paper was to
hopefully clarify for any non-radiologists, the
anticipated standards which should be followed,
in a sense, a standard operating procedure for
undertaking ultrasound, which had the support
of the ESR and therefore credibility. Professor
Sidhu described how it was important that the
position paper provided the necessary guidance
because when using ultrasound, it is not the
machine which does the job but the operator.
If the operator is not competent, neither is the
output from the machine! In short, it is vital that
operators will need to practice, learn and
develop all the time to perfect the technique
to ensure that they get the best use from the
device.
In terms of ensuring continued best practice,
Professor Sidhu outlined documents produced
by the ESR were designed to support non-
radiologist operators. This advice encouraged plans for three speakers at the meeting and
participation in audits of their service but who will discuss different models of ultrasound
additionally and equally important, was that practice. Firstly, there is the German model, in
non-specialists needed to maintain their skills which many GPs perform ultrasound as well as
and competence through an examination of the having a centralised hospital department run by
practice all the time, together will ensuring radiologists, but with other medical specialists
equipment maintenance, the environment used effectively dipping into the service. Second is
to perform imaging and how best to manage the Russian model, whereby both radiologists
patient throughput, all of which were essential and other physicians only do ultrasound and no
for adherence to professional standards. other imaging modality. The third, and often
Professor Sidhu hinted that with a rapid pace of perceived as a controversial model, is the one
development in ultrasound technology, it is deployed in the UK, where it is the radiologists
highly likely that the professional standards of who performs less scanning, taking on more
today would require updating in the near future. specialised examinations (e.g. MSK) and
He pointed to the fact that equipment was delegating the sonographers to effectively
becoming smaller, so that handheld devices are undertake most of the scanning, and providing
able to do a reasonable job and ultrasound diagnostic reports. He felt that a discussion of
technology is also available for use on the different models would undoubtedly
smartphones and an iPad for scanning. provoke a lively debate. Professor Sidhu
mentioned that tied in with this debate will be
Future plans a position paper on where the ESR believes
Professor Sidhu indicated that one of his aims ultrasound should sit within radiology and how
for the ESR over the next few years was to the speciality should evolve over the coming
define the place of ultrasound within radiology years. Professor Sidhu, though not the final
more clearly. He remarked on how the position arbiter on any decisions, felt that in the future,
of ultrasound within radiology is far less clear perhaps radiologists should not see themselves
cut than say 20 years ago and that is often seen as guardians of the ultrasound world. He added
as the ‘Cinderella’ modality in radiology. He that anyone from whatever subspecialty and
noted for instance how today, a lot of younger who has an interest and can demonstrate
radiologists were more interested in CT and MRI competency and safety in their practice should
scanning because this was perceived as being be encouraged to use ultrasound. Professor
more cutting edge and that ultrasound is often Sidhu believed that there was nothing inherently
seen as harder work than the other modalities. wrong with, for example, a rheumatologist
After all, clinicians must operate the device, sit upskilled in the use of ultrasound, if they saw
with the patient, and scan them, whereas there the benefit of the imaging modality in their
is no direct patient contact with MRI and CT, assessment of a patient. He also thought it
with the hard work coming from the ability to possible that radiologists could retain
form a diagnostic image, readily interpretable. ultrasound within their departments but
He revealed how for the next ESR meeting in allowing access to physicians from different
2022,4 the committee is preparing a session specialities with an overarching goal of
dealing with where they believe ultrasound will improvements in patient care.
sit in 20 years’ time. He stated that there are A further advantage of ultrasound
9 | HHE 2021 | hospitalhealthcare.com INTERVIEW
highlighted by Professor Sidhu was the enormous developments in ultrasound
flexibility of the modality. In contrast to the technology, and which were of huge benefit.
static imagery of an MRI or CT scan, ultrasound He mentioned that a difficulty was that many
was performed in real-time. Consequently, it people still see ultrasound as only black and
was possible during the scan to enquire as to white, but that this is no longer the case and
whether the patient experienced any pain or ultrasound has a far greater capability for
discomfort, particularly if the imaging indicated imaging that all other modalities. He cited how
a potential cause for the pain. Alternatively, the multiparametric ultrasound imaging can be
patient may offer a snippet of history during the used to assess patients with steatotic livers6 and
scanning, and which helps to confirm the that other innovations such as colour Doppler
diagnosis, neither of which are available to ultrasound, contrast ultrasound and
radiologists when interpreting other imaging elastography ultrasound,7 which looks at the
modalities. stiffness of the liver, the amount of fibrosis and
scarring have all proved to be of value in patient
On the impact of the pandemic on imaging care. He added that a further advantage of the
Professor Sidhu described how King’s was very developments in ultrasound was that the
busy during the first and second waves of the technology was less expensive than other
COVID-19 pandemic.5 With the global modalities and safe. He sensed that in the next
cancellation of routine imaging during the first couple of years there would be many further
wave, the radiology department was quiet with innovations with ultrasound-based technology
ultrasound becoming extremely useful within and that these would continue to be patient-
the intensive care unit as a point-of-care for friendly. Using the example of scanning the liver
imaging of patients’ lungs; this was done of a two- or three-year-old child, Professor
predominately by the pulmonary physicians Sidhu described how for an MRI scan, the child
although radiologists did perform some needed to be sedated perhaps, given the
abdominal scans. He added that during the contrast agent gadolinium, and kept still.
second wave, the department was a lot more However, for an ultrasound scan, the child
prepared and continued with as much routine remains awake, and the parents can also be
scanning, if patients could safely attend the present to help with any possible anxiety.
References hospital, but suspects that this has resulted in He thought that as an imaging modality,
1 Nyhsen C et al. Infection a huge backlog of imaging awaiting to be radiologists would be ultimately unwise to give
prevention and control in undertaken. While the magnitude of this up on ultrasound, adding that the technology
ultrasound – best practice
recommendations from backlog remains uncertain, Professor Sidhu is now at a level where the device does almost
the European Society of remarked that there are still a lot of patients everything for the operator, adjusting the
Radiology Ultrasound
Working Group. Insights waiting to be scanned. parameters automatically to produce the
Imaging 2017;8(6):523–35. best image.
https://pubmed.ncbi.nlm. On the key learnings since the pandemic Another development that had made
nih.gov/29181694/
2 European Society Professor Sidhu thinks that an important a considerable impact on ultrasound mentioned
of Radiology. Position learning from the pandemic is that services by Professor Sidhu was artificial intelligence.
statement and best practice
recommendations on the need to become more patient centric and that The technology can recognise the organs
imaging use of ultrasound the provision of imaging services should under investigation, identifies any abnormalities
from the European Society become easier and more accessible for the as well as providing a differential diagnosis.
of Radiology ultrasound
subcommittee. Insights patient. With this idea in mind, there is likely to He added that it even writes the report for the
Imaging 2020;11:115. be a wholesale shift of routine outpatient operator although currently, it still needs
https://insightsimaging.
springeropen.com/ scanning out of the acute hospital and make a clinician to interpret the results of the scan.
articles/10.1186/s13244-020- greater use of community-based imaging,
00919-x a move he says which has been supported by On the skills that radiologists will require
3 ESR Executive Council
2009; European Society government. He mentioned that although this in the future
of Radiology. ESR position change had been under discussion for several Professor Sidhu thinks that will all the emerging
paper on ultrasound.
Insights Imaging years, it was really brought into sharper focus as technologies, some radiologists have been left
2010;1(1):27–9. https:// a consequence of the pandemic. After all, he behind simply because the developments in
pubmed.ncbi.nlm.nih. reflected on how it has been ludicrous to bring ultrasound are largely driven by physicians in
gov/22347899/
4 ESR Congress. www. large numbers of patients into a busy hospital other specialties; in particular, hepatologists.
myesr.org/congress/ for routine/GP imaging. Consequently, there is He explained how a key driver is not so much
ecr2022.
5 Panayiotou A et now a move in progress to establish diagnostic that other specialists embrace the technology
al. Escalation and hubs, adjacent or close to the hospital and but more that unlike radiologists, hepatologists
De-escalation of the introducing agreed patient pathways to ensure and other specialties do not have routine access
Radiology Response to
COVID-19 in a Tertiary that only those patients who need further to CT and MRI, ensuing the best aspects of
Hospital in South London: management must visit the hospital. Professor ultrasound are utilised constantly, before
The King’s College Hospital
Experience. Br J Radiol Sidhu felt over the next few years, elective reverting to another imaging modality.
2020;93:20201034. imaging could be undertaken within the hub Even though in the future ultrasound might
6 Basavarajappa L et al. and that this would release capacity with the well move outside of the sphere of radiology,
Multiparametric ultrasound
imaging for the assessment hospital, allowing time to see acute patients and Professor Sidhu still believes that there will
of normal versus steatotic those who required other forms of always be a need for radiologists to be skilful in
livers. Sci Rep 2021;11:2655.
https://www.nature.com/ interventional or complex imaging, with the ultrasound. As a profession, they possess the
articles/s41598-021-82153-z important caveat, that the hospital service is necessary skills to match up the results from all
7 Sigrist R et al. Ultrasound accessible for patients when needed. the other scans and images and in doing, so will
Elastography: Review of
Techniques and Clinical continue to make an important contribution to
Applications. Theranostics On the current exciting technological patient care.
2017;7(5):1303–29. https://
www.ncbi.nlm.nih.gov/pmc/ developments
articles/PMC5399595/ Professor Sidhu noted how there were
10 | HHE 2021 | hospitalhealthcare.com INTERVIEW
Meet the Expert: Neelam Dugar
After specialising in oncology imaging at Manchester, Neelam Dugar is now a consultant radiologist
at Doncaster and Bassetlaw NHS Trust and also Chair of the Radiology Informatics Committee at the
Royal College of Radiologists. Hospital Healthcare Europe had the pleasure of speaking with her about
her career to date and to discuss recent documents produced by the College on the use of artificial
intelligence in radiology and the development of a vetting procedure for inappropriate scan requests.
Organisation of services at the Trust supplement for a summary of guidance). The
Dr Dugar’s department has approximately guidance defined the standards for how AI
16 radiologists and, with a newly purchased third should be incorporated into the radiology
CT scanner, the department is extremely busy, information (RIS) and picture archiving and
operating on an almost conveyor belt-like basis. communication systems (PACS). Dr Dugar
In a typical day, radiographers will perform highlighted how, in some respects, AI is
around 1000 imaging investigations including considered a very broad term and can be
those for elective, acute and ward patients. interpreted differently depending on the
As there is a requirement to have A&E CT scans context. For the present document, the RCR
reported on within an hour, Dr Dugar informatics group considered AI in the narrow
emphasised the importance of prioritising the context of ‘computer vision’ used for radiology
workload within the team. Hence, one radiologist image pre-analysis. As Dr Dugar explained,
is always allocated to report emergency scans, because AI systems have already been
and while others do elective work. During the developed for facial recognition, given that the
evening and weekends only one radiologist is role of a radiologist is to visualise images and to
available for undertaking emergency CT and MRI make interpretations to inform the ongoing care
scan reporting. Night-time emergency radiology of patients, it seemed only right that this should
has now been outsourced to Australia. Since be the area to focus upon.
starting her role over 17 years ago, the However, a primary focus was to ensure that
workload had expanded considerably due to IT vendors could develop the necessary
a combination of increased expectations and infrastructure to incorporate AI systems with
national guidelines that often recommend the different hospitals. A further consideration for
use of imaging. For example, she described how the implementation of AI was the apparent
17 years ago, during a typical Sunday, she might national shortage of radiologists in the UK.
be called upon to report one emergency scan For instance, in a 2018 report,1 it was noted how
but on a recent weekend shift, her hospital in the UK, only one in five UK Trusts and health
performed 100 emergency CT and MRI scans. boards had enough interventional radiologists
She feels that no other specialty has to provide safe 24/7 services to perform urgent
experienced that kind of explosion in workload. procedures.
Dr Dugar defined how the AI workflow
On the work of the RCR Informatics Committee guidance should work in practice, explaining that
and her role as Chair the AI system would initially review the image
Dr Dugar emphasises that technology is the before it was seen by a radiologist. The AI
backbone of radiology and had a desire to make system algorithms were such that it was able
best use of technological advances as a means to highlight any relevant features, which is also
of enhancing patient care. She explained that within the remit of radiologist. Nevertheless,
she was appointed as informatics advisor in whereas the AI systems are capable of detecting
2015, because of an interest in the topic coupled some abnormalities, the radiologist would then
with the fact that she had led the development combine these findings with other test/imaging
of digitisation in her own department. She results, and any other relevant clinical findings,
suggested that the Royal College of Radiologists to create a more personalised report for the
(RCR) felt that it was necessary to have patient.
a committee that was able to set the standards
of what should be achieved by all radiology Will AI replace radiologists in the future?
departments implementing informatics. In other If the AI system can do the essential job of
words, the RCR Informatics Committee was a radiologist, surely these individuals can be
tasked with defining the standards and hence, easily replaced? Dr Dugar disagrees. She
best practice, which should be achievable revealed how in 2016 AI pioneer, Geoffrey
through hospitals’ information technology (IT) Hinton, had said “we should stop training
systems. radiologists now. It’s just completely obvious
Out of this work came the publication that within five years, deep learning is going to
Integrating artificial intelligence (AI) with the do better than radiologists.”2 At the time, she
radiology reporting workflows (see later in the said this created a major staffing crisis,11 | HHE 2021 | hospitalhealthcare.com INTERVIEW
especially in the US, which saw a downturn in AI system simply identifies any abnormality and
doctors choosing radiology as a career, fearing is unable to make a subjective judgement within
that they would be deemed superfluous in the the context of any other clinical findings.
near future. But, as Dr Dugar added, medicine Dr Dugar labelled the AI system as a ‘junior
is not maths – if it were then there would be no radiologist’, i.e., it was able to provide a limited
need for a radiologist! She feels that it is virtually role as a preliminary reviewer on images.
impossible to create an ‘artificial’ radiologist Nonetheless, she did believe that in the future,
simply because of the huge number of with improvements in AI occurring, the input
algorithms that would be required to emulate from a radiologist might be unnecessary,
the thought-processing of a radiologist. especially for simple imaging, e.g., reporting on
Dr Dugar believes that having an AI system the presence/absence of a fracture. However,
evaluating a scan goes some way towards the radiologists would still be required to interpret
need for two independent reviewers of a scan more complex imaging from MRI or CT scans.
result. This is considered as best practice, She added that while an AI system could identify
lending support to the metaphor that “two a filling defect in the lungs and report the most
heads are always better than one”. As she said, likely cause to be a pulmonary embolism, as
this is the current recommendation for breast a radiologist, you are always thinking laterally
cancer screening. She stressed that having two about other differential diagnoses.
independent reviews was necessary because
even though individual radiologists are highly On the vetting and cancellation of
trained, they are fallible. Thus, from a safety inappropriate scan guidelines
perspective, dual review is the ideal standard. As Dr Dugar described, being both medically
The integration of an AI system was also qualified and trained in radiology allowed her
important but for a very different reason. and her colleagues to assess whether or not
Dr Dugar highlighted that, in reality and with a particular imaging request was appropriate.
a national shortage of radiologists, it becomes She emphasised how often both junior doctors
impossible to achieve the two-reporter standard and those from other specialities, may not be
for images. One of the key reasons for a second completely clear on which imaging tests were
reporter was to the minimise the phenomenon correct. The vetting (triaging) and cancellation
of satisfaction of search, which describes the of inappropriate radiology requests document
situation where some lesions remain undetected was introduced simply to help manage the
after an initial lesion. As Dr Dugar illustrated, workload within radiology departments.
when a radiologist finds an abnormality, they An important part of Dr Dugar’s role is to always
become fixated on that particular problem and vet or triage any requests for imaging that reach
start to process this finding within the context of the department. This vetting process, she added,
other clinical information and sometimes ignore was crucial because of the high workload of the
other findings. With an AI system able to review department, which makes it impossible to
the image prior to the radiologist, it effectively perform every exam request.
becomes that second reporter and While the vetting process amounts to
a helper, alerting the radiologists to the full a clinical assessment task in itself, Dr Dugar
range of abnormalities present on the image. highlighted how within her department over
In discussion with colleagues, a barrier to greater 90% of the vetting process was undertaken by
use of AI is the perception among some the radiographers rather than the radiologists.
radiologists that the system is very sensitive This had been made possible through the
but not specific. Using the example of the introduction of a protocolised approach for the
assessment of a lung scan, Dr Dugar explained radiographers. Moreover, Dr Dugar believes that
that while the AI system would report on the radiographers can quickly acquire the necessary
presence of tiny nodules, the focus of the vetting skills and then approve and book a scan
radiologist was in looking for metastases. or reject the request. A further advantage to
With greater knowledge of the patient’s clinical radiographer-based vetting, is that, as these
history than the AI system, the radiologist can individuals are involved in performing the
potentially discount the relevance of these imaging, they are able to quickly assess, and
nodules and advise accordingly. In contrast, the then cancel, any duplicate requests and in some12 | HHE 2021 | hospitalhealthcare.com INTERVIEW
cases, even determine if the request would be of transformation within the NHS. She thinks this
additional value, i.e., if the request is for was of enormous benefit, enabling more virtual
a broadly similar scan. A difficulty for meetings which were a great advance compared
radiographers, however, is that without the to teleconferences. Another important
necessary medical training, they may feel development for work–life balance was allowing
uncomfortable cancelling an imaging request radiologists to have workstations at home.
that was requested on clinical grounds and in Dr Dugar says that having an interest in digital
such instances, the protocol would dictate that technology, she had tried to implement greater
the request is forwarded to the radiologist. home working for some time, but her request
As a consequence of introducing the vetting was always denied due to lack of funding.
process in her department, Dr Dugar felt that on However, she also thinks in the future, this
a typical day, she might be asked to vet up to innovation of homeworking and virtual meetings
30 requests and allocates up to 30 minutes of will not revert to pre-pandemic times but there
her day to this task. She thinks that such vetting will still be a balanced need for office working.
is a key task given that the department performs
around 1000 scans each day. Although some of On the evolution of the imaging landscape over
the requests passed to her from radiographers the next few years
can be challenging, in many cases, it can Dr Dugar believes that AI algorithms will develop
sometimes be very straightforward and require in the next two to five years and become a much
simply altering the request to a more better preliminary reporter on many more things
appropriate imaging modality. For more such as fracture detection, lung nodule
complex cases, she will need to review the detection etc. She mentioned how AI is already
patient’s medical history or initiate a discussion being used in brain imaging for strokes.
with the referring clinician to discuss the best She worries, however, that future innovations in
option. In cases where the request is rejected, AI by computer scientists will require additional
Dr Dugar ensures that the requesting clinician is funding, and that this should not be at the
informed of her decision and the rationale expense of a radiologist training.
behind the cancellation. She thinks that the Another potential growth area she feels is
departmental system, being fully electronic has in the evolution of enterprise imaging3 and
streamlined the whole request/cancellation revealed how all her own radiology department’s
process. images have already been archived and made
Dr Dugar expressed the view that the vetting available throughout the enterprise. An
document was desperately needed because in important current problem, she explained, was
some radiology departments, no vetting process how various medical images from other
was in place. She realised that part of the reason specialties/departments have been generated
behind this lack of vetting was largely due to but are stored in different locations and formats
a lack of functionality within the hospital’s without the correct patient identifiers etc. and
internal IT system. The purpose of the vetting are not indexed properly (e.g., endoscopy
guidance was thus to ensure that while not all images, ECG, audiometry, sleep studies etc).
NHS Trusts employed the same vendors, these Incorporation of all the images and graphs in
vendors would modify the IT infrastructure to a single and accessible location will be of
enable electronic communication for the vetting enormous value, not only to radiologists but also
process. As Dr Dugar said, in discussion with all treating physicians. With the ability to review
radiologists from outside of her own all images, and together with other pieces of
department, the cancellation process was often clinical data, it will allow radiologists to create
not communicated to the original requesting a much more personalised report for the patient.
clinician and this led to internal friction and, in Although improvements in smartphone
some cases, the radiologists in an attempt to technology allow for image review, Dr Dugar
appease the requesting clinicians, decided to no thinks that at the present time, the quality of the
longer triage requests, with a resultant increase images is not of sufficient quality for diagnostic
in their workload. Although it seems unusual purposes. Furthermore, from a medico-legal
that the whole of the NHS must deal with perspective, she would not use the images
different IT vendors, Dr Dugar is against the reviewed on a smartphone for reporting. She
idea of a national vendor. She thinks that with also felt that while mobile scanning units for MRI
such a huge monopoly, there would be little and CT scans were available and could be
incentive to innovate. What is more important utilised for elective work, these imaging
she feels, is that the same workflow processes modalities would still need to remain within the
References should be adopted in the different NHS hospital premises, where the equipment was
1 Bassett M. Radiologist Trusts, to improve the efficiency of radiology needed for emergency scans.
shortage deepens in the UK.
www.rsna.org/news/2019/ departments, even if this occurs through Image acquisition and interpretation were
May/uk-radiology-shortage dissimilar IT systems. separate, and Dr Dugar believes that she does
(accessed June 2021). not need to be present at a mobile scanning unit
2 Marcus G, Little M.
Advancing AI in health care: On the impact of the pandemic on imaging and can remain either in the office or at home to
It’s all about trust. www. services undertake her interpretive role for the images.
statnews.com/2019/10/23/
advancing-ai-health-care- Dr Dugar said that for her, radiology services did However, radiologists (whether remote or
trust/ (accessed June 2021). not stop during the pandemic although the on-site) must continue to work closely with the
3 Petersilge C. The focus shifted to COVID patients. She felt that her radiographers operating the scanners to provide
evolution of enterprise
imaging and the role of the own work, which is either cancer or emergency- support and advise on appropriateness and
radiologist in the new world. based, did not slow during the pandemic. She vetting/triaging support. Radiologists and
www.ajronline.org/doi/
full/10.2214/AJR.17.17949 believed that one of the greatest changes radiographers must always work as teams to
(accessed June 2021). because of the pandemic was the digital improve patient care.13 | HHE 2021 | hospitalhealthcare.com GUIDELINE SUMMARY
Integrating artificial
intelligence with the radiology
reporting workflows
This guidance from the Royal College of Radiologists sets out the standards that a department
should meet when integrating artificial intelligence into already established systems, producing a safe
seamless system with the patients at the centre
The fast pace of developments in artificial the system will query and retrieve a prior similar
intelligence (AI) means that the technology will image from the picture archiving and
have an important role to play in many clinical communication system (PACS) for comparative
specialities, including radiology and will change, analytical purposes. A further advantage of
hopefully in a positive direction, the way in using an AI system, is ‘computer-assisted triage’,
which patient care is delivered. which helps with the prioritisation of reporting
AI platforms and algorithms are designed to worklists once an abnormality has been
work in collaboration with existing technologies detected.
and have a wide range of potential uses in Nevertheless, the RCR report emphasises
radiology. For example, in magnetic resonance the importance of radiologists acknowledging
imaging (MRI), an AI algorithm can detect the limitations of an AI system report, i.e., its
multiple sclerosis, strokes, brain bleeds etc. sensitivity and specificity, and what these
Within the arena of computed tomography figures mean in the context of the specific
(CT), AI systems are designed to detect skull pathology. In other words, the AI system is
fractures, brain haemorrhages, infarcts, and simply a supportive tool and radiologists should
tumours. In body CT, the introduction of AI has not become overly reliant upon on the AI
a role in mammography, allowing for the findings and assume that these findings will be
detection of both suspicious lesions and 100% accurate all the time.
calcification. The overarching aim of the RCR report is
Once an image has been captured by the firstly to ensure that any innovations in AI are
radiographer, the AI will perform a ‘pre-analysis’ fully integrated into existing reporting systems
of the image, and, if an abnormality is detected, and secondly, to define the necessary standards14 | HHE 2021 | hospitalhealthcare.com GUIDELINE SUMMARY
required to enable radiology service providers General standards for data output
to facilitate this integration without creating Any AI platform adopted should have standard
additional burden for staff. output, and which must include:
The report does not make any specific Graphical representation of the region of
recommendations about which AI system interest (of the detected abnormalities) or
should be purchased, or any ethical mark-up/pointers using global technical
considerations related to the use of AI, and standards (DICOM) so that images can be
finally discusses the issue of AI solutions for viewed in the PACS viewers.
workflow and radiology management efficiency. • AI detected abnormalities should be output as
The report is directed more towards defining text e.g., fracture, infarct etc.
the parameters within which an AI platform • A notification that the image analysis has
should operate. been completed.
• Some AI alerts may be defined as critical
Standards within the system and should be pre-specified
The report begins with a series of standards by the radiologist.
for the use of AI systems. • A declaration or disclaimer should be sent out
1 AI must be integrated seamlessly with existing including the list of any abnormalities which
radiology information systems (RIS) and PACS were evaluated by the AI system. This might, for
without creating an additional burden for example, include a CT scan that detected a
radiologists. brain haemorrhage. It is also necessary to
2 The accuracy of the AI algorithms must be include the sensitivity and specificity (or true/
clearly declared to both the radiologist and false positives or negatives) of the applied
others involved in patient management. algorithm for each of the abnormality being
3 The AI finding should be communicated to evaluated.
the RIS and PACS through existing and global With the RIS, it will be necessary to
technical standards. incorporate additional data fields which capture
4 The department workflow should be AI abnormalities and any alerts.
sufficiently robust to ensure that the AI analysis The report concludes on a positive note
is complete and available on PACS before being saying that: “AI image pre-analysis is likely to
viewed and interpreted by a human. have a very positive impact on radiologists’
An important element of the report is the future working lives if properly integrated into
necessity to ensure that all instrumentation, the reporting workflow”.
e.g., scanners, RIS, PACS and the AI platform,
all work cooperatively within the radiology A copy of the full guidance can be viewed here.
department. It is also necessary that the AI www.rcr.ac.uk/publication/integrating-artificial-
platform only begins the analysis once the intelligence-radiology-reporting-workflows-ris-
radiographer has completed the examination and-pacs
and has sent the information to the AI system,
i.e., that the imaging should be ‘pre-analysed’
before reaching the PACS for displayed.You can also read
