Optimising Quality of Diagnostic Imaging

Aim

Improve the quality of imaging referrals by assessing adherence to existing guidelines, identifying deficiencies, and implementing strategies for better documentation and patient care.

Outcomes

This audit will provide critical insights into the current quality of imaging referrals and highlight areas for improvement.
The findings will be used to:

• inform the development of structured referral forms with updated fields for essential clinical details
• enhance referrer education on best practices for imaging requests
• improve communication between clinicians and radiologists to optimise diagnostic accuracy
• support ongoing quality improvement initiatives within Caboolture Hospital
• establish a framework for continuous monitoring and future audits to sustain improvements in referral quality.

The audit revealed considerable inconsistencies in referral quality. Among the 49 referrals, 24.5% scored seven points or less, with a median of nine points and range of five to 12 points. 100% of referrals included accurate patient identification, while only 24.5% provided referrer contact details. Legibility issues were identified in 18.4% of referrals. While 93.9% included a differential diagnosis, only 57.1% documented relevant past medical history, and 44.9% documented examination findings. Among patients with malignancy, 75% of referrals documented details about the history of malignancy, but only 22.2% of those included information on whether the patient was immunosuppressed.

Investigations, such as pathology (18.4%) and prior imaging (12.2%) results, were rarely mentioned. The findings highlight the urgent need
for improved documentation in imaging referrals to enhance diagnostic accuracy and optimise patient care. Implementing structured referral forms with mandatory fields for key medical information is essential to addressing these gaps. These measures have the potential to significantly improve referral quality, minimise diagnostic uncertainty, and ultimately enhance patient outcomes.

Background

Radiologic interpretation heavily relies on the ‘detection’ of abnormal findings that support a diagnosis, which occurs through a cognitive process called ‘goal-directed feature search process’ where images are evaluated to search for features that either support or disprove the diagnosis. As expected, this would require sufficient clinical information to be available to the interpreting radiologist to interpret the image appropriately. Literature has already established how a lack of explicit questioning of a clinical diagnosis and inadequate clinical information can result in missed diagnoses.

The application of imaging referral guidelines has been shown to reduce radiology workload and improve diagnostic imaging utilisation. This implies that clinical information provided on referrals impacts key stakeholders, including patients, radiologists, and treating teams, to optimise quality of care and resource allocation. In Caboolture Hospital, imaging is provided externally via I-MED Radiology where radiology staff are unable to routinely access Queensland Health systems to review patient history and information to aid imaging interpretation.  This leaves the radiologist with only the information provided on the referral, or otherwise to contact the referring clinician to discuss the patient’s case, further highlighting the necessity of adequate imaging referrals. RANZCR does not have a formal criteria or guideline for radiology requests. However, they have published a position statement regarding the quality of referrals recommending that referrals include the following information: identity of the patient, identity of the referrer, sufficient clinical detail to justify and select the diagnostic imaging, as well as being unambiguous without legibility issues for clear communication between clinicians.

This audit aims to review the quality of diagnostic imaging referrals in Caboolture Hospital to identify areas of improvement based on the RANZCR recommendations. A key outcome we aim to review is medical history, especially those that may critically impact imaging interpretation such as malignancy and immunosuppression.

Discussion

The findings demonstrate that there is a substantial proportion of imaging requests that do not provide sufficient clinical information which may impact patient safety and resource allocation and identified areas for improvement as largely being providing adequate medical history, especially regarding malignancy and immunosuppression. It should be considered that requesting clinicians, who are often the most junior of the treating team, may not be aware of the significance of clinical history, subsequently omitting this information, or this information may be overlooked due to the acute presentation seemingly being irrelevant.

A suggestion to address this issue would be to include a dedicated section on past medical history and a questionnaire as a part of the referral request to act as a visual cue for referring clinicians as a compulsory questionnaire. Further prompting that I-MED Radiology has no access to The Viewer and other Queensland Health systems may be required to remind clinicians that all relevant information must be either documented in the request form or verbally discussed. An example we have formulated is attached. In addition to the verbal discussion above, we also suggest that treating teams should consider a verbal discussion and advice from radiology if multiple imaging studies are required with equivocal findings or unclear diagnosis. We hope this will benefit all stakeholders, where the treating team can discuss the clinical questions directly with the radiologists to seek expertise in obtaining the most appropriate, useful imaging and compare previous scans.

Another suggestion is regarding The Viewer and Queensland Health iEMR  access for I-MED radiologists to allow reporting radiologists to review patient medical history and pathology as required. I-MED radiologists are often located remotely and solely rely on the imaging referral for a ‘handover’ to interpret the scans. Access to medical records with the introduction of iEMR would help manage this concern. To address gaps in imaging referrals, I would recommend automating the collection of critical information through integrated systems like The Viewer or iEMR and formalising verbal communication pathways between clinicians and radiologists. Additionally, using data analytics to track missing information could help target specific departments for improvement.

This project could succeed in other Queensland Health facilities by streamlining referral processes, improving communication, and ensuring radiologists have access to patient histories to enhance patient safety and resource allocation.

References

1. Pitman A. Quality of referral: What information should be included in a request for diagnostic imaging when a patient is referred to a clinical radiologist? Journal of Medical Imaging and Radiation Oncology. 2017 Jan 31;61(3):299–303.
2. Bassiouni M, Bauknecht HC, Muench G, Olze H, Pohlan J. Missed Radiological Diagnosis of Otosclerosis in High-Resolution Computed Tomography of the Temporal Bone—Retrospective Analysis of Imaging, Radiological Reports, and Request Forms. Journal of Clinical Medicine. 2023 Jan 12;12(2):630.
3. ‌Heriot G, McKelvie P, Pitman A. Diagnostic errors in patients dying in hospital: Radiology’s contribution. Journal of Medical Imaging and Radiation Oncology. 2009 May 26;53(2):188–93. doi:10.1111/j.1754-9485.2009.02065.x
4. Tay, YX., Foley, S., Killeen, R., Ong, MEH., Chen, RC., Chan, LP., et al. Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review. European Radiology. 2024 Jul 3;
5. RANZCR. Quality of Referrals Position Paper [Internet]. The Royal Australian and New Zealand College of Radiologists. [cited 2024 Nov]. Available from: https://www.ranzcr.com/college/document-library/quality-of-referrals-position-paper

Acknowledgements

Dr Thakur Manas Singh, Director of I-MED Radiology Caboolture Hospital, and Dr Gunjan Chawla, Director of Clinical Training at Caboolture Hospital, for their invaluable guidance and supervision throughout the course of this project.