|Year : 2021 | Volume
| Issue : 1 | Page : 20-24
Clinical governance in radiologic practice: Evaluating the appropriateness of radiologic investigation considering patient clinical information using the radiology request form
Ebbi Donald Robinson1, Olukumni Yetunde Ijeruh1, Woroma Wonodi2, Rufus Abam1
1 Department of Radiology, Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria
2 Department of Paediatrics, Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Submission||29-Dec-2020|
|Date of Decision||29-Dec-2020|
|Date of Acceptance||16-Apr-2021|
|Date of Web Publication||30-Jun-2021|
Dr. Ebbi Donald Robinson
Department of Radiology, Rivers State University Teaching Hospital, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Introduction: Clinical governance in radiology is an improved quality assurance program where the patient well-being is the central focus concerning radiologic service using the radiology request form (RRF). Methodology: The study was a 6-month descriptive study conducted from January 2020 to June 2020. A total of 2053 request forms were collated retrospectively and evaluated to ascertain the appropriateness of the clinical information with the investigation requested. A 3 stage Likert scale of appropriate somewhat appropriate and inappropriate was used and the data analyzed using the statistical package for the social sciences (SPSS) IBM Corp. version 23.0 (Armonk, NY: USA). The results were expressed in percentages and frequencies and presented in tables and charts. Results: Of the 2053 request forms, X-rays constitute 32.54% while ultrasound scans and computed tomography (CT) investigations constitute 43.21% and 5.46%, respectively. Clinical information was indicated in 51.39% of the RRF, out of which 75.95% of the clinical information were adequate while 13.93% were not in keeping with the investigation. Ultrasound scan request had the highest inappropriate clinical information (54.68%) followed by plain radiography request (41.73%) whereas all the CT request was in tandem with the investigation. Conclusion: There are occasional clinical information and radiologic request mismatch. This may be due to the filling of the RRF by medical interns or nonmedical personnel such as allied health workers with less knowledge on radiologic imaging modalities. The audit recommends proper supervision of young clinicians and continues medical education concerning the rational use of imaging modality.
Keywords: Clinical audit, clinical governance, clinical information, radiologic practice, radiology request form, Rivers State University Teaching Hospital, ultrasonography
|How to cite this article:|
Robinson ED, Ijeruh OY, Wonodi W, Abam R. Clinical governance in radiologic practice: Evaluating the appropriateness of radiologic investigation considering patient clinical information using the radiology request form. Biomed Res J 2021;8:20-4
|How to cite this URL:|
Robinson ED, Ijeruh OY, Wonodi W, Abam R. Clinical governance in radiologic practice: Evaluating the appropriateness of radiologic investigation considering patient clinical information using the radiology request form. Biomed Res J [serial online] 2021 [cited 2022 Jan 21];8:20-4. Available from: https://www.brjnmims.org/text.asp?2021/8/1/20/320130
| Introduction|| |
The accountability and continual evaluation to improve services with associated high standard of patient care constitute clinical governance,, which also involves the provision of quality services by creating an environment of excellence where clinical patient cares will flourish., Clinical governance is a universal terminology used to cover all the activities that help to sustain and improve high standards of patient care. It is concerned with improving the standard of care rendered to patients., The main component of clinical governance includes clinical audit, risk management, education, and training, as well as clinical effectiveness and research. Therefore, it can be applied in radiologic practice, pathology, obstetrics, and gynecology and indeed every sphere of clinical practice. Radiology is a branch of medicine that deals with the use of imaging modalities for the diagnosis, treatment, and follow-up of patients. The use of radiologic investigations is increasing as the day goes by with the advent of more imaging modalities.
The clinical audit is one of the major components of clinical governance and has been in existence for many years, however, the need for an audit is increasing and gaining more relevance as the day goes by. Many organizations including the European Society of Radiology (ESR),,, the European Commission (EC), the International Atomic Energy Agency, and Medical and Dental Consultants' Association of Nigeria have advocated the need necessitating clinical audits.
According to the EC guidelines for clinical audits for medical radiological practices, clinical audit is the systematic evaluation or review of medical radiological procedures, which is billed to improve the quality and outcome of care. It was also documented by the commission that this outcome can be achieved through a well-structured review system whereby radiologic procedures and results are re-evaluated in correlation to the investigation and against documented gold standards for effective medical radiologic outcome and clinical support.,
The need for clinical governance evaluation with respect to radiologic practice cannot be overemphasized especially with the use of ionizing radiation which could predispose patients to biological side effects. The audit is necessitated to reduce repeat examination and/or multiple investigations which may include the use of high doses of ionizing radiation. A proper audit will help clinicians to be well educated concerning the type of radiologic investigation that best suits the clinical presentation and open a proper channel of communication between the radiologist and the clinician. Not only will this proffer better radiologic investigation, it will also be of more economic value by reducing patients' cost following multiple investigations.
The mode of communication between the clinician and the radiologist is through the use of the radiology request form (RRF) which contains the patient's identity, age, gender, and the requests by the clinician (medical practitioner) regarding the type of radiologic investigation among others. RRFs ought to be adequately completed to convey the desired information.
Notwithstanding, the RRF provides information concerning the patient and the investigation(s) being requested, and the nonindication of the patients' clinical information could pose a serious challenge to the interpretation of the investigation. Similarly, a bigger problem of inappropriate interpretation arises when there is a mismatch between the clinical information and the investigation requested. This can result to repeat study, more cost on the patient, medical errors as well as delay in instituting early management with overall poor service delivery and poor patient outcome.
The inadequate filling of RRF is already known as a global menace. Studies have evaluated the complete filling of RRF by doctors, and majority of the studies have shown a defective or suboptimal completion of the form. A study by Akintomide et al. in an audit with 580 radiologic request forms revealed that 86.6% constituted the most completed request form while 26.67% account for the least completed. Similarly, a study by Afolabi et al. also showed that, out of the 202 RRF evaluated, 89.1% had complete and adequate information. A prospective study in three facilities across Nigeria, Ghana, and Sierra Leone revealed that the absence of clinical information is one of the commonly omitted information.
Clinical governance is an improvement of quality assurance program where the patient well-being is now the central focus. The unnecessary exposure to ionizing radiation can be reduced effectively by quality assurance program which is a type of clinical governance were the patient is the principal focused. This can also identify the cause of the unnecessary exposure which could be overexposure or underexposure among other factors and to ensure that every exposure to ionizing radiation in radiologic practice is justified. According to Almalk et al., overexposure and underexposure constitute majority of the causes of repeat examination accounting for 32.91% and 28.94%, respectively.
The index study is aimed to evaluate the appropriateness of radiologic investigation requested considering the clinical information provided on the RRF. The correlation will provide more insight to clinical governance as it relates to radiologic services and the overall quality of patient care.
| Methodology|| |
The study was a 6-month analytic descriptive study conducted at the Radiology Department of the Rivers State University Teaching Hospital (RSUTH), Nigeria, from January to June 2020. The institution is a 375-bedded state-owned tertiary health facility that offers specialized health-care services in different specialties and subspecialties.The radiology department is well equipped with state of the art radiologic equipment, with the capability of performing any type of radiologic investigation. The department serves the hospital and other health facilities within and outside the state.
Ethical approval for this study was granted by the Ethics Committee of the RSUTH. A total of 2053 request forms were collated retrospectively and analyzed to evaluate the appropriateness of the clinical information with the requested radiologic investigation. The appropriateness is evaluated using a 3 stage Likert scale appropriate, somewhat appropriate and inappropriate. The validity of the correlation between the clinical indication and the radiologic investigation was approved by a randomly constituted medical board comprising of specialists from the clinical departments.
Data were collated and analyzed using the IBM Statistical Package for the Social Sciences (SPSS) version 23. The results were then expressed in percentages and frequencies and presented in tables, charts, and graphs.
| Results|| |
A total of 2053 request forms were collated and evaluated. Of the 2053 request forms, 55.09% (n = 1131) were original request forms of the RSUTH, while 26.98% (n = 554) were referral request forms from other hospitals whereas 17.92% (n = 368) were improvised forms written on plain sheets of paper [Figure 1]. [Figure 2] shows that 41.35% of the patients are males, 53.19% (1092) are females while 5.46% (112) had no gender indicated in the form.
The analysis also showed that X-rays constitute 32.54% (668), while ultrasound scans, magnetic resonance imaging (MRI), mammography, and computed tomography (CT) investigations constitute 43.21% (887), 13.83% (284), 4.97% (102), and 5.46% (112), respectively [Table 1]. It is illustrated in [Figure 3], that 51.39% of the request form had the clinical information of the patient indicated while 48.61% of the forms do not contain the clinical information(s). Of the 51.39% with clinical informations, 75.95% (758) of the clinical informations were adequate, while 13.93% (139) were not adequate [Figure 4].
|Figure 4: Appropriateness of the clinical information on the radiology request forms|
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Ultrasonographic investigations had the highest number of inappropriate clinical information accounting for 54.68% of the investigation form [Table 2]. Plain radiographic investigation had 41.73% of inappropriate clinical information whereas all the CT request was in consonance with the investigation. MRI request forms had 0.72% of the overall inappropriate clinical information [Table 2].
|Table 2: Appropriate clinical information in the various imaging modalities|
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| Discussion|| |
Majority of the request forms (55.09%) were original request forms of the Department of Radiology, RSUTH. Meanwhile, 26.98% of the request forms were from other hospitals. This suggests that the Department of Radiology, RSUTH, is a tertiary institution that receives investigation referral from other primary and secondary health facilities around the region (within the South-South geopolitical zone). Some of the requests (17.92%) were written on plain sheets of paper. This could be attributed to the inequitable distribution of the original request forms within the clinical departments, clinics and accident and emergency, or it may be due to outright unavailability of the forms. The unavailability of the forms could also be due to delay in the printing press or administrative bottlenecks. However, majority of the forms were original forms from either the RSUTH or private public and private facilities.
Gender is not only required for patient identification but also pertinent in disease classification and predilection. It is well known that certain disease conditions may have the predilection for male or females as the case may be, thus proper documentation of the gender will enhance effective and precised radiologic diagnosis and improve the overall patient outcome. Female patients were the most sent for radiologic investigation accounting for 53.19% of the patients while males constituted 41.35% of the patients. The reason may be due to the fact that women are 33% more likely to visit the hospital than men., It is, however, interesting to note that 5.46% of the request forms did not indicate the gender of the patients. This finding indicates that a cumulative of 94.54% of the forms has the gender of the patient documented which is similar to that documented by Robinson et al. where 94.87% of the forms had the gender of the patients documented. The finding was also in consonance with the study by Agi et al. In their study, 97.3% of the RRFs had the patients' gender well documented. The percentage of forms that had no gender documented could be due to work overload on the doctors, stress, and carelessness.,
The result showed that ultrasound scans are the most requested radiologic investigation. The reason for this is not known, however, it may be attributed to the use of nonionizing radiation and its relative availability. Ultrasonography is seconded by plain radiography while CT scan was the least requested investigation.
Clinical information concerning the patient was indicated in 51.39% of the forms while 48.61% of the forms do not contain the patient's clinical information(s). The result obtained in the index study is higher than that obtained in the study by Afolabi et al. where 34.4% had a completed form with clinical information, whereas in the study by Akinola et al. with 144 consecutive request forms revealed that 99.3% had the clinical history filled. The disparity may be due to the variation in the sample size. The reason for not documenting the clinical information cannot be well comprehended, because clinical information is a foundation that supports the radiologist in image interpretation.,, Of the 51.39% with clinical information documented in the forms, 75.95% were in consonance with the requested investigation while 13.93% were not in line with the investigation requested. Ultrasonographic investigations had the highest number of mismatches, followed by plain radiographic investigation (41.73%). CT request was in consonance with the requested investigation.
The reason for the discordant request cannot be explained, however, it could be related to the outright allocation of filling of the request form to medical interns and very junior doctors. It can also be attributed to poor knowledge of radiologic imaging modalities owing to the fact that the duration of study of radiology in medical schools spans between 2 weeks and 4 weeks. This duration is very short and does not allow younger doctors to be adequately exposed to the principles and practice of radiology including the ever evolving imaging modalities. It is not uncommon for clinicians to loose grip of radiologic modalities and the ability to request for the most appropriate investigation. The reason for the clinical information and investigation request mismatch may also be due to nonmedical personnel filling request form and sending clients for radiologic investigation when they have little or no training or knowledge concerning medical imaging. This could be the case for traditional birth attendance, local bone healers, and other allied health practitioners who wish to strengthen their practice using imaging modalities. There is a paucity of documentation regarding radiologic clinical audit and the index study, therefore, it is important that more studies should be done to improve radiologic services.
| Conclusion|| |
The study shows that radiologic request forms are occasionally not available in the clinical departments and wards. Information in the request forms is sometimes not complete, and patient gender is not indicated. The study also revealed that there was a clinical information and radiologic request mismatch. The reason for the discordance cannot be explained, however, it has been related to the outright allocation of request form filling to interns and very junior clinician with less knowledge of radiologic imaging modalities. There is a paucity of information concerning this subject, therefore, it is important that more studies to done as a form of clinical audit to improve radiologic services.
The audit recommends the need for proper supervision of young clinicians and continues medical education concerning radiologic imaging modalities and the rational use of imaging modality. Review of the medical curriculum with an increase in the duration of time allocated to radiology posting in medical schools is recommended. The proper education of non-medical doctors on how to fill the RRF in other to obtain an effective radiologic service is also recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Smith-Bindman R, Miglioretti DL, Larson EB. Rising use of diagnostic medical imaging in a large integrated health system. Health Aff (Millwood) 2008;27:1491-502.
European Society of Radiology. ESR subcommittee on audit and standardsClinical audit-ESR perspective. Insights Imaging 2010;1:21-6.
European Society of Radiology. European Commission guidelines on clinical audit. Statement by the European Society of Radiology. Insights Imaging 2011;2:97-8.
European Commission. European Commission Guidelines on Clinical Audit for Medical Radiological Practices (Diagnostic Radiology, Nuclear Medicine and Radiotherapy). Radiation Protection No 159; 2009. Available from: https://ec.europa.eu/energy/sites/ener/files/documents/159.pdf
. [Last accessed on 2017 Jun 16].
Depasquale R, Crockford MP. Are radiology Request forms adequately filled in? An audit assessing local practice. Malta Med J 2005;17:36-8.
Jegede F, Mbah HA, Dakata A, Gwarzo DH, Abdulrahman SA, Kuliya-Gwarzo A. Evaluating laboratory request forms submitted to haematology and blood transfusion departments at a hospital in Northwest Nigeria. Afr J Lab Med 2016;5:381.
Akintomide AO, Ikpeme AA, Ngaji AI, Ani NE, Udofia AT. An audit of the completion of radiology request forms and the request practice. J Family Med Prim Care 2015;4:328-30.
] [Full text]
Afolabi OA, Fadare JO, Essien EM, Ann IB. Audit of completion of radiology request forms in a Nigerian specialist hospital. Postgrad Med 2012;10:48-52.
Jumah KB, Gordon-Harris L, Agahowa JI. Common faults in filling of radiological request forms. East Afr Med J 1995;72:744-5.
Balding C. From quality assurance to clinical governance. Aust Health Rev 2008;32:383-91.
Almalki M, Abulfaraj WH, Bhuiyan SI, Kinsara AA. A study on radiographic repeat rate data of several hospitals in Jeddah, Radiat Prot Dosimetry 2003;103:323-30.
Analysis of Radiological Examination Request Forms in Conjunction with Justification of X-Ray Exposures Department of Health. The Ionizing Radiation (Medical Exposure) Regulations 2000, with Supplementary Guidance on Good Practice; 2000. Available from: http://www.doh.gov.uk/irmer.htm
. [Last accessed on 2019 Jun 16].
Buvinić M, Medici A, Fernández E, Torres AC . Gender differentials in health. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al
., editors. Disease Control Priorities in Developing Countries. 2nd
ed., Ch. 10. Washington (DC): The International Bank for Reconstruction and Development/The World Bank; 2006. [Last accessed on 2020 Dec 21].
Bertakis KD. Gender differences in the utilization of health care services. J Fam Pract 2000;49:147-52.
Robinson ED, Ijeruh OY, Wonodi W, Abam R, Wekhe C. Radiology Request Form; Evaluating Its Complete Filling In South-South, Nigeria. Journal of Radiation Medicine in the Tropics | Volume | Issue | January-June 2021. Accepted for publication. In issue preparation
Agi C, Alagoa PA, Fente BG. A simple audit of radiological request forms at the university of Port Harcourt teaching hospital. Niger Health J 2015;15:151-4.
Irurhe NK, Sulaymon FA, Olowoyeye OA, Adeyomoye AA. Compliance rate of adequate filling of radiology request forms in a Lagos university teaching hospital. World J Med Sci 2012;7:10-2.
Castillo C, Steffens T, Sim L, Caffery L. The effect of clinical information on radiology reporting: A systematic review. J Med Radiat Sci 2021;68:60-74.
The Royal Australian and New Zealand College of Radiologists. Radiodiagnosis Training Program Curriculum. Sydney: The Royal Australian and New Zealand College of Radiologists; 2014.
van der Gijp A, van der Schaaf MF, van der Schaaf IC, Huige JC, Ravesloot CJ, van Schaik JP, et al
. Interpretation of radiological images: Towards a framework of knowledge and skills. Adv Health Sci Educ 2014;19:565-80.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]