Towards best practice in interventional radiology draws together the findings from visits to interventional radiology (IR) services at proposed major trauma centres in England during 2011/12. This record of their major findings provides a definitive read for trust chief executives and commissioners to help better inform IR service reviews. (June 2012)

1. NHS
CANCER
NHS Improvement
Diagnostics
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Diagnostics
Towards best practice in
interventional radiology British Society of
Interventional
Radiology
June 2012

2. This document sets out case studies using service
delivery models that provide benefits for patients
and staff. The clinical teams have shared their
learning so that their experiences may be a stimulus
to others to improve local interventional radiology
(IR) services.

3. 3
Towards best practice in interventional radiology
Contents
Executive summary 4
Key messages 5
Patient foreword 6
Glossary of terms 7
Abbreviations 8
Introduction 10
Networking 12
Funding issues 14
Facilities 15
Staffing and team working 16
Patient and public engagement and experience 18
Leadership 20
Low volume procedures 22
Case studies
Appendix A. Networking 24
Appendix B. Funding 32
Appendix C. Staffing and MDT working 34
Appendix D. Patient engagement and experience 45
Appendix E. Leadership 51
Bibliography and suggested further reading 52
Contacts 53
Acknowledgements 54

4. 4 Executive summary
Executive summary
Towards Best Practice in Interventional Radiology draws together the major
findings that came out of the visits to interventional radiology (IR) services
at the proposed major Major Trauma Centres during 2011/12. Examples of
best practice to provide benefits for patients and staff are described.
The work by the NHS Improvement team to review IR services across
England confirms that further improvements in IR are necessary to ensure
equitable access to IR services for patients. The clinical teams at these
centres shared their learning so their experiences may be a stimulus to Professor Erika Denton
others. National Clinical Director
for Imaging
We urge you to read this report and to review the IR services you provide
for those in your care. This report will support you to improve local IR
services.
Professor Erika Denton* Professor Keith Willett* Professor Keith Willett
National Clinical Director for Imaging National Clinical Director for National Clinical Director
Trauma Care for Trauma Care
* The views of Professor Erika Denton and Professor Keith Willett are given in a
clinical capacity and as national experts in the field. They do not in themselves
impose any mandatory requirements on NHS organisations although
commissioners are expected to take them into account.

5. Key messages 5
Key messages
• High quality IR services are essential for safe and
effective patient care.
• There is variation in provision of IR throughout England,
particularly for potentially lifesaving emergency and
out-of-hours procedures.
• Despite this there are already many examples of good
practice and service delivery across the country.
• Networking will be essential to improve access to IR.
There are challenges in developing effective operational
delivery networks but there are already good examples of
these in the UK.
• A good well resourced IR service can contribute to
significant savings (both financial and non-financial)
along care pathways in both planned and emergency
care.
• The opportunity exists to use improvement techniques of
standard work and visual management to create agreed
standard operating procedures. This can support a
network approach to providing on-call across a number
of organisations.

6. 6 Patient foreword
Patient foreword
Provision of IR services enhances To be perceived as a world class From a patient’s perspective IR offers
better outcomes for patients service, providers have to recognise the opportunity for a better patient
receiving elective and non elective that patients’ groups are frustrated overall experience including reduced
care for many conditions. Both that examples of best practice from length of stay and improved clinical
commissioners and providers, within and outside of the UK, be it in outcome.
including the medical profession and patient management, practitioner
specialist IR staff need to recognise training or in communicating the
that patients and their carers need value of IR are often overlooked
more information and knowledge ‘because our organisation is
about IR services. Communicating different.’ This is wasteful and
the value of IR is vital to address the arrogant. IR has the capacity to
differences of providing acute care, transform patient management, but
such as when the patient arrives the benefits appear, to date, mostly
unconscious and elective care which only recognised by a small group of Pat Kelly
requires the patient’s consent for a highly committed, specialist and Lay Member
booked procedure. personally motivated practitioners. Royal College of Radiologists
Confusion about who performs IR Clinical Radiology Patient's
Importantly, patients and their persists - surgery, or radiology? It Liaison Group
representatives want to be assured does not help the patient that this
that best practice in IR is provided to debate has persisted unresolved for
all service users on an equality of over twenty years.
access basis across the country. This is
an aspirational objective while Patients’ representatives have to be in
services are being improved and a position to challenge Clive Booth
evidence gathered. The challenge for commissioners and providers on the Former Chairman
commissioners and providers of true role of IR including a patient Royal College of Radiologists
health care will be to ensure that journey based on examples of best Clinical Radiology Patient's
good health care outcomes requiring practice, including adequate access Liaison Group
IR are equally available wherever one to out-patient clinics, admission
lives. rights and support staff.

7. Glossary of terms 7
Glossary of terms
A&E Accident and Emergency MR/MRI Magnetic Resonance Imaging
AAA Abdominal Aortic Aneurysm MDT Multidisciplinary Team
BSIR British Society of Interventional Radiology MTC Major Trauma Centre
CCG Clinical Commissioning Group NICE National Institute for Clinical Excellence
CEO Chief Executive Officer NVD National Vascular Society Database
CPX Cardiopulmonary Exercise Testing OC On Call
CT Computed Tomography OP Outpatient
CIP Cost Improvement Programme PACS Picture Archiving Communication System
DCC Direct Clinical Care PbR Payment by Results
DGH District General Hospital PCI Percutaneous Coronary Intervention
DOQI Disease Outcome Quality Initiative PICC Peripherally Inserted Central Catheter
ED Emergency Department PPM Planned Preventative Maintenance
eEVAR Emergency Endovascular Aneurysm Repair QA Quality Assurance
EPR Electronic Patient Record QIP Quality Improvement Programme
EVAR Endovascular Aneurysm Repair RCR Royal College of Radiologists
EWTD European Working time directive RETA Registry of Endovascular Treatment
of Aneurysms
HDU High Dependency Unit
RIS Radiology Information Systems
HPB Hepato-biliary
SLR Service Line Reporting
HR Human Resources
SVS Society for Vascular Surgery
HRG Healthcare Resource Group
TACE Transcatheter arterial chemoembolisation
IR Interventional Radiology
TEVAR Thoracic Endovascular Aneurysm Repair
IT Information Technology
TIPS Transjugular intrahepatic portal
ITU Intensive Therapy Unit systemic shunt
IV Intravenous UAE/UFE Uterine Artery (or Fibroid) Embolisation
IVC Inferior Vena Cava US Ultrasound
MHRA Medicines and Healthcare Products
Regulatory Agency

8. 8 Procedure descriptor
Procedure descriptor
Embolisation A minimally invasive procedure which involves the selective occlusion of
blood vessels to prevent haemorrhage.
EVAR Endovascular repair used to treat an abdominal aortic aneurysm A graft is
placed in the aorta via the femoral arteries, without an abdominal incision,
using X-rays to guide the graft into place. When this procedure is performed
in an emergency setting it is called an Emergency Endovascular Aneurysm
Repair (eEVAR)
Fistulogram An X-ray taken of a fistula after a contrast medium has been injected.
Hepatobiliary A term used to describe the liver, gallbladder and bile ducts.
Nephrostomy An artificial opening created between the kidney and the skin used to drain
urine from the kidney to a bag outside the body.
TACE A minimally invasive procedure to restrict the blood supply to a tumour.
TEVAR A minimally invasive approach to repair a thoracic aortic aneurysm. A graft
is placed in the aorta via the femoral arteries, using X-rays to guide the graft
into place.
TIPS or TIPPS A procedure where a metal tube is passed across the liver

10. 10 Introduction
Introduction
The White Paper, Equity and Towards Best Practice in
Excellence: Liberating the NHS1 and Interventional Radiology sets out case
the Health and Social Care Act 20122 studies using service delivery models
details how the improvement of that provide benefits for patients and
healthcare outcomes will be staff. They are set around seven key
measured using outcomes achieved themes:
for patients rather than the processes
by which they are achieved. • Networking
• Funding
Building on this aim, one of the • Facilities
major purposes of The NHS • Staffing/MDT working
Outcomes Framework 2011/123 was • Patient experience
‘to act as a catalyst for driving quality • Leadership
improvement and outcome • Low volume procedures,
measurement throughout the NHS by
encouraging a change in culture and and align the case studies to the five
behaviour, including a stronger focus domains (table 1)
on tackling health inequalities.’
The NHS Outcomes Framework is Table 1
structured around five domains. Each
of the five domains will be supported Domain 1 Preventing people from dying prematurely
by a suite of NICE quality standards
which will provide authoritative Domain 2 Enhancing quality of life for people with long term conditions
definitions of what high-quality care
looks like for a particular pathway of Domain 3 Helping people to recover from episodes of ill health or
care. These quality standards are following injury
currently being prepared.
Domain 4 Ensuring that people have a positive experience of care
Domain 5 Treating and caring for people in a safe environment and
protecting them from avoidable harm
1www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
2www.legislation.gov.uk/ukpga/2012/7/contents/enacted/data.htm
3www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

11. Introduction 11
The site visits and this report were Interventional radiology was felt to
inspired by the two reports on be a significant challenge by many of
interventional radiology published by the proposed Major Trauma Centres
the Department of Health in 2009 (MTCs) and a series of site visits were
and 20104,5. The 2010 report undertaken.
Interventional radiology: guidance for
service delivery discussed how the
NHS can improve quality, safety and
productivity while delivering Preferred acute patient pathway
comparable or better outcomes for
patients with shorter hospital stays 24/7 network coordinator On scene triage Enhanced
and fewer major complications. It in ambulance service care team
suggests and describes how IR
services can help to ensure patient
safety whilst delivering the highest On call medical Direct Indirect
consultant transfer transfer
quality care. (<45 mins) (geography, time
critical intervention)
A further driver was the 2010 report
by the NHS Clinical Advisory Group
MAJOR TRAUMA CENTRE TRAUMA UNIT
Regional Networks for Major Trauma6
?
stated that ‘the delivery of effective Consultant led trauma team Trauma team
ongoing trauma care and Immediate operating theatre Immediate CT scan
All specialties Resus, assess and ? transfer
management relies upon appropriate Immediate CT scan
availability of imaging techniques.’ Interventional radiology
Specialist critical care
The key themes section within the
document identifies ‘Acute
Intervention including...
interventional radiology,’ and laid out
a key recommendation: Towards Best Practice in appendix to the document and also
Interventional Radiology builds on the on the NHS Improvement website at
At Major Trauma Centres work done in 2011/12 to visit all of (www.improvement.nhs.uk).
interventional radiology the agreed and proposed Major Additional case studies will be added
capability will attend within 60 Trauma Centres in England. It draws on the website as they become
minutes 24 hours a day. together the major findings that available and new examples of best
Interventional suites should be came out of the visits and cites practice are identified.
ideally co-located with operating examples of best practice. These
rooms and/or resuscitation areas. examples are provided as an
4www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109130
5www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121904
6www.excellence.eastmidlands.nhs.uk/welcome/improving-care/emergencyurgent-care/major-trauma

12. 12 Networking
DOMAIN DOMAIN DOMAIN DOMAIN
1 3 4 5
Networking
The recent Vascular Society Setting up a operational delivery Examples of good practice
publication, The provision of services network can be challenging with 1.Networked on call IR services
for patients with vascular diseases difficulties that may include: between several major centres
20127 emphasises the importance of around Glasgow with radiologists
good clinical operational delivery • historically poor communication and nurses travelling to the patient’s
networks. Whilst this document between sites; location. To overcome the issue of
largely refers to vascular surgery and • possible threats to income flows; availability of specialist consumables
interventional radiology (IR) related to • reluctance of staff to work on new the travelling staff carry a large box
vascular surgery the same principles and unfamiliar sites; of IR equipment such as wires,
apply to all forms • risks of transferring critically ill catheters and embolisation coils. This
of IR. patients; good practice example is described in
• bed availability if patients need to more detail in the Appendix A.
In many UK hospitals there are be transferred between sites;
difficulties in providing interventional • staff shortages; 2.Networked on call IR services
procedures required to support the • differing practices and skill sets on between a large hospital in Coventry
full range of clinical activity taking different sites; and with four interventional radiologists
place within that centre. This has • standardising equipment and and a smaller hospital in a nearby city
been confirmed by a recent detailed pathways across sites. (Nuneaton) with two interventional
survey that shows variable and radiologists. The emergency on call
patchy provision of IR throughout As with any service improvement, service is based in Coventry. In order
England8. For example, many where these issues have been to overcome the issues of different
hospitals admit acute medical and overcome there has been skill sets, experience and working
surgical emergencies but have no engagement and good practices and the challenge of
provision for emergency embolisation communication between clinicians working in an unfamiliar environment
for haemorrhage. and managers on all involved the Nuneaton radiologists have
locations. Examples of successful regular elective IR lists in Coventry.
The areas of greatest difficulty are operational delivery networks in This good practice example is
complex, low volume procedures and different geographical environments described in more detail in the
the provision of emergency out-of- are given below. Appendix A.
hours IR in general. This particularly
applies to smaller acute hospitals
where there will never be sufficient
numbers of specialised staff to create
a stand-alone on call rota. It is likely
that effective networking between
centres is the only means of
achieving a sustainable solution that
will enable equitable access to IR
services across the country.
7Vascular Society of Great Britain and Ireland. The Provision of Services for Patients with Vascular Disease. London 2012.
www.vascularsociety.org.uk/library/vascular-society-publications.html
8www.improvement.nhs.uk/diagnostics/InterventionalRadiology/IRServiceProvisionMap/tabid/114/Default.aspx
Interventional Radiology Service Provision Mapping 2011

13. Networking 13
3.Networked on call IR services
between two similar sized hospitals in
a rural setting (Exeter and Torbay),
each with three interventional
radiologists. Week days and evenings
are covered locally with the
radiologists on a 1:3 rota Monday to
Thursday on each site. Over
weekends there is one interventional
radiologist on call for both sites,
resulting in an acceptable 1:6
weekend rota. The radiologist usually
travels to the patient’s hospital and
there are interventional nurses and
radiographers on call on both sites to
enable this. This good practice
example is described in more detail in
the Appendix A.
4.Agreed pathways between centres
for low volume/specialist services
such as hepatobiliary or thoracic
aortic intervention.
5.Implementation of radiology
nursing cross site rotation. The
system supports safe practice,
increased knowledge base and
nursing job satisfaction, plus aids
recruitment. Cost savings can be
made by reducing two on call rotas
to one. This good practice example is
described in more detail in the
Appendix A.

14. 14 Funding issues
DOMAIN DOMAIN DOMAIN DOMAIN
1 2 3 5
Funding issues
Almost without exception during the Clinical coding decisions, prioritise new service
site visits to the MTCs, funding issues Interventional radiology cases often developments or plan new clinical
and concerns were raised by all of proceed or change once the patient investments. However where a
the teams visited. The issues fell is ‘on the table’ and this is not always service costs more to deliver than the
largely into five categories. reflected accurately in the notes or income it receives for delivering the
on the Radiology Information System service it takes a team with foresight
Getting income for referrals from (RIS). This makes accurate clinical to recognise the non financial
other hospitals coding impossible. Clinical coding is incentives of delivering this service.
This was a significant cost pressure most usually done by a team of
for many departments. There were admin staff remote from radiology. In Examples of good practice
few examples of agreed referral some centres there was little 1.Accuracy of coding for IR
pathways and funding streams. recognition of why it is important to procedures is vital to reflect workload
Where a referral protocol was in accurately reflect the procedure and ensures maximum income for IR
place it was mostly between clinical codes and in others frustrations that departments. This ensures that
specialties and the first IR knew of they felt powerless to influence the resources follow clinical activity. This
the origin of the patient was when process. good practice example is described in
they received the request. more detail in the Appendix B.
Internal re-charging
This was reported as a much more Several sites had set up a system of 2.Internal recharging was seen
significant problem where DGHs internal charging. Setting up the working well in several of the sites
provided an in hours or simple IR system had proved to be a lot of visited. At least two sites
service but did not undertake initial work but where it was working demonstrated that it was possible to
complex procedures or provide an well was felt to be hugely beneficial. reduce unit costs.
out of hour’s service.
The two primary reasons cited were; 3.Sites delivering an OP service or
Tariffs • to influence decisions that affect post procedure telephone follow up
Despite significant progress centrally the service by showing how much were working with their clinical
many sites reported that the tariff did ‘income’ the service could coding teams to secure the tariff for
not adequately reflect the actual cost generate; and imaging services.
of delivering the service. This was • to reflect back to referrers the true
particularly apparent in centres costs of an IR intervention.
offering a tertiary level of care where
they were asked to undertake the Service line reporting (SLR)
most complex cases and often the SLR measures profitability of its
out of hours work for surrounding services by monitoring cost, income,
DGHs. activity and use of resources. It can
enable a trust to increase its
productivity by providing financial
information to make informed

15. Facilities 15
DOMAIN DOMAIN
4 5
Facilities
Equipment and site guidance – Delivering an EVAR
Theatre design should ensure that all Service (2010)9. It should be of Examples of good practice
consumable equipment (catheters sufficient size to permit full 1.Monthly QA checks on dose and
stents, embolic material etc) is in a anaesthetic facilities, including piped image quality are recorded on a
suitable equipment storage area gases, drugs and anaesthetic database and displayed graphically.
immediately accessible from the IR equipment. This allows trends to be quickly
theatre. Consumable equipment identified and in one site had
should include a full range of The theatre environment should have supported a dose reduction of
equipment suitable for embolisation a staffed recovery area to allow approximately 30%.
to control haemorrhage, stents and reception and onward transfer of
stent grafts suitable for major and patients to other environments. 2.Having procedure trolleys made up
minor vessel repair and a ‘bail out and ready for quick access when
box’ with everything needed for The theatre should be located as required in an emergency was in
complications. close as possible to the emergency place at several of the sites visited.
CT scanner and care taken to ensure
Major Trauma Centres should be able a rehearsed rapid transfer facility. 3.IT resilience for CT scanners that
to provide Thoracic Endovascular may be required for major trauma,
Aneurysm Repair (TEVAR) for IT links had been achieved by hardwiring a
appropriate cases and facilities, Access to Picture Archiving & PC for each scanner separate from
pathways and workforce should be in Communication Systems (PACS) PACS within the CT control room.
place to support this activity. workstations and RIS systems should
be available within the IR theatre.
At present, there is variation in the Teleradiology links are vital and
provision of emergency Endovascular access to a robust and rapid transfer
Aneurysm Repair (eEVAR) for of imaging scans from hospitals
ruptured abdominal aneurysms. Trial throughout the local trauma
data on open surgical versus operational delivery network is
endovascular repair will report in the essential. If image exchange portals
near future and are likely to inform are required these must be tested
future practice. Where the service is regularly and robustly to ensure there
provided, the Interventional are no delays in image transfer and
Radiology facilities should preferably should be available 24/7 at both
be of theatre standard ventilation and sending and receiving hospitals.
if being used for endovascular repair
should comply with the relevant
MHRA (Medicines and Healthcare
products Regulatory Agency)
Joint Working Group to produce guidance on delivering an Endovascular Aneurysm Repair (EVAR) Service. (2010)
9
www.mhra.gov.uk/home/groups/clin/documents/news/con103000.pdf

16. 16 Staffing and team working
DOMAIN
4
Staffing and team working
The provision of an IR service requires • easier separation/identification of procedures for most of their time at
teamwork both within radiology and funding; work. However, even in larger units
with other specialities. Planning • protection of demands from non-IR the number of trained IR radiographers
service provision will relate to demand radiology; may be small and the on call may
which in turn will vary depending on • autonomy for service provision; and therefore be onerous. Combining the
clinical commitments locally and use of easier access to outpatient facilities. on call with radiographers from e.g.
other resources (see networking Disadvantages: CT, Cardiac Labs and Neuro-
above). Staffing levels will reflect this • IR radiologists will usually drop other intervention could have the advantage
and will need to be tailored for radiology skills. Although this may of creating a larger pool of
individual departments. The IR team mean greater individual experience, radiographers; however, careful local
usually comprises radiologists, IR the workload will need to be greater planning is required as Percutaneous
nurses, IR radiographers, clinical to provide the elective work and Coronary Intervention (PCI) and neuro-
assistants and support staff including therefore justify enough IR intervention can use up a lot of
clerical staff, porters and managerial radiologists to maintain an on-call radiographer time. Maintaining
support. rota; competency across these different
• maintaining a non-vascular IR service subspecialties would then be required.
24/7 availability of IR nursing staff and and on call rota; and
radiographers with experience of IR • vascular surgery contributes a Interventional nurses
theatre is essential. All day, every day variable proportion, often less than The RCR document Guidelines for
availability of an Interventional 50%, of the IR vascular workload. Nursing Care in Interventional
Radiologist with experience in Radiology (2006)10 emphasized the
embolisation for haemorrhage control IR as part of the radiology service. importance of nurses in IR
and treatment of vascular injuries with Advantages: departments. Effectively all radiology
stent and stent grafts is essential. • IR radiologists with other departments that undertake IR
subspecialty skills can be employed. procedures now have their own
There are different issues relating to This can justify a greater number of nurses. However, the job description
each of the groups involved in the IR radiologists and aid provision of varies widely between trusts. Almost
clinical care of IR patients. on-call IR. all units with significant IR demand will
Disadvantages: also provide an on-call IR nurse service.
Radiologists • maintaining competency with non IR Some larger institutions even provide
Interventional radiologists’ portfolios demands a fixed time commitment; two nurses on call. Pooling nurses
and workload vary enormously and • identification of funding and from other departments has been
there are many different IR service funding streams. introduced to facilitate this and may
models across the NHS. involve cross covering of neuro-
IR as part of a operational delivery intervention and cardiac theatres.
IR as part of a vascular service. network service.
At least two NHS trusts now provide IR Please see ‘networking’ section. Extended role of IR nurses has been
services under the umbrella of vascular successfully introduced in a number of
services, separated from the Imaging Interventional radiographers institutions and includes amongst
Department. All IR units will have radiographers on others:
Advantages: call for IR procedures. In larger units • involvement in an IR out-patient
• integrated working with vascular the radiographers will all be trained in clinic;
surgery; IR and probably assisting in elective IR • pre-assessment of patients;
www.rcr.ac.uk/docs/radiology/pdf/GuidelinesforNursing
10

17. Staffing and team working 17
• insertion of central lines; Friday afternoon lists over run with 6.Patients treated by EVAR require
• undertaking arterial punctures; procedures that could wait until the surveillance scans at one month, 6
• ascites drainages; and following day but not over a whole months, 12 months and annually
• nurse led pain control. weekend. One site has instigated thereafter to monitor aneurysm sac
regular weekend daytime IR lists to size and check for the presence of
The role of an IR nurse in the patient overcome this issue. This has helped endoleaks as per Society for Vascular
pathway is variable. There is potential to relieve pressure on beds and Surgery (SVS) guidelines. Patients
for involvement in the pre-operative, reduced length of stay. This good can be lost to follow up. One site
pre-procedural, procedural and practice example is described in has developed a robust system to
recovery components. Many hospitals more detail in the Appendix C. ensure that patients are invited for
have recovery areas managed outside their surveillance scans in a timely
the radiology department. One of the 4.Historically, surgical placement of manner. This good practice example
advantages to this arrangement lines required an in-patient stay, is described in more detail in the
includes the flexibility in staffing a theatre time and a surgeon / Appendix C.
larger unit. Having recovery ‘in-house’ anaesthetist. This service was
has the advantage of protected beds identified as ideal for advanced 7.Patient selection and prioritisation of
and specialised skills. practice and several sites have elective patients requiring EVAR led
moved to the placement of lines by one site to develop a database with
Examples of good practice radiology nurses or radiographers. a scoring system to aid the decision
1.Radiology matrons were in place at This good practice example is making process. The database tracks
several of the sites visited. This role described in more detail in the elective patients through their work
gave the service opportunities of Appendix C. up for EVAR and subsequent post-
support and input at a senior procedural surveillance. Additionally,
nursing level that was found to be 5. Where the IR out of hours workload the database allows prospective data
invaluable. is insufficient to warrant a shift collection on aneurysm morphology,
system a ‘light duties’ rota can be device performance and unit
2.A cascade system has been introduced. At one site each IR mortality, morbidity and the
established to ensure that the IR performs a week on call and full requirement for secondary
response in an emergency situation week-end cover. During this week intervention. This good practice
of a ruptured aortic aneurysm is no routine lists are booked for the example is described in more detail
efficient and timely and that each on call IR. The diagnostic and non in the Appendix C.
member of the team is aware of clinical components of an
their role. This good practice interventional radiologist’s job can 8.Extending the role of the
example is described in more detail still be covered during this week, radiographer has been developed in
in the Appendix C. but at hours that are more flexible an IR department, underpinned by
to allow sufficient rest after an protocols approved by the Trust
3.Many IR departments find additional onerous night on call. This good protocols group. This good practice
pressure on a Friday afternoon and practice example is described in example is described in more detail
Monday morning IR lists due to more detail in the Appendix C. in the Appendix C.
bottlenecks of in-patient demand.

18. 18 Patient and public engagement and experience (PPEE)
Patient and public engagement DOMAIN
and experience (PPEE) 4
The Government has shown an comment those that did were able to • Evidence suggests a strong link
ongoing commitment to involve describe the reassurance that clinical between good communication and
people in their own healthcare and in staff provided. On reflection, patient satisfaction and many of
the planning, review and delivery of patients were able to identify a the sites visited invested time in
health care. Equity and Excellence – number of weaknesses through their direct communication between the
Liberating the NHS¹ states ‘Too often, trauma pathway including: IR team and the service user.
patients are expected to fit around • the need for better pre-hospital • Almost all undertake regular
services, rather than services around assessment to ensure people are patient audit review of services,
patients….’ Patient and public transferred to a hospital best however it must be recognised that
engagement and experience has equipped to treat their injuries; the gathering of feedback to make
become a statutory requirement of all • a number of hospitals which they changes or improvements to
NHS organisations. It ensures that were taken to were not equipped services, is of little use if sites then
service providers have the to deal with their needs; fail to act upon the feedback
opportunity to listen, understand and • in some instances ambulances within the organisation.
respond to service user needs, caused great discomfort and were • All sites used a variety of
perceptions and expectations. This not adequately equipped to information leaflets, both national
can then be used to inform transport them; and local however it must be kept
continuous improvement and service • sometimes care was perceived to in mind that studies12 show that
transformation. be sub standard by professionals health information for patients and
who did not have the expertise to the public is written at an above
Stakeholder engagement including deal with their injuries and in some average reading ability, making it
patient representation will be instances wrong treatment difficult for some service users to
required in development of care resulting in prolonged and multiple understand.
pathways. The Regional Trauma treatments and delayed recovery; • The British Society of Interventional
Network Engagement Project11, using and Radiology (BSIR) have developed a
a multi strand engagement approach, • a complete lack of co-ordination number of patient literature leaflets
appeared to ensure that sufficient and support once people are these have been developed to
breadth and depth of contributions discharged from acute hospital provide standard and consistent
were achieved. The combination of care. messaging for patients and reduce
activities facilitated both quick and the need for local IR teams to
easy responses from a high volume of This is the type of structured process spend time developing their own.
self selecting respondents as well as which is required to further develop
supporting in-depth and considered services in ways which ensures
contributions from a carefully patient confidence in service delivery.
selected mix of stakeholders
including patients exploring their Most of the sites visited recognised
experiences and making the value of engaging with patients
recommendations. Although a and service users in a variety of ways.
number of patients were not able to
Department of Health. Regional Trauma Networks. Engagement Strands Report (2010) London
11
Coulter A and Ellins J. (2006) The quality enhancing interventions project: patient focused interventions. London: The Health Foundation.
12

19. Patient and public engagement and experience (PPEE) 19
• Patients must be made aware of
the risks and benefits of IR when
compared to more conventional
surgical or medical procedures. This
is not always possible when urgent
intervention is required in trauma
situations. Patients can be assured
by good clinical governance that
risk is minimised and managed by
robust clinical protocols based on
best evidence and constant review
of critical incidents.
Examples of good practice
1.Several sites have set up new and 3.Patient feedback following 4.Several sites have introduced
follow up patient clinics in imaging fistuloplasty revealed that patients dedicated written care pathways to
or out-patient (OP) departments for found the procedure extremely ensure consistency of care in
interventional radiologists to see, painful and traumatic and also patient needing either elective or
counsel and consent new patients suggested that some patients may emergency intervention.
and to see follow up patients. An refuse further interventions. This
increase in patient satisfaction has poor quality experience needed to 5.An IR patient satisfaction survey
been demonstrated. These good be addressed and a nurse led pain has been undertaken to gain
practice examples are described in management service using an feedback about the quality of the
more detail in the Appendix D. opiate analgesia was introduced. service. The aim was to determine
This has had a major impact on the patient experience and
2.Other sites follow up their patients effective pain management. Results highlighted any potential areas for
post procedure by telephone. This from a pain audit tool showed that improvement. This good practice
attracts a tariff. a large percentage of patients example is described in more detail
subsequently reported a pain score in the Appendix D.
of less than five and patients were
happier to return for further
procedures. This good practice
example is described in more detail
in the Appendix D.

20. 20 Leadership
DOMAIN DOMAIN DOMAIN
3 4 5
Leadership
A good IR service requires close team Financial solvency is clearly a key Clinical and strategic leadership is
work and cross discipline co- component of the ability of the Trust vital in developing links with
operation to ensure correct patient to achieve success in this field as IR is neighbouring Trusts both in terms of
and procedure selection and timely an expensive modality, although IR establishing appropriate referral
service delivery, particularly in the may be (and usually is) considerably pathways and protocols and in
setting of acute trauma. Skilful and cheaper than other treatment creating effective clinical operational
inspirational leadership at all levels in options13. Good financial leadership delivery networks. This might assist
the team maintains morale under at executive level however will realise with managing demand and ensuring
working conditions that are often at the potential of IR to generate that appropriate patients are referred
high stress levels. Developing IR income by appropriate operational on to IR centres.
teams into effective components of a delivery network arrangements, and
major trauma team needs strong by ensuring that activity is correctly Leadership and support from IT
executive leadership, particularly with captured and charged. services is also important to ensure
the forthcoming challenges of that communications are maintained
vascular reconfiguration adding to Within IR teams we have seen 24 hours 7 days a week, particularly
the pressure for services. examples of good leadership from in relation to image transfer, and we
clinicians, radiographers and nursing have seen several examples where
Executive leadership has been seen to staff. Conversely we have seen teams have struggled to provide
have an important role in the examples where elements of the optimum patient care because
development and function of IR team are dispirited by a sense of lack images cannot be transferred to the
teams. Where good leadership was of involvement and integration either tertiary centre in a timely manner.
seen the importance of IR was owing to lack of leadership by their
recognised and the teams were more professional peers or of the wider Across the country the effectiveness
likely to be supported by adequate team. Good leadership supports all of leadership is very variable, notably
resource in terms of equipment and members of the team to make them at executive level. Sites exhibiting
manpower, and to figure in the feel useful and valued, and also good leadership are often hard
strategic plans of the Trust. Where provides the possibility of professional pressed but cope with enormous
this was not evident IR teams are development of team members pressures, whereas demoralisation
more likely to be understaffed and within their own sphere. and stress are the hallmark of sites
working with substandard or Co-operative working across where some elements of this effective
outdated facilities, struggling to traditional boundaries can lead to a leadership are missing.
identify the way forward. greater sense of teamwork and
enhance the robustness of the
service. An example of this would be
non consultant led services such as
line insertion developed by nursing
and/or radiographic staff with the
necessary support from consultant
colleagues. Patients and clinicians
have benefited considerably where
this has been achieved.

21. Leadership 21
Examples of good practice
1.The introduction of a ‘radiologist of
the day’ to whom all queries are
directed allows other IR staff to get
on with work without interruption.
This system has improved
productivity and made managing
the workload simpler. All work is
clearly displayed on a white board
and this is constantly updated. It
contains a list of pending cases so
the team are aware of outstanding
cases, priority can easily be re-
ordered or if an opportunity
presents the appropriate case can
easily be added. The interventional
radiologists cross cover for each
other, vet and add cases to each
other’s lists.
2.A monthly diary meeting attended
by all IR consultants where
commitments are discussed in
advance so that the team know
who to approach on any given
session to discuss or perform
emergency interventions. Where
possible absences are covered but
lists are not booked if a session
cannot be covered. This prevents
patients having to have their
procedures cancelled. This good
practice example is described in
more detail in the Appendix E.

22. 22 Low volume procedures
Low volume DOMAIN DOMAIN DOMAIN DOMAIN DOMAIN
1 2 3 4 5
procedures
Some clinical scenarios and Patient selection Procedural
procedures occur sufficiently Selecting the right patient for a All members of an IR team need to
infrequently that it may be difficult to particular treatment pathway requires maintain technical and clinical skills.
maintain clinical and technical skills. experience. Even if the technical skills This applies equally to radiologists,
Given the complexity and differences are well honed poor patient selection radiographers and nurses. However
of this across organisations an exact can have disastrous consequences. within a team at any one time there
definition of what constitutes a low Practitioners are encouraged to: may be different levels of experience.
volume procedure is not possible. It • have a low threshold for calling For example a radiologist of limited
has been suggested that, as a rule of and discussing cases with experience of bronchial embolisations
thumb, a procedure should be experienced colleagues, both might be working with a nurse or
considered to be of low volume if, locally and at other centres of radiographer who has experience of
typically, an operator is exposed to a excellence. Teleradiology and data many bronchial embolisations. Good
clinical scenario at a frequency of less transfer can play a major role here. teamwork is key to successful
than once every three months. In the All IR radiologists providing outcomes in all clinical environments
context of trauma, this threshold may emergency IR cover should be able but perhaps more so when dealing
be reached for procedures such as to access images at home; with low volume procedures. Equally
thoracic stent grafting for aortic • where possible develop written anaesthetic support is vital and allows
trauma. More generally even referral criteria and appropriate the IR team to concentrate on
common presentations may become treatment algorithms for all clinical procedural technical skills.
low volume for an individual if he/she scenarios particularly those which
is not exposed in day to day practice might be considered low volume Optimise the chances of a successful
because others have a special for everyone in the department. outcome by:
interest. In reality, IR practitioners will These should be updated through • good honest pre-procedural team
know when skills and experience are direct experience and new briefing that MUST include all who
being eroded through lack of literature; will be involved;
exposure and must be expected to • set up regular morbidity and • having written procedure
take steps to maintain skills especially mortality meetings both within guidelines to use as a refresher;
where these skills are likely to be departments and within regions to • maintaining competency in all
required in the emergency setting. share experience. Such meetings procedures that might happen as
must be recognised in job plans; an emergency out of hours.
Analysing the problems posed by low and Remember that many technical
volume procedures, and thinking • remember that informed consent skills are transferable e.g. UAE
about solutions, is best done by needs to include the information to provides perfect high volume skill
considering the initial clinical the patient that the clinical scenario sets that can be transferred to the
presentation, the technical skills is unusual and experience is limited occasionally performed
required and the post operative care and that there is an alternative embolisation for post partum
that will give the patient the best outside of IR. haemorrhage. Emergency TEVAR
chance of survival. will be more familiar to those
carrying out many abdominal aortic
EVARs;

23. Low volume procedures 23
• maintaining competencies by
doubling up i.e two radiologists
working together during elective or
day time emergency procedures.
Again it is important that the
absolute need for this is recognised
by hospital management and that
it is built into job plans and costing
of procedures;
• considering external training where
feasible;
• using simulation techniques where Despite the above it is recognised Examples of good practice
available to maintain familiarity that in the emergency setting it may 1.In Nottingham the radiologists
with devices and clinical decision. be in the patient’s best interest to double up for low volume cases
Such facilities exist and will become attempt a life saving procedure even such as TEVAR and TIPS and they
more widely available in the future; if inexperienced in that technique. keep a record of who has done
• signing up to a ‘maintenance of With use of the measures discussed what, making sure that they all
competency agreement’ and clarify above it may be possible to mitigate maintain sufficient numbers of
what procedures the IR team is against any potential adverse cases.
happy to undertake, both in an outcomes should this scenario occur.
elective and in an emergency
setting. Stick to the agreement There are ways in which clinical and
and review it regularly; and technical skills can be maintained to
• recognising where there are cover all clinical scenarios. Patient
scenarios where skills cannot be safety demands that every effort is
maintained, formal pathways must made to do this on the part of
be available to other hospital individuals and teams. Management
clinicians, preferably published on must play their part in providing an
the hospitals trust intranet. Formal environment that patients can have
agreements must be made with the confidence in. All IR teams will come
referral hospitals and across clinical scenarios which will
commissioners involved in such present them with new challenges.
decisions and pathways. An The recognition by all involved of
example of a procedure that might their limitations in such situations,
require such action would be TIPS seeking advice and help acutely but
for uncontrollable bleeding. thinking ahead electively will
ultimately provide the best possible
outcomes.

24. 24
A: Networking
Delivering an out of hours IR service utilising
consultants from a neighbouring hospital
University Hospital Coventry and Warwickshire NHS Trust
Summary The two George Eliot consultants The realignment of the diagnostic
Since October 2011, a full out of operate on a 1:6 rolling general on- imaging rotas demanded a
hours interventional radiology service call rota at the George Eliot site and significant change for all UHCW
has been provided at the University perform a dual on-call being consultant radiologists (body
Hospital Coventry and Warwickshire available concurrently for the UHCW imaging 1:7, neuroimaging 1:9 and
NHS Trust (UHCW) site on a 1:6 IR rota. The UHCW general and intervention 1:6). The number of
basis. This has involved four neuro rotas were reconfigured to specialist registrars assigned to the
consultants from UHCW with agreed release Intervention consultants for department was increased enabling
contractual support from two further the IR rota who in turn dovetail with a 1:7 out of hours compliant
consultant interventional radiologists the George Eliot rota. registrar rota to support the
from a neighbouring Trust (George diagnostic service.
Eliot Hospital, Nuneaton). UHCW is It was agreed that UHCW would pay
a large 1200 bed modern teaching for one weekly in hours direct clinical The George Eliot consultants are
hospital which now has major care (DCC) of intervention activity paid an agreed number of DCCs to
trauma centre status. George Eliot for the two George Eliot Radiologist cover their daytime and out of hours
Hospital is a smaller district general on the UHCW site for basic service IR cover.
hospital. The two sites are around delivery and so that they could play a
10 miles apart. central role in the Trust’s IR activity. Results
These sessions started three months Overall impact
Context and background in advance of the on-call rota to The changes have been very
UHCW is set up to be a Major enable familiarisation with local positively received by our clinical
Trauma Centre. Vascular services for staff, rooms and equipment. colleagues. Provision of the rota
the three acute Warwickshire Trusts enabled UHCW to achieve full Major
had previously been reconfigured A clinical lead for IR was appointed Trauma Centre status. This has been
successfully with six vascular and a specialist group formed. The a major advance in delivery of
surgeons participating in a clinical lead co-ordinated all the specialist care to the patients of
centralised on-call service at the arrangements and made Coventry and Warwickshire and
UHCW site. A fourth consultant presentations to relevant clinical provides an excellent base for further
interventional radiologist was colleagues (Emergency Department, development of IR services in the
appointed in September 2010. This Anaesthesia, General Surgery and future. In the first few months of
allowed the move to a full cover out Orthopaedics). operation, numerous patients have
of hours IR rota for vascular and benefited from prompt percutaneous
trauma services. The Trust has all What resources/ investment intervention and avoided open
major medial and surgical sub were needed? surgery.
specialities on site with the A sterile ultrasound (US) needle
exception of specialist paediatric guide was purchased to enable US How was the change measured?
surgery. guided intervention for consultants A log of out of hours interventional
who required it. A document procedures has been kept along with
How was the change made? detailing the agreed clinical service an hours monitoring exercise for the
Informal clinical level discussions was developed following the consultants involved. In addition,
between consultants from the two template provided by the Royal the impact on nursing and
hospitals with subsequent discussion College of Radiologists. With this radiography staff has been logged
at clinical director level. Once broad information, a review of on the shelf over the initial months in order to
principles were agreed, management stents and embolisation coils was assess the service impact and
meetings took place to agree precise undertaken to cover the emergency requirements for the future.
operation and clinical governance workload; essentially the stock was
structures. doubled.

25. 25
How has good practice been Future plans
sustained? The rota provides an excellent
All six consultants continue their platform for further developments
normal update, clinical governance including acute EVAR/TEVAR and
and appraisal processes. In expansion into acute colorectal
particular, the IR group has formed a stenting. A business case for uterine
quarterly meeting for business and fibroid embolisation (UFE) is at an
clinical case review/presentation. A advanced stage and once these
future specialist IR MDT and elective patients have begun to
morbidity/mortality meeting is attend the department, an
planned. All consultants now appropriately provided service for
submit their personal data at the acute post partum haemorrhage will
BSIR national registries for both be enabled.
vascular and non vascular index
procedures. We plan to develop a local specialist
IR MDT with a morbidity/mortality
Lessons learnt component to the meeting.
The collaboration between the two
hospitals has resulted in an excellent From this established base, we plan
working arrangement for the to build a service which can expand
provision of a specialist IR service to and adapt to the future and
the local population. The changing needs of our local
consultants had the vision to see population adopting new techniques
how future service configurations and technologies as they become
might be shaped and have been available.
commendably flexible in assisting a
larger organisation to make the Contact
necessary advances. Patients from Dr James Harding,
Coventry and Nuneaton including Consultant Radiologist
the whole catchment area for the Email: james.harding@uhcw.nhs.uk
Major Trauma Centre will benefit as
a result of this.
The concept of the two George Eliot
consultants being on call for both
diagnostic and interventional
radiology appears sustainable to
date.

26. 26
A: Networking
Implementation of radiology nursing
cross site rotation
Newcastle upon Tyne Hospitals NHS Foundation Trust
Summary We believed that the nursing and Although this system of working had
Radiology nursing cross site rotation medical staff would provide a more been informally discussed with the
was implemented in Newcastle upon efficient service when working nursing staff in previous years, a
Tyne Hospitals NHS Foundation Trust together on a regular basis, thereby formal meeting was arranged out of
(NuTH), in order to provide a single getting to know each other well. We hours in order to avoid any
nurse on call rota, to support the felt this to be an important part of interruptions. Both registered nurses
interventional radiologists. It providing a high standard, out of and health care assistants were
provides registered nursing cover for hours interventional radiology invited and an agreement was made
emergency out of hours radiological service, when the RVI became a level to give staff who attended, time
intervention. Registered nurses 1 Major Trauma Centre in April 2012. back in lieu. A matron chaired the
below band 7 are rostered to work meeting and most staff attended.
in the radiology departments at the The aim was also to create a flexible
Royal Victoria Infirmary and Freeman service as the registered nurses would At that time there were both positive
Hospitals. Each radiology be able to cover their colleagues on and negative comments made about
department performs different either site during holidays, sickness the introduction of this system. The
interventional procedures, although and leave due to the European senior sisters compiled a written
there is some overlap. This was working time directive. The staff survey that was completed
challenging in terms of skills and experience gained would enable safe anonymously. The results showed
experience and required careful and practice to occur when working on that some staff were reluctant to
comprehensive planning. This system call without the presence and support make the change in practice whilst
aims to provide safe practice, of other radiology nursing colleagues. others looked forward to the
increased knowledge base and challenge and variety of work.
nursing job satisfaction, plus aid There was also a financial incentive,
recruitment. Cost savings were also as savings would be made by A nursing rota was developed to
made by reducing two on call rotas, reducing two on call nursing rotas, include cross site rotation of qualified
to one. to one. As only one on call rota was nurses below band 7, between both
now required, changes to the skill hospital radiology departments. This
Context and background mix of staff nurses and health care commenced in June 2010.
The interventional radiologists at the assistants could be made, resulting
Royal Victoria Infirmary (RVI) and the in further cost savings for the The two band 7 senior sisters
Freeman Hospital (FH) implemented radiology directorate. permanently remain on their
a single radiologist on call rota individual sites as managers,
specifically aimed at providing out of This system would reduce the although work closely together and
hours cover for emergency amount of on call undertaken by the frequently visit the opposite site.
interventional radiological nurses from 1:5 to 1:10, thereby One of them previously worked on
procedures across both sites in improving their work life balance. In the opposite site and therefore had
October 2009. contrast however, it would reduce a good overview of the service on
the amount of on call undertaken, both sites. This helped in
Following this, there was a review of thereby reducing the amount of understanding how staff needed
radiology nursing and it was decided overtime paid to staff. to be allocated on each site.
that the registered nurses could mirror
their system. The idea was to provide How was the change made? In October 2010, the most
experienced nurses who would be Firstly, discussions between the experienced radiology nurses began
knowledgeable, safe and proficient in senior sisters, matron and medical to participate in a single nurse on
assisting with all types of intervention staff were made and it was agreed call rota that covered the RVI and
undertaken on each site. They would that it could be advantageous to FH. The less experienced joined the
also have good geographical implement cross site working for rota at a later date when they were
knowledge of both sites and know qualified nurses below band 7. deemed competent.
where equipment was stored.

27. 27
What resources/ investment for the directorate and Trust. There A list of medical device
were needed? was some well-established staff who competencies was compiled, training
Initially savings were limited as were reluctant to change. We dealt given and sign off when staff were
experienced staff (including band 7 with this by encouraging staff competent. The competencies are
senior sisters) provided on call cover involvement and asking them to undertaken on an annual basis.
for the less experienced, until they discuss how they felt the rotation
were deemed competent to should be implemented. This Band 7 sisters continue to shadow
undertake solo on call. In effect, this allowed staff to feel more involved in staff on call when necessary.
reverted back to having two nurses the process.
on call together, but for shorter Lessons learnt
periods of time. Results Although the possibilities of cross
Overall impact site rotation had been discussed
Ultimately money was saved on the Cross site rotation has given the occasionally during the previous few
nursing staff budget by reducing the registered radiology nursing staff years, the staff still did not seem
nurses on call from two to one as confidence to participate in prepared for the change in practice.
only one standby payment needed providing a single nurse on call rota
to be made. Also, the band 7 senior that covers two hospital radiology In hindsight we feel that formal staff
sisters withdrew from the on call departments. It provides a safe discussions could have been started
rota, thereby reducing the costs system of working and continuity for earlier in an effort to allow staff
created through more expensive the radiologists on call. Staff more time to come to terms with the
overtime payments. relationships have developed further changes.
during cross site rotation. Patients
Time investment was required to: benefit by receiving safe care from Newly appointed staff who were
• undertake extra training for staff well trained, knowledgeable and employed on the basis of working
who were assessed by the senior experienced staff. across site, were very positive in
sisters on an individual basis; what they could gain from working
• set up quarterly cross site meetings How was the change measured? in two separate environments and
that alternate across site. Initially Quarterly cross site staff meetings were excited by the learning
these were arranged out of hours, were set up and minutes taken to opportunities presented. Currently
but recently, with the cooperation provide an update for those who they are happy and feel as though
of the medical staff, they have could not attend. their working practice is well
been arranged for early in the balanced.
morning to avoid minimal The staff survey was repeated after
disruption to the work load; 12 months. The results were fairly After 18 months of cross site
• compile new rotas, holiday and off similar to the results of the initial rotation, the established nurses have
duty requests spreadsheets; survey settled down well and the whole
• improve and update equipment group are sharing knowledge and
lists on both sites as a learning How has good practice been best practice across site.
tool and aid during call outs; and sustained?
• create a medical device All new radiology nursing jobs are Future plans
competency list to include medical advertised to work across both sites. Continue with the rotation.
devices used across site, and use it
as a training guide for staff. Cross site rotation has continued, Contact
although the frequency of rotation Dr Ralph Jackson,
The senior sisters invested a lot of depends on staff experience and Consultant Radiologist
time with staff as they explained training required, therefore is Email: ralph.jackson@nuth.nhs.uk
regularly, the need for cross site organised on an individual basis.
rotation to occur and its advantages

28. 28
A: Networking
Networked on call interventional
radiology across two sites
South Devon Healthcare NHS Foundation Trust
and Royal Devon and Exeter NHS Foundation Trust
Summary How was the change made? What resources/ investment
Two neighbouring DGHs, 25 miles The Torbay radiologists started their were needed?
apart in a rural location each have own in-house on call service whilst There was a relatively small increase
three interventional radiologists. In discussions were ongoing in Exeter. in pay costs, for the changes in job
order to provide formal on call IR This was on a 1:3 rota, clearly not plans and on call frequency for the
services 24/7 they have developed a sustainable in the long term. In the radiologists and for the formal on
networked solution. first year of this service the cases call for the nurses and
were audited and it was felt by the radiographers. (In Torbay this
Context and background referring clinicians and intensive care equated to approximately an
Royal Devon and Exeter has a teams that a significant minority of additional £66,000 per annum and
catchment population of patients would not have been had been built into the business
approximately 370,000 and Torbay’s suitable for transfer if Exeter had cases for recent general radiologist
catchment resident population is been on call. appointments.)
approximately 280,000. There are
significant increases in transient The planned model was therefore Results
population during holiday seasons. changed with the default position Overall impact
being that the on call radiologist There is always interventional
At each site there are three travels to the site of the patient. The radiology emergency cover at both
interventional radiologists. radiologists visited each other’s sites, 24/7, providing a safe and
Emergency out-of-hours IR had been departments to get to know the secure service. This is extremely well-
provided on an ‘ad hoc’ basis. With layout and staff. Consumables such received by the other clinicians
increasing frequency of cases there as wires and catheters were similar within the hospitals. Increased
was significant risk of being unable in each department but all awareness of the service has led to a
to find a willing or available staff radiologists satisfied themselves that significant increase in out-of-hours
member (radiologist, radiology their preferred kit was available on cases compared to the previous ad-
nurse, interventional radiographer) both sites. hoc arrangements. However, all of
and staff were becoming unhappy these cases are felt to be appropriate
about being called in when not on On both sites the discussion and and the frequency of call-outs is still
call. planning included radiology relatively low. In order to maintain a
department managers, medical degree of control and to ensure
The two Torbay and three Exeter directors and senior executives, the appropriateness of referrals the on
vascular surgeons have been running radiology nurses and interventional call interventional radiologists will
a successful cross-site emergency on radiographers, and the general only take calls from consultants.
call vascular surgical service for radiologists.
several years. For this service the How was the change measured?
usual approach is for the emergency On weekday evenings and nights Diaries of activity are kept and the
patient to be transferred by each site covers its own emergency service audited.
ambulance to the on call site if work. From Friday evening to
required. The interventional Monday morning and on bank
radiologists initially favoured a holidays there is one interventional
similar model for an IR on call radiologist on call, covering both
service, feeling unenthusiastic about sites. The radiologists’ rota is
having to do urgent cases in an therefore 1:3 week days, 1:6
unfamiliar environment. weekends. For every night and
weekend there are radiology nurses
and interventional radiographers on
call at both sites. This service has
been running for 20 months.

29. 29
How has good practice been The agreed portfolio of work
sustained? covered on both sites on call
The radiologists from both sites meet includes nephrostomy, abscess
to discuss the service and cases drainage, peripheral vascular
performed. Now that both the intervention and embolisation for
vascular surgeons and the haemorrhage. Renal access work is
interventional radiologists have only done at Exeter and therefore
cross-site rotas this has encouraged fistula salvage was not included.
further development of formal cross- Only one of the six radiologists
site MDT working. performs TIPSS and two of the
Torbay radiologists do not perform
Lessons learnt PTCs. These procedures are therefore
As in many radiology departments only provided on an ad hoc basis,
there was reluctance from the depending on which radiologist is on
general radiologists regarding these call or contactable. We thought that
changes as the interventional we had thought of everything but
radiologists would come off the did not realise that the Exeter
general on call rota. To some extent surgeons ask for urgent colonic
this was ameliorated by linking these stenting for obstruction whereas this
changes with expansion in overall is not done at Torbay. This is the one
radiologist numbers in response to procedure that was requested at the
growing workload. Now that the weekend by an Exeter surgeon but
service is well-established the could not be performed as the on
majority of non-interventional call radiologist was from Torbay.
radiologists are very happy with it;
they no longer have the difficulty of Future plans
being asked to arrange an urgent The service is working well and
interventional case at the weekend, appears sustainable. We continue to
either feeling forced to do strengthen the links between the IR
something they are uncomfortable and vascular surgical units at both
with or having to phone around to sites.
find a colleague who is not on call.
Contact
As an unexpected consequence for Dr R Seymour,
two DGHs, on a few occasions at Consultant Radiologist
weekends we have received patients Email: richard.seymour@nhs.net
transferred from another hospital
because the clinicians there are
aware that we have the only formal
IR on call service in the region.

30. 30
A: Networking
Development of cross-site 24/7/365 interventional
on-call service covering nine individual hospital units
NHS Greater Glasgow & Clyde
Summary The agreement for new posts was Results
A case for change to work established within an overall Overall impact
collaboratively across several Trusts framework that included improving • The change has provided a 24
to deliver a 24/7 IR service to cross-cover and working in hours hour IR on call service on every day
patients every day of the year. between adjacent units and merging of the year with improved equity
equipment and procurement to both of access to IR services.
Context and background reduce costs and improve cross-site • There has been direct positive
There was increasing recognition of working. feedback for the IR team. Having
the importance of IR in patient developed the case for change
pathways particularly for An IR on-call manual was developed. they recognised the impact they
haemorrhage control with variation It included both processes and were making in acute care.
in access to out of hours procedures. This allowed the clinical • Reduced referral time for out of
interventional radiology across the groups to debate the detail of service hours work received very positive
local areas. There was no formal IR provision prior to service introduction. feedback from all clinical staff and
on call rota and the informal rota enhanced the profile of IR services
was placing stress on specific points What resources/ investment across the area.
of the IR team. were needed? • Consolidation of consumables
• Additional staff funding was across sites was very valuable in
There were nine trained required. This was not seen solely service provision and has resulted
interventional radiologists across the to support out of hours but was in a cost saving.
area however on-call was part of the framed to improve service • Using the separate projects of
general diagnostic rota. There was provision and equality of access procurement etc did develop a
no formal nurse on-call rota at the both in and out of hours. sense of identity among the units.
time of inception. Equipment and • Medical staff required changes to • The IR manual was very valuable,
equipment levels across the area job plans - this impacted on the particularly in the initial stages for
particularly of consumables was diagnostic on-call rota. Further both external and internal groups.
varied. redesign of diagnostic rota
occurred. How was the change measured?
How was the change made? • Medical staff had to accommodate We have published audits of our
The clinical case for change was changes that meant cross-site service against the RCR guidance for
established with the clinical team working both in and out of hours. 24/7 IR services. We have a research/
including nurses and radiographers • Nursing staff required significant audit interest in outcomes for IR
in a series of facilitated meetings. negotiation to terms and techniques and have submitted for
The managerial support was conditions - this took a publication a paper on 30 day
excellent after the case for change considerable time to work outcomes after OOH intervention.
was established and resource through. For a period reduced
support was agreed. We did not numbers of nursing staff How has good practice been
focus only on OOH services and participated and this placed sustained?
accepted that we would have to pressure on this group. Nursing The on call service requires a
change in hours services as well. staff also had to adapt to cross-site consistent focus and evolves as
working across several hospitals. clinical requirements change. We
• Most sites already had dedicated have established an Interventional
radiographic staff, however there Forum that meets regularly to
was concern about undertaking discuss all aspects of the service. The
unfamiliar procedures. forum contains representation from
radiographers, nurses and
managerial structures.

31. 31
Lessons learnt • Achieving a sustainable nursing
• Clinical leadership within each of on-call has required on going
the groups was essential and this work. The nursing group have very
was enhanced by the projects and much supported this initiative
an understanding of the case for however negotiation of terms and
change. conditions is time consuming.
• The process was at times difficult • We rationalised equipment across
and required real persistence - this the sites to facilitate cross-site
may not have happened without working for all staff groups. We
the above. also developed embolisation bags
• Defining the scope of services is - this is a portable complete
essential - the IR team involved consumable kit which includes
would not have signed up to an contrast catheters embolic agents.
open ended agreement. In This is stored at two sites across
addition, we had to accept that the area and is transported to
the important targets to cover cases outside the main units.
were the common life threatening
emergencies initially haemorrhage. Contact
We have since adopted a wider Dr Iain Robertson,
range of procedures. Consultant Radiologist
• We were merging units that did Email:
not previously have a close iain.robertson2@ggc.scot.nhs.uk
working relationship. We used the
development of the discrete
projects; procurement of
consumable equipment, facilitated
meetings and development of IR
manual to help form a more
cohesive unit.
• There were initial challenges from
diagnostic colleagues due to the
impact on their rota. We could
have perhaps involved them more
closely in the development of the
case for change.