The efficacy of preliminary clinical evaluation for emergency department chest radiographs with trauma presentations in pre- and post-training situations

Preliminary clinical evaluation (PCE): A transnational scoping review of current radiography practice

INTRODUCTION

Image interpretation by radiographers has gained widespread recognition; however, current evidence provides very limited knowledge of the state and scope of practice transnationally. This study therefore sought to explore the current state and scope of preliminary clinical evaluation (PCE) practice to further understand international best practices in terms of policy, training and education, and practice competence of radiographers when carrying out PCE.

METHOD

A comprehensive literature search was completed via federated electronic databases (EBSCOhost and Web of Science) and professional radiography platforms for journal articles and policy or practice guidance documents, respectively. Data were charted from eligible studies following screening of articles in accordance with the predefined eligibility criteria. Themes were generated using inductive narrative analysis.

RESULTS

Thirty-one peer reviewed articles and 5 radiography practice policy documents were identified. Over 60% of the included studies were carried out in the United Kingdom and Australia with about 60% focused on projectional radiography of the appendicular and axial skeletons. Three main themes were developed and included: scope of PCE practice and implementation; PCE proficiency indicators; factors influencing PCE participation and performance.

CONCLUSION

Gaps exist around defined scope of practice, standardisation, commenting format and compliance with policy. There is very limited evidence around PCE practice in cross-sectional imaging, thus, it is difficult to ascertain the current state and scope of practice internationally. There is a need for countries to develop standard commenting frameworks as well as enforcement of compliance. Additionally, more research is required to ascertain the competence and benefits of PCE practice within cross sectional imaging.

Impact of Imaging on Surgical Management of Penetrating Chest Trauma: Experience From a High-Volume Trauma Center in a Resource-Constrained Environment

Background Penetrating chest trauma is a significant cause of morbidity and mortality, with the need for accurate and timely diagnosis being crucial in determining appropriate management. This study aims to evaluate the role of computed tomography (CT) imaging in the assessment and surgical management of patients with penetrating chest trauma at a high-volume trauma center in a developing country. Objective To assess the contribution of CT imaging in the evaluation and surgical management of patients presenting with penetrating chest trauma at a resource-limited trauma center in Pakistan. Methods A cross-sectional observational study was conducted in the Thoracic Surgery and Radiology Departments of Lady Reading Hospital, Peshawar, from January 2024 to June 2024. A convenient sampling technique was used to include 139 patients with penetrating chest trauma. Demographic details, trauma complications, fractures, and management strategies were recorded. Thick-slice, non-contrast, chest CT scans were performed and reviewed by a consultant radiologist. Data analysis was carried out using SPSS version 26 (IBM Corp., Armonk, NY). Results The study included 139 patients with a mean age of 26.7 ± 8.2 years (range: 8-70 years). The majority were male (126, 90.6%), and the most common mode of injury was firearm trauma (83, 59.7%). The most frequently observed complications were pneumothorax (110, 79.1%), hemothorax (112, 80.6%), and lung injury (88, 63.3%). Fractures were noted in 54 (38.8%) patients, with rib fractures being the most common (31, 22.3%). The most common management approach was tube thoracostomy (116, 83.5%), followed by conservative management (10, 7.2%) and open thoracotomy (6, 4.3%). Conclusion CT imaging is an invaluable tool in the assessment of penetrating chest trauma, aiding in the identification of hidden injuries and influencing surgical management decisions. Although thin-slice contrast-enhanced CT is the standard protocol in our resource-constrained setting, non-contrast axial CT scans offer critical diagnostic information and guide timely management. Its use significantly improves patient outcomes, especially in a resource-limited setting.

Preliminary clinical evaluation: Where are we? An international scoping review

BACKGROUND

The College of Radiographers' vision was that diagnostic radiographers in the UK would be writing preliminary clinical evaluations (PCE) on images. Their 2013 policy supporting the use of PCE has not been updated in a decade and it might be suggested PCE practices in the UK have not really moved on, though elsewhere it appears to have gained traction. The aim of this scoping review was to establish the current global status of the use of PCE.

METHOD

The Arksey and O'Malley scoping review framework and PRISMA-ScR guidelines were used to develop a protocol to identify studies between January 2013 to January 2024 using six databases. Collated literature was analysed using content analysis to identify themes.

RESULTS

52 relevant studies were identified for inclusion. Studies focused predominantly on evaluating accuracy, education, perceptions, and new initiatives. Themes identified a developing role in the use of PCE internationally, perhaps more than in the UK, and in a range of modalities and clinical settings though projectional radiography remains the mainstay. Barriers and drivers to the use of PCE were identified in addition to some quality mechanisms used to support PCE implementation, though impact of implementation was not well explored.

CONCLUSION

Considering PCE has been an aspiration for more than a decade, it remains relatively infrequently researched. There is growing scope internationally, particularly in Australia, yet there is no real evaluation of the impact and role that PCE may have.

IMPLICATIONS FOR PRACTICE

Until further research into the potential impact of PCE and barriers to its implementation, it is likely practices may not evolve with the risk AI technologies may supersede necessity for the practice.

Using chest X-ray to predict tube thoracostomy in traumatic pneumothorax: A single-institution retrospective review

BACKGROUND

Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy.

METHODS

We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression.

RESULTS

There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm.

CONCLUSION

Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Radiographer abnormality flagging systems in the UK - A preliminary updated assessment of practice

INTRODUCTION

Radiographer abnormality flagging systems have been in use in the UK for over 30 years, with the guidance of the Society and College of Radiographers indicated that the preliminary clinical evaluation (PCE), or comment, be the preferred system of choice. This study aimed to provide an updated assessment of current practice based upon a previous 2008 study.

METHODS

A cross-sectional online survey was disseminated via Twitter and aimed at departmental and reporting leads. It requested information on the types of flagging and reporting systems operated, scope of the systems employed, required education of participants, and the role of audit.

RESULTS

Responses were received from 31 Trusts within the UK. Red dot systems were employed in 90% (n = 28) of sites, with 26% (n = 8) undertaking PCE. Skeletal radiographs were most commonly reviewed (90%; n = 28) followed by chest (58%; n = 18) and abdomen (32%; n = 10). Only 13% (n = 4) sites indicated if the image was normal but 71% (n = 22) allowed the radiographer to indicate if they were unsure. There was marked variation in the educational requirements and use of audit.

CONCLUSION

Compared to 2008 there appears to be quite minimal change in practices in the UK. There does appear to be some increase in the use of flagging systems generally and a higher proportion of PCE systems in comparison to red dot but the use of education and audit does not necessarily show much development in the past 15 years.

IMPLICATIONS FOR PRACTICE

Significant conclusions cannot be drawn due to limited sample size, however, it may support further study and consideration in relation to implementation and potentially standardisation of abnormality detection systems may be justified.