BSIR Spring Newsletter 2024

Spring Newsletter 2024

Spring Newsletter

WELCOME FROM OUR EDITOR I am hoping that by the time this edition of the BSIR newsletter hits your inbox we have all enjoyed at least a few days of sunshine and Spring is in full bloom!

Whilst our specialty is innovative and exciting, the reality of everyday work can place a huge burden on our wellbeing, be that physical, mental, emotional or any combination of these.

Hence the primary theme for this newsletter is around well-being in interventional radiology. Firstly, Mohamad Hamady and Raman Uberoi set the scene by presenting the UK survey on IR burnout conducted by al Rekaby et al. Then Bella Hausen and colleagues share invaluable advice on how they approach well-being in Preston. Who knew goat yoga was a thing?! Kunal Khanna (Guildford) continues the theme of physical well-being sharing some of his exercise tips to maintain his top IR and (alleged) golf game! Conrad von Stempel (London) also shares with us an aspect of his everyday work that he finds super rewarding.

Finding something we enjoy, whatever it may be, is so incredibly important to maintain our well-being.

The second, and somewhat related, theme which several IR departments face is the growth in activity and lack of adequate IR capacity. I am hugely thankful to Tariq Ali (Norwich) and Neil Gupta (Coventry) for sharing insights from their recent successful experiences in installing impressive IR facilities. The keyword is perseverance!

We also hear from Raghuram Lakshminarayan (Hull) about the upcoming IR Getting It Right First Time (GiRFT) initiative. Kayleigh Hizzett (Bradford) reports on the very successful SIRNR Spring CPD event. Finally, Nike Alesbury (our CEO) gives us a summary of BSIR activity and upcoming events to look forward to.

Happy reading and, as always, feel free to drop me an email if there are any news pieces you feel we should cover and, better still, volunteer to write one!

Dr Narayan Karunanithy

BSIR newsletter editor Consultant Interventional Radiologist (London) office@bsir.org

EVENT UPDATE Spring officially sprung in Brighton last week, as the well-established BSIR Advanced Skills Course (ASC) opened with rainbows and views over the beach. As ever, places on this course were in high demand and we welcomed a full cohort, as well as a renowned faculty leading a programme focussed on vascular skills, devised by Dr Chloe Mortensen, Chair of the Education & Training Committee, with support from colleagues.

It was great to see such a full programme , receiving excellent feedback from participants: “Brilliant days! Jam-packed. Well structured. Learnt loads. Good balance of talks, workshops, industry, discussion and practical. Thanks so much.”

Events season is now in full swing, with the ASC followed closely by the BSIR Paediatric IR UK meeting in May, in Birmingham, and BSIR IOUK in Edinburgh in June. We continue to be very well supported by our industry partners, for which we are extremely grateful; we could not run our education and scientific programmes without collaborating with our partners, old and new.

Behind the scenes, we are also working on the BSIR presence at CIRSE in Lisbon in September and returning to Brighton later in the year for BSIR 2024 in November. I hope to see many of you at one, or more, of the BSIR events this year.

Please do also keep an eye out for BSIR webinars coming in the next few months, as the calendar of online events is filling up nicely for the rest of the year, featuring discussions that we hope to be topical for our members and beyond.

Nike Alesbury BSIR Chief Executive Officer

WELL-BEING IN INTERVENTIONAL RADIOLOGY Interventional Radiology (IR) is a vibrant new age speciality delivering life-changing, if not life-saving, treatments, some of which were not possible until recently. Success has however evoked a myriad of difficulties, some of which can pose real risks to the future of IR. We will focus on two issues of immediate concern which are linked in one way or another. One internally, with the feeling of compromised well-being of interventional radiologists and one externally, from specialties that wish to take over some of our key procedures.

"65% reporting moderate to severe emotional exhaustion" Well-being is the experience of health, happiness, and prosperity. It includes having good mental health, high life satisfaction, a sense of meaning or purpose, and the ability to manage stress. Why is this important in the context of Interventional Radiology? Well, we know that quite the opposite is happening for IR’s in the UK as reported by Ahmad alRekabi et al recently. There is a high risk of burnout among UK IR’s with 65% reporting moderate to severe emotional exhaustion (EE), 46% depersonalisation (DP) and 77% low to moderate feelings of personal accomplishment (PA). Workload as well as, sex and age correlated strongly.

Currently, IR’s workload, as well as onerous on call commitments, continues to increase. To make things even more untenable, the Royal College of Radiologists (RCR) census has once again highlighted the shortfall within radiology of the numbers of radiologists, not least in IR. Consequently, 90% of clinical directors are concerned about patient safety, with only 48% of Trusts able to provide 24/7 IR cover. 79% of clinical directors are also concerned about the shortage of IR’s resulting in patients receiving more invasive treatments in their hospitals. This is also at a time when there is a stream of revolutionary improvements in patient treatments taking place in several fields such as oncology IR, prostate and joint embolization, stroke thrombectomy etc, which need ever more IRs.

“...only 48% of Trusts can provide 24/7 IR cover” This situation cannot continue and urgent changes are necessary to support UK IRs (2). This includes a range of measures of increasing training numbers, looking at ways of keeping IRs in the workforce for longer, reducing administrative burdens and greater support for on-call with appropriate rest periods, and organising network support for IR in District General Hospitals.

It is known that workload is not the only factor contributing to burnout. Research has identified five other key domains which all play an important role, including control, reward, community, fairness and values (3-6). Whilst burnout is not uncommon among medical professions, it is peculiar that all factors are closely pertinent to interventional radiology. Jim Reekers, in his CVIR Endovascular commentary, has nicely explained the meaning of those factors, why they are implicated in IR and highlights that other than workload, all of these factors result from the current position of interventional radiology not being recognised as a fully independent specialty and therefore lacks a clear identity (7). Without faculty or specialty status, with all their privileges and responsibilities, IR problems cannot be addressed effectively.

“Without faculty or specialty status, with all their privileges and responsibilities, IR problems cannot be addressed effectively. “ To add to this massive task of improving well-being amongst IRs, we, as a profession, are vulnerable to other specialties who at any stage can choose to undertake key IR procedures regardless of what quality of care would be offered to patients, because IR’s are not in control of their destiny. This will further deepen the negative feelings of resentment, unfairness and lacking recognition. Without faculty or speciality status, with a defined identity, which creates and support the clinical role and weight of IR, our profession will continue to struggle.

The longer it takes to attain IR faculty or specialty status, the more damage will result to the discipline of IR and greater will be the problems for future generations to deal with.

Professor Mohamad Hamady

Consultant Interventional Radiologist, Imperial College London

Dr Raman Uberoi

Consultant Interventional Radiologist, Oxford University Hospitals NHS Foundation Trust Medical Director Professional Practice, Royal College of Radiologists.

References 1.AlRekabi A, Chen M, Patel N, et al. Well-being and burnout amongst interventional radiologists in the United Kingdom. Cardiovasc Intervent Radiol. 2023;46:1053–63. https://doi.org/ 10.1007/s00270-023-03455-5.

2.Uberoi R, Ramsden W, Halliday K. Commentary on: well-being and burnout amongst interventional radiologists in the UK. Cardiovasc Intervent Radiol. 2023. https://doi.org/10.1007/ s00270-023-03518-7.

3.Kristy Threlkeld, ‘‘Employee burnout report: COVID-19’s impact and 3 strategies to curb It’’, March 11, 2021. UK.indeed.com.

4.Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422.

5.Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychi atry.

2016;15(2):103–11.

6.Schaufeli WB, Enzmann D. The burnout companion to study and practice: a critical analysis. London: Taylor & Francis; 1998.

7.Reekers J. Burnout in Interventional Radiology: a Multifactorial Problem. Cardiovasc Intervent Radiol. 2023 Dec;46(12):1759-1760.

EXERCISE IN INTERVENTIONAL RADIOLOGY In Interventional Radiology (IR) the demand for the service has increased dramatically over the last few years but the resources and numbers are nowhere near other European countries or other specialities to meet the demand. The pressures and increasing frustration are enough to impact the well-being of all team members.

What is also unique to Xray-led minimally invasive work in IR is the wearing of heavy lead aprons for long periods of time during most procedures. Some demand awkward positions and postures that place significant strain on the musculoskeletal system. The lack of homogenous evidence to what tools should be used to prevent operator harm from scatter radiation or direct radiation at present differs across sites, specialities, and countries.

Back in 2019 the World Health Organisation (WHO) recognised BURNOUT as syndrome likely due to chronic unmanageable stress at a workplace. (ICD11). Three symptoms define the entity: (i) feelings of energy depletion or exhaustion, (ii) increased mental distance from one’s job or feelings of negativism or cynicism towards one’s job and (iii) a sense of ineffectiveness and lack of accomplishment. The ICD-11 includes burnout among the factors influencing health status or contact with health services. This was not based on robust evidence-based medicine and many question the absence of other key signs and symptoms such as anhedonia, dysphoria, neurovegetative and psychomotor alterations, cognitive impairment, or suicidality.

Nevertheless, what many can agree on is that not enough is done to break this cycle.

One well recognised intervention to both issues discussed above is exercise!

Here Dr Eriksson shares his frequent exercises that help strengthen the back, hips, and legs

Posture is crucial for our line of work. Techniques and exercises that help strengthen the back, hips, and legs. These muscle groups together with the core are fundamental parts of the postural musculature. Regarding upper body exercises: a push and a pull variation can be used.

Squat variation and hinge variation along with key core muscle strengthening workout help strengthen core pelvic and intraabdominal groups that play key role in posture but also in late post-partum repair.

It is important to stress the importance of decompression of the spine. lying on back, with legs in a 90-degree angle. This is effective restorative technique and can easily be applied in between long cases.

Mobilisation of the spine in rotation is important as we stand in static positions for long periods of time.

Whilst strength training is important, cardiovascular exercises are encouraged and they can be as simple as brisk walk or hike in beautiful surroundings, camping/being in nature, or for some open water swimming or even goat yoga! Open water swimming, studies in 2023 have suggested, may lead to improvements in wellbeing, reductions in mental distress symptomatology. ‘Blue spaces involve embodiment, mindful presence, community and much more, offering for some a therapeutic accretion which sustains mental health and wellbeing across a lifetime’. This along with a balanced healthy diet, eating local and in season suggests a reduction inflammation and hopefully prevention of illnesses.

With regards to radiation protection and reduction of scatter radiation to operators, the availability or reality of being able to have zero-gravity in most IR centres and procedures is unrealistic. For now, adequate tailormade lead, fitted appropriately, especially to female operators and the use of ceiling mounted lead were possible is paramount. Other new tools such as mind and head peace, advanced software, artificial intelligence, and future robotics warrant more exploration and attention.

We hope all readers benefit from the above suggestions and 2024 proves to be a year of healthier change and care for our well-being, as well as that of our patients!

Useful links Open water swimming https://www.swimming.org/openwater/open-water-swimming-venues/ https://www.swimming.org/openwater/wild-swimming-blue-spaces-project/ Yoga with goats https://yogawithgoats.co.uk/Yoga/ Mind and head peace https://texray.io/products/ Dr Bella Hausen Dr Mona Mossad Dr Abdulrahman Alvi Dr Mats-Ola Eriksson

LEAD GOWN LIMBO! An Essential 20-Minute Daily Stretchy Survival Routine for Interventional Radiologists Being an interventional radiologist is no easy feat. From intricate procedures to long hours spent in the interventional suite, the job demands both mental acuity and physical endurance. But amidst the complexities of the profession, it's easy to overlook the importance of self-care.

Daily stretching is not just a luxury; it's a necessity for interventional radiologists.

Picture this: You are donned in your heavy lead gown, manoeuvring around equipment, contorting your body to get the perfect angle for a procedure. Sounds familiar, right? But here's the kicker – that lead gown is like wearing a suit of armour, except it weighs a ton and doesn't come with superhero's strength.

Over time, it takes a toll on your body, leading to muscle tension, stiffness, and even injury.

That's where daily stretching comes in – it's your secret weapon against the tyranny of the lead gown and the rigours of the job.

Now, let's dive into five essential stretches that every interventional radiologist needs to incorporate into their daily routine.

Just 20 minutes a day…even at work!

Thoracic Extension Stretch Begin by sitting tall on a chair with your feet flat on the floor.

Interlace your fingers behind your head, gently supporting the weight of your head.

Inhale deeply and exhale as you arch your upper back backward, pushing your chest forward.

Hold the stretch for 15-30 seconds, feeling a gentle opening in the front of your chest and shoulders.

Repeat for 2-3 repetitions.

This stretch helps counteract the forward posture often adopted during procedures, promoting thoracic extension and relieving tension in the upper back and shoulders.

Doorway Pectoral Stretch Stand in a doorway with your arms bent at a 90degree angle and elbows at shoulder height.

Place your forearms on either side of the doorway, with your palms facing forward.

Lean forward slightly, allowing your chest to open and stretch.

Hold the stretch for 20-30 seconds, feeling a gentle stretch across the front of your shoulders and chest.

Repeat as needed throughout the day.

This stretch targets the pectoral muscles, which can become tight from prolonged periods of reaching and manipulating equipment during procedures.

Upper Trapezius Stretch Sit or stand tall, reaching one arm behind your back and resting your hand on the opposite side of your lower back.

Gently tilt your head to the opposite side, bringing your ear towards your shoulder.

Hold the stretch for 20-30 seconds, feeling a stretch along the side of your neck and upper shoulder.

Repeat on the other side.

This stretch helps release tension in the upper trapezius muscles, which can become overactive and tight from maintaining a static posture during procedures.

Thoracic Rotational Stretch Sit up tall in a chair with your shoulders back and down.

Cross your arms over your chest with a gentle downward pull on the shoulders Leading with yours arms, rotate until you feel a stretch in the upper back.

Inhale deeply and exhale as you twist your torso.

Hold for 15-30 seconds, feeling a gentle rotation through your thoracic spine.

Repeat on the other side.

This stretch improves thoracic mobility and helps counteract the rotational movements often required during procedures.

Child’s Pose Begin on your hands and knees, with your wrists aligned under your shoulders and your knees under your hips.

Lower your hips back towards your heels as you reach your arms forward, lowering your chest towards the floor.

Rest your forehead on the ground and relax your arms alongside your body.

Hold the stretch for 30-60 seconds, focusing on deep breathing and relaxing tension in your back and shoulders.

Slowly return to the starting position.

Child’s pose gently stretches the entire back, shoulders, and hips, providing relief from the prolonged static positions commonly maintained during procedures.

Incorporating these five essential stretches into your daily routine can work wonders for your physical well-being as an interventional radiologist. Not only do they help counteract the strain of wearing a heavy lead gown, but they also promote flexibility, reduce the risk of injury, and improve overall comfort during procedures. So, the next time you find yourself gearing up for a day in IR, don't forget to extend, stand, rotate and stretch your way to a happier, healthier you. Just 20 minutes of self-care a day can go a long way in making a heavy day just that little bit lighter – lead gown and all.

Dr Kunal Khanna Consultant Interventional Radiologist Frimley Health

2024 Events

NIRS

BSIR IOUK ANNUAL MEETING 2024

Sat. 21st September CarriageWorks Theatre, Leeds

Wed. 12th - Thurs. 13th June The Royal College of Physicians, Edinburgh

Info Here

Info Here

BSIR PAEDIATRIC IR UK ANNUAL MEETING 2024 Mon. 20th May IET Birmingham Info Here

BSIR ASM 2024 Wed. 6th - Fri. 8th November Brighton

Info Here For all event and webinar activities - please visit: www.bsir.org/events

TALKING ABOUT PAE "...Well, imagine your prostate is like a large Lindor chocolate truffle… ... yes, like those red ones at Christmas, bear with me… ... well imagine your pee pipe runs through the center of that…”

Our weekly prostate artery embolisation (PAE) clinic involves similar conversations where we dream up new analogies to explain the abstract concepts of extrinsic urethral compression, embolics, liquefaction, wires, and catheters.

The conversation goes on:

"Now imagine I leave that Lindor in the glove box on a hot day, the whole thing melts a bit and the center becomes liquid, that's what I’m going to do to your prostate… and that will improve your peeing…”

The next part of the conversation usually astonishes our patients. These are patients who have been turned down for prostate resection (TURP or HOLEP) due to anesthetic concerns or who are on interminable waiting lists with long-term catheters. Increasingly, we are seeing younger men wanting to avoid a transurethral procedure (who may be a bit more Google-savvy).

The clinic continues:

“… with a tiny tube from your wrist… … yes! It's one and a half meters long and steerable… … day case, you can go home a few hours after we finish… … of course, you will be awake and can watch it all on the screen, or listen to a podcast, it’s up to you!… … sure, we will do some tests but in principle happy to book you in a month or two”.

Among the new referrals are the three-month follow-up calls. I approach these with trepidation as it is like waiting for an exam result when I hear the results of their post-PAE International Prostate Symptom Score questions (IPSS) and flow rate. However, for the vast majority, PAE patients are incredibly grateful. There is nothing better than hearing:

“thank you, now I can get through the night or get to ‘half-time’ or to the interval”.

As IRs, a large part of our patient interaction is with those in extremis and on only one or two occasions: intubated and ventilated bleeding patients, delirious frail patients for a palliative nephrostomy, last-ditch crural angioplasty, or a tragic palliative oncological embolisation. This is in stark contrast to PAE. I get real joy and satisfaction from the combination of shared long-term patient ownership with our urologists, who see IR as a genuine solution to their oversubscribed prostate clinics. This is coupled with an often challenging and substantially technical procedure that satisfies any IR's dream to practice ‘telekinesis’ (a claim my boss claims to have mastered) i.e. when the self-shaped 0.014” wire flicks around the bend of the corkscrew internal iliac anterior division, deflects off a plaque in the pudendal origin, and sails into the prostate artery (at least sometimes!).

The extension to who and what we can treat in interventional radiology, has led to an exciting rapid evolution of the specialty and how we are fast becoming an independent specialty. There are many similar IR-led services across the UK with colleagues leading multidisciplinary clinics in arteriovenous malformations, peripheral vascular disease, fibroid, osteoarthritis, and hepatocellular carcinoma treatments, to name a few.

In my job, this ‘ying’ to the on-call emergency ‘yang’ gives me a balance and why PAE is fast becoming one of the best parts of my working week.

Dr Conrad von Stempel BSIR scientific programme committee chair Consultant Interventional Radiologist

FROM BEDLAM TO EXEMPLAR: NCIR'S SAGA OF SURVIVAL, SOCKETS, AND SURPRISING SUCCESS The transformation of the Norfolk Centre for Interventional Radiology (NCIR) into a leading centre for minimally invasive procedures has been nothing short of a Herculean task, revealing the resilience, ingenuity, and sheer grit of our team. Let's not mince words: the journey has been a gauntlet, with expectations piled high on the doctors' shoulders and support seemingly as scarce as hen's teeth.

A Bumpy Inception

The saga began with the opening of the new NNUH PFI Hospital in 2001. Initially, our IRU suite was crammed in with Cardiology, sharing everything short of their lunch. By 2007, as both Cardiology and IR expanded, we moved across the hall. This new suite, complete with a 5-bed recovery area, was a welcomed upgrade, but soon, it too was bursting at the seams due to the relentless demand for IR services.

Maximising Resources (Or Trying To

In an attempt to wring every last drop of utility from our facilities, we stretched operational hours thin and scrambled to back-fill any scheduling gaps. We juggled significant procedures between the Vascular Theatre and our suite with the finesse of a circus act, making the most of a mobile C-arm. Saturdays, once sacred, were now fair game for additional worklists, a testament to our "dedication" (or desperation).

The Odyssey to a New Unit March 2018 marked the ambitious plan to erect a new IR unit on the hospital's rooftop. Despite having a dedicated Project Manager, the consultants found themselves moonlighting as architects and engineers, diving into the minutiae of data points, electrical sockets, and the labyrinthine details of room layouts. It seems medical school left out the module on structural engineering and fire regulations— oversights that threw wrenches into our construction plans, necessitating floor and ceiling reinforcements heavy enough to support our high-tech Pheno and Q systems.

Unquantifiable?

Medical Work?

Facing these hurdles, it's mildly amusing yet profoundly sobering to note the steep learning curve for consultants entrenched in business and contract management—fields as alien to them as Martian soil. The irony wasn't lost on us as we navigated vendor negotiations and equipment selections with the dexterity of a newbie playing a violin for the first time.

Exemplar Status: A Sigh of Relief Miraculously, amidst this cacophony of challenges, NCIR achieved BSIR exemplar status—not merely for our shiny gadgets but for our patient-centric ethos and the unquantifiable work poured into every aspect of the centre's operations. This accolade isn't just a feather in our cap; it's a testament to the relentless grind behind the scenes, often unnoticed yet crucial to our success.

Looking Through the Rear-view Mirror

The leap from a cramped shared space to our tailor-made, state-of-the-art haven represents more than just a physical transformation. It's a narrative of navigating healthcare innovation with a cocktail of optimism and cynicism, powered by a commitment to high-standard training, simulation-based exercises, and collaborative research.

Adjusting the AV system for recording of cases.

Tariq Ali, Consultant Interventional Radiologist, Norfolk and Norwich University Hospital NHS Trust

As a beacon for advances in IR, NCIR's evolution underscores the unglamorous yet pivotal role of perseverance, teamwork, and an undying commitment to excellence in patient care—a journey marked not by the path of least resistance but by the relentless pursuit of making the impossible, possible.

I WANT A BRAND-NEW IR SUITE! HOW DO I GET ONE? The majority of IR activity is hidden, as it's encompassed within the admission under another specialty. If managers cannot “see” the value of IR and the potential savings, they cannot be expected to fund & resource expansion.

STEP 1 – Separate IR budget from general radiology IR day case units can demonstrate activity & enable income attribution to IR, but only if IR has a separate budget from general radiology, otherwise the IR data is easily lost within a forest of diagnostic work. In addition, IR day cases make up only a small proportion of overall work (around 15%) and patients must be admitted under the care of an IR consultant for income to be attributed appropriately.

STEP 2 – Transfer patient care to IR consultants for IR procedures Capturing procedures performed on inpatients & day case patients admitted under other specialties (i.e. to day surgery or medical day case units) is key to demonstrating overall IR activity. This can be achieved through the temporary transfer of care on the hospital patient management system, from the referring consultant to an IR consultant for the duration of the IR procedure. This would generate a separate "episode of care" within the overall "admission spell" & procedural activity can then be attributed to IR. In fact, if the IR procedure is the "dominant procedure", the entire admission tariff would be attributed to the IR budget. Whilst this could be seen as a potential cause of conflict, one must remember, this isn't real money, but more about attributing activity appropriately.

Figure: 7-bed IR Day Case Unit at University Hospital Coventry

STEP 3 – Identify IR procedure to demonstrate “bed day savings” Not only does having a separate IR budget enable you to demonstrate activity & income, but a further tool is "bed day savings". Choosing index IR procedures with reduced hospital admission time (e.g. fibroid embolisation vs hysterectomy, ablation vs resection, angioplasty vs bypass etc.) you can demonstrate considerable "bed day savings" which in a time of considerable bed shortage, is a powerful driver for increased funding and/or resource.

Figure: The IR Theatre Suite at University Hospital Coventry

STEP 4 – Ensure accurate coding & comorbidities of IR procedures Accurate coding makes up the final piece of the puzzle to ensure IR procedures derive the appropriate HRG income tariff, which can vary wildly based on the input information, such as in the example below for a percutaneous liver tumour ablation:

Initial Coding: Procedure Code

J034

“Thermal Ablation of Liver Lesion”

Diagnosis Code

D134

“Benign Neoplasm of Liver”

HRG Generated

GA13A

“Minor Hepatobiliary Procedure”

£2,296

Corrected Coding: Procedure Code

J127

“Percutaneous Ablation of Liver Lesion”

Diagnosis Code

C220

“Malignant Neoplasm of Liver”

HRG Generated

YG01B

“Percutaneous Ablation of Liver”

£6,649

In addition, thorough inclusion of comorbidities on discharge paperwork which coders can add into a patient record, can considerably increase the tariff: Procedure

HRG

Elective Tariff

Emergency Tariff

IVC Filter Insertion CC Score 0-2

YR22C

£1,017

£3,873

IVC Filter Insertion CC Score 3-6

YR22B

£1,140

£6,042

IVC Filter Insertion CC Score 7+

YR22A

£6,125

£14,626

Whilst time consuming, cross-checking expected procedural coding with that done by the coding team, can generate thousands of £'s in a few hours. It also enables you to feedback frequently occurring errors, thus educating & improving coding for IR procedures in the long term. Considering coders are overworked, underpaid (Band 4) and non-medical, it's unsurprising they won't get it right without some guidance & assistance, and they are often delighted to have medical input.

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STEP 5 – Tell the world about IR

Sharing the data you collect with colleagues, managers and finance through as many forums as possible, will help percolate the notion that IR is a cost-effective, low-risk, high tariff generating specialty, with rapid recovery & reduced bed days.

Figure: The largest of the 4 IR Theatres at University Hospital Coventry Dr Neil Gupta Consultant Interventional Radiologist University Hospitals Coventry & Warwickshire NHS Trust

GETTING IT RIGHT FIRST TIME FOR INTERVENTIONAL RADIOLOGY After several years of waiting and many months of negotiation, NHS England have kickstarted a GIRFT project for interventional radiology.

Getting It Right First Time (GIRFT) is a national programme designed to improve the treatment and care of patients in the NHS Getting It Right First Time The programme undertakes clinically led reviews of individual specialties, combining wide-ranging data analysis with the input and professional knowledge of senior clinicians to examine how things are currently being done and how they could be improved.

The aim is to flag areas of unwarranted variation in how services are delivered and seek to set new benchmarks for how we could be doing it better first time around.

The project also searches out areas of clinical excellence, to highlight practice that excels in terms of clinical outcomes, cost efficiency and/or patient experience. The findings are then distilled as part of a final GIRFT report and recommendations made. Finally, there is an implementation phase where the GIRFT team supports Trusts, commissioners, and integrated care systems to deliver the improvements recommended.

www.gettingitrightfirsttime.co.uk

The programme was first conceived by Professor Tim Briggs to review elective orthopaedic surgery; it delivered an estimated £30m-£50m savings in orthopaedic care in the first 12 months after the pilot programme. Since then, GIRFT has looked at over 40 surgical and medical specialities and developed other NHSE work streams such as the Further, Faster programme which specifically focuses on ways to reduce 52 week waits.

On behalf of the BSIR, a freedom of information (FOI) request was sent out to collate the number and types of IR procedures performed between 2017 to 2021. 112 English Trusts which responded showed that we as a group performed more than 1.2 million procedures during that period. This information along with publications from our membership highlighting the positive aspects of day case units, IR ward beds etc, were used to nudge NHS England to consider an IR GIRFT. Many months of negotiations, led by Raghu Lakshminarayan, led to developing a scoping document which helped secure the funding for the IR GIRFT.

It was hugely encouraging to see strong interest in the recent advertisement for the IR GIRFT’s clinical lead position, confirming that our speciality is heavily invested in clinical excellence and the future of our specialty. Alex Barnacle has now been appointed to that role. We will be working with the Royal College of Radiologists to convene a team of IR experts to direct the programme.

It is anticipated that the IR GIRFT will be a 2-year programme. We’ll keep you updated on our progress through the newsletter and at the ASM and look forward to discussing the project with you all as it evolves. Involvement of the BSIR members in making this programme a success will lead to immense strides towards establishing uniform best practice across the UK and provide the Society & our members with the necessary support to push local providers to help deliver better care for our patients.

Dr Alex Barnacle Clinical Lead, IR GIRFT program, NHS England Consultant Interventional Radiologist

Dr Raghuram Lakshminarayan BSIR Vice President Consultant Interventional Radiologist

BSIR NURSES AND RADIOGRAPHERS INAUGURAL SPRING CPD EVENT, IN PARTNERSHIP WITH TERUMO On Saturday 9th March the very first BSIR Nurses and Radiographers inaugural Spring CPD event in partnership with Terumo was held at the Hilton Doubletree in Leeds.

The BSIR Nurses and Radiographers group was approached by Terumo last year as Terumo enjoys working with not only key opinion leaders but also feel it is important to work with all communities of practice and foresaw an opportunity where they could work more closely with the nurses and radiographer groups involved in IR. The proposal of the CPD event aligned with the aims of the BSIR Nurses and Radiographers group which are to share good practice, network and provide opportunities to discuss issues impacting the professions such as recruitment, career development and workforce planning.

The event was free to BSIR nurses and radiographers group members and for non-members a delegate fee of £25 was required to attend.

Delegates were treated to a day full of interactive sessions, with a morning of lectures on a variety of topics comprising of radiation safety, patient safety, simulation training and advanced practice roles along with three keynote speakers Dr Nazia Khan Consultant Anaesthetist and President of the Society of Anaesthesia and Radiology, Dr Phil Haslam Past President of the BSIR and Dr Linda Kelly Global Vascular Access Expert. Followed by an afternoon of hands-on interactive workshops from industry partners.

The venue offered a relaxed interactive approach to the whole day with various networking opportunities and the rooms were buzzing during all sessions.

On The event was a complete success with positive comments from delegates and industry partners with all delegates recommending future events to their clinical colleagues.

“It was a great day” “A superb meeting with quality speakers” “Well organised event” “All presentations relevant and I would give them all 5/5” Thanks especially go to Peter Sutton, Kay Hizzett and Fiona Irvine for bringing the event and programme together. Our Main sponsor Terumo and the industry sponsors BVM Medical, Argon Medical Devices, Vygon, and Aquilant and to all our presenters.

The event was successfully accredited by the Society and College of Radiographers and therefore endorsed with their CPD credits. We are also hoping to gain accreditation from the Royal College of Nursing for future events.

BSIR Nurses and Radiographers group are already looking forward to planning their next CPD event, this is the beginning of a great future of relevant and required educational events for the IR nurses and radiographers’ community and we are excited to be leading the way.

Kayleigh Hizzett, Assistant Professor and Year One Lead of Diagnostic Radiography, University of Bradford.

Chair of BSIR Nurses and Radiographers Special Interest Committee

DO YOU CONSENT FOR DEATH? With the publication of NAP 7, a national audit project by the Royal College of Anaesthetists', looking at peri-operative cardiac arrest, it challenges our view of patients coming to IR and what we should be consenting for.

“65% of patients have stated a fear of 'not waking up' “ Studies have previously shown that 65% of patients have stated a fear of 'not waking up' (Mavridou 2013) and though for most patients coming to IR this will not be a concern, as we increase the number of anaesthetic supported lists, this may be a question more frequently asked of the team. The question is, "is it a valid question?”.

Of course, the answer is complicated. Over the past 3 years since COVID, surgical patients have become more co-morbid, with a reduction in ASA 1 patients and an increase in ASA 2,3 and 4 patients. The average body mass index (BMI) has also increased going from a borderline healthy BMI of 24.9 kg/m-2 to an overweight BMI of 26.7 kg/m-2 with a 7% increase in severe obesity. The patient population is also older, admittedly only by 2.3 years but if you put this all together, we have a surgical population that is "less fit”!

NAP7 defined perioperative cardiac arrest as ‘chest compressions and/or defibrillation in a patient having a procedure under the care of an anaesthetist’.

The audit showed perioperative cardiac arrest had an overall incidence of approximately 1 in 3000 anaesthetics, with the most common cause being major haemorrhage, followed by bradyarrhythmia and cardiac ischaemia.

When looking specifically at radiology, the audit found it accounted for 1.7% of anaesthesia caseloads in the Activity survey and 2.6% of NAP7 reports. The patient cohort reported on were generally older, with more comorbidities having urgent, complex procedures often out of hours. Though most cardiac arrests occurred in interventional radiology, several also occurred in the CT scanner. In keeping with the rest of the report, haemorrhage remained the leading cause for perioperative arrest followed by cardiac arrhythmias. Sadly, outcomes were poorer than average with a 52% mortality rate compared to 25% for all activity in the report.

REMOTE LOCATIONS In comparison Endoscopy, which had a similar level of activity at 1.1% accounted for only 0.3% of cases reported to NAP7. Ophthalmology and Dental despite higher levels of activity, similarly had less than 1% of cases reports of perioperative cardiac arrest. Overall Radiology seems to have a disproportionately higher rate of arrest for volume of activity and both anaesthetic and patient factors have been cited.

Overall NAP7 found radiology, cardiology and vascular surgery to have poorer outcomes, with interventional cardiology having one of the highest prevalence for perioperative cardiac arrest.

PRE ASSESSMENT

‘Getting pre-assessment right to avoid delays and complications later’ One of the key recommendations from NAP7 was focussing on timely pre-assessment and the use of risk scoring systems. The aim of pre-assessment has always been to get patients both fit and ready for their procedure. Supporting high-risk patients from the beginning, using every patient contact as an opportunity to optimise co-morbidities, and measuring deterioration in chronic conditions can help to get patients fitter, whilst on waiting lists. Preassessment routinely picks up new issues particularly cardiac ones such as new onset AF and new ECG changes and having clear pathways and guidelines to manage such patients may reduce the incidence of cardiac arrhythmias during their procedure. .

MONITORING For general anaesthetic cases, most were found to meet the minimum standard of monitoring recommended by the Association of Anaesthetists’. However, monitoring was less consistent at times of transfer, either from anaesthetic room to theatre or theatre to recovery. If continuous monitoring has been in place, some cases would have been picked up earlier.

On assessment of overall care delivered to patients when they had a perioperative cardiac arrest, though judged “good” it was noted that senior support in isolated locations, at times, was inadequate.

SUMMARY IR centres need to focus on robust pre-assessment pathways that utilise existing processes for assessment and well validated scoring systems.

Identifying and counselling high-risk patients appropriately is also key. Addressing these will hopefully lead to even better short and long term outcomes for patients undergoing interventional radiology procedures.

Dr Nazia Khan Consultant Anaesthetist, Guy’s & St Thomas’ NHS Foundation Trust.