RANZCR: The State of Neurointervention Practice in Western Australia

The Royal Australian and New Zealand College of Radiologists (RANZCR) Inside News June 20202

Interventional neuroradiology (INR) has developed as a specialty rapidly over the last 20 years but its status varies in different continents and states. Neuroradiology was the first recognised subspecialty in radiology in the early seventies and, from this beginning, early interventions were restricted to palliation of arteriovenous malformation and congestive cardiac failure. The proliferation of endovascular techniques in the late 1990s/early 2000s, specifically for aneurysm treatment, gave baseload numbers for INR to practise. This combined with a simultaneous explosion of accurate non-invasive vascular imaging (MRA and CTA) increased the numbers of patients requiring treatment.

The opportunity to practice as a fulltime interventionist has been a reality in WA since 2000. In some cities this is hampered by a lack of infrastructure and understanding of the requirements to do so when viewed through the prism of a traditional general radiology department. Diagnostic radiology has a myriad of players, modalities and interest groups. The potential for INR can also be hamstrung by a lack of understanding or support from administration/allied craft groups and further compounded by the invisibility of the interventionist to the public.

Neurological Intervention and Imaging Services of Western Australia (NIISwa) was formed in 2007, as a holistic allembracing approach to patient care.

We focused on the following elements:

• Admission rights

We had enjoyed these for many years, but they require suitable junior staff to manage the patient’s hospital admission.

• Ward junior staff

A single Fellow is inadequate, and we required, as does any clinical team, a medical registrar and two RMOs attached to our service, enabling a consultant-led practice. An offshoot of this practice is that we now have 10 years of junior staff (more than 200) who intimately know what benefits

INR provides and act to make the department more visible to the medical community. NIISwa furthered our exposure by having a medical student attached to the unit and affording nursing staff and students study days to attend our unit.

• Clinical governance of patients’ admission

This is essential, especially if there is a complication. The appropriate therapy or advice is given by the expert practitioner rather than being filtered through related parties. Liaising and counselling family is best directed by the expert practitioner rather than under the bedcard of a third party. Follow-up and discharge planning are more efficient and accurate for GP liaison.

• Ward support

Provision of beds with patients under our bedcard and daily ward rounds have normalised INR activity, with nursing and allied staff welcoming the input and interest of the team. Equal access to paramedical staff (physiotherapy, occupational therapy and speech) makes treating patients easy and routine, even with complications, as we are part of the furniture not ’the X-ray guys who want something’.

• Anaesthetic support

75 per cent of INR procedures are category 1 emergencies. It was and is inappropriate that INR units are given one to two days of general anaesthetic support when other disciplines were given daily access to anaesthetic support. The provision of 14 sessions of support per week at one site and seven sessions at other sites, enables appropriate and rational treatment of patients and allows new procedures to flourish. A separate anaesthetist is on call specifically for our service including an anaesthetic technician.

• Expert MIT and nursing staff

NIISwa nurses and MIT staff are full-time which has a logarithmic effect on room turnover, appropriate device stocking, procedure time and calm advice from the right of the operator late at night. It engenders team spirit and a great working environment, good for staff, anaesthesia, related craft groups and the patient.

• Administrative support

This is essential to enabling all outpatient visits, whether new or followup, to be logged and a letter to the referring doctor, with a copy to the GP, to be produced. This closes the loop and clearly demonstrates to the medical fraternity who is performing the procedure and prescribing the therapy so any questions or complications can be directed to the right person.

• Standardised imaging follow-up

Arranged by the INR and organised by the administrative team, this allows the INR who performed the procedure to follow up and use the imaging report to triage the patient back to out-patients, plan therapy, additional follow-up and send a copy to the GP with a clinical plan. No case is reported by another radiologist therefore none are lost to the system. It is a closed, efficient loop and medico-legally sound.

• Expansion of outpatient clinics

We now have 14 clinics per week including a 3-month modified Rankin Scale (mRS) stroke clinic that allows us to independently assess suitability for treatment and follow-up of patients from statewide specialty and non-specialty referrals.

• Position at the table

Involvement in decision-making with administration is essential. A highvolume dedicated specialty has more chance of cutting through than occasional operators working in a large multi-interest radiology group. Positions such as the Neuroscience Divisional Director, membership to the State Stroke Advisory Committee and hospital executives give INR a voice.

• New procedures

We can introduce new procedures more easily as the infrastructure and human support makes the environment favourable to do so, both with new devices (pipeline, web, thrombectomy) and revolutionary procedures (venous stenting for intracranial hypertension and middle meningeal artery embolisation for chronic subdural haematoma). These are added to the routine epistaxis, tumor embolisation, DAVF/AVM/peripheral vascular anomaly treatment, carotid and vertebral artery stenting, vasospasm and other ancillary procedures.

• Data collection and research

This is centralised and benefits from the set-up of the department with contemporaneous statistics on stroke outcome available 24/7.

• CCINR accredited high-volume INR practitioners

CCINR accredited INRs are the linchpin of the service resulting in a uniform approach to pathology and treatment with regular morbidity and mortality meetings. Weekly INR case conferences regarding upcoming cases and weekend phone calls to a friend for extra support are routine. A collegiate atmosphere allows discussion of complications and a practice-wide minimum standard of care is demanded.

The establishment of a stand-alone interventional neuroradiology specialty group cross campus state service (NIISwa), supported by diagnostic neuroradiologists, was welcomed by neurosurgery, neurology, ICU and anesthesia, who saw the patient benefits as they worked closely with INR. Interestingly, at its commencement, the sole resistance encountered was from other radiologists. It has been seen however to be a highly beneficial exercise and made rolling out a 24/7 stroke service seamless and amazingly cost-effective with few new resources available to the department. Length of stay for aneurysm cases is less than 36 hours and the endovascular treatment of SAH and stroke treatment have revolutionised patient outcome, quality of life and cost to the state.

Figure 1 shows that procedures have exponentially increased over the last six years with no additional INR consultants. The benefits of a high-volume service have been demonstrated innumerable times in many fields of surgery and INR is no different.

INR can be practised in many ways but leveraging expertise in a unit with high volumes results in a great working environment, recognition by patients and related craft groups and excellent patient outcomes with associated large cost savings.

Australasian radiology would benefit from similar models being employed in other areas, as performing the procedure is a small part of the service. For general IR to flourish, its value needs to be acknowledged and embraced by both the medical community and diagnostic radiologists, recognising its clinical requirements and infrastructure in a meaningful way.

This will enable interventional radiologists to practice as fully-fledged clinicians, warts and all, rather than merely developing novel techniques that pass to other craft groups that possess the infrastructure as a given.

Clinical A/Prof Will McAuliffe FRANZCR CCINR

Consultant Interventional Neuro Radiologist Neurological Intervention and Imaging Service WA

Do you have any IR or INR articles you would like to contribute to future editions? Please email your interest to interventional@ranzcr.edu.au