Shared learning database

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Published date:
February 2013

Alder Hey Children's NHS Foundation Trust has developed a service level agreement (SLA) to ensure the effective reporting of neuroimaging as part of the investigation for epilepsy. This agreement has established a network between Alder Hey Children's NHS FT and the Blackpool Victoria Hospital, the Shrewsbury and Telford Hospitals Trust, and other hospitals in the North West of England and North Wales to provide second opinions on paediatric neuroimaging. The service aligns with NICE CG137 Epilepsy (recommendations 1.6.19-1.6.22) and QS27 The epilepsies in children and young people (quality statement 3) "Children and young people who meet the criteria for neuroimaging for epilepsy have magnetic resonance imaging".

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

In order to ensure the effective reporting of neuroimaging as part of the investigation of epilepsy, it is important that the practitioner interpreting the results has the correct skills to be able to do this. The ideal pathway to ensure this happens would be for all images to be interpreted by radiologists with special expertise in paediatric neuroimaging. However this expertise is often limited to specialist (tertiary centres) meaning that the interpretation of images is often completed by radiologists who may not have the necessary training and skills to be able to do this effectively.

Our aim was to develop a new model of service delivery for paediatric neuroimaging, which would establish a clinical network providing access to a specialist centre offering paediatric imaging expertise and advice to other units as needed.

Reasons for implementing your project

NICE CG137 recommends that neuroimaging should be used to identify structural abnormalities that cause certain epilepsies. (Rec 1.6.19), that MRI should be the imaging investigation of choice in children, young people and adults with epilepsy. (Rec 1.6.20)
CG137 also recommends that MRI is particularly important in those:
- who develop epilepsy before the age of 2 years or in adulthood - who have any suggestion of a focal onset on history, examination or EEG (unless clear evidence of benign focal epilepsy)
- in whom seizures continue in spite of first-line medication. (Rec 1.6.21)

Previously, MRI scans undertaken and reported in the district general hospitals were reported by non-specialist general radiologists. The standard of these reports varied considerably and many general radiologists felt increasingly uncomfortable about reporting specialist paediatric imaging.

The issue could only be addressed by ensuring that those medical practitioners who routinely interpret and report MRI scans as their main job description:
a) Have the appropriate training
b) Always seek advice and if necessary establish a link with or request a 'second opinion' from their counterparts in the tertiary, paediatric neurology centre.

In addition, medical practitioners (ie: paediatricians and adult physicians / neurologists) should not be expected to undertake the routine reporting of brain MRI scans.

Increasingly, our consultant radiologists were being asked to provide expert advice and / or re-interpret paediatric neuro images from other hospitals. This was largely being done on an ad hoc basis and was beginning to have a significant impact upon both the consultants and the clerical staff's workload. In order to ensure appropriate governance and formalise this arrangement a service level agreement was developed.

How did you implement the project

Blackpool and Shrewsbury district general hospitals have now established a formal link with its tertiary paediatric (neurology) centre at Alder Hey to have childrens' MRI scans reported by a specialist.

Negotiation was required to gain acceptance of the principle that the referring hospitals should pay a charge for the service to cover both the consultant's time and the clerical and administrative costs involved in managing scans transferred electronically via the IEP (Image Exchange Portal). Standard operating procedures were agreed to ensure that referrals contained all of the relevant clinical information required and that the images are matched to the correct patient.

Key findings

Those district general hospitals that now have formal SLAs with our Imaging Department now have full access to expert paediatric radiological advice at all times. They can therefore be assured that their paediatric patients will receive the best possible service available in a timely and efficient manner. Last year we provided a total of 3013 second opinion reports for other hospitals (NB: This was not just for MRI interpretation. This was a total for ALL second opinions we were asked for).

Consultants in paediatric neurology that provide a peripatetic outreach neurology service to the district general hospitals also benefit from this paediatric radiology SLA. When the consultants see children in an outreach clinic they know that any neuro-imaging will have been reviewed and reported by the Alder Hey paediatric neuro-radiologists. This will obviate the need for this neuro-imaging to be then reviewed again at Alder Hey. This improves efficiency and ultimately the overall care of these children.

The additional income generated has allowed the additional workload to be absorbed in to the working day at Alder Hey. The model is now also being used to provide a first and second opinion service for imaging of Non Accidental Injury in some centres.

Key learning points

The implementation of the SLA has been made possible by effective communication, the availability of the necessary electronic imaging links and a willingness on the part of all parties involved to agree a solution that is mutually beneficial and puts the needs of the patient and the quality of service provided at the forefront of the agreement.

There were no real barriers to implementation as we were approached by the referring Trusts who wished to use our paediatric expertise so they were willing to pay the charge which we felt was reasonable. We based this on what other Trusts were charging for a similar service.

Contact details

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Primary care
Is the example industry-sponsored in any way?