I sort of. It's a pleasure to introduce three speakers today, Alex Novak, consultant in emergency medicine and ambulatory care here.
Lois Brent, associate director of clinical studies and consultant in emergency medicine.
And Phil Homebrewers, consultant in Emergency Medicine.
So I'll hand over to them. Thanks very much. Thanks very much.
I'm Alex Novak. The free in here and we're all consultants here in a new age.
Quite a few familiar faces here actually already,
and we're in the process of going through something of a renaissance at the moment in developing our
academic and also innovative and a portfolio of projects and some of the things that have come up,
particularly around imaging in the emergency department, relationship with radiology and clinical pathways.
And this is what we really want to talk to you about today.
So this is going to be I mean, I'll give you a bit of background and context and that sort of flesh out some of the ideas.
And then really what this is is a brief portfolio of four distinct projects.
Both have similar themes running through them and just reflect some of the ways in
which we're trying to develop our approach to imaging in the acute care pathways.
Phil, I will hand over to fairly shortly,
and he takes some questions that he has to go and stem the tide at the front door in a minute, so I would try and get through.
So really, the context of this is that the the economics of acute health care is this country's rapid flux at the moment,
and I think this is no surprise to anybody in the room.
There's tremendous pressure on the front door services, which is steadily rising at sort of 10 15 percent increase year on year in attendances.
And as everyone knows, the hospital is just fit to burst. We've got no bed space and that creates a tremendous pressure.
And it puts, particularly on the clinical staff time and attention of clinicians is just become this this incredibly precious resource.
And equally, the one which is going on sort of sort of key diagnostic tests of imaging.
This one of our key resources, the cost a trimming down, becoming more accessible, generally becoming cheaper, technologies becoming cheaper.
And this is leading to a big shift in cost benefit towards pushing some of these tests,
which are previously fairly ringfenced into the specialities and into inpatient care by actually pushing closer to the front door.
One of the movements that you guys may be aware of those same day emergency care and this is a big drive by NHS England at the moment,
covering every speciality in pretty much every speciality in the hospital responding to this at the moment.
And this is the only thing, perhaps, that there is a tangible health economic benefit in getting people through the
diagnostic pathway and the care pathway quickly so within a 24 hour period.
And that, of course, is no news to any doctors. We discharge about 78 percent of our patients anyway.
But the idea of perhaps tying some of the longer clear care pathways together and trying to see if we can get
people through the whole process and get them physically out of the hospital in that time and all this as well,
is that a backdrop of technological change? The machine learning is as have big implications for imaging.
We have a big centre here which we'll talk about in a second in Sydney and this
this really sort of extends the potential for the capabilities of imaging into new
diagnostic domains and also the capabilities of auto reporting or so automated reporting
in the way of processing large volumes of images quickly and directing clinicians.
And this has been articulated by John Bellis in the Life Sciences industrial section.
He really sets digital imaging, and this process to streamline care is one of the key themes in that.
And this leads us neatly onto the Insieme, which is an Oxford led partnership.
The idea of time between clinical academic industry and old patient groups all together and fitting a sort of streamlined pipeline for innovation.
So developing AI to also get an hour into practise and into commerce.
And this was a really a direct response if I see the results of a large grant that came as part of the life sciences strategy.
This is, as I said, is led in Oxford. And you can see this is a cluster of the various sort of spin off companies and products and academic partners.
But actually, the network is right the way through the nation, and that's that's the fabric of this is something happening everywhere,
not just in an isolated so that that gives you context and drives why we thought it was important to come talk to imaging all these
these teams of exemplar projects we've got I've got a surgical leading to maybe wondering why I'm talking to surgeons about by the end,
do you need all of these sort of surgical pathways? And so what we is, and I feel it, that's why it's one of our early success stories.
Martin, thank you very much, Alex.
I'm starting with a very simple and I'm going to talk about something that some of you may have seen in some time in your career, say Floyd.
Injuries, which is a which is it's a it's an interesting little topic for EEG because it sounds very trivial injury.
But yet it's one of the very few minor injuries that caused serious serious problems if we don't identify it.
It's a hard injury to identify and. This is the paradigm that a child's right.
This happens still in most emergency departments across the country, you come in with a little bit of wrist soreness.
You put in a plaster for 10 of 14 days and then someone else comes in, look, looks at you.
Now why has this happens? Well, it's happened for two reasons.
Primarily, it's it's happened because.
The thickest has been seeing the sickest, that's the old, the old talk, and that's unfair, but it's actually on trains.
People are a very junior essay shows or whatever we call them now in the first few months of training in the position,
they've seen this group of patients and they're not they're not by no means.
The thing is they're just not trained. So we've been having the totally the wrong group of people saying this group of patients.
And because of that, we then had to make sure that they got an expert review, which the decision was generally for other reasons or go on to.
That was 14 days. The second reason actually the investigation that we do to look for this injury is not very good, and I'll come back to that.
So in most departments, just to manage this horrible flow that that Alex has talked about,
what happened was that any patient with any sort of vague form of wrist injury,
and it was probably something totally different from escape as injury got stuck in the blast,
the 14 days taken out were taken out tax free status or whatever,
and then came back 14 days later to be reviewed in an easy clinic and a fracture clinic.
Enormous cost to society, enormous cost to a lot of people. Quite a few patients actually got quite used to this and actually knew, well,
if I just for my emergency department, I'll get put in plaster and I'll have two weeks off work.
So not a good treatment, they're not, so we got Oxford's always a bit different, isn't it?
And Oxford was very different here.
So many of you will remember twenty five years ago, Peter Waller and Keith Willett designed this trauma service and the trauma service.
One of the one of the things was every patient with the fracture will be reviewed the next day.
So there was an expert review the following day,
which got rid of a few of the patients because they identified that there were some other injuries in that.
But still it was so many coming back two weeks later for later examinations that didn't work quite well.
And now my trauma colleagues said to me, actually, we're seeing one of these patients every day with a little bit of soul rest in these clinics.
You know, we see a one a day. We're not very good at it. We don't really know what's going on.
We're not kind of specialists. We can't make the diagnosis. How do you sort it out?
So we went back and thought, Well, what could we do differently? Nice has says two things about this injury.
It says you should have early expert review, so away from the sickest for the thickest, the thickest.
It said you should consider one morally. So they were the faces of all of.
So we introduced this new algorithm, this is the first part of its patients who presents with a suspected psych ward injury.
If you have three positive signs and the signs are very straightforward, sensitive, so began someone called snuff box.
Send this over to Skype or cubicle and pain telescoping thumb if you have any of those signs, a significantly positive fit in the first.
So you should discuss the patient with a senior to get the senior review and or deciphered X-rays.
The reason the city discussion that is you don't want everyone getting scapegoated extra if you get an x ray,
you almost committed to your treatment pathway. The expert we put on the ABC is that and we've now changed that, so we realise we've got a much,
much better expert group and then does most of this work is now done by an
emergency nurse practitioners who to all manage virtually all of these patients.
You see them in the orange and red group, they're not seen with Coconino, right?
Then the patient goes home and has their MRI, and it's a very straightforward pathway.
And it's been in process for about a year now.
I must show you some of the figures from the first few months and a little bit about the first year.
But first of all, let's look at some of the X-rays just to show you how difficult this is.
You know, this comes a little bit back to what Alex is saying about machine reporting.
I'll be quite happy if we have machine reporting of these films because we're crap at it.
Radiologists a crack at it. I reporter, I'll be honest, you know,
because I know because I've seen the MRI results afterwards and you actually look in that get your report really means relatively little.
So that's that's one film. This is a scapegoat.
See, it looks. It's quite nice here.
Perhaps a suggestion this is reported as normal is a bit of a cubicle on the side, perhaps a suggestion there's something going on there.
Reports it is normal, but when you see the MRI facilities, often it's all this soft tissue swelling of marrow oedema.
They're not that important injury. That injury would heal quite well.
But it wouldn't have been spotted in the old system. It's another one beautiful looking sky boy looks smooth.
That's probably normal. Was reported as normal by both us and the radiologists.
But you look at it a little bit closer to town, this bottom bit here.
Maybe there's a line there. Retrospect, the scope and the retrospective scope shows, if you look at it,
that is just a big fracture through a bit of a scale it that you would not expect.
Significant injury, because that may well get a vascular necrosis, a useless hands.
And there it is on the seats, which the insurgents, Chris Little and his group used to monitor healing.
A few weeks later, showing the fracture quite clearly at the base of the skateboard.
This one, perhaps is, I think, is the most worrying because it looks entirely entirely normal, and I would.
Assure you that 100 percent of machines, 100 percent of people would report that as normal.
And yet, as the MRI, which shows the fractures through the waste escape a very significant injury,
if this isn't treated very, very carefully, the patient could end up with a useless rest.
So that's why we're doing it. That's why we need this in the classification.
That's why we need to get the right group. Having this investigation, an easy, easy is like a Harry Potter sorting hat.
That's what we do. We sought patients out.
We drop them in to the right path and hopefully we treat most of them, 78 percent of them and get them home without any follow up.
So this is our first 50 patients. We analyse this before and we thought we'd get about one day and we're right.
Forty seven days you have 50 patients, male female split is about half.
Most of them are correct. In the park where we started, we were putting a few too many.
So we corrected that. It's about what I'm talking about x rays.
We thought that 80 percent of the X-ray connective outside the radiology, but it was the same 80 percent was only 80 percent agreement.
So actually, reportings, you know, it really doesn't mean anything if anyone thinks it's normal, low.
The patient goes on to get an MRI, so this failsafe that you wouldn't think something's abnormal weakness abnormal.
The patient goes straight into a fracture that gets followed. Accept fail safe in radiology.
Thinks it's normal, but we don't get anyway. The patient's already gone to a fracture mix.
It always feels safe. But this is showing you actually reporting doesn't have much value.
And this injury is not a very good investigation. So 76 percent of the first 15 Typekit ended up having, you know, the rest of them,
they were in the flight or they had a fracture of the skateboard, already 48.
And so we've got straight into the neck or hands on it or.
The head injury of another bone that went straight into a fracture connector.
Of those group, the 76 percent, so probably the 35 patients who had the MRI, if you don't have it, it's because they say.
And we contacted all of these, oh, I've actually better now. And so before they got the MRI, they said that they're better.
We've written to them and said, if you've got any ongoing symptoms, you must come back.
This is a slide I'm most proud of, because it shows how effective this sorting is.
Sixty four percent had the MRI. Seventy percent of our patients have got a true radiological injury,
so that's quite a high pick up rate compared with most scans that people take out.
Of those, nearly 30 percent have the diagnosis. We're looking for a scapegoat fracture.
My managers are keen on this, but none of the patients come back to us.
Half of them go to the Hanzlik. A few guys are practical because they've got other injuries.
And about almost a third goes straight from MRI and don't come back to the hospital at all.
So they come back once for their MRI and actually what happens from the MRI is all the MRI revotes.
Results are reviewed by a hand specialist. I have one of these.
If it's if the MRI because the patient discharge and sit on top of the.
The practical facts behind. So 40 percent of this group of patients don't come back at all, so it's much more effective use of our resource.
We the reason the big wait for MRI is only four days and six days.
The patient knows that diagnosis. So this is what Alex was saying.
We're bringing back the diagnostics to the place they should be.
We're making it timely. We're improving patient care. And actually, we've done this with what cost.
No cost has been no funding. Nothing else has happened. We've just changed it.
We've probably added more. We have added a slight MRI burden, but we've decreased the clinic burden across the organisation.
First, yeah, I'm just looking at the first year. There's lots of other interesting stuff, we're picking up enormous amounts of other injuries,
which we don't know are significant or not at the moment.
We're going to probably change our protocols at the high end of the high age group because the elderly don't get this injury.
People less than 10 don't get this injury, so we probably need different protocols for that, and we're still still at the roughly the same number.
So we're probably getting just about less than one a day and roughly five more eyes.
We. It's always good to get some feedback, so this was an anaesthetic colleague from the trust who came in with this injury.
And you need your rest. So do things to me satisfy you?
So he was able to be reassured that he could go back to work.
So taking appropriate investigations. Doing them at the right time.
Sorting patients who were.
Many questions to do with the treatment any more than the of warning that what we do now is whilst the patient is awaiting the MRI,
which is average is four or five days, they get put in a future just in a splint.
And so if if they get a confirmed fracture of the X-ray, they go straight into to escape the past and then straight onto a hand clinic?
If we just can't see if you have a normal X-ray, we're getting a splint for five days and then they have that MRI following the MRI.
If it's negative to come out with a splint and immobilise and immobilised, you know, eight, nine days earlier, which is better for them.
The other ones go straight on to a fracture clinic or home clinic where they get put
in escape would cost Chris Little and my hand surgeon colleague then manages these.
They are managed in the cost. They have serial settings to look for the healing of the waste to the sky for it.
And then some that don't, [INAUDIBLE] go on and they need they need a screw put in.
So pretty much anything is the best advice is that all these numbers and on Earth very often.
The largest drop in the bucket is always the best policy.
Our. And that risks that.
The substance of the possibility that that is something that is made up of you said I don't know.
I think it's a really good question. Thanks. I know, I agree.
We had some excellent with my radiology colleague has been fantastic in supporting this process.
He had some doubts originally about whether we would pick up. False injuries by marrying too early.
So our original policy was always when we first started was to put a delay of 48 hours in before the MRI actually by mistake.
If you've got MRI on day one or day two and the injuries were picked up or no injury was picked up.
So that is false. So we've already proved that that is false. So yes, you can.
MRI for from from from moments one.
X-rays are such a cheap investigation.
I, you know, I doubt whether we should get rid of the plain X-ray because you could pick up all the things on it.
But but perhaps this is okay for your X-rays is that as I've shown, it's you know,
it's it's not really is the best we had 20 years ago, but it's it's no good.
So perhaps it would be just wrist X-rays, which would show most of the risk fractures.
And then if you suspect the more, I would love someone to buy a small part MRI for the front door.
That, to me is the future, and that's where we'll be in another 10, 20 years.
Thank you very much. Hello, I'm Lois brand, and I'm going to spend 10 minutes just talking to you about a work in progress,
actually, this isn't the finished article like fills. This is a work in progress and I became interested in the management of elderly
chest trauma a couple of years ago when we had a series of really quite significant
cases which were missed either because of our lack of care in clinically
assessing the patients or a lack of adequate imaging or a combination of both.
And one of those was the Siri, unfortunately. So this is in the context of what we're understanding nationally as changing face of major trauma.
So these are admissions in the last year to the trauma centre here.
And the green people are the ones who have an injury severity score of greater than 15 and so classified as major trauma.
And you'll see that over 40 percent of those are in the age group 65 plus.
So what was originally sort of perceived to be an injury, a a problem of of younger, particularly male patients caused by high energy attacks?
Mainly actually major trauma is now predominantly a disease of the older individual,
and most of these major trauma patients are actually getting their trauma from a fall from standing height.
So you can see from this graph here, the older you get, the more likely your trauma is to be sustained by a fall of less than two metres.
Comfortingly, the older you get, the less likely you are to be shot or stabbed.
And this causes a problem for us, as you can see as you digest this slide.
That's our triage system. Our pre-hospital triage system is set up to very accurately identify those
people who need a trauma team at the front door and need to be assessed early.
We're very good at picking up major trauma in patients in a younger age group, but we are not good at picking up major trauma in people who are older.
When we think about the number of people who come into our emergency departments here in the air and also across the Horten,
we see about 100 older falls a week.
And of those, a very tiny number will have sustained major trauma.
We are not good at picking those up, and that's because of co-morbidities, particularly if they're cognitively impaired.
It's more difficult. It's because of the fact that they might be on beta blockers and so don't mount a tachycardia response to their haemorrhage.
It's because they've got smaller brains encased within their cranium, and when they have blood in there,
they don't always show that so, so much as as a younger brain might, which might be more quickly squashed.
So lots of reasons why we find it very difficult to pick these people up.
And as a result of this, we manage these patients differently. Now, arguably we should be we should be managing these patients differently.
They probably don't need a full trauma team response, but they do need to be identified early and managed appropriately.
Tom, have recognised that this is a significant problem,
because the way that we've set up our major trauma response across the country is really targeted to the lower age group and high energy trauma.
But this is now a big problem with our older patients.
So they did a they looked at what we were currently doing across the UK and produced this report in 2017 and found that the
older trauma patient is less likely to come to the major trauma centre and substantially denied access to the expertise.
They're more likely to be treated by a junior doctor because when these bullies come in,
they just next to be seen next to be seen by the junior doctor,
who probably will not realise that these patients have got to be looked at very, very carefully in order to rule out major trauma.
More likely to have delayed investigation is less likely to have surgery more likely to die.
However, in the survivors, there's only a little bit more disability than in younger patients.
So specifically thinking about imaging on in chest trauma in the older patients.
We know that plane films are useless when we're dealing with major trauma, so we don't even bother with them if we have a trauma call.
And we're seeing the patient in rhesus and they've been hit by a bus. We might do quick, a very quick chest and pelvic X-ray.
There's not going to slow us down at all actually in recess.
But then we will move very quickly once the patient is stabilised and within 30 minutes to doing a
whole body CT scan because we know that's the only way we're going to pick up significant injury.
However, as we've already said, the older patients there are lots and lots of them, and they're sustaining these traumas by a low force mechanism.
And and we need to find the needle in the haystack. Chest X-rays are, we know, inadequate to pick up a lot of these injuries.
So we were left with a real problem that we couldn't ask radiology to pick up the slack here and scan everybody.
We needed to try and find a way of working out how to identify the patients
who needed cross-sectional imaging without breaking the radiology department.
So the first thing that we did was identify some key questions and we went to the literature.
So the first question was how does chest trauma in the elderly differ from that of the general adult population?
And the literature is quite clear on this. There were three key papers that that we focussed on,
and it says elderly patients who sustained blunt chest trauma with rib fractures have
twice the mortality and thoracic morbidity of younger patients with similar injuries.
And for each additional rib fracture in the elderly, mortality increases by nearly 20 percent and the risk of pneumonia by nearly
30 percent in elderly patients are prone to complications with rib fractures,
even when minor trauma was the cause. So just identify clinically significant injury missed on Chest X Ray.
This was more difficult to answer because there were no papers that look specifically at the older patients,
but looking at a couple of papers that did this address this question in adults,
it was clear that CTE detected clinically significant injuries and up to 50 percent of rib fractures are missed on plane x ray.
Does early identification of these injuries positively impact the clinical course?
I mean, this was a key question to answer for our radiology colleagues who didn't want
to be doing these seats just so that we could get an accurate diagnosis,
but it wouldn't actually change the management.
And there were four papers that we looked at here one perspective what do you retrospective and a literature
review that looked at this question and all concluded that early identification and aggressive pain management,
physiotherapy and where appropriate, surgical fixation improves morbidity and mortality in these elderly patients.
The final question What identifies patients who would benefit from this CT chest is, as you would imagine, the most difficult question to answer.
There were two papers that came some way to addressing this,
but it wasn't terribly clear how we were going to be able to sift out this needle in the haystack.
So we did our best from taking what we found in the literature to try and come up with a clinical decision tool to aid our
clinicians in the EDA to decide who should get a scan after reading the literature and and having this series of misses.
I just wanted everybody who fell over who had got chest tenderness to have a CT, but that was clearly going to be a non-starter with the radiologists,
who are very overwhelmed already by the amount of work that they're doing for us.
So we put together this guideline and have since then reviewed the guideline and and seen what the effect has been.
He once was. We've done this on the patient and identified the injuries in the chest wall as a plain CTVNews.
We don't use contrast CT for these patients. We can then calculate the battle score, which then informs their onward management.
So the battle score is is a it's it's been.
What's the word? It's a what's the word Alex beginning with L and I'll come back to that anyway.
It's that the battle score is well recognised as a tool to help stratify risk in patients with chest wall injury.
And you'll see from here that we have a guideline which suggests that those with minor injuries can go home.
Those with a moderate battle school can be admitted for pain relief and mobilisation under the medical team,
and anybody with a better score of 21 or more will be discussed with their thoracic team.
And there is some flexibility here. Those who are not needing fixation and who the cardiothoracic team think can be managed
under the medical team can then be discussed with the medical team and managed through them.
And that's often the best pathway for those who are not going to have surgical fixation.
So these are some of our numbers, we looked at six months of data before we implemented the guideline is six months after those of you who
are still conscious will notice that the numbers before are significantly lower than the numbers after.
I don't think that represents the fact that we had more patients during that six months.
It's just unfortunate that in between the pre and the post,
we had a complete change in the way that we recorded data about patients diagnosis within the department and that was beyond our control.
It does mean, however, that these sorts of things are now much easier to look at, but it means that it's difficult to compare accurately pre and post.
But what you can glean from here is that a greater proportion of patients had a CT scan afterwards than before, but it's not a huge increase.
You'll also see in the post and numbers that quite a few had a chest X-ray first,
and that's not what we would have wanted to happen, because that's probably not really very useful.
I think that when the patients need an image, then they need CT here.
We're not adding anything by doing the chest X-ray, but you'll see that it's actually quite useful.
We wouldn't have been able to put that through ethics to say,
we want everybody to have a chest X-ray so we can compare whether the city really is picking up something that's more useful,
but that that little which there on the right is actually quite useful for us, as it turns out.
So of the patients who had a city at the numbers was 65 post implementation.
You will see that out of those 65, only nine of those were no more so, but a massively high pick up rate,
which makes me feel very anxious that we are missing significant patients.
None of the patients in the six month period came back with something related that weren't picked up on CT.
But these are small numbers, so you can see we're picking up an enormous amount of chest pathology.
This is the slide that I mentioned where these 27 patients who happened to have both Chest X-ray and CT.
We compared the findings of the two. And as you can see here, we are picking up significant injuries on the C.T., which are being missed on the X-ray.
The other thing which I think is important is that when we looked at the data
retrospectively and looked at the number who met the criteria on the guideline,
I mean, it's obviously difficult to be accurate because you're looking back at the notes rather than seeing the patient in front of you.
But looking back of the 62 people who met the criteria for scan, two thirds of those was scanned.
And of the 65 patients who didn't meet the criteria for a scan, one third of those were scanned anyway.
And of those about a half, we found significant injury and which makes me think again.
We need to rethink this guideline and lower the threshold even more for scanning in this group of patients.
So looking forward, we're going to continue reviewing the data,
further developing the imaging guideline and ongoing education of our of our clinical staff is obviously really, really important.
Unless you undress these people and go over them with a fine tooth comb,
you are going to miss significant injury and ongoing review and development of the inpatient pathways obviously key to this as well.
OK, I'll take questions at the end after yours. Thank you very much. Thank.
And prove it. OK,
so I'm going to just give you a quick before we take some questions of these and just kind of run through very quickly through to further projects
about both of which actually bring a collaboration with surgical colleagues say the first of these is a small pilot asked to be put together.
And this is based around imaging pathways and to keep ghost with suspected acute ghost and presentation.
So no news to anyone here that gallstone disease is really common.
This is a prevalence of around 50 percent in the population in the developed world.
There's three sort of key imaging modalities, so ultrasound, which is very operate, is relatively cheap.
Out of the three, very operator dependent a lot of noise and signal and is often quite insensitive to picking up some of the gallstones himself.
And then, he said, issues with the common bile duct, those LCP,
which is obviously very invasive and expensive, tends to require admission or at least a day case.
And again,
quite a lot of intraoperative variability and in the current gold standard is another step which is very good to of sensitivity and specificity,
Finkelstein disease and the complications around it.
It's non-invasive, considered expensive, but actually coming down in price and in most of the stage is actually a similar similar cost to ultrasound.
Again, is somewhat qualitative, and it relies a lot on the judgement of a radiologist to say whether the bile ducts are dilated or not.
So one of the companies working in Oxford is perspective, where we have a sort of research relationship,
and they came up with an algorithm for interpreting and MCP quantitatively.
This is being used in things like primary sclerosing cholangitis, fatty liver disease, looking at vibrations.
One of the perhaps the less sort of more marginal possibilities, though,
is to look at the biliary tree itself and actually find some quantity quantitative imaging for as an objective finding.
And you get images like this, particularly one on the end.
You can see the sort of red hot spots and these these different colours reflect different diameters.
And it's actually possible to get a score for an overall dilatation or otherwise of the bilby dream and predict the detective struction.
And what? Why is this relevant as well? We became interested in pathways for these patients in terms of imaging,
and most people realise the standard sort of test of choice in an age has been in the ultrasound scan.
The idea is that, you know, this can be fairly quickly and cheaply discharge.
Make a decision whether or not they need an MRI scan.
If there's any suspicion of any obstruction further up, the ultrasound is not sufficient to give you the full diagnostic picture.
And we ran a six week the disclaimer.
This is about three years ago and things have shifted quite considerably with the advent of ambulatory care in the ICU.
But broadly speaking, you can see here there's about half out of sort of 36 patients.
So roughly, you know, when one a day give or take, 27 of them see the option and these actually 14.
So over half of them actually went on to have an MRI anyway.
And the point about this is obviously there's there's not much value in doing an ultrasound in some of the ActionScript.
If they're going to have to go on and doing more anyway,
why not just do the MRI and this when you add in the time to reports and the admission times and the consequent length of stay like this?
Well, it becomes quite a big economic problem. So again, the times of these probably improved over the last couple of years,
but not dramatically was like twenty four hours to get an ultrasound report and up to about 40 hours.
Neither of these are mean figures to get an MRI report,
and this is a this is a big delay for patients in terms of complications and outcomes is also just a big admission burden.
So we're putting our heads together collectively so between any spacing, altering surgery and quality,
helping with radiology and supported by the prospective diagnostics, we put together a pilot project which is ongoing at the moment as very small.
Just 64 patients split 50 50 between direct them LCP, so within 24 hours and Standard Care, which is when the clinician feels is needed.
So this is ongoing as we speak in media.
So what's tricky here in these kind of things is how you decide what your primary outcome is because of course,
the length of stay may actually be increased by an MRI. If you if you find a complication that needs only you, that needs any LCP.
So we came up with this sort of composite end point, which is the cost of final diagnostic reports and the cost of admission up to that point,
which you get a diagnostic report, which then doesn't change.
So that was sufficient to allow discharge when we're looking at some secondary outcomes, as well as the cost of admission patient outcomes and.
Perhaps one of the more interesting drivers for this is the Explorer Chathams, all the patients who consented to have right to use their images,
anonymized images to develop the algorithms looking at BBC itself so that the outcome was
of whether we can perhaps develop a sort of validated quantitative measure of looking
at the pill retrieval because essentially the inclusion criteria says adult patients
suspected gallstone disease with acute abdominal pain and just anything mild intervention.
All of these are about a 10 percent increase in the lefties. So fairly pragmatic at the moment we have about 14 patients recruited and we're looking
to compete in spring next year and hopefully we'll be able to present more then.
So that that's one of the projects I wanted to talk to you about,
just because I'm aware with specific three or four time I've talked to you quickly about the next one, which is the critical care suite and the G.
This basically is a mobile X-ray machine with embedded tech, which and again,
the evaluation is ongoing now as we speak, and this has two key capabilities.
One is image optimisation and one is picking up pneumothorax and prevalence in the 80s is fairly low,
actually says five to seven for about 8000 to 10000 machines per from single antigenic and in primary spontaneous, it's about eight point six.
So it's fairly low, but it's present in there. And of course, this excludes thoracic surgery.
Patients eventually all have a pneumothorax when you open the chest.
This is what we tend to be faced with the needy, and as you can see, if we're looking for inimical acts,
we might be able to spot this here, but it's not something that leaps out of you.
And certainly, if you were a junior reporter or someone in a hurry, you quite distracted.
This is not always an easy one to spot. It was a frequent cause of the phone call, you know, sort of subsequent reporting.
And of course, this is actually what we tend to see in any which is a chest x ray slumped over with all the other things going on.
And every time there's a pneumothorax. So this this kind of illustrates the point where I could fit in terms of detection because she's the best
one in the world is very tricky and is certainly tricky if you're not suspecting it in the first place.
And this is the critical care suite. So this you can see here. This is the X-ray comes up with a point, a point of care image.
And this has already been put together in the states. They've done their diagnostics. The stats are kind of interesting.
So the over there, the ones I picked out, the the negative predictive idea was pretty good.
It's pretty good at telling you if there isn't one, which actually for me is any doctor is actually the most useful thing.
I want to know whether it's reliable, positive predictive value, considerably less so.
But it's possible to tweak the sensitivity of the various configurable thresholds, depending on on how concerned you are.
So this allows you to change depending on where, which particular you work,
and it also has this intelligent auto rotate so as to avoid the kind of slumped image.
So this enables the detector to interpret sort of standardised X-ray film, and it also improves it for the clinicians.
So we're running a market valuation in this at the moment. This is in collaboration with Elizabeth during of Essex and Vegas,
and the Insieme machines are already in place and I'm collecting images and we're looking at completing this in the next few weeks.
Following on from this, we've put in ethics for perhaps the key question,
which is is it any good in terms of detecting you with these over and above clinicians?
So this is going to run a subgroup analysis where we look at different groups of clinicians, ICU docs, docs, radiologists, radiographers,
nurses and different levels of seniority and just compare the algorithms against them,
see to see what you see where it says, and we'll look to see that with that 12 months.
This is pretty small fry stuff, but perhaps pneumothorax wouldn't be the most immediate thing.
Grab everyone's attention here. But the point of this really, I guess,
is proof of principle that this can be fairly quickly updated the the algorithms already in process Numa peritoneum factor.
All these things are quite easy to miss on chest x rays, and this is what can we look to to replicate this for various other areas of the pathology?
So that's it in terms of the presentation. So it's for projects or very different arenas as far as emergency medicines are concerned,
but all involving the same kind of principles about bringing expensive tech early in the
pathway to have an overall cost benefit and some indications of where technology might fit in.
And you're likely to be seeing many more of these. Thanks very much and investment.