Patient safety and image transfer between referring hospitals and neurosciences centres: an alternate best practice?

Having read with great interest the recent paper to this journal by Crocker et al., we commend the authors for highlighting a topic that is of crucial importance to the effective functioning of any regional neurosurgical unit, in particular to the timely management of emergency referrals. We would like to make a few observations based on the practice in our unit, which serves seven referring district general hospitals and a catchment population of about 2 million people. Croker et al. explain that the advent of digital picture archiving and communications systems (PACS) over the last decade has made possible the rapid electronic image transfer via web-based software. They assert that both the National Health Service (NHS) Modernisation Agency’s Neuroscience Critical Care (2004) report recommending broadband-based teleradiology as a cornerstone of a regional neurosurgical unit and the NHS Connecting for Health’s attempts for improvement of neuroscience teleradiology systems through its National Programme for Information Technology in the NHS (launched 2005) have been disappointing in their implementation. They support these assertions with a well-conducted national survey of practice and a more detailed prospective audit of their own region. They appear to suggest that direct web access to referring hospital PACS is the desired standard but is hampered by various issues such as software incompatibilities, data protection concerns and cumbersome hierarchical approval for use in each NHS organisation. Finally, they comment on the image exchange portal (IEP) being implemented in England this year, which is not a system of direct web access to referring hospital PACS but rather a digital imaging and communications in medicine (DICOM) format push from the referring hospital PACS to the regional neurosurgical unit’s PACS. In our region, a DICOM-push network was set up in 2005. All NHS CT and MRI scanners in the region came on-line to this teleradiology network by September 2008. Images are sent from scanners in the region to a central server by request of the referring clinician to the local radiographer. Image viewing is web browser based (RADINa; Ferrania Imaging Technologies, Italy). This can be visualised from any computer within our hospital, which, therefore, provides equal accessibility to within-Trust PACS scans. The same access is available with hospital-provided secure laptops. Thus, all images can be readily viewed by the neurosurgical consultant on-call at home as well as by the neuroadiology consultant, obviating the need for a local radiological report. Additionally, this versatility can be advantageous in designing compliant rotas for trainees. The system has generally proved reliable, and the request for scans on CD delivered by couriers has largely been confined to out-of-region referrals. This system has further advantages not discussed by Crocker et al. All scans from the whole of the region are viewed on a single browser platform, which is efficient and convenient for discussing at radiology meetings and multidisciplinary team meetings (neuro-oncology, spine, etc.). In comparison, direct web access to referring hospital PACS will be cumbersome for this purpose because each referring hospital would have to be logged in to separately in serial fashion. Also, our RADIN central server maintains the ‘pushed’ images in perpetuity unless they are intentionally deleted. The IEP as well as the alternative PACS-exchange systems that are being introduced in many hospitals currently have limited time frames for preservation of images.