Greening the Fluoroscopy Pathway

Case study submitted as part of Lancet Commission call for case studies.

Team members / location: Samantha Holmes/ England UK 

Issue: The videofluoroscopy service was allowed speech therapists to request referral of patients into the clinic via the patient’s GP or medical professional. Medical professionals were also able to refer directly. However, referring professionals did not always have sufficient understanding of the rationale for undertaking a videofluoroscopy, and there was an insufficient triaging protocol to identify inappropriate patients before they underwent the procedure. This was highlighted through retrospective audit of one year's data, showing 10% of completed procedures were considered to have been clinically inappropriate or unnecessary. Videofluoroscopy is a very resource- and carbon-intensive procedure, alongside its inherent exposure of patients and staff to ionising radiation, so the percentage of inappropriate referrals had significant implications.

Intervention:  An initial audit of the service led to the identification of a number of potential improvement projects. It was agreed to first address the number of inappropriate procedures being conducted. The timeline for this was 12 months. We started by modifying the existing referral pathway into the clinic by introducing a triage process to identify inappropriate referrals earlier in the process, while also circumventing these referrals being made at all. The intended impact of these changes was to decarbonise the pathway; reduce wastage of resources and prevent unnecessary radiation exposure of staff and patients. We also ran multiple education and engagement events with relevant healthcare professionals to improve their understanding of the clinical purpose of the procedure. A standard operating procedure was written, which outlined the new referral pathway, and this was then circulated to stakeholders and referring professionals. Repeat audit evaluated the outcome of the changes on a yearly basis. 

Outcomes:  

• Environmental: Carbon footprinting has not been completed on fluoroscopy, although there is a paper from a urology team in Europe that has produced some figures on the energy consumption of fluoroscopy machines and estimated the annual carbon emissions of a machine at 2220–2427kg CO2e. We are not looking to reduce the number of videofluoroscopy procedures that are performed annually, but to rationalise the use of those procedures to ensure that there less waste built into the system.  
• Social: Videofluoroscopy is considered the 'gold standard' of dysphagia assessment due to the information it yields about a person's swallow function; aspiration risk and potential for benefit from rehabilitatory or compensatory swallowing manoeuvres. Rationalising what is a carbon-intensive procedure to only those patients with a clinical need allows us to benefit those who most need it. Appropriate management of swallowing difficulties can have a huge social impact, due to the social nature of eating and drinking. 
• Financial: There is no UK data on the cost of running a videofluoroscopy clinic. The cost of undertaking a private videofluoroscopy is between £300-£400, hence there would be a predicted financial impact on preventing videofluoroscopy being performed on patients who did not need it. 15 (10%) of patients in the first audit cycle were identified as having been inappropriately referred, which would result in a projected £4500-£6000 annual savings. 
• Clinical: Patient outcomes: The initiative has improved patient safety as it has reduced unnecessary exposure to radiation. It has also reduced waiting times in the clinic by freeing up capacity, which has allowed us to offer more timely fluoroscopy procedures to patients who need it. This has wide-reaching impact i.e. a patient who has been reliant upon tube-feeding in the community, who may then be able to progress back on to oral nutrition after having a videofluoroscopy, with subsequent implications for reduced hospital travel and use of resources through the cessation of enteral feeding. Population outcomes: Timely identification and management of swallowing difficulties has significant impact on the health of the population, alongside prevention of the complications of inadequate nutrition or aspiration-related adverse health events secondary to dysphagia, which can result in reliance upon enteral nutrition or prolonged hospital admissions. Optimal utilisation of the videofluoroscopy clinic as a resource results in increased capacity for those who needs it, and also prevents those who don't need it experiencing an unjustified radiation dose. 

Key learning point: The limitation of this was that the triaging process was felt to be more onerous from referring staff, resulting in a reduction in overall number of patients being referred for the procedure. The key element of success of the procedure was interdisciplinary working, as this was a collaborative effort between speech & language therapy and radiography. The other element of success was the engagement and cooperation from stakeholders, such as the acute and community speech and language therapy teams who refer into the clinic.