THE RED DOT SYSTEM

Emergency Diagnosis Impact and Digital Radiology Implementation

A Review

José Manuel Coelho

1,2,3

and Pedro Pereira Rodrigues

1,4

Faculty of Medicine of the University of Porto, Al. Prof. HernâniMonteiro, 4200-319 Porto, Portugal

Faculty of Sciences of the University of Porto, Rua do Campo Alegre, s/n, 4169-007 Porto, Portugal

Imagiology Department of Hospital Center of Porto, Stº António Hospital

Largo Prof. Abel Salazar, 4099-001 Porto, Portugal

LIAAD, INESC Porto, L.A. & CINTESIS - Center for Research in HealthTechnologies and Information Systems

University of Porto, Porto, Portugal

Keywords: Red dot, Radiographer abnormality detection, Radiographer report, PACS, Digital radiography.

Abstract: Radiographer abnormality detection schemes (RADS) were introduced in the early 1980s to assist

emergency departments. The development of PACS systems are affecting health professionals forcing them

to evolve along, reviewing images on a computer monitor rather than on radiographic ﬁlm. This article

reviewed published articles that evaluated the impact of the use of a Red Dot System in patient outcome of

emergency trauma patients and assessed the implementation of a Red Dot System in a Radiology

Department with digital radiography and PACS. Few articles addressed the implementation issues and use

of a Red Dot system in Computed Radiology. Radiographer skeletal red dot studies, had sensitivity and

specificity of, respectively, 0.71 and 0.96 pre-training, and 0.81 and 0.95 post-training, compared with a

reference standard. The use of radiographer abnormality detection schemes such as Red Dot and reporting

has the potential to improve the diagnosis and outcome of emergency patients. The arrival of Information

Technologies (IT) to healthcare and the introduction of Digital Radiography have limited the functionality

of RADS due to incompatibility of new technology with the standard practice. New image technology

solutions in Radiology should enhance the development and utilization of radiographer skills in RADS

environments.

1 INTRODUCTION

Radiographer Abnormality Detection Schemes

(RADS) were introduced in the early 1980s in UK

where the radiographer marks a radiograph (usually

a red dot sticker – thence the name) that he believes

to show an acute abnormality to alert emergency

doctors to the possible presence of an abnormality. If

he is able to identify it correctly, then he can issue a

comment or a report where he would describe the

location, extent and type of the pathology, and its

clinical importance. The aim is to assist emergency

departments (ED) addressing the shortage of

radiologists and is implemented in ED’s where the

radiologist is not always available to issue a

radiography report, leaving the interpretation to the

referring doctors.

The development of digital radiology and Picture

Archiving Systems (PACS) is affecting health

professionals forcing them to evolve along,

reviewing soft copy images on a computer monitor

rather than on radiographic ﬁlm. New questions

have arised about the best way to adapt and

implement RADS with monitor image reviewing,

abnormality signalling and transmission of the

radiographer’s report to the referring doctor

becoming limited by Computed Radiography

systems (Snaith and Hardy, 2008) and the paperless

patient-management systems of today’s hospitals.

The purpose of this article was to review

published articles that evaluate the impact of the use

of a Red Dot System in patient outcome of

emergency trauma patients and assess the

implementation of RADS in a Radiology

Department with digital radiography and (PACS).

508

Coelho J. and Pereira Rodrigues P..

THE RED DOT SYSTEM - Emergency Diagnosis Impact and Digital Radiology Implementation: A Review.

DOI: 10.5220/0003135305080511

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2011), pages 508-511

ISBN: 978-989-8425-34-8

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

2 METHODS

A search of the literature was undertaken using the

PubMed database with relevant keywords, in studies

published since 1999, which resulted in 343 articles.

The included studies addressed the use of Red Dot

(or RADS) with digital radiology and its impact on

emergency patient management. After a title/abstract

analysis, 308 studies were excluded, remaining 35

studies with 11 overlapping resulting in 24 potential

relevant studies. After a full text analysis 6 studies

were found eligible to support this article.

3 RESULTS

The 6 eligible studies for this review assessed the

accuracy of radiographers red dot or reporting, the

costs and effects of introducing radiographer

reporting in ED and the current practice of RADS.

Only one of the eligible articles addressed the effects

of Information Technologies, particularly Computed

Radiology, on the implementation and use of Red

Dot systems or RADS.

3.1 Accuracy of Radiographer’s Red

Dot of Emergency Radiographs

Radovanovic and Armfield, (2005) have found that

the accuracy of untrained radiographers and ED

doctors in identifying abnormal radiographs were

quite similar: 87% and 89%, respectively.

Brealey, Scally, Hahn, Thomas, Godfrey and

Crane (2006) registed a pooled sensitivity and

specificity of radiographer’s red dot for all body

areas of, respectively, 0.88 (CI 0.88–0.90) and 0.91

(CI 0.90–0.92) (Bowman, 1991; Morrison, Hendry,

Fell and Stothard, 1999). One study (Hargreaves and

Mackay, 2003) assessed skeletal red dot without

training with sensitivity and specificity, respectively,

of 0.71 (CI 0.62–0.79) and 0.96 (CI 0.93–0.97); and

with training was 0.81 (CI 0.72–0.87) and 0.95 (CI

0.93–0.97).

3.2 Accuracy of Radiographer’s

Reporting

Radovanovic and Armfield, (2005) found a

correlation between the radiographer’s experience or

seniority, and the accuracy in their identifying

abnormalities. The authors analysed the ability of

radiographers to accurate identify the abnormality

that was noticed and report it, without training, and

calculated it at 85% in one study (Orames, 1997)

and 93% in another one (Smith and Younger, 2002)

(Smith and Younger, 2002).

Brealey, Scally, Hahn, Thomas, Godfrey and

Crane (2006) calculated the pooled sensitivity and

specificity for radiographer reporting of the skeleton

on emergency radiographies in five studies: 0.90 (CI

0.89 – 0.92) and specificity 0.94 (CI 0.93 – 0.94),

respectively, using as reference standard radiologists

of variable grades.

These authors had already published a review

article (Brealey, Scally, Hahn, Thomas, Godfrey and

Coomarasamy, 2005) to determine the accuracy of

radiographer reporting in clinical practice with

summary sensitivity estimate of 92.6% (CI 92.0 –

93.2) and specificity of 97.7% (CI 97.5 – 97.9).

3.3 Implementation of RDS / RADS

and Digital Radiology

Snaith and Hardy (2008) sent a questionnaire to 456

UK sites (ED and minor injuries units), where they

tried to find the main technologic issues regarding

the use and implementation of RDS and RADS.

From the 306 (n=306/456; 74%) responses, a

RADS was in operation in 284 sites (n=284/306;

92.8%), and of these, 221 sites (n=221/284; 77.8%)

operated a red dot scheme; 7 sites (n=7/284; 2.5%)

operated a radiographer comment system; and a

further 54 sites (n=54/284; 19.0%) operated both a

red dot and comment scheme. Two sites (n=2/284;

0.7%) indicated that a RAD system other than red

dot or radiographer commenting was operated, but

no more details were given about the kind of system

used.

There were 275 sites from 306, with a red dot /

reporting system with 21 different methods of

abnormality flagging: the phrase “red dot” annotated

on the computed radiography (CR) (n=83/275;

30.2%); a red dot sticker affixed to the printed

radiograph (n=71/275; 25.8%); and an asterisk (*)

annotated on the CR image (n=43/275; 15.6%).

Other annotation methods were registed.

There were identified 8 different methods of

communicating radiographer findings in the 61 sites

providing written comment on the radiographs (also

operating a red dot system): use of a radiographer

comment form (n=24/61; 41.4%); space for

radiographers to annotate findings on the imaging

request card (n=12/61; 20.7%); and verbal

communication (n=7/61; 12.1%). Other methods

included a note on the PACS system or the

Radiology Information system (RIS); a hand written

post-it note; and a stamp on the request card.

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The implementation of PACS had limited the

functionality of RADS due to incompatibility of new

technology with standard RADS practice and, in

many cases the radiographer’s ability to detect

abnormalities was being interfered by the monitor

quality.

3.4 RADS Costs an Effects on

Emergency Patient Management

The costs and effects of introducing selectively

trained radiographers signalling and reporting on an

ED were evaluated by Brealey, King, Hahn,

Godfrey, Crowe, Bloor, Crane and Longsworth

(2005) for the appendicular skeleton, using a

retrospective controlled before and after design.

They concluded that the “introduction of

radiographer reporting did not have a negative effect

on ED radiograph reporting accuracy, patient

management or outcome” (Brealey, King, Hahn,

Godfrey, Crowe, Bloor, Crane and Longsworth,

2005). This authors analysed a previous study

(Piper, Paterson and Ryan, 1999) were the costs of

introducing radiographer reporting in four UK

National Health Service trusts ranged from nil to

15000£ (approx. 17.200€ ) per annum. Brealey’s

analysis showed that the cost of introducing

radiographer reporting saved the Radiology

Department 361£ (approx. 415€) and further cost

savings could be made as radiographers acquire the

same experience as radiologists and if secretaries

typed the radiographer’s reports.

4 DISCUSSION

The radiographer’s role in trauma has been

traditionally limited to image acquisition, but in

some countries has changed dramatically to include

responsibility for image interpretation. This

evolution is related with the technological advances

and the personnel shortages in some countries health

systems like United Kingdom and Australia. In these

countries radiographers have been taking on some

responsibilities which were previously from the

domain of radiologists. These additional

responsibilities have been termed “role extension” or

“skill-mixed” (Williams, 2006).

Red Dot is about image pattern recognition

which requires a methodical visual analysis and

effort, as opposed to reporting which is an analytical

approach to the percepted image features, with

consequent process of deduction and induction to

understand the pathological basis of the

abnormalities shown and their medical significance

(Brealey, Scally, Hahn, Thomas, Godfrey and Crane,

2006).

There is some evidence about the accuracy of

radiographer’s red dot and report of emergency

radiographs in clinical practice. Radiographer’s

accuracy is affected by body area being the skeletal

area the one with better accuracy results. Also, there

is a similar accuracy in identifying radiographic

abnormalities between untrained radiographers and

ED doctors (Radovanovic and Armfield, 2005) (87%

and 89%, respectively). The investment on a proper

evidence based education and training, like pos-

graduated courses, improves the ability of

radiographers to report on radiographs with accuracy

comparable to radiologists (Brealey, Scally, Hahn,

Thomas, Godfrey and Crane, 2006) (0,93 sensitivity

and 0,98 specificity). This level of accuracy in

clinical practice would only be maintained if a

clinical audit were to be implemented periodically to

assess possible divergences trough time and

maintain quality (Brealey, S., Scally A., Hahn S.,

Thomas N., Godfrey C. and Crane S., 2006).

The reviewed articles suggest that radiographers

commenting on plain radiographs do not adversely

affect patient management or outcome. A Red Dot

or RADS can bring benefit to the patient reducing

the risk of missed abnormalities, thus preventing

misdiagnosis, particularly in ED with less

experienced doctors. These schemes can speed up

the patient care in a busy ED, with benefit to the

patient, providing assistance to ED staff in

departments where a radiologist may not always be

available. The radiographer’s contribution to

emergency reporting has relieved the radiologist’s

workload and led to an increased job satisfaction for

radiographers, enhancing their professional status

and improving relations between them and ED staff.

It has been stated also that when a radiographer has

to provide a comment (diagnosis) from their own

films the quality of their images improve

(Radovanovic and Armfield, 2005).

Despite these advantages, flagging and reporting

schemes may offer some limitations. Red Dot is

limited by the fact that it is only possible to signal

normal from abnormal giving no information about

the characteristics and severity of the image. Thus

this system can supplement a radiologist report but

cannot replace it. There is concern about ED doctors

may end up relying too heavily on the opinion of

radiographers since the absence of a red dot on

radiography does not exclude the possibility of an

abnormality (Brealey, Scally, Hahn, Thomas,

Godfrey and Crane, 2006). Other concerns are the

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staffing shortages, financial issues and difficulties

for radiographers to combine these extra duties with

normal labour. Within the radiographer profession

there are also some concerns: about the possibility of

development of division between radiographers who

report and those who don’t; the fear of increased

pressure is sometimes present; radiologists may feel

threatened by radiographers advancing into areas

previously considered their own (Radovanovic and

Armfield, 2005).

The rapid technological evolution is affecting

radiographers and other health professionals. The

implementation of digital radiography has limited

the functionality of Red Dot and RADS due to

incompatibility of new technology with the standard

practice of RADS (flagging and reporting). The

arrival of Information Technologies (IT) to

healthcare has brought new solutions to old

problems but along with it came some new ones and

limitations, such as need to compensate for the lack

of films trough the hospital with placement of a pc

on each of emergency work rooms for ED doctors

for radiography review. The use of high quality

monitors in every place is not cost effective and,

usually, the option is to go for less expensive and

less quality monitors which sometimes hinder the

correct image review.

The traditional red dot sticker to highlight

abnormal images has been substituted, in Digital

Radiology systems, with the use of image

annotations (e. g. “RED DOT” or “*”, among

others). Since there is no official support for a

radiographer comment on RIS software, the

reporting communication has been limited. The

solution is going back to the paper form or putting a

comment on PACS images.

5 CONCLUSIONS

The use of RADS schemes, such as Red Dot, does

not adversely affect the emergency patient

management and has the potential to improve the

timely and cost-effective diagnosis, outcome and

management of emergency patients. These systems

have become a determinant factor to the contribution

of radiographers to the trauma image review process

and to the management of patients in the ED.

New image technology solutions in Radiology

should enhance the development and utilization of

radiographer skills in RADS environments. The

challenge is to use the new IT solutions in Radiology

and ED to maximize those skills and promote

flexible team work in a multiple disciplinary

healthcare environment.

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