In this scoping review, eight primary studies and one literature review were identified addressing RLD in either ED or MIU at various UK locations. This limited number of studies may in part be due to a low uptake of research activity in radiography in general30.
Differing RLD methodologies were described and those investigating LOS evidenced reductions with RLD, compared to SDC3,9,11,13,23,25,26,27. RLD demonstrated potential to increase clinical assessment capacity for ED staff3,13,27, and therefore staff efficiency11,23,26. This was also true for remote access general practitioners25. RLD was a variable protocol-driven process offering potential of generalisability and widespread implementation31.
Another theme was reduction in image interpretation errors improving recall and re-attendance rates3,23,25. This could improve patient outcome32 and decrease likelihood of litigation33; a key concern of radiographers surveyed24. Radiographer hot reporting has demonstrated cost effectiveness with significant reductions in interpretive errors, compared to ED clinicians34. Therefore RLD cost effectiveness was also likely, combining hot reporting with improved staffing efficiency.
The studies identified positive outcomes, albeit mostly with short time frames3,27 and small sample sizes29. It was important to understand why RLD was not more widely utilised. The concern of litigation has already been identified24. A further consideration was radiography culture, where a less supportive work environment could impede role development35. At non-RLD sites, radiographers surveyed preferred commenting on images to RLD; this was the reverse for RLD active sites24. This could be further explained through resistance by radiographers to change35, or less confidence with an unfamiliar process24. Also, the small number of RLD active radiographers, up to three3 per study was noted. RLD radiographers could be considered champions actively promoting the initiative31, within a supportive culture35. They would have resistance to departmental culture issues through belief in RLD31. Generalisability of RLD28 may therefore be reliant on the presence of champions, rather than a concept accepted by all appropriately qualified radiographers31.
With low RLD radiographer numbers, inconsistent uptake of RLD could be expected3,23. Integration of RLD would require consistent use of the protocol-driven process31 requiring more RLD radiographers. This was implemented following one study which extended RLD service to evenings and weekends23. Pathways of RLD use on different days of the week were also modelled26. With 51% of RLD eligible patients attending ED at the weekend; efficient and potentially cost effective use of RLD could occur on these days26.
Further themes emerged around inter-professional working9,13,25 and radiographer training in discharge3,13,23,24. Radiographers consistently interpreted images more accurately than they expected to7. Therefore, future training emphasis requires focus on discharge3. Given the radiographers’ concern over litigation24, use of protocol-driven pathways and appropriate governance systems2 could encourage engagement.
ED staff could be motivated to support this competency-based training in discharge, once their increased workload capacity was recognised3,13,27. This capacity was through a decrease in the number of clinical assessments required with increased use of RLD26. In addition, ED clinician engagement in protocol development and implementation should reduce the potential of RLD appropriate patients presenting without a management plan3, 31.
Strengths and limitations
This is the first scoping review on RLD utilising a comprehensive searching strategy. As such, there is inclusion of both quantitative outcomes and qualitative content allowing contextualisation of the current RLD evidence base.
Ideally there would have been two reviewers at abstract screening stage and reviewing data extraction stages14. However, the 10% title and abstract check and full text screening produced full agreement between assessors.
The quality of studies was not assessed12,14. Small sample sizes were identified as limitations3,27, with one study having five participants27. Larger sample sizes would have increased the power of the study and therefore likelihood of demonstrating true effect of RLD29. Henderson23 included SD and CI in results, which acknowledged variance of LOS, with patients not discharged within the expected four hours1. This was omitted by other studies therefore variance of waiting times could impact study results29.
Potentially there was a further bias with the focus from the radiographer perspective, despite RLD overlapping with ED25. Knapp et al did include interviews with ED staff and PPI focus group, although extending this to ED based studies would address this13.
The narrative synthesis evidenced areas where further investigation could be considered. Reduced recall and re-attendance3,23 and service streamlining were identified; however financial impact was not explored. Quality-adjusted life-year (QALY) benefits for patients are possible with increased likelihood of receiving the correct treatment at initial presentation32. Hot reporting identified £23.40 saving per patient8, therefore a good rational for extending DES modelling26 to a cost effectiveness study of RLD across radiology and ED. Savings could offset the cost of training and salary increase for radiographers, a motivation for engagement with RLD24. A previous study identified radiographer reporting as more cost effective than radiologists. However, further work was required for implementation of the pathway36. Innovative thinking between radiology and ED would be required to action the cost effectiveness outcome.
The majority of studies focussed on the radiographer role and Henderson et al23 recommended a randomised controlled trial (RCT) as further research. Given the variations in RLD, a cluster RCT with process evaluation would be appropriate to aid fidelity of implementation and give context to outcome variations37,38. This process would include other stakeholders’ perspectives, such as ED staff and patients25. As small sample sizes have been identified as study limitations, this would ensure use of larger sample sizes and therefore should give more power to the study37,38. Alternatively, action research – problem solving and improving practice whilst actively undertaking the discharge role, would be a relevant research method, encompassing all relevant parties38,39.
Emphasis specifically on the discharge element was required, as the innovative element of RLD2. This could be achieved through DES modelling26 of RLD, from the ED perspective, given the evidence of capacity increase3,13,27. Alternatively, a time and motion study – monitoring and timing the specific RLD activities, would identify inefficient areas or give improvement targets40 within the discharge process. This research could directly address the requirement to manage the increasing number of ED and MIU patients3,10,25,26.