IR is playing an ever increasing role in the acute management of pathologies presenting across the clinical specialties both as the primary and secondary line of treatment (Ierardi et al., 2015). Both recent guidelines and standards of practice highlight the importance of having an interventional radiology team who are able to respond to a wide variety of clinical scenarios (Chakraverty et al., 2012; The Royal College of Radiologists, 2017).
With the rapidly expanding healthcare provision across Singapore, including both recent and future planned acute medical hospital openings, a well-trained, dedicated and certified IR team is a necessity for the delivery of first world medical care. Our data, as would be expected for a new hospital has shown a progressive increase in volume of work. In part, however, we suspect the availability of our team has altered the referral pathway and therapeutic regimes of emergency patients, and thus contributed to the increased workload. This is contrary to a recent study spanning 3.5 years across 11 hospitals offering a formal out-of-hours IR service covering a population of 1.2 million that concluded there was no evidence of expansion of demand despite availability (Christie et al., 2013). The increased volume of out-of-hours work, 240% from the 1st compared to the 5th year, arguably impacts the workflow pattern of the on-call interventionalists.
Recommendations are for a minimum of 6 radiologists to provide a comprehensive 24/7 IR service (The Royal College of Radiologists, 2017; Tsetis et al., 2016; The Royal College of Radiologists, 2014), with appropriate provisions for next-day radiology cover in the event of overnight cases, to allow sufficient rest and avoid compromise to patient safety. Our team has grown from a single interventionalist to 4, with a dedicated trained specialist IR nursing and radiography team. As demonstrated by Goltz et al. (Goltz et al., 2014) and in our study, we have managed to provide a 24/7 IR service with 3 first on-call radiologists. This partly reflects the geography of the city state, in which travel to the hospital is manageable within 45 min from most parts of the island, thus allowing an off-site on-call system. However, long-term sustainability based on 3 interventionalists is difficult and networking solutions with nearby units would allow a more healthy rota of 1:6 for a population of < 1 million (Ierardi et al., 2015; Lerner et al., 2014). In addition, a cascade system of workflow led by our specialist trained nurses allows a rapid and smooth patient pathway from point of acceptance of referral by the Interventional Radiologist on-call, to the IR procedure and subsequent discharge back to the clinical team’s care. This may serve as a benchmark for newer units with potentially larger capacity for their expected workload projections and implications of this for their IR teams.
In tandem with the rising volume of cases, we have experienced increasing complexity of interventional procedures requested and performed. The increase in abdominopelvic angiography and embolization procedures reflects our institute’s development of an acute trauma unit and IR’s subsequent role in their management. A fully supportive IR team is critical to avoid the reported differing standards of care and outcome experienced by a patient dependent upon time of presentation to hospital (Schwartz et al., 2014). Despite the relatively few number of interventionalists (4 interventional radiologists vs 23 diagnostic radiologists), it should not impede initiation or continuation of a 24/7 service. In our unit, since the introduction of a two-tier on-call system, > 95% of the cases can be handled by the first on-call interventional radiologist. Only a much smaller percentage of cases require the further expertise of our more seasoned interventionalist.
Our unit has also experienced a greater proportion of the work being performed during the weekends; 40.2% in 2015 compared to 27.1% in 2010. This probably reflects an increasing preferential utilization of IR services during the weekend and, our flexible and responsive action in-hours.
In this study, we included all cases that were started out-of-hours. This therefore did not include any urgent emergency cases performed within regular working hours or those cases extending beyond the regular working day. As we were proposing to study the utility of out-of-hours IR work, cases that may be deemed neither life nor limb threatening were also included such as those that were delayed due to accommodation of emergency cases. Nevertheless, a responsive IR team can undoubtedly benefit patient’s care and overall satisfaction, preventing prolonged in-hospital stays.