09/02/2012 1 Setting up a service Setting up a service Getting training Getting training Anna Gomez, Consultant Radiologist Owen Arthurs, Radiology SpR Addenbrooke’s Hospital, Cambridge BIR meeting, February 2012 Setting up a Service Purpose Background and rationale for change Clinical Evidence Patient Pathway Activity and Income Purpose Provision of a regional service for fetal MR imaging based in Cambridge Ensure provision of a comprehensive fetal medicine service Background Rosie Hospital Comprehensive tertiary level fetal medicine service Currently local patients requiring MR studies referred to Sh ffi ld Sheffield 2012 Rosie Hospital Extension Clinical Evidence Referrals are currently made to confirm or further characterise abnormalities seen on ultrasound CNS CHEST ABDOMEN OTHER
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09/02/2012
1
Setting up a serviceSetting up a serviceg pg pGetting training Getting training
Anna Gomez, Consultant Radiologist
Owen Arthurs, Radiology SpR
Addenbrooke’s Hospital, Cambridge
BIR meeting, February 2012
Setting up a Service
Purpose
Background and rationale for change
Clinical Evidence
Patient Pathway
Activity and Income
Purpose
Provision of a regional service for fetal MR imaging based in Cambridge
Ensure provision of a comprehensive fetal medicine service
Background
Rosie Hospital
Comprehensive tertiary level fetal medicine service
Currently local patients requiring MR studies referred to Sh ffi ldSheffield
2012
Rosie Hospital Extension
Clinical Evidence
Referrals are currently made to confirm or further characterise abnormalities seen on ultrasound
CNS
CHEST
ABDOMEN
OTHER
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Patient Pathway
Current pathway
Referral to Fetal Medicine Department
Sheffield MR
Second Sheffield MR if necessary
Limitations
Distance to Sheffield
Time delay
Fragmented service
Patient Pathway
Current pathway
Referral to Fetal Medicine Department
Sheffield MR
Second Sheffield MR if necessary
Limitations
Distance to Sheffield
Time delay
Fragmented service
Patient Pathway
Proposed Patient Pathway
All fetal MR studies performed in Cambridge
Advantages
Quicker turnaround
Local reporting
Shorter distance for patient
Activity and Income
Activity
2010 – 20 referrals to Sheffield
2012 – 180 patients estimated
Income
Currently funded by research grant
Bid for local funding/case of need
Guidelines ?
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Activity and Income
MR Machines
Currently 4 MR clinical machines on site
1 research machine
Evelyn Trust Grant
Activity and Income
Financial requirements for installing and running MR machine
VERSUS
Undertaking the work on existing MR machines
Activity and Income
Reporting
‐ No on site expertise for sole reporting
‐ 2.4 whole time paediatric radiology consultants
‐ Number of cases versus service provision
Activity and Income
Local scanning and reporting
Double reporting in Sheffield
Advantages
‐ Governance
‐ Training
‐ Part of a network
Getting training ?Getting training ?
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Getting training
• How to train in fetal MRI ?
• UK or abroad ?
• UK – Newcastle, Sheffield, Glasgow
E P i B l Vi• Europe – Paris, Brussels, Vienna,
• Worldwide – Melbourne, US, Canada, Israel ?
Getting training
• How to train in fetal MRI ?
• UK or abroad ?
• UK – Newcastle, Sheffield, Glasgow
E P i B l Vi• Europe – Paris, Brussels, Vienna,
• Worldwide – Melbourne, US, Canada, Israel ?
• Contact Elspeth Whitby
• Spent 1 week in Sheffield
• How to scan, case library, Practical setup, GE imaging
Funding
• 1 year sub‐specialty Paediatric Radiology fellowship e.g. Melbourne
• European School of Radiology, European Society of Paediatric Radiology
• Awards up to 4000 euros for 3 months travel & accommodation
• Training provided for free by host institution
• British Institute of Radiology, GE Fellowship
• Up to £2500 to study abroad, also small fund for medical students
• University of Cambridge travel fund
• Royal College of Radiologists – RCOG ?
• http://www.rdfunding.org.uk/
L’Hopital Robert Debre
L’Hopital Robert Debre
• Women and Childrens Hospital
• 70,000 medical and surgical admissions
• No Accident / Emergency department
• 8 Paediatric Radiologists, cover all – fetal through Neuro
• + several Attaches• + several Attaches
• 2 Chef de Clinique / fellow
• 7 interns / registrars
• Normal workload of 200 – 300 antenatal MRI / year
Studying in France ?
• Language; Radio pediatrique
• IRM – Imagerie de Resonance Magnetique
• Termination laws determine timing of MRI.
• UK – Termination <24 weeks, latest MRI around 22 weeks
• France Termination on request <12 weeks• France – Termination on request <12 weeks
• France – Termination >12 weeks (“at any stage”) if there is serious risk to mother or fetus’ condition is considered incurable following MDT discussion
• Pathology issues – no restriction on keeping / retaining organs, so fetopathological correlation easier than UK, easy to go to back to cases.
• Use of CT
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French practice
• 4 – 8 MRI per week, selected cases, fitted into normal MR lists.
• Biometric data, to confirm ultrasound findings, to look for brain abnormalities.
• Weekly Joint MDT – obstetric led, many other specialties
• Monthly feto‐pathology MDT
• 1 mg maternal flunitrazepam (Rohypnol) for fetal sedation
• 3 plane T2 w FSE imaging, axial, coronal, sagittal
• 3 plane T1 w GRE / FLAIR
• Diffusion sequence, axial (b=700)
• Additional imaging as indicated, e.g. FLAIR
• Repeat sequences with movement artefact
• Body imaging – add Balanced GRE sequence e.g. FIESTA