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Audit of Indications for Plain Abdominal Films from the Emergency Department

Catriona Reid1, Susanne Soin1, Cheng Fang1, Akkib Rafique1

1London North West Healthcare NHS Trust

In 2011, it was noted in a London DGH that many AXRs
RCR guidelines for plain abdominal radiography
requested by the Emergency Department were not
indicated according to RCR iRefer guidelines. • Clinical suspicion of perforation or obstruction
• Acute exacerbation of inflammatory bowel disease
• Palpable mass (specific circumstances)
• Constipation (specific circumstances)
• Acute and chronic pancreatitis
STANDARD • Constipation (specific circumstances)
• Sharp/poisonous foreign body
100% of AXR to meet iRefer guidelines
• Smooth and small foreign body, e.g., coin (specific
• Blunt or stab abdominal injury

METHOD 1st action plan: Educational Poster

This was a retrospective study of all AXRs requested by
the Emergency department over a 4 week period in
November 2011. The indication of the AXR, the result of
the film and whether further images were obtained, were
Attention All Doctors
noted. An intervention was put in place and a re-audit Did you know....?
was completed in December 2014. ONE Abdomen X-ray has an equivalent
dose of radiation as 35 Chest X-rays
AXRs are not indicated for non specific abdominal pain

Examples of inappropriate AXR Recommended indications for AXR:

Clinical suspicion of bowel
RESULTS 1ST ROUND RIF pain ?cause obstruction
173 AXR were requested in 26 days (6.65 per day). Only RUQ pain ?cause
Ingestion of sharp or potentially
poisonous foreign body
59% of X-rays in this audit had an appropriate indication. Epigastric pain ?cause
Missing IUCD
Renal colic
76% were unremarkable and 24% showed abnormal Sepsis ?cause
Post Gastrografin follow through
findings. 40% of patients had further imaging. Abdominal mass

In abdomen pain without clinical

suspicion of bowel obstruction:
AXR is not usually indicated
1ST ACTION PLAN Consider USS, erect CXR, CT KUB or
The radiology department circulated educational posters CT abdomen as first line imaging
throughout the hospital with examples of appropriate modality – please discuss with senior
If AXR requested by surgeons – please
indications. Radiographers now discuss AXR requests if indicate this on request form
they are not indicated according to guidelines and seek
advice from the duty radiologist.
The radiology department will only accept Abdomen X-ray requests for the
above indications and only when the patient is referred from a Consultant
or Registrar.


The audit cycle was completed in December 2014. 54
AXR were requested in 18 days (3 per day). 100% of Results summary
AXR requested were found to be appropriate. We also
found a 55% reduction in number of films requested. As Pre-intervention Post-intervention
before, 75% were unremarkable and 42% of patients percentage of percentage of
went on to have further imaging. films indicated films indicated

59% 100%


reduction in
We continue to ensure posters are in circulation. Our
plan is to re-audit in one year to ensure standards are 55% number of films
maintained as junior doctors rotate through the hospital.
’The use of plain abdominal x rays in the emergency department’, J E Smith and E J Hall, Emerg Med J 2009 26: 160-163

iRefer, Adult guidelines, Gastrointestinal system