Medical Imaging Stream Position Paper · 4 MIS Position Paper 2016-2021 Foreword Medical Imaging is...

Medical Imaging Stream

Position Paper

2017-2022

2 MIS Position Paper 2016-2021

Contents

Contents ............................................................................................................................................................ 2

Abbreviations ..................................................................................................................................................... 3

Foreword ............................................................................................................................................................ 4

Our Community .................................................................................................................................................. 6

The Medical Imaging Stream ............................................................................................................................. 7

Our Patients, Families, Carers and Referring Doctors – safety, equity, efficiency and quality ....................... 11

Our Research .................................................................................................................................................. 13

Our Education .................................................................................................................................................. 16

Our Services .................................................................................................................................................... 17

RPA – Department of Radiology ..................................................................................................................... 19

RPA – Department of PET and Nuclear Medicine (Molecular Imaging) ......................................................... 24

Concord – Department of Radiology ............................................................................................................... 30

Concord – Department of Nuclear Medicine ................................................................................................... 35

Canterbury – Department of Radiology ........................................................................................................... 37

Balmain – Department of Radiology ................................................................................................................ 40

Overview of Priorities ....................................................................................................................................... 40

Medical Imaging Stream Priorities ................................................................................................................... 42

Appendices ...................................................................................................................................................... 44

Appendix 1: Medical Imaging Stream Publications ......................................................................................... 44

Appendix 2: Medical Imaging Stream Grants .................................................................................................. 48

Appendix 3: Developing KPIs in RPA Radiology for: a) CT access time for ED patients and b) access to MR

scans for inpatients .......................................................................................................................................... 49

Appendix 4: RPA Department of PET and Nuclear Medicine Clinical Indicators ............................................ 51


Abbreviations

24/7 24 hours 7 days per week

BH Balmain Hospital

SLHD Sydney Local Health District

CAD Computer-aided Detection

CIs Clinical Indicators

Concord Concord Repatriation General Hospital

CPD Continuing Professional Development

CR Computed Radiography

CT Computed Tomography

ED Emergency Department

Lifehouse Chris O’Brien Lifehouse Comprehensive Cancer Centre

EIR Enterprise Imaging Repository

FDG [18

F]-Fluorodeoxyglucose

FOV Field-of-View

FTE Full-time Equivalent

GMP Good Manufacturing Practice

ICU Intensive Care Unit

KPI Key Performance Indicator

MDT Multidisciplinary Team Meeting

MIS Medical Imaging Stream

MoH Ministry of Health

MR Magnetic Resonance

NM Nuclear Medicine

PACS-RIS Picture Archiving and Communication System - Radiology Information System

PET Positron Emission Tomography

RPA Royal Prince Alfred Hospital

SMILE PACS-RIS for Sydney Local Health District

TCH The Canterbury Hospital

TGA Therapeutic Goods Administration

US Ultrasound


Foreword

Medical Imaging is indispensable to modern medical care and with a few exceptions some type of

imaging procedure is carried out on every inpatient and most outpatients who are treated at SLHD facilities.

Medical Imaging can provide the clinical diagnosis in many cases; assist in treatment planning be it with

medical therapy, surgery or radiation; assess the response or lack of response to different therapies and be

used to directly treat a variety of conditions by stenting or removing clot from critical vessels, obliterate

bleeding aneurysms, treat certain conditions by using radionuclide therapy that is directed to the specific

involved end-organ and deliver chemotherapies directly into tumour vessels. Increasingly Medical Imaging is

able to provide a biomarker of the underlying disease process, which can then be used to identify pre-

symptomatic at-risk groups and determine the efficacy of treatment. Medical Imaging plays and will continue

to play a major role in ‘precision medicine’ where therapy is directed to the specific problem(s) in each

patient.

Medical Imaging continues to advance at a rapid pace and modern biomedical engineering is producing

major advances in hardware and software on a regular basis and usually, although not always, at

considerable expense. Voice recognition software, for example, is relatively inexpensive and can transform

the turn-around-time for medical imaging reports whereas new high end MR, CT and PET-MR scanners

require the investment of several million dollars. Such is the power of medical imaging that many specialties

outside the conventional imaging fields aspire to use these imaging technologies but there can also be a

tendency to rely on an imaging study when simpler approaches may suffice.

Current health systems struggle with rising costs, fragmentation of services, concerns about patient

safety and changing disease demographics. Hence, the cost-effectiveness and the safety and quality of each

new approach should be appropriately and carefully scrutinised. Health professionals have a responsibility to

critically assess the role and use of imaging in patient care rather than introduce a potentially expensive

modality based on a subjective need. Unfortunately, there is not a simple algorithm that can achieve these

goals. Clear, transparent decision-making and priority setting will help to ensure that our health services

have the appropriate tools to provide high quality and safe care. In the Medical Imaging Stream (MIS) we

attempt to address these issues each time new or replacement equipment is sought with an evaluation of the

relative need, benefits, value and costs through a well-structured Business Case and weigh them against

competing technologies, changing models of care and patient needs. Any investment in new imaging

technologies, however, only proceeds after appropriate approval of the relevant Business Case by the

Hospitals, District and NSW Ministry of Health and the identification of the funding for each new device(s).

There are a number of other challenges facing the MIS. There is an increasing need to provide services

where the funding from the Federal Government, via Medicare reimbursement, or direct funding from the

MoH is not available. In some instances these are simple procedures but in other cases they are expensive,

requiring the purchase of additional equipment and possibly involving the use of a number of different

specialties outside medical imaging. The fractionation of the Radiology medical staff, to enable participation

in private Radiology practices, provides the opportunity for more individuals to cover a single position but it

also impacts on the continuity of care. Thus far, the introduction of private radiology practices into public

hospitals has been limited. SLHD has decided to operate its own public Medical Imaging service and as such

is committed to making it work. Importantly, there is a culture across the MIS where our Medical Imaging

Departments have re-invested in major equipment via Departmental Trust Funds. Thus, fees raised from

bulk billing of imaging services, are ‘reinvested into the system’ to replace and introduce new equipment

rather than relying on the general funds from the District or the MoH. Needless to say that such a culture

would be lost with the privatisation of medical imaging services.

In the following pages there is an overview of the individual SLHD Medical Imaging Departments and the

challenges and the priorities for each. These priorities were influenced by the two ‘Medical Imaging Think


Tanks’ that SLHD has held in 2013 and 2015. These forums were designed to explore the areas that are

important to SLHD for clinical care and research; the priorities are divided into operational and investments.

i) Operational priorities:

complete the RPA data migration from the legacy Agfa archive to the new SMILE SLHD PACS-RIS and

transfer Concord / Canterbury / Sydney Dental Hospitals to the SMILE PACS-RIS;

develop consistent, meaningful clinical and performance indicators across the MIS with targeted

reduction in waiting times for scans that affect patient management and patient hospital stay;

increase research within the Medical Imaging Departments;

improve access and workflow for interventional services, including neurointervention, across SLHD but in

particular at RPA where 3 new angiography suites will be installed in late 2016 / early 2017, with

associated increase in recurrent resources so that waiting times are significantly reduced;

explore the use of decision support analytic tools to reduce unnecessary imaging requests;

improve video conferencing / bandwidth to allow remote participation in multidisciplinary teams (MDTs);

install a dedicated interventional simulator to prepare and train staff in the techniques associated with

interventional procedures in the body and the brain;

introduce new PET ligands for clinical care in the neurosciences and cancer;

establish robust internal Morbidity and Mortality meetings for all interventional procedures in

Departments of Radiology across SLHD;

establish mechanisms to evaluate new / emerging endovascular devices and technologies prior to use in

Radiology across SLHD and integrate the purchase of all devices / catheters used in Radiology

intervention into the planned new SLHD device tracking system;

improve procurement processes for major equipment at all levels – Department, Hospital, District and

MoH with relevant KPIs and,

engage widely with SLHD GPs to provide imaging services such as general nuclear medicine and CT

through the HealthPathways program.

ii) Priorities for investment in imaging technologies:

replace analogue fluoroscopy, general X-ray, mobile X-ray, OPG and CR systems with digital technology

and upgrade existing CT at Canterbury;

establish human and pre-clinical PET-MR at RPA;

introduce an additional MR and CT and replace the existing CT at Concord;

replace the analogue general rooms, mobile x-ray devices with digital technology at RPA and install an

interventional CT at Lifehouse;

improve imaging modalities and access to Breast Imaging across SLHD and,

establish PET-CT at Concord.

SLHD has a proud and deserved reputation as a Medical Imaging leader with a number of ‘first-in-

country’ milestones. It is a reputation built on hard work, innovation, imagination, continuous improvement

and dedication to improve the care we deliver to our patients. Nevertheless there are important areas where

we need to improve and new directions that we need to pursue to ensure that we maintain these high

standards.

Professor Michael Fulham

Director of the Department of PET and Nuclear Medicine at RPA,

Clinical Director, Medical Imaging Stream, SLHD


August, 2016.

Our Community

Sydney Local Health District (SLHD) comprises the eight local government areas (LGAs) of Ashfield,

Burwood, Canterbury, City of Sydney (part), Canada Bay, Leichhardt, Marrickville and Strathfield. SLHD

currently has a population of 610,695 (Australian Bureau of Statistics, 2014) and by 2021 the SLHD

population is expected to reach 681,490 and in 2031 it will be 772,370. Figure 1, Figure 2 and Table 1 show

these projected changes. The growth in the aged and the “old-old” population of SLHD is especially

important for healthcare delivery over the next two decades, with a predicted increase of 78.1% in the 70-84

year and 98.9% in the 85+ year age groups.

Figure 1: Map of the SLHD confines and suburbs

Major planned urban developments include the new Green Square development in the City of Sydney,

urban consolidation along Parramatta Road, the Central to Eveleigh rail corridor, the Bays at Rozelle, new

developments in Rhodes, Breakfast Point, the Canterbury rail corridor, and Redfern/Waterloo. In the five

years between 2009 and 2014, the population of SLHD grew by 8% (45,266 people), Canada Bay grew by

15% and Sydney local government areas by 10%.

At the 2011 census, there were 4,875 people who identified as Aboriginal or Torres Strait Islander living

in SLHD and 19% (943 persons) were aged > 50 years. Forty three percent (43%) of SLHD residents also

identified that they spoke a language other than English at home. The population growth and its aged cohort

in SLHD in future years will place significant pressure on health care including medical imaging services.

Figure 2: SLHD population growth 2011-2031

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

2011 ERP 2016 2021 2026 2031

Canterbury (C) +25% growth

Canada Bay (A) +39% growth

Sydney (C) +50% growth

Marrickville (A) +26% growth

Ashfield (A) +23% growth

Strathfield (A) +37% growth

Leichhardt (A) +21% growth

Burwood (A) +39% growth


Source: NSW Department of Planning & Environment Population and Household Projections, 2014 *Sydney South and Sydney West

SLAs only

Table 1: Projected population growth and % change in SLHD from 2011-2031 by age group

Age-Related Projections 0-14 15-44 45-69 70-84 85+ Total

2011 (ERP) 87849 296240 149664 39472 8711 581936

2021 111353 325796 179621 52270 12453 681493

2031 124437 349683 210635 70290 17323 772368

% Change 42 18 41 78 99 33

Source: NSW Department of Planning & Environment Population and Household Projections, 2014

The Medical Imaging Stream

Medical Imaging (MI) is a general term used to describe the production of images of the human body

using a variety of technologies for patient care. MI is an indispensable component of modern healthcare and

some type of imaging is undertaken for the management of virtually every clinical condition, with a few

exceptions. In 2014-2015 over 250,000 scans were carried out across SLHD in the Medical Imaging

Departments. The SLHD Medical Imaging Stream (MIS) comprises the Departments of Radiology at Royal

Prince Alfred (RPA), Concord Repatriation General (Concord - CRGH), Canterbury (The Canterbury Hospital

- TCH) and Balmain Hospitals (Balmain - BH) and the Department of Molecular Imaging (PET and Nuclear

Medicine) at RPA and the Department of Nuclear Medicine at Concord. The Department at BH is managed

through RPA. Each Department has a Director who is a medical officer, a Chief Medical Radiation Scientist

(MRS) and there is a Nurse Unit Manager responsible for nursing staff in the Departments. The Director of

the Radiology at Concord is also the Director at Canterbury.

The imaging services provided by the MIS across SLHD range from plain X-rays and bone scans to

sophisticated imaging using combined imaging devices such as SPECT-CT, PET-CT, Magnetic Resonance

(MR) imaging and complex interventional radiological techniques in the body and the brain that can require

general anaesthesia.

Figure 3: Location of the Medical Imaging Departments across the SLHD

The NSW Ministry of Health (MoH) produce the Guide to the Role Delineation of Clinical Services which

describes the minimum support services, workforce and other requirements for the safe delivery of clinical

services, including Radiology and Nuclear Medicine Services. Level 6 is the highest level of role delineation.

All the Medical Imaging Departments at RPA and Concord are Level 6. Canterbury is a Level 4 Radiology


service which provides general radiography, CT, ultrasound (US) and imaging in operating theatres. At

Balmain there is a Level 3 Radiology service that provides general radiography.

The administration across the MIS is undertaken by the Clinical Director (Professor Michael Fulham),

Business Manager, Clinical Manager, shared with Cancer Services, and the PA for Prof Fulham in his roles

as Clinical Director and Director of the Department in collaboration with the Directors of the Departments.

The key MIS staff are listed in Table 2. Daily Departmental operations are managed by the Director, the

Chief MRS, the NUM or Clinical Nurse Specialists and the senior clinicians.

Table 2: Medical Imaging Stream key staff

Medical Imaging Stream

Clinical Director Professor MJ Fulham Business Manager Mrs A Lang

Clinical Manager Mrs A Lofaro Admin Support Mrs L Stojanovski

RPA

Department of Radiology

Director Dr R Waugh Chief MRS Ms S Jeram

Nurse Unit Manager Ms C McGuinness Admin Ms M Barra

Department of PET & NM

Director Professor MJ Fulham Chief MRS Mrs J Brackenreg

Clinical Nurse Specialist Ms M Nicolas Admin Mrs L Stojanovski

Concord


Director Dr D Rowe Chief MRS (acting) Mr Po Cheng

Nurse Unit Manager Ms D O’Neill Admin Ms J Peck

Department of Nuclear Medicine

Director Dr R Russo Chief MRS Mr C Frater

Nurse Unit Manager Ms D O’Neill Admin Ms R Tassone

Canterbury


Director Dr D Rowe Chief MRS (acting) Mr Steven Jiang

Admin Ms L McDonald

The MIS workforce includes medical specialists, medical radiation scientists (MRS), nursing, scientific,

administration, information technology staff and hospital assistants and is outlined in the Table 3. The MRS

staff (formerly referred to as radiographers and technologists) are the largest component of the workforce.

As part of the new curriculum for Radiology Registrar Trainees there is the development of Training

Networks across NSW. RPA, Concord and Westmead Hospital form the Western Network. The Network will

be responsible for Registrar recruitment and rotations that will include rural and private sites.

Table 3: SLHD Medical Imaging Staff

Clinical Staff RPA

Radiology

RPA

PET & NM

Concord

Radiology

Concord

NM

TCH BH Total

Staff Specialists 16.5 2 11 2 1 0 32.5


Clinical Staff RPA

Radiology

RPA

PET & NM

Concord

Radiology

Concord

NM

TCH BH Total

Visiting Medical Officers 0.7 0 1 0 0 0 1.7

Registrars 18 2 9 1 1 0 31

Medical Radiation Scientists 80.5* 9.2 39.6 6 14.6 1.2 151.1

Nursing 20.9 5 17.7 2 1 0 46.6

Scientific Staff 0 9.4 0 1 0 0 10.4

Hospital Assistants & Workflow Co-ordinators

12.7 0 4.6 0 0 0 17.3

Health Service Managers 1.6 0.9 0 0 0 0 0.9

Administration Officers 24.8 3.8 13.7 2 3 0 47.3

IT Staff 1 0 1.5 1 0.5 0 4

Others 1 0.75 0 0 0 0 1.75

TOTAL 176.1 33.05 98.1 15 21.1 1.2 344.55

Notes: * 8 FTE are seconded: Cardiology (2), Foetal medicine (4), Breast Screen NSW (2); data represent FTE not actual number of

staff

Workforce Challenges

rapid changes in technology: Engineering advances are occurring daily in medical imaging be it new

scanning devices that are more effective, modular and faster, new interventional devices / catheters that

restore blood flow to organs / retrieve blood clots from occluded blood vessels and advances in software

that improve report generation and visualisation. The new skills required to assimilate and then maximise

these advances requires constant new learning / training at all levels in the MIS staff.

provision of services 24 hours a day and 7 days a week (24/7): There is an increasing need to provide

certain services continuously as the provision of care moves to a 24/7 environment. Whilst this is

relatively easy for some services such as plain radiography and CT, it is more problematic as the

modality complexity increases e.g. interventional radiology, MR and PET-CT and additional staff will be

required to provide such services.

fractionation of staff: Increasingly some staff choose to work part-time and this poses major challenges in

rostering and continuity of care; in addition, with the increasing move to sub-specialisation in radiology

the provision of some modalities is then dependent on particular individuals. As an example, there is a

staff establishment of 16.2 Full Time Equivalent (FTE) staff specialists for Radiology at RPA but this FTE

is serviced by 27 staff specialists, only 2 of whom are full-time. Across SLHD there is now a policy of

requiring radiologists to commit to 0.6 of a FTE to help ameliorate this issue.

utilisation of imaging technologies by medical staff outside the imaging disciplines: The importance of

medical imaging to patient care is underscored by the interest of other medical craft groups to expand

their influence to traditional imaging areas such as cardiac imaging and vascular intervention. This is a

global trend. Imaging Departments have the requisite skillset and necessary infrastructure for cost-

effective care delivery but the doctors who previously referred patients now want to undertake, for

example, the therapeutic options offered by interventional radiology. There has not been a single

solution identified for this situation and it continues to pose important challenges for the future.

interventional radiology: Increasingly interventional radiology offers relatively non-invasive methods to

treat complex disorders that previously required major surgery with all the associated complications and

expense. The cases treated with interventional radiology in the body and the brain, however, are


becoming more complicated, some need to be available 24/7 and there is a shortage of skilled

operators.

sonographer shortage: There is a shortage of MRS sonographers in the public health system; private

practices offer higher remuneration and unfortunately at present there are many sonographers who are

trained in the public system but who then choose to practise privately. The solution to this shortage

remains problematic.

Equipment

SLHD has a large inventory of imaging equipment that differs between each site (see Table 4). The MIS

notifies the Federal Government, on an annual basis, of all medical imaging equipment that is used for

Medicare billing and also when a new pieces of equipment is installed or rendered obsolete. The annual

submission is by location of each service and the Departments are identified by a Location Specific Provider

Number (LSPN). It is important to emphasise that the majority of this equipment has been purchased from

internal Departmental Trust Funds rather than from the MoH or grants from the Federal Government. Such

Trust Funds would not be available if a private imaging provider was responsible for delivering imaging

services to the hospitals in SLHD.

Table 4: Imaging modalities available across the different SLHD Imaging Department sites

Radiology Modalities

Site General +

mobile X-ray

US CT MR Breast

Imaging

Fluoroscopy

+ mobile II

Angiography Interventional Procedures

RPA

Concord

TCH

BH

PET and Nuclear Medicine Modalities

Site SPECT SPECT-CT PET-CT Radionuclide

Therapy Gamma Cameras Cyclotron

RPA

Concord

TCH

BH

In the Medicare Benefit Schedule (MBS) there is a Diagnostic Imaging Services Table that lists the

scheduled fees. For the majority of devices there are 2 fees: a) K items refer to studies carried out on newer

or upgraded equipment where 100% of the MBS fee can be charged and b) NK items where approximately

50% of the MBS fee can be charged when the equipment is older or ‘beyond capital sensitivity’. The Federal

Government identifies the recommended ‘useful’ or ‘effective life’ of medical imaging equipment and refers to

it as ‘Capital Sensitivity’. The intention is to ensure that providers of medical imaging equipment provide

relatively up-to-date equipment. In Table 5 the ‘Capital Sensitivity’ ages of common imaging equipment are

outlined.

Table 5: Capital sensitivity for various imaging modalities

Modality Effective Life

(years)

Maximum Extended Life after upgrades

(years)


Modality Effective Life

(years)

Maximum Extended Life after upgrades

(years)

Ultrasound (US) 10 15

Computed Tomography (CT) 10 15

X-ray 15 20

Orthopantomogram (OPG) 15 20

Mammography 10 15

Fluoroscopy 15 20

Nuclear Medicine (excluding PET) 10 15

Magnetic Resonance (MR) 10 20

Angiography 10 15

Accreditation

All Departments participate in the Hospital Accreditation carried out by the Australian Council of

Healthcare Standards (ACHS). There were no non-compliances at the recent ACHS accreditation at RPA in

late 2015 where there were commendations made regarding the use of Clinical Indicators for continuous

improvement in the RPA Department of PET and Nuclear Medicine.

In 2007, the Federal Government introduced the Diagnostic Imaging Accreditation Scheme (DIAS). The

DIAS requires that Departments of Medical Imaging meet the 15 National Safety and Quality Health Services

Standards introduced by the Australian Commission on Safety and Quality in Health Care. The Scheme

mandates that medical and MRS staff are appropriately licensed for the tasks that they undertake and that

equipment is serviced by appropriately trained engineers. The DIAS has a four year cycle. Importantly, DIAS

is linked to Medicare billing and a Department must be accredited to bulk bill the Federal Government for

imaging services. In SLHD all Departments have ‘full-suite’ accreditation.

Therapeutic Goods Administration Licensing

The RPA Department of PET and Nuclear Medicine operates the only public hospital medical cyclotron in

NSW. The medical cyclotron produces the short-lived PET radioisotopes (PET ligands) which are used for

PET-CT scans. The cyclotron was installed in mid-2002 and has produced PET ligands for clinical use since

January 2003. In January 2014, the Department obtained a Good Manufacturing Practice (GMP) license for

the production of PET ligands from the Federal Therapeutic and Goods Administration (TGA). In doing so,

RPA became the first public hospital in Australia to obtain a TGA PET manufacturing license. The TGA

carries out ongoing audits, at short notice, to ensure compliance with the Code. The last audit was in mid-

2015 and the Department performed very well so that the next audit is due in mid-2017. There is also an

annual requirement to report the activities in the cyclotron to the NSW Environmental Protection Authority

(EPA).

Our Patients, Families, Carers and Referring Doctors – safety, equity, efficiency and quality

Our ‘consumers’ are the patients who undergo studies in our Imaging Departments across SLHD and

also our referring doctors who rely on the results of imaging studies to help patient management. The MIS is

committed to providing safe, equitable, timely, appropriate and high quality care to the patients, their families

and carers in SLHD and also to those patients who are referred from outside our District. Such an approach

requires that: our staff are appropriately credentialed and trained; our imaging equipment is safe and well


maintained; the modalities are tailored to the individual patient and the performance of the various imaging

tests is based on reliable evidence; there is sound leadership and governance of the activities of the Stream.

Our referring doctors have a need for fast, accurate and reliable results using the best available

technologies.


Our Research

Research and education can enhance all aspects of clinical care and medical imaging. Most imaging-

related research in the Stream is undertaken in collaboration with other Departments as Imaging

Departments tend not to have their ‘own patients’ such as cardiology, neurology, thoracic surgery etc.

Further, Imaging Departments often have limited time to perform their own research. Hence, most of the

current research activity relates to imaging studies done on behalf of other investigators in the clinical trial

setting. Nevertheless, the MIS does do meaningful and relevant research and it is committed to improving its

research output and increasing the contribution to knowledge and understanding. The following section

outlines the major research activities of each Department.

The Medical Imaging Stream publications and grants are listed at Appendices 1 and 2.

RPA - Department of Radiology

The Department participates in 13 clinical trials listed below in Table 6 and there is one study underway

that is led by staff in Radiology.

Table 6: RPA Department of Radiology current Clinical Trials

Study Name Clinical Area Imaging

1 E5501 Gastroenterology US ± CT/MR

2 MPM MR Oncology MR

3 X14-0091 Rheumatology X-ray

4 MISSTIE III Neurology / Neurosurgery CT and MR

5 X15-00037 3921187 Rheumatology CXR

6 ABX203-002 Gastroenterology US

7 NGM 15-0105 Gastroenterology Liver Biopsy, MR

8 M14-868 Gastroenterology Liver Biopsy, US, CT/MR

9 MK-3475-048 Oncology CT

10 ALCYONE Oncology CXR

11 GS-US-337-1431 Gastroenterology Liver Biopsy (US or CT)

12 X15-0040 Rheumatology X-ray

13 Ovista 3007 Rheumatology X-ray

Table 7: Other Research Studies within the Department

Study Name Imaging

1 Prognostic parameters in pulmonary hypertension MR

RPA - Department of PET and Nuclear Medicine (Molecular Imaging)

The Department participates in a number of clinical trials on behalf of a number of other Departments in

SLHD and also other research centres in Sydney (see Table 8). The Department has been a ‘Core’ Imaging

lab for some of the national and international Haematology clinical trials. It also has a track record of

performing basic science, animal, clinical and translational research and has success in obtaining funding

from peak grant bodies.

The Department performed the first randomised controlled trial of an imaging modality in Australia in


1999-2000 and this work was pivotal in obtaining Medicare funding for lung cancer PET scans. The key

areas of research interest are in: patterns of disease / disease mapping; dementia; epilepsy; brain tumours;

the lymphomas; prostate and pancreatic cancer; improved image visualisation; content based image retrieval

and managing ‘big’ imaging data. Staff are developing new PET ligands for the evaluation of tau and B-

amyloid deposition and inflammation in neurodegenerative diseases; and 68Gallium-labelled ligands for

neuroendocrine tumours and prostate cancer. Autoradiography facilities have been set up to complement the

work being undertaken in basic science with new PET ligands. There are 40 active research studies – 30

clinical trials and 10 other research projects including 2 animal research studies. In the international

dementia study (DIAN-TU), which is a treatment trial in patients with dominantly inherited Alzheimer’s

disease the Department manufactures the PET ligands. The Department has successful research

collaborations with individuals and groups including: the Faculty of Engineering and IT at the University of

Sydney (USyd); the School of Chemistry and the Faculty of Pharmacology at USyd; the Lowy Cancer

Research Centre and School of Chemistry at the University of New South Wales (UNSW); the School of

Chemistry at the University of Wollongong; Macquarie University (School of Advanced Medicine); the Brain

and Mind and Centre at USyd; Neuroscience Research Australia (NeuRA) at UNSW; Sendai / Chiba /

Tohoku Universities in Japan; the National Polytechnic University in Xi’an and Shanghai Jiao Tong University

in China.

Table 8: RPA Department of PET and Nuclear Medicine current Clinical Trials

Study Name Clinical Area Tracer Imaging

1 DIAN-TU-001 International dementia trial 18

F-FDG/11

C-PiB/18

F-AV-45/18

F-AV-1451 PET-CT

2 BO21223 Haematology 18

F-FDG

PET-CT

3 BO29337 Haematology 18

F-FDG PET-CT

4 C16020 Haematology 18

F-FDG PET-CT

5 C25001 Haematology 18

F-FDG PET-CT

6 GO27878 Haematology 18

F-FDG PET-CT

7 CCTL019C2201 Haematology 18

F-FDG PET-CT

8 ALLG NHL25 Haematology 18

F-FDG PET-CT

9 MK3475-087 Haematology 18

F-FDG PET-CT


F-FDG PET-CT


F-FDG PET-CT


F-FDG PET-CT

13 PCI-32765DBL3001 Haematology 18

F-FDG PET-CT

14 PCI-32765FLR2002 Haematology 18

F-FDG PET-CT

15 PCI-32765MCL3002 Haematology 18

F-FDG PET-CT

16 SGN35-014 Haematology 18

F-FDG PET-CT

17 ACE-LY-004 Haematology 18

F-FDG

PET-CT

18 ASSG11 Oncology 18

F-FDG PET-CT

19 ASSG21 Oncology 18

F-FDG PET-CT

20 CBKM120F2203 Oncology 18

F-FDG PET-CT

21 MesomiR 1 Oncology 18

F-FDG PET-CT

22 PENAO-01 Oncology 18

F-FDG PET-CT

23 SGH-RT-UGI-001 Radiation Oncology 18

F-FDG PET-CT

24 TROG 09.03 Oncology 18

F-FDG PET-CT

25 ANZGOG 0902 Oncology 18

F-FDG PET-CT

26 BAY 73-4506/15982 Gastroenterology 99m

Tc-MDP Bone Scan

27 XL184-309 Gastroenterology 99m

Tc-MDP Bone Scan


28 CA209-459 Gastroenterology 99m

Tc-MDP

Bone Scan

29 AG-221-AML-004 Haematology 99m

Tc-ULTRATAG GHPS

30 CFZ014 Haematology 99m

Tc-ULTRATAG GHPS


Study Name Tracer Imaging

1 Best evidence to best practice: Implementing an innovative model of care for nutritional management of patients with head and neck cancer

18F-FDG PET-CT

2 Toward patient centered care: A medical image viewer with voice recognition and automated image navigation

All PET-CT PET-CT

3 A retrospective review of the correlation of maximum Standard Uptake Value with histopathological subtype and clinical endpoints in the primary staging of lymphoma

18F-FDG PET-CT

4 Impact of PET on the staging of mesothelioma and effect of talc pleurodesis on FDG uptake

18F-FDG PET-CT

5 Imaging β-amyloid burden and neuroinflammation in the brain of non-human primates

18F-FDG /

11C-PiB PET-CT

6 The metabolic signature of C9orf72-related FTD, MND and

FTD-MND: FDG PET-CT comparison with C9orf72-negative cases

18F-FDG PET-CT

7 In vivo markers of disease activity in motor neuron disorders - linking structure to function

18F-FDG PET-CT

8 Development of PBR170 for imaging neuroinflammation PBR170 PET-CT

9 An exploration of the mechanism of the Olfactory Stress Test: A pilot study

18F-FDG /

11C-PiB PET-CT

10 New prostate cancer imaging agents in mouse models of disease PBR316/PBR111/

PBR310/PBR170/PBR132

microPET-CT

Concord - Department of Radiology

The Department currently provides imaging for 17 clinical trials. There is a small amount of research

generated by radiology trainees internally due to the inclusion of research in the college curriculum. The

Department currently employs a part time research assistant from Trust Funds and it is anticipated, research

will increase in line with increased clinical activity.

Table 10: Concord Department of Radiology current Clinical Trials


1 PREVAIL Oncology CT

2 GALLIUM Haematology CT

3 THELO Exercise & Sport Science X-ray

4 ASTELLAS Oncology CT

5 SHINE Haematology CT / MR

6 IMPROVE Renal CT

7 CAM MS Study Neurology MR

8 YO28252 Oncology CT

9 Alisertib Haematology CT

10 GO27878 Haematology CT

11 MK3475-087 Haematology CT

12 ALLG NHL27 Haematology CT


13 BIBF 1120 / Lume Colon 1 Gastroenterology CT

14 GO29436 Oncology CT

15 ALLG NHL29 Haematology CT

16 PHOENIX Haematology CT

Concord - Department of Nuclear Medicine

The Department is involved in a portfolio of research activities that include the Clinical Trials listed in

Table 11 and other Departmental projects listed in Table 12. The Department believes that it is restricted in

the research projects it can undertake and would do more research if an onsite PET scanner was available.

Table 11: Concord Department of Nuclear Medicine current Clinical Trials


1 ZIPP Endocrine Bone Scan

2 ENZAMET Medical Oncology Bone Scan

3 PROSPER Medical Oncology Bone Scan

4 MesomiR1 Medical Oncology Stress MIBI

5 PLATO Medical Oncology Bone Scan

6 EMBRCA Medical Oncology Bone Scan

7 PREVAIL Medical Oncology Bone Scan


Study Name

1 ARS: geometric centre analysis of colonic transit measurements in patients with sub-total colectomy

2 Adjuvant intra-arterial Iodine 131 Lipiodol following sugery for hepatocellular carcinoma: a single centre experience

3 Retrospective review of Yttrium synovectomies in relation to outcome and complications for comparison to current literature

4 Velocity estimation for mucociliary transit studies using purpose written software

5 Evaluate the benefit of SPECT/CT to planar imaging following yttrium synovectomy and progress

6 Evaluation of the distribution of active osteoarthritis in the cervical spine

7 Quantitation of thyroid uptake post I-131 Lipiodol therapy

Our Education

Education supports accreditation, professional registration, professional development, career

development, staff recruitment / retention and the provision of high quality care. All MRSs are registered with

the Australian Health Practitioner Regulation Agency (AHPRA) and are required to accrue 60 hours of

Continuing Professional Development (CPD) activity over a three-year period. All Departments conduct

clinical training programs for undergraduate MRSs. Each year new graduates are employed under the

supervised practice program (SPP). Nursing staff are similarly registered with AHPRA. The Nursing and

Midwifery Board of Australia requires that all nurses on the register, participate in at least 20 hours of

continuing nursing professional development. Senior medical staff, if Physicians, participate in the Royal

Australasian College of Physicians (RACP) Continuing Professional Development (CPD) program called

MyCPD, where reporting is required annually; if Radiologists, they participate in the Royal Australian and

New Zealand College of Radiologists (RANZCR) Clinical Radiology CPD program, which is a three year

cycle grouped into seven categories. The Departments of Radiology at RPA and Concord are accredited

with the RANZCR for radiology training for junior medical staff. In 2016-2017, Radiology Training networks


will come into effect and RPA, Concord and Westmead will form the Western Radiology Network. The

Department of Nuclear Medicine at Concord is accredited for advanced training in Nuclear Medicine and the

Department of PET and Nuclear medicine at RPA is accredited for training in PET-CT.

All Departments participate in Multidisciplinary Team Meetings (MDTs), which are held weekly throughout

the major Hospitals. Imaging is a particularly important component of these MDTs and there is a

considerable amount of time required to prepare the cases for these meetings. This time commitment is

particularly onerous for the Departments of Radiology in SLHD given the complexity of care that is provided

and the number of sub-specialty groups that conduct MDTs. In conjunction with the Agency for Clinical

Innovation (ACI) and RANZCR, the RPA Department of Radiology supports quarterly conference education

evenings for radiologists, radiographers and nurses which are videoed and distributed throughout the state.

The Department of PET and Nuclear Medicine holds annual tutorials for University of Sydney

undergraduates from the Faculty of Engineering and Information Technology to expose them to the value of

Bioinformatics in modern healthcare. The Department is actively involved in teaching and academic

supervision of medical professionals, university students and postdoctoral fellows. The Department of

Nuclear Medicine at Concord hosts a monthly journal club for NM scientists and Physicians and also runs

laser operator safety training.

Our Services

Changing Models and Delivery of Care

Advances in all facets of medical and surgical care have an impact on medical imaging services but the

contrary also applies and advances in engineering in the medical field can have major and disruptive flow-on

effects on the daily delivery of medical and surgical care across SLHD. All such changes have cost

implications and so not all such advances can be readily implemented. It is not the intention of this paper to

provide an exhaustive list of these changes but some general examples are listed below:

Imaging ‘signatures’ (or biomarkers) of particular diseases will provide important diagnostic and

prognostic information for example in cancer, cardiovascular disease and the neurosciences, some of

which are not currently treatable (Alzheimer’s disease).

The increasing use of CT and MR in clinical cardiology and cardiothoracic surgery will alter the triaging

of patients with heart disease and modalities such as echocardiography and general nuclear medicine

cardiac studies will be less required.

The ability to restore neurological function and reduce the morbidity of stroke by the acute removal of

blood clots in cerebral blood vessels using neuroradiological interventional techniques is a major

advance in care. It requires the rapid co-ordination of multiple teams from ambulance services,

Emergency Department staff, neurology (medical and nursing), anaesthetics, radiological (medical,

MRS, nursing) staff with flow-on effects to hospital and ICU beds as the time-window for effective

intervention is short and so other procedures may need to be postponed.

An ability to categorise specific diseases by the expression of specific proteins has led to new insights

about therapy and increasingly treatments are being directed to critical subcomponents that drive the

disease. Radionuclide therapy that is directed to a particular cell type will be more widely used in the

future for example in the treatment of different tumour types.

The marked increase of patients with chronic liver disease in SLHD and advances in the delivery of local

liver therapies has led to an increasing number of radiological interventions to manage the ensuing

complications of chronic liver disease.


The assessment of response to various therapies is increasingly reliant on medical imaging whether it be

a patient with Multiple Sclerosis who has regular MR scans, a patient with a Lymphoma who has regular

PET-CT scans or a patient with a lung cancer where treatment decisions depend on the results of the

imaging test.

Studies performed

The imaging studies carried out in SLHD vary markedly in complexity and simplicity. At one end of the

spectrum a plain X-ray of the chest is done in what seems like less than a second and many (66-67%, for

RPA and Concord) of studies done in Radiology are such plain radiographic examinations. Digital technology

now makes this process even simpler. A CT of the torso can now be done in less than a minute; an US of

the abdomen may take 30 minutes to be performed but a procedure to embolise a tumour in the adrenal

gland may take 3 hours or more. General nuclear medicine and PET studies typically take much longer to

perform with longer data acquisition times on the scanners e.g. a nuclear cardiac stress scan can take up to

4 hours with delayed imaging; a routine PET-CT scan can take 20 minutes of scan time but the patient is

injected with the PET tracer 60 minutes before the patient is then placed on the scanning bed. More details

of the studies performed in each Department are provided in the following pages but as a general overview

there were over 260,000 studies done across the SLHD in 2014-15 (see Table 13 below).

Table 13: SLHD Medical Imaging studies 2014-2015 by site

Site Number of Studies

Radiology RPA 128597

Concord 79383

Canterbury 36033

Balmain 2024

PET-CT RPA 10670

General Nuclear Medicine

RPA 1536

Concord 3385

Total 261628

PACS-RIS (Picture Archiving and Communication Systems – Radiology Information Sytems)

The first enterprise-focussed PACS in the country was installed at RPA in 2001. It provided images to

clinicians when and where they were required and it was a ‘revolution’ in the provision of care. The District

then implemented the State-wide rollout of the GE PACS-RIS in an incremental fashion. The RIS supplies

the data intensive backbone to tie patient demographic data to the patients’ images including patient reports,

unique identifying information, billing data and any alerts. The roll-out began in the former Sydney South

West Area Health Service (SSWAHS) and the PACS-RIS was then shared between South West Sydney

LHD and SLHD. SLHD decided to implement its own PACS-RIS that has become to be known by the

acronym SMILE. The implementation of SMILE, which went ‘live’ in September 2013 necessitated the

migration of the image data from the original Agfa PACS that was installed in 2001 at RPA. This data

migration has not been without issues and is still proceeding. Concord, Canterbury and some Sydney Dental

Hospital (SDH) images are on the original SSWAHS system and now need to be migrated to SMILE. This

migration is due to commence in the near future and is planned to be completed in May 2017. This project is

a critical focus for the MIS and has important cost considerations.


RPA – Department of Radiology

The Department provides a comprehensive diagnostic, interventional and consultative service for patients

and referring doctors. Over 128,597 studies were done in 2014-2015. The Department has an establishment

of 177.29 FTE staff. Of these, 8 FTE MRSs are rostered to the Departments of Cardiology, BreastScreen

NSW and the Women’s and Babies Foetal US service. The associated activity in these areas is not included

in the Radiology statistics. A radiology trainee Registrar is on site 24/7 providing image interpretation and

support for CT scans that are performed out of hours and there is minimum of 3 MRSs on duty. When

compared to Concord Radiology there is an important difference in relation to the fractionation of the staff

specialists. At RPA there is an establishment of 16.2 FTE staff specialists and this 16.2 is serviced by 27

radiologists, only 2 of which are full-time. Whilst this provides a variety of skills when a service is 24/7 there

are inevitable gaps, interruptions to the continuity of care and problems with rostering. The imaging

modalities are available 24/7 with the exception of breast imaging. There have been a number of recent

major equipment purchases for the Department. Procurement processes have been completed for the

replacement of 2 of the 3 CT scanners in the Main Department (the 16- and 64-slice scanners) and they will

be installed in the latter half of 2016. Procurement has also been completed for 3 new angiography suites (2

replacements and 1 new additional suite) in the Main Department with 2 single and 1 biplane device. These

devices will be installed in late 2016; the biplane device will be particularly valuable for complex neuro-

interventional studies.

The Imaging services are distributed across the RPA campus and on both sides of Missenden Road

where imaging is provided for Lifehouse. The locations are as follows:

The Main Department in the Clinical Services Building;

Institute of Rheumatology and Orthopaedics (IRO) - inpatients and outpatients;

RPA Medical Centre - for the pre-admission clinic;

Lifehouse - inpatients and outpatients and,

Operating Theatres - hybrid theatre, intraoperative MR and Image Intensifier (II) services.

Studies Performed

The different types of studies that were carried out in 2014-2015 are shown in Table 14. General X-ray,

which has low complexity, very short scan duration and high throughput represents 67% of the overall

workload. Digital, rather than analogue, plain radiography will improve patient throughput, image quality and

also reduce the radiation exposure. In late 2013, the Lifehouse imaging service, provided by RPA, was

commissioned with a CT, general radiography, fluoroscopy, mammography, mobile X-ray, mobile II and US.

Table 14: RPA Department of Radiology studies 2014-2015

Study Type #

X-ray 81534

MR 6787

CT - diagnostic 20637

CT - interventional 843

Interventional Radiology 2483

Fluoroscopy + Operating Theatres 5237


Study Type #

US - diagnostic 8803

US - interventional 511

Mammography 1762

Total 128597

CT

CT studies have increased by 39% over the past 3 years (see Figure 4) and this is expected to increase

further with the installation of the 2 new CT scanners that will replace the older and slower 16- and 64-slice

scanners later in 2016. These new scanners will be faster, more versatile and will be valuable for the

expanding roles of CT in cardiac disease and stroke.

Figure 4: RPA Department of Radiology CT studies 2012-2015

MR Imaging

A 3Tesla (T) MR scanner was commissioned in September 2013. There are existing 1.5T scanners in

the main Department and in the Operating Theatres. The intraoperative MR is one of only a few scanners in

Australia and it is used to guide neurosurgical tumour resections. The Departmental 1.5T MR scanner

operates 7 days a week from 7am – 8pm Monday – Friday and 8.30am – 4.30pm weekends and mainly

scans outpatients. The 3T scanner operates 5 days a week 8am – 6pm and is used for inpatients and for

research studies. Since the installation of the 2nd

MR scanner there has been a 36% increase in the number

of MR studies (see Figure 5).

0

5000

10000

15000

20000

25000

ED and Ward Patients Outpatient Total

CT Exams per year 2012-2013




Figure 5: RPA Department of Radiology MR studies 2012-2015

Notes: 2nd

MR installed in Sept 2013

Breast Imaging

Breast services - diagnostic mammography, US imaging, interventional procedures (hookwires, biopsies

and mammotomes) - are provided at Lifehouse. The service operates Tuesday – Thursday and the number

of studies is shown in Figure 6. The demand for breast imaging has increased markedly since Lifehouse

became operational. The Department participates in voluntary RANZCR Annual Mammography Facility

Accreditation where the objective is to produce consistent, high quality breast images.

Figure 6: RPA Department of Radiology Breast Imaging 2014-2015

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Hookwire Mammogram Mammatone US - bilateral US - unilateral US - hookwire US - biopsy

2014

2015

0

1000

2000

3000

4000

5000

6000

7000

8000

ED Ward Outpatient Total

2012 - 2013

2013 - 2014

2014 - 2015


Interventional Radiology

The Department has particular expertise in the provision of complex diagnostic and interventional

radiology. Dr Waugh leads the interventional team; he has vast experience and super-specialised skills in

intervention. The demand for this technology is continuing to increase and later this year, 3 new angiography

suites will be installed – 2 single plane and 1 biplane device. The installation of the new interventional rooms

will also see a change in workflow in the Department; the rooms and the workflow will be ‘re-designed’ to

focus on the patient rather than the type of procedure being undertaken thus allowing the needs of the

patient to dictate when the procedure is done rather than the current historical situation where there is a

‘body room’ and a ‘neuro room’. In addition, the changed workflow will also include the commencement of an

intra-Departmental Interventional Morbidity and Mortality meeting where all procedures undertaken in the 3

new rooms will be discussed. Further, a device to ‘simulate’ intervention is planned for purchase to assist the

up skilling of staff and Radiology Registrar trainees.

Equipment

The location and age of RPA imaging equipment is outlined in Table 15. The 16- and 64-slice CT

scanners will both have been replaced by September 2016. Fluoroscopy in the Main Department fluoroscopy

is restricted due to the age of the current equipment.

Table 15: RPA Department of Radiology imaging devices

Item Number Location Equipment Age

0 - <5 years

5 - <10 years

10 - <15 years

>15 years

MR 1.5 T 2 Main Department x 1; OT x 1 1 1

MR 3 T 1 Main Department x 1 1

CT 16-slice 1 Main Department interventional scanner x 1

1

CT 128-slice 2 Main Department x1; Lifehouse x 1 2

CT 256-slice 1 Main Department x 1 1

Angiography 4

Main Department single plane x 2, dual plane x 1;

Hybrid Lab - OT x 1

1 2 1

General X-Ray Analogue 5 IRO x 1; Main Department x 3; Medical Centre x 1

1 2 2

General X-Ray Digital 2 Lifehouse x 1; IRO x 1 2

General X-Ray OPG 2 Main Department x 1; IRO x 1 2

General X-Ray Tomography 1 Main Department x 1 1

Mobile X-Ray Analogue 9 IRO x 1; Wards x 8 9

Mobile X-Ray Digital 4 Lifehouse x 1; ICU x 2; ED x 1 4

Fluoroscopy (analogue) 1 Main Department x 1 1

Fluoroscopy + DR System 1 Lifehouse x 1 1

Fluoroscopy Mobile II 6 Lifehouse x 1; IRO x 1; OT x 4 2 3 1

US (diagnostic) 6 Main Department x 3; Lifehouse x 1; Lifehouse Breast Imaging x 2

3 3

US (small interventional) 3 Lifehouse x 1; Main Department x 2 3



0 - <5 years

5 - <10 years

10 - <15 years

>15 years

Mammography (digital) 2 Lifehouse Breast Imaging x 2 1 1

Prone Biopsy Table 1 Lifehouse Breast Imaging x 1 1

Abbreviations: IRO = Insitute of Rheumatology and Orthopaedics; ICU = Intensive Care Unit; ED = Emergency Department; DR =

Digital Radiography; OT = Operating Theatres

Expansion within the Main Department is restricted due to space constraints. Capacity for an

interventional suite, US, MR and an additional CT imaging room exists within the Lifehouse imaging area

should additional services be required. General rooms and mobile equipment need replacement, as does the

Department’s fluoroscopy system.

Performance Indicators

With the commencement of services in Lifehouse, Key Performance Indicators (KPIs) have been

collected; these are listed in Table 16 below. RPA continues to meet or exceed these KPIs. Additional KPIs

under development are the CT access time for ED patients to CT and the access to MR scans for inpatients.

These are shown in Appendix 3.

Table 16: RPA Lifehouse KPIs 2014-2015

KPI Total Achieved Percentage Target

SLHD to provide written reports for routine cases within 8 hours of the procedure being conducted

7957 7078 89 80%

Each booked X-ray procedure or imaging to be performed within 60 minutes of scheduled appointment time

8578 7904 92 75%

Each booked non-urgent CT scan to be carried out within 5 Business Days of the request being made

873 770 88 75%

Each booked urgent CT scan to be carried out within 1 Business Day of the request being made

252 252 99 75%

Each booked non-urgent US scan to be carried out within 5 Business Days of the request being made

108 98 91 75%

Each booked urgent US scan to be carried out within 1 Business Day of the request being made

31 30 97 75%

Each booked non-urgent MR to be carried out within 15 Business Days of the request being made

278 241 87 80%

Each booked urgent MR to be carried out within 1 Business Day of the request being made

42 39 93 80%

Each booked semi-urgent mammography and US procedure to be carried out within 10 Business Days of the request being made

378 378 100 75%

Each booked initial diagnosis biopsy procedure to be carried out within 10 Business Days of the request being made

128 125 98 75%

Each booked therapeutic interventional procedure to be carried out within 2 Business Days of the request being made

67 66 99 75%

Each booked elective interventional procedures (including portocath insertions) to be carried out within 10 Business Days of the request being made

190 186 98 75%


Challenges

Managing waiting times within clinically appropriate times for MR, CT and interventional cases;

Integration of Lifehouse patients into the RPA RIS when they attend for interventional, MR and out of

hour procedures;

Meeting KPIs for Lifehouse activity;

Maintaining staff establishment and,

Managing requests for studies that may not be appropriate / indicated.

Priorities

Initiation of Lean program in imaging to improve patient flow and reduce waiting times;

Replacement of mammography unit, fluoroscopy suite, general X-ray and mobile systems and an

interventional CT in Lifehouse and;

Installation of a dedicated interventional simulator to prepare and train staff in the techniques associated

with interventional procedures in the body and the brain.

RPA – Department of PET and Nuclear Medicine (Molecular Imaging)

The Department performs general Nuclear Medicine (NM), specialised PET-CT studies and also

operates a Medical Cyclotron with associated radiochemistry production and QC laboratories. The cyclotron,

produces the short-lived PET radioisotopes (PET ligands) that are used in PET-CT scans. RPA was one of

the first NM Departments and had one of the first PET scanners in Australia. General NM is still mainly used

in heart disease with the assessment of cardiac viability and function, bone disease, lung conditions and

thyroid disorders although other procedures are performed for virtually any organ in the body.

The combined PET-CT scanner revolutionised clinical diagnosis and markedly improved patient

throughput. PET-CT technology has continued to advance. The Department has performed more than

81,000 PET and PET-CT patient studies as of June 2016, which is the largest experience in Australia and

one of the largest in the world. The Department operates the only cyclotron in a public hospital in NSW. It

was installed in mid-2002 and in January 2003 produced PET ligands for use at RPA; distribution to other

sites began soon after and RPA now has a State-wide role in the provision of PET ligands. In January 2014,

the Department obtained a PET GMP manufacturing license from the TGA and in doing so became the first

public hospital cyclotron site in Australia to obtain a TGA license. The Department has a strong basic and

clinical research program and has been developing new PET tracers for basic and clinical research with a

specific focus on dementia and prostate cancer. The Department has 33.15 FTE staff. The Director of the

Department is also the SLHD Clinical Director of the MIS. Daily nursing operational activities are co-

ordinated by the Clinical Nurse Specialist who reports to the NUM in Radiology. The scientific workforce,

who operate the cyclotron, includes radiochemists, physicists, hospital scientists and a radiation safety

officer (RSO) who also has a hospital-wide role.

Studies Performed

From 1 July 2014 to 30 June 2015, nearly 7000 patients were scanned; 78% were outpatients, 17%

were inpatients and 5% were patients from other hospitals; 5335 were PET-CT patients.


General Nuclear Medicine

The number and diversity of the general NM studies done in the Department are listed in Table 17. The

table reflects the emphasis on cardiac scans. Additional services are listed in Table 18; these comprise

physician consultations, radionuclide therapy studies (mainly for treating thyroid disorders) and ECGs that

are done with the cardiac scans. Figure 7 outlines the trend in the number of general NM studies done from

2008 and it shows the steady decline in the number of scans. The explanation for these findings include the

proliferation of private NM practices adjacent to RPA where the simpler, more straightforward scans are

done, the advent of competing technologies, in particular, CT in the evaluation of suspected pulmonary

emboli and heart disease and the lack of a SPECT-CT scanner at RPA. This latter was remedied with the

commissioning of a new 16-slice SPECT-CT in January 2016 and a program is underway to increase patient

referrals.

Table 17: RPA Department of PET and Nuclear Medicine – general NM studies 2014-2015

Study Type #

Adrenal 6

Biliary 2

Bone 427

Brain (epilepsy) 14

Cardiac - GHPS 245

Cardiac - Shunt 1

Cardiac - Sestamibi 462

CSF Flow 14

Dacro (Tear Duct) 16

Gallium 47

GI Bleed 1

GMT (Gastric Emptying) 25

Iodine Whole Body Scan 45

Lung (VQ) 76

Lung Quantitation (Diff) 1

Lymph (Flow) 1

Marrow (Bone) 2

Meckels 1

Octreotide 2

Parathyroid 15

Pleuro-Peritoneal Fistula 1

Renal 77

Renal GFR 28

Salivary 3

Thyroid (Uptake) 18

WBC 6

Total 1536

Note: no SPECT-CT scanner


0

500

1000

1500

2000

2500

3000

2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er

of

Stu

die

s

General Nuclear Medicine Patient Studies

Table 18: RPA Department of PET and Nuclear Medicine – other general NM services 2014-2015

Other Services #

Ablation Therapy (Cancer) 45

Thyroid Therapy (Thyrotoxicosis) 1

Consults 52

ECG 447

Total 545

Figure 7: RPA Department of PET and Nuclear Medicine – general NM studies 2008-2015

PET-CT

In 2015, 5628 PET-CT patients were scanned with patients attending from throughout NSW and the

near-Pacific region. In Table 19, the number and sub-types of PET-CT scans are summarised. These were

predominantly FDG whole body scans for staging and restaging malignancy. Neurological scans are done

for patients with recurrent primary brain tumours, refractory epilepsy and those suspected of having a

neurodegenerative disease. Although cardiac viability studies were thought to be one of the mainstays of

PET when it was first introduced, these studies have essentially ceased and comprise 1% of all PET-CT

scans; this reduction was compounded by the Federal Government withdrawing Medicare reimbursement for

cardiac PET scans. Table 20 identifies the other procedures done in PET as well as the number of batches

of PET ligands. All PET patients have a low dose CT scan performed; the CT is done to measure the

attenuation of photons and to provide anatomical localisation of the abnormalities detected on the PET

component to provide better interpretation. There is no formal report for the CT scan, however, findings are

included in the imaging report. Electroencephalograms (EEGs) are done with neurological PET-CT scans to

detect seizure activity.

Table 19: RPA Department of PET and Nuclear Medicine PET-CT studies 2014-2015


Study type #

Whole Body PET-CT 4947

Neurological PET-CT 381

Cardiac PET-CT 7

AC-CT 5335

Total 10670

Notes: AC-CT = Attenuation Correction-CT scans

Table 20: RPA Department of PET and Nuclear Medicine PET-CT additional services 2014-2015

Other services / Cyclotron batches #

EEG 344

FDG batches to RPA 249

FDG batches to other sites 1186

Other PET ligands (research & clinical) 155

Total 1934

Figure 8 identifies the patient studies each calendar year across all PET (1992-2003) and PET-CT (since

mid-2003) scan types. Since 2009, there has been expansion of PET-CT to other hospitals in Sydney; the

dip in 1996 related to a 3-month period of downtime when the single PET scanner suffered water damage.

Figure 8: RPA Department of PET and Nuclear Medicine PET (1992-2003) and PET-CT (since mid-2003) scans for

each calendar year

Figure 9 shows changing models of care in the management of patients with lymphoma, lung and bowel

cancer. The reduction in lymphoma scans since 2012 relates to changes in the Medicare reimbursement

schedule.

0

1000

2000

3000

4000

5000

6000

7000

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er

of

Pa

tie

nt

Sc

an

s

PET and PET-CT Patient studies each calendar years 1992-2015


Figure 9: Different sub-groups of whole body PET and PET-CT scans since the later 1990s

Equipment

Reliability of imaging equipment in the Department is essential for providing a quality diagnostic service.

The service and maintenance schedule is overseen by our scientific staff. Table 21 provides a summary of

equipment location and age.

Table 21: RPA Department of PET and Nuclear Medicine major equipment

Item # Location Equipment Age

0 - <5 years

5 - <10 years

10 - <15 years

>15 years

SPECT scanners 2 L7, Bldg 63 1 1

SPECT-CT scanner* 1 L7, Bldg 63 1*

PET-CT scanner 2 L7, Bldg 63 1 1

Cyclotron 1 L2, Bldg 63 1

Radiochemistry Labs and GMP Production Room

1 L2, Bldg 63 1

* SPECT-CT scanner was installed December 2015


The Department has had a longstanding emphasis / interest in patient quality and safety and has been

recording / collecting / analysing ‘meaningful’ Clinical Indicators (CIs) since the 1990s. An annual Clinical

Indicator report is compiled, which allows the Department to identify areas that require attention/further

improvement. An abbreviated form of the Clinical Indicator Report up to 2014-2015 is listed in Appendix 4.

The Department also reports some of these CIs to the RPA Executive at the monthly Imaging Meetings and

an example from July and August 2015 is shown below.

0

500

1000

1500

2000

2500

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er

of

PE

T-C

T S

tud

ies

Whole Body PET Studies by Clincial Sub-groups

GIT

Gyn

Head & Neck

Haem

Lung

Melanoma

Other

Soft-Tissue


Table 22: Some CIs from RPA Department of PET and Nuclear Medicine that are reported to the RPA Executive

Department of Molecular Imaging: PET & Nuclear Medicine Monthly KPIs – July & August 2015

July 2015 August 2015

Report Turn-around-time (TAT): All reports available same day study completed

PET rate 100.0% 100.0%

Mean time for reports to be completed (min) 41.8 54.2

Report completed range (min) 2.0 - 229 3.3 - 317.1

Mean time for reports to be sent to referrers (min) 81.7 74.1

Report sent range (min) 13.3 - 277.2 10.4 - 399.3

Nuclear Medicine rate 100.0% 99.1%

Mean time for reports to be completed (min) 72.4 56.0

Report completed range (min) 0 - 316.8 1.1 - 289.1

Mean time for reports to be sent to referrers (min) 94.6 82.5

Report sent range (min) 1.2 - 334.5 2.1 - 1068.3

Waiting period for ALL PET scans (Whole body, Neuro & Cardiac): Scan within 5 working days of receiving request

Rate 100.0% 100.0%

Mean waiting time (days) 1.7 1.7

Waiting time range (days) 0 - 4 0 - 4

Correct isotope administered: All patients receive the correct isotope and dose

PET & Nuclear Medicine rate 100.0% 100.0%

Quality testing of clinical PET radiopharmaceuticals produced in the RPA cyclotron: All batches should pass QC

Rate 100.0% 100.0%

Staff radiation monitoring: All staff should be within dose constraints

Rate 94.3% 96.7%

PET-CT Patient uptake times: All patients scanned within 2 minutes of ideal uptake time

Rate 83.6% 85.8%

Challenges

Medicare funding has not kept pace with the new indications for PET-CT and increasingly there are

requests to perform scans that are not reimbursed by Medicare;

insufficient space on level 2 to accommodate the development of the new PET ligands that will be

required for cancer and the neurosciences;

maintain the PET service at the cutting-edge without a clinical PET-MR scanner;

lack of pre-clinical animal imaging which is essential for new PET ligand development and,

the need to attend multiple simultaneous MDTs with limited clinical staff.

Priorities

Improve general NM service by increasing referrals now that the SPECT-CT scanner has been installed;

Provide new radionuclide therapies e.g. Yttrium-90 SIR-Spheres for liver cancer;


Introduce new PET ligands (68

Ga-dotatate, 68

Ga-PSMA, FLT, HK4; PBR-170; PBB3; PiB; THK) for

clinical management and research;

Purchase and install a pre-clinical PET-MR scanner for basic research;

Purchase and install a clinical PET-MR scanner for clinical and research studies and,

Improve video-conferencing so that remote participation in MDTs is enabled.

Concord – Department of Radiology

The Department of Radiology provides a 24/7 service for inpatients and outpatients and there is out-of-

hours on-call Radiologist and Radiology Registrar trainee cover. The Department provides a comprehensive

range of services including plain radiography, fluoroscopy, operating theatre imaging, CT, MR, US and

image guided intervention including angiography, renal, biliary, oncology services, deep organ biopsies, port

insertions, TACE and a comprehensive venous access service. Concord Radiology is also responsible for

the administration and management of the imaging service provided at Canterbury with rotation of medical

staff to the Canterbury Department of Radiology. The Department is also aligned with Sydney Dental

Hospital and provides image reporting for orthopantamograms (OPG) and lateral skull X-rays. There is not a

private radiology practice located in the immediate vicinity of Concord Hospital, and so the Department has a

large outpatient load. Close to 80,000 studies are conducted per annum, with a ratio of approximately 75:25

for inpatient and outpatient service delivery. The Department’s current staffing establishment is 98.1 FTE

with MRSs onsite 24/7. Radiology Trainee coverage occurs only till 10pm in the evening. The last 18 months

has seen the installation of new MR and CT scanners and work is progressing for the replacement of the

dual source CT scanner and 3 general X-ray rooms, which are now outdated.

Studies Performed

In the 2014-2015 financial year, the Concord Radiology Department performed 79,399 examinations.

Table 23 provides a breakdown by modality for the scans performed during this period. Over the last four

years there has been a 4% increase in overall workload across CT, MR and US. Increase in image guided

procedures and therapies such as line insertions and microwave tumour ablation will see interventional

radiology continue to increase.

Table 23: Concord Department of Radiology studies 2014-2015

Study Type #

General X-ray 48724

MR 4756

CT - diagnostic 14892

CT - interventional 351

Angiography / Interventional 576

Fluoroscopy 3676

US - diagnostic 5225

US - interventional 1061

Mammography 122

Total 79383


CT

There has been an increase in the demand for CT as shown in Figure 10. In particular, there has been

an increase in studies done in patients from the ED Department, which reflects the changing models of care,

particularly within the cardiac area. There has been a 22% increase from the 2011-2012 to 2014-2015

financial year and a 60% increase in workload from ED. If this trend continues there will be a need for a 3rd

CT scanner in the near future.

Figure 10: Concord Department of Radiology CT studies from 2011-2015

MR Imaging

Concord was the first public hospital in Australia to install a 3T MR scanner for routine clinical work. This

scanner was replaced in late 2015 and will allow for faster scans and more versatility in the types of studies

that can be undertaken. For MR imaging there is a heavy focus on outpatient imaging. Changing models of

care are seeing an increased role of MR in cardiac work-ups, cardiac diagnosis and in oncology services. In

the four years from 2011-2012, there has been an 11% increase in the number of MR examinations

performed with outpatient scans in 2014-2015 representing 79% of the workload. Increasingly MR imaging is

being applied to new disease types including prostate and breast disease, inflammatory bowel disease and

its role in tumour diagnosis and staging and heart disease is expanding as the technology improves. In

Figure 11, the increase in demand for MR studies is shown and a 2nd

MR scanner will be required in the near

future.

0

2000

4000

6000

8000

10000

12000

14000

16000

2011-2012 2012-2013 2013-2014 2014-2015

Nu

mb

er

of

CT

Exam

s

Financial Year

CT Studies Per Year

ED

Ward

Out-patient

Total


Figure 11: Concord Department of Radiology MR studies from 2011-2015

Equipment

The Department’s imaging equipment, including the age of each device is shown in Table 24. The

mammography unit is an analogue device and although the mammography workload at Concord is not high

the device is required for clinical care and will be replaced in the coming financial year.

Table 24: Concord Department of Radiology Imaging Equipment

Description Number Location Equipment Age

0 - <5 years

5 - <10 years

10 - <15 years

>15 years

MR 3 T 1 Main Department x 1 1

CT 64 slice 1 Main Department x 1 1


Angiography Suite 2 Main Department x 1

Hybrid Lab - OT x 1 2

General X-Ray Analogue 3 Main Department x 2

ED X-ray room x 1 3

General X-Ray OPG 1 ED X-ray room x 1 1

Mobile X-Ray Analogue 2 Wards x 2 1 1

Mobile X-Ray Digital 2 ICU x 1; ED x 1 2

Fluoroscopy Analogue 2 Main Department x 2 1 1

Fluoroscopy Mobile II 3 Theatres x 3 1 1 1

US Full Diagnostic 4 Main Department x 4 3 1

US Small Interventional 2 Main Department x 1 1 1

Mammography Analogue 1 Breast Imaging x 1 1

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

2011-2012 2012-2013 2013-2014 2014-2015

Nu

mb

er

of

MR

I Exa

ms

Financial Year

MR Studies Per Year

ED

Ward

Out-patient

Total



The Department’s performance indicators for performing CT scans requested from ED are shown in

Table 25 which shows that approximately 80% of requested scans are done within 2 hours of the request on

weekdays; the percentage is slightly lower on weekends when there are fewer staff.

Table 25: Concord Department of Radiology ED CT studies

2013-2014 2014-2015

Weekday

Time # studies

< 2 hr

Total #

studies

% studies

< 2hr

# studies

< 2 hr

Total #

studies

% studies

< 2hr

00:00-05:59 116 159 73.0% 117 153 76.5%

06:00-11:59 418 528 79.2% 409 525 77.9%

12:00-17:59 907 1119 81.1% 923 1182 78.1%

18:00-23:59 538 613 87.8% 580 695 83.5%

Total 1979 2419 81.8% 2029 2555 79.4%

Non-Weekday

Time # studies

< 2 hr

Total #

studies

% studies

< 2hr

# studies

< 2 hr

Total #

studies

% studies

< 2hr

00:00-05:59 73 95 76.8% 161 205 78.5%

06:00-11:59 117 182 64.3% 73 96 76.0%

12:00-17:59 317 416 76.2% 134 211 63.5%

18:00-23:59 203 250 81.2% 342 426 80.3%

Total 710 943 75.3% 710 938 75.7%

Challenges

Reducing the waiting time for outpatient MR, US and CT studies;

Long outpatient waiting times during busy clinics dates due to lack of efficient general X-ray rooms;

Delays in inpatient portering frequently means inpatients can be late for scheduled studies;

Delays for general radiography for inpatients due to insufficient, modern general X-ray rooms and,

Provision of a mammography service with aged equipment makes training and maintenance of skills

problematic.

Priorities

Upgrade of analogue general rooms and CR systems to digital general rooms providing faster

throughput and improved image quality;


Replacement of dual source CT scanner and mammography unit;

Increased utilisation of existing MR scanner to reduce waiting time for inpatients and purchase of a

second MR scanner;

Recruitment of suitable Staff Specialist Radiologists to meet current FTE establishment;

Investment in 3rd

party oncology software and radiologist focused software tools including CAD for

Breast MR and,

Installation of a 3rd

CT scanner.


Concord – Department of Nuclear Medicine

Concord Department of Nuclear Medicine provides a service for inpatients and outpatients of Concord

and Canterbury, nursing homes and Department of Veteran Affairs (DVA) patients. There is active

involvement in research projects. The Department conducts diagnostic nuclear medicine procedures in

relation to rheumatology, oncology, cardiac conditions, orthopaedics, rheumatology, respiratory and

provision of specific therapeutic radionuclide therapy for treatment of thyroid cancer and hepatocellular

carcinoma. No paediatric services are provided. The current Department staffing establishment is 15 FTE.

Studies Performed

The Concord Department of Nuclear Medicine performs a wide variety of studies and like all NM

Departments there are a variety of other services that are provided in addition to routine scanning. The type

and number of studies undertaken are listed in Table 26, including the CT scan done with the SPECT in a

SPECT-CT scan. The additional services provided in the Department are listed in Table 27.

Table 26: Concord Department of Nuclear Medicine studies 2014-2015

Subtype #

Adrenal 3

Biliary 15

Bone 805

Card Shunt 1

Brain 31

Colon 17

CSF flow 1

Renal 55

Gallium 36

GMT 12

Reflux 43

Cardiac 104

GI Bleed 1

Iodine Scan 62

Breakthrough 15

Lung 392

Lymph 13

Marrow 11

Meckel's 5


Subtype #

Sentinel Node 45

Parathyroid 46

Cardiac 480

Cardiac 10

Dacro 22

Thyroid 116

WBC 23

ACCT 1021

Total 3385

Table 27: Concord Department of Nuclear Medicine other services 2014-2015

Other Services #

Consult 148

Ablation therapy 24

Thyroid Therapy 20

Lipiodol Injection 16

Electrocardiogram 465

Thyrogen 1

Yttrium Injection 17

Total 691

Equipment

The key imaging equipment including age and location that is currently installed and available within the

Department is summarised below in Table 28.

Table 28: Concord Department of Nuclear Medicine imaging equipment

Description Number Location Equipment Age

0 - <5 years

5 - <10 years

10 - <15 Years

>15 years

Gamma Cameras 1 Main Department x 1 1

SPECT Camera 1 Main Department x 1 1

SPECT-CT 2 Main Department x 2 1 1


Nuclear Medicine in Australia is seeing an increasing reliance on PET imaging as there is a decline in

the more traditional nuclear medicine examinations. It is proposed that molecular imaging will guide specific

patient management decisions in addition to diagnostic services. This will include: a) targeted radionuclide

therapies in the management of disease particularly in the field of oncology; b) the evaluation and

management of cognitive impairment, in line with the ageing population and advances in treatment of such

diseases. An increase in oncology patients is predicted, given an increasing population (particularly in the

local area) and an increasing overall incidence of malignancy. Stage One of the Concord Hospital

redevelopment will include the site consolidation and development of oncology services which may result in

increased referrals.

Challenges

Inability to provide PET imaging on site;

Increasing demands for attendance at MDTs.

Priorities

redevelop the Department’s infrastructure and services to include a PET service with the installation of a

PET-CT scanner;

expand research and,

maintain the Department’s accreditation for training Nuclear Medicine Registrars.

Canterbury – Department of Radiology

The Canterbury Hospital (TCH) Department of Radiology provides CT, general radiography, US,

fluoroscopy and operating theatre imaging services Monday to Friday during business hours. A 24/7

emergency onsite service for CT, general radiography and theatre imaging is provided after hours. Complex

procedures and out of hours ultrasounds are provided by Concord Department of Radiology. The

Department is managed and overseen by the Director of the Department of Radiology at Concord. The MRS,

clerical and nursing staff are all Canterbury employees. The Staff Specialists and Radiology Registrar

Trainees rotate to the Department from Concord. The Department has 21.1 FTE. The Chief MRS at

Canterbury manages daily operational activities. Portering services are provided by the hospital ward

assistants and are not dedicated imaging staff. Some MRS staff are currently in casual and temporary

positions and conversion to permanent positions would help maintain the efficient running of the Department.

Studies Performed

The Department of Radiology at Canterbury currently performs just over 36033 studies each year as

shown in Table 29.

Table 29: Canterbury Department of Radiology studies 2014-2015

Study Type #

General X-ray 27063

CT 4889

Fluoroscopy 674


Study Type #

US 3407

Total 36033

In 2013, 24/7 on-site imaging commenced. Prior to this, staff were called back to provide urgent out of

hours imaging at considerable expense. The current service meets the needs for ED and inpatients. Over

the last 5 years there has been an increase in activity, which mirrors the increase in ED, inpatient and

outpatient attendances. There has been a 29% increase in the number of CT scans done over this period

and a 42% increase in US studies. Although the majority of US services from the antenatal clinic are referred

to private practices external to the hospital there has been increased demand from the Antenatal Clinic and

Emergency Department. Increases in mobile radiography (31%) and general X-ray studies (10%) have also

taken place and overall there has been a combined workload increase of 16%.

Figure 12: Canterbury Department of Radiology study trends 2010-2015

Equipment

The Department of Radiology at Canterbury has 5 imaging devices that are old and 2 of these have

passed the capital sensitivity limit; the equipment list is shown at Table 30. The fluoroscopy equipment

requires replacement as currently the majority of fluoroscopic procedures are sent to Concord Hospital.

Table 30: Canterbury Department of Radiology imaging equipment


0 - <5 years

5 - <10 years

10 - <15 years

>15 years


General X-Ray Analogue 2 Main Department x 2 1 1

General X-Ray OPG 1 Main Department x 1 1

Mobile X-Ray Analogue 3 Wards x 3 1 2

Fluoroscopy Analogue 1 Main Department x 1 1

Fluoroscopy Mobile II 1 Operating Theatre 1

0

1000

2000

3000

4000

5000

6000

2010/2011 2011/2012 2012/2013 2013/2014 2014/2015

Nu

mb

er

of

Exam

inat

ion

s

Mobile Radiography

CT

Fluroscopy/procedures

Ultrasound



0 - <5 years

5 - <10 years

10 - <15 years

>15 years

US Full Diagnostic 2 Main Department x 2 2

Performance

Regular reviews of the Department’s turnaround time are undertaken. Below is a snap shot of the

information captured for ED at Canterbury, CT referrals and the turn-around-time for the examination (see

Table 31). Similar statistics are collected for ED general requests, inpatient CT and general requests.

Table 31: Canterbury Department of Radiology ED CT turnaround time 2013-2015

2013-2014 2014-2015

Weekday

00:00-07:59 TAT < 120 min 344 375

00:00-07:59 TAT > 120 min 22 37

00:00-07:59 Total 366 412

00:00-07:59 < 60 min (%) 94.0% 91.0%

Weekday

08:00-16:59 TAT < 120 min 1121 1321

08:00-16:59 TAT > 120 min 325 320

08:00-16:59 Total 1446 1641

08:00-16:59 < 60 min (%) 77.5% 80.5%

17:00-23:59 TAT < 120 min 882 1026

17:00-23:59 TAT > 120 min 139 147

17:00-23:59 Total 1021 1173

17:00-23:59 < 60 min (%) 86.4% 87.5%

Non-weekday

00:00-07:59 TAT < 120 min 1 8

00:00-07:59 TAT > 120 min 0 1

00:00-07:59 Total 1 9

00:00-07:59 < 60 min (%) 100.0% 88.9%

08:00-16:59 TAT < 120 min 38 30

08:00-16:59 TAT > 120 min 9 1

08:00-16:59 Total 47 31

08:00-16:59 < 60 min (%) 80.9% 96.8%

17:00-23:59 TAT < 120 min 24 20

17:00-23:59 TAT > 120 min 3 5

17:00-23:59 Total 27 25

17:00-23:59 < 60 min (%) 88.9% 80.0%

Challenges

Aged equipment - the Department does not have a revenue stream. Key purchases would increase the

efficiency in the Department and perhaps allow the generation of funds to purchase equipment.

Workforce - of the 14.6 FTE MRSs, 25% are casual, which makes staff rostering / training and the

provision of an efficient service problematic; additional permanent staff will be required to ensure that


there is effective CT and US training.

Sonographers - there is a shortage of sonographers; staffing levels do not allow for a two year training

commitment for a staff member to become accredited.

Out of Hours CT - the provision of a 24/7 imaging service has meant an increase in the number of CT

scans done and also an increase in the call-backs for the Radiology Registrar trainees.

Priorities

Replace old analogue fluoroscopy, general X-ray, mobile x-ray, OPG and CR systems with digital

equipment and two US devices;

Convert casual and temporary MRS positions to permanent positions to maintain an efficient 24/7

service;

Upgrade existing CT which will extend capital sensitivity life to 2023;

Develop a Business Case to expand US services.

Provide MR services with the installation of a licenced MR

Balmain – Department of Radiology

The imaging service at Balmain is managed and overseen by the RPA Department of Radiology. A

limited (general and mobile X-ray) imaging service 9am – 5pm, seven days a week, is provided for inpatients

and the GP casualty. Radiologist support and reporting of images is provided offsite via the 24/7 service at

RPA. There is a staff establishment of 1.4 FTE with staff rotating from the general RPA Department of

Radiology roster; clerical duties are performed by the MRS with support provided by the RPA Clerical

Manager.

Studies Performed

There are less than 10 patients a day who use this service. There has been a steady decline in the

number of studies performed at BH from about 3800 in 2009-2010 to 2024 in 2014-2015, consistent with its

current clinical role.

Equipment

The two imaging devices are > 15 years old; there is an analogue general radiography system, a mobile

X-ray device and CR is utilised to digitise images. A ‘bucky unit’ was relocated from RPA to Balmain hospital

in Feb 2016; the device is 16 yrs old but reliable and meets the clinical needs of the Hospital. The imaging

equipment, however, will remain under review and replacement will be considered based on need and

reliability of the existing devices.

Overview of Medical Imaging Stream Priorities

The priorities from each Department are listed below:


RPA Department of Radiology

Initiation of the Lean program to improve patient flow and reduce waiting times, in particular, for

intervention (neuro- and body) with the installation of the 3 new angiography rooms in 2016/2017;,

Replacement of the mammography unit, fluoroscopy suite, general X-ray and mobile systems and the

installation of an interventional CT at Lifehouse and,

Installation of a dedicated interventional simulator to prepare and train staff in the techniques associated

with interventional procedures in the body and the brain.

RPA Department of PET and Nuclear Medicine

Improve general NM service by increasing referrals now that the SPECT-CT scanner has been installed;

Provide new radionuclide therapies e.g. Yttrium-90 SIR-Spheres for liver cancer;

Introduce new PET ligands (68

Ga-dotatate, 68

Ga-PSMA, FLT, HK4; PBR-170; PBB3; PiB; THK) for

clinical management and research;

Purchase and install a human clinical PET-MR and a pre-clinical PET-MR scanner for clinical care and

basic research and;

Improve video-conferencing so that remote participation in MDTs is enabled.

Concord Department of Radiology

Upgrade of analogue general rooms and CR systems to digital general rooms providing faster

throughput and improved image quality;

Replacement of dual source CT scanner and mammography unit;

Increased utilisation of existing MRI scanner and purchase of a second MR scanner;

Recruit suitable Staff Specialist Radiologists to meet current FTE establishment

Investment in 3rd

party oncology software and radiologist focused software tools including CAD for

Breast MR and,

Install a 3rd

CT scanner.

Concord Department of Nuclear Medicine

Redevelop the Department’s infrastructure and services to include a PET service with the installation of

a PET-CT;

Expand research and,

Maintain the Department’s accreditation for training Nuclear Medicine registrars.

Canterbury Department of Radiology

Replace old analogue fluoroscopy, general X-ray, mobile x-ray, OPG and CR systems with digital

equipment and two US devices;

Convert casual and temporary MRS positions to permanent positions to maintain an efficient 24/7


service;

Upgrade existing CT which will extend capital sensitivity life to 2023;

Develop a Business Case to expand US services.

Provide MR services with the installation of a licenced MR

Medical Imaging Stream Priorities

To achieve the MIS goals the service priorities for the next 5 years (2016-2021) can be separated into:

i) operational priorities and

ii) priorities for investment in imaging technologies.

It should be emphasised that investment in imaging technologies will only occur after the relevant Business

Cases are approved by the individual hospitals, District, and MoH and the funding source for each new

device(s) is identified. They are as follows:

i) Operational priorities:

complete the RPA data migration from the legacy Agfa archive to the new SMILE SLHD PACS-RIS and

transfer Concord / Canterbury / Sydney Dental Hospitals to the SMILE PACS-RIS;

develop consistent, meaningful clinical and performance indicators across the MIS with targeted

reduction in waiting times for scans that affect patient management and patient hospital stay;

increase research within the Medical Imaging Departments;

improve access and workflow for interventional services across SLHD but in particular at RPA with the

installation of 3 new angiography suites in 2016 so that waiting times are significantly reduced;

explore the use of decision support analytic tools to reduce unnecessary imaging requests;

improve video conferencing / bandwidth to allow remote participation in MDTs;

install a dedicated interventional simulator to prepare and train staff in the techniques associated with

interventional procedures in the body and the brain;

introduce new PET ligands for clinical care in the neurosciences and cancer;

establish robust internal Morbidity and Mortality Meetings for all interventional procedures in

Departments of Radiology across SLHD;

establish mechanisms to evaluate new / emerging endovascular devices and technologies prior to use in

Radiology across SLHD and integrate the purchase of all devices / catheters used in Radiology

intervention into the planned new SLHD device tracking system and,

improve procurement processes for major equipment at all levels – Department, Hospital, District and

MoH with relevant KPIs and,

engage more widely with SLHD GPs to provide imaging services such as general nuclear medicine and

CT through the HealthPathways program.

ii) Priorities for investment in imaging technologies:

replacement of analogue fluoroscopy, general X-ray, mobile X-ray, OPG and CR systems with digital

technology, replace ultrasound systems and upgrade the existing CT at Canterbury ;


human and pre-clinical PET-MR at RPA;

an additional MR and CT and replacement of an existing CT at Concord;

replacement of analogue general rooms, mobile x-ray devices with digital technology and the installation

of an interventional CT at RPA and Lifehouse;

improve imaging modalities and access to Breast Imaging across SLHD and,

PET-CT at Concord.


Appendices

Appendix 1: Medical Imaging Stream Publications

RPA Department of PET and Nuclear Medicine

Journal Articles, Abstracts, Peer-reviewed Conference Proceedings, Book Chapters (2014-2015)

2015

Ahn E, Bi L, Jung Y, Kim J, Li C, Fulham M, Fend DD. Automated saliency-based lesion segmentation in

dermoscopic images. Conference Proceedings IEEE Engineering in Medicine and Biology Conference (EMBC

2015) 2015 Aug; 2015:3009-12. doi: 10.1109/EMBC.2015.7319025 (epub ahead of print)

Barrington SF, Kirkwood A, Franceschetto A, Fulham MJ, Roberts TH, Almquist H, Brun E, Hjorthaug K, Viney

ZN, Pike LC, Federico M, Luminari S, Radford J, Trotman J, Fossa A, Berkhan L, Molin D, D’Amore F, Sinclair

DA, Smith P, O’Doherty MJ, Johnson PW. PET-CT for staing & early response: Results adapted therapy in

advanced Hodgkin Lymphoma (RATHL) (CRUK/07/033). Blood. 2016 Jan 8. pii:blood-2015-11-679407 (epub

ahead of print)

Huang R, Bi L, Li C, Jung Y, Kim J, Fulham M, Feng D. A locally constrained knowledge-based random walk

approach for airway segmentation on low-contrast computed tomography (CT) images. International

Conference on Digital Imaging Computing Techniques and Applications (DICTA 2015). 2015 Nov 23-25;

Adelaide, Australia; pp. 1-7.

Zhang F, Song Y, Cai W, Liu S, Liu S, Pujol S, Kikinis R, Xia Y, Fulham M, Feng D, ADNI. Pairwise latent

semantic association for similarity computation in medical imaging. IEEE Transactions on Biomedical

Engineering (epub ahead of print 10 Sep 2015)

Zhang F, Song Y, Cai W, Hauptmann AG, Liu S, Pujol S, Kikinis R, Fulham MJ, Feng DD, Chen M. Dictionary

pruning with visual word significance for medical image retrieval. Neurocomputing. 2015 Nov 17 (in press)

Cui H, Wang X, Lin W, Zhou J, Eberl S, Yin Y, Feng D, Fulham M. Primary lung tumor segmentation from PET-

CT volumes with spatial-topological constraint. International Journal of Computer Assisted Radiology and

Surgery. epub ahead of print; 2 July 2015.

Bi L, Kim J, Wen L, Feng D, Fulham M. Automated threshold region classification using a robust feature

selection method for PET-CT. In: 12th IEEE International Symposium on Biomedical Imaging (ISBI 2015) 2015

Apr 16-29; New York, NY, USA; pp.1435-1438.

Liu S, Cai W, Liu SQ, Zhang F, Fulham M, Feng D, Pujol S, Kikinis R. Multimodal Neuroimaging Computing: A

review of the applications to neuropsychiatric disorders. Brain Informatics. Springer Berlin Heidelberg. 2015;

2(3):167-180.

Liu S, Cai W, Liu SQ, Zhang F, Fulham M, Feng D, Pujol S, Kikinis R. Multimodal Neuroimaging Computing:

The workflows, methods and platforms. Brain Informatics. Springer Berlin Heidelberg. 2015; 2(3):181-195.

Knoppman AA, Wong CH, Stevenson RJ, Homewood J, Mohamed A, Somerville E, Eberl S, Wen L, Fulham M,

Bleasel AF. The relationship between neuropsychological functioning and FDG-PET hypometabolism in

intractable mesial temporal lobe epilepsy. Epilepsy & Behavior. 2015;44C:136-14.

Kumar A, Nette F, Klein K, Fulham M, Kim J. A visual analytics approach using the exploration of

multidimensional feature spaces for content-based medical image retrieval. IEEE Journal of Biomedical Health

and Informatics. 2015;19(5):1734-1746.

Kao SC, Fulham M, Wong K, Cooper W, Brahmbhatt H, MacDiarmid J, Pattison S, Sagong JO, Huynh Y, Leslie

F, Pavlakis N, Clarke S, Boyer M, Reid G, van Zandwijk N. A significant metabolic and radiological response

after a novel targeted microrna-based treatment approach in malignant pleural mesothelioma. American Journal

of Respiratory and Critical Care Medicine. 2015; 191 (12): 1467-1469.

Cui H, Wang X, Zhou J, Eberl S, Yin Y, Feng D, Fulham M. Topology polymorphism graph for lung tumor

segmentation in PET-CT images. Physics in Medicine and Biology. 2015; 60 (12): 4893.

Gnaneswaran S, Tandy B, Fulham MJ. Brown fat FDG uptake abolished by radiotherapy. Clinical Nuclear

Medicine. 2015; 40(5):437-438.

Li C, Wang X, Eberl S, Fulham M, Yin Y, Feng DD. Supervised variational model with statistical inference and

its application in medical image segmentation. IEEE Transactions on Biomedical Engineering. 2015; 62 (1):


196-207.

Song Y, Cai W, Huang H, Zhou Y, Feng D, Wang Y, Fulham M, Chen M. Large margin local estimate with

applications to medical image classification. IEEE Transactions on Medical Imaging. 2015;34(6):1362-1377.

Liu S, Liu S, Cai W, Che H, Pujol S, Kikinis R, Feng D, Fulham MJ. Multi-modal neuroimaging feature learning

for multi-class diagnosis of Alzheimer's Disease. IEEE Transactions on Biomedical Engineering. 2015;

62(4):1132-1140.

Mattner F, Quinlivan M, Greguric I, Pham T, Liu X, Jackson T, Berghofer P, Fookes CJR, Dikic B, Gregoire MC,

Dolle F, Katsifis A. Radiosynthesis, in vivo biological evaluation, and imaging of brain lesions with [123I]-

CLINME, a new SPECT tracer for the translocator protein. Disease Markers. 2015; Article ID 729698, 11 pages.

Song Y, Cai W, Zhou Y, Feng D, Fulham M. Lesion detection with extremal regions in thoracic PET-CT images.

Journal of Nuclear Medicine. 2015; 56 (Suppl 3): 1783.

Mattner F, Hung TT, Bourdier T, Lee BJ, Henderson D, Poon JC, Doan J, Lam P, Power C, Eberl S, Katsifis A,

Fulham M. Evaluation of the TSPO radiotracer 18F-PBR316 in prostate tumour models. World Molecular

Imaging Congress 2015. ID: 2319573

Jung Y, Kim J, Fulham M, Feng DD. Volume rendering augmentation on slice of interest (SOI) for visualisation

of thoracic PET-CT. International Journal of Computer Assisted Radiology and Surgery. 2015; 10 (Suppl

1):S194-195.

Bi L, Kim J, Feng DD, Fulham M. Automated regions of interest (ROIs) tracking for PET-CT image series using

cellular automata segmentation. International Journal of Computer Assisted Radiology and Surgery. 2015; 10

(Suppl 1):S21-22.

Mattner F, Hung T-T, Bourdier T, Lee B, Henderson D, Poon J, Doan J, Power C, Katsifis A, Fulham M.

Evaluation of 18F-TSPO radiotracers in a prostate tumour model using PET. Journal of Nuclear Medicine. 2015;

56 (Suppl 3): 555.

Roberts MP, Nguyen V, Ashford ME, Berghofer P, Wyatt NA, Krause-Heuer AM, Pham TQ, Taylor SR, Hogan

L, Jiang CD, Fraser BH, Lengkeek NA, Matesic L, Gregoire MC, Denoyer D, Hicks RJ, Katsifis A, Geguric I.

Synthesis and in vivo evaluation of [123]Melanin-targeted agents. Journal of Medicinal Chemistry.

2015;58(5):6214-6224.

Lengkeek NA, Roberts MP, Zhang L, I-Chieh JL, Fookes CJR, Dikic B, Herzog H, Katsifis A, Greguric I.

Synthesis and binding affinity of fluorine containing NG-acyl and sulfonyl BIBP3226 derivatives: Ligands for the

NPY Y1 receptor. Australian Journal of Chemistry. 2015; http://dx.doi:10.1079/CH15569.

Cui H, Wang X, Zhou J, Eberl S, Feng D, Fulham M. Improved segmentation accuracy for thoracic PET-CT in

patients with NSCLC using a multi-graph model (MGM). Journal of Nuclear Medicine. 2015; 56 (Suppl 3): 2527.

Amhaoul H, Hamaide J, Bertoglio D, Reichel SN, Verhaeghe J, Geerts E, Van Dam D, De Deyn PP, Kumar-

Singh S, Katsifis A, Van Der Linden A, Staelens S, Dedeurwaerdere S. Brain inflammation in chronic epilepsy

model: Evolving pattern of the translocator protein during epileptogenesis. Neurobiology of Disease.

2015;82:526-539.

Callaghan PD, Wimberley CA, Rahardjo GL, Berghofer PJ, Pham TQ, Jackson T, Zahra D, Bourdier T, Wyatt N,

Greguric I, Howell NR, Siegele R, Pastuovic Z, Mattner F, Loc’h C, Gregoire MC, Katsifis A. Comparison of in

vivo binding properties of the 18-kDa translocator protein (TSPO) ligands [(18)F]PBR102 and [(18)]PBR111 in a

model of excitotoxin-induced neuroinflammation. European Journal of Nuclear Medicine and Molecular Imaging.

2015;42(1):138-151.

Asih PR, Ji B, Katsifis A, Mattner F, Caruso D, Melcangi RC, Higuchi M, Martins RN, Barron AM. In vivo

evaluation of the therapeutic potential of novel translocator protein (TSPO) ligands for the treatment of

Alzheimer’s disease. Alzheimer’s & Dementia. 2015;11(7, Suppl):P156-157.

2014

Kumar A, Jinman K, Fulham M, Dagan F. Efficient PET-CT image retrieval using graphs embedded into a

vector space. 36th Annual Conference Proceedings of the IEEE Engineering in Medicine and Biology Society

(EMBC 2014). 2014 Aug 26-30; Chicago, IL, USA; pp.1901-1904.

Asih PR, Barron AM, Ji B, Katsifis A, Mattner F, Verdile G, Gupta VB, Trengove R, Martins RN. Novel

translocator protein (TSPO) ligands for the potential treatment of Alzheimer’s Disease: A next generation

alternative to conventional hormone therapy. Alzheimer’s & Dementia. 2014; 10(4) Suppl: 860-861.

Li C, Li A, Wang X, Feng D, Eberl S, Fulham M. A new statistical and dirichlet integral framework applied to liver

segmentation from volumetric CT images. In: 13th International Conference on Control Automation Robotics &

Vision (ICARCV 2014). 10-12 Dec; Singapore; 2014. pp. 642-647.


Bi L, Kim J, Feng DD, Fulham M. Classification of thresholded regions based on selective use of PET, CT and

PET-CT image features. 36th Annual Conference Proceedings of the IEEE Engineering in Medicine and Biology

Society (EMBC 2014); 2014 Aug 26-30; Chicago, IL, USA; pp. 1913-1916.

Jung Y, Kim J, Fulham M, Feng DD. Opacity-driven volume clipping for slice of interest (SOI) visualisation of

multi-modality PET-CT volumes. In: 36th Annual Conference Proceedings of the IEEE Engineering in Medicine

and Biology Society (EMBC 2014); 2014 August 26-30; Chicago, IL, USA; pp. 6714-6717.

Song Y, Cai W, Zhou Y, Fulham M, Feng D. Volume-of-interest retrieval for PET-CT images with a conditional

random field alignment. Journal of Nuclear Medicine. 2014; 55 (Suppl 1): 2065.

Kumar A, Kim J, Fulham M, Feng D. Creating graph abstractions for the interpretation of combined functional

and anatomical medical images. In: Joint Proceedings of the 4th International Workshop on Euler Diagrams (ED

2014) and the 1st International Workshop on Graph Visualization in Practice (GViP 2014); Melbourne, Australia;

2014; pp.63-72.

Liu S, Liu S, Cai W, Che H, Pujol S, Kikinis R, Fulham M, Feng D. High-level feature based PET image retrieval

with deep learning architecture. Journal of Nuclear Medicine. 2014; 55 (Suppl 1): 2028.

Zhang F, Song Y, Cai W, Zhou Y, Fulham M, Eberl S, Shan S, Feng D. A ranking-based lung nodule image

classification method using unlabeled image knowledge. In: 11th IEEE International Symposium on Biomedical

Imaging (ISBI 2014) 2014 April 29 - May 2; Beijing, China; pp. 1356-1359.

Zhang F, Song Y, Cai W, Lee MZ, Zhou Y, Huang H, Shan S, Fulham MJ, Feng DD. Lung nodule classification

with multilevel patch-based context analysis. IEEE Transactions on Biomedical Engineering. 2014;61(4):1155-

1166.

Zhang F, Song Y, Liu S, Pujol S, Kikinis R, Fulham M, Feng D, Cai W. Semantic association for neuroimaging

classification of PET images. Journal of Nuclear Medicine. 2014; 55 (Suppl 1): 2029.

Xia Y, Lu S, Wen L, Eberl S, Fulham M, Feng DD. Automated Identification of Dementia Using FDG-PET

Imaging. BioMed Research International. 2014; Article ID: 421743, 8 pages.

Wong CH, Mohamed A, Wen L, Eberl S, Somerville E, Fulham M, Bleasel AF. Metabolic changes in occipital

lobe epilepsy with automatisms. Frontiers in Neurology. 2014;5:135.

Wang X, Ballangan C, Cui H, Fulham M, Eberl S, Yin Y, Feng D. Lung tumor delineation based on novel tumor-

background likelihood models in PET-CT images. IEEE Transactions on Nuclear Science. 2014;61(1):218-224.

Tychyj-Pinel C, Ricard F, Fulham M, Fournier M, Meignan M, Lamy T, Vera P, Salles G, Trotman J. PET-CT

assessment in follicular lymphoma using standardized criteria: central review in the PRIMA study. European

Journal of Medicine and Molecular Imaging. 2014;41(3):408-415.

Song Y, Cai W, Huang H, Wang X, Zhou Y, Fulham MJ, Feng DD. Lesion detection and characterization with

context driven approximation in thoracic FDG PET-CT images of NSCLC studies. IEEE Transactions on

Medical Imaging. 2014;33(2):408-421.

Pinna AE, Walter J, Fulham MJ. Bruxism-before and after images-on 18F-FDG PET-CT. Clinical Nuclear

Medicine. 2014;39(6):564-566.

Liu S, Cai W, Wen L, Feng DD, Pujol S, Kikinis R, Fulham MJ, Eberl S. Multi-channel neurodegenerative

pattern analysis and its application in Alzheimer's disease characterization. Computerized Medical Imaging and

Graphics. 2014;38(6):436-444.

Kumar A, Kim J, Wen L, Fulham M, Feng D. A graph-based approach for the retrieval of multi-modality medical

images. Medical Image Analysis. 2014;18(2):330-342.

Knopman AA, Wong CH, Stevenson RJ, Homewood J, Mohamed A, Somerville E, Eberl S, Wen L, Fulham M,

Bleasel AF. The cognitive profile of occipital lobe epilepsy and the selective association of left temporal lobe

hypometabolism with verbal memory impairment. Epilepsia. 2014;55(8):e80-84.

Cai W, Zhang F, Song Y, Liu S, Wen L, Eberl S, Fulham M, Feng D. Automated feedback extraction for medical

imaging retrieval. In: 11th IEEE International Symposium on Biomedical Imaging (ISBI 2014); 2014 Apr 29 -

May 2; Beijing, China; pp. 907-910.

Cui H, Wang X, Zhou J, Fulham M, Eberl S, Feng D. Topology constraint graph-based model for non-small-cell

lung tumor segmentation from PET volumes. In: 11th IEEE International Symposium on Biomedical Imaging

(ISBI 2014) 2014 Apr 29 - May 2; Beijing, China; pp. 1243-1246.

Bourdier T, Henderson D, Fookes CJ, Lam P, Mattner F, Fulham M, Katsifis A. Synthesis of [C]PBR170, a

novel imidazopyridine, for imaging the translocator protein with PET. Applied Radiation and Isotopes.

2014;90C:46-52.

Bi L, Kim J, Feng D, Fulham M. Multi-stage thresholded region classification for whole-body PET-CT lymphoma


studies. In: Golland P, Hata N, Barillot C, Hornegger J, Howe R, editors. 17th Medical Image Computing &

Computer-Assisted Intervention (MICCAI 2014); Sep 14-18; Boston, MA, USA. Springer International

Publishing; 2014. 8673: p 569-576.

Ryu SW, Waugh A, Allman KC. Portosystemic shunting in superior vena cava obstruction by tumour

demonstrated on ventillation-perfusion lung scan. Journal of Nuclear Medicine Technology. 2014;42(2):118-

119.

Ryu SW, Allman KC. Native aortic and prosthetic vascular stent infection on 99mTc-Labeled white blood cell

scintigraphy. Journal of Nuclear Medicine Technology. 2014;42(2):120-121.

Vivash L, Gregoire MC, Bouilleret V, Berard A, Wimberley C, Binns D, Roselt P, Katsifis A, Myers DE, Hicks RL,

O’Brien TJ, Dedeurwaedere S. In vivo measurement of hippocampal GABAA/cBZR density with [18F]-

flumazenil PET for the study of disease progression in an animal model of tempoal lobe epilepsy. PloS One.

2014;9(1):e86722.

Ashford ME, Nguyen VH, Greguric I, Pham TQ, Keller PA, Katsifis A. Synthesis and in vitro evaluation of

tetrahydroisoquinolines with pendent aromatics as sigma-2 (σ2) selective ligands. Organic & Biomolecular

Chemistry. 2014;12(5):783-794.

Garg N, Trotman J, Tan I, Yiannikas C, Fulham MJ, Burrell JR. Distal demyelinating neuropathy: Could it be

neurolymphomatosis? Journal of Clinical Neuroscience. 2014; 21 (11): 2046.

Song Y, Cai W, Eberl S, Fulham MJ, Feng DD. Feature-centric lesion detection and retrieval in thoracic images.

In: Chen CH, ed. Computer Vision in Medical Imaging. MA USA: World Scientific. 2014; pp. 75-94.

Concord Department of Radiology

Journal Articles, Abstracts, Peer-reviewed Conference Proceedings, Book Chapters (2014-2015)

2015

Georgiou A, Prgomet M, Lymer S, Hordern A, Ridley L, Westbrook J. The impact of a health IT changeover on

Medical Imaging Department work processes and turnaround times: a mixed method study. Applied Clinical

Informatics 2015 Jul 8: 6(3):443-53.

Ridley LJ, Limaye S. Toxic Epidermal Necrolysis – an investigation to dye for? The Medical Journal of Australia.

2015 Jul 20; 203(2):76-8.

Dr Edwin Ho, Professor Marc A. Gladman (Consultant colorectal surgeon, CONCORD), Dr Michael Suen

(consultant colorectal surgeon, CONCORD) and Dr Jessica Yang. Surgical-radiological correlation of complex

perianal sepsis: case study highlights. European Society of Gastrointestinal and Abdominal Radiology Annual

Meeting 2015, 9 June - 12 June 2015, Paris, France. *Awarded a Certificate of Merit by the conference

organisers.

2014

Naoum C, Kritharides L, Thomas L, Ng AC, Ridley L, Falk GL, Yiannikas J. Modulation of phasic left atrial

function and left ventricular filling in patients with extrinsic left atrial compression by hiatial hernia. International

Journal of Cardiology. 2014. Oct 20; 176(3):1176-8.

Naoum C, Khoury V, Ridley L, Mase S. Persistent left and absent right superior vena cava: combined functional

and anatomic assessment with transthoracic echocardiography and computed tomography. Echocardiography.

2014. Sep; 31(8):E267-8/


Appendix 2: Medical Imaging Stream Grants

RPA Department of PET and Nuclear Medicine grants 2014-2015

Granting Body Project Title Amount (AUD)

Start Finish

ARC

Discovery Grant

Biomedical visual image analytics: Information retrieval for multi-disciplinary decision support

$390,000 2016 2019

NHMRC

Team Grant

Non-Alzheimer’s disease degenerative dementias: Identifying prodromal genetic/familial phenotypes, modifying factors, and protein variations involved in progression*

$6,449,246 2015 2019

MNDRIA ALS in vivo markers $100,000 2016 2016

ARC

Linkage Grant

OMNI–Modality Medical Image Analysis and Visualisation $355,000 2014 2017

ARC

Discovery Grant

An integrated virtual functional human body (VFHB) $342,000 2014 2016

NHMRC

Project Grant

Circulating biomarkers in advanced classical Hodgkin Lymphoma

$513,447 2014 2016

PCFA Development and evaluation of novel TSPO radiotracers for imaging prostate cancer using positron emission tomography

$300,000 2013 2015

ARC

Linkage Grant

Med–graphic avatar – a comprehensive, holistic and customizable model for personal health care records

$386,000 2011 2014

*Associate investigator on this grant

Abbreviations: ARC = Australian Research Council; NHMRC = National Health and Medical Research Council; PCFA = Prostate Cancer Foundation of Australia; MNDRIA = Motor Neuron Disease Research Institute of Australia


Appendix 3: Developing KPIs in RPA Radiology for: a) CT access time for ED patients and b) access

to MR scans for inpatients

Notes:

Table A data excludes CT abdo-pelvis studies due to preparation time being in excess of 1hour

'Seen time' is calculated from the time of receipt of electronic order to the start time of the procedure

Data counted is the number of patient presentations

BD = Business Day

Table A: RPA Radiology KPIs for CT access time for ED patients

KPI - Seen Time of Emergency Department patients requiring CT

Seen Time Target > 1 Business Hour from Electronic Order

Target 90%

EXAM_YEAR CT KPI

(< 1 hr) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Grand

Total

2014 N 43 49 45 33 48 53 51 47 61 48 41 49 568

Y 455 410 454 438 487 459 453 515 504 509 498 476 5658

2014 Total

498 459 499 471 535 512 504 562 565 557 539 525 6226

Achieved Target

91% 89% 91% 93% 91% 90% 90% 92% 89% 91% 92% 91% 91%

2015 N 39 66 58 52 44 69 53 59 51 51 58 67 667

Y 581 491 514 500 505 510 544 539 548 522 543 525 6322

2015 Total

620 557 572 552 549 579 597 598 599 573 601 592 6989

Achieved Target

94% 88% 90% 91% 92% 88% 91% 90% 91% 91% 90% 89% 90%

Change in patient

numbers from

previous year

24% 21% 15% 17% 3% 13% 18% 6% 6% 3% 12% 13% 12%

122 98 73 81 14 67 93 36 34 16 62 67 763

Table B: RPA Radiology KPIs for CT access time for all inpatients - excluding ED

KPI - Seen Time of all inpatients patients requiring CT excluding patients from the Emergency Department;

Seen Time Target> 3 Business Days from Electronic Order

Target 90%

EXAM_YEAR CT KPI

(< 3 BDs) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Grand

Total

2014 N 83 96 59 56 66 43 69 61 60 56 59 58 766

Y 401 358 457 467 495 438 505 476 478 504 471 465 5515

2014 Total

484 454 516 523 561 481 574 537 538 560 530 523 6281

Achieved Target

83% 79% 89% 89% 88% 91% 88% 89% 89% 90% 89% 89% 88%

2015 N 46 62 73 59 45 43 53 53 62 79 75 55 705

Y 422 437 467 437 446 481 454 502 457 457 440 478 5478

2015 Total

468 499 540 496 491 524 507 555 519 536 515 533 6183

Achieved Target

90% 88% 86% 88% 91% 92% 90% 90% 88% 85% 85% 90% 89%

Change in

patient numbers

from previous

year

-3% 10% 5% -5% -12% 9% -12% 3% -4% -4% -3% 2% -2%

-16 45 24 -27 -70 43 -67 18 -19 -24 -15 10 -98


b) Inpatient MR access

Table C: RPA Radiology KPIs for MRI access time for inpatients

KPI - Seen Time of All Inpatients requiring MRI

Seen Time Target > 1 Business Day from Electronic Order

Target 70%

EXAM_YEAR MRI KPI

(< 1 BD) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Grand

Total

2014 N 41 28 41 36 39 46 43 25 32 47 35 45 458

Y 100 94 109 95 121 91 111 104 108 101 110 87 1231

2014 Total

141 122 150 131 160 137 154 129 140 148 145 132 1689

Achieved Target

71% 77% 73% 73% 76% 66% 72% 81% 77% 68% 76% 66% 73%

2015 N 41 50 39 45 44 51 45 49 57 52 60 34 567

Y 104 93 120 104 103 108 110 101 93 97 119 110 1262

2015 Total

145 143 159 149 147 159 155 150 150 149 179 144 1829

Achieved Target

72% 65% 75% 70% 70% 68% 71% 67% 62% 65% 66% 76% 69%

Change in

patient numbers

from previous

year

3% 17% 6% 14% -8% 16% 1% 16% 7% 1% 23% 9% 8%

4 21 9 18 -13 22 1 21 10 1 34 12 140

Table D: RPA Radiology KPIs for MRI access time for inpatients

KPI - Seen Time of All Inpatients requiring MRI

Seen Time Target> 3 Business Days from Electronic Order

Target 90%

EXAM_YEAR MRI KPI

(< 3 BDs) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Grand

Total

2014 N 8 7 18 4 7 15 6 2 5 19 9 13 113

Y 133 115 132 127 153 122 148 127 135 129 136 119 1576

2014 Total

141 122 150 131 160 137 154 129 140 148 145 132 1689

Achieved Target

94% 94% 88% 97% 96% 89% 96% 98% 96% 87% 94% 90% 93%

2015 N 13 15 13 12 13 15 5 11 17 19 17 9 159

Y 132 128 146 137 134 144 150 139 133 130 162 135 1670

2015 Total

145 143 159 149 147 159 155 150 150 149 179 144 1829

Achieved Target

91% 90% 92% 92% 91% 91% 97% 93% 89% 87% 91% 94% 91%

Change in

patient numbers

from previous

year

3% 17% 6% 14% -8% 16% 1% 16% 7% 1% 23% 9% 8%

4 21 9 18 -13 22 1 21 10 1 34 12 140


Appendix 4: RPA Department of PET and Nuclear Medicine Clinical Indicators

The Department has been collecting core clinical indicators since 1999-2000. All clinical indicators are

reviewed on an annual basis for performance, relevance and value and Clinical indicators that are no longer

considered to be valuable are dropped. Demonstrated continuous good performance in some clinical

indicators has meant that these have been moved to random audits. The core indicators - turn-around-time,

correct isotope into the correct patient and wait times – are still measured despite continued very good

performance. The Tables below record data for the last 5 years and the date of the commencement of the

data collection is indicated. All the various steps to improve performance have been deleted for the individual

Indicators below for brevity for this report but they are available for interested readers.

1. Turn-around time (TAT) for patient reports (since 1999)

1a. TAT for PET reports

Fiscal Yr Rate Numerator Denominator % Change in Pt No’s

Mean time for reports to be

finalised (min) = sent to referrers

Median time for reports to be



checked (min) = reporting

completed



completed

2014-2015 99.9% 5,334 5,335 5.4 93.2 83.7 46.5 37.5

2013-2014 100% 5,064 5,064 -1.0 130.5 118.1 53.9 42.6

2012-2013 100% 5,116 5,116 -8.2 125.6 116.8 58.7 41.1

2011-2012 100% 5,573 5,573 -13.5 85.8 74.5 45.6 32.5

2010-2011 99.9% 6,439 6,441 2.5 72.2 56.1 41.5 24.5

2009-2010 99.7% 6,262 6,283 3.1 104.1 71.9 61.3 33.6

Definitions: Rate = All reports are to be completed and sent the same day as the study is completed (Pre 2014-2015, calculated within

a 24 hour time period); Numerator = Number of reports finalised within the nominated time frame; Denominator = Number of patients

scanned; Checked = Report completed and ready to be sent; Finalised = Report sent (faxed / emailed / posted) from the Department by

Office Admin Staff to the Referring Dr.

1b. TAT for ALL reports: PET & NM








completed



completed

2014-2015 99.8% 6,960 6,971 3.7 91.5 78.9 49.2 36.7

2013-2014 99.9% 6,717 6,722 -5.2 125.0 110.1 61.9 44.3

2012-2013 99.9% 7,087 7,090 -6.7 120.3 108.3 69.5 45.0

2011-2012 99.9% 7,591 7,599 -13.0 102.5 77.0 70.8 39.2

2010-2011 99.9% 8,728 8,734 0.2 75.8 54.5 54.6 28.5

2009-2010 99.4% 8,672 8,720 -0.7 115.3 71.7 81.1 37.8

Definitions: see 1a


1c. TAT for NM reports








completed



completed

2014-2015 99.4% 1,626 1,636 -1.3 85.9 57.1 57.7 31.9

2013-2014 99.7% 1,653 1,658 -16.0 108.5 72.8 86.4 52.4

2012-2013 99.8% 1,971 1,974 -2.6 106.7 73.4 97.6 62.7

2011-2012 99.6% 2,018 2,026 -11.6 126.2 89.4 118.1 82.0

2010-2011 99.8% 2,289 2,293 -5.9 105.3 76.2 99.7 54.1

2009-2010 98.9% 2,410 2,437 -9.2 144.5 70.5 132.2 59.1

Definitions: see 1a

2. Waiting time for PET patients to be scanned (2a since 1997; 2b-2e since 2003)

2a. ALL PET scans: Whole Body (WB) - surgical/oncology, Neurological & Cardiac [Old Method]

Fiscal Yr Rate Numerator Denominator Notes

2014-2015 63.0% 3,386 5,335 Old Method This data is kept as it represents the total number of patients scanned and historically this was how the waiting times were calculated. It is not a fair representation of the actual waiting times due to the inclusion of the very large “Other” group, which includes follow-up studies (booked on the day requested often months in advance), patients that have been offered an appointment but have declined and thus are rescheduled and overseas visitors (OSV). Since follow-up appointments are booked when requested the waiting time is considered to be zero. This old method also included weekends and shutdown periods where we are unable to scan. Due to this misrepresentation the Departmental database was modified in July 2003 to enable a more accurate assessment of the waiting times by 1 - ability to identify the “Other” group of patients we are able to exclude them from the calculations and 2 - removing weekends and shutdown periods from the calculations.

2013-2014 66.3% 3,357 5,060

2012-2013 66.0% 3,374 5,115

2011-2012 65.4% 3,644 5,569

2010-2011 57.1% 3,676 6,441

2009-2010 58.2% 3,655 6,283

2008-2009 60.9% 3,711 6,096

2007-2008 64.0% 3,572 5,584

2006-2007 56.5% 2,739 4,850

2005-2006 38.5% 1,727 4,482

1999-2000 32.0% 471 1,472

Definitions: Rate = All patients to be scanned within 1 week of receiving the request; Numerator = Number of patients scanned within 1

week of receiving request; Denominator = Number of patients scanned

2b. ALL PET scans (WB, Neurological & Cardiac) - with exclusions

Fiscal Yr Rate Numerator Denominator Rate 2 Rate 3 Rate 4 Add on patients

Rate 5 Median Wait

(days)

Mean Wait

(days)

Range (days)

2014-2015 100% 2,643 2,643 45.8% 74.0% 88.2% 186 100% 2 1.9 0 - 7

2013-2014 99.9% 2,704 2,708 53.0% 80.2% 92.3% 225 100% 1 1.7 0 - 8

2012-2013 99.4% 2,807 2,825 41.2% 73.6% 88.6% 150 99.9% 2 2.0 0 - 10

2011-2012 97.8% 3,004 3,073 30.8% 63.7% 81.1% 96 99.9% 2 2.5 0 - 12

2010-2011 96.8% 3,296 3,404 14.2% 57.8% 71.3% 66 99.8% - - -

2009-2010 97.3% 2,988 3,070 16.0% 47.0% 69.5% 70 99.8% - - -

Definitions: Rate = All patients to be scanned within 1 week of receiving the request; Numerator = Number of patients scanned within 1

week of receiving request; Denominator = Number of patients scanned; Exclusions = removing the “Other” group, weekends and

shutdown periods for the cyclotron when it is not possible to scan; Groups = Urgent (<3 days), Semi-Urgent (<7 days), Non-Urgent (<14

days or no specified date), Other = Follow-up appointments, OSV, patients that reschedule, Trial Patients etc.; Rate 2 = Urgent, Semi-


Urgent & Non-Urgent patients scanned within 1 day of receiving request; Rate 3 = Urgent, Semi-Urgent & Non-Urgent patients scanned

within 2 days of receiving request; Rate 4 = Urgent, Semi-Urgent & Non-Urgent patients scanned within 3 days of receiving request;

Add ons = additional patients added to the daily schedule without notice such as; i) urgent’s, ii) patients that arrive without a booking

and iii) patients that require an additional study that wasn’t identified until the patient was in the Department (e.g. poor request

information, at the patient’s request etc.); Rate 5 = Urgent and Semi-Urgent patients scanned within 7 days of receiving request

2c. WB PET scans - with exclusions

Fiscal Yr Rate Numerator Denominator Number of WB scans

(no exclusions)

Rate 5 % Change in WB scans

Median Wait (days)

Mean Wait (days)

Range (days)

2014-2015 100% 2,461 2,461 4,947 100% 5.6 2 1.9 0 - 7

2013-2014 99.8% 2,490 2,494 4,684 100% -0.6 1 1.7 0 - 8

2012-2013 99.5% 2,583 2,596 4,714 100% -9.1 2 2 0 - 10

2011-2012 98.1% 2,802 2,857 5,185 99.9% -14.0 2 2.4 0 - 12

2010-2011 97.0% 3,063 3,157 6,032 100% 3.4 - - -

2009-2010 97.5% 2,784 2,854 5,831 99.9% 3.0 - - -

Definitions: see 2b

2d. Neurological PET scans - with exclusions

Fiscal Yr Rate Numerator Denominator Number of Neuro scans

(no exclusions)

Rate 5 % Change in Neuro scans

Median Wait (days)

Mean Wait (days)

Range (days)

2014-2015 100% 177 177 381 100% 2.1 2 2.1 0 - 7

2013-2014 100% 212 212 373 100% -5.3 1 1.9 0 - 6

2012-2013 97.8% 218 223 394 100% 5.1 2 2.6 0 - 9

2011-2012 92.9% 195 210 375 100% -2.7 3 3.7 0 - 12

2010-2011 93.7% 193 206 385 100% -11.3 - - -

2009-2010 94.1% 193 205 434 100% 6.9 - - -

Definitions: see 2b

2e. Cardiac PET scans - with exclusions

Fiscal Yr Rate Numerator Denominator Number of Neuro scans

(no exclusions)

Rate 5 % Change in Neuro scans

Median Wait (days)

Mean Wait (days)

Range (days)

2014-2015 100% 5 5 7 100% 133.3 2 2.0 1 - 3

2013-2014 100% 2 2 3 100% -57.1 2 2 2 - 2

2012-2013 100% 6 6 7 100% -22.2 1 1.3 1 - 2

2011-2012 87.5% 7 8 9 100% -166.7 2 2.8 1 - 10

2010-2011 100% 17 17 24 100% 33.3 - - -

2009-2010 100% 11 11 18 100% -35.7 - - -

Definitions: see 2b


3. Correct isotope administration into the correct patient (since 1996)

3. PET & NM

Fiscal Yr Rate Numerator Denominator Investigation of incidents (from 2008 onwards)

2014-2015 99.9% 6,970 6,971 1 NM patient was given DMSA orally instead of DTPA for a gastric emptying study - study was able to be interpreted with no consequence to the patient

2013-2014 100% 6,722 6,722 -

2012-2013 100% 7,090 7,090 -

2011-2012 100% 7,599 7,599 -

2010-2011 100% 8,734 8,734 -

2009-2010 99.9% 8,719 8,720 1 NM patient was injected with MIBI instead of mIBG due to misinterpretation of request form by the referring Dr and our staff

Definitions: Rate = All patients should be given the correct isotope; Numerator = Number of correct isotope administrations;

Denominator = Number of patients scanned

4. Daily scanner quality control (QC) (since 1996)

4. QC is performed, checked and recorded

Fiscal Yr Rate PET scanners

Rate NM scanners

Rate for all scanners

Scanner events

2014-2015 100% 100% 100% Recommend that this CI be moved to a yearly audit. JB 11/2/16

2013-2014 100% 98.8% 99.3% -

2012-2013 100% 100% 100% -

2011-2012 100% 100% 100% -

2010-2011 100% 100% 100% PET: Truepoint PET-CT scanner decommissioned December 2010, replaced by a 2nd mCT PET-CT scanner (bCT) 1st bCT pt scanned 4/2/11

2009-2010 100% 100% 100% PET: Biograph PET-CT scanner decommissioned November 2009, replaced by mCT PET-CT scanner. 1st mCT pt scanned 14/12/09

Definitions: Rate = All scanner QC should be performed, checked and recorded

5. Staff radiation monitoring (since 2006)

5a. Medical Radiation Scientists (MRS)

Fiscal Yr Rate - WB Numerator Denominator Rate - Finger Numerator Denominator

2014-2015 3.9% 6 153 3.3% 5 153

2013-2014 1.5% 2 131 3.1% 4 130

2012-2013 0% 0 121 5.9% 7 119

2011-2012 3.6% 4 112 0.9% 1 110

2010-2011 12.4% 16 129 10.1% 13 129

2009-2010 6.1% 8 131 9.9% 13 131

Definitions: Rate = No notifications should be received; Numerator = Number of notifications; Denominator = Number of badges

issued;


5b. Scientific & Chemistry staff

Fiscal Yr Rate - WB Numerator Denominator Rate - Finger Numerator Denominator

2014-2015 6.8% 8 118 2.5% 6 239

2013-2014 2.4% 3 125 1.7% 4 237

2012-2013 4% 4 113 0% 0 203

2011-2012 6.3% 7 112 0.5% 1 198

2010-2011 10.4% 10 96 0.6% 1 166

2009-2010 11.9% 10 84 0% 0 132

Definitions: see 5a

5c. Medical & Nursing staff

Fiscal Yr Rate - WB Medical

Numerator Denominator Rate - Finger

Medical

Numerator Denominator Rate - WB Nursing

Numerator Denominator

2014-2015 4.8% 2 42 0% 0 16 0% 0 69

2013-2014 0% 0 53 0% 0 24 0% 0 70

2012-2013 0% 0 57 0% 0 23 0% 0 67

2011-2012 0% 0 58 0% 0 24 0% 0 71

2010-2011 1.7% 1 60 0% 0 24 0% 0 82

Definitions: see 5a

6. PET patient service measures (6a since 1999; 6b-6c since 2004)

6a. PET patients inconvenienced by FDG supply problems

Fiscal Yr Rate 1 Numerator 1 Denominator Rate 2 Numerator 2 Denominator Comment

2014-2015 0% 0 5,335 0% 0 5,335

2013-2014 0% 0 5,064 0% 0 5,064 January 2014 - Cyclotron received TGA Licence

2012-2013 0% 0 5,115 0% 0 5,115

2011-2012 0.4% 22 5,573 0.3% 17 5,573 30/4/12 Cyclotron breakdown requiring parts, 1st inj 16:27 - 5 pts scanned; 17 patients were postponed

2010-2011 0.4% 27 6,441 0% 0 6,441 18/2/11 FDG module problem, 1st inj 8:15 - all pts scanned

2009-2010 0% 0 6,283 0% 0 6,283

Definitions: Rate 1 = No PET Patients should be inconvenienced by FDG supply problems; Rate 2 = No PET Patients should be

postponed due to FDG supply problems (RPA production data only); Numerator 1 = Number of patients inconvenienced by > 45

minutes due to FDG supply problems; Denominator = Number of patients scanned; Numerator 2 = Number of patients postponed to

another day due to FDG supply problems.


6b. PET patients inconvenienced by scanner problems

Fiscal Yr Rate 1 Numerator 1

Denominator Days with only 1

scanner

Number of scanning

days

Rate 2 Numerator 2

Denominator Comment

2014-2015 0.82% 44 5,335 19.5 249 0% 0 5,335

2015 Mar, Apr mCT & bCT upgrade to CBM 11/5/15 - bCT ICS down 17/2/15 - bCT PRS down 21/7/14 - bCT CT error

2013-2014 0% 0 5,064 6.5 247 0% 0 5,064

2012-2013 0.74% 38 5,115 20 245 0.12% 6 5,115 9/8/12 - mCT water leak 15/10/12 - mCT PET temp error 12/4/13 - bCT cooling system

2011-2012 0.39% 22 5,573 0.04% 2 5,573 30/9/11 - mCT restart error 28/10/11 - mCT leaking fluid 29/5/12 - bCT failed restart

2010-2011 0.73% 47 6,441 0.09% 6 6,441 4/2/11 - 1st bCT pt scanned Truepoint decommissioned Dec 2010

2009-2010 0.56% 35 6,283 0.14% 9 6,283 14/12/09 - 1st mCT pt scanned Biograph decommissioned Nov 2009

Definitions: Rate 1 = No PET Patients should be inconvenienced by scanner problems; Rate 2 = No PET Patients should be

postponed due to scanner problems; Numerator 1 = Number of patients inconvenienced by > 45 minutes due to scanner

problems;Denominator = Number of patients scanned; Numerator 2 = Number of patients postponed to another day due to scanner

problems; Scanner = PET-CT scanner plus associated computer acquisition and processing systems; CBM = Continuous bed motion

6c. PET patient “No Shows” and patient factor cancellations

Fiscal Yr Rate 1: No Shows

Numerator 1 Denominator 2nd appt given Rate 2 Numerator 2 Denominator

2014-2015 1.35% 72 5,335 49 0.32% 17 5,335

2013-2014 1.52% 77 5,064 52 0.06% 3 5,064

2012-2013 1.21% 62 5,115 45 0.14% 7 5,115

2011-2012 1.40% 78 5,573 59 0.11% 6 5,573

2010-2011 1.63% 105 6,441 76 0.17% 11 6,441

2009-2010 1.80% 113 6,283 82 0.13% 8 6,283

Definitions: Rate 1 = Patients that fail to show up for their appointment; Rate 2 = Patients that are cancelled due to patient factors

(illness, claustrophobia, high BSL, refusal); Numerator 1 = Number of patients that are no shows;Denominator = Number of patients

scanned; No Show = patients (or their representative) who were given and accepted an appointment but failed to turn up.

7. Quality testing of tracers produced in the RPA cyclotron (since 2002)

7a. Quality testing of clinical batches of F-18 tracers produced in the RPA cyclotron

Fiscal Yr Rate FDG Numerator Denominator Rate NaF Numeator Denominator Rate Fluoride

(API)

Numerator Denominator

2014-2015 99.7% 332 333 100% 32 32 100% 5 5

2013-2014 100% 249 249 100% 3 5,064


7a. Quality testing of clinical batches of F-18 tracers produced in the RPA cyclotron

2012-2013 100% 248 248 100% 7 5,115

2011-2012 100% 259 259

2010-2011 100% 248 248

2009-2010 100% 249 249

Definitions: Rate = All batches produced should pass QC; numerator = Number of batches that passed; Denominator = Number of

batches produced; FDG = Fluorodeoxyglucose; NaF = Sodium Fluoride; API = Active Pharmaceutical Ingredient

7b. Quality testing of clinical batches of C-11 tracers produced in the RPA cyclotron

Fiscal Yr Rate PIB Numerator Denominator

2014-2015 100% 4 4

Definitions: see 7a

8. PET-CT patient uptake times

8a. bCT Scanner - WB studies: Desired uptake = 60 minutes

Fiscal Yr Rate +/- 2min Rate below (-2)

Rate above (+2)

Range (min) Mean Median Rate +/- 5min

2014-2015 79.3% 0.76% 19.9% 50 - 105 60.5 59 91.6%

2013-2014 80.9% 0.70% 18.2% 55 - 163 60.6 60 91.6%

2012-2013 84.2% 0.50% 15.2% 50 - 96 60.3 59 94.0%

2011-2012 73.8% 3.30% 23.0% 52 - 96 61 60 89.5%

2010-2011 56.5% 21.0% 22.0% 51 - 138 60.8 59 88.7%

Definitions: Rate = All patients should be injected within +/- 2min of the desired uptake; Uptake = Time between injection and start of

scan

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