Enhancing Adherence to British Thoracic Society Guidelines for Follow-Up Chest Radiographs in Community-Acquired...

Community-acquired pneumonia (CAP) is a common respiratory infection in adults, associated with significant morbidity and mortality, particularly among hospitalized patients. National guidelines recommend follow-up chest radiographs (CXRs) for patients with persistent symptoms or elevated risk of occult malignancy, such as smokers or those aged over 50 years. However, inconsistent adherence to these protocols, often due to process-related barriers, necessitates quality improvement initiatives to enhance patient care and reduce diagnostic delays. An internal audit identified poor compliance, prompting this quality improvement project (QIP).

To evaluate and improve adherence to British Thoracic Society/National Institute for Health and Care Excellence guidance for approximately six-week follow-up CXR after CAP using a two-cycle QIP. The primary objective was to improve CXR completion compared with baseline (32%) toward the ≥90% audit standard. Secondary objectives were to increase Virtual Pneumonia Clinic (VPC) referrals and Critical Alert System (CAS) inclusions. These aims were measurable, time-bound, and guideline-aligned, consistent with SMART framing.

A retrospective two-cycle audit in a UK ED was conducted. Cycle 1 included 50 adults with radiologically confirmed CAP (1 November 2023-3 March 2024). Outcomes were completion of a follow-up CXR at approximately six weeks, referral to a VPC (consultant-led virtual follow-up for CAP imaging/clinical review), and inclusion of CAS (electronic, closed-loop radiology alert tool for urgent/safety-critical results with mandatory acknowledgement). Although VPC and CAS are UK-specific labels, their functions, i.e., telehealth follow-up for higher-risk CAP and closed-loop radiology alerts with mandatory acknowledgement, are internationally applicable and align with American Thoracic Society/Infectious Diseases Society of America and best-practice results communication guidance. A multi-component eight-week intervention bundle was implemented (11 March-5 May 2024), comprising staff education, enhanced electronic discharge documentation with mandatory prompts, multilingual patient information leaflets, and a standardized CAS with electronic routing to the named requester. Cycle 2 re-audited 50 consecutive eligible adults (31 March-31 July 2024), and the impact of interventions was assessed.

Cycle 1 showed follow-up completion of 16/50 (32%; 95% CI: 21-46), VPC referral of 12/50 (24%; 95% CI: 14-37), and CAS inclusion of 3/50 (6%; 95% CI: 2-16). Cycle 2 showed follow-up completion of 35/50 (70%; 95% CI: 56-81; χ² p<0.001), VPC referral of 38/50 (76%; 95% CI: 63-86; χ² p<0.001), and CAS inclusion of 36/50 (72%; 95% CI: 58-83; χ² p<0.001). Among ED-discharged patients who completed follow-up, ED-initiated CXR follow-up requests increased from 5/12 (42%; 95% CI: 19-68) to 24/28 (86%; 95% CI: 69-94; Fisher's exact p=0.008). No obvious unintended effects (alert fatigue or workload escalation) were observed during the study period.

A low-cost, multi-component intervention produced statistically significant gains in adherence to follow-up CXR after CAP in our ED (from 16/50 (32%) to 35/50 (70%)). Embedding education, mandatory discharge prompts, patient information, and robust alerting workflows was feasible and scalable. Continued monitoring and iterative optimization are required to achieve and sustain the prespecified ≥90% compliance standard.