MIDLAND REGION CLINICAL ACCESS CRITERIA FOR COMMUNITY REFERRED RADIOLOGY Review V8 July 2016

Transcription

1 MIDLAND REGION CLINICAL ACCESS CRITERIA FOR COMMUNITY REFERRED RADIOLOGY Review V8 July 2016 Page 1 of 31

2 Contents Introduction... 3 General X-ray Abdomen... 4 Ankle... 4 Chest... 5 Paediatric Chest... 5 Elbow... 5 Hand/Wrist... 6 Hip... 6 Paediatric Hip... 7 Knee... 7 Shoulder... 8 Skull... 8 Spine... 8 TMJ... 8 Ultrasound (US) Abdomen... 9 Carotid Doppler... 9 Paediatric Hips... 9 Paediatric Renal... 9 Renal Pelvic Scrotal Neonatal Spine Thyroid Vascular Computed Tomography (CT) CT Head CT Chest CT Abdomen CT KUB CT Colonography CT Sinus Mammography and Breast Ultrasound Mammography Ultrasound Breast Prioritisation Methodology...20 Appendix 1 - Current by DHB Appendix 2 - Planned by DHB Appendix 3 al Advisory Group Members Page 2 of 31

3 Introduction The following regional access criteria for primary referred radiology referrals have been developed from a number of sources, including the draft National Community Radiology Criteria (Nov 2013). These criteria have been developed to improve equity of access across the Midland Region. They are a minimum that should be provided and should be read in conjunction with the Prioritisation Methodology detailed in Appendix 2 (when we have redefined this in line with National guidelines). DHB s will advise local GP s where copies of these access criteria are available. We are unable to accept any patient referral for investigation without the required actions being completed and the results supplied with the referral. If your patient does not meet the criteria but you think that an investigation is warranted, please phone a DHB Radiologist for advice. If they advise an investigation please document their name as well as all clinical information on the referral form. Primary Care Nurse Practitioner Referrals The RANZCR considers that appropriately qualified Nurse Practitioners should be able to refer for diagnostic imaging testing within their particular clinical context as approved by the local radiation licensee. NPs are expected to apply the practice expectations for public protection set out in the Nurse Practitioner practice standard Competencies for the nurse practitioner scope of practice Page 3 of 31

4 GENERAL X-RAY Abdomen Standard indications for x-ray referral Diagnosis of constipation where patient history is unobtainable e.g. autism, special needs Follow up of diagnosed renal stones with a KUB x-ray Suspected renal tract stone use local pathway Referral for x-ray not typically indicated Acute abdomen: Discuss with acute surgical services or emergency services access points Vague central abdominal pain Suspected colorectal neoplasm (refer to colorectal cancer guidelines) Suspected constipation (other than in specific patient groups as above). Suspected abdominal masses refer to ultrasound Ankle Standard indications for x-ray referral Two of the below needed to qualify. The pain has been present for >4 weeks. The pain was sudden in onset and is severe and <4 weeks duration. There is pain or swelling where previous arthroplasty There is a palpable mass or deformity. There is limited ROM (range of movement). There is evidence of inflammatory arthritis. Known arthritis with symptoms meeting local criteria for surgical consideration (if has not been xrayed in the past 6 months) Referral for x-ray not typically indicated Suspected septic arthritis: refer for acute review Acute gout. Ankle Trauma Use Ottawa Ankle Rules Page 4 of 31

5 Chest Standard indications for x-ray referral The x-ray result will influence patient management. Follow up xray where abnormal x-ray related to infection or failure following treatment *take out Referral for x-ray not typically indicated Pneumonia doesn t require routine CXR follow up unless there are risk factors or red flags including age>50 years or age >40 years if smoker, suspicious radiologic findings on initial CXR or incomplete clinical resolution at 6 weeks (this is a guideline only and there may be local pathways which apply) Routine assessment of hypertension Routine monitoring of known pulmonary sarcoidosis Routine x-ray for asbestos exposure surveillance Follow-up of nodules detected on chest x-ray or CT other than where recommended by reporting or reviewing specialist (consider referral for respiratory specialist review) Initial investigation of heart murmur, unless signs of complications such as heart failure Routine follow-up of asymptomatic patients on amiodarone. Paediatric Chest Standard indications for x-ray referral Acute chest infection/sepsis consider acute referral to specialist as per local pathway Recurrent productive cough if resistant to treatment or additional clinical features i.e. pyrexia Wheeze with additional features such as fevers and localised crackles, chronic heart or respiratory disease and immunocompromised patients Suspected/inhalation foreign body. Referral for x-ray not typically indicated Incidental finding of a murmur Uncomplicated (afebrile) presentation of asthma/bronchiolitis. Elbow Standard indications for x-ray referral Pain has been present for >4 weeks and no response to treatment and/or not reproduced on examination. Unrelenting severe pain <4 weeks. Significant restriction in ROM (range of movement) after 4 weeks. Unexplained deformity/palpable enlarging mass or swelling. There is evidence of inflammatory arthritis. Referral for x-ray not typically indicated Page 5 of 31

6 Suspected septic joint: refer for acute review Acute gout Hand/wrist Standard indications for x-ray referral Swelling confirmed on examination Deformity Strong history of Inflammatory symptoms >12 weeks with increased inflammatory markers +/- swelling +/- deformity Long (>1year) history of Inflammatory symptoms (without increased inflammatory markers or swelling or deformity) Pain with red flags Red flags include: Persistent deep pain unrelated to activity Night pain in the absence of obvious cause. Referral for x-ray not typically indicated Acute gout Suspected inflammatory arthritis <12 weeks with no significant inflammatory markers or swelling or deformity Guidance Dedicated wrist views do not typically provide additional information to single PA hand view. Where inflammatory arthritis is suspected consider requesting an AP feet x-ray as well. Hip Standard indications for imaging referral Undiagnosed hip pain present for more than 4 weeks where the x-ray is expected to change management Hip pain with red flags and / or history of recent injury Known osteoarthritis where symptoms meet local criteria for surgical consideration (not required if previously x-rayed within 6 months) Pain in previous arthroplasty. Red flags include: Persistent deep pain unrelated to activity Night pain in the absence of obvious cause. Referral for x-ray not typically indicated Suspected septic arthritis: refer for acute review at Emergency Department /Orthopaedic Department Mild symptoms and normal examination findings Follow up of known or suspected osteoarthritis unless development of red flags or meets local criteria for surgery Page 6 of 31

7 Paediatric Pelvis/hips Standard indications for x-ray referral Pain Limp Risk factors/ soft signs or suspected development dysplasia of the hip (DDH) after 5-6 months of age. Guidance Capital femoral epiphyses ossify on average at 5-6 months of age; DDH can usually be reliably excluded from this age onwards on x-ray. Slipped upper femoral epiphysis require urgent orthopaedic referral. < 5-6 months of age if clinical suspicion of DDH ultrasound is the investigation of choice refer local pathway Paediatric Lower and Upper limb Standard indications for x-ray referral Focal bone pain Referral for x-ray not typically indicated Osgood-Schlatters, Severs and other apophysitides- x-rays not generally required for diagnosis or management Knee Standard indications for x-ray referral, typically performed erect *take out Undiagnosed knee pain present > 4 weeks where the x-ray is expected to change management Knee pain with red flags Known osteoarthritis with symptoms meeting local criteria for surgical consideration (not required if previously x-rayed within 6 months) Pain in previous arthroplasty Swelling or deformity Red flags include: Persistent deep nagging pain unrelated to activity Night pain in the absence of an obvious cause Referral for x-ray not typically indicated Suspected septic arthritis: refer for acute review Mild symptoms and normal examination finding Follow up of suspected or known osteoarthritis unless red flags develop or clinically now meets criteria for surgical consideration Suspected meniscal and ligament injury Page 7 of 31

8 Shoulder Standard indications for x-ray referral Suspected bone/joint pathology (>4 weeks) with red flags present Pain in previous arthroplasty *take out put in ankle known OA Red flags include: Any unexplained deformity, mass, or swelling Persistent deep nagging pain unrelated to activity Night pain in the absence of an obvious cause Referral for x-ray not typically indicated Recent onset pain in the absence of red flags Frozen shoulder (unless the condition does not follow its expected natural history) Pre-requisite for a trial of steroid injection (when a reasonable clinical diagnosis has been made and red flags are excluded) Suspected septic arthritis: refer for acute review at Emergency Department /Orthopaedic Department. Skull Routine x-ray not indicated. Please discuss with radiologist if concerns. *out Spine Standard indications for x-ray referral Unrelenting spine pain > 8 weeks Spine pain with red flags Spine pain and osteoporosis or prolonged use of corticosteroids Significant spinal deformity Red flags include: Persistent deep pain unrelated to activity Night pain in the absence of obvious cause History of cancer Immunosuppression Signs of infection : refer for acute review Referral for x-ray not typically indicated Coccyx pain Acute uncomplicated spine pain without red flags Guidance For high clinical suspicion of infection or cancer consider referral for acute review Page 8 of 31

9 TMJ Xray is not indicator for TMJ pain Sinuses Plain Xrays are not indicated Page 9 of 31

10 ULTRASOUND Abdomen Standard indications for ultrasound referral Asymptomatic with abnormal Liver Function Test (LFTS) - more than 1.5 times normal range persisting for at least 3 months Suspected biliary tract obstruction or malignancy (infective causes and medications excluded) e.g. persistently raised ALP/?GAT +/- bilirubin Abdominal mass or other palpable abdominal abnormality Painless jaundice without obvious cause Clinical biliary colic/gallstones (not already imaged) or use established pathway Suspected asymptomatic aortic aneurysm (AAA)- Refer to local vascular guidelines - Required Actions Please supply appropriate biochemistry and dates with abdominal ultrasound referral Carotid Doppler Use local pathways Not typically indicated for asymptomatic carotid bruits Paediatric Hips No direct access; refer local pathway Paediatric Renal Refer local pathway Page 10 of 31

11 Renal Standard indications for ultrasound referral Loin pain suggesting renal tract obstruction Haematuria persistent isolated microscopic haematuria > 25 year old (defined as 2 or more episodes of positive urine dipstick of 1+ or more i.e. not trace) and infection excluded and renal impairment (as defined below) macroscopic haematuria with UTI excluded persistent isolated microscopic haematuria >25yo (on two or more on MSU; not dipstix) and infection excluded and normal renal function Chronic urinary retention with palpable enlarged bladder Renal Impairment No prior relevant renal imaging and recheck with good hydration. Acute kidney injury (increase in serum creatinine of more than 50% from baseline and/or decrease in egfr of more than 50% from baseline) AND Consider direct referral to renal service. Progressive chronic kidney disease (> 5 ml/min/year egfr loss or > 10 mls/min over 3 years) Polycystic kidney screening >20 years where family history Guidance Proteinuria >1.0g/24hours or protein/creatinine ratio >100 mg/mmol or albuminuria (albumin/creatinine ratio>65 mg/mmol) - consider referral to renal physician If long term stable elevated creatinine/low egfr then potential for any reversibility low therefore US findings unlikely to change management. In diabetic with known diabetic complications, ultrasound may not be indicated. Groin Standard indications for ultrasound referral Non reducible groin mass present for >3 weeks. If mass is suspicious for cancer please refer to specialist Page 11 of 31

12 Guidance Most hernias can be diagnosed clinically and ultrasound is rarely required Some local pathwayts may exist for hernia Page 12 of 31

13 Adult UTI urea splitting organisms, history of malignancy, calculi, previous surgery, obstruction symptoms Or in: Females: > 3 documented UTI's in 6 months, or 6 in a year despite adequate courses of culture specific antibiotics. This pattern implies bacterial persistence rather than recurrence. (Ensure that patient has not previously been investigated with imaging) Males: Recurrent pyelonephritis with no previous imaging. Recurrent or persistent infections (if not previously investigated with imaging) Paediatric Renal US (please see local guidelines) Child < 12 months with first UTI Any child with recurrent UTI or complicated UTI Follow up of antenatal hydronephrosis or as recommended by specialist Required Actions Please supply appropriate biochemistry and dates with renal ultrasound referral Neck US Standard indications for ultrasound referral Salivary gland mass persisting for > 3 weeks Suspected lymph node or undifferentiated neck mass - >3 weeks, > 1.5cm and no obvious infection or medical cause Guidance If cancer is suspected, refer local specialist Page 13 of 31

14 Pelvic Standard indications for ultrasound referral Post menopausal bleeding (bleeding after 1 year of amenorrhoea) Pelvic Mass or uterine size >12 weeks. Request Ca125 also Primary amenorrhoea (delay menarche after age of 18years with appropriate endocrine assay) IUCD not visible Polycystic Ovary Syndrome (PCOS) only if appropriate biochemical signs of hyperandrogensism or oligo- or amenorrhoea. If both present US not required. Chronic Pelvic pain/ suspected endometriosis persisting symptoms over at least 3 month with PID excluded Heavy menstrual bleeding (heavy cyclical menstrual bleeding over several cycles) and Age > 45years or Age >35years with at least one of the following: Weight >90kg Risk factors for endometrial hyperplasia (nulliparity, infertility, FH endometrial/colon cancer, use of either Tamoxifen or unopposed oestrogens, P.C.O.S) First degree relative less than 60 years old with a diagnosis of endometrial or bowel cancer Suspected ovarian cyst (tenderness and pain for > 4 weeks) Required Actions All referrers should have completed ALL of the following: I have removed a copper IUCD and observed for 3 months, or there is no IUCD present I have carried out a pelvic examination, visualized the cervix and taken a smear and STI check if appropriate Those patients without risk factors have had no improvement with a three month trial of medical management (hormonal/tranexamic acid/mirena) Appropriate biochemical profiles to be supplied for PCOS Ultrasound referrals Local pathways should be followed Not typically indicated for Page 14 of 31

15 Fibroud followup, simple ovarioan cyst <5cm in pre-menopausal/ low risk woman Primary dysmenorrhea Page 15 of 31

16 Scrotal Standard indications for ultrasound referral Scrotal masses with concerning features i.e. testicular, painless, nontransilluminating, rapidly growing (urgent urology referral recommended) Scrotal masses where it is unclear if the swelling is testicular or extratesticular New hydrocele in adults (may be secondary to testicular cancer). Referral for imaging not typically indicated Non-solid (transilluminating) scrotal masses Hydrocoele in children Long-standing hydrocoele in adults Acute inflammatory conditions and only refer for ultrasound if symptoms and /or swelling fail to resolve with antibiotics Chronic orchalgia in the absence of abnormality on examination Guidance Urgent referral to Urology or General Surgery should not be delayed by a wait for ultrasound scan if there are red flags for: testicular torsion testicular cancer strangulated inguinal hernia acute testicular trauma Scrotal masses can often be diagnosed clinically. If unsure, seek a second opinion from a general practitioner colleague or specialist. Neonatal Spine No direct access Thyroid Standard indications for ultrasound referral Rapidly enlarging mass. (If you have any concerns discuss or refer to an Endocrinologist or a Hospital Specialist red flags for malignancy <20 years and >60 years history of neck cancer rapid growth of nodule hard, ill-defined Page 16 of 31

17 or fixed nodule, hoarseness, dysphagia or dysphoria, cervical lymphadenopathy) Euthyroid goitre Palpable nodules Page 17 of 31

18 Vascular Standard indications for ultrasound referral Pulsatile mass for investigation Suspected deep venous thrombosis (DVT) use local pathway Page 18 of 31

19 CT SCANNING CT Head Standard indications for CT referral Undiagnosed cognitive impairment with one or more high risk featuresage less than 60 rapid (i.e 1 or 2 months) unexplained decline in cognition or function recent and significant head trauma unexplained neurological symptoms (eg new onset of severe headache or seizures) History of cancer with high risk of intracranial metastases (particularly lung, breast, colon/pancreatic, genitourinary, melanoma, head and neck cancers and lymphoma). use of anticoagulants or history of bleeding disorder history of the combination of urinary incontinence, balance and gait disorder early in the coursed of dementia as may be found in Normal Pressure Hydrocephalus (NPH) any new localising sign (eg hemiparesis or a Babinsky reflex) unusual or atypical cognitive symptoms or presentation (eg progressive aphasia) gait disturbance Chronic Headache (lasting more than 3 months for more than 15 days per calendar month) with one or more of the following: new onset >50 yrs change in pattern of headaches with increase in frequency or severity aggravated by exertion or Valsalva associated with nausea and vomiting background systemic illness with cerebral complications or im=nvilvement; especially malignmancy (breats, lung, melanoma) Cognitive Decline The main reason for imaging is to identify and rule out pathologies other than Dementia of the Alzheimer s type and Vascular Dementia. A careful neurological screening examination is to be carried out including a brain CT scan, if there are one or more of the following in addition to cognitive decline (for example a MoCA Score of less than 26 or similar decline using validated assessment tools see initial cognitive assessment node): If a CT is indicated, clinician (GP or hospital doctor) to request via radiology as per local pathway agreements. Headache in Children Page 19 of 31

20 As per local pathway Page 20 of 31

21 Guidance While CT may be appropriate as part of the workup, initial discussion with a local relevant specialist is recommended for patients with: Focal neurological signs Notes Clinical circumstances determines urgency If patient is pregnant consider specialist opinion Additional Notes Cognitive Decline If you are unsure or there are unusual/atypical symptoms, or there is clinically significant immunosuppression, then seek advice through the advice line in your local information node CT Chest On recommendation by Radiologists from an Abnormal Chest Xray with suspected cancer reported. Required Actions Please enclose a copy of the report recommending further investigation with your referral Specialist referral should not be delayed whilst waiting for an investigation where there are red flag symptoms CT Abdomen On recommendation by Radiologists from an Abnormal Ultrasound or CT Colonography with suspected cancer reported. Required Actions Please enclose a copy of the report recommending further investigation with your referral Specialist referral should not be delayed whilst waiting for an investigation where there are red flag symptoms Page 21 of 31

22 CT KUB Referral for CT KUB is the preferred imaging investigation for: Non pregnant patients with renal colic Guidance Referral should be guided by your local pathway which may include Primary Options Consider renal ultrasound in younger or pregnant patients CT Colonography Use local pathway CT Sinus Referral for CT sinus not indicated unless there is local pathway which supports this, where there is failed medical management Page 22 of 31

23 MAMMOGRAPHY AND BREAST ULTRASOUND Mammography Please refer to local pathways which would supercede these guidelines Asymptomatic Women a mother or sister or daughter with pre-menopausal breast cancer or bi-lateral breast cancer, or a breast histology demonstrating an at risk lesion. Imaging to start 10 years before diagnosis of the youngest first degree relative, but not before 30 years. Alternating with BSA from 45 years. NOTE: MRI is advised if less than 30 years refer to specialist. a breast histology demonstrating an at risk lesion (for example,atypical hyperplasia If previous breast cancer annually. NB After 5 years can re-enter BSA Symptomatic Women If new breast symptom, not lactating or pregnant and any of the following: Palpable lump and no normal mammogram in the last year Bloody or serous nipple discharge 35 years and over (If under 35 refer for Ultrasound) New inversion of Nipple) Referral for Mammogram not typically indicated for: Breast pain without associated lumps or other symptoms Bilateral male breast enlargement Guidance If you are unsure please discuss with a radiologist Page 23 of 31

24 Page 24 of 31

25 Ultrasound Breast Women <35 years with symptoms as follows: Palpable lump and no normal mammogram in the last year Bloody or serous nipple discharge New inversion of Nipple) Men with unexplained or suspicious unilateral breast enlargement Axillary lymph node enlargement or suspected lymph node enlargement in the absence of obvious infectious cause. Referral for ultrasound not typically indicated Breast pain alone Bilateral male breast enlargement. Guidance Referral to local breast service for advice / assessment and multidisciplinary work up is preferable and where this is available locally would supersede these recommendations In the absence of access to breast clinic services patients over the age of 35 and all patients presenting with suspicious masses should be referred for mammography along with ultrasound as part of the initial work up. Pagets disease is not excluded with normal imaging. If clinical concern seek Surgical assessment. Page 25 of 31

26 Prioritisation Methodology The following methodology will be used by Midland DHB Radiology Departments. It is subject to the interpretation of clinical information in the referral and service capacity. Note that any procedure should only be requested where the results (either positive or negative) will alter the management of the patient s condition/will either confirm or eliminate significant disease from the differential diagnosis. URGENT: Priority description Where immediate treatment and management of acute condition is dependent on diagnosis: Timeframe Imaging takes place within 7 working days. High clinical probability of malignancy or serious inflammatory/infective condition. High clinical probability of fracture. Major functional impairment including uncontrolled pain. Risk of significant permanent damage to tissues or systems if diagnosis is delayed. SEMI-URGENT: Conditions where there is possibility of malignancy, serious inflammatory / infective condition, and complications or where imaging may affect short term management. Imaging takes place within 4 weeks. ROUTINE: Conditions with minor functional impairment and where imaging is unlikely to affect short term management, but likely to affect long term management. DECLINED: Imaging takes place within 6 weeks (key performance indicator measure) Referrals that meet the criteria but are unable to be offered within 4 months Referrals that do not meet the criteria Page 26 of 31

27 Appendix 1 Current by DHB Table by DHB showing CURRENT referral access pathway by procedure type Procedure BOP DHB Lakes DHB Tairawhiti DHB General X-ray Abdomen Ankle Chest Paediatric Chest Elbow Hand/Wrist Hip Paediatric Pelvis/hips Paediatric Lower/Upper Limb Knee Shoulder Spine Ultrasound Abdomen Carotid Doppler, Local Gallbladder Local Paediatric Hips No, Local Local Local Local Renal Paediatric Local Local Renal Pelvic, Local HMB Taranaki DHB On Hold On Hold Waikato DHB Vascular Lab No direct, Paediatric Orthopaedic Clinic Page 27 of 31

28 Scrotal Thyroid Vascular for AAA, DVT CT Scanning CT Head Headache CT Head Cognitive Decline CT Head Headache in Children CT Chest CT Abdomen No without discussion No, Local No, Local Radiologist recommendation only Radiologist recommendation only CT KUB Local CPO in development Local with Consultant Referral Local with Consultant Referral Chest Physician No Radiologist request only via for AAA, DVT Local with Consultant Referral CT Colonography Local Local Local CT Sinus No Mammography and US Breast Mammography to Private US Breast to Private for AAA, DVT GP Limited Local with Specialist Referral Local with Specialist Referral Limited Limited Limited via Map of Medicine Renal Colic No Limited Page 28 of 31

29 Appendix 2 Planned by DHB Table by DHB showing PLANNED referral access or pathway by procedure type once new criteria have been published Procedure BOP DHB Lakes DHB Tairawhiti DHB General X-ray Abdomen Ankle Chest Paediatric Chest Elbow Hand/Wrist Hip Paediatric Pelvis/hips Paediatric Lower/Upper Limb Knee Shoulder Spine Ultrasound Abdomen, Local Gallbladder Carotid Doppler Local Local Local Paediatric Hips No Local, Local Renal Paediatric Renal Local Local Pelvic, Local HMB Scrotal Taranaki DHB On Hold On Hold Waikato DHB Vascular Lab No direct, Paediatric Orthopaedic Clinic Local Page 29 of 31

30 Thyroid Vascular for AAA, DVT CT Scanning CT Head Headache CT Head Cognitive Decline CT Head Headache in Children CT Chest Identify volumes Increase CR Contract, identify additional resources Identify volumes Increase CR Contract, identify additional resources No, Local Radiologist recommendation only CT Abdomen Radiologist recommendation only CT KUB Local CPO in development CT Colonography Local with Consultant Referral Local with Consultant Referral Chest Physician No Radiologist request only via for AAA, DVT Local with Consultant Referral Local Local Local CT Sinus No Mammography and US Breast Mammography to Private US Breast to Private for AAA, DVT GP Identify volumes Increase CR Contract, identify additional resources Identify volumes Increase CR Contract, identify additional resources Local with Consultant Referral Radiologist recommendation only Radiologist recommendation only Local pathway via MOM Renal Colic No No Page 30 of 31

31 Appendix 3 Midland Radiology Advisory Group Members Members of the Midland Radiology Advisory Group who have reviewed the Regional Criteria for Community Referred Radiology are as follow: Roger Lysaght Name Title Organisation Service Manager, Ambulatory Service Lakes DHB Andrew Klava HOD Radiology Lakes DHB Gloria Crossley Clinical Services Manager- Allied Health, Scientific & Technical Taranaki DHB Alina Leigh Consultant Radiologist Taranaki DHB Sue Howard Clinical Imaging Manager Taranaki DHB Kevin Harris Assistant Group Manager Waikato Hospital Waikato DHB Zubayr Zaman Consultant Radiologist Waikato DHB Rose Newman Consultant Radiologist Waikato DHB Kim McAnulty Consultant Radiologist Waikato DHB Sabaratnam Muthukumaraswarmy HOD Radiology Waikato DHB Jill Wright Regional Radiology Manager BOP DHB Roy Buchanan HOD Radiology BOP DHB Helen Seymour Consultant Radiologist BOP DHB Gerard Eager Consultant Radiologist BOP DHB Leigh Potter Radiology Service Manager Tairawhiti DHB Charles Robinson HOD Radiology Tairawhiti DHB Lisa Hughes GP Liaison Lakes DHB Mike Agnew/Stewart Ngatai Portfolio Manager Planning and Funding BOP DHB Sue Matthews Primary Options Coordinator WBAY PHO Joe Bourne GP Liaison BOP DHB Nick Hanna GP BOP Rawiri Keenan MHN (GP) Waikato Page 31 of 31