Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Examinations under IR(ME)R

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1 Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging V3.0 December 2013 Page 1 of 11

2 Table of Contents 1. Introduction Purpose of this Policy/Procedure Scope Definitions / Glossary Ownership and Responsibilities Standards and Practice Dissemination and Implementation Monitoring compliance and effectiveness Updating and Review Equality and Diversity... 7 Appendix 1. Governance Information... 8 Appendix 2. Initial Equality Impact Assessment Form Page 2 of 11

3 1. Introduction 1.1. This procedure is designed to enable non medical clinicians to refer patients for clinical imaging This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. The purpose of this policy is to provide a mechanism through which nonmedically qualified staff may refer patients for clinical imaging The document details the clinical governance, training and education required for the role of referrer under the Ionising Radiation (medical exposure) Regulations, known as (IR(ME)R), 2006, the MHRA (2007) recommendations for Magnetic Resonance Imaging (MRI), NPSA (2007) Safer Practice Notice 16 and Medicines (Administration Radioactive) Substances (MARS) 1978). 3. Scope This document is designed to support non medical clinicians or their clinical supervisors through the authorisation process. 4. Definitions / Glossary 4.1 Referrer: Describes the clinician who has met training and governance requirements to request clinical imaging. 4.2 Practitioner: Justifies the requests by ensuring net benefit and appropriateness to clinical care 4.3Operator: Clinician who acquires the imaging. 5 Ownership and Responsibilities 5.1 The document and all related radiology procedures are owned and managed by the Clinical Imaging Service. 5.2 The Clinical Imaging Department is responsible for ensuring those wishing to undertake the role have acceptable protocols in order to comply with the regulations and recommendations that govern our practice. 5.3 Role of the Managers Line managers are responsible for: The non-medical referrer s clinical supervisor and line manager, are responsible for ensuring that the appropriate training has been undertaken to allow this extended role, any training must satisfy the regulatory bodies, RCHT Radiation Protection Advisor and the Professional Lead within Clinical Imaging.. Page 3 of 11

4 5.4 Role of the Clinical Imaging Clinical Governance Group The Clinical Imaging Clinical Governance Group is responsible for: The ratification of protocols prior to Trust approval. This will be evidenced by the additional signatory. 5.5 Role of Individual Staff All staff members are responsible for: The non-medical referrer must have received sufficient training and be assessed as competent to make clinical imaging referrals. 6 Standards and Practice 6.1 Referrals It is the responsibility of the referrer to provide sufficient information to enable the justification of the examination and clarify its expectations. The examination must have a net benefit (i.e. the exposure of the patient to radiation or strong magnetic fields is warranted) and be justified in accordance with the Royal College of Radiologists irefer guidance; the clinical imaging team will decline any referrals that are considered inappropriate. All referrals must be legible and should indicate clearly the name and role of the referrer e.g. Triage Nurse, Community Nurse, Extended Role Physiotherapist In order for the most appropriate examination to be performed the referral must provide the following information regarding the region to be examined and relevant clinical information. The examinations requested must be stated in the clinical imaging protocol otherwise the referral must be discussed with the responsible medical referrer who must also sign the paper referral or make an electronic referral. If the referrer requires guidance, they must seek advice from a medical referrer and where appropriate a radiologist or radiographer prior to the referral. All referrals must be in keeping with IR(ME)R/ MRI referrer protocols in relation to women of childbearing age. It is the referrer s responsibility to check pregnancy status prior to requesting clinical imaging. 6.2 Interpretation The Clinical Imaging Department is responsible for acquiring, analyzing and reporting of diagnostic images, to enable non-medical referrer s to make an informed clinical decision. In the case of unexpected or adverse findings including those outside of the referrer s scope of practice, the professional and clinical responsibility to act on the information appropriately remains with the referrer. The referrer must discuss the findings with the medical clinician who holds overall responsibility for the patient i.e. Consultant/ General Practitioner. Depending upon the urgency of the case this must be immediate action or within the next working day. Page 4 of 11

5 6.3 Image Interpretation Outside of the Clinical Imaging Department For non- medical staff (other than reporting radiographers) responsible for the initial interpretation of plain film radiographs an appropriate education programme must be completed. The results of the image interpretation must be documented within the patient s record and signed by the clinician (medical or non-medical) who undertook the analysis If the findings are adverse or unexpected, the referrer (even if not the responsible medical clinician) retains the duty of care to act on this result appropriately. As detailed in section 6.2, the referrer must discuss the findings with the referrer and medical clinician who hold overall responsibility for the patient i.e. Consultant/ General Practitioner. Depending upon the urgency of the case this must be immediate action or within the next working day. 6.4 IR(ME)R Referrer Education 6.4.1The referrer must meet the requirements relevant to the modality they are requesting (i.e. IR(ME)R, MRI Safety). Non-medical referrers should also consult professional guidance, for example the Guidance for Clinical Imaging Requests from Non-Medically Qualified Professionals (RCR, 2008) which is supported by several professional bodies The clinical imaging service will not provide training in patient assessment or the appropriate use of radiology as a diagnostic tool; this is the responsibility of the requesting department and clinical supervisor For referrer s requesting MRI examinations, training in MRI safety is provided by the MRI team a minimum half day attendance to the department is required. For RCHT employees requesting examinations under IR(ME)R, on-line training is available through the learning management system (LMS); community teams will be given access to on-line training and asked to complete a declaration form. Page 5 of 11

6 6.5 Gaining approval for IR(ME)R referrer Clinical/Service need for non-medical referrer is established The department/ practitioner wishing to undertake the role approaches the Consultant Radiographer in Clinical Imaging to: Discuss their clinical role, Whether this is a new service or replaces medical referrals The imaging they would like to request, The number of patients they anticipate to refer Practitioner(s) must develop a protocol which defines their practice in relation to imaging, (see appendix A), supply a scope of practice and undertake IR(ME)R/MRI/US referrer training. Evidence of training must be demonstrated to the imaging department before the approval of the protocol(s) through a declaration form (CIF.02) obtainable from the imaging service. Each member of staff who will be undertaking the role must sign an entitlement form (supplied by the imaging department) to provide a specimen signature. Each non-medical referrer who will be undertaking the role must sign an entitlement form (CIF.01 supplied by the imaging department) to provide a specimen signature. Each non-medical referrer must complete an Entitlement Form (CIF.01) which is approved by clinical imaging department; the practitioner is then entered onto the departmental database, a request is made to IT for the referrer to be available on CRIS. If appropriate, Maxims accounts are upgraded to gold. A confirmation letter is sent to the Practitioner The non- medical referrer receives written confirmation of approval and requesting rights. Page 6 of 11

7 7 Dissemination and Implementation 7.1 Documents are shared on the Trust documents library 8 Monitoring compliance and effectiveness Element to be monitored Lead Approval process in section 6.5 Governance & Quality Radiographer Tool Frequency Reporting arrangements Ensure audit trail is correct Annually CICG This will be documented in minutes of the meeting The lead or committee is expected to read and interrogate the report to identify deficiencies in the system and act upon them Acting on recommendations and Lead(s) Change in practice and lessons to be shared Governance Radiographer is responsible for acting upon findings within agreed timescales Required actions will be identified and completed in a specified timeframe Consider stating this responsibility in committee terms of reference Learning will be shared with relevant referrer s/teams. Evidence of this will be through CICG minutes. 9 Updating and Review 9.1 Document will be reviewed 3 yearly unless practice dictates otherwise. 9.2 Revisions can be made ahead of the review date when the procedural document requires updating. Where the revisions are significant and the overall policy is changed, the author should ensure the revised document is taken through the standard consultation, approval and dissemination processes. 9.3 Where the revisions are minor, e.g. amended job titles or changes in the organisational structure, approval can be sought from the Executive Director responsible for signatory approval, and can be re-published accordingly without having gone through the full consultation and ratification process. 9.4 Any revision activity is to be recorded in the Version Control Table as part of the document control process. 10 Equality and Diversity This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 7 of 11

8 Appendix 1. Governance Information Document Title Date Issued/Approved: 4 December 2013 CI.REF.01 Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Date Valid From: 4 December 2013 Date Valid To: 4 December 2016 Directorate / Department responsible (author/owner): Christine Bloor, Consultant Radiographer Naomi Burden, Governance Radiographer Contact details: Brief summary of contents Procedure to authorise non medical clinicians to request imaging procedures. Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: October 2013 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: X-ray, MRI, CT. Ultrasound, nuclear medicine, imaging, radiology, IR(ME)R, MARS, ARSAC, MHRA, non-medical referrer, referrals. RCHT PCH CFT KCCG Director of Nursing, Midwifery and Allied Health Professions. Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and X-ray Examinations under IR(ME)R CICG Bruce Daniel, DGM CSSC Emma Spouse, Diagnostics Lead {Original Copy Signed} Internet & Intranet Page 8 of 11 Clinical / Clinical Imaging Intranet Only IRMER, MARS, MHRA, CQC RCHT Patient Identification Policy

9 Training Need Identified? RCHT Consent to Treatment/Examination RCHT Standards of Record keeping RCHT Infection Control RCHT Radiation Safety Policy Ionising Radiation (medical exposure) Regulations Royal College of Nursing Guidance for Clinical Imaging Requests from Non-Medically Qualified Professionals NPSA16 Safer Practice Notice: Early Identification Of Failure To Act On Radiological Imaging Reports. No Version Control Table Date Versio n No Summary of Changes Nov New documented created Sept Reformatted and approved Oct Reformatted and nuclear medicine added Changes Made by (Name and Job Title) Naomi Burden Governance Radiographer Christine Bloor Consultant Radiographer Naomi Burden Governance Radiographer All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 9 of 11

10 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Directorate and service area: Is this a new or existing Policy? Existing Clinical Imaging Name of individual completing Telephone: assessment: N. Burden 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Procedure to authorise non medical clinicians to request imaging procedures. 2. Policy Objectives* Demonstrates the standards and expectations of the Imaging Department when considering and approving non medical requesting. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Maintain high standards Demonstrate compliance with regulations Yearly audit of the process Patients NO b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age x No impact on this group. Page 10 of 11

11 Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership x x x x x No impact on this group. No impact on this group. No impact on this group. No impact on this group. No impact on this group. Pregnancy and maternity x No impact on this group. Sexual Orientation, x No impact on this group. Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. The aim of the procedure is to facilitate patient care, there is no impact in any of the groups. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 11 of 11

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