CLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING

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1 CLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING RATIONALE The aim of this Protocol is to provide guidance and good practice recommendations for health care professionals involved in clinical imaging processes, regarding requests for all modalities of imaging procedures (ionising and non-ionising) from non-medically qualified health care professionals. To authorise health care practitioners to request specified imaging examinations, practitioners must adhere to the Ionising Radiation Regulations IR (ME)R (2000) and the Royal College of Radiologist Guidelines The Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R 2000) provide health protection of individuals undergoing medical exposures involving ionising radiation, including requirements regarding requests for X-ray examinations. This Protocol applies to registered healthcare professionals undertaking the role of referrer under the Ionising Radiation (Medical Exposure) Regulations IR(ME)R. Procedure complies with NHS Litigation Authority Risk Management Standards (2013) for the Trust for clinical diagnostic tests. Responsibilities under IR(ME)R The Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R 2000) and The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006, require employers to provide a framework for radiation protection for medical exposures. The regulations provide clarity on the responsibilities of the referrer, practitioner and operator, as well as the employer. TARGET GROUP The protocol applies to all clinical staff who request clinical imaging procedures for patients. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. Registered practitioners have a duty of care that cannot be delegated at any time. The Practitioner acting as referrer must be doing so in accordance with IR(ME)R 2000, all practitioners must ensure they have received sufficient training and assessed as competent. All practitioners must have completed IR(ME)R training. Service - Multidisciplinary 1/7

2 RELATED POLICIES Please refer to relevant Trust policies and procedures IMAGING METHODS WHICH USE X-RAYS Radiography This is an X-ray usually for looking at broken bones or at the chest or teeth. A machine directs a beam of X-rays through the part of your body that is being examined and on to a special film. A picture is produced on the film of the structures the X-rays have passed through in your body. Imaging must be undertaken for the benefit of the patient as its primary function. Within the context of IR (ME) R 2000: Unplanned care: The referrer has responsibility for providing sufficient medical information relevant to the imaging procedure requested. The Practitioner (normally a radiographer or radiologist) is responsible for justifying the exposure using information provided by the referrer. The Practitioner will decide the most appropriate clinical imaging procedure. Strictly, the referrer is requesting a clinical opinion from the practitioner rather than an X-ray examination.) Health care professionals may therefore be referrers under these Regulations, provided they have the competence (conferred by training and experience) to provide the medical data required to enable the practitioner (usually a radiologist) to decide whether there is net benefit to the patient from the exposure. This entitlement to act as a referrer would also specify the scope of referrals: that is, the types or range of conditions for which the health professional can be the referrer (e.g. for nurse s injuries to extremities only). Where the radiographer has any doubt about a request, this will be discussed initially with the referrer, and if unresolved, with a Radiologist, before undertaking the examination. Eligibility criteria for a referrer IR (ME) R requirements: The health professional must be currently registered with a professional Body. It is the duty of individual clinician s to maintain their registration The health professional must ascertain whether the service user has had recent imaging from another referral source e.g. GP before requesting X-rays. An up-to-date list of individuals entitled by the employer to act as referrer must be established, maintained and made available to the clinical imaging service provider. This entitlement maybe by name or professional group, and must include the range of referrals that may be made by each. Eligibility criteria for a referrer - professional requirements The health professional must be sufficiently competent to assess a patient and have competence in: Service - Multidisciplinary 2/7

3 History taking Assessment and Physical examination Formulating diagnoses and being aware of varied differential diagnoses Clinical reasoning and decision making skills Communication skills The health professional must understand their professional accountability arising from their regulatory body s code of conduct, any medico-legal issues related to their scope of practice. The health professional must have an understanding of IR(ME)R 2000 through appropriate training and experience, including awareness of the risks of radiation exposure. Referral Acceptance Criteria In order to comply with the Ionising Radiation (Medical Exposure) Regulations 2000, all patients must have a signed request form which contains patient identification and all relevant clinical information. All mandatory information must be included on the request form: Patient Name and Address including post code Date of Birth Relevant clinical diagnosis X-ray examination required and views required Referrer information and referrers signature evident on form Risk of pregnancy - Last Menstrual Period details (LMP) - females only Pregnancy When referring females you must ask all females of child bearing age (12-60 years of age) if there is any chance of pregnancy and the dates of their last menstrual period (LMP). - If they say yes to risk of pregnancy the referral must not proceed. - If they are not sure they need to have a pregnancy test to rule out pregnancy. NURSES REQUESTING X-RAYS Nursing staff can only request x-rays of patients aged 5 years and over and only plain film X-ray examinations for injuries outlined below: Radius/Ulna Hand Tibia/Fibula Foot Areas where foreign bodies are suspected in a wound in the above areas only. If the request falls outside the agreed referral criteria, the radiographer may refuse to perform the examination. Service - Multidisciplinary 3/7

4 Diagnostic Standards to Promote and Maintain Patient Safety a. How the Screening/Diagnostic procedure is requested b. How the clinician treating the patient is informed of the results (including timescales) c. How the patient is informed of the results (including timescales) d. Taking action on the result of diagnostic /screening tests (including timescales) :- expert interpretation of the result documentation of the result how patient is followed up or referred following a screening Which staff are authorised to request this test? Description of how each step in the process is undertaken Unplanned Care - The imaging procedure is requested by registered nurses or clinicians and a referral made either electronically or paper based Unplanned care Through the use of the PAC system the clinician views digital x-ray Unplanned care The clinician managing their care views the digital x-ray and makes a provisional diagnosis and informs the patient whilst they are in the department All treatment, discharge and referral decisions must be consistent with clinical findings and diagnosis and implemented during the patients attendance in the service Unplanned Care The radiologist report is input onto the current IT system and pooled for view by the service within five days. Additionally a paper record is sent to the MIU. All reports are reviewed by a registered nurse who then share the results with a medical practitioner if there is an anomaly between the report and the previous diagnosis Unplanned care All clinician interpreted results are documented in the patients health records at the time of their attendance, The paper copy of the result is filed centrally in MIU, with the results easily accessible electronically via Cerner Millennium This only occurs if there is a discrepancy between their clinician s diagnosis and treatment and that of the radiographer. In this instance as mentioned above the patient is contacted. The imaging department will hold a list of referrer either individuals or staff groups. Additional comments:- The request is within the scope of their practice with a clear rationale to do so. At this stage they do not receive a radiographers report At this time the patient is advised that the x-ray will be formally reported upon by radiologist within five days who may advise further review. In which case they will be contacted to re-attend the MIU Clinicians should have knowledge of, and access to, necessary onward referral pathways If there is inconsistency the registered nurse discusses the findings with the clinician on duty, and if needed invites the patient to re-attend for further review within five days. There is a tracking system in place to monitor successful contact with the patient and their resultant attendance. If the patient is not contactable by phone a letter is sent. If they still do not attend the unit, the patients GP is informed of the x-ray result As the service uses electronic patient records the results are not added to the patients specific electronic record, but stored on site Patients are usually contacted by phone call Service - Multidisciplinary 4/7

5 INTERPRETATION OF RESULTS AND REPORTING Patients are given an initial assessment result and patients are informed that they may be contacted by phone or letter to return for review All imaging procedures will be reported by a Consultant Radiologist, unless the results are transferred to another hospital for treatment. All reports are reviewed by a registered nurse who then shares the results with a medical practitioner for confirmation that there is no anomaly between the report an previous diagnosis and treatment If the results show a problem that cannot be treated within the service, a referral will be made either back to the patient s GP or to a secondary care consultant as indicated by the clinical findings and this will be recorded in the patient s health records. WERE TO GET ADVICE FROM If further advice is needed refer to a Medical Practitioner or refer to Secondary care for further advice. INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. If any concerns re this section discuss with a senior procedure lead in the Quality and Governance Service REFERENCES Department of Health (2000) The Ionising Radiation (Medical Exposure) Regulations London: DH. Department of Health (2002) Developing key roles for nurses and midwives: A Guide for Managers. Royal College of Nursing (2008) Clinical imaging requests from non-medically qualified professionals. Statutory Instrument (2006) The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006, London: HMSO. Service - Multidisciplinary 5/7

6 CONTROL RECORD Title Clinical Protocol for Requesting Clinical Imaging by Non- Medically Qualified Health Care Professionals. Purpose The aim of this Protocol is to provide guidance and advice and good practice recommendations for health professionals who request imaging procedures. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Judith Roberts/ Sandra Murphy Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved 14 th October 2013 Date formally approved by October 2013 Quality, Patient Experience & Risk Group Method of distribution Intranet Archived Date Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 A Baker N New protocol to support requests for clinical imaging by Non-Medically Qualified Health care professionals Status New / Revised / Trust Change Service - Multidisciplinary 6/7

7 RISK ASSESSMENT FOR SCREENING PROCEDURE Name of Screening Procedure: Procedure for taking clinical imaging Date risk assessed: Risk assessed by: Advanced Practitioner Quality and Governance Service Criteria a. Process for requesting the screening/diagnostic procedure The patient cannot be suitably positioned to obtain adequate pictures or imaging b. Process for informing the clinician treating the patient of the result c. Process for informing the patient of the result d/e. Process for action if referral required after a screening test Identify risks from the process of conducting the test if relevant Likelihood that process will fail Low Medium High Risk identified in process The referrer has responsibility for providing sufficient medical information relevant to the imaging procedure requested The patient may not be able to lie or be suitably positioned to allow for the imaging procedure to take place. The results are not reported on by radiologist and results are not forwarded to the clinician. Patient may not be informed of their results within an appropriate timeframe Difficulty contacting a Medical Practitioner or patients own GP Mitigation/Controls Where the radiographer has any doubt about a request, this will be discussed initially with the referrer, and if unresolved, with a Radiologist, before under taking the examination The health professional is able to comprehensively assess patient needs and has knowledge of the anatomy and physiology of the system / organ being imaged Urgent results are returned back to the patient s clinician within a shorter time period. It is the responsibility of the health professional who requested the procedure to discuss with relevant person(s) regarding informing the patient of their results. A medical practitioner to be informed of the results or the patient s own GP on the same day of the results Equipment failure To arrange for an alternative machine to be used Service - Multidisciplinary 7/7

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