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CLINICAL GUIDELINE FOR REFERRAL TO CLINICAL IMAGING

1.0 Aim/Purpose of this Guideline The purpose of this guideline is to allow appropriately qualified and authorised practitioners to request specified imaging procedures, adhering to the Ionising Radiation Regulations IR(ME)R, MHRA Safety Guidelines for MRI Equipment in Clinical Use and the Royal College of Radiologist Guidelines (i-Refer).The aims of this document are:

To inform the referrer of their legal responsibilities when requesting such procedures.

To highlight the Trust’s referral criteria which provide the referrer with guidance on making an appropriate imaging request.

To provide the referrer with access to relevant information and training.

2.0 The Guidance 2.1 Distribution and Dissemination

This document is to be made available:

Via the RCHT document library.

During the web-based Ordercomms training.

During classroom based radiation protection training sessions

2.2 Summary of the Referral Process

Referrer- After a thorough clinical assessment of the patient, the clinician uses their professional judgement to decide if an imaging procedure is required. Referrers must ensure:-

The correct patient is referred by ensuring the patient’s identification details are accurate.

Sufficient legible clinical information is provided to enable the request to be justified (abbreviations should not be used)

Contraindications to the imaging procedure have been considered (e.g. some pacemakers in MRI)

Pre-procedural information is supplied (e.g. eGFR for examinations requiring contrast, clotting parameters for interventional procedures).

Any additional information or particular requirements are given.

Practitioner- (usually within the Clinical Imaging Department) – This individual evaluates the referrer’s request to ensure study is justified, i.e. potential clinical information from study outweighs any risks to demonstrate an overall ‘net benefit’. Risks include radiation, magnetic safety, and those associated with additional procedures such as contrast.

Operator- Undertakes procedure & ensures all clinical information is acquired for a clinical judgement to be made. This person is responsible for ensuring the safety of the patient during the examination, for example during the use of ionising radiation or strong magnetic fields.

CI.GEN.PPG.15 Clinical Guideline for Referral to Clinical Imaging v3.0

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2.3 Authorisation to Refer Only appropriately qualified Health Care Professionals may request imaging procedures, as defined in section 2.3.1 and 2.3.2.

2.3.1 Medical/Dental Practitioner RCHT recognises any medical or dental practitioner registered with the General Medical Council or General Dental Council as an authorised referrer, provided that practitioner has met the CPD requirements of that body with regard to imaging procedures and examinations. Within the Medical profession, the scope of requesting is as follows: F1 and F2 doctors may independently request plain films only.

All more complex imaging (including US, CT, MRI and Nuclear Medicine)

must be authorised by a middle grade or above. This should be after discussion with a named consultant or following an agreed protocol. An F1 or F2 grade doctor may put the request on Maxims but must clearly state the name of the consultant who has seen the patient and made the decision to request.

All interventional procedures should be requested by a Consultant.

2.3.2 Non Medical/ Dental Professionals

RCHT also recognises other health care professionals who are enabled to refer patients. These practitioners must demonstrate the clinical expertise to assess the need for imaging and also meet IR(ME)R training requirements. Practitioners must have imaging referral in their scope of practice / job description and be operating under a Trust approval protocol as defined in RCHT Protocol for the Requesting of Clinical Imaging by Non-Medical Professionals.

2.4 Referral Criteria All internal referrals for imaging should be made via maxims. Referrals from healthcare professionals outside of RCHT may be made using signed paper copy requests. It is a key requirement for the referrer to make appropriate imaging requests and it is a legal requirement for RCHT to establish referral criteria to guide referrers. The Trust has adopted the referral criteria contained within the Royal College of Radiologists document ‘I REFER’ for this purpose. This is accessible at http://nww.irefer.nhs.uk/ from the NHS network; further information can be found on www.rcht.nhs.uk/imaging. All referrals should be made in accordance with this document, where there is any doubt the case should be discussed with a Radiologist.

2.4.1 Factors to Be Considered Before Making a Referral Following an assessment of the patient’s condition and health needs, the referrer must take the following into account when considering imaging:

http://nww.irefer.nhs.uk/

http://www.rcht.nhs.uk/imaging


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Prior imaging - has it been done before? Is an appointment for similar imaging pending? Will it influence the patient care? (consider timescale on which examination will be conducted) Are supplementary procedures required (e.g. contrast agents,

anaesthetics)? Are there any contraindications to the procedure? Female patients: If the imaging procedure involves radiation or strong magnetic fields, can the pregnancy status be confirmed? MRI referrals: Is the patient safe to be in an environment which uses strong magnetic fields? 2.4.2 Referral Information It will be necessary for the referrer to supply the following information on the request for imaging or an interventional procedure:

Sufficient patient information to enable identification of the patient; in RCHT this will be correct detail on the electronic requesting system.

Abbreviations should NOT be used unless the fully written version is included with the first use of the abbreviation (Trust Policy to Manage Information and Records)

Details of the x-rays view(s)/techniques requested which are in

keeping with RCR referral criteria.

Sufficient clinical information to enable the Practitioner to justify the procedure. This must include the background information regarding clinical state and the condition/pathology about which information is sought (e.g. query fracture).

Referrer name and contact details; it is a legal requirement that

referrers are correctly identified. In addition the imaging department may need to contact the referrer urgently with critical or urgent unexpected findings.

Any other information which the referrer deems appropriate including

specific needs to be addressed e.g. disability, cultural/religious. 2.4.3 Referral Process Imaging will accept referrals made via:

Electronic requesting : i.e. Maxims/ordercomms RCHT request card: Original or fax of original sent directly from

GP/referrer: photo/photocopies are not accepted RCHT dental referral form

Referrals made by Non-NHS providers must be on a referral form and must meet the requirements of section 2.4.2. Only registered professionals may make referrals as per section 2.3.

2.4.4 Urgent Referrals


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Urgent referrals must be clearly marked as such on the referral. Time critical referrals (e.g. those requiring imaging within 24-48 hours such as suspected acute cauda equina syndrome) must be discussed with a radiologist. All on-call referrals must be discussed with a radiologist.

2.5 Justification Each referral for an imaging procedure must be justified on an individual basis by the Practitioner (usually working within the imaging department). For a request to be justified, the potential benefit from the diagnostic information obtained to assist in diagnosis or management, should outweigh the associated risks. When considering whether a referral is justified, the following factors are considered:

The availability and findings of previous images The specific objectives of the procedure in relation to the history and

examination of the patient The total potential diagnostic or therapeutic benefit to the individual The risks associated with the procedure (e.g. ionising radiation, magnetic

field, contrast induced AKI, or specific risks of an interventional procedure.) The efficacy, benefits and risk of available alternative techniques having the

same objective but involving no, or less risk to the patient.

Further Royal College of Radiologists guidance can be accessed via http://nww.irefer.nhs.uk/ from the NHS network; further information can be found on www.rcht.nhs.uk/imaging. Referrals which do not meet justification criteria or which contain inadequate/illegible information will be declined. The referrer will be informed of this decision either verbally or in writing. 2.6 Medico-Legal Exposures Imaging procedures purely for medico-legal purposes should be avoided whenever possible. The request should clearly identify that the procedure is requested on medico-legal grounds and provide sufficient information to allow justification. 2.7 Research Trials Where the imaging procedure is requested as part of a research trial, this should be clearly indicated on the request accompanied by the trial name. 2.8 Risks associated with Radiation Basic training on radiation health risks is available for referrers on the Trust’s electronic training systems and is provided for some employee groups (e.g. F1/F2 doctors in a classroom session at induction. For ease of reference, the radiation risk tables from these training packages are reproduced in appendix 1.

2.9 Risks Associated with Strong Magnetic Fields Strong magnetic fields can pose a serious risk to health and well-being of patients. The use of magnetism in combination with powerful radiofrequencies can damage implanted devices including pacemakers; this damage can be permanent and life threatening. Referrers must ensure patients are ‘MRI Compatible’ in accordance with the MRI Screening Protocol (available on the document library) and MRI checklist (available on the Clinical Imaging website). 2.10 Risks Associated with Contrast

http://nww.irefer.nhs.uk/



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Patients with pre-existing renal disease are more likely to develop complications such as acute kidney injury (AKI) and nephrogenic systemic fibrosis (NSF) as a result of contrast agents administration during some imaging techniques. All referrers must comply with RCHT Clinical Guideline for Avoiding Contrast Induced Nephropathy; further guidance is available at www.rcht.nhs.uk/imaging .

3.0 Monitoring compliance and effectiveness

Element to be monitored

Referrals against criteria in 2.5.2

Lead Specialty Director: Clinical Imaging

Tool On-going monitoring via Datix

Frequency Monthly review of datix reports

Reporting arrangements

Reported to Clinical Imaging Clinical Governance (CICG) meeting.

Acting on recommendations and Lead(s)

Specialty Director is responsible for implementing any actions Required actions will be identified and completed in a specified timeframe (documented in minutes of CICG)

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within 1 month). A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 3.


http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


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Appendix 1.Risks related to the Exposure to Ionising Radiation Examination Typical Effective

Dose Range (mSv)

Excess lifetime risk

of cancer per exam

Lifetime Risk of

Cancer Incidence

Natural underlying lifetime cancer risk 1 in 3 333 in 1000

51Cr GFR

X-ray Dental intra-oral

<0.01 <1 in 106 333 in 1000

X-ray Skull

X-ray Chest

0.01 – 0.1 1 in 106

to

1 in 105

333 in 1000

X-ray Thoracic spine

X-ray Abdomen

X-ray Pelvis

X-ray Mammogram

99mTc Renogram

99mTc Lung perfusion

0.1-1.0 1 in 105

to

1 in 104

333 in 1000

Barium swallow

Barium meal

Barium follow

Barium enema

CT head

X-ray IVU (6 films)

X-ray Lumbar spine (all views)

CT Chest

99mTc Thyroid

99mTc Infection

131I Iodine post abalation

99mTc Bone

99mTc MUGA/First pass

99mTc Myocardial perfusion

1.0 – 10 1 in 104

to

1 in 103

334 in 1000

CT Abdomen

CT Pelvis

99mTc Parathyroid

201Tl Myocardial perfusion

10 - 50 1 in 103 to

1 in 300

336 in 1000

Adapted from ‘Revised radiation doses for typical x-ray examinations’, Wall BF. British Journal Radiology 1997. 70:437-439, Notes for Guidance on the Clinical Administration of Radiopharmaceuticals and Use of Sealed Radioactive Sources (Administration of Radioactive Substances Advisory Committee March 2006) and lifetime cancer risk coefficients from ICRP Report 103.


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Radiation Dose to the Conceptus NB. The lists of studies in each group are NOT exhaustive.

Examination Typical

Conceptus Dose

Range (mGv)

Risk childhood

cancer per exam

Probability of

child with no

childhood cancer

Natural underlying lifetime

cancer risk

1 in 500 99.8%

X-ray Skull

X-ray Dental intra-oral

X-ray Teeth

X-ray Chest

X-ray Thoracic spine

X-ray Mammogram

CT Head/neck

51Cr GFR

0.001-0.01 <1 in 106 99.8%

CT Pulmonary Angiogram

X-Ray Abdomen

X-Ray Barium meal

X-Ray Pelvis

X-Ray Hip

CT Pelvimetry

CT Chest and Liver

99mTc Lung perfusion

99mTc Renogram

99mTc Thyroid

0.1 – 1.0 1 in 105

to

1 in 104

99.79%

X-ray Barium Enema

X-ray IVU (6 films)

X-ray Lumbar spine (all views)

CT Abdomen

99mTc Bone

99mTc Myocardial perfusion

1.0 – 10 1 in 104

to

1 in 103

99.7%

CT Abdomen

CT Pelvis

99mTc Myocardial

18-F PET Whole body scan

10 - 50 1 in 103 to

1 in 500

99.3%


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Appendix 2. Governance Information

Document Title Clinical Guideline for Referral to Clinical Imaging v3.0 CI.GEN.PPG.15

Date Issued/Approved: June 2015

Date Valid From: June 2015

Date Valid To: June 2018

Directorate / Department responsible (author/owner):

Dr B. Rock N. Burden Clinical Imaging Service.

Contact details: 01872 255086

Brief summary of contents This protocol sets out the standards for all practitioners requesting clinical imaging procedures.

Suggested Keywords: Imaging, X-ray, MRI, Ultrasound, contrast, safety, RCR, Radiology, refer, request, IR(ME)R, referrer.

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: March 2015

This document replaces (exact title of previous version):

Protocol for Referral to Clinical Imaging v2.0

Approval route (names of committees)/consultation:

CICG Gov DMB (CSSC)

Divisional Manager confirming approval processes

Sally Rowe Divisional Director, CSSC

Name and Post Title of additional signatories

Janet Gardner Divisional Governance Lead, CSSC

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical/Clinical imaging

Links to key external standards IR(ME)R


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MHRA Safety Guidelines for MRI Equipment in Clinical Use Royal College of Radiologist Guidelines (i-Refer).

Related Documents:

RCHT Radiation Safety Policy RCHT Protocol for the Requesting of Clinical Imaging by Non-Medical Professionals MRI Safety Screening Contrast Induced Nephropathy

Training Need Identified? No

Version Control Table

Date Version No

Summary of Changes Changes Made by

(Name and Job Title)

Unknown V1.0 Initial Issue Unknown

Nov 2011 V2.0 Revised to ensure fitting with IR(ME)R

T. Foy, RPA N. Burden, Governance & Quality Radiographer

25.3.2015 V3.0 Document revised to include all imaging procedures.

Dr B. Rock N. Burden

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.


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Appendix 3. Initial Equality Impact Assessment Screening Form

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence

Age Age groups are not affected by this protocol.

Sex (male, female, trans-

gender / gender reassignment)

Gender will not be an issue under this protocol unless the patient is suspected/confirmed pregnant and radiation protection protocols will be applicable

Name of service, strategy, guideline, policy or project (hereafter referred to as policy) to be assessed: Clinical Guideline for Referral to Clinical Imaging v3.0

Directorate and service area: Clinical Imaging

Is this a new or existing Procedure?

Existing

Name of individual completing assessment: Naomi Burden

Telephone: 01872 255086

1. Procedure Aim*

To clarify referral criteria for clinical imaging requests.

2. Procedure Objectives* To ensure the referrer full understand their responsibilities when requesting medical imaging.

3. Procedure – intended Outcomes*

Clear standards in place Local document which reflects the requirements of the

law in relation to ionising radiation

4. How will you measure the outcome?

Through audit and monitoring

5. Who is intended to benefit from the Procedure?

Staff and patients

6a. Is consultation required with the workforce, equality groups etc. around this procedure? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure.

No

7. The Impact Please complete the following table.


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and medical opinion will be sought.

Race / Ethnic communities /groups

Racial groups are not affected by this protocol.

Disability - Learning disability, physical disability, sensory impairment and mental health problems

The Practitioner would discuss any needs with the radiographer, to ensure good image quality.

Patient information is available in different formats. The department’s comforter and carer policy can allow carer’s or others to remain with patient if extra support is needed.

Religion / other beliefs

The practitioner is expected to consider the patients holistic needs, as is the Radiographer during interactions. Should the patient be required to remove any items during the examination this will be discussed and consent obtained.

Marriage and civil partnership

Not affected by this protocol

Pregnancy and maternity If pregnancy is suspected or confirmed then radiation protection protocols will be applicable and a medical opinion will be sought.

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

Not affected by this protocol

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.

There is no negative impact.

Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of members carrying out the Screening Assessment

1. N. Burden 2.

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 _______________


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Date ________________