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COMMUNITY SERVICES DIVISION CLINICAL SERVICE

BASED POLICY DOCUMENT

GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE

PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES

Policy Number: 49 Scope of this Document: Nurse Practitioners within

Liverpool Walk In Centres Recommending Committee: Clinical Policies Working

Group Approving Committee: Clinical Standards Group Date Ratified: July 2018 Next Review Date (by): July 2020 Version Number: Version 7 - 2018 Lead Executive Director: Executive Director of Nursing

and Operations Lead Author(s): Clinical Nurse Managers

Practice Development Mentor Service Manager

Nurse Clinicial (Walk In Centres)

COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

2018 – Version 7

Striving for perfect care and a just culture

of 30 49 - GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES. Version 7 July 2018

COMMUNITY SERVICES DIVISION CLINICAL SERVICE BASED POLICY DOCUMENT

GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE

PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES

Further information about this document:

Document name

GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES (49)

Document summary To provide guidance for Nurse Practitioners who order and interpret x-rays within Liverpool Walk in Centres’

Author(s)

Contact(s) for further information about this document

Clinical Nurse Managers, Practice Development Mentor, Service Manager, Nurse Clinician Liverpool Walk-In Centres’.

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with This document can be made available in a range of alternative formats including

various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History: Version 8 Ratified by Clinical Standards Group July 2018

Version 8

Transferred to Mersey Care NHS Foundation Trust Template, with reference to Liverpool Community

Health NHS Trust replaced with Mersey Care name and branding

6 Jun-19


http://www.merseycare.nhs.uk/

SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy


1. Introduction 5

2. Definitions 5

3. Duties and responsibilities 5

4. Criteria for X-Rays 6

5. Nurse Practitioner Procedure to be Observed 6

6. Surveillance – X-Ray Department 9

7. Hot Reports 11

8. X-Ray Reporting 11

9. Training Requirements 12

10. Impact Assessment 12

11. Implementation / Monitoring 12

12. Linked Areas / Information 13

13. Relevant Legislation / Statutory Requirements

14. References Appendix 1:-X-Ray Criteria

Appendix 2::-Clinical Indicators

Appendix 3:-LCH WIC Adults Directorate X-Ray Competency

Appendix 4:-X-Ray interpretation mentorship log

Appendix 5.-X-Ray interpretation audit/reflection sheet

Appendix 6:-List of Recognised Signatories

Appendix 7.-Implementation Plan

Appendix 8:-Walk-in Centre Framework for Ordering & Interpreting x-rays

Appendix 9:-Nurse Led WICs Clinical Guidelines Acute Wounds

Appendix 10.:-Flow Chart for Following up Fractures Identified by Nurse

Practitioners

Appendix 11.-Walk-In Center’s Clinical Competencies for Referring for and Interpreting X-

rays


1. Introduction Clinical Nurse Managers, Nurse Clinicians, Practice Development Mentor for Walk-In Centre’s, Consultant Radiologists, Radiographers from the York Centre and Aintree Hospital NHS Trust (UHA) Radiology Department have developed these guidelines, to ensure patient presenting with minor injuries receives a quality and safe service when undertaking the need for radiological interventions. This will fulfill the requirements of the patient/service users who receive emergency care from staff employed by Mersey Care NHS Trust. The organisation is committed to ensuring that all staff are trained and equipped to perform their role effectively. 1.1 Status This is a clinical guideline document for use in Mersey Care NHS Foundation Trust Community and Mental Health services (MCFT) Liverpool Walk-In Center’s.(LWIC) 1.2 Purpose These guidelines are designed to give clarity and guidance around requesting and initial interpretation of x-rays by Nurse Practitioners working within LWIIC The guidelines are designed to ensure that all staff working for, or on behalf of MCFT LWIC, provides an optimal level of service delivery to this specific patient population. The advice and guidance contained within these guidelines are based upon the latest researched-based evidence and has been agreed by a number of professionals. 1.3 Scope These guidelines apply to Nurse Practitioners working within MCFT LWIC on a permanent basis, who have demonstrated the ability to interpret x-rays and have fulfilled the appropriate legal requirements.

2. Definitions Below is a list of definitions used within the guidelines: AED :- Accident and Emergency Department. APNP: – advanced Pediatric Nurse Practitioner CRIS :– Computerised Radiology Information System. CPD :- Continual Professional Development. Hot Reports: – A report is requested on the x-ray for the same day. PACS System – Picture Archiving Communication System (Digital x-ray).

Page 5 of 30 49 - GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES. Version 7 July 2018

IR(ME)R – Ionising Radiations (Medical Exposure) Regulations. 2000. NPs - Nurse Practitioners. These are qualified nurses who have had extra training so that they can work in LWIC without a doctor being available on the premises. PACS:- Picture achiving communication system Virtual fracture Clinic:-Patients x-rays and medical notes are electronically reviewed by RLBGUH Orthopaedic consultant within 72 hours and further management plan is decide upon were the patient may not need to attend the hospital

WIC – Walk in Centre. A Nurse–led minor injuries and Walk-In unit staffed and managed by Nurse Practitioners who work to specific guidelines and protocols which have been signed off by Liverpool Community Health Trust NHS Trust. York Centre X-ray departments, part of Liverpool Community Health NHS Trust.

3. Duties and Responsibilities Clinical Nurse Manager

To ensure that all Nurse Practitioners requesting and interpreting x-rays have undertaken appropriate training within this field. To satisfy IR (ME)R 2000 the updated list must be sent to the Superintendent Radiographer at the York Centre/ Principal Radiographer (Non-Medical Referrers) Nurse Practitioner

All Nurse Practitioners undertaking x-ray requests must undertake IR (ME)R training on an annual basis.

There will be an annual review of the authorised signatures of those Nurse Practitioners who may refer for radiological investigation.

4. Criteria for X-Rays The criteria for x-raying patients, (both Adults and Children’s), with MCFT is detailed at Appendix 1 for all Nurse Practitioners working within LWIC All Nurse Practitioners must have undertaken the appropriate area of training for the specific x-rays they are ordering and interpreting Pediatric x-ray training is covered in the guidelines for requesting and interpretation of X-Rays for children under 16yrs age.


5. Nurse Practitioner Procedure to be observed

The guidance addresses the issue of Professional Self-Regulation for staff through the use of continual professional development (CPD) and a competency framework to ensure that learning objectives have been met and practice is safe. The following lays down steps that must be taken to protect both staff and MCFT and support the Nurse Practitioners decision making process.

Triage

First point contact with the patient is usually triage If the joint were the fracture is located is severely displaced with the skin at risk from hypoxia and fracture blisters DO NOT REQUEST X-RAYS. Refer to a local AED via emergency Paramedic transfer

History Taking and Examination

• Take history and examine the patient before requesting the X-Ray.

• Establish mechanism and force of the injury and use this information to deduce which resultant abnormalities are likely to occur.

• Check for other associated injuries. e.g. ‘Colles’ fracture, concomitant with radial

head fracture • Does the patient fit the criteria for an x-ray? Please see Appendix 1 for further

information.

• Consider Non-accidental injuries – follow safeguarding policies were appropriate.

Requesting

• Check the name and date of birth of patient having the x-ray taken

• Request an x-ray only when necessary. If the diagnosis of the fracture will not

alter management, reconsider the rationale for x-ray.

• If the patient does not fit the requesting criteria but it is in the best interest of the patient ie clinically fracture but not history or significant trauma, the requesting practitioner must state their rationale within the patient notes.

Interpreting


• Check the name and date of birth of patient for whom the x-ray has been requested.

• Never look at an x-ray without seeing the patient and never see the patient

without looking at the x-ray

• When looking at the x-ray consider and assess alignment, bones, cartilage, joints and soft tissues

• Re-examine the patient if the x-ray does not show what the clinical signs have

suggested.

• Ensure that the correct limb has been x-rayed.

• If the x-ray does not look normal, and the Nurse Practitioner is not confident in diagnosis, judgment should be used either request an urgent same day report. or refer the patient on to an Accident and Emergency Department depending on the problem and circumstances.

• Treat the patient not the x-ray. (Tender in anatomical snuffbox suspect and treat as scaphoid fracture ie:-refer to the redressing clinic in RLBUHT for reassessment for x-ray 10 days later).

• Fracture present:- fax patients notes through to virtual fracture clinic on 0151-706-2050 explain to patient that they will review notes and contact them within 72 hours on the future

• Splint appropriately depending on fracture (Futura splint/Scaphoid splint ,

neighbor strapping )

6. Surveillance – X-Ray Department ‘Red Dot’ flagging system

• It is recognised that the senior / superintendent radiographer is duty bound, by his/her own Professional Codes of Conduct, to question any unusual and/ or seemingly inappropriate requests for an x-ray investigation. All requests must be justified under IRMER 2000.

• The Senior/ Superintendent Radiographer will highlight any fracture/ abnormality, bringing it to the attention of the Nurse Practitioner for patients referred into Garston and the York Centre for their X-Rays (red dot on x-ray and/or indicates on the x-ray referral form when patient returns)

• All negative x-rays or those where hospital referral is not required will have a

written report available within two working days. In the event of hospital/ statutory bank holidays this time would be extended to a maximum of five


working days

7. Hot Reports For those x-ray where it has not been possible to make a definite diagnosis it is desirable to obtain an urgent report.

For Garston and Old Swan

• A phone call should be made to the Consultant Radiographer at the Royal Liverpool Hospital Trust (RLBUHT) for reporting either the same day or next day.

For Smithdown

• At Smithdown Children’s Walk-In Centre a phone call should be made to the Orthopedic on call to assess the x-ray

These images are a priority for reporting and the report conveyed to respective Walk-In Centre though agreed method depending on the locality of the WIC and be available on the PAC’s system for the Nurse Practitioner to access on the same working day.

If the Hot Report cannot be obtained within this timeframe, the Nurse Practitioner should manage the patient according to the clinical presentation.

8. X-Ray Reporting • Responsibility for formal reporting of x-rays will be held by the Consultant

Radiologist • Where patients’ are transferred to another hospital the image should be transferred

by an agreed method. The Nurse Practitioner referring must provide a written interpretation in the clinical notes. The responsibility for clinical evaluation of the image is then transferred to the clinician who reviews the patient and their clinical notes.

Agreed methods of patient information transfer are,

• Burned on to CD disc • Through national interpretation software (PACs)

For any further method being considered for transferring patient specific x-ray information advice should be sought by Information Governance Team.

9. Training Requirements This guidance will be used by Nurse Practitioners within MCFT LWIC’s who are:--


• Registered General Nurses • Have relevant experience of working in Accident and Emergency Departments

or • Have received relevant agreed training along with mentorship within LWIC

All Nurse Practitioners will undergo training in order to meet required level of competency. This will include: Interpretation adult X-rays

• Radiological hazard training to meet Ionizing radiation medical exposure regulations (IRMER) (2000) yearly.

• IR (ME)R training is accessed via ESR and is online training

• Below elbow/below knee anatomy instruction t h r o u g h M S K c o m p e t e n c y f r a m e w o r k a l o n g w i t h r e v i e w a n d m e n t o r s h i p b y an appropriately competent Registered Health Practitioner employed within LWIC.

• For NP’s with no previous AED experience, training by a mentor who has

completed the relevant competencies, for observation and assessment skills for the treatment of patients presenting with minor injuries.

• Current TNA x-ray interpretation study days identified as appropriate

• Skills needed to perform examination; primary diagnosis and care management of below elbow/below knee limb injuries.

• Clinical indication for x-ray.

• Teaching of radiological anatomy and pathology, including normal variants and indication for x-ray by the appointed mentor provided prior to interpretation training and competency assessment (appendix 3 and 11 )

• Experienced staff need to maintain continual professional development in the interpretation of x-rays as outlined in appendix 3,

• Staffs who have completed their WIC induction or previous training in x-ray

referral (for staff who commenced in post prior to the induction program) and their IRMER training has been completed will be put on to the x-ray system as a referrer.

• The full name and their registration / pin number and which sites they will be

referring from. Will be sent to the Superintendent Radiographer who will liaise with RLBGUHT to get them onto the x-ray system.

• Staff who have completed Interpretation training will be given a log in and

password to PACS


Paediatric x-ray interpretation This training and experience is outlined within the guidelines for the requesting and interpretation of X-Rays for children under 16yrs

10. Equality Analysis

An equality Analysis has been undertaken during the policy development and the evidence collated is with the author of the policy and the Equality and Diversity Lead of Liverpool Community Health NHS Trust.

11. Implementation / Monitoring

• The Director of Operations is responsible for implementing this guidance; however, this process has been delegated to the Clinical Nurse Managers of the Walk In Centre’ s that undertake x-rays. (Appendix 8).

• LCH Governance Team are responsible for ensuring that this document is reviewed and if required revised in light of legislative, guidance or organisational change. This process will be delegated to the author of these guidelines.

• Review shall be no more than 3 years unless practice changes within the time

scale. This guidance will be audited yearly v i a P D R and will be led by the Clinical Nurse Managers based at M C F T LWIC’s The audit results will be cascaded to the staff within the WICs via local governance arrangements.

12 Linked Areas/Information This policy is to be read in conjunction with the following:

• Consent Policy • Liverpool Walk In Centre’s Clinical Handbook • IRMER (2000) • Clinical Record Keeping Policy • Risk Policies • Safeguarding Policies • Guidelines for the requesting and interpretation of x-rays for children under 16yrs

13 Relevant Legislation/Statutory Requirements

• First level Nurse registered with the NMC. • NMC Code 2015 • NMC Record keeping: Guidance for nurses and midwives (2009).


• IR(ME)R (2000).

14 References 1. S Meek, J Kendall, J Porter, R Freij (1998). Can Accident and Emergency

Nurse Practitioners Interpret Radiographs? Multicentre Study. The Journal of Emergency Medicine; 15:105 – 107

2. NMC The Code:2015 . 3. NMC Record keeping: Guidance for nurses and midwives (2009) London: NMC 4. Making a Difference (1999). Strengthening the Nursing and Midwifery and Health

Visiting Contribution to Health and health care. D.O.H London. 5. Nicholson D.A. And Driscoll P.A. (1996) The ABC of Emergency

radiology BMJ publishing Group. 6. McCrae R (2001) Practical Fracture Treatment Churchill Livingstone 3rd Edition. 7. The Ionising Radiation Regulations 1999 Approved Code of Practice and

Guidance. The Stationery Office Ltd 1999. 8. The Ionising Radiation (Medical Exposure) Regulations 2000 The Stationery

Office Ltd 2000 9. Hardy M and Barret C (2004) Interpretation of trauma radiographs by

radiographers and nurse practitioners in the UK: a comparative study. The British Journal of Radiology, 77, 657-661

10. Chudleigh J (2004) Nurse requested x –rays in A&E Department. Emergency Nurse, vol 11, 32-35

11. Baird A (2005) Nurse requested X-Rays in Primary Care Practice Nursing, vol 16, no.3, 146-14

12. WIC Competency Framework 13. Nurse led l WICs Handbook


Appendix 1 X-Ray Criteria

Site Garston

Old Swan

Smithdown

Inclusive ages

16 years and over 16 years and over 1year to and including 15 years

Inclusions All areas below knee and below elbow where injury has been sustained 10 days ago or less and clinical indicators for x-ray are present.

This may be extended to 14 days if patient has been on holiday at time of injury.

Open wound with suspicion/ likelihood of embedded radio- opaque foreign body, removable within the Nurse Practitioners parameters of care. (Refer to WIC clinical Handbook

Failed conservative treatment within 48 hours of original injury and the relevant clinical indicators are present.

Consider higher threshold for x-ray in patients with learning disabilities, etc.

All areas below knee and below elbow where injury has been sustained 10 days ago or less and clinical indicators for x-ray are present.

This may be extended to 14 days if patient has been on holiday at time of injury.

Open wound with suspicion/ likelihood of embedded radio- opaque foreign body, removable within the Nurse Practitioners parameters of care. (Refer to WIC clinical Handbook)

Failed conservative treatment within 48 hours of original injury and the relevant clinical indicators are present.

Consider higher threshold for x-ray in patients with learning disabilities, etc.

Clavicle and upper limb, knee, and lower leg, ankle and foot, where injury has been sustained 14 days ago or less and clinical indicators for x-ray are present. Open wound with suspicion/ likelihood of embedded radio- opaque foreign body, removable within the Nurse Practitioners parameters of care. (Refer to WIC clinical handbook) Failed conservative treatment within 48 hours of original injury and the relevant clinical indicators are present.

Uncomplicated crush injuries to phalanges Consider higher threshold for x-ray in patients with learning disabilities, etc.

Site Garston Old Swan Smithdown

Exclusions All the following are excluded from treatment at the WIC and must be referred onto AED or their GPs:

• Children under 16 years, refer to criteria

for X-ray at Smithdown Children’s Walk- In Centre or refer to Alder Hey Children’s Hospital AED

• Injuries over 10 days old unless patients been on holiday then 14 days.

Do not X-ray the following and refer to AED: • Injuries which require immediate

orthopaedic intervention e.g. Clinically extensive compound/ complicated fractures

• Evidence of altered motor and or sensory power to affected limb

• Circulatory impairment to affected limb

• Injuries outside of the inclusion criteria

All the following are excluded from treatment at the WIC and must be referred onto AED or their GPs:

• Children under 16 years, refer to

criteria for X-ray at Smithdown Children’s Walk- In Centre or refer Alder Hey Children’s Hospital AED

• Injuries over 10 days old unless patients been on holiday then 14 days.

Do not X-ray the following and refer to AED:

• Injuries which require immediate

orthopaedic intervention e.g. Clinically extensive compound/ complicated fractures

• Evidence of altered motor and or sensory power to affected limb

• Circulatory impairment to affected limb


• Children under 1 year or 16 years and over

• Injuries which require immediate orthopedic intervention e.g. Clinically extensive compound/ complicated fractures

• Injuries over 14 days old

Do not X-ray the following and refer to AED: • Evidence of altered motor and or

sensory power to affected limb • Injuries to the skull,

spinal injuries, ribs, pelvis, femur


Appendix 2 Clinical Indicators

BELOW ELBOW BELOW KNEE • History of significant injury likely to

cause fracture below elbow • Falls onto outstretched hand

• Pain, swelling, bruising and

bone tenderness to local area • New Deformity on examination

• Lacerations involving glass opaque

foreign body

• History of significant injury likely to cause fracture to lower leg/ankle and foot

• Pain, swelling, bruising and bone

tenderness to affected area • New deformity on examination

• Inability to weight bear - more than five

steps on the affected side • History of twisting ankle injury in women

over the age of fifty years (increased likelihood of fibula fracture)

• Foreign body localization in soft tissues

• For women of childbearing age (12 to 55) we use the 28-day rule (Royal College of Radiographers Guidelines 1995) with the exception of extremities

• Pregnancy or possible pregnancy is a relative contraindication to x-rays of the distal

limit • It is the responsibility of the operator (Senior/ Superintendent Radiographers) to ask re

possibility of pregnancy before proceeding with the exposure • If pregnancy cannot be excluded the date of the last menstrual period should be

ascertained and recorded on the request form • The operator must then consult with the referrer (Nurse Practitioner) and if in the

judgment of the referrer, the clinical need for the x-ray outweighs the minimal risk, the examination should proceed with lead protection of the abdomen and pelvis

Appendix 3:- LWIC Adults X-ray competency Please refer to Section 9:-Training requirements. Introduction All staff that are required to interpret x-rays on behalf of MCFT LWIC must have completed:

• Ionising Radiation (Medical Exposure ) regulations IRMER training on a yearly basis

• Staff who have commenced in post after 2009 must have undertaken the Walk in Centre induction that includes sessions on

o History taking and examination o Assessing injuries and wounds o And be able to evidence their competence in these areas

Prior to interpretation, they will have undertaken CPD via The Norwich X-Ray Image Interpretation course which is accredited by the Society of Radiographers. The course is primarily aimed at radiographers who provide a "red dot" service to A&E. This CPD has the appropriate components for ensuring that Nurse Practitioners requesting and interpreting X-Rays within LWIC gain the knowledge and skills in order to provide a quality service to WIC clientele. Course Outline The course is designed to outline:

normal anatomy and normal variants common fractures, including their prevalence and mechanism of injury subtle injuries that are often missed radiologically - but which are clinically significant soft tissue signs in the absence of obvious bony injury fracture classification risk factors, including potential pathological conditions, which may either predispose

to the injury or be an incidental finding other associated injuries following initial diagnosis radiographic projections to aid the non-radiographer in diagnosis

It is hoped that by reading through each module and referring to the associated images provided, the user will become more accurate in their interpretation skills, so giving a high quality service to clinician and patient Modules The four modules the adult WIC staff will be required to complete working in the Adult Directorate are Hand Wrist Foot Ankle

And can be accessed via the following link http://www.imageinterpretation.co.uk/

http://www.imageinterpretation.co.uk/

The Nurse Practitioner will be required to register on the site and following completion of the Modules undertakes the assessment attached to the Module. On successfully attaining the required pass (95%) a certificate will be generated. The Nurse Practitioner will be required to produce these certificates to their mentor and a photocopy must be sent to the Practice Development Mentor. Failure to do so may suspend your interpretation practices. All new interpreters will undertake an interpretation training session agreed by LWIC and be assigned a Mentor and complete 20 practical reviews with their mentor. (Appendix 4) Mentors must be competent in Minor Injury Assessment and experienced X-Ray interpreters- ensuring that they are auditing their own X-rays. Experienced X-Ray interpreters may need to subsequently retake these modules dependent on;

• How many x-rays they see within a year ( less than 60 ) • To ensure they are updated with the correct terminology

This will be dependent on the locality and frequency of patient presenting for x-rays within their working environment All experienced interpreters will be required to audit their own x-rays against the radiologist’s reports. The following sample is suggested by the Consultant and Clinical Lead for Mersey Care radiology,

• 20 x-rays every 4 months • An agreement in 95% of cases. (19 out of 20).

If you are unable to undertake 60 interpretations of X-Rays a year within your clinical field, i.e. you are part time or have not seen appropriate patient presentations you will be required to complete the 4 Module assessments stated above – yearly, to ensure on going competency. You will also need to show evidence of auditing the X-rays you have interpreted. (Appendix 5) Where the individual is not achieving the appropriate pass mark, they need to undertake the refresher training attached to each module and gain a pass mark before undertaking further interpretation.

Appendix 4 X-Ray interpretation mentorship log (for new staff developing interpretation skills) Name of Practitioner: Date of last IRMER training: Mentor ………………………………………….

Date ID /DOB

Locality Presenting issue Clinical finding X-ray Your impression

Mentors impression

Radiologist report and date

Comments

Local guidelines for requesting/ interpretation x-rays by Nurse Practitioner within LWIC’s November 2012. V4.1

Appendix 5 X-Ray interpretation audit/reflection sheet. (for X-ray Interpreters) Name of Practitioner Date IRMER training Date ID /

DOB Locality Clinical presentation Impression of X-Ray Radiologist report

and date. Same findings Yes/No

Comments


Appendix 6

Authorised signatures of Nurse Practitioners who can request and interpret X-rays.

Each WIC keep a record in their x-ray file And send copy to the superintendent radiographer at the York center Via FAX 300-8274 Walk in center:-

Nurse Practitioner Signature


Appendix 7 Implementation Plan

1. Ensure all staff working within LWICs are aware of the local guidelines

Use forum of staff meeting and via the process of PDR

Ensure all staff are aware of clinical effectiveness website

On-going process

2. Clinical audit of patients attending with minor injuries who require x- ray

Take random sample of clinical notes to review the outcome

Track patients journey from booking in to discharge or referral to other service

Yearly audit

3. Regular review of evidence- based literature in relation to ordering and interpreting x- rays

All staff responsible for searching and sharing information from reputable sources

Review policy if information is relevant

Policy changes to be put before clinical policies group before ratification

4. Work closely with Radiographers, Consultant Radiographer and Radiologist

Link in with Consultant Radiographer to report on x-rays from Liverpool CH WICs and be involved in any formal/informal teaching sessions

All staff to attend bi yearly sessions with Consultant Radiologist/ Radiographer

On-going process

5. All staff to engage in regular Clinical supervision as per Trust guidelines

Clinical supervision to form part of team meetings

All staff to contribute and be involved in clinical supervision process

On-going process


Appendix 8 – Walk-In Centre Framework for Ordering and Interpreting X- Rays

Competency Comments/evidence Date Achieved

1:-First level nurse employed by MCFT on a permanent basis at LCH Walk-In Centre’s.

2. To attended authorised Training session one interpretation and complete the Norwich online training

3. To complete IR(ME)R training on a yearly Via IRME(R) e-learning.

4. Proven experience / knowledge of minor injuries.

5. Participate in Clinical supervision. Identify any learning needs through process of PDR.

Name of Nurse Practitioner: Signed: Date: Name of Assessor: Signed: Date


Appendix 9 - Nurse Led WICs Clinical Guidelines Acute Wounds Table 1: Classification of wounds based on degree of microbial contamination

Criteria Classification

Contaminated Contaminated wounds are open (avulsive), fresh, traumatic wounds< 4 Hours old or wounds from surgical operations involving major breaks in sterile technique or gross spillage from the gastrointestinal tract.

Dirty Purulent inflammation (e.g. abscess); preoperative perforation of Respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma or open traumatic wounds >4 hours old.

Adapted from Robin Chard AORN Journal 2009

A wound classification system formula used by surgical team used for grading the extent of microbial contamination, has four categories which is then used to indicating the chance that a patient will develop an infection. All traumatic wounds that constitute a breech in the skin integrity fall within the last two categories presenting at the Liverpool WIC making them either contaminated or dirty (Table1).

The object of cleaning the wound is to remove both organic and inorganic debris to create an optimum healing wound environment and is an essential part of the wound management. Cleansing and removal of foreign bodies and devitalised tissue has been shown to reduce infection. Dead tissue, foreign debris, devitalised tissue and haematomas must be Removed to reduce the number of contaminating bacteria and deprive any remaining of their breeding environment by doing so you ensure that the remaining tissue is viable with a Good blood supply. If there is extensive devitalized tissue or the repair of the wound is beyond competencies of the practitioner to repair then they should be referred appropriately.

Deeper structure involvement such as muscles and tendons should be referred prior to any wound closure for further assessment.

Embedded foreign debris should be removed as soon as possible. Removal of embedded foreign particles requires either local or regional anaesthesia. A sterile scrub brush soaked in saline may be used to removes the embedded debris from wounds especially gravel from abrasions preventing a ‘tattoo’ effect making a more cosmetically aesthetic wound. If glass or a radio opaque material is the suspected foreign body an x-ray of the wound should be ordered if access to x-ray is not available then the patient will need to be referred to a service where this is available.

0.9% Normal saline is regarded as the most appropriate and preferred cleansing solution within the WIC because it is a nontoxic, isotonic solution that does not damage healing tissues it is also versatile as it is dispensed in pods for accurate irrigation if required.


Clinical Policy WIC v3 (Page: 111 of 132).


Appendix 10 - Flow Chart for Following up Fractures Identified by Nurse Practitioners.

Patient is treated as per Nurse Led WIC Clinical Guidelines

and referred to next available Fracture Clinic for

further assessment.

X –ray Radiologists report reviewed in WIC and entered onto patient notes.

If Radiologist report states no fracture

reported as a fracture in the WIC – Nurse Practitioner will converse with

radiology team for clarification of report and for further education re normal variant.

Local guidelines for requesting/ interpretation x-rays by Nurse Practitioner within LWIC’s November 2018

Appendix 11 - WIC Clinical Competencies for Referring for and Interpreting X-rays

Competency Descriptor KSF Evidence x-ray Referral/Interpretation

Band 5

Band 6

Band 7

CNM / Band 7 team leader

Has the ability to refer patients for x-ray within LCH and departmental guidelines.

1. Demonstrates awareness of the IR(ME)R guidelines and the legal requirements for completing x-ray referral forms.

2. Identify the surface and skeletal anatomy relevant to area of x-ray:

i) ADULTS

a) Lower leg to foot b) Forearm to hand c) Foreign body localization

ii) CHILDREN

a) Clavicle to hand b) Knee to foot c) Foreign body localization

HWB 6,7

HWB 6, 7. C5 C1

C1- C5 C3

Attendance at Ir (me) r training on a yearly basis. Completed x-ray referral forms

Clinical audit. Reflective diary. Direct supervision.

Audit of notes. Reflective diary. Direct supervision.

Access to clinical guidelines. Audit of notes.

N/A

N/A

Pro

I

Pro

I

Pro

I

Local guidelines for requesting/ interpretation x-rays by Nurse Practitioner within LWIC’s November 2018

Competencies for Referring for and Interpreting X-rays

Use Descriptors – p -participative, s - supervised, I - independent, Pro- proficie

3. Demonstrate knowledge of the process for referring patients for x-rays.

4. Demonstrates appropriate justification for x-ray to be performed.

5. Demonstrates the appropriate referral of patients for x-ray.

Audit of notes. Direct observation. Patient log.

N/A

N/A

N/A

I

I

I

I

I

I

I

I

I

Competency Self- assessment

Mentor / preceptor assessmen

Review Review Review Review Review Review Review Review

1 2 3 4 5

Date and Signature:

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GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES. Version 7 – July 2018.

guidelines for requesting and interpretation of x … · 2019-06-27 · initial interpretation of...

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