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HEYH Radiology Requesting Protocol 44

TP/2012 Protocol 44 Radiographers HEY December 2014 1 of 22

Hull and East Yorkshire Hospitals NHS Trust

PROTOCOL FOR NON MEDICAL STAFF

REQUESTING RADIOLOGICAL EXAMINATIONS

Guidelines written

by :

Trevor Parker, Andrew Stephens

Department : HEY Radiology Department

Nature of Protocol : 1. Guidelines for Requesting MRI orbits by

Radiographers

2. Guidelines for Radiographers authorising additional

and/or more appropriate radiological examinations

from those explicitly requested by the referring

healthcare professional. These authorisation

protocols are required under IRMER regulation 6(5).

Pre MRI orbits – annex A

Plain film – annex B

CT – Annex C

IRT – Annex D

MSK Sonographers – Annex E

The guidelines should be used in conjunction with

Radiology IRMER documents HEYRAD10, standard

operating procedures and examination protocols.



Professional managers approving protocol:

Name Signature Date

Line Manager (MRI/CT) Nicola Webster

Line Manager (Plain Film) Ann McFadyen

Line Manager (IRT) Anita Echlin

Line Manager (Ultrasound) Pamela Parker

Lead for protocol Trevor Parker

Consultant Radiologist Dr C Rowland-Hill

Imaging Services Manager Martine Nutman

Date of Protocol : December 2014

Review Date : December 2016

Staff eligible to authorise and request under this protocol Qualified radiographers (registered with the Health Professions Council) employed by Hull And East Yorkshire Hospitals NHS Trust. Working within the guidelines set by speciality clinical area leads.

Rationale To ensure that radiographers are applying skills and knowledge in providing the most appropriate examination for the patient. Radiographers who directly refer i.e. pre MRI ORBITS will have undergone appropriate training, will be able to demonstrate their knowledge of indications for requesting, their responsibilities in relation to obtaining the image and ensuring that a report is generated.

Indications Refer to relevant speciality annex.



Contraindications Pregnancy status for females between the ages of 12 and 50 yrs of age should be considered and discussed with the original referrer or a radiologist when appropriate.

Requests The requesting radiographer will ensure that the request contains the following accurate minimum data set:

Full name of patient

Date of Birth

Address

Hospital Number (if available)

Lead Clinician

Patient location [Referring Clinic]

Name of Nurse requesting

LMP for female patients of child bearing age [if known]

Relevant clinical details If on failure of electronic requesting - manual cards are used - Addressographs should be used where at all possible. Details should be confirmed / checked with the patient/carer/advocate.

Test Results It is the responsibility of the original referrer to ensure results are acted upon, and recorded in the patient’s records.

When to contact medical staff Medical staff (the original referrer or a radiologist) should be consulted where there is any doubt as to the appropriateness of any request or changes/additions to requests.

Accountability The requesting/authorising radiographer is accountable for ensuring that they are working within the appropriate guidelines and that records are correctly entered either electronically or on manual request cards, and that all images are made available to the medical team.

Record of Agreement The record of agreement and approved protocol will be kept in the Radiology Department. A copy of the protocol and record of agreement will be kept on each unit involved with authorising and/or requesting under this protocol. Additions and amendments to the agreement record must be sent to the Clinical Governance Radiographer for approval, before implementation, by the relevant Line Manager named on the protocol.



Reference and source documents Health Professions Council, Standards of Proficiency – Radiographers

HEYH CP 016 (Policy on Consent to Examination or Treatment)

HEYH CP 226 (Policy on Introduction of New Clinical Procedures and Techniques)

HEYH CP 137 (Health and Safety at Work Policy, Section 12)

HEYH CP 325 (Policy on the use of ionising radiations, including x-rays and radioactive substances)

HEYRAD10 Employers Written Procedures required under the Ionising Radiation (Medical Exposures)

Regulations 2000 (IR(ME)R)

HEYRAD11 Radiology Department Guidelines for X-ray Referrals

IR(ME)R 2000 (and amending legislation 2006)

NHS Reform and Health Care Professions Act 2002

NPSA Safer Practice Notice Feb 2007. Early Identification of Failure to Act on Radiological Imaging Reports

Society and College of Radiographers, Code of Conduct and Ethics



Adjustment to the scope of professional

practice.

Magnetic Resonance Imaging Department.

Hull and East Yorkshire Hospitals Trust.

1 - The requesting of plain film radiographs of the orbit/skull for the purposes of excluding metallic foreign bodies by MRI Radiographers. 2 - The interpretation of plain film radiographs and/or CT head scans for the exclusion of metallic intra-ocular foreign bodies by MRI Radiographers. 3 - The recording of an appropriate report onto the Radiology reporting system.

4 – Basic PACS training to enable point 2. Updated Dec 2014. Review Date Dec 2016.



History of the scheme.

Patients attending the MRI department without first disclosing a history of injury to the eye involving metallic objects are a common occurrence.

Ho et al conclude that retained IOFB (metallic) are well tolerated and typically have minimal adverse visual prognosis. They should be managed

conservatively in the absence of specific indications for removal (ref 1) Historically, a patient in US with ocular injury involving 2mm x 3.5mm retained ferromagnetic foreign body resulted in unilateral blindness after undergoing

MRI (Kelly et al – ref 8).

Our first main step is screening the patient. BAMRR (ref 7) recommend a questionnaire to obtain information concerning prior injury from metallic foreign bodies. We found that speedy resolution of the problem was only possible when there was a Radiologist immediately available to

- Discuss the circumstances of the injury with the patient - Review any relevant cranial x-rays - Write a request for the orbit examination if required - Review the orbit x-ray once it has been performed.

In a department working a 12 hour day, it is not possible to send away and rebook any patient with a dubious history when a radiologist is not available.

The College of Radiologists (ref 2) state - ‘As in other areas of healthcare, some radiological services are being delivered by non-medically qualified healthcare professionals. In the interests of good clinical care and patient safety these individuals should work in a team with ready access to a fully trained radiologist for advice. The types of investigation which may be suitable for primary reporting by healthcare professionals without the benefit of a medical degree are those where there is a single organ investigation, with a single suspected pathology and a yes/no answer.’ By devolving these duties to suitably trained MRI Radiographers, relevant patient records could be promptly reviewed or appropriate plain films undertaken and reviewed at times when a Radiologist may be unavailable. The service is improved as the need to re-appoint patients for this reason has been resolved and the patient is happy as everything can be undertaken in one visit.



Why Plain film?

The most commonly recommended imaging modality for the screening of

metallic IOFBs is plain radiography. (Bailey and Robinson – ref 3)

The Medicines and Healthcare products Regulatory Agency (MHRA- ref 4) state ‘where the presence of metal fragments in the eye is suspected but unproven and no x-ray is available, it should be policy to obtain an ocular x-ray to confirm or negate presence of metal before MR scanning is performed’ Other possible imaging methods – Ultrasound – may be superior to MR or CT for evaluating tissue damage caused by an IOFB but requires a skilled operator to determine whether retained particles are intra- or extra – ocular. Metal detectors – manufactures claim can detect small metallic particles within the orbit. Research has concentrated on ingested FB’s. Felt to be an

unlikely option. (Bailey and Robinson – ref 3)

Purpose.

This document is designed to outline the skills required by MRI Radiographers who wish to adjust their scope of practice to include the interpretation of plain films of the orbit, skull vault or sinuses and/or CT scans of the head for the purposes of excluding the presence of metallic intra-ocular foreign bodies.

Aim.

The Radiographer will be able to accurately interpret plain films of the orbit, skull vault and sinuses, and/or head CT scans for the purposes of excluding metallic intra-ocular foreign bodies in accordance with local guidelines.

Objectives.

The Radiographer will:



- Understand the potential risks of performing an MR examination in the presence of an intra-ocular metallic foreign body.

- Know the indications for requesting plain x-rays of the orbits prior to

MR examinations.

- Understand current ionising radiation regulations. (The trust runs a course for diagnostic radiographers).

- Be able to accurately interpret x-rays of the orbit, skull vault and

sinuses for the purposes of excluding metallic intra-ocular foreign bodies.

- Be able to interpret CT scans of the head for the purposes of

excluding metallic intra-ocular foreign bodies – further training may be required here.

- Be able to record a report of their findings on the Radiology

Reporting system.

- Be able to use PACS workstations to view appropriate studies.

Guidelines.

For MRI Radiographers requesting and reviewing x-ray examination of the orbits for the exclusion of metallic intra-ocular foreign bodies.

1. The Radiographer (MRI) who wishes to adjust the scope of his/her professional practice in this area must be able to demonstrate theoretical knowledge related to the rationale for requesting x-rays of the orbit for the purposes outlined in this training programme. Competence will be assessed using a standard questionnaire (orbit form 1) and the results held on file.

2. The Radiographer must be aware of the relevant regulations regarding

the exposure of individuals to ionising radiation (ref 5). Competence will be assessed using a standard questionnaire (orbit form 1) and the results held on file.

3. The Radiographer must be able to demonstrate awareness of the

circumstances that are likely/unlikely to cause a penetrating injury. Competence will be assessed using a standard questionnaire (orbit form 1) and the results held on file.



4. The Radiographer will undertake a number of test film viewings from a

library of suitable radiographs. The results of which will be discussed with the orbit scheme facilitator and recorded on training document (orbit form 2).

5. The Radiographer will undertake a minimum of 6 supervised ‘live’ film viewings of actual patients attending for MR examinations. All ‘live’ viewings will be recorded on orbit form 3, which each Radiographer will maintain as their personal record of film viewings.

6. All images must be viewed on a DS workstation. Images must not be

viewed on a standard pc.

7. Only when both the facilitator and the Radiographer, wishing to extend the scope of his/her practice, are both satisfied with the level of competence achieved will the Radiographer be permitted to request and view films within the scope of this scheme unsupervised.

8. At all times, the Radiographer will be at liberty to decline to request or

view films.

9. The Radiographer will refer any cases he/she are not entirely confident in to suitably qualified Radiologist.

10. Upon completion of the training, Mrs N Webster will be informed

of the adjustment to the scope of professional practice. Mrs M Nutman, Radiology Manager should also be informed. This is the responsibility of the individual not the facilitator.

11. Competence and updating. Due to the sporadic nature of the

requirement for orbit x-rays, it maybe difficult to gain sufficient ‘live’ experience to maintain a high level of competence. If an individual does not view 5 ‘cases’ in a period of 1 year, they should ask for a further film file test to be performed.

Orbit form 1.

ADJUSTMENT TO THE SCOPE OF PROFESSIONAL PRACTICE.



MRI DEPARTMENT

HULL AND EAST YORKSHIRE HOSPITALS TRUST.

The requesting of plain films of the orbit for the purposes of excluding metallic foreign bodies by MRI radiographers.

QUESTIONNAIRE.

Name ______________________________________

Orbit form 2.

TRUE FALSE

1 All patients who report an eye injury will require an orbit x-ray.

2 All patients who report an eye injury involving metal fragments will require an orbit x-ray.

3 All patients who report an eye injury involving fast moving metallic fragments will require an orbit x-ray.

4 Only patients who report an injury with fast moving ferromagnetic fragments require an orbit x-ray.

5 Patients who report an eye injury but had the fragment removed in hospital do NOT require an orbit x-ray.

6 Patients whose eye injury was more than 10 years ago do NOT need an orbit x-ray.

7 Only patients who report an injury with a high speed metallic fragment, on whom there is no previous cranial imaging, require

an orbit x-ray.

8 Women can only have orbit x-rays if they are within 28 days of the start of their last menstrual cycle.

9 Patients that have worked with a lathe may have suffered a penetrating injury to the eye.

10

Patients that have always worn eye protection and deny any injury to the eye do not need an orbit x-ray.

11

Patients that have used power tools without eye protection but have never had an injury and don’t have any relevant radiological

exams must have an orbit x-ray.

12

Only ferromagnetic metals will experience any force in a moving magnetic field.

13

Patients who experience ocular discomfort when entering the magnet bore should be removed from the bore as quickly as

possible.

14

Patients who experience ocular discomfort when entering the magnet bore should be removed from the bore as slowly as

possible.

15

A patient who enters the scanner with a metallic foreign body in their eye may go blind.

16

Small fragments entering the eye under gravity are unlikely to cause a penetrating injury.

17

Small fragments blown into the eye by the wind are unlikely to cause a penetrating injury.

18

Patients who have had corneal surgery should not have MRI investigations.

19

Patients who have had squint corrections can have MRI investigations.

20

Retained intra-ocular metallic foreign bodies will always be visible to an optician or ophthalmologist.




MRI DEPARTMENT



ORBIT X-RAYS ANSWER SHEET. Review all the films for all the studies. Write your interpretation of the films in the comments box. Make additional notes on the back if required. Your answer should indicate if the patient is safe to scan, probably safe, definitely unsafe, requires further views, needs a radiologist opinion or any combination of these.

PA Lat.

CT Comment

1 1

2 1 1

3 1

4 2

5 1

6 2

7 1

8 3 1



9 1

10 1

11

1 1

12 1 1 1

13 2

14 1

15 1 1

16 1 2

17 1

18 1

19 1

20

1



21 1

22 1

23 2 1

24 2 1

25 1

26 1

27 1

28 1 1

29 1

30 1 1

31 1

32

1

33 1



34 1

35 2 1

36 1

37 1

38 1

39 2 2



Orbit form 3.


MRI DEPARTMENT



Minimum of 6 required. Record of 'Live' Viewings

Date

HEY Number Supervising Radiographer

Comments

Cases to be reviewed on PACS.



HEY number

HEY1268456 HEY0754718 HEY1332325 HEY0997566 HEY0055703 HEY0832175 HEY0579225 HEY1043783 HEY0542321 HEY0426626 HEY0436873 HEY1082139 HEY1162334 HEY1355676 HEY1319717 HEY0817811 HEY0973905 HEY1294120 HEY0453717

This section aimed to gain and improve PACS skills and

become more accustomed to CT images (where appropriate).

References and further reading.



1 - Retained intraorbital metallic foreign bodies – Ho VH, Wilson MW, Fleming JC, Hail BG. Opthalm. Plast. Reconstr. Surgery 2004 May; 20 (3):232-6 2 - Standards for the Reporting and Interpretation of Imaging Investigations. Royal College of Radiologists. January 2006. See Y drive, MRI dept, Orbit reporting scheme forms. 3 - Screening for intra-orbital metallic foreign bodies prior to MRI: Review of the evidence. William Bailey, Leslie Robinson. Radiography (2007) 13, 72-80. See Y drive, MRI dept, Orbit reporting scheme forms. 4 - Devices Bulletin:Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use. MHRA DB2007 (03) December 2007. See Y drive, MRI dept, Orbit reporting scheme forms. 5 - IR(ME)R 2000. See Y drive, MRI dept. 6 - Questions and Answers in Magnetic Resonance Imaging (2

nd Ed). Elster AD, Burdette

JH. 7 - BAMRR Website. 8 - Ferromagnetism of intraocular foreign body causes unilateral blindness after MR study - Kelly WM, Paglen PG, Pearson JA, San Diego AG, Soloman MA. AJNR 1986; 2:243-5

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kelly%20WM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Paglen%20PG%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Pearson%20JA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22San%20Diego%20AG%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Soloman%20MA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus




Guidelines for Requesting and Authorising by Radiographers – Annex B General Radiography

Radiographers are entitled to authorise, under IRMER regulation 6(5), additional and/or more appropriate radiological examinations from those explicitly requested by the referring healthcare professional if the following guidelines are followed. These guidelines have been written to allow flexibility – the Radiographer still has the appropriate freedom to exercise professional judgement to ensure the necessary clinical information is gathered:

1. Imaging the opposite side (from that requested) where clinical indications and/or patient

presentation indicate the incorrect side has been requested. 2. Additional examination/s; indicated by pathology visualized on the original requested

examination.

Chest x-ray for patients going to theatre as indicated in agreed pathway i.e. fracture NOF or shaft of femur. Full length tibia/fibular when a complicated ankle fracture is visualized. Full length forearm when a dislocation is visualized on a wrist or elbow. Full length femur when a pathological hip fracture is visualized.

3. Changing to a more appropriate examination (from that requested) as indicated by clinical

indications and/or patient presentation e.g.

Scaphoid views where only wrist has been requested. Finger views where hand has been requested or vice versa Toe views where foot has been requested or vice versa

Omitting non standard examinations which are unsupported by clinical indications/history e.g.

Lateral chest. C-spine for query cervical rib [Chest x-ray is the exam of choice].

4. When the examination on a hand written form has not been filled in; it can be added if the

indications and patient history/presentation make it obvious e.g.

Chest x-ray for any of the valid reasons in the Exam Protocols Specific extremity x-rays if they are named and/or specific anatomy is identified in the clinical details.

5. Trained extended role radiographers working to specific schemes of work can authorise barium enema examinations



6. Radiographers can authorise referrals with reference to agreed X-ray referral guidelines

(HEYRAD11) and the General X-ray Referral Criteria, Standard Operating Procedures and

Exposure Authorisation Protocol.

7. Radiographers can authorise referrals by specified government law enforcement agency

personnel where there is a formal agreement in place with Hull and East Yorkshire Hospitals

NHS Trust which justifies the exposure.

8. Radiographers can authorise referrals by specified musculoskeletal sonographers as outlined

in Annex E of this protocol.




Guidelines for Requesting and Authorising by Radiographers – Annex C

CT Radiographers

Radiographers are entitled to authorise, under IRMER regulation 6(5), additional and/or more appropriate radiological examinations from those explicitly requested by the referring healthcare professional if the following guidelines are followed. These guidelines have been written to allow flexibility – the Radiographer still has the appropriate freedom to exercise professional judgement to ensure the necessary clinical information is gathered:

Changing Requested Exam. Radiographers under delegation from radiologists, protocol outpatient CT request cards. Available on the Y drive is a list of indications and protocols. The requesting doctor may have selected/inserted the incorrect CT code; the radiographer will change this to the correct examination as per the list of indications and protocols. Eg Request made for CT Chest High resolution, indications mass on CXR for staging. This would be changed to the correct CT Chest with contrast.

Additional Examinations. Radiographers add exams at time of scanning, due to the pathology demonstrated on the initial scan. Radiologists have delegated this task to radiographers. A list of common exams added is available on the Y drive.




Guidelines for Requesting and Authorising by Radiographers – Annex D Interventional Radiology Theatres (IRT)

The named radiographers can request any examination/s that have been agreed and justified by

the clinical team at the Vascular and TACE Multi Disciplinary Team Meetings.

It is responsibility of the relevant clinical team to ensure that results are reviewed and acted upon

as appropriate and to record outcomes in the patient record

Record of agreement:

NAME SIGNATURE DATE

Guy Archer

Ann-Marie Callis

Anita Echlin

Hilary Finnis

Angela Westlake




Guidelines for Requesting by Radiographers – Annex E

Musculoskeletal (MSK) Sonographers

Specified MSK sonographers may refer patients for x-ray/s of the appendicular skeleton if:

There is history of recent trauma with no x-ray.

The scan has not answered the clinical question and there is a suspicion of relevant/significant bony involvement.

The scan has answered the clinical question but an x-ray may add to diagnostic confidence.

The scan is inconclusive and an x-ray may complement and/or substantiate findings. These guidelines are written in agreement with the lead MSK consultant radiologist acting as the IRMER Practitioner in justifying the exposures. The specified MSK sonographers - acting as IRMER referrers - will ensure that all referrals are relevant to clinical management and within the remit of these guidelines. They must provide relevant indications/clinical history for the operator. It is the referrer’s responsibility to ensure that a formal report is completed. Record of agreement:

NAME SIGNATURE DATE

C Drury

T Parker

N White

R Wilson

K Zgoda

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