nurse/non-medical requested x-rays

WAHT-NUR-060 It is the responsibility of every individual to check that this is the latest version/copy of this document.

Nurse/Non Medical Requested X-Rays WAHT-NUR-060 of 40 Version 5.5

Nurse/Non-Medical Requested X-rays

This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in

consultation with the patient and /or carer. Health care professionals must be prepared to

justify any deviation from this guidance.

INTRODUCTION The NHS Plan (DOH 2000) and Making a Difference (DOH 1999), the government’s strategy for nursing and midwifery, highlighted the need to introduce new roles and new ways of working for nurses, midwives and allied health professionals to help improve services and the quality of patient treatment and care. The aim of introducing a policy to support nurses and non-medical practitioners to request x-ray examination is to ensure prompt diagnosis and treatment and the delivery of patient focused high quality care.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS : Trained staff identified within this policy.

Lead Clinician(s) Philip Goode Specialist Nurse Practitioner

Approved by Trauma & Orthopaedics Countywide Directorate Meeting on:

12th January 2016

This guideline should not be used after end of: 12th January 2018



Key amendments to this guideline

Date Amendment By:

14/09/2010 Appendix 6 – Add Specialist Practitioner – Medicine and Specialist Physiotherapist

Sharon Ellson

16/11/2010 Appendix 3 – Total Knee replacement – AP weight bearing knee and lateral knee

Sharon Ellson

27/07/2011 Appendix 13 – Add A&E nurses – Criteria change to chest X-Rays in preceding 48 hours

Sharon Ellson

01/05/2013 Guideline changes to reflect introduction of online requesting

Philip Goode

01/05/2013 Change heading from ‘Appendix’ to ‘Protocol’ Philip Goode 01/05/2013 Addition of CT/MRI to protocols 1,8,9,12,15 Philip Goode 01/05/2013 Restriction of protocol 6 to WRH practitioners and

Trustwide Specialist Physiotherapists Philip Goode

01/05/2013 Addition of protocol 7 for T&O Practitioners (ALX) Philip Goode 01/05/2013 Addition of protocol 19 for GI specialist nurses Philip Goode 01/05/2013 Change of protocol 9 from ‘Vascular Nurse Specialist’

to ‘Nurse Consultant’. Protocol changes to reflect post. Philip Goode

01/05/2013 Protocols 16 and 18 changes from Heaf to Mantoux test for screening in TB

Philip Goode

01/05/2013 Appendicular views added to protocol 1 Philip Goode 01/05/2013 Appendix A added – requesting on behalf of Philip Goode

23/08/2013 Incorporation of pre exisiting DEXA protocol into policy – Protocol 20

Philip Goode

14/08/2015 Document extended for 12 months as per TMC paper approved on 22nd July 2015

TMC

12/01/2016 Protocol 21 added – senior orthopaedic nurses in fracture clinic (ALX)

T&O Directorate



Nurse/Non Medical Requested X-rays

Introduction The NHS Plan (DOH 2000) and Making a Difference (DOH 1999), the government’s strategy for nursing and midwifery, highlighted the need to introduce new roles and new ways of working for nurses, midwives and allied health professionals to help improve services and the quality of patient treatment and care. Within the NHS Plan (DOH 2000) the Chief Nursing Officer identified 10 key roles for nurses and as a result nurses are being empowered to undertake a wider range of clinical tasks including the right to make and receive referrals, admit and discharge patients, order diagnostic tests and prescribe drugs. The practice of nurses requesting x-rays has been pioneered the in the field of Accident & Emergency (A&E) and is now common practice in many departments. Research has shown that nurses are able to request x-rays appropriately (Lindley-Jones and Finlayson 2000) and has demonstrated other benefits including reduction in transit time (Allerton & Justham 2000), more efficient use of nursing time and skills, improvement in the overall quality of service and increased staff and patient satisfaction (Parris et al 1997, Ward 1999) The aim of introducing a policy to support nurses and non-medical practitioners to request x-ray examination is to ensure prompt diagnosis and treatment and the delivery of patient focused high quality care.

Competencies Required This role is restricted to the following staff groups:

Specialist practitioners and out of hours practitioners in Medicine, Surgery, Trauma and Orthopaedics, Theatres and Pre-assessment and non medical practitioners e.g. physiotherapists and podiatrists

Specialist Nurses

Critical Care Outreach Team

Qualified nurses, working in Accident & Emergency, Medical Assessment Unit, Coronary Care and Minor Injury Units across Worcestershire Acute Hospitals NHS Trust.

All staff requesting x-rays must have successfully completed an appropriate training programme either recognised by the Trust or supported by the Training and Development team and appropriate clinicians. All practitioners will be registered on the Trust list of referrers as per IR(ME)R rules. All staff completing the programme will be expected to demonstrate knowledge of:

Trust protocol for nursing and non-medical staff requesting x-rays

Implications and hazards of radiological examinations

Ionising Radiation (Medical Exposure) Regulations- IR(ME)R 2000

Locally agreed protocols for the individual referrer

Professional accountability and responsibility as outlined in the NMC Scope for Professional Practice and the individual professions’ Codes of Professional Conduct



Specialist Practitioners/Specialist Nurses, Minor Injury Staff and Critical Care Outreach staff will also be expected to demonstrate knowledge of:

Patient assessment and management

How to interpret the X-rays they are requesting, in order to prioritise the need for clinical intervention

Staff will be expected to be familiar with the PACS system.

Patients Covered

Patients covered under this guideline will vary according the practitioner’s role or area of

work – see separate appendices. No patients under the age of 3 years will be included in this

protocol.

Special Points X-rays must only be requested when the results, either positive or negative may have the potential to alter patient management X-rays must not be requested on women of child – bearing age that are known to be or may be pregnant. Although any concerns regarding this can be discussed with the Radiographers for a final decision. If the Radiographer considers that the x-ray request is not clinically justified, he/she will address any queries to the referrer and if necessary the radiographer will seek advice from a radiologist. Where the individual practitioner is requesting a CXR, every effort must be made to ensure that the patient has not had a recent CXR within the last 6 weeks – Images can be transferred from most Trusts in the UK. Where this is the case the PACS team should be contacted via the web link on PACS to arrange transfer of the images (Mon-Fri 9-5). Exceptions to this are new onset symptoms or tube placement.

It is the responsibility of the person requesting the x-ray to ensure that a member of the medical team also sees the x-ray and that the results of the examination are recorded in the patient’s medical record. Nurse practitioners working in minor injury and accident & emergency departments are responsible for reviewing their own x-rays and recording the results in the patient’s medical record. The registered practitioner must have undergone the agreed training programme devised for this role as agreed by the Director of Nursing and Radiology Clinical Director and achieved the necessary competencies before commencing practice. The radiology department will hold a list of approved staff and specimen signatures. Where the protocols do not cover advancements in practice staff should refer Appendix A for “requesting on behalf of” application.



Guideline For the majority of staff the clinical need for an x-ray must be established through the clinical history obtained and examination of the patient, for ward based staff x-rays may be requested according to ward based protocol. Once the need for an x-ray has been identified, it is good practice to obtain verbal consent from the patient. This includes informing the patient of the potential risks as well as the possible benefits of undertaking the investigation. Alternatives if available can be discussed at this point. The x-ray request must contain all relevant information including presenting complaint, current symptoms and relevant past history in order to clinically justify the request. Where possible the request must be submitted via the Trusts electronic requesting system. Where this is not possible requests must be legible, signed, have the requesters name printed and a contact bleep/telephone number. All x-ray requests must be in line with:

The Royal College of Radiologists Making the best use of a Department of Clinical Radiology http://www.rcr.ac.uk/publications.aspx?PageID=310&PublicationID=362

Locally agreed protocols for the individual referrer Please Note: If an x-ray has been done but cannot be located despite searching, then a clinical incident form must be filled in if the radiograph needs to be repeated.

Monitoring Tool STANDARDS

Item % Exceptions

Request forms are complete 100

When handwritten, requests are legible 100

The professional making the x-ray request has undergone training

100

The x-ray request is clinically justified 100

All x-rays requested by non- medical staff are reviewed by staff competent to do so. Where staff do not have the competence or the result is unclear, then the medical team should review. Results should be recorded in the patients notes.

100

CT+MRI decisions are documented in medical notes and all requests clearly state “requested on behalf of…..”

100

http://www.rcr.ac.uk/publications.aspx?PageID=310&PublicationID=362



Need for x-ray identified

X-ray permitted under protocol

YES

NO

Await medical

assessment

Complete x-ray request (and send to x-ray department if

handwritten)

Radiographer to check name of referrer against approved staff list and protocol.

YES

NO

Request referred back

to department

manager

Radiographer to check that request can be clinically justified from information on request card.

YES

NO Discuss

with x-ray referrer

X-ray examination carried out Justified Refused

Referrer to ensure that a member of the medical team sees the x-ray and

that the results of the examination are recorded in the patient’s medical

records

Referrer qualified to interpret x-rays

Interpret x-ray and ensure that the results are recorded in the

patient’s records.

YES NO

NO

YES

Obtain patient’s verbal consent

X-ray requesting process for nurses and allied health professionals



References

Allerton J, Justham D (2000) Nurse practitioners and the Ottawa Ankle Rules: Comparisons with medical staff in requesting x-rays for ankle injured patients. Accident & Emergency Nursing 8, 110-115

Department of Health (1999) Making a Difference, London, DOH

Department of Health (2000) The NHS Plan, London, DOH

Lee K M, Wong T W, Chan R, Lau C C, Fu Y K, Fung H (1996) Accuracy and efficiency of x-ray requests initiated by triage nurses in an Accident & Emergency department Accident & Emergency Nursing 4, 179-181

Lindley –Jones M, Finlayson B J (2000) Triage nurse requested x-rays – the results of a national survey Journal of Accident & Emergency Medicine 17: 108-110

Parris W, McCarthy S, Kelly A M, Richardson S (1997) Do triage nurse initiated x-

rays for limb injuries reduce transit time? Accident & Emergency Nursing 5, 14-15

Royal College of Radiologists Making the best use of a Department of Clinical

Radiology – Guidelines for Doctors


Ward W (1999) Key issues in nurse requested x-rays Emergency Nurse Vol 6 No 9

19-23




CONTRIBUTION LIST

Key individuals involved in developing this document

Name Designation

Phil Goode Specialist Nurse Practitioner

Tracy Robson Superintendent radiographer

Circulated to the following individuals for comments

Name Designation

Dr Umesh Udeshi CD Radiology

David Hill Chief Radiographer

Pat Gowenlock Radiology WRH

Peter Holland Chair – Radiation Safety Committee

Specialist Nurses/AHP Trustwide

Chris Williams Superintendent Radiographer

Circulated to the following CD’s/Heads of dept for comments from their directorates / departments

Name Directorate / Department

Circulated to the chair of the following committee’s / groups for comments

Name Committee / group

Protocol 1


Out of Hours Practitioners/Specialist Practitioners/Perioperative Practitioners X-ray Protocol

For adult patients aged 16 years or above

Following appropriate clinical examination and assessment the following investigations may be requested

Investigation Clinical problem/Criteria

Erect Chest X-ray PA (AP

view if unable to do PA)

Acute exacerbation of chronic obstructive airways disease

Erect Chest X-ray(AP view if

unable to do PA)

Pulmonary embolism

Erect Chest X-ray (AP view if

unable to do PA)

Pericarditis/pericardial effusion


unable to do PA)

Pneumonia


unable to do PA)

Pleural effusion


unable to do PA)

Haemoptysis


unable to do PA)

Acute exacerbation of asthma with either chest pain, clinical

signs of pneumothorax, pyrexia or raised WCC


unable to do PA)

Life threatening asthma- PEF < 33% predicted or best, or

SpO2 < 92% or PaO2 <8 Kpa.


unable to do PA)

Pneumothorax


unable to do PA)

Central chest pain? myocardial infarction.


unable to do PA)

Chest pain ?aortic dissection.


unable to do PA)

Post insertion of a fine bore nasogastric feeding tube with

guide wire or jejunostomy tube to confirm placement.

See Trust policy WHAT-NUR-065

Erect Chest x-ray, (AP view if

unable to do PA)

Supine abdominal x-ray

Acute abdominal pain? Perforation or obstruction.

http://nww.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11691&type=full&servicetype=Attachment

Protocol 1



Erect Chest x-ray Post insertion of central venous access devices (CVAD) to confirm position.

Erect Chest x-ray Post insertion of peripherally inserted central catheters (PICC) to confirm position.

Erect Chest x-ray Post insertion of a chest drain to confirm accurate tube placement.

Erect Chest x-ray Acute onset of shortness of breath? Left ventricular failure or worsening heart failure.

Erect Chest x-ray Post removal of a chest drain – provided competences associated with chest drain removal have been completed.

Erect Chest x-ray Post cardiac arrest and successful resuscitation to:-

- Confirm correct siting of tracheal tube, gastric tube,

central venous line.

- To exclude left ventricular failure

- To exclude pulmonary aspiration

- To exclude pneumothorax

- To establish size and shape of heart

Abdominal x-ray Acute exacerbation of inflammatory bowel disease of colon.

Forearm/wrist/hand/scaphoid Mechanism of Injury, Focal bony tenderness and Loss of function.

Elbow Mechanism of Injury, Focal bony tenderness and loss of function

Humerus Mechanism of Injury, Focal bony tenderness, loss of function

Shoulder Mechanism of Injury with restriction of shoulder movements/loss of function on movement

Clavicle Mechanism of injury, Focal bony tenderness, Obvious deformity.

X-ray pelvis with lateral x-ray

hip

Fall with inability to weight bear – patients over 65

Protocol 1


Ankle Mechanism of Injury– refer to the Ottawa ankle rules and document on request

Knee Mechanism of Injury– refer to the Ottawa knee rules and document on request

Foot, Mechanism of Injury, Focal bony tenderness, loss of function

Tibia/Fibula Mechanism of Injury, Bony tenderness, non-weight bearing, bony deformity

CT/MRI Requests may only be initiated by a Consultant. Any request submitted following this request must have the following:

Documented decision in medical notes.

Documented in clinical history stating “Requested on behalf

of ……………..”

Protocol 2


Critical Care Outreach X-ray Protocol

For adult patients aged 16 years or above

Following appropriate clinical examination and assessment the following investigations may be requested




Acute exacerbation of chronic obstructive airways disease


unable to do PA)

Pulmonary embolism


unable to do PA)



unable to do PA)

Pneumonia


unable to do PA)

Pleural effusion


unable to do PA)

Haemoptysis


unable to do PA)

Acute exacerbation of asthma with either chest pain,

clinical signs of pneumothorax, pyrexia or raised WCC


unable to do PA)

Life threatening asthma- PEF < 33% predicted or best, or

SpO2 < 92% or PaO2 <8 Kpa.


unable to do PA)

Pneumothorax


unable to do PA)

Central chest pain ? myocardial infarction


unable to do PA)

Chest pain ?aortic dissection


unable to do PA)

Post insertion of a fine bore nasogastric feeding tube such

as a Flocare Pur tube with guide wire or jejunostomy tube

to confirm placement

Protocol 2



Erect Chest x-ray Post insertion of central venous access devices (CVAD) to confirm position.

Erect Chest x-ray Post insertion of peripherally inserted central catheters (PICC) to confirm position.

Erect Chest x-ray Post insertion of a chest drain to confirm accurate tube placement.

Erect Chest x-ray Acute onset of shortness of breath? Left ventricular failure or worsening heart failure.

Erect Chest x-ray Post removal of a chest drain – provided competences associated with chest drain removal have been completed.

Erect Chest x-ray Post cardiac arrest and successful resuscitation to:

Confirm correct siting of tracheal tube, gastric tube, central venous line

To exclude left ventricular failure

To exclude pulmonary aspiration

To exclude pneumothorax

To establish size and shape of heart

Protocol 3


Pre-operative/Perioperative Assessment Nurses X-ray Protocol

For adults aged 16 years or above

Orthopaedic X-ray Protocol

Procedure X-ray and reason

Total Hip replacement To have AP pelvis and lateral hip within 6 months of operation

Revision Hip replacement To have AP pelvis and lateral hip to include the whole prosthesis within 6 months of operation

Total knee replacement AP weight bearing knee and lateral knee

Other knee surgery AP weight bearing, lateral skyline views within 6 months of operation

Lumbar spinal decompression/fusion

AP and lateral lumbar spine – if not done in previous 3 years

Total shoulder replacement Shoulder AP within 6 months of operation

Rotator Cuff repair Shoulder AP within 6 months of operation

Impingement Shoulder AP within 6 months of operation

Shoulder instability Shoulder AP within 6 months of operation

Removal of metal work Up to date x-ray showing all metalwork

Cervical X- ray Protocol

Investigation Criteria

Cervical spine

Lateral and AP

In patients with rheumatoid arthritis or Downs Syndrome x-rays may be used to evaluate spinal instability. Cases must be discussed individually with the surgeon and anaesthetist.

Chest X-ray protocol


Erect Chest X-ray Pre-operative chest x-ray should be taken for:

All patients with acute chest disease.

All immigrants (persons arriving in the country within the last 6 months) from areas with endemic TB, if no previous CXR available

Patients who following history, examination or pathology may have lung/heart disease

All patients with a known primary malignancy if no x-ray within last 6 months

All patients undergoing cardiac/chest surgery if no x-ray within last 6 months

Protocol 4


Emergency Department Nurse X-ray Protocol

For adults and children age 5 or above

Qualified nurses in A&E, who have successfully completed the Trust training programme and

competency, may request x-rays on patients attending A&E with traumatic injuries when

there is clinically a very high suspicion of a fracture i.e. deformity, swelling, severe pain, bony

tenderness or loss of function. Special Points

Nurses will only request X-rays on children when there is parental consent.

Patients who require parenteral analgesia will be referred for medical advice

All radiographs must be reviewed by the doctor in A&E before the patient leaves the department.


Finger/thumb Mechanism of Injury, Focal bony tenderness and Loss of function


Elbow Mechanism if Injury, Focal bony tenderness and loss of function

Humerus Mechanism of Injury, Focal bony tenderness, loss of function

Shoulder Mechanism of Injury with restriction of shoulder movements/loss of function on movement

Clavicle Mechanism of injury, Focal bony tenderness, Obvious deformity.

Ankle Mechanism of Injury– refer to the Ottawa ankle rules

Knee Mechanism of Injury– refer to the Ottawa knee rules

Foot Mechanism of Injury, Focal bony tenderness, loss of function

Pelvis and Hip Patients aged 65 or above with mechanism of injury eg. fall with suspected fractured neck of femur, non weight bearing and loss of function.

Foreign bodies To exclude foreign bodies when there is a clear history of penetration by a foreign body made of metal, stone or glass. X-rays to exclude foreign bodies are restricted to the areas in the ED Nurse protocol

Protocol 4


Band 6 Nursing Staff and above trained and approved by ED Consultant



Chest Pain

Erect Chest X-ray (AP view

if unable to do PA)

Acute onset of breathlessness or worsening of pre-existing

breathlessness


if unable to do PA)

Hypoxia (oxygen saturations below 94%)

Erect Chest X-ray(AP view

if unable to do PA)

Diagnosis of pneumothorax


if unable to do PA)

Diagnosis recent aspiration


if unable to do PA)

Haemoptysis


if unable to do PA)

Diagnosis of myocardial infarction/cardiac

arrhythmia/angina/heart failure


if unable to do PA)

Diagnosis of exacerbation of COPD/asthma


if unable to do PA)

Elevated white cell count > 12 x 109 / L


if unable to do PA)

Diagnosis of pneumonia/chest infection

Protocol 5


Emergency Nurse Practitioner - Emergency Departments and Minor Injury Units

For adults and children aged 3 or above Special points

Other x-rays may be requested after prior discussion with the radiographer, following advice and instruction from a clinician. (This information must be documented on the x-ray request form).

X-rays requested by Emergency Nurse Practitioners may be reviewed independently.


Finger/thumb Mechanism of Injury, Focal bony tenderness and Loss of function


Elbow Mechanism if Injury, Focal bony tenderness and loss of function

Shoulder Mechanism of injury with restriction of shoulder movements/loss of function on movement

Clavicle Mechanism of injury ,focal bony tenderness and obvious deformity

Foot including toes Mechanism of injury, bony tenderness and loss of function

Ankle History of trauma – refer to the Ottawa ankle rules

Knee History of trauma – refer to the Ottawa knee rules

Tibia/Fibula Mechanism of injury, bony tenderness, non weight bearing, bony deformity

Pelvis and Hip Patients aged 65 or above with mechanism of injury eg. fall with suspected fractured neck of femur, non weight bearing and loss of function.

Foreign bodies To exclude foreign bodies when there is a clear history of penetration by a foreign body made of metal, stone or glass. X-rays to exclude foreign bodies are restricted to the areas in the ENP protocol

CXR Age 3 – 16

To exclude metal FB

Metal detector activating above diaphragm

OR

Metal detector not activating with good history of swallowed metal FB

Protocol 6

Nurse/Non Medical Requested X-Rays

WAHT-NUR-060 of 40 Version 5.5

Nurse Practitioner in Trauma & Orthopaedics (WRH) and Specialist Physiotherapist.

For adults over 16 years

Special Points

For patients with orthopaedic and trauma conditions seen in pre-admission clinics, pre-operatively and postoperatively as an inpatient or in follow up clinics

X-rays requested by the specialist practitioner in trauma and orthopaedics may be reviewed independently (according to IRMER rules)

Where appropriately trained, Physiotherapists should request under the separate

Trust Guideline (WAHT-PHY-021)


Knee – AP, Lateral views and skyline views

Feet - AP, Lateral and Medial views

Full leg -AP and lateral views

Forearm -AP and Lateral views

Wrist -AP and lateral views

Humerus and shoulder -AP, lateral, Oblique views

Pelvis- AP

Hip - Lateral

Lumbar spine - AP and lateral

Patients presenting with pain, deformity, unexpected swelling.

Patients following surgery

Inpatients and outpatients

Check of position

History of injury

Erect Chest X-ray Post insertion of a fine bore nasogastric feeding tube, (radio-opaque or with guide wires inserted), or jejunostomy tube to confirm placement

See Trust policy WHAT-NUR-065

Erect Chest X-ray(AP view if unable to do

PA)

Pulmonary embolism


PA)

Pneumonia

http://www.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=9899&type=Full&servicetype=Attachment

http://nww.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11691&type=full&servicetype=Attachment

Protocol 6




Erect Chest X-ray

Pre-operative chest x-ray should be taken for :


All patients with chronic chest disease if no CXR for 6 months



All patients with a known primary malignancy

Protocol 7



Orthopaedic Nurse Practitioners (ALX)

For Adults only

First line 1/7 post-op views only

Images will be reported by a radiologist or Reporting radiographer


Knee - AP &Lateral Post-op total knee replacement

Post-op knee re-surfacing

Post-op partial knee replacement

Hip - AP pelvis & lateral Post-op total hip replacement

Post-op hip re-surfacing

Shoulder -AP &Lateral Post-op shoulder replacement

Elbow - AP &Lateral Post-op elbow replacement

Ankle - AP &Lateral Post-op ankle replacement

Wrist - AP &Lateral Post-op trapezium replacement

Hand - AP &Lateral Post-op MCPJ replacement

Protocol 8



Respiratory Specialist Nurses

For adults aged 16 years or over


Erect Chest X-ray PA & lateral if required (AP view if unable to do PA)

Post PICC line insertion to confirm position

Erect Chest X-ray PA & lateral if required (AP view if unable to do PA)

Acute exacerbation of bronchiectasis

Erect Chest X-ray PA & lateral if required

(AP view if unable to do PA)

Acute exacerbation of chronic obstructive

airways disease



Acute exacerbation of asthma with either

chest pain, clinical signs of pneumothorax,

pyrexia or raised WCC

Erect Chest X-ray (AP view if unable to do

PA)

Life threatening asthma- PEF < 33%

predicted or best, or SpO2 < 92% or PaO2

<8 Kpa.



Follow up for known malignancy - excluded if

recent x-ray (within 6 weeks) available,

unless request based on clinical presentation

of patient eg, exacerbation of symptoms



Follow up after thoracic surgery- if clinical

presentation indicates a need.



Screening for tuberculosis contacts



Outpatient follow –up COPD, Sarcoid,

Pulmonary fibrosis, Pneumonia, Asthma

CT/MRI Requests may only be initiated by a Consultant. Any request submitted following this request must have the following:

Documented decision in medical notes.

Documented in clinical history stating

“Requested on behalf of ……………..”

Protocol 9



X-ray protocol for Vascular Nurse Consultant

For adult patients aged 16 or over


Erect Chest X-ray Pre-operative chest x-ray should be taken for:


All patients with chronic chest disease if no CXR for 6 months



All patients with a known primary malignancy

Feet and or Calcaneum ? osteomyelitic changes

Ankle

Knee

Feet

Pelvis

Lumbar spine

Patients presenting with pain, deformity, unexpected swelling.to differentiate musculo-skeletal problem from vascular problem.

Patients following surgery

Inpatients and outpatients

History of injury

CT/MRI Any decision for CT/MRI should be made by

Consultant and discussion clearly

documented in the medical notes with the

request clearly stating, in the request text,

which Consultant made the decision.

“Following discussion with……………”

Protocol 10



X-ray protocol for Rheumatology Nurse Practitioners


Xray Criteria

Erect Chest X-ray Baseline investigation prior to commencing treatment with disease modifying agents where previous x-ray more than 6 months ago

Upper Limb Baseline investigation to determine progressive/degenerative changes where previous x-ray more than 6 months ago

Lower Limb Baseline investigation to determine progressive/degenerative changes where previous x-ray more than 6 months ago

Peripheral joints Baseline investigation to determine progressive/degenerative changes where previous x-ray more than 6 months ago.

Protocol 11


X-ray protocol for Specialist Nurses for Heart Disease – Rapid Access Chest Pain




PA)

Unexplained ongoing chest pain

Erect Chest X-ray PA (AP view if unable to

do PA)

Pulmonary embolism


PA)



PA)

Pneumonia


PA)

Pleural effusion


PA)

Haemoptysis


PA)

Pneumothorax


PA)

Acute onset of shortness of breath ?left

ventricular failure


PA)

Chest pain ?aortic dissection


PA)

All immigrants (persons arriving in the

country within the last 6 months) from areas

with endemic TB, if no previous CXR

available


PA)

Smokers with suspected malignancy

Protocol 12


X-ray protocol for Specialist Oncology and Haematology Nurses



Erect Chest X-ray (AP view if unable to do PA)

Post insertion of peripherally inserted central catheters (PICC) to confirm position

Erect Chest X-ray (AP view if unable to do PA

Post insertion of central venous access devices (CVAD) to confirm position

Erect Chest X-ray (AP view if unable to do PA

Screening for neutropenic patients with respiratory symptoms

Pelvis Known cancer patients complaining of bony pain or symptoms suggestive of bony metastases

Hip Known cancer patients complaining of bony pain or symptoms suggestive of bony metastases

Femur Known cancer patients complaining of bony pain or symptoms suggestive of bony metastases

Humerus Known cancer patients complaining of bony pain or symptoms suggestive of bony metastases

Spine

Known cancer patients complaining of bony pain or symptoms suggestive of bony metastases







Protocol 13



X-ray protocol for Diabetic Specialist Nurses /Podiatrists/Tissue Viability Nurse



Foot and calcaneum X-ray To exclude or monitor osteomyelitis, charcots

joints and foreign bodies.

Protocol 14



X-ray protocol for MAU&CCU


Qualified nurses, band 6 or above, working in A&E,MAU & CCU who have completed the recognised Trust training will be able to request the following x-rays.




Chest Pain


unable to do PA)

Acute onset of breathlessness or worsening of pre-existing

breathlessness


unable to do PA)

Hypoxia (oxygen saturations below 94%)


unable to do PA)

Diagnosis of pneumothorax


unable to do PA)

Diagnosis recent aspiration


unable to do PA)

Haemoptysis**


unable to do PA)

Diagnosis of myocardial infarction/cardiac

arrhythmia/angina/heart failure**


unable to do PA)

Diagnosis of exacerbation of COPD/asthma**


unable to do PA)

Diagnosis of pneumonia/chest infection**


unable to do PA)

Elevated white cell count > 12 x 109 / L**

Protocol 15


X-ray protocol for Specialist Urology Nurse/Rapid Access Urology Clinic Nurses- Trust Wide


Plain abdominal X-ray (KUB) As part of the protocol for these clinics to

assess skeleton for sclerotic metastases,

and for renal tract calculi

Ultrasound KUB

Patients attending out patient clinic as a new

referral or proven malignancy

Plain x-rays of Chest, Pelvis, Spine (depending on bone scan report)

For patients with proven urological cancers

Plain x-ray of Chest

For diagnosis & staging of urological cancers

Trans rectal ultrasound guided biopsy of prostate gland

For diagnosis of prostate cancer







Protocol 16



X-ray protocol for Occupational Health Nurse

For adult employees – aged over 16 years


Erect Chest X-ray Pre employment of health care staff with

direct patient contact, who are from countries

with a high prevalence of TB (40

per100,000) who have not yet had a clear

chest x ray result on entry to the country-

screening for Tuberculosis

Mantoux result of 9mm or over with

respiratory symptoms indicative of TB-

screening for Tuberculosis

Respiratory Health surveillance as required

by Health and Safety Legislation, due to

exposure in the workplace of substances

hazardous to health. Eg Silica, Asbestos

Protocol 17



X-ray protocol for Specialist Breast Care Nurse


Mammogram Follow up annual screening for

women over 40 years of age

considered to be at moderate risk of

developing breast cancer as a result

of their family history – patients’ age

35-40 yrs - requests only after

discussion with consultant.

Annual post surgical follow up of

patients treated for breast cancer

Patients attending one-stop

mammography clinic after discussion

with consultant breast surgeon

Dexa scans Patient has been diagnosed with a

primary breast cancer.

Patient is post- menopausal.

The histopathology of the cancer has

been identified as oestrogen receptor

positive.

Patient has been commenced on an

aromatase inhibitor.

Protocol 18



X-ray protocol for Specialist TB Nurse


Erect Chest X-ray Screening for tuberculosis for immigrants

who are from countries with a high

prevalence of TB (40 per100,000) who have

not yet had a clear chest x ray result on entry

to the country.

Screening for tuberculosis for individuals with

respiratory symptoms indicative of TB.

Screening for tuberculosis for asymptomatic

individuals with strongly positive Mantoux

tests (9mm or over regardless of age)

Contact tracing: examination of close

contacts of patients with pulmonary

tuberculosis

Protocol 19



X-ray protocol for Upper GI/Colorectal Specialist Nurse









Barium Swallow For patients presenting with history or

dysphagia and/or dysmotility

Barium meal with follow through For patients presenting with dysmotility or

symptoms suggestive of obstruction.


PA)

Acute onset of breathlessness or worsening

of pre-existing breathlessness

Abdominal x-ray Acute exacerbation of inflammatory bowel

disease of colon.

Erect Chest x-ray, (AP view if unable to do

PA)

Supine abdominal x-ray

Acute abdominal pain? Perforation or

obstruction.

Protocol 20



X-ray protocol for Osteoporosis/Fracture Liaison Specialist Nurse



Dexa scan Investigation following NICE guidelines

(TA160 & TA161) and Worcestershire

guidelines for osteoporosis, where patient

has risk factors, in order to determine

treatment options

Protocol 21



Appendix A

“Requesting on behalf of” (ROBO)

Protocol 21



Directorate of Radiology

Radiology Requesting from ICE – Referrals input into ICE on behalf of a Clinician by Non-Medical Staff

Introduction: Robust methods need to be devised to ensure that electronically generated

requests for imaging procedures are authorised only by properly trained individuals. Guide to Justification for Clinical Radiologists Ref No: BFCR(00)5 The Royal College of Radiologists, August 2000 Ionising radiation (e.g. X-rays) can be harmful. Radiology and the Trust must operate under statute law IR(ME)R – Ionising Radiations (Medical Exposure) Regulations, Medical Exposure) when patients are referred for an examination which expose them to Ionising radiation. This ensures protection to the patient and that X-rays are only used if there is clear clinical justification and benefit to the patient. This helps to keep the dose of radiation that individual patients and the population of the country, receive from medical exposure as low as possible. IR(ME)R lays down stringent guidelines and regulations, which if the Trust or individuals ignore can lead to prosecution in a court of law.

Background: Requests historically are made using a handwritten request and only carried

out when signed by the referring clinician (usually a Doctor or other suitable trained, and IR(ME)R trained, health professional. The way requests are made is changing and most if not all requests will be made electronically using the ICE system. Using ICE is normally uncomplicated, as the clinician has been granted electronic password access to refer patients for radiological examinations. The clinician makes the request by entering this data into the ICE system. Radiology receive the information electronically as to who referred the patient but also who entered the data into ICE. Some clinicians, due to reasonable workflow practice, may ask radiology, that specific non medical staff i.e. specific nursing staff for certain clinics or midwives for antenatal ultrasound examinations are granted access to enter the request into ICE, following protocol or clinical assessment of the patient by the clinician.

Requirement: In order for clinicians to do this, and ensure proper compliance with

IR(ME)R and maintain proper clinical governance this will only be granted via a proper written procedure. The purpose of this form is to ensure that the individuals (the clinician and non medical staff) fully understand the issues and have both signed to enable their ICE access for radiology requesting, to be activated. Once signed please photocopy for you own records and send the original back to Tracy Scarborough, c/o General Management, Alexandra Hospital in hard copy format only. Radiology will then contact the ICE Team to amend your settings. You will be advised when this has been carried out.

Protocol 21



** Please print below your full name and role that this Form applies to: ……………………………………………………………………………………………………………………………….

I will only input radiological requests into ICE following clear instruction from the clinical staff (the consultant(s) who is the referrer, named on this form), who has made a clinical assessment of the patient and the radiological examination(s) required or this is done under protocol identified on this form.

I understand that I am inputting the request on behalf of the named Consultant(s) and I fully understand that I cannot make an electronic order for a radiological test on my own behalf or for anyone other than the named clinical staff included within this document.

I will only complete an ICE order if the patients demographic details, the examination being requested and the clinical history is absolutely clear and unambiguous. If it is not then I will refer this back to the consultant prior to the ICE request being submitted.

Failure to comply with this would be a breach of IR(ME)R regulations, if the request is for an examination involving X-rays e.g Chest X-ray, CT scan or Nuclear Medicine study. I understand that failure to comply could bring about prosecution in a Court of Law

For examinations not involving radiation e.g. MRI and Ultrasound then this would be breach of normal Trust guidelines and practice and could be a disciplinary offence.

Note: Form must be signed and returned in hard copy format only – email versions will not be accepted Signed:…………………………………………………(non medical staff member) Dated……………………………………………………………. Signed:…………………………………………………(Consultant 1) Print Name……………………….. Dated……………………………………………………………. Signed:…………………………………………………(Consultant 2) Print Name……………………….. Dated……………………………………………………………. List any other additional Consultants who you refer on behalf of: …………………………………………………………………………………………………………………………… This from may be modified or updated from time to time and may then require re submission.

Protocol 21



Protocol 21

Senior Orthopaedic Nurses in Fracture Clinic (ALX)

For Adults only

Follow up x-rays to assess alignment and healing in fracture clinic

X-rays may also be ordered if the clinic letter from the patient’s previous attendance

at # clinic states ‘x-ray on arrival’ with clear instructions of the limb/joint required

and is within this protocol.

Investigation

Criteria

Calcaneus – AP and Axial

Non operatively treated

At 1/2/3 weeks to check alignment and at 6 & 12 weeks to check healing

Operatively treated

At 1/2/6/12 weeks to check healing

Foot – DP and Oblique and/or Lateral


At 1/2/3 weeks to check alignment and at 6 weeks to check healing

Operatively treated

At 1/2/6 weeks to check healing

Ankle – AP and Lateral


At 1/2/3 weeks to check alignment and at 6 & 12 weeks to check healing

Operatively treated

At 1/2/6/12 weeks to check healing

Tibia and Fibula – AP and Lateral


At 1/2/3 weeks to check alignment and at 6/12 weeks to check healing

Operatively treated

At 1/2/6/12/16 weeks to check healing

Femur – AP and lateral Non operatively treated

At 1/2/3 weeks to check alignment and at 6/12 weeks to check healing

Operatively treated

At 1/2/6/12/16 weeks to check healing

Wrist – DP and Lateral



Operatively treated

Protocol 21



At 1/2 & 6 weeks to check healing

Forearm – AP and Lateral



Operatively treated

At 1, 2 & 6 weeks to check healing Elbow – AP and Lateral


At 1/2/6/12 weeks to check alignment and healing

Operatively treated

At 1/6/12 weeks to check alignment and healing

Humerus – AP and lateral



Operatively treated At 1, 2 & 6 weeks to check healing

Shoulder – AP and axial



Operatively treated


Clavicle – AP and 30 degree angle



Operatively treated

At 1/6/12 weeks to check healing

Protocol 21



Protocol 21 Senior Orthopaedic Nurses in Fracture Clinic, Alex Orthopaedic Centre

Follow up X rays undertaken to assess alignment and bony healing in fracture clinic (ALX)


Ankle fractures AP(Mortise) and Lateral views Weight bearing if possible (6 and 12 weeks)

Non operatively treated at 1/2/3 weeks to check alignment and

at 6 & 12 weeks to check healing Operatively treated

at 1/2/6/12 weeks to check healing

Proximal tibial fractures and fractures of the tibial shaft AP and Lat views (weight bearing if possible)


at 6/12 weeks to check healing Operatively treated

at 1/2/6/12/16 weeks to check healing

Metatarsal, phalangeal fractures and Lisfranc injuries


at 6 weeks to check healing Operatively treated

at 1/2/6 weeks to check healing

Talar and Calcaneal fractures Non operatively treated at 1/2/3 weeks to check alignment and

at 6/12 weeks to check healing Operatively treated

at 1/2/6/12 weeks to check healing

Wrist and forearm fractures in children (NOT torus fractures) AP and Lateral views

Non operatively treated At 1/2/6 weeks to check alignment and

healing Operatively treated (K wiring / Plating / Nailing)

At 1,2 and 6 weeks to check healing

Wrist fractures in adults AP and Lateral views


at 6 weeks to check healing Operatively treated

at 1,2 and 6 weeks to check healing

Clavicle fractures AP and 30 degree inclined views

Non operatively treated Children: at 6 & 12 (if necessary) weeks

to check healing Adults: at 1/6/12 weeks

Operatively treated Adults: at 1/6/12 weeks

Proximal Humeral fractures in adults Non operatively treated

Protocol 21



AP and Lateral views (+Axial if comfortable) At 1/2/6 weeks to check for alignment and healing

Operatively treated At 1/6/12 weeks to check healing

Elbow fractures in children (Supracondylar / lateral and medial condyle / radial neck) AP and Lateral views

Non operatively treated 1/2/6 weeks to check alignment and

healing Operatively treated

1/6 weeks to check alignment and healing

Elbow fractures in adults (Distal humeral, Olecranon, radial head and neck) AP and Lateral views

Non operatively treated 1/2/6/12 weeks to check alignment and


1/6/12 weeks to check alignment and healing

Hand fractures in adults and children AP/Oblique/Lateral views

Non operatively treated At 1/4 weeks to check for alignment and


At 1/4 weeks to check healing

Hip and Femoral fractures (Usually adults) Almost all are operatively treated At 6/12 weeks for all Delayed unions may require further

imaging, check against last letter

1. Appropriate radiographs for any limb or joint may also be ordered if the clinic letter from the

patient’s previous attendance in fracture clinic states ‘X ray on arrival’ with clear instructions

on the limb /joint to be x rayed.

2. In case of any doubt, this should be clarified with a doctor in the fracture clinic.

3. If the radiographer is not happy with the request, clarification should be sought from the

Consultant in the fracture clinic.

4. All staff requesting x-rays must have successfully completed an appropriate training

programme either recognised by the Trust or supported by the Training and Development

team and appropriate clinicians. All practitioners will be registered on the Trust list of

referrers as per IR(ME)R rules.

5. All staff completing the programme will be expected to demonstrate knowledge of:

6. Trust protocol for nursing and non-medical staff requesting x-rays

7. Implications and hazards of radiological examinations

8. Ionising Radiation (Medical Exposure) Regulations- IR(ME)R 2000

9. Locally agreed protocols for the individual referrer

10. Professional accountability and responsibility as outlined in the NMC Scope for Professional

Practice and the individual professions’ Codes of Professional Conduct

nurse/non-medical requested x-rays

Documents