Document Name: OUT OF HOURS RADIOLOGY
Prepared By: Dr T Baker – Emergency Department Director
Dr Vijay Patheyar- Radiologist
Mr Luke Pontonio – Chief Radiographer
Introduction
Rationale
Although the Emergency Department operates 24 hours a day, not all
hospital resources can do the same. In order to maximize the number of
daytime radiographers, an urgent only service is available after hours.
Deciding to call in a radiographer at night may reduce the number of
radiographers available the next day.
Principles
Radiographic imaging should only be ordered at night if it will significantly
change the management of a patient. Positive images that confirm a
diagnosis and negative images that exclude a diagnosis can both be
useful. Radiographs should be ordered if a delay in imaging could
adversely affect patient outcome. This can occur when uncertain
diagnosis or inability to exclude important diagnosis result in
Delayed critical treatment
 Example: Confirming air under the diaphragm prior to laparotomy.
Delayed critical investigation
 Example: Excluding asymmetrical ICP rise prior to a lumbar
puncture.
Delayed transport to critical care services
 Example: Excluding pneumothorax prior to trauma transport by air.
Delayed transport for urgent surgery
 Example: Confirming fracture type underlying open wound.
Prolonged patient pain because treatment cannot be initiated
 Example: Confirming first dislocation of shoulder prior to reduction.
Prolonged patient pain because treatments cannot be removed
 Example: Many hours in cervical collar when it could be removed if
imaging showed no fracture.
Approval
These guidelines apply to all radiographic imaging ordered from the
Emergency department and wards (inpatients) at South West Healthcare,
Warrnambool.
Junior medical staff have less confidence in their clinical skills and
compensate by ordering more investigations. Often these investigations
are not needed urgently. Sometimes they are not needed at all, or another
investigation would be better. For this reason interns and second year
HMOs should not order investigations without discussing the case
with senior ED doctors or senior inpatient doctors. This means that
if the patient does not fall in to the criteria (refer below) and if HMO 2
and below is in charge, the medical / surgical registrar should be called.
When the indication for imaging meets the parameters below, doctors may
call the radiographer directly. If the radiographer is unconvinced that the
conditions are met, the case should be discussed with the on-call
radiologist. Please re-read the appropriate section of this protocol so that
you can provide clear reason for the investigation.
If you disagree with the radiologist’s decision, you may wish to get the
relevant inpatient or emergency specialist to speak directly to the on-call
radiologist.
Document1
It should not be assumed that non urgent imaging should be performed
out of hours purely because the Radiographer is already on the premises.
If there is an x-ray examination (that is not the primary reason for the call
in) that you feel should be performed, it should be discussed with the
Radiographer. It will be performed if deemed suitable.
Atypical
cases
You may feel that a patient with a situation not covered by this guideline
also requires imaging. Discuss these patients with the radiographer, or, if
necessary, the on-call radiologist.
Business
Hours
Monday to Friday
8:30AM to 5:00PM – Ultrasound and MRI
8:30AM to 9:00PM – CT and X-rays
Weekends and public holidays
9:00AM to 5:30PM – CT and X-rays
There is no MRI service available outside these hours. CT, ultrasound and
X-rays can be ordered out of hours as described in these guidelines.
Three points are particularly important for our service at Warrnambool
 There are only two full-time sonographers. All requests for
ultrasound must be considered very carefully so that the service
remains viable.
 If a radiographer is called in after 1 AM, they will not be available
to work the next morning. If at all possible, delay films needed in
the early hours of the morning until 8:30 AM.
 Consider carefully your decision to have a CT scan performed, the
patient dose for these scans are significantly higher than that of a
plain film x-ray (CTPA is approximately equivalent to 300-400 chest
x-rays). Also the IV contrast media is nephrotoxic in nature so
should only be administered to patients with healthy renal function
(eGFR > 60).
Contact
Number
To speak to the radiologist-on call, ring switchboard and ask to be directed
to the radiologist-on call. Clearly spell out that you are not looking for the
radiographer or sonographer.
Approved Indications by modality
Urgent
indications for
ultrasound
1)
2)
3)
4)
5)
Acute limb ischemia
Paediatric trauma
Ectopic pregnancy ( after +ve pregnancy test & bhcg )
Suspected ovarian torsion
Suspected testicular torsion.
Urgent
indications for
CT
1) CT brain for stroke, bleed or trauma.
2) Acute abdomen
3) Abdominal trauma
Approved indications by system
Respiratory
It can be difficult to diagnose the underlying cause for a patient’s
respiratory distress. As treatments can be quite different (diuretics,
anticoagulants, bronchodilators), it is important to make the diagnosis as
soon as possible. Certain diagnoses (such as pneumothorax or large
pleural effusion) can be treated immediately if they can be confirmed.
Discussion with senior ED staff or inpatient registrars before deciding to
order a film is good practice.
Urgent radiology is indicated for
Shortness of breath of uncertain diagnosis with any of the following
 Increased work of breathing
 Tachypnoea
 New hypoxia (saturation <95%)
Possible pneumothorax
Possible thoracic dissection
Possible large pleural effusion requiring urgent aspiration (and post
aspiration film also)
Urgent radiology is seldom indicated for
Shortness of breath where the patient is not in respiratory distress.
 Example: Probable mild to moderate pneumonia
Shortness of breath where the diagnosis is certain and the patient is
improving
 Example: Acute asthma
Possible pulmonary embolus where the patient is stable
 Unless the patient has a high risk of bleeding, the patient can be
anticoagulated and imaged the next day.
Trauma
Warrnambool is designated as a Regional Trauma Service in Victoria’s
Trauma system. It is tasked to provide resuscitation and stabilisation of
major trauma patients prior to their transfer to a trauma centre, as well as
definitive care of less severe injuries. Delayed diagnosis of head injury or
acute bleeding increases the likelihood of an adverse outcome.
Urgent radiology is indicated for:
Any trauma meeting major trauma criteria
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Head injury with any of the following
 Focal neurology
 Glasgow Coma Score <14 (even if possibly due to intoxication)
 Suspected skull fracture
 Anticoagulant use (will need rescan at 24 hours also)
Neck injury with any of the following
 Focal neurology
 Severe neck pain
 Inability to maintain c-spine precautions due to poor patient
compliance
 Significant patient discomfort due to hard collar when delay in
imaging is likely to be many hours
Chest trauma with any of the following
 Respiratory distress
 Hypoxia
 Significant pain
 Significant chest wall or sterna tenderness
Abdominal trauma with any of the following
 Rebound or guarding
 Hypotension or tachycardia
 Macroscopic haematuria
Pelvic Trauma with
 Pain on pelvic springing
Abdominal
Urgent radiology is seldom indicated for
 Mild symptoms in low impact injury
 Intoxicated patients (GCS14) tolerating a collar where intoxication
precludes collar removal, even if CT clear.
Unless the diagnosis under consideration is likely to require immediate
surgery, imaging can be delayed. If the patient is unstable, immediate
surgery may be more appropriate. Early discussion with the surgical unit is
good practice.
Urgent radiology is indicated for
Acute abdomen
 Obtain surgical advice. Immediate transfer or operation may be a
better option.
Possible organ rupture
Possible volvulus
Possible leaking aortic aneurysm
Possible ectopic pregnancy
 Please confirm pregnancy and discuss with gynaecology registrar first.
Urgent radiology is seldom indicated for
Abdominal pain with localized abdominal signs
Orthopaedic
Most patients with limb fractures can be made comfortable with splinting
and analgesia. They can return the next day for x-ray. Even moderately
displaced fractures are unlikely to be operated on after hours. They
should also be splinted, but the patient may need to remain in hospital
until x-ray is available the next morning.
Urgent radiology is required for
Open fractures
Fractures with significant limb deformity or neurovascular compromise.
Possible dislocation, if immediate relocation is possible
 It is preferable if a post-reduction film can also be done if the
patient could then go home.
 Patient with recurrent shoulder dislocation may sometimes be
relocated without x-ray.
Possible cauda equine syndrome
Urgent radiology is seldom indicated for
Mild or moderately displaced fractures with little chance of neurovascular
problems.
Suspected fractures
Neurological
Urgent radiology is indicated for
Cerebrovascular accident with any of the following
 Time since symptom free < 4.5 hours
 Possible intra-cerebral bleed
Example: associated anticoagulant, hypertension headache
 GCS < 14
 Deterioration
Focal seizures
Prior to lumbar puncture
 Discuss with ED consultant, paediatric, or medical registrar. CT is
not always needed, especially for children.
Urgent radiology is seldom indicated for
Transient ischaemic attack, if symptoms resolved
Post seizure, if patient is returning to normal GCS
Syncope, without focal neurology or abnormal vital signs
Other
In general, intensive care patients should not have their imaging delayed.
Urgent radiology is indicated for
Patients being transferred to a critical care bed or for urgent surgery
 Example: Post central venous line placement
Patients requiring anticoagulation, but require exclusion of bleeding
 Example: Possible pulmonary embolus and altered mental state –
exclude intracerebral bleed.
Urgent imaging is seldom required for
Possible acute coronary syndrome, if chest is clear and the patient is not
being transported
Possible deep venous thrombosis if patient is safe to be anticoagulated.
 Patient can receive low molecular weight heparin until the next
day. If that day is a weekend or public holiday, discuss the case
with the medical unit.
Peripheral foreign bodies