Information for Imaging Referrers
1.
General Information
The purpose of Imaging is to assist the clinician in coming to the correct diagnosis and enabling them
to monitor treatment using the most appropriate, evidence based, cost effective and available
examination.
Most examinations require the use of ionising radiation (x rays, CT and nuclear medicine). Their use
is governed in a very tight legal framework- Ionising Radiation (Medical Exposure) Regulations 2000
known as IR(ME)R. These deserve their own section (see below). However please remember as the
doctor or non medical referrer either signing the request card or submitting the electronic referral it is
you personally confirming that the patient needs the examination to be performed and you are legally
responsible. We therefore have very strict guidelines about what is acceptable.
Consultant Radiologists are there to guide you and assist in maximising your patient care. They know
and work with your Consultants closely. There are no junior medical staff in Imaging. If you are at all
unsure how to proceed Consultant Radiologists can be found in Imaging A, route 234, and also in the
OPDCC imaging Department, route 005.
Outpatient requests are still on paper at present. All in patient requests are electronic via ’ order
comms’. You will receive appropriate training by the IT team on how to use the system. All images are
obtained and stored on the PACS and are immediately available when processed by the
Radiographers. The reports are available on FUSION a few minutes after the radiologist has
authorised it.
The following sections are just an introduction, to the Imaging department.
2. Geography of Imaging
Imaging A
The main department in West Wing provides in-patient services including, CT, Nuclear Medicine, MRI,
as well as the bulk of general radiography including Accident and Emergency. This is where you find
Radiologists, the In- Patient Scheduler, the senior radiographers for each discipline, the Imaging
Seminar room and the main out-patient booking office.
Antenatal Clinic Route 122
Obstetric ultrasound only is based in this department. The occasional in-patient.
Portable Radiography
For extremely sick patients for whom it would be unsafe to move, portable plain radiography can be
carried out. Mainly for CXR’s and only infrequently for other body parts. Please bear in mind that
these areas are not designed to withstand high dose x- rays and the risk of unnecessary exposure is
therefore greater. Also portable machines do not give the image quality of departmental films.
Breast screening and Mammography -Route 126 Family and Diagnostics OPD.
Please complete a paper referral for these examinations
OPDCC Imaging Department
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OPDCC Imaging includes CT services, digital radiography, dental radiography and screening
procedures including interventional vascular services. There is a walk in service for plain radiography
from outpatients and most GP exams.
Dr Almallah and Dr Amir have their offices here and generally there is a radiologist available to
discuss cases.
3.
Radiation Protection
Radiation Protection and Ionising Radiation (Medical Exposure) Regulations 2000
As a referrer you have a key role to play in minimising the radiation dose received by members of the
public. It is important that you fully understand your role under current legislation and the effects of
radiation.
The doses for most medical exposures are quite small, when considered in relation to the benefit to
the patient from improved diagnosis. Exact doses are difficult to quote since these will vary between
patients, depending on patient size, and clinical indications. It is, therefore, imperative that in your role
as a referrer you consider the risk / benefit for every radiation exposure you request. You must ensure
that for all referrals the examination requested has the potential to alter the patient’s clinical
management and have clear medical benefit, and that the risks associated with radiation exposure
are justified. This will ensure that the radiation dose to the patient will be kept as low as reasonably
practicable.
You must ensure that the information you require from the radiological examination is not already
available from any previous imaging, even if they were requested by another clinician or team, or at
another hospital.
To help put these radiation doses into perspective, the table below relates certain examination to the
equivalent background radiation received, and the relative risk.
Procedure
CT Abdomen
CT Chest
Barium Enema
Radioisotope Bone Scan
Barium Meal
IVU
CT Head
Barium Swallow
Lung Ventilation
Lumbar Spine
Abdomen
Pelvis
Hip
Skull
Chest
Limbs and Joints
Typical Effective Dose
(mSv)
10
8
7.2
4
2.6
2.4
2.0
1.5
0.3
1.0
0.7
0.7
0.4
0.06
0.02
<0.01
Equivalent number of
chest xrays
500
400
360
200
130
120
100
75
15
50
38
35
20
3
1
<0.5
Approximate equivalent period of
background radiation
4.5 years
3.6 years
3.2 years
1.8 years
15 months
14 months
10 months
8 months
7 weeks
5 months
4 months
4 months
2 months
9 days
3 days
<1.5 days
The Health Protection Agency is concerned with the radiation protection of patients undergoing
medical exposure. Within the Agency the Medical Dosimetry Group conducts surveys of diagnostic
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radiology practice in the UK, compiles a national database of doses received by patients and
recommends national reference doses for common x-ray examinations. Radiology Departments
strive to ensure that their dose reference levels fall within these guidelines. However, these are in
the context of the request being justified.
The IR(ME) Regulations came into force in January 2001, and replaced the Protection of Persons
undergoing Medical Exposure or Treatment (POPUMET) 1988. These regulations outline the legal
requirements for all those involved in radiographic examinations. Below is a summary of the main
points. This is not a complete record and you must ensure that you are familiar with and comply
with the full Regulations.
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In line with IR(ME)R 2000, a correctly completed Department of Radiology referral must be
submitted prior to investigation for every radiological examination. This must be written or
completed electronically by the referrer.
The patient must be identifiable from the referral. Name, date of birth and hospital number must
be present together with the Consultant. It is the responsibility of the referrer to ensure that the
correct patient ID is clear on the referral, and that it is for the correct examination, relevant to the
patients condition.
The referrer must be identifiable. When making a paper referral it is important that there is a
referrers signature and name written legibly, together with contact number / bleep.
It is helpful if the patient’s mode of transport to radiology can be selected, and whether that
patient needs oxygen
It is important that if the patient is barrier nursed or has any special requirements that this is noted
on the referral, to enable us to prevent cross infection and cater for individual needs.
Clinical indications and questions must conform to those in the radiology department protocols. If
they do not, or there is insufficient information to justify the examination, then it should not be
performed. You will be contacted to supply further information.
For all females of reproductive age, where the investigation involves irradiating the abdomen (and
all nuclear medicine examinations) the date of the last menstrual period must be stated on the
referral.
If the referral is incompletely or illegibly completed, legally the examination cannot be performed
and will be returned to the referrer.
The referrer must supply sufficient medical information to enable the practitioner to justify the
examination. It is intended that the departmental protocols will assist the referrer to ensure that
the patient only receives an exposure of radiation when the result will affect the management of
that patient, thus keeping the overall dose to the population as low as reasonably achievable.
These Referral and Justification protocols are based on the Royal College of Radiologists
Guidelines and in compiling them we consulted widely with our clinical colleagues within the
Trust.
4.
Imaging Team
The Imaging department has a close team philosophy. The Consultant Radiologists clinically lead the
radiographers, nuclear medicine technicians, support workers and clerical staff. Radiologists act as
Practitioners as per IR(ME)R. Any urgent requests particularly for CT/MRI/NM and interventional
radiology needs to be personally discussed. Individuals you may like to get to know:
Radiologists
Dr H Rai - Clinical Director Of Imaging,
Dr C L Holland
Dr P Sada
Dr F Almallah
Dr R Amir
Dr M G Thuse
Mrs Jo Lydon, Imaging Manager and Mrs Vanessa Palmer Superintendent, lead the radiography team
together with Mrs Julie Hannon, Superintendent Sonographer
Mr Tom Johnson – Fluoroscopy Team Leader
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Mr Paul Fraser – CT Team Leader
Ms Lucy Hodgkiss – Nuclear Medicine Lead
Mrs Jo Davies – Plain film Team Leader
Mrs Judith Davis - Manager Lister InHealth MRI
Miss Heather Gwillym – Training and Development lead
3.
Requesting an Examination
Only put pen to paper or finger to keyboard if you understand the need for the exam and think it will
change management. As you can see for section 3 above the regulations that control radiation are
very tight. Ensure you have discussed the exam with the patient and they understand and can give
verbal consent (simple exams) or written consent (complex exams). Please ensure the patient hasn’t
already had the examination. A particular problem arising for patients following ward transfers. Also
ensure that follow ups are not too soon.
Request cards for very routine outpatients can be sent via internal post but please ensure personal
delivery to Imaging A for very urgent and cancer cases. Outpatient cards for routine exams go to
OPDCC x-ray. MRI cards need to go directly to MRI.
In patient requests via order comms. If you want to guarantee a same day exam you need to talk
personally to a radiologist. If the patient is a complex case and is known to a radiologist try to
discuss the cases with the same Consultant
Request cards- In/out patient - white
Buff - A&E
Green - GPs
MRI – yellow
However, if you have access to the electronic order comms system, please use it to make your
referral. We will receive your request sooner and can ensure that your patient receives their
examination in a more timely manner.
If you do use a paper referrals please complete fully. All sections of the request card are important. If
demographic labels are used make sure they’re correct and current and write the patient’s name in
the box below. Every year we have errors with the wrong labels used. This represents a serious
clinical risk. In the department we check the patient’s identity with wristbands, address and date of
birth. Therefore if these are missing the forms are returned to the originator for correct completion. If
you are unsure which exam to select, for instance CT or MRI please discuss the case with a Senior or
Radiologist. Ticking transport arrangements may not seem important to you but portering is our main
constraint. Therefore if a patient can walk to the department they will get their examination much
faster.
It is essential that we are informed if there is any possibility that your patient could be pregnant.
Whilst the majority of low dose diagnostic imaging examinations present very little risk of cancer
induction to the fetus, it is essential that the examination is clinically justified and the dose kept to a
minimum, consistent with the diagnostic requirements. High dose procedures should be avoided in
pregnant women. However, if such examinations are considered to be clinically justified, the risk is
still very low in absolute terms. It is essential that as a referrer you ask female patients of child
bearing age if there is any possibility of them being pregnant. You should note the date of their last
menstrual period on the referral to allow the Practitioner to justify the procedure.
Clinical information – You must provide full and detailed clinical indications in order for us to justify the
examination. For example abdominal pain is not enough, right flank pain, pyrexia, dysuria and +ve
dipstick when requesting an ultrasound are more appropriate. Legally you must provide us with
sufficient clinical information to justify the exposure. Anything you have picked up as co-existing
medical conditions we need a note of. This includes any special handling instructions, e.g. previous
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CVA, hearing or visually impaired, confusion and risk of infection. Anything you encounter difficulties
with clerking the patient we need to know.
Weight is important as some equipment has weight limits and we can’t necessarily do all tests. CT
weight limit is approximately 200kg and screening 135kg. MRI although weight limit isn’t a problem
the diameter of the magnet can be limiting.
There are risks of administering iodinated contrast media, as well as anaphylaxis there are risks of
non-ketotic hyperosmolar coma in diabetic on glucagon. There is also a risk of contrast induced
nephropathy which is dose related also related to underling renal and cardiac status.
In patients undergoing examination of the colon prior to purgative preparation there is a check list that
needs completing to ensure that at risk patients are not dehydrated.
Signing, printing and bleep numbers - Please make sure these are actually legible. Please also print
your name and provide contact number / bleep number, should we need to contact you. If you are a
non-medical referrer please also print your job role.
4.
MRI requests.
Lister In Health, our private partner, provide our MR services. MR’s take longer than CT’s and there is
therefore pressure on the service. Any routine MR’s will wait and there is often a significant delay on
in-patients also. As well as the basics of the ordinary request form above the MR radiographers need
the specific MR risk assessment section filling in
Please check for a history of claustrophobia- many appointments are lost, up to 10% because of this.
The risks of MRI in early pregnancy are unknown and we try and avoid to MRI anyone in 1ST and 2nd
trimester. Walsall has a rich industrial heritage and many mature men suddenly remember previous
potential intra-ocular metallic foreign bodies. We can x-ray to exclude these in this case.
Gadolinium can cause irreversible renal fibrosis in patients with previous renal impairment. We
therefore avoid this. If necessary in-patients with renal impairment we can give CT contrast but some
patients may require haemofiltration.
We do not have a full range of MR monitoring equipment or ventilators. Therefore requests for any
HDU/ITU patients need to be discussed with a radiologist.
5.
Imaging requests outside office hours
The main department is open from 0830hrs to 1730hrs Monday to Friday. After this time plain films can be
organised by bleeping the radiographers - bleep 8115 or by ringing ext 7405.
CT, Ultrasound and contrast examinations are organised via switchboard asking for the Consultant
Radiologist. Please ensure your cases have been discussed with your seniors, Consultant preferably but
at least the middle grade on-call.
The only situation where you contact the CT radiographers directly is in the case of stroke, particularly in
patients in whom thrombolysis is being considered, when you need a scan within 24 hours of admission.
All other scans go via the Radiologist.
There are no out-of-hours MRI scans, although the service runs 12 hours per day, 7 days per week.
Therefore some emergencies can be accommodated.
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