Orientation Manual for The Northern Hospital Emergency Department
CHAPTER 3: INVESTIGATIONS
CONTENTS

Radiology processes and policies
o Filling out requests
o Plain radiology
o CT, MRI, Ultrasound
o Radiology after hours
 Ultrasound
 MRI
o Renal protection and contrast usage

Pathology
RADIOLOGY
A private contractor, Healthcare Imaging Services, provides radiology services at TNH.
See the prompt policy regarding radiology requesting. For further information on
specific tests, a prompt advanced search for radiology department may give the
information required.
Filling out requests
To ensure your patient receives the correct test in a timely manner, please ensure that
your request slip is filled out correctly, and that the correct process is followed.
Important parts of the forms include
1. The location of the patient – including if you expect them to be moved in the near
future
2. A contact phone number for yourself – the main ED number 58610 is usually the
most convenient
3. Legible signature and print name
4. Urgency
5. Clinical notes enable the radiographer to determine if special views may be
needed, as well as the radiologist to be guided in their reporting.
6. Contrast risks – diabetic, on metformin, renal impairment, allergies
7. Pregnancy
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Plain radiology
The request may be taken around to the department, time stamped and placed in the
emergency box.
Any medical staff can order plain radiology, and nursing staff as part of their bundles of
care can order certain plain radiology.
CT, MRI and Ultrasound
All CT, MRI and Ultrasound requests must be discussed with and signed by an ED
consultant, or after hours the senior ED registrar.
All requests must then be discussed with the appropriate radiologist to give advice on
the correct test, and to plan the timing/ urgency of the test. Their signature is required
for Category 1 – same day testing.
After hours (when i-Telerad is reporting), this step is omitted. You only need to discuss
the test with i-Telerad if there is a clinical need.
The request is then handed to the CT radiographer, or the ultrasonographer. It is useful
to also discuss any specific needs of the patient with the radiographer involved.
Ultrasound
Careful consideration needs to be given to whether the tests needs to be done out of
hours. The sonographer needs to be called in from home to do the test. This is a costly
process. The following statements offer principles and questions to guide the decision
to order an after-hours scan. They do not cover every possible scenario, and each
patient’s needs should be assessed individually.
1. Is the clinical problem life threatening? e.g. ectopic pregnancy
a. Will the scan determine the need for urgent surgery?
b. Is the patient unstable and needs to go to theatre and the imaging is not
necessary?
c. Has a discussion occurred with the on-call obstetrician to prioritise?
2. Is the problem organ threatening? e.g. testicular torsion, ovarian torsion.
a. Should the patient be going to theatre for exploration, and the imaging will
not change this process?
b. Has the on-call urologist or gynaecologist been involved in the decision?
3. Will the imaging determine the need for theatre and the operation will occur
after hours? E.g. appendicitis.
a. If theatre will not be arranged after hours, the imaging can be done
urgently in the morning
4. Is an ultrasound the most appropriate test, or is an alternative available?
5. Consultation with appropriate senior staff should occur with these questions in
mind.
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MRI
A prompt document informs on the ordering of MRI scans in general. Currently the
indications for after hours MRI are for acute spinal cord compression and spinal cord
trauma. The principles and questions are similar to that for ultrasound.
1. Involve a senior clinician in the decision making and prioritisation
2. Is the problem life, limb or organ threatening
3. Will the imaging make a difference to the management process, or determine the
need for an urgent procedure, or surgery
4. Is the test the most appropriate available, or is their an alternative
Radiology after hours
Prompt policy and procedure exists to inform on the out of hours procedures for
radiology
Renal protection and contrast usage
Many trials and meta-analysis of the use of N Acetyl cysteine to prevent renal
impairment during contrast usage exist. Results are somewhat mixed. For example see:
http://jasn.asnjournals.org/content/15/2/251.full
“the current widespread use of NAC is probably appropriate because (1) there is no
other effective drug treatment and because NAC is (2) inexpensive, (3) safe, and (4) well
tolerated.
http://www.bestbets.org/bets/bet.php?id=851
“Clinical bottom line: The current evidence does not support the routine use of IV NAC
to prevent contrast nephropathy in patients with renal impairment. Administration also
comes with a reasonable risk of anaphylactoid reaction. Simple measures such as iv
hydration with isotonic saline and use of non ionic contrast should be utilised.”
Hydration, careful clinical evaluation and reversal of risk factors should be standard
practice. Low dose non-ionic contrast agents may be an alternative.
Prompt policies exist on renal impairment and intravascular iodinated contrast, and the
use of N Acetyl cysteine, intravenous fluids and bicarbonate for renal protection.
The dose for urgent CT scans is 1.2g in 1000ml of N/Saline given over 1 hour for a
patient that will tolerate the fluid load.
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PATHOLOGY
Private contract with Healthscope
Blood is often drawn by nursing staff, but in times of heavy workload or difficulty they
may request assistance from medical staff
Requests are paper based, and are normally be signed by medical staff. Nursing staff
may also sign for pathology that is part of their bundles of care
Group and hold / cross-match must be dated and signed with the same signature on
both the tube and form
Most tests can be sent by the pneumatic tubes, the lists of tests that cannot be sent are
listed near the pneumatic tubes. Please take careful note of this.
Tests that cannot be sent by pneumatic tubes can be sent by hand with the nursing
attendants.
Green pathology tubes are used in the ED for all standard tests. These tests will be
processed as urgent:
EUC
LFT
Troponin
CMP
BHCG
Glucose
CRP
Lipase
Paracetamol
Digoxin
LDH
CK
Any biochemistry, flow cytometry or serology outside the above panel requires a
orange/yellow tube and will not be processed as urgent.
Updated August 2015
Dr R Coutts
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