Mid Notts Pathways



Imaging Referral Protocol for Advanced Nurse Practitioners In General PracticePractice:_____________________________________ContentsIntroductionAccountability and ResponsibilitiesDocumentationReferral StandardsCriteria for Imaging RequestsClinical AuditX-Ray Referral ProtocolUltrasound Scan Referral Protocol (including CT scan referral for possible renal colic)Dexa Scan Referral ProtocolPractice IssuesReferral ProcedureRadiology Department- Statement Of IntentIntroductionThe Advanced Nurse Practitioner (ANP) is an experienced Nurse Practitioner who has undertaken further training and developed a sound knowledge and skill base.The Advanced Nurse Practitioner (ANP) must hold State Registration with the NMC, be a recognised Independent Prescriber with the NMC and have completed an appropriate Nurse Practitioner Course at MSc Level.The overall aim of this protocol is to enable ANPs within General Practice to request imaging procedures for patients presenting with undifferentiated and undiagnosed conditions where the imaging investigation is needed as part of the patient’s clinical management.The ability to order diagnostic imaging not only enhances the ability to manage ANP led care but allows true collaborative working to be achieved. The Royal College of Nursing (RCN) has collaborated with the Royal College of Radiologists (2008) to produce guidance that supports imaging staff to accept requests for clinical imaging from nurses and other non-medical professionals.?The ability of the ANP to refer for imaging examinations will facilitate the delivery of holistic patient care at the point of contact and promote the formulation of appropriate clinical management plans.It will also facilitate good time management for the ANP, the GP and for the patient. It will reduce the need for multiple appointments and help to reduce the waiting times to see a GP.The ANP must have attended initial IR(ME)R training and update sessions as outlined in the NMC Code of Conduct (NMC 2015).?Accountability and ResponsibilitiesNurse referrers will be accountable for their own actions in accordance with the NMC Code of Professional Conduct (NMC 2015).?Under IR(ME)R 2000, the Nurse will become a referrer and will then be clinically responsible for the request of the imaging examination.?GPs within the individual GP practices where ANPs undertake requests for imaging examinations will be clinically responsible for all patients under the care of the Nurse Referrer.?GPs within the individual GP practices where ANP imaging referrals occur, will be available to all Nurse Referrers for advice about imaging requests.?The requesting ANP is responsible for following up the imaging request and directing the patient to appropriate care as indicated in the imaging report.?On receipt of an imaging report the patient’s GP will have overarching accountability for ensuring that appropriate action / follow up is taken for the patient.?DocumentationAny imaging examination request by an ANP will be documented in the patient’s electronic medical record at the time the request is made.?If the ANP does not have access to the medical records when assessing the patient, the imaging request will not be completed until the medical notes are available.?Referral StandardsThe information provided by the referring ANP must be:? Legible.? Accurate.? Specific as to the reason for the request.?Criteria for Imaging Requests?The ANP must establish if there have been any previous imaging examinations that would be relevant and include any relevant previous clinical information that will allow the ANP and radiographer to justify the net benefit to the patient.The ANP must consider the possibility of pregnancy when requesting x-ray examinations and may refer for x-rays above the diaphragm and below the knee, but only after a discussion with the GP, the patient and relevant information must be documented on the imaging request.The radiologist may decline any referrals that are deemed to be inappropriate, unjustified or are not covered in this protocol. A registered GP must then examine and refer the patient, if appropriate.The ANP will ensure the correct biographical information is entered on the request form.?The ANP will complete relevant clinical information and the anatomical area to be viewed on the request including provisional diagnosis.?Appropriate verbal and/or written information will be provided to the patient by the ANP at the time of referral and this will be documented in the clinical record.?Interpretation, evaluation and recording of the imaging results will be undertaken by the ANP, under the supervision of the patient’s GP within the Practice to ensure optimal clinical management, follow up and documentation.If it is discovered that an imaging examination that has been requested is no longer necessary, the ANP must ensure the imaging department is notified to prevent unnecessary radiological exposure and/or wasted imaging appointments.Clinical Audit The referring ANP in partnership with their Lead GP will conduct an agreed annual audit of imaging referrals and the results will be shared with the Radiology Department if required. This audit will form part of the ANP annual appraisal.Potential topics for annual audit are listed below:All imaging examination requests are appropriate.All results are received for the imaging examinations requested by the ANP.Appropriate follow up care is undertaken as indicated in the imaging examination report by the ANP.Monitor the number of imaging examinations requested by the ANP.X-Ray Imaging Referral Protocol for Advanced Nurse Practitioners Requests will be limited to:Chest x-rayUpper and Lower limbs > 5 years for injury and > 16 years for other clinical indications (see below), Shoulder, spine, pelvis, hip and knee x-ray for possible OA and pre-orthopaedic referralNOTE: Request for X-Ray investigation must never replace admitting the patient acutely or referring to secondary care if this would be more appropriate Chest X-Ray for Adults Clinical indications for chest x-ray referral Persistent unexplained cough >3/52. Haemoptysis. Unexplained SOB. Unexplained weight loss / night sweats / lymphadenopathy. Pyrexia of unclear originHoarseness >3/52. Severe exacerbation of COPD/Abnormally frequent exacerbations COPD. Suspected heart failure. Suspected pleural effusion. Suspected TB. Suspected pneumonia. Suspected pneumothorax. Suspected inhalation of foreign body. Follow up x-ray if requested by radiology for pneumonia, heart failure, pleural effusion or pneumonthorax. Musculoskeletal X-RaysFor patients >5 years old for trauma and >16 years for other clinical indications.7.21. Pelvis and hipUn-resolving pain after standard treatmentsBone painHip painDeformities 7.22. Upper Limb & Lower Limb (Fingers, Hand, Wrist, Forearm, Scaphoid, Elbow, Shoulder, Clavicle, Toes, Foot, Ankle, Tibia, Fibula) Trauma where suspected fracture or FB (Glass only) Joint pain and/or stiffnessBony deformitiesBone pain?Swelling related to joint or bone 7.23. Knee (including Patella-Femoral Joint) Trauma where suspected fracture or FB Joint pain and/or stiffnessBony deformitiesSwelling related to joint or boneLocking or giving way of jointPersisting painUltrasound Scan Imaging Referral Protocol for Advanced Nurse Practitioners (Including KUB CT Scan for un-resolving pain thought to be due to renal colic)Suspected/confirmed conditions warranting ultrasound examination for patients over age 16 years ??Permitted Ultrasound Scan Examinations for Advanced Nurse Practitioners?Patients can be referred for the following: -?Suspected gall bladder disease.Newly diagnosed renal failure or an unexplained decline in eGFRRecurrent proven urinary tract infections Missing CoilMenorrhagia Pelvic pain and or new bloating (after a clinical examination, normal vaginal swab results, up to date cervical screening and no red flag symptoms suggestive of ovarian cancer including a raised Ca125)Testes- as per the Mid Notts referral criteria for GP access to scrotal USSC 2012Liver USSC- as per the Mid Notts Liver Function Testing Pathway (Feb 2013)?The following ultrasound examinations are NOT available for ANP request?Obstructive jaundice Palpable mass in the abdomenSuspected malignancy BreastThyroid/Neck MassVascular studiesScreening for aortic aneurysmMusculoskeletal Lumps and bumpsEXAMINATION OF THE HEPATO BILIARY SYSTEM?Ultrasonography will show the state of dilatation of the intrahepatic duct system as well as the common bile duct. It will demonstrate stones in the gall bladder and is the investigation of choice in acute and chronic cholecystitis and pancreatic disease. Patients with clinical features of obstructive jaundice should be referred as they may deteriorate rapidly if they develop biliary sepsis.?IMAGING IN RENAL DISEASE?HaematuriaRefer to the haematuria clinic. Ultrasound is the best way to investigate haematuria but it does not reliably exclude bladder tumours, hence the need for referral and cystoscopy. An urgent ultrasound scan can be requested at the same time as an urgent urological referral so that the results are accessible at the initial appointment.?Renal ColicUltrasound is not indicated. Consider CT scan referral for un-resolving pain thought to be due to renal colic. This referral is not available on ICE so a hard copy request on the designated referral card should be completed and submitted.?Recurrent urinary tract infection in young females (under 45 years) (Recurrent is defined as 2 or more UTI’s in 6m or 3 or more in 12m with no persistent visible haematuria after treatment with antibiotics)?Renal ultrasound is the examination of choice as underlying pathology is rare but consider a urological referral if there are risk factors for an abnormality of the renal tract, a history of urological surgery, multi-drug resistant bacteria or symptoms of a fistulaUrinary tract infection in males and new infection in elderly females over 60 years Renal ultrasound is the examination of choice but refer to secondary care if:?An abnormality of the renal tract is identifiedThere is a history of recurrent or persistent unexplained UTI’sThere is a history of unexplained visible haematuria or persistent non-visible haematuria with dysuria and a raised white cell count on blood testing.An abnormal prostate examination and PSA result.?ProteinuriaImaging is unlikely to be helpful.?HypertensionUltrasound cannot reliably exclude renal artery stenosis or adrenal pathology. Patients with severe hypertension resistant to multiple drug therapy should be referred to a Physician for further evaluation.Dexa Scan Referral Protocol for Advanced Nurse PractitionersSuspected/confirmed conditions warranting Dexa examinations for patients over the age of 18 years?Advanced Nurse Practitioners may refer for Dexa scans if they have the expertise to assess the patient.?Referral criteria?Osteopenia reported on a Spine x-ray by RadiologistPatient on long term glucocorticoid treatment (longer than 6 months) Patients with history of vertebral, femoral neck or Colles fractures.Fragility fractures age 50-74 years as these patients are more likely to be at risk of osteoporosis (as per QOF).Patients with disease known to cause osteoporosis (e.g. hyperparathyroidism, malabsorption)Women with early menopause (≤45-year-old) or prolonged amenorrheaAny other clinical reason must be referred by a General PractitionerIt is anticipated that the nurses will be familiar with the patient and can explain the procedure to them.?There are some exclusions or additional criteria: -?If the patient has any metalwork in the hips or spine, or has L-spine fractures,this must be noted on the referral.If the patient is due to attend an examination involving contrast/ technecium injections, the DXA appointment should be made 1 week after (if not before).If the patient has had a previous DXA scan, the follow-up appointment must be at least 12 months after the most recent DXA scanIf the patient has had L-spine surgery/x-ray report diagnosing gross degenerative change AND bilateral hip replacements, DXA cannot be performed.All patients must be: -Over 18 years old.Not weight more than 150kg (24 stone) as the weight limit for the table is 200kg but the images over 150kg is such that they are impossible to analyse and provide inaccurate results.Not pregnant.Able to lie flat on their back.Able to walk a short distance and get onto the table with minimal assistance as the table does not adjust in height.PRACTICE ISSUES The Advanced Nurse Practitioner must have the ability to: -Distinguish relevant anatomy and surface markings.Demonstrate relevant skills in clinical examination.Correctly complete the request on ICE.Follow up and action and results by having a robust system in place.Audit radiology requests annually. Procedure for X-Ray, Ultrasound, CT KUB and DEXA referrals by Advanced Nurse Practitioners in General Practice Patient appointed to see Nurse Practitioner. Nurse Practitioner undertakes assessment of both diagnosed and undifferentiated, undiagnosed problems.If the ANP is unsure of the need for imaging examination the patient should be discussed and /or referred to the GP for further assessment.Correctly complete the appropriate investigation request as per this protocol on ICE which is linked to the patient’s electronic record (except for the KUB CT Scan for un-resolving pain thought to be due to renal colic as this needs to be requesting using the designated referral card). The imaging examination is performed if the radiographer is satisfied that the referral is appropriate and relevant information is documented.Consultant Radiologist produces report. Report forwarded to Nurse Practitioner via ICE and actioned as appropriate (involving GP if deemed necessary).Systems are in place to ensure follow up action is robust.Annual audit of imaging examination requests involving GP Mentor.Radiology Department- Statement of IntentOnly examinations stated within this document can be referred for by the approved non-medical referrers.Imaging can only be requested when the results, either positive or negative, will alter patient managementThe Referrer must comply with the referrer Criteria when requesting an imaging examination.An X-Ray will only be carried out after it has been justified in accordance with the Medical Exposures Manual.The Operator will take the standard projections of the area requested and additional projections if they believe them to be necessary and appropriate. They have the right to refuse to perform an imaging examination if the following is not completedReferral information must be made electronically and include the following:Relevant clinical informationPatient ID, i.e. full name, full address and date of birthNHS number GenderDate of LMP if female between the ages of 12 and 60Is patient pregnant or breastfeeding?Does the patient have an infection?MobilityOther relevant information, e.g. allergy to imaging contrast media, disabilities, language difficulties.The Clinical indication is not appropriate for justification.Irradiation of the patient is unnecessary.There is no benefit or no alteration to patient management because of the examination.Radiology will generally be carried out in accordance with the criteria laid down in the Royal College of Radiologists ‘Making the best use of Clinical Radiology’ which can be accessed via must be in place to provide assurance that all results are reported and that there are clear policies and/or service level agreements for the management of any results that will not be reported by the radiologist or appropriately trained radiographer. The Referrer is responsible for ensuring that a written evaluation is carried out by a person appropriately trained for this task. This may be the subject of audit. (An evaluation’ is defined as the interpretation of the information arising from the medical exposure, and the implications of this information).If it is discovered that an examination that has been requested is no longer necessary, the referrer must ensure the Imaging Department is notified immediately to prevent an unnecessary exposure being made.ReferencesNursing and Midwifery Council. Code of Professional Conduct (2015)..uk/standards/code/read-the-code-online/Doncaster and Bassetlaw Hospitals NHS Foundation Trust (2012) Imaging Referral Protocol for Nurse Practitioners.NHS Eastbourne, Hailsham & Sleaford CCG, Hastings & Rother CCG (2016) Policy for X-ray Referral by Qualified Nurse Practitioners working in General Pra Forest Hospitals NHS Foundation Trust (2012) Referral criteria for GP Access for Scrotal Ultrasound.Sherwood Forest Hospitals NHS Foundation Trust (2013) Liver Function Testing Pathway. GP Information Sheet.Royal College of Radiologists (2008). Clinical imaging requests from non-medically qualified professionals. 2nd edition.?rcr.ac.uk/clinical-imaging-requests-non-medically-qualified-professionals-2nd-edition?Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER)?.uk/government/publications/the-ionising-radiation-medical-exposure-regulations-2000?The Royal College of Radiologists (2012) iRefer - Making the best use of clinical radiology referral guidelines (7th edition), London RCRrcr.ac.uk/clinical-radiology/being-consultant/rcr-referral-guidelines/accessing-guidelines ................
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