CLINICAL GUIDELINE FOR CLINICAL IMAGING REFERRAL PROTOCOL FOR NURSE SPECIALISTS IN HEART FUNCTION WITHIN RCHT Summary. Start The non-medical practitioner has received sufficient training to make clinical referrals within their speciality The non-medical referrer has received the correct imaging training requirements IR(ME)R/ MRI SAFETY Imaging QSI Lead authorises referral entitlement and maxims access No Referral is within the NMR scope of practice outlined in section 2.4 Yes Discuss with responsible medical practitioner or a consultant radiologist before proceeding. Further examinations must be made by the medical practitioner/consultant. Imaging not required Imaging required Referral for imaging procedure requested on maxims End Clinical imaging department acquires, analyses and reports the diagnostic images. The non-medical referrer is responsible for checking the radiology report and acting on the finding appropriately and documenting actions and outcomes within the clinical care/patient record End
1. Aim/Purpose of this Guideline 1.1. This protocol applies to Clinical Nurse Specialists in Heart Function employed by RCHT who are undertaking the role of referrer under the Ionising Radiation (Medical Exposure) Regulations IR(ME)R. 1.2. The purpose of this protocol is to authorize appropriately qualified non-medical practitioners to request specified imaging examinations, adhering to the Ionising Radiation Regulations IR(ME)R, MHRA Safety Guidelines for MRI Equipment in Clinical Use and the Royal College of Radiologist Guidelines (i- Refer). 1.3. Referrer: in the context of this protocol the term referrer refers to a health care worker who is authorised to refer individuals for X-rays. 2. The Guidance 2.1. Responsibilities The non-medical Practitioner in acting as referrer must do so in accordance with IR(ME)R17 and the RCHT Radiation Safety Policy. The non-medical practitioner must have received sufficient training and be assessed as competent to make clinical imaging referrals. The non-medical practitioner s clinical supervisor and the Radiation Protection Advisor (RPA) are responsible for ensuring that the appropriate training has been undertaken. 2.2. Class of Healthcare Professional and Approved Clinical Areas Nurse Specialists (Heart Function) working in Cornwall who are employed by (RCHT). 2.3. Training and Education This protocol applies to Nurse Specialists (Heart Function) plus further education and training within clinical history taking and physical examination that are competent to examine and assess patients for clinical imaging. All practitioners must have: Been assessed by the heart function nursing service lead as: Competent to carry out a cardiovascular clinical assessment Competent to formulate a clinical management plan in line with local, national and international evidence based guidance. Completed IR(ME)R training Completed MRI Safety training with the relevant RCH team. A list of authorised referrers will be retained by the Nurse Specialists (Heart Function) team and the Clinical Imaging Department. Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 2 of 10
2.4 Description of the Procedures to which the protocol applies Chest X-Ray Cardiac MRI Myocardial Perfusion Scans (Nuclear Medicine) Cardiac CT Arm venograms (for patients who require pacing procedures) 2.5 Referral Process and Excluded Areas. The clinical information must state clinical history, clinical findings, potential diagnosis and the specific area to be examined. If the Nurse Specialist (Heart Function) is in doubt as to whether an investigation is required or which is most appropriate, they will discuss the case with the responsible medical practitioner or a Consultant Radiologist prior to requesting. The Nurse Specialist (Heart Function) will be informed of any significant radiological findings as per the Clinical Imaging Reporting Protocol (access via www.rcht.nhs.uk/imaging). Nurse Specialists (Heart Function) will be responsible for checking the radiology report and acting on the findings appropriately. In the case of an unexpected adverse finding, refer to Clinical Imaging Reporting Protocol (access via www.rcht.nhs.uk/imaging), the Nurse Specialist (Heart Function) will discuss this with the responsible medical practitioner within 24 hours of receipt of the report or if on Friday the next working day. 2.5.1 Excluded Areas All examinations and patient groups not defined within this protocol. The nonmedical practitioner must not operate under this protocol in clinical areas not specified with section 2.4 2.5.2 Excluded Patients Children under 18 years of age Patients who are, or may be, pregnant Patients who are, or may be pregnant. If an X-ray examination is deemed necessary due to overriding clinical reasons in a patient who is or may be pregnant the referral must be made by a Doctor. Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 3 of 10
2.6 Unexpected & Adverse Findings The Clinical Imaging Department is responsible for acquiring, analyzing and reporting of diagnostic images, to enable the Nurse Specialist (Heart Function) to make an informed clinical decision. In the case of unexpected or adverse findings including those outside of the practitioner s scope of practice, the professional and clinical responsibility to act on the information appropriately remains with the Nurse Specialist (Heart Function). The Nurse Specialist (Heart Function) must discuss the findings with the medical practitioner who holds overall responsibility for the patient i.e. Consultant/ General Practitioner. Depending upon the urgency of the case this must be immediate action or within the next working day. All discussions will be documented (within clinical care/ patient record) and must include actions and outcomes; this record must be open to audit. 2.7 Documentation All documentation will be in compliance with the Department of Clinical Imaging requirements and the RCHT Standards of Record Keeping. It is a requirement of the Clinical Imaging Department that all non-medical referrers document their job title on the request; Failure to do so may result in the examination being declined. 2.8 Audit and Risk Management Nurse Specialist (Heart Function) will audit their practice regularly. Any clinical incident that arises as a result of requesting Clinical Imaging must be reported appropriately. Audit results will be reported to the Nurse Specialists (Heart Function) Consultant Cardiologist clinical supervisor and their line manager. 2.9 Continuing Professional Development As a result of on-going audit any Nurse Specialist (Heart Function) currently requesting x-rays falling below the agreed standard in terms of inappropriateness of requesting will be withdrawn from the scheme and further training given until the required standard is met. Each Nurse Specialist (Heart Function) is responsible for maintaining their professional development. 2.10 Accredited and authorized Healthcare Practitioners All specimen signatures are found on the IR(ME)R Entitlement Referrer Form and held by Clinical Imaging. All names will be added to the IR(ME)R referrer database also held by the Clinical Imaging Department. Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 4 of 10
3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Requesting within the scope of this protocol Imaging Quality and Service Improvement Lead Monitor imaging requests made through the hospital ordercomms system. All non-medical referrers working within this protocol will be audited annually to ensure requesting is within scope of practice dictated by this protocol. Referrals requested will be checked on ordercomms (maxims) over a three month period, those referrers who are not requesting correctly will be investigated further by looking retrospectively at the previous 12 months referrals. Audits will be reported to the Clinical Imaging Governance group, which meets on a monthly basis. Minutes of the meeting will record decisions and actions; these are produced by the Imaging PACS team. Audits will be reported to the Clinical Imaging Governance group, which meets on a monthly basis. Minutes of the meeting will record decisions and actions; these are produced by the Imaging PACS team. Any recommendations will be communicated to the referrer and their supervisor immediately. Discussed and communicated from CICG. 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 5 of 10
Appendix 1. Governance Information Document Title Clinical Guideline for Clinical Imaging Referral Protocol for Nurse Specialists in Heart Function within RCHT Date Issued/Approved: 28.02.2018 Date Valid From: 28.02.2018 Date Valid To: 28.02.2020 Directorate / Department responsible (author/owner): CSCS / Clinical Imaging Glenda Shaw Imaging QSI Lead Contact details: 01872 255086 Brief summary of contents A protocol to enable Nurse Specialists in Heart Function to request limited imaging. Suggested Keywords: Target Audience Executive Director responsible for Policy: Non-medical referrer imaging RCHT CPFT KCCG Medical Director Date revised: 28.02.2018 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Clinical Guideline for Clinical Imaging Referral Protocol for Nurse Specialists in Heart Function within RCHT Clinical Imaging Governance Committee (CICG) GovDMB Associate Director CSCS Diagnostic Imaging Lead Divisional Governance Lead {Original Copy Signed} Name: {Original Copy Signed} Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 6 of 10
Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Internet & Intranet Clinical / Clinical Imaging Intranet Only Ionising radiation (Medical Exposure) Regulations RCHT Patient Identification Policy RCHT Consent to Treatment/Examination RCHT Standards of record keeping RCHT Radiation safety Policy NO Version Control Table Date August 2012 Version No V1.0 Initial Issue Summary of Changes Changes Made by (Name and Job Title) Christine Bloor Consultant Radiographer April 2015 V2.0 Feb 2018 V3.0 Formatting update and change in job title. Training and education requirements/competencies Updated to reflect change in clinician scope New trust template. Joanna Davies CNS (Heart Function) Glenda Shaw Image Quality & Service Improvement Lead Joanna Davies CNS (Heart Function) All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 7 of 10
Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. CLINICAL GUIDELINE FOR CLINICAL IMAGING REFERRAL PROTOCOL FOR NURSE SPECIALISTS IN HEART FUNCTION WITHIN RCHT Directorate and service area: CSCS/ Clinical Imaging Name of individual completing assessment: Glenda Shaw Is this a new or existing Policy? Existing Telephone: 01872 255086 1. Policy Aim To authorize appropriately qualified non-medical practitioners to request specified X-ray examinations, adhering to the ionising radiation Regulations IR(ME)R and the Royal College of radiologists guidelines 2. Policy Objectives To enable appropriately trained (job title) to request the specified X- Ray examinations. 3. Policy intended outcomes To ensure that X-Ray referrals are made by an appropriately trained practitioner and within a specific remit. 4. How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? Patients through prompt assessment and appropriate referral as appropriate. Patients through prompt assessment and appropriate referral as appropriate. Workforce Patients Local groups Please record specific names of groups External organisations Other Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 8 of 10
7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Glenda Shaw Date of completion and submission 28/02/2018 Names and signatures of members carrying out the Screening Assessment 1. Glenda Shaw 2. Human Rights, Equality & Inclusion Lead Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 9 of 10
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed: Glenda Shaw Date 28/02/2018 Failure) Working within The Royal Cornwall Hospitals Trust V3.0Page 10 of 10