POLICY FOR X RAY REFERRAL BY QUALIFIED NURSE PRACTITIONERS WORKING IN GENERAL PRACTICE APPROVED BY: Chief Nurse May 2016 EFFECTIVE FROM: May 2016 REVIEW DATE: May 2018
Version Control Policy Category: Quality and Safety Relevant to: Nurse Practitioners within General Practice Version History Version Date Changes Made: No. 2 Aug 2013 Revised version by Lead Nurse Practitioner 2.1 21/04/2016 Review by Interim Risk and Business Planning Manager 2.2 21/04/2016 Review by Governance and Policy Officer 2.3 06/05/2016 Review by Primary Care Workforce Tutor 3 13/05/2016 Review by Chief Nurse Contents Version Control... 2 1. STAFF QUICK REFERENCE GUIDE.... 3 2. ELIGIBILITY AND EDUCATIONAL CRITERIA OF NURSE PRACTITIONERS.. 3 3. DOCUMENTATION.... 4 4. RESPONSIBILITY.... 4 5. CLINICAL AUDIT STANDARDS.... 5 6. REFERENCES.... 5 7. EQUALITY STATEMENT... 5 8. MONITORING AND REVIEW.... 6 Appendix 1: Suggested Framework to Support Reflective Practice... 7 Appendix 2: Flowchart for X-Rays requested by Nurse Practitioners in agreed Clinical Areas... 9 Appendix 3: Chest X-Ray Procedure... 10 Appendix 4: Appendicular X-Ray Referrals Adults only... 11 Appendix 5: Plan for Dissemination of Procedural Documents... 12 2016 X-Ray Referral Policy 2 of 12
1. STAFF QUICK REFERENCE GUIDE. 1.1. Eastbourne, Hastings and Seaford Clinical Commissioning Group (CCG) and have a joint staff structure. This policy covers both organisations and they are referred to jointly as the CCG. 1.2. Nurse Practitioners General Practice may only submit X-Ray request for those parts of the body covered by this document, i.e. the chest or the appendicular skeleton. 1.3. Radiographs will only be requested when the results, either positive or negative, will alter patient management. 1.4. The referral by the Nurse referrer must comply with referral criteria before sending the patient for X-Ray. 1.5. The Radiographer will be responsible for authorising the request following the practitioner s guidelines 1.6. The Radiographer will take the standard projections of the area requested and additional projections if they believe them to be necessary and appropriate. 1.7. This gives the Radiographer the right to refuse to perform an X-Ray if: The referral criteria are incomplete. The clinical indication is not within the Practitioner s Guidelines as per East Sussex Hospitals NHS Trust IR(ME)R 2000 working document. Irradiation of the patient is unnecessary. There is no benefit, or no alteration to patient management will result. 1.8. In the event of a Radiographer refusing to perform an X-Ray, the request will be returned to the Nurse requester / patient s GP to seek clarification and resolution of the rejected referral. 2. ELIGIBILITY AND EDUCATIONAL CRITERIA OF NURSE PRACTITIONERS. 2.1. Objective: to enable Nurse Practitioners within General Practice to request X- Ray examinations for patients presenting with undifferentiated and undiagnosed conditions where X-Ray is needed as part of the patient s clinical management. 2.2. The ability to order diagnostic imaging not only enhances the ability to manage nurse practitioner 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. 2016 X-Ray Referral Policy 3 of 12
2.3. The Referrer must be a formally recognised Nurse Practitioner (NP) General Practice who has completed either a BSc (Hons) / MSc programme in Nurse Practitioner Studies. 2.4. The Referring Nurse Practitioner must undergo annual appraisals with the Lead Nurse Practitioner for the CCG. 2.5. The Referred must have attended initial IR(ME)R training and update sessions as outlined in the NMC Code of Conduct (NMC 2002). 3. DOCUMENTATION. 3.1. Any request for an X-Ray examination by a Nurse Practitioner will be documented in the patient s medical notes (either electronic or Lloyd Jones) at the time the request is made. 3.2. If the Nurse Practitioner does not have access to the medical records when assessing the patient, the X-Ray request form will not be completed until the medical notes are available. 4. RESPONSIBILITY. 4.1. Nurse referrers will be accountable for their own actions in accordance with the NMC Code of Professional Conduct (NMC 2002). 4.2. Under IR(ME)R 2000, the Nurse will become a referrer and will then be clinically responsible for the request of the X-Ray. 4.3. GPs within the individual GP practices where ALL Nurse Referrers undertake requests for X-Rays will be clinically responsible for all patients under the care of the Nurse Referrer. 4.4. GPs within the individual GP practices where Nurse Practitioner X-Ray referrals occur, will be available to all Nurse Referrers for advice with regard to X-Ray requests. 4.5. The requesting Nurse is responsible for following up the X-Ray request and directing the patient to appropriate care as indicated by the X-Ray report. 4.6. On receipt of an X-Ray report the patient s GP will have overarching accountable for ensuring that appropriate action / follow up is taken for the patient. 2016 X-Ray Referral Policy 4 of 12
5. CLINICAL AUDIT STANDARDS. 5.1. An annual clinical audit will be undertaken by Radiographers under the direction of the Lead Radiographers within the Trust to audit the quality of the referrals. 5.2. The audit report will be submitted to the East Sussex Healthcare Trust s Radiation Protection Committee. 6. REFERENCES. 6.1. Nursing and Midwifery Council. Code of Professional Conduct. www.nmc.org.uk/standards/code/read-the-code-online/ 6.2. irefer - the essential radiological investigation guidelines tool, from The Royal College of Radiologists (RCR). www.rcr.ac.uk/clinical-radiology/being-consultant/rcr-referralguidelines/accessing-guidelines 6.3. Royal College of Radiologists. Clinical imaging requests from non-medically qualified professionals. 2 nd edition. www.rcr.ac.uk/clinical-imaging-requests-non-medically-qualified-professionals- 2nd-edition 6.4. Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) www.gov.uk/government/publications/the-ionising-radiation-medical-exposureregulations-2000 7. EQUALITY STATEMENT In applying this policy, the CCG will have due regard for the need to eliminate unlawful discrimination, promote equality of opportunity, and provide for good relations between people of diverse groups, in particular on the grounds of the following characteristics protected by the Equality Act (2010); age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic. 2016 X-Ray Referral Policy 5 of 12
8. MONITORING AND REVIEW. 8.1 This policy and procedure will be reviewed every two years. Where review is necessary due to legislative change, this will happen immediately. 8.2 An Equality Analysis Initial Assessment has been carried out on this policy. As a result, there is no anticipated detrimental impact on any equality group. 8.3 This policy makes all reasonable provision to ensure equity of access to all staff. There are no statements, conditions or requirements that disadvantage any particular group of people with a protected characteristic as defined by the Equality Act (2010); age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic. 2016 X-Ray Referral Policy 6 of 12
Appendix 1: Suggested Framework to Support Reflective Practice 1. Annual Audit of Nurse Practitioner: Referrals for plain film X-Rays Name of Nurse Practitioner: Audit period: Plain film X-Rays requested during the audit period The clinical record clearly states the reason for referral The clinical record demonstrates consistency with East Sussex Healthcare NHS Trust criteria of requesting X- Rays Number 2. Responsibilities of the Radiology Department pertaining to the Protocol for X-Ray examination requesting by Qualified Nurse Practitioners 2.1. All work is carried out in accordance with relevant current legislation in particular The Ionising Radiation (Medical Exposure) Regulations 2000: IRMER (Ionising Radiation Medical Exposure) and it is the responsibility of the Radiology Department to implement this. 2.2. Under IRMER 2000 it is the responsibility of the PRACTITIONER undertaking an examination to justify each examination based upon the clinical information given by the REFERRER. It is therefore essential that when a patient is referred for a radiological opinion, the referring clinician (including nurse practitioners requesters) provides the practitioner with sufficient information to carry out this justification process. 3. Referral Standards 3.1. The information provided by the referrer must be: Legible. Accurate. Specific as to the reason for the request. Meet the criteria for X-ray requests (see section 4 below). 3.2. Where the referring clinician does not fulfil these requirements the request will be returned with a written explanation of why the request does not comply with the justification procedure. 2016 X-Ray Referral Policy 7 of 12
3.3. If there is any query regarding the validity of the request, or in the event of a Radiographer refusing to perform an X-Ray, the request form will be returned to the referrer / patient s GP to seek clarification and resolution of the rejected referral. 3.4. Request sheets will be annotated with: Nurse Practitioner requested X-Ray please report 3.5. All examinations must be reported by a Radiologist and the report forwarded to the requested Nurse Practitioner and patient s GP as soon as practicable 3.6. In the event of an abnormality or adverse findings revealed as a result of X-Ray examination, the requesting nurse will refer the patient to the medical practitioner with clinical responsibility for the patient s medical care; in accordance with routine practice as shown in the flow chart in Appendix 2. 3.7. The clinical Lead in Radiology and the Director of Operations give consent to the implementation of this protocol and undertake responsibility for the competence of the staff making the request. 4. Criteria for X-Ray Requests 4.1. The referrer will ensure correct biographical information is entered on the request form. 4.2. The referrer will complete relevant clinical information and the anatomical area to be viewed on the request sheet including provisional diagnosis. 4.3. Appropriate verbal and/or written information will be provided to the patient by the Nurse at the time of referral and this will be documented in the clinical record. 4.4. Identification of medical practitioner with clinical responsibility for the patient s medical care, who will receive a copy of the report. 2016 X-Ray Referral Policy 8 of 12
Appendix 2: Flowchart for X-Rays requested by Nurse Practitioners in agreed Clinical Areas Patient referred for assessment by Nurse Practitioner NP discharges patient and forwards discharge summary to patient s GP NP assesses patient Does clinical judgement indicate need for X-Ray? Episode of patient care complete No Yes Does the patient meet protocol criteria? No Yes Consultant or GP to request X-Ray NP completes X-Ray request Report generated by radiology and forwarded to NP with copy to consultant or patient s GP or directly to GP if GP generated Is continued nursing input indicated as a result of X-Ray findings? YES Refer patient onto Practice Nurse NO Discharge care or refer back to GP 2016 X-Ray Referral Policy 9 of 12
Appendix 3: Chest X-Ray Procedure REFERRAL NURSE PRACTITIONERS GENERAL PRACTICE Chest X-Ray for Adults NOTE: Request for X-Ray investigation must never replace admitting the patient acutely if this would be more appropriate 1. Clinical indications for referral for Chest X-Ray Persistent unexplained cough >4/52. Haemoptysis. Unexplained SOB. Unexplained weight loss / night sweats / lymphadenopathy. Hoarseness >4/52. Severe exacerbation of 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. 2. The following criteria are NOT indicated Routine diagnosis and treatment of hypertension. Routine follow up of Asthma / COPD. Uncomplicated rib fracture. Simple URTI. 3. Procedure for chest X-Ray referrals for Nurse Practitioners in General Practice Patient appointed to see Nurse Practitioner. Nurse Practitioner undertakes assessment of both diagnosed and undifferentiated, undiagnosed problems. X-Rays performed. Consultant Radiologist produces report. Report forwarded to Nurse Practitioner with copy to patient s own GP. Radiology department keep paper trail as audit. 2016 X-Ray Referral Policy 10 of 12
Appendix 4: Appendicular X-Ray Referrals Adults only The following x-ray examinations may be requested for patients who have not been X-Rayed and who have had an MRI scan within the past 12 months. 1. Shoulder X-Ray. Persistent (6/52), severe pain unresponsive to treatment. 2. Lower Limb 2.1. Hip. Chronic hip pain non hip cause excluded plain AP X-Ray both hips. 2.2. Knee. Chronic knee pain identified anterior knee pain only excluded - >45 years. 2.3. Foot / Ankle. If ordering foot or ankle X-Ray for chronic pain request AP and lateral weight bearing views. 3. Procedure for Appendicular Skeletal X-Ray Referrals for Nurse Practitioners in General Practice Patient appointed to see Nurse Practitioner. Nurse Practitioner undertakes assessment of both diagnosed and undifferentiated, undiagnosed problems. Skeletal X-Rays requested as diagnostic aid in line with Ottawa and agreed guidelines. X-Rays performed. Consultant Radiologist produces report. Report forwarded to Nurse Practitioner with copy to patient s own GP. Radiology department keep paper trail as audit. 2016 X-Ray Referral Policy 11 of 12
Appendix 5: Plan for Dissemination of Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee / group for consideration and approval. Acknowledgement: University Hospitals of Leicester NHS Trust. Title of document: Policy for X-Ray Referral by Qualified Nurse Practitioners working in General Practice Date finalised: May 2016 Dissemination lead: Print name and contact details Previous document already being used? If yes, in what format and where? Proposed action to retrieve out-ofdate copies of the document: To be disseminated to: All General Practice Surgeries within NHS Sussex Yes (Please delete as appropriate) Nurse Practitioner Lead Bexhill Hospital 01424 735600 Hard copy held by each Nurse Practitioner in General Practice and Radiology Departments at EDGH and Conquest Hospital To request on delivery of new version that previous Policy should be destroyed and replaced by in date version How will it be disseminated, who will do it and when? Disseminated by email by Nurse Practitioner Lead Paper or Electronic Electronic Comments Dissemination Record - to be used once document is approved. Date put on register / library of procedural documents Date due to be reviewed Disseminated to: (either directly or via meetings, etc) Format (i.e. paper or electronic) Date Disseminated No. of Copies Sent Contact Details / Comments 2016 X-Ray Referral Policy 12 of 12