Published 13 July 2020

Referral pathways for imaging examinations have changed due to Covid 19. Many referrers are not seeing their patients face to face and are now using video conferencing or telephone assessments before making a referral.

Organisations should have in place a clearly documented referral process for managing virtual referrals which includes an up-to-date list of authorised referrers.

The SoR has identified the following reference sources to support departments in assuring their governance processes to maintain quality and safety in the new way of working.

1. The Quality Standard for imaging(1)

CL1

‘An agreed process should be in place to ensure all relevant information is supplied within each referral, including: the patient’s name; contact details; date of birth; NHS number; all clinically relevant information; and full contact details for the referrer. An agreed template would be helpful. This may include a registration number or PIN unique to the referrer. Acquiring clinically relevant information from patients should be done in a sensitive manner and in an appropriate environment. Staff should respect patients’ knowledge and understanding of their own experience, their own clinical condition, their experience of their illness and how it impacts on their life (see also standard statement PE4).  

All referrals should be vetted, justified, authorised and prioritised. Vetting ensures that the patient receives the right examination or procedure, with the correct imaging protocols, in the right circumstances. Each referral should be subject to a justification process taking account of clinical indications and the requested imaging modality.

Where the examination involves ionising radiation, it must be justified by an entitled IR(ME)R Practitioner or authorised under guidelines issued by the Practitioner, to ensure that the benefits to the patient of each examination or procedure outweigh the risks associated with ionising radiation. The process must include consideration of alternative modes of imaging and should be in consultation with the referrer and patient.

A procedure should be in place for documenting the process in the patient’s record and include dealing with requests that are not justified, or for recommending alternative examinations or procedures where appropriate. Referrals should be prioritised to ensure the most urgent cases are dealt with first, to meet specified timescales. Procedures should be regularly reviewed in the light of audit information, safety notifications and developments in clinical practice.’¹

2. IR(ME)R 2017(2,3)

IR(ME)R 2017 does not specify that the referrer has to see or physically examine the patient but what they must do is comply with regulation 10 (5) The referrer must supply the practitioner with sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure requested by the referrer to enable the practitioner to decide whether there is a sufficient net benefit as required by regulation 11(1)(b).²

For sensitive imaging examinations such as the medical exposure of children Regulation 12. Optimisation may aid in directing referral pathways.  For example, these types of referrals might be Consultant to Consultant or paediatric specialist to paediatric specialist and need to be reviewed as part of new virtual pathways.

In addition to this the employer must ensure they can comply with the condition of schedule 2 1. (b) to identify individuals entitled to act as referrer or practitioner or operator within a specified scope of practice;In effect this means good governance in terms of IT access, not sharing passwords or using generic passwords for referrals.

Where a Non-Medical Referrer is entitled under a system of work or scope of practice linked to referral rights from a specific clinic or physical location this will need to be updated using the usual governance processes to reflect a virtual referral.

3. Referrals for MRI(4)

Referring clinicians have a responsibility to complete the relevant safety section on the referral form and/or submit any safety information known to them about the patient (ideally at the time of referral, in consultation with the patient).

(Continued below)

(Continued from above)

4. Summary For all referrals

Referrals should include a detailed clinical history and clearly state the examination(s) being requested.

Organisations should have in place a clearly documented referral process for managing virtual referrals which includes an up-to-date list of authorised referrers.

Referral forms should be signed and dated and include the date of request and the signature of the referring clinician.  In in the case of an electronic referral the referring clinician must be clearly identified .

An audit process for auditing virtual referrals should be developed and implemented.

Consideration should be given to:

• the communication process should there be queries from the referrer, the practitioner, the operator or the patient
• safeguarding issues that might otherwise be missed due to the virtual process e.g. domestic abuse, suspected physical abuse in children
• consent issues
• risk-benefit discussions

 5. Future support

A new Clinical Imaging Board IR(ME)R audit project , led by RCR should be published before the end of this year. The SCoR is involved. The new process has a section for auditing vetting and justification of referrals. 

Work on updated Non Medical Referrer (NMR) guidance led by the Royal College of Nursing (RCN) with input from SCoR is due to be published although there is currently no date for this.

Bibliography

1.        Royal College of Radiologists, and College of Radiographers (2019). The Quality Standard for Imaging (formerly ISAS) | Society of Radiographers. Available at: https://www.sor.org/about-radiography/quality-standard-imaging-formerly-isas [Accessed July 9, 2020].

2.        The British Institute of Radiology, The Royal College of Radiologists, Institute of Physics and Engineering in Medicine, The Society and College of Radiographers, and Public Health England (2020). IR(ME)R Implications for clinical practice in diagnostic imaging, interventional radiology and diagnostic nuclear medicine (London) Available at: www.rcr.ac.uk [Accessed July 10, 2020].

3.        Government, U. (2017). The Ionising Radiation (Medical Exposure) Regulations 2017 (London, UK) Available at: http://www.legislation.gov.uk/uksi/2017/1322/pdfs/uksi_20171322_en.pdf [Accessed July 9, 2020].

4.        The British Association of Magnetic Resonance Radiographers, and The Society and College of Radiographers (2019). Safety in Magnetic Resonance Imaging 1st ed. (London: SCoR, BAMRR) Available at: www.sor.org [Accessed July 10, 2020].

Published 13 July 2020