BIR POSITION STATEMENT: Governance requirements for Non-Medical referrers to radiology

Abstract

The ability to request clinical imaging is included in many advanced roles of health-care professionals in the UK and is seen as a useful component in ensuring patients receive the right care, by the right person, at the right time. In order that diagnostic imaging referrals are appropriate, timely and safely made, the British Institute of Radiology has produced a position statement on the governance requirements covering clinical imaging requests from non-medical referrers (NMRs). This document is intended to help define the role of a NMR and to ensure they are practising responsibly and safely, within professional and legal frameworks, as part of the wider interprofessional team.

Introduction

Health care in the UK is characterised by interdisciplinary working and collaboration by health professionals. The provision of services to the public, particularly in a context of unprecedented demand and severely limited resource, depends on professionals constantly reviewing and exploring how their work together can improve quality and efficiency. Over the past 15 years, nurses and allied health professionals have extended their roles to help improve the service delivered to patients in the National Health Service (NHS). This development has included the role of the Non-Medical Referrer (NMR) to radiology. ¹

This paper gives guidance on the governance arrangements required for a NMR to ensure that diagnostic imaging referrals can be appropriate, timely and safely made and in compliance with UK legislation (based on the European Basic Safety Standard Directive. ² Namely, the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) ³ and the Ionising Radiation (Medical Exposures) Regulations 2018 for Northern Ireland, ⁴ hereon referred to as IR(ME)R. These regulations define a number of duty holders. The ‘referrer’ means a registered health-care professional who is entitled in accordance with the employer’s procedures to refer individuals for exposure to a practitioner. The ‘practitioner’ means a registered health-care professional who is entitled in accordance with the employer’s procedures to take responsibility for an individual exposure, including justifying and authorising the procedure. The ‘operator’ means any person who is entitled, in accordance with the employer’s procedures, to carry out the practical aspects of an exposure.

Under IR(ME)R, the referrer must supply the practitioner with sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure, to enable the practitioner to decide whether there is a sufficient net benefit in carrying out the requested procedure.

Who can be a Non-Medical referrer (NMR)?

The IR(ME)R regulations require that all referrers must be a registered health-care professional. Specifically, they must be a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health-Care Professions Act 2002 ⁵ ; for example: Nurses, Radiographers, Physiotherapists. To give an indication of the careful control of professions permitted to refer to Radiology, two different cases are considered below.

Physician associates

Physician associates ⁶ are medically trained, generalist health-care professionals, who work alongside doctors and provide medical care as an integral part of the multidisciplinary team. Physician associates are practitioners working with a dedicated medical supervisor, but are able to work autonomously with appropriate support. Physician associates are on the voluntary register for the General Medical Council ⁷ (GMC) and therefore do not meet the requirements of IR(ME)R. Therefore, they cannot be entitled under employer’s procedures to act as NMRs for examinations involving ionising radiation, although this may change in the future.

Nurse associates

This role was introduced into the NHS to bridge a gap between health and care assistants and registered nurses. Although they are included on the Nursing and Midwifery Council (NMC) register, for the purposes of IR(ME)R, their scope of practice and training is outside that of the minimum scope required of an NMR under IR(ME)R. See the NMC standards of proficiency for registered nursing associates. ⁸

The role of the radiology department with respect to NMRs

Whilst it is recognised that NMRs are invaluable in improving patient care pathways, the demand from increasing numbers of health-care professionals to become NMRs has led to an increasing regulatory and administrative burden on radiology departments in ensuring employers meet their obligations.

The IR(ME)R employer often delegates responsibility via local governance arrangements (which can include oversight by a Radiation Protection Committee) to the Radiology department. Radiology departments then provide the appropriate management and governance of NMRs. Following training and in the presence of an agreed written scope of practice, radiology should ensure NMRs are suitably entitled to refer and included on the radiology register.

Employers should be aware of the difficulties in ensuring only entitled NMRs refer to radiology, particularly where referral is via a paper-based system or an electronic system that does not enable restriction of referral rights to an individual’s scope of practice. These systems make it difficult for IR(ME)R practitioners or operators to ensure referrers are entitled and are working within their agreed scope of practice. Radiology departments can support the employer in carrying out regular auditing of NMR activity to ensure compliance with NMR written protocols, where both restriction and non-restriction systems are present. The use of robust incident management systems are also useful for identifying areas of non-compliance and possible trends with either individuals or specific service areas.

The role of the NMR

There are four basic types of non-medical referrers in practice:

1. NMR referring as part of a clinical team, where they will be acting on a radiology report as opposed to evaluating the image itself.

2. NMR referring as part of a clinical team, where a doctor will do an initial review (clinical evaluation) of the imaging prior to radiology issuing a formal report.

3. NMR referring as an autonomous practitioner, but as part of the clinical team who will be reviewing the images (clinical evaluation) and making a decision on patient treatment prior to the radiology report being issued.

4. NMR referring as an autonomous practitioner, where they are the senior responsible clinician for the patient. This role would be recognised as that being undertaken by a consultant nurse, midwife or allied health professional. ⁹

The referrer, as the autonomous non-medical professional, must ensure that following the clinical evaluation (see note below) of the medical radiation exposure, that a decision is made about the ongoing management of the patient based on the results of the evaluation. The decision and ongoing action in support of the patient must be recorded and discussed with the patient. This is to ensure that an action is taken by the referrer following each medical exposure.

Failure to communicate and act upon critical, urgent or significant findings ¹⁰ can have very serious consequences for patients. Therefore, it is important that NMRs accept their responsibilities in this regard and develop fail-safe back-up mechanisms.

Note on clinical evaluation

The employer must take steps to ensure that a clinical evaluation of the outcome of each exposure is recorded, where “evaluation” means ^3,4 interpretation of the outcome and implications of, and of the information resulting from, an exposure.

Alongside the role of the NMR, it is important to consider when NMRs act on the images prior to the formal radiology report, e.g., emergency department or minor injuries. IR(ME)R regards clinical evaluation as an operator duty, which requires that they are appropriately trained to undertake the clinical evaluation and are appropriately entitled in writing to act as an operator under IR(ME)R.

What training should the NMR receive?

Whilst not explicitly required under IR(ME)R, it is strongly recommended that all NMRs should receive appropriate training prior to being entitled as a referrer. The training may be delivered in-house, via an educational institution, e-Learning or a combination, but should include:

• Principles of radiation protection

• Benefits and risks of the examinations being requested. This should include an understanding of the ionising radiation dose levels for the type of examinations to be requested and the ability to identify if there is a safer alternative to the requested exam.

• Responsibilities of NMR in relation to patient safety and clinical governance

• Overview of local referral pathways, including the use of electronic referral systems where appropriate and the cancellation process.

• Availability and use of referral guidelines e.g., Royal College of Radiologists iRefer ¹¹

• Professional and legislative responsibilities

• Introduction to the governing legislation ^2–4

There may also be benefit to the NMR to attend the radiology department, where this can be facilitated, giving them insight into how examinations are performed and how radiology act on referrals.

The UK joint working party guidance on IR(ME)R ¹² suggests that NMRs should complete update training on a regular basis (for example, at least every three years) in addition to the continuing professional development (CPD) requirements undertaken in their area of clinical expertise. Guidance on training is also available in the RCN guidance. ¹

Governance principles

A summary of items that should be considered in order to ensure that NMRs refer safely and appropriately, and safeguarding high standards of care, is given below:

• The entitlement of staff to be NMRs is the responsibility of the employer under IR(ME)R. This should be delegated in the written procedures to a suitable body within the organisation, for example the radiology department or the radiation protection committee

• A NMR must be formally entitled and logged on a register held by the radiology service, which is available to IR(ME)R Practitioners and Operators

• The NMR must read, understand and adhere to the relevant employers IR(ME)R procedures.

• All NMRs must be appropriately trained in their area of clinical expertise

• All NMRs should receive training in radiation protection. This could include the BIR video course on radiation safety, ¹³ NHS eLearning for Health ¹⁴ and face-to-face training, together with spending time in the appropriate modalities in Radiology.

• Each NMR must have a defined scope of practice

• There should be a process for regular review of NMR practice through an agreed audit programme

• NMRs should complete update training at appropriate intervals, for example: every three years

• The NMR must engage in CPD appropriate to their scope of practice and functions as a referrer

• With the exception of the Consultant NMR (role four in above examples), there should be a doctor, either Consultant or General Practitioner, who is responsible for providing mentorship, advice, guidance and patient care in any team who have NMRs.

• The IR(ME)R employer must ensure the Consultant NMR acting as an IR(ME)R operator has appropriate training to act on reports or carry out clinical evaluation and an awareness of the governance in place to ensure patient safety

• Where an NMR is to act on the images prior to the formal radiology report, they need to be appropriately trained and entitled to act as an IR(ME)R operator for clinical evaluation. The employer must ensure there is an appropriate governance structure and training in place to support this practice. This needs to ensure that consideration is given to the IR(ME)R regulatory requirements and patient safety. The radiology department can provide advice on what is appropriate from both an IR(ME)R and patient safety perspective.

• There must be processes for mitigating the risks of failure to act on diagnostic results for both results acknowledgment and clinical management handover, as identified by the National Patient Safety Association (NPSA) Safer Practice Notice 16: Early Identification of failure to act on Radiological Imaging Reports ¹⁵

• When an NMR is referring to another employing organisation both organisations should agree the entitlement before the NMR’s employer entitles the NMR

• Entitlement must be given in writing

• The radiology department must ensure that the appropriate feedback of learning is provided to the NMR in response to radiation incidents or near-miss reports.

• The radiology department must ensure the relevant employer’s procedures under IR(ME)R are accessible to the NMR

• The radiology department must ensure local referral guidelines are available to the NMR

• In the interests of patient safety, the employer must take appropriate action if the NMR is referring ‘out of scope’ or audit consistently indicates non-compliance. Such action might include removal of NMR access to the referral processes.

Referring for high dose examinations

Due to the increased risks associated with high dose examinations ¹⁶ (such as CT and PET-CT), additional consideration of those entitled to make such referrals is warranted. It is therefore recommended that these should only be made as part of a multidisciplinary team, or National Institute for Health and Care Excellence ¹⁷ (NICE) defined patient care pathways or consultant-led care pathway. In any case, this should be detailed within the NMR’s entitlement protocol.

Also, where the scope of practice of an NMR may include examinations that require the administration of radionuclide substances, the suitability of referrals from a NMR should be agreed with the IR(ME)R practitioner Licence Holder. ¹⁸

Referrals for MRI and ultrasound

Although there are no statutory regulations covering referrals for MRI and ultrasound, best practice is to follow the principles set out for referrals for examinations involving ionising radiation

The Medicines & Health-care products Regulatory Agency (MHRA) recommends ¹⁹ that MRI referrals should only be accepted from a registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with the employer’s procedures to refer individuals for MRI.

A NMR undertaking MRI referrals should undergo training in MRI safety (for example: https://www.e-lfh.org.uk/programmes/mri-safety/) to ensure they are aware of the hazards and contraindications associated with MRI. All NMR MRI referrals must include the relevant clinical information, enabling the accepting clinician to determine whether there are any additional safety considerations associated with the examination.