CHHS18/092

Canberra Hospital and Health ServicesOperational Procedure Medical ImagingContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Provision of Medical Imaging Reports....................................................................2

Section 2 – Communication of Urgent and Unexpected Findings.............................................3

Section 3 – Radiographs – Copying, Disposal, Storage and Transfer.........................................4

Section 4 – Substituted and Additional Tests or Procedures.....................................................6

Section 5 – Management of Pregnant Patients and Staff..........................................................6

MRI........................................................................................................................................7

CT.......................................................................................................................................... 7

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References.............................................................................................................................. 10

Search Terms.......................................................................................................................... 10

Attachments............................................................................................................................10

Attachment 1 – Importing Imaging to PACS Request Form................................................12

Attachment 2 – MRI Pregnancy Consent Form...................................................................13

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CHHS18/092

Purpose

This document outlines the procedures in place within the Medical Imaging department at Canberra Hospital and Health Services (CHHS) to ensure effective and safe patient care. It outlines the processes in place to ensure appropriate and timely medical imaging procedures and provision of results to referring clinicians.

It includes information on: Provision of Medical Imaging Reports Communication of Urgent and Unexpected Findings Copying, Disposal, Storage and Transfer of Radiographs Substituted and Additional Tests or Procedures, and Management of Pregnant Patients or Staff

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Scope

This document applies to all staff employed by CHHS working in the Medical Imaging department. This includes Radiologists, Registrars, Radiographers, Sonographers, Nuclear Medicine Scientists, Nursing and Administration staff and students working under supervision.

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Section 1 – Provision of Medical Imaging Reports

This document outlines the Medical Imaging department’s procedure for providing appropriate and timely reports to referrers.

SystemThe Medical Imaging department utilises an integrated digital patient information and image storage system (RISPACs) that requires imaging requests to be made online by Canberra and Calvary Hospital staff i.e. specialists and medical, nurse practitioners and nurses initiating imaging requests under an approved policy. Faxed or paper requests are accepted by external referrers and in emergency situations in the hospital.

Reporting ProcessAll radiology reports are available online and also faxed to nominated referrers usually within 24 hours of completion of the patient scan or procedure.

Online reports include the registrar [unauthorised] report prior to the completion of the consultant radiologists [final authorised] report and any amended final report. Once the radiologist report is finalised it replaces the registrar report which is then only visible in an electronic version of the patient’s record.

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A primary diagnosis is only performed on images which are of acceptable diagnostic quality to the reporting radiologist.

Each Medical Imaging report should contain the following: Referrer’s name and address Date the report is issued Date the imaging procedure was performed Unique patient details, including full name, date of birth, hospital identification number. Clinical history /details provided by referrer Imaging procedure and modality Imaging procedure results including any measurements Reason and result for any self-determined imaging Comparison with any previous relevant imaging.

Addendum reports or amendments must be identified on the report and include on whose authority it was made.

ResponsibilityThe consultant radiologist is responsible for the supervision, interpretation and reporting of the entire study.

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Section 2 – Communication of Urgent and Unexpected Findings

Medical Imaging Radiologists and registrars will communicate urgent and unexpected findings/results to the referrer or treating team according to the procedure below. This procedure encapsulates the need for clinical diagnostic expediency and clear communication pathways for such cases.

Procedure When there are urgent or significant unexpected findings the following steps must be followed: The reporting Radiologist must immediately attempt to communicate directly with the

referrer or the treating team who will be providing clinical follow up. These results should be communicated in keeping with the requirements of the CHHS Clinical Handover Procedure.

A record of actual or attempted direct communication must be maintained either in Radiology Information System (RIS) or in a departmental communication log book, including date, time of call/s and phone/pager numbers contacted. Communication with the referring team will also be documented in the medical imaging report. If there is no response, the Radiologist should escalate through the referring team (ie. junior medical officers, registrar and consultants) to ensure the result is communicated. If contact is unable to be made this will be documented on the patient’s medical imaging report.

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Section 3 – Radiographs – Copying, Disposal, Storage and Transfer

Radiographs will be handled in accordance with the following procedures. Radiologists will provide a written opinion via a hardcopy or digital image to the referring physician (see section 1). The output of the diagnostic aspect of the Medical Imaging Department is therefore the provision of a medical imaging report.

Storage and DisposalAccording to the ACT Health Records Disposal Schedule Policy, images and their reports must be maintained in accessible and safe storage for designated time periods as outlined below. Refer to the ACT Health Records Disposal Schedule Policy for more information. Film files – Hardcopy:

The Medical Imaging Department keeps film records for a minimum of 7 years after last attendance at an ACT Health facility, or until the patient attains or would have attained, the age of 25 years, whichever is longer. Copies of text reports are included in the patient’s Clinical Record on the Clinical Record Information System (CRIS) and maintained in accordance with the Territory Records (Records Disposal Schedule – Health Treatment and Care Records) Approval 2017 (No 1) – Notifiable instrument NI2017—629.

No films are to be dispatched to a destination outside the hospital without the patient’s approval in writing or written approval from the responsible consultant. Notification to the Medical Imaging Office or out of hours the Radiographer on duty is required.

Digital Images: Stored indefinitely on the Picture Archival Communication System (PACS). No CDs of digital images are to be dispatched to a destination outside the hospital without the patient’s approval in writing or written approval from the responsible consultant.

Importing of Digital Images to PACSCDs of images taken at non ACT Health facilities can be imported into PACS upon request by the referring doctor or CHHS radiologist (see attachment 1 for request form). Each request requires an Importing of Images request form to be completed and will be actioned based on clinical need. A hard copy of this form can be obtained from the reception staff in the Medical Imaging Reception. The requesting Medical Officer is responsible for obtaining consent from the patient for the importing of the images and returning the CD to the patient when the request has been completed

Inpatient and Outpatient Images

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All patient images are available to be viewed on the Picture Archival Communication System (PACS) from within the ACT Health network by authorised users. Images can also be burned to a CD/DVD for viewing and external distribution.

During PACS downtime /maintenance, patient images will not be available for viewing until the system is restored. In the case of an emergency images taken on the day can be viewed directly from the imaging equipment and a verbal report can be dictated to the treating team by a Radiologist.

Note: Staff at Calvary are able to view images on the Picture Archival Communication System (PACS) via an ACT Health networked PC and with the appropriate user privileges.

Release of radiographsPatients who do not reside in the ACT or immediate surrounding area may take their images back to the physician responsible for their continuing treatment. In this case the following actions are to be observed: Wherever possible, the images are to be reported before release to the patient/carer. The original request form is to be scanned onto the Radiology Information System (RIS)

with an approval form containing the patient’s signature and the films/CD destination tracked on the computer system

Patients may view the reports of their own examinations by: Using an application for access under the Health Records (Privacy and Access) Act 1997.

This application can be made through the Clinical Records Service.

Legal firms who are seeking client information can request that the Medical Imaging department provide them with the relevant diagnostic images and associated reports. Patient consent accompanied by a letter from the firm representing the client must be provided. Refer to Court Orders Addressed to ACT Health Procedure.

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Section 4 – Substituted and Additional Tests or Procedures

This section outlines the Medical Imaging department’s practice when there is a requirement for substituting a test or adding a procedure; and how that change is communicated to the referrer or treating team.

ProcedureWhen it is determined from the clinical information in a request/referral that an alternative diagnostic imaging examination or modality would be more appropriate, or an additional examination is necessary, then all reasonable steps should be taken to contact the requesting practitioner before providing the substituted or additional examination.

Procedures /tests should only be substituted or added by a Radiologist or Radiology Registrar.

All requests for change must be recorded in the patient tracking change procedure screen in ACT Health RIS System (syngo Workflow).

After demographic details and order numbers have been confirmed the change procedure record must include- Procedure- revised/new procedure required Reason for change- relevant reason selected from list or free text entered Procedure Comment- any additional comments including notes from the consultation

with the referring practitioner or a record of the attempt/s to speak with the referring practitioner

Initials of the person completing the Change Procedure screen

Alterations to procedure/test requests via the Change Procedure Screen may only be initiated by a Radiologist or Radiology Registrar.

Other accredited Departmental Radiographer/Sonographer/Nuclear Medicine Technicians can only alter a test after discussion with a radiologist (Consultant or Registrar), and after the same steps have been followed.

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Section 5 – Management of Pregnant Patients and Staff

The following steps outline the processes in place to ensure the safety of pregnant patients and staff within the Medical Imaging departments (MRI and CT).

MRIAll patients to be scanned must be informed of the potential risks involved and consent gained prior to undergoing the MRI (see attachment 2 for consent form). The Medical

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Imaging department will provide the patient with the information and consent form prior to presenting to the department for scanning.

The consultant radiologist rostered to MRI must deem prior to scanning being conducted thatthe proposed scan: is needed before the end of the pregnancy to guide management provides information not available by other non-ionising means is justified by risk-benefit balance, with waiting not clinically prudent.

When scanning a pregnant patient it is recommended that scans are performed in the normal/whisper mode. Specific Absorption Rate (SAR) limits should be observed and not increased from normal mode. It is advised that MRI scans be avoided by pregnant patients during the first trimester. Technologists be aware of reducing flip angle GE 80-50, and tse Haste 150-130.

Pregnant staff members should not remain in the scan room whilst scanning is occurring. Otherwise, they may continue to work normally. MRI staff may liaise with the Medical Imaging Operations Manager and opt out of all scan room work during the first trimester.

CTThe procedure for dealing with pregnant or possibly pregnant patients falls into 3 sections1. Determining pregnancy status of females of reproductive capacity2. Deciding if the CT scan should be performed on a pregnant patient and steps taken to

minimise and calculate dose3. Procedure when patient is found to be pregnant after an examination has taken place

Determining pregnancy status The primary responsibility for identification of patients at risk rests with the referring

doctor, while the radiography and nursing staff provides a secondary backup. The question “Is there any chance that you could be pregnant?” must be asked to the patient. The answer to this question is then recorded on the Radiology Information System (RIS).

If the answer is “No” the scan will be performed following normal radiation safety guidelines.

If the patient is unsure they will be referred back to the treating team until a beta-HCG test has been performed. If this is not possible, such as in the case of outpatients, a positive answer includes all those who feel they may be pregnant, or are trying to fall pregnant and those who are sure they are pregnant.

Procedure when the patient is pregnant If the patient is pregnant or suspected to be, then the CT request must be referred to a

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directive that "Only urgent examinations of the pelvis and lower abdomen should be carried out during pregnancy and particular care should be taken to avoid irradiation of the foetus whenever practicable".

A strong clinical indication is required for any procedure in this situation and the risk versus benefit scenario will be discussed between the Radiologist and the referring doctor.

If the procedure is to go ahead then verbal informed consent is obtained from the patient and noted in the RIS. The referring doctor and the radiologist responsible for the radiological examination should take all reasonable steps to advise the pregnant patient of the potential risks of radiation exposure of the foetus. Royal Australian and New Zealand College of Radiologists (RANZCR) recommends that written informed consent be obtained if the pelvis is in the direct beam.

The Radiation Management Plan for Radiology requires that:o If the foetus is to be irradiated, the radiographer should inform a senior radiographer

who will ensure that the minimum radiation dose technique is employed and that all the necessary radiographic factors are recorded.

o The Radiation Safety Officer/Medical Physicist must be informed as soon as possible so that the foetal absorbed dose can be calculated.

o The following information must be recorded in order for the dose estimates to be made:- Patient’s height and weight- Particular x-ray apparatus used- Part of the body irradiated and projection (e.g. AP, LAT)- Entrance field size- Focus to surface distance (FSD)- X-ray filtration in mm of aluminium- kVp, mAs (or mA and time) and the number of exposures for radiographic studies- kVp, mA and total screening time for fluoroscopic studies- kVp, mA, slice thickness, rotation time, beam pitch and scan length for CT studies.

When performing a CT scan on a pregnant patient, standard precautions include shielding the abdominal and pelvic regions with a lead gown and strong compliance to the “As Low As Reasonably Achievable” (ALARA) principle. Reducing scan field in the z axis (superior-inferior direction) will help decrease the dose as will the use of Real EC dose modulation.

Procedure when patient is found to be pregnant after a CT Scan If the patient is found to be pregnant after a scan then the Radiation Safety Officer

should be informed as soon as possible to perform an estimation of the radiation dose to the foetus.

If a pregnant patient is accidentally exposed to x-rays, both the Radiation Safety Officer/Medical Physicist and treating medical specialist must be immediately informed for foetal risk assessment. The radiographer must also submit a Riskman incident report.

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Implementation

This operational procedure will be available on the ACT Health Policy Register and be communicated to all staff through line managers, staff meetings and unit orientation.

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Related Policies, Procedures, Guidelines and Legislation

Policies ACT Health Consent and Treatment Policy ACT Health Records Disposal Schedule Radiation Safety Management Plan

Procedures CHHS Clinical Handover Procedure CHHS Patient Identification and Procedure Matching Policy ACT Health Records Disposal Schedule Clinical Records Management Manual Court Orders Addressed to ACT Health

Legislation and Standards Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011 Commonwealth Department of Health & Ageing Diagnostic Imaging Accreditation

Scheme: Standard 4.2 Provision of Service Standards – Stage 2. RANZCR Standards of Practice for Diagnostic & Interventional Radiology: Standard 5-3.3

Substituted & Additional Procedures, Version 9.1. The Australian Council on Healthcare Standards (ACHS) Clinical Indicators – Australasian

Clinical Indicators report: Radiology Indicators, version 4, 2006. Commonwealth Department of Health & Ageing Diagnostic Imaging Accreditation

Scheme: Standard 4.1 Communicating with Requesting Practitioners Standard – Stage 2. RANZCR Standards of Practice for Diagnostic & Interventional Radiology: Standard 5-5-1

Interpretation and Reporting the Results, Version 9.1 (2009). Royal Australian & New Zealand College of Radiologist MR Safety Guidelines Dec 2017 Commonwealth Department of Health & Ageing Diagnostic Imaging Accreditation

Scheme: Standard 4.1 Communicating with Requesting Practitioners Standard – Stage 2. RANZCR Standards of Practice for Diagnostic & Interventional Radiology: Standard 5-5-3

Communication of Imaging Findings and Results, Version 9.1. ARPANSA Radiation Protection Series No. 3: Radiation Protection Standard for Maximum

Exposure Levels to Radiofrequency Fields - 3 kHz to 300 GHz (2002). Allied Health Professionals ACT Standards of Practice

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References

1. Reference Manual For Magnetic Resonance Safety, Implants And Devices: 2016 Edition, Frank G Shellock, Biomedical Research Publishing Company, 2016

2. The Royal Australian and New Zealand College of Radiologists (RANZCR) Policy: Diagnostic Radiology and Pregnancy (2005)

3. The Royal Australian and New Zealand College of Radiologists (RANZCR) Position Statement: Computed Tomography and Radiation Risks (2010) http://www.ranzcr.edu.au/about/guidelinesandpolicies/index.cfm#radiology

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Search Terms

Medical Imaging, Diagnostic Imaging, CT, Pregnant, Radiographer, MRI, Ultrasound, Sonographer, Nuclear Medicine, PET, X-ray reports, RISPACS and Images

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Attachments

Attachment 1 – Importing Imaging to PACS Request Form Attachment 2 – MRI Pregnancy Consent Form

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 14/03/2018 Complete Review Chris Bone, DDG CHHS CHHS Policy Committee

This document supersedes the following: Document Number Document NameTCH11:154L Medical Imaging - Radiographs Copying Disposal Storage and TransferSAH11:021 Medical Imaging - CT-  Managing Pregnant Patients in CT

Provision of Imaging Reports – Medical ImagingCHHS13/321 Medical Imaging MRI-Pregnant Patient and Staff  SOP

Communication of urgent and unexpected findings – Medical ImagingSubstituted and Additional Tests or Procedures – Medical Imaging

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Attachment 1 – Importing Imaging to PACS Request Form

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Attachment 2 – MRI Pregnancy Consent Form

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