Referral Guidelines for Diagnostic Imaging at the Queen Square Imaging Centre
Next routine review: October 2023 Author: Peter Sutton
Printed versions of these guidelines are regarded as uncontrolled. Referrers should be careful to always check these online guidelines for the most recent and up to date guidance.
Please use the quick links below to explore each section of the guidelines:
The Ionising Radiation (Medical Exposures) Regulations 2017 (IR(ME)R) lay down basic measures for the protection of patients from unnecessary or excessive exposure to X‐ rays during diagnostic examinations.
They also have specific guidance for Employers, Practitioners, Operators and Referrers in their responsibilities as Duty Holders. This document is intended to be a helpful guide to the practical applications of the regulations for Referrers and includes a section on the basic principles of radiation safety. It also provides guidance on making a referral for diagnostic imaging to either the Queen Square Imaging Centre or Chenies Mews Imaging Centre.
A Brief Overview of IR(ME)R 2017
Categories of Duty Holder under IR(ME)R 2017
The Ionising Radiation (Medical Exposures) Regulations of 2017 identify different categories of duty holder, each of whom has a responsibility to ensure the safe administration of ionising radiation to patients undergoing medical exposures. The duty holders we are concerned with in this guide are:
- The Employer
- The Referrer
- The Practitioner/Operator
Under IR(ME)R 2017, the Employer (QS Enterprises Ltd) is responsible for putting into place a system of policies, protocols and procedures which will govern referrals, ensure that justification of exposures takes place, and that a clinical evaluation of all diagnostic procedures is recorded. The aim is to ensure that radiation doses to patients are kept as low as is reasonably practicable.
The Employer is responsible for ensuring that the diagnostic findings and clinical evaluation of each medical exposure is recorded in the patient’s notes. If it is known before an exposure that no clinical evaluation will occur, then the exposure cannot legally be justified and therefore should not take place.
The Medical Exposures Directive requires that each request for a medical exposure must be justified by a practitioner or authorised by a radiographer (Reg.6.(1).(a)) prior to exposure being made.
Medical and Non‐medical Practitioners who act as Referrers are classed as Duty Holders who are entitled in accordance with the employer’s procedures to refer individuals for medical exposure to a Practitioner. Referrers must be aware of their responsibilities under IR(ME)R before they may refer patients for diagnostic imaging examinations involving the use of ionising radiation.
QSE recognises the following medical Referrers for diagnostic examinations involving the use of ionising radiation:
- Hospital Consultants
- Junior Doctors
- General Practitioners
Non‐Medical referrers may also be recognised by QSE’s Medical Advisory Committee and given authorisation to refer for diagnostic examinations involving the use of ionising radiation.
Referrers have a legal obligation to provide all necessary clinical information relating to the patient and the examination. Guidance regarding these requirements is provided in the following section ‘Referral Guidelines for Referrers’.
Practitioners and Operators
The role of the Practitioner (usually the Radiologist) and the Operator (usually the Radiographer) can appear to overlap. The Practitioner (Radiologist) must be sufficiently knowledgeable to be able to justify an exposure before authorising it to take place. If, in certain circumstances it is not practicable to obtain justification from the Practitioner, the Operator can authorise an exposure for some examinations under Practitioner protocols or guidelines.
Practitioners and Operators must follow departmental guidelines and protocols as authorised by the Employer.
Practitioners and Operators have a legal obligation to refuse to justify an exposure when insufficient or incorrect clinical information is provided.
Practitioners and Operators are responsible for justifying and authorising individual medical exposures based upon an assessment of the information supplied by the Referrer.
Practitioners and Operators must consider:
- The specific objectives of the exposure and the characteristics of the patient involved.
- The total potential benefits, including direct health benefits to the individual and society.
- Any potential detriment to the individual.
- The efficacy, benefits and risks of all available alternative techniques.
The Practitioner must pay special attention to:
- The necessity of the exposure
- Exposures on medico‐legal grounds
- Exposures that have no direct health benefit for the individual
- The urgency of the exposure in cases involving a female where pregnancy cannot be excluded, in particular if the abdominal and pelvic regions are exposed.
If the Practitioner or Operator considers the request not to be compliant with IR(ME)R, they are legally bound to refuse to justify the imaging request.
Requirements for Patient Identification
In order to avoid an unintended radiation exposure or wrong imaging investigation on a patient, all imaging requests must correctly identify the individual for whom the examination is intended. QSE staff are bound by the QSE Policy for Patient Identification. To enable this, imaging request forms must bear at least three unique patient identifiers from the following list;
- Full name
- Date of birth
- Hospital Number (EPIC MRN Number), if known.
A contact telephone number and/or email address is also desirable so that our administration team can arrange the patient’s attendance quickly and efficiently.
Requirements for Clinical Information
Sufficient clinical information for the examination to be justified must be included on the request. This must include details of previous diagnostic examinations and/or medical records relevant to the medical exposure requested. Without this information the Practitioner will be unable to consider the potential benefits or detriment of the request and will therefore be legally unable to justify the exposure.
If the information provided is insufficient, the department is legally bound to return the request to the Referrer with a request for more clinical information.
If the Practitioner considers that a medical exposure cannot be justified, they will not legally be able to proceed. This decision will then be communicated to the Referrer.
Authorising your Referral
It is a legal requirement that all radiology referrals are authorised by the referrer. Subsequently, all request forms must be signed and dated by the authorised referrer. Electronic referrals may be accepted but must be submitted from the authorised referrers secure access account. To facilitate the efficient return of results to the referrer, a practice address and preferred method of receipt is also required.
Assistance with Referrals – “iRefer”
Referrals for medical exposures should be made in accordance with documented referral criteria. The criteria used by QSE’s practitioners will be based on those provided in the “iRefer ‐ Making the best use of clinical radiology” document, published by the Royal College of Radiologists.
QS Enterprises has set up a generic user account for iRefer within its own license. Referrers may access iRefer using the following details:
Make a referral
Referrals can be made to either to the Queen Square Imaging Centre (CT and MRI) or the Chenies Mews Imaging Centre (MRI only) either electronically, via EPIC order or via a standard request form.
QSE’s request forms are available for download using the following links. Alternatively, an outpatient diagnostic referral form may also be used if the patient is being referred from the Queen Square Private Consulting Rooms.
- To refer to the Queen Square Imaging Centre, the relevant referral form may be downloaded or completed online and submitted securely at www.qsprivatehealthcare.com/professionals/referral/
- To refer to the Chenies Mews Imaging Centre, the appropriate referral form may be downloaded or completed online and submitted securely at: www.cheniesmews.com/referral/
When making a referral, please communicate any special requirements, including the need for an interpreter, special assistance, or any specific booking requirements. Our administration team will then make direct contact with the patient to schedule an appointment and provide them with all necessary advance information.
Training Requirements for Referrers
There is no legal requirement within the Regulations that Medical or Non‐Medical Referrers are trained in radiation safety/IR(ME)R awareness prior to being entitled to act as referrers.
However, it is normal practice for Radiology Departments to require such training to be undertaken. Medical Referrers who hold current GMC registration are deemed to have received this training prior to their recognition by QSE as a referrer. QSE maintains records of all recognised referrers within its Radiology information System, including GMC number and practice address.
Non‐Medical Referrers will be required to present evidence of formal training in radiation safety/IR(ME)R awareness to the QSE Medical Advisory Committee as part of the approval process.
A radiology request is a legal document and must be filled in accordingly. In order to avoid unnecessary delay to scheduling, it is essential that correct patient identification details are included, as well as enough clinical information and a provisional diagnosis. Finally, referrers must provide a legible signature or submit the referral via secure access control to authorise the referral.
Informing the patient of the Risk and Benefit of Radiation Exposure
Under IR(ME)R 2017 “wherever practicable, and prior to an exposure taking place, the patient or their representative is provided with adequate information relating to the benefits and risks associated with the radiation dose from exposure”.
In the first instance, this discussion should be had with the patient by the Referrer prior to referral for examination. The discussion should include how the imaging will allow them to be able to make a diagnosis or monitor the progress of the patient’s treatment. This should also include an explanation of how the benefits of the examination (in making the right diagnosis or providing the correct treatment) outweigh the very low risk involved with the exposure itself.
It should be emphasised that the risk of cancer induction is extremely low and an indication of approximate average UK background equivalent radiation time given. UK Background equivalent radiation equivalent times for examinations relevant to QSE’s scope of practice include:
|Examination||Examination Equivalent Background Radiation Dose|
|CT Head 6 Months||6 months|
|High Resolution Chest CT||5 Months|
|CT Chest||2 Years|
|CT Chest and Abdomen||3 Years|
|CT Chest, Abdomen and Pelvis||4 Years|
|CT C‐Spine||1 Year|
|CT Pulmonary Angiogram||2 Years|
Source: Ionising Radiation Exposure of the UK Population: 2010 Review, PHE, 2016 HPA‐CRCE‐012 Frequency and Collective Dose for Medical and Dental X‐Ray Examinations in the UK 2008, HPA, 2010
The Possibility of Pregnancy
The Referrer is also required to check the LMP (Last Menstrual Period) dates of all patients capable of reproduction, aged 12 – 55 years before referring them for an examination of the abdominal, pelvic or upper femoral regions.
Failure to do so may result in the Radiographer being unable to carry out the examination until checks can be made. This might result in delay to the examination and ongoing care.
Patients who have doubts about their dates, or who could be pregnant, should be offered a pregnancy test.
Referrers should clearly indicate on the request form if it is known or suspected that a patient is pregnant at the time the request is made and must indicate that the clinical necessity of performing the examination overrides the question of possible pregnancy.
For patients that are known to be pregnant, a formal consent form must be completed with the patient by the referrer prior to referral and sent with the referral to the imaging department.
Recording of Clinical Evaluation
It is the responsibility of the referrer to carry out and record a clinical evaluation of each examination report. Radiology reports will be issued direct to the referrer by QSE and in most cases, also be available on EPIC. It is QSE policy that all clinical examinations (including those that may have been abandoned prior to the completion of the examination) will be reviewed by a radiologist and a report published.
It is also helpful to the imaging department if the referrer would consider the following when referring a patient for examination:
- The need for pain relief and removal of radio‐opaque objects prior to examination. This can prevent unnecessary repeat exposures due to patient movement, or obscuration of the area under investigation.
- Patients who are informed are generally more co‐operative. Patients should be informed by the referrer why the referrer is requesting an examination, where they are going and what to expect.
Risk Management and Incident Reporting
QSE expect all employees to undertake training in risk management and maintain awareness of QSE policies on risk management and incident reporting. Any patients, who undergo a procedure that was not intended as a result of mistaken identification, or other procedural failure, and who has consequently been exposed to an unnecessary ionising radiation dose, will be considered as having received an unintended dose of radiation. (Regulation 4.(5))
QSE will investigate these occurrences, supported by the nominated Radiation Protection Advisor. The detailed investigation required by this regulation will be aimed at:
- Establishing what happened
- Identifying the failure
- Deciding on the remedial action required to minimize the chance of a similar failure in future.
- Estimating the doses involved and recording the incident.
Legislation assumes that no radiation dose is entirely free from risk and Radiographers have a legal duty to ensure that doses are ‘As Low As Reasonably Practicable’ ‐ this includes a legal responsibility to refuse to carry out procedures if the risk /benefit is not clear.
Referrers are strongly encouraged to consider the following question when referring a patient for medical exposure:
Will this examination influence /affect the immediate management of the patient?
“Before you request a test, you should first ask yourself what you are going to do if the test is positive, then ask yourself what you are going to do if the test is negative. If the answer is the same, do not do the test.”
This guide is intended to provide referrers with an overview of the requirements set out within the Ionising Radiation (Medical Exposures) Regulations 2017, as well as practical guidance on managing referrals for diagnostic imaging. However, circumstances may arise where further guidance or advice is needed. Referrers are encouraged to contact the following key personnel:
For CT/Ionising Radiation related enquiries:
CT Clinical Lead Radiographer and QSE Radiation Protection Supervisor
Mr Trent Sparks
Phone: 020 7833 2513
Superintendent: Queen Square Imaging Centre
Ms Fiona Bower
Phone: 020 7833 2513
For all MRI and MRI Safety related enquiries:
MR Safety Officer and Superintendent: Queen Square Imaging Centre
Ms Fiona Bower
Phone: 020 7833 2513
MR Safety Officer and Cardiac MRI Superintendent: Chenies Mews Imaging Centre
Ms Louise McGrath
Phone: 020 3887 0566
- Relevant Regulations, Policies and Procedures
- Ionising (Medical Exposures) Regulations 2017 Statutory Instruments 2017 No 1322 http://www.legislation.gov.uk/uksi/2017/1322/made
- IR(ME)R Employer’s Procedures
- QSE Local Rules for Radiation Safety in CT
- QSE Escalation of Incidents Procedure
- QSE Ionising Radiation Safety Policy
- QSE Radiation Contingency Plans and Risk Control in Diagnostic Radiology