policy for requesting and interpretation of x-rays by … · 2020. 9. 16. · policy 49 - request...

Policy 49 - REQUEST AND INTERPRETATION OF X-RAYS BY NURSE PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES. Version 9 August 2020

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COMMUNITY SERVICES DIVISION CLINICAL SERVICE

BASED POLICY DOCUMENT

POLICY FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE

PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES

Policy Number: 49

Scope of this Document: Nurse Practitioners within Liverpool Walk In Centres

Recommending Committee: Clinical Policies Working Group

Approving Committee: Clinical Standards Group

Date Ratified: August 2020

Next Review Date (by): August 2022

Version Number: Version 9 - 2020

Lead Executive Director: Executive Director of Nursing and Operations

Lead Author(s): Clinical Nurse Managers Operational Service Manager

(Walk In Centres)

COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

2020 – Version 9

Striving for perfect care and a just culture


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Further information about this document:

Document name

GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES (49)

Document summary To provide guidance for Nurse Practitioners who order and

interpret x-rays within Liverpool Walk in Centres

Author(s)

Contact(s) for further information about this document

Sonia Roberts Operational Service Manager Liverpool Walk-In Centres

[email protected]

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with SD17 – Safeguarding Adults

SD13 – Safeguarding Children

This document can be made available in a range of alternative formats including various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control: Version History:

Version 8 Ratified by Clinical Standards Group July 2018

Version 8

Transferred to Mersey Care NHS Foundation Trust

Template, with reference to Liverpool Community

Health NHS Trust replaced with Mersey Care name

and branding

6 Jun-19

Version 9 Routine review undertaken and presented / circulated

to Clinical Standards Group for ratification August 2020

COMMUNITY SERVICES DIVISION CLINICAL SERVICE BASED POLICY DOCUMENT

GUIDELINES FOR REQUESTING AND INTERPRETATION OF X-RAYS BY NURSE

PRACTITIONERS WITHIN LIVERPOOL WALK IN CENTRES

mailto:[email protected]

http://www.merseycare.nhs.uk/


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SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the

welfare of children and adults, including:

being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult;

knowing how to deal with a disclosure or allegation of child /adult abuse;

undertaking training as appropriate for their role and keeping themselves updated;

being aware of and following the local policies and procedures they need to follow if they have a

child / adult concern;

ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team;

participating in multi-agency working to safeguard the child or adult (if appropriate to your role);

ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles,

responsibilities and accountabilities, will differ depending on the post you hold within the

organisation;

ensuring that all staff and their managers discuss and record any safeguarding issues that arise at

each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and

discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age,

disability, sex, race, religion and belief (or lack thereof), sexual orientation, gender reassignment,

pregnancy and maternity and marital and civil partnership status. The Equality Act also requires regard

to socio-economic factors.

The trust is committed to promoting and advancing equality and removing and reducing discrimination

and harassment and fostering good relations between people that hold a protected characteristic and

those that do not both in the provision of services and in our role as a major employer. The trust

believes that all people have the right to be treated with dignity and respect and is committed to the

elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998.

Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in

everything they do. It is unlawful for a public authority to perform any act which contravenes the Human

Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy


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Contents

1. Purpose and Rationale 5

2. Outcome Focused Aims and Objectives 5

3. Scope 5

4. Definitions 5

5. Duties 6

6. Process 6

7. Consultation 10

8. Training and Support 10

9. Monitoring 12

10. Equality Impact Analysis 12

11. Appendices 17

Section Page No


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1. PURPOSE AND RATIONALE

1.1 Clinical Nurse Managers, Nurse Clinicians, Practice Development Mentor

for Walk-In Centres, Consultant Radiologists and Radiographers from the

Liverpool University Hospitals NHS Foundation Trust (LUFHT) Radiology

Department have developed this policy document, to ensure patients

presenting with minor injuries receive a quality and safe service when

undertaking the need for radiological interventions.

1.2 This will fulfill the requirements of the patients / service users, who

receive emergency care from staff employed by Mersey Care NHS

Foundation Trust.

2. OUTCOME FOCUSED AIMS AND OBJECTIVES

2.1 The policy is designed to ensure that all staff working for, or on behalf of

the Trust’s Walk In Centres, provide an optimal level of service delivery to

this specific patient population. The content of the policy is based upon the

latest researched-based evidence and has been agreed by a number of

professionals.

2.2 The organisation is committed to ensuring that all staff are trained and

equipped to perform their role effectively. This policy is designed to give

clarity and guidance around requesting and initial interpretation of x-rays

by Nurse Practitioners working within Liverpool Walk In Centres.

3. SCOPE

3.1 This policy is applicable to all Nurse Practitioners working for the Trust, within its Walk In Centres on a permanent basis; who have demonstrated the ability to interpret x-rays and have fulfilled the appropriate legal requirements.

4. DEFINITIONS

4.1 The table below outlines the definitions used throughout this policy document:

AED Accident and Emergency Department

APNP Advanced Pediatric Nurse Practitioner

CRIS Computerised Radiology Information System

CPD Continual Professional Development

Hot Reports A report is requested on the x-ray for the same

day.

IR(ME)R Ionising Radiations (Medical Exposure)

Regulations. 2017. This is a National training

programme for anyone including Nurse

Practitioners within Mersey Care, when

requesting and interpreting x-rays, to provide an


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understanding around the radiation of each x-ray

NPs - Nurse Practitioners These are qualified nurses who have had extra

training so that they can work in LWIC without a

doctor being available on the premises

PACS PACS System – Picture Archiving

Communication System (Digital x-ray)

Virtual Fracture Clinic Patients x-rays and medical notes are

electronically reviewed by LUHFT Senior Physio

within 72 hours and further management plan is

decided upon were the patient may not need to

attend the hospital

LWIC / WIC Liverpool Walk In Centres / Walk in Centre. A

Nurse–led minor injuries and Walk-In unit staffed

and managed by Nurse Practitioners who work

to specific guidelines and protocols which have

been signed off by the Trust.

York Centre X-ray departments, within LUHFT

The Trust or MCFT Mersey Care NHS Foundation Trust

LUHFT Liverpool University Hospitals NHS Foundation

Trust

5. DUTIES

5.1 Clinical Nurse Manager

5.1.1 To ensure that all Nurse Practitioners requesting and interpreting x-rays have undertaken appropriate training within this field.

5.1.2 To satisfy IR(ME)R 2017 the updated list must be sent to the

Superintendent Radiographer at the York Centre/ Principal Radiographer & [email protected] (Non-Medical Referrers)

5.2 Nurse Practitioner

5.2.1 All Nurse Practitioners undertaking x-ray requests must undertake IR

(ME)R training on an Biannual basis.

5.2.2 There will be an annual review of the authorised signatures of those Nurse Practitioners who may refer for radiological investigation, and sent to [email protected] as well for ensuring accuracy of central lists

6. PROCESS

6.1 Criteria for X-Rays

6.1.1 The criteria for x-raying patients, (both Adults and Children’s), with MCFT is detailed at Appendix 1 for all Nurse Practitioners working within LWIC




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6.1.2 All Nurse Practitioners must have undertaken the appropriate area of training for the specific x-rays they are ordering and interpreting

6.1.3 Pediatric x-ray training is covered in the guidelines for requesting and

interpretation of X-Rays for children under 16yrs age.

6.2 Nurse Practitioner Procedure to be observed

6.2.1 The policy addresses the issue of Professional Self-Regulation for staff

through the use of continual professional development (CPD) and a

competency framework to ensure that learning objectives have been

met and practice is safe.

6.2.2 The following lays down steps that must be taken to protect both staff

and the Trust and support the Nurse Practitioners’ decision making

process.

6.3 Triage

6.3.1 The first point contact with the patient is usually triage

6.3.2 If the joint where the fracture is located is severely displaced with

the skin at risk from hypoxia and fracture blisters DO NOT REQUEST

X-RAYS.

6.3.3 Refer to a local AED via emergency Paramedic transfer

6.4 History Taking and Examination

6.4.1 When taking the patient’s history and undertaking an examination, the

following process and points must be followed:

a. Take history and examine the patient before requesting the X-Ray.

b. Establish mechanism and force of the injury and use this information to

deduce which resultant abnormalities are likely to occur.

c. Check for other associated injuries. e.g. ‘Colles’ fracture, concomitant with radial head fracture

d. Does the patient fit the criteria for an x-ray? Please see Appendix 1 for

further information.

e. Consider Non-accidental injuries – follow safeguarding policies where appropriate.

6.5 Requesting

6.5.1 Check the name and date of birth of patient having the x-ray taken,


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Request an x-ray only when necessary. If the diagnosis of the fracture

will not alter management, reconsider the rationale for x-ray.

6.5.2 If the patient does not fit the requesting criteria but it is in the best

interest of the patient i.e clinically fracture but not history or significant

trauma, the requesting practitioner must state their rationale within the

patient notes.

6.6 Interpreting

6.6.1 Check the name and date of birth of patient for whom the x-ray has

been requested.

6.6.2 Never look at an x-ray without seeing the patient and never see the

patient without looking at the x-ray

6.6.3 When looking at the x-ray consider and assess alignment, bones,

cartilage, joints and soft tissues

6.6.4 Re-examine the patient if the x-ray does not show what the clinical

s igns have suggested.

6.6.5 Ensure that the correct limb has been x-rayed.

6.6.6 If the x-ray does not look normal, and the Nurse Practitioner is not

confident in diagnosis, judgment should be used either request an

urgent same day report. or refer the patient on to an Accident and

Emergency Department depending on the problem and

circumstances.

6.6.7 Treat the patient not the x-ray. (Tender in anatomical snuffbox suspect

and treat as scaphoid fracture. All suspected scaphoids should be sent

to virtual fracture clinic, they will send the patient an appointment for

reassessment for x-ray 10 days later).

6.6.8 Fracture present:- fax patients notes through to virtual fracture clinic on

0151-706-2050 / 0151 529 2544 or email [email protected]

explain to patient that they will review notes and contact them within 72

hours

6.6.9 Splint appropriately depending on fracture (Futura splint / Scaphoid

splint , neighbour strapping )

6.7 Surveillance – X-Ray Department

6.7.1 Flagging system


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a. It is recognised that the senior / superintendent radiographer is duty bound, by his / her own Professional Codes of Conduct, to question any unusual and / or seemingly inappropriate requests for an x-ray investigation. All requests must be justified under IRMER 2017.

b. The Senior / Superintendent Radiographer will highlight any fracture/ abnormality, bringing it to the attention of the Nurse Practitioner for patients referred into Garston and the York Centre for their X-Rays (red dot on x-ray and/or indicates on the x-ray referral form when patient returns)

c. All negative x-rays or those where hospital referral is not required will have

a written report available within two working days. In the event of hospital/ statutory bank holidays this time would be extended to a maximum of five working days

6.8 Hot Reports

6.8.1 For those x-ray where it has not been possible to make a definite

diagnosis it is desirable to obtain an urgent report:

a. For Garston and Old Swan - A phone call should be made to the Consultant

Radiographer at the Royal Liverpool Hospital Trust (RLBUHT) for reporting either

the same day or next day.

b. For Smithdown - At Smithdown Children’s Walk-In Centre a phone call should be

made to the Orthopedic on call to assess the x-ray

6.8.2 These images are a priority for reporting and the report conveyed to

respective Walk-In Centre though agreed method depending on the

locality of the WIC and be available on the PAC’s system for the

Nurse Practitioner to access on the same working day.

6.8.3 If the Hot Report cannot be obtained within this timeframe, the Nurse

Practitioner should manage the patient according to the clinical

presentation.

6.9 X-Ray Reporting

6.9.1 Responsibility for formal reporting of x-rays will be held by the

Consultant Radiologist

6.9.2 Where patients are transferred to another hospital the image should be

transferred by an agreed method. The Nurse Practitioner referring must

provide a written interpretation in the clinical notes. The responsibility for

clinical evaluation of the image is then transferred to the clinician who

reviews the patient and their clinical notes.


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6.9.3 Agreed methods of patient information transfer are:

a. Burned on to CD disc

b. Through national Image transfer portal software (PACs)

6.9.4 For any further method being considered for transferring patient specific x-ray

information advice should be sought by Information Governance Team.

7. CONSULTATION

7.1 Consultation relating to the content of this policy has been taken with the relevant

key colleagues within the Division, including the WIC Nurse Practitioners and Clinical Services Manager for Urgent Care.

7.2 The policy has been socialised with the Clinical standards Group, as part of its ratification process.

8. TRAINING AND SUPPORT

8.1 All Nurse Practitioners will undergo training in order to meet required level of

competency. This will include:

8.1.1 Interpretation adult X-rays

a. Radiological hazard training to meet Ionizing radiation medical exposure regulations

(IRMER) (2017) Bi-annual

b. IR (ME)R training is accessed via ESR and is online training

c. Upper Limb from Clavicle and shoulder to hand /below knee to foot anatomy instruction

t h r o u g h M S K c o m p e t e n c y f r a m e w o r k a l o n g w i t h r e v i e w a n d

m e n t o r s h i p b y an appropriately competent Registered Health Practitioner employed

within LWIC.

d. For NP’s with no previous AED experience, training by a mentor who has

completed the relevant competencies, for observation and assessment skills for

the treatment of patients presenting with minor injuries.

e. Current TNA x-ray interpretation study days identified as appropriate

f. Skills needed to perform examination; primary diagnosis and care

management of Upper Limb from Clavicle and shoulder to hand /below knee to

foot injuries.

g. Clinical indication for x-ray.

h. Teaching of radiological anatomy and pathology, including normal variants and

indication for x-ray by the appointed mentor provided prior to interpretation training

and competency assessment (appendix 3 and 11 )


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i. Experienced staff need to maintain continual professional development in the

interpretation of x-rays as outlined in appendix 3,

j. Staffs who have completed their WIC induction or previous training in x-ray referral

(for staff who commenced in post prior to the induction program) and their IRMER

training has been completed will be put on to the x-ray system as a referrer.

k. The full name and their registration / pin number and which sites they will be

referring from. Will be sent to the Superintendent Radiographer who will liaise with

RLUH to get them onto the x-ray system.

l. Staff who have completed Interpretation training will be given a log in and password

to PACS

8.1.2 Paediatric x-ray interpretation

a. Radiological hazard training to meet Ionizing radiation medical exposure regulations

(IRMER) (2017) Bi-annual.

b. IR (ME)R training is accessed via ESR and is online training

c. Upper Limb from Clavicle and shoulder to hand /below knee to foot anatomy instruction

t h r o u g h M S K c o m p e t e n c y f r a m e w o r k a l o n g w i t h r e v i e w a n d

m e n t o r s h i p b y an appropriately competent Registered Health Practitioner employed

within LWIC.

d. For NP’s with no previous AED experience, training by a mentor who has completed

the relevant competencies, for observation and assessment skills for the treatment of

patients presenting with minor injuries.

e. Current TNA x-ray interpretation study days identified as appropriate

f. Skills needed to perform examination; primary diagnosis and care management of

Upper Limb from Clavicle and shoulder to hand /below knee to foot injuries.

g. Clinical indication for x-ray.

h. Teaching of radiological anatomy and pathology, including normal variants and

indication for x-ray by the appointed mentor provided prior to interpretation training

and competency assessment (appendix 3 and 11 )

i. Experienced staff need to maintain continual professional development in the

interpretation of x-rays as outlined in appendix 3,

j. Staffs who have completed their WIC induction or previous training in x-ray referral (for

staff who commenced in post prior to the induction program) and their IRMER training

has been completed will be put on to the x-ray system as a referrer.


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k. The full name and their registration / pin number and which sites they will be referring

from. Will be sent to the Superintendent Radiographer who will liaise with RLUH to get

them onto the x-ray system.

l. Staff who have completed Interpretation training will be given a log in and password to

PACS

9. MONITORING

9.1 Compliance with the policy will be managed on an on-going basis, via monitoring of

Team Leaders of WICS and the Operational Clinical Manager for WICS.

10. EQUALITY IMPACT ANALYSIS

Equality Impact Analysis – Relevance screening A screening process can help judge relevance and provides a record of both the process and decision. Screening should be a short exercise that determines relevance for all new and revised

strategies, policies, services and functions. Completed at the earliest opportunity it will help to determine:

the relevance of proposals and decisions to equality, and

whether or not it is necessary to carry out a full equality impact analysis

Division/Programme: Community Services Division / Clinical Policies Set

Service area/Project: Policy 49 – Request and Interpretation of X-Rays by Nurse Practitioners within WICS

Lead person:

Sonia Roberts – Clinical Service Manager - WICS

Date:

1 July 2020

1. Title: Equality Impact Assessment Screening of Reviewed Policy (Policy 49 – Request and Interpretation of X-Rays by Nurse Practitioners within WICS)

Is this a: <Tick as appropriate> Change to an existing Strategy / Policy New Strategy/policy Change to Service(s) / Function (s) Other If other, please specify:

x


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Equality Impact Assessment Screening of Standing Policy (Policy 49 – Request and Interpretation of X-Rays by Nurse Practitioners within WICS)

2. Summary of the intended outcome of the strategy, policy, Service(s) for function(s) being assessed. Please also detail if this links to a corporate equality objective:

This policy is designed to set out a standardised procedure for all Community Services Division staff, who are undertaking ear irrigation as part of their duties. 3. Who will be affected Nurse Practitioners working within Trust WICs

4. Relevance to equality

All the Trusts policies, projects, strategies, services and major developments affect patients, carers, service users, employees or the wider community. These will also have a greater or lesser relevance to equality and diversity. The following questions will help you to identify how relevant your proposals are. When considering these questions think about age, carers, disability, gender reassignment, race, religion or belief, sex, sexual orientation, pregnancy and maternity and any other relevant characteristics (for example socio-economic status, social class, income, military veterans, unemployment, residential location or family background and education or skills levels).

Questions Yes No

Is there any indication or evidence (including from consultation with relevant groups) that different groups have different needs, experiences, issues and priorities in relation to the proposed policy or proposal?

x

Is there potential for or evidence that the proposed policy or proposal will affect different population groups differently (including possibly discriminating against certain groups)?

x

Have there been or are there likely to be any public concerns (including media, academic, voluntary or sector specific interest) about the policy or proposal?

x

Could the proposal affect how our services, commissioning or procurement activities are organised, provided, located and by whom?

x

Could the proposal affect our workforce or employment practices?


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x

Does it relate to an area of work with known inequalities?

x

Is there a greater impact on any protected group (that is not consistent with the policy aims?)

x

Is there potential for or evidence that the proposed policy or proposal will discriminate or not promote equality of opportunity or promote good relations between different groups?

x

Is there an opportunity to further advance and promote equality?

x

Is there a communications issue?

x

Is there a sensitivity issue regarding the needs of different cultures?

x

Is there an impact on the Trusts ability to achieve national targets or to satisfy inspection body standards?

x

Is there a risk of loss of reputation, service restriction or loss of confidence in the Trust?

x

If you have answered no to the questions above please complete section 6 If you have answered yes to one or more of the above and;

Believe that the policy or proposal is equality relevant, please complete section 5 and carry

out a full Equality Impact Analysis

Believe you have already considered the impact of your proposal on equality and diversity and there is little or no relevance, please go to section 4

Believe that whilst the policy or proposal is equality relevant, a full Equality Impact Analysis is not necessary at this stage, please go to section 4

4. Considering the impact on equality and diversity

If you have answered yes to one or more of the screening questions and believe that the policy or proposal is not equality relevant or that a full equality impact analysis is not required at this stage, please provide specific details for all three areas below:

How have you considered equality and diversity? (think about the scope of the proposal, who is likely to be affected, equality related

information, gaps in information and plans to address, consultation and engagement activities (taken place or planned) with those likely to be affected) The policy has been assessed from an equality perspective and there have been no areas identified where there would be any differentiation between those within specific protected characteristic groups.


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Key findings (think about any potential positive and negative impact on the different protected characteristics, potential to promote strong and positive relationships between groups, potential to bring groups/communities into increased contact with each other, perception that the proposal could benefit one group at the expense of another) The administration of x-rays as a method of investigation prior to appropriate treatment should not present any benefit to a group at the expense of any other.

Actions (think about how you will promote positive impact and remove or reduce negative impact) This policy is to be used for process and procedure guidance – there are no equality related issues related to this policy.

5. If the policy or proposal is equality relevant, you will need to carry out a full Equality Impact Analysis

Date to scope and plan your equality impact analysis:

Date to complete your equality impact analysis:

Lead person for your equality impact analysis: (Include name and job title)

<Name> <Job Title>

6. Governance, ownership and approval Please state here who has approved the actions and outcomes of the screening

Name Job title Date

S Roberts

Clinical Service Manager 1 August 2020

For use by the Equality Impact Analysis Sub Group:

Governance, ownership and approval State here which members of the Equality Impact Analysis Sub Group Quality assured the actions and outcomes from the equality impact analysis relevance screening.

Name Job Title Date


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Appendix 1 X-Ray Criteria

Site Garston

Old Swan

Smithdown

Inclusive

ages

16 years and over 16 years and over 1year to and including 15 years


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Site Garston Old Swan Smithdown

Inclusions Clavicle and upper limb, knee, and lower leg, ankle

and foot, where injury has been sustained 14 days

ago or less and clinical indicators for x-ray are

present. This may be extended to 14 days if patient has been on holiday at time of injury. This time frame may be extended as Long as there is a National NHS Response to the Covid Pandemic and that as soon as this occurs it shall triger a review or removal of the amendment. The Practitioner would also review to ensure that no previous imaging has been performed, by checking global C&M PAC’sOpen wound with suspicion/ likelihood of embedded radio- opaque foreign body, removable within the Nurse Practitioners parameters of care. (Refer to WIC clinical Handbook

Failed conservative treatment within 48 hours of original injury and the relevant clinical indicators are present.

Consider higher threshold for x-ray in patients with learning disabilities, etc.

Clavicle and upper limb, knee, and lower leg, ankle and foot,

where injury has been sustained 14 days ago or less and

clinical indicators for x-ray are present. This may be extended to 14 days if patient has been on holiday at time of injury. This time frame may be extended as Long as there is a National NHS Response to the Covid Pandemic and that as soon as this occurs it shall triger a review or removal of the amendment.

The Practitioner would also review to ensure that no previous imaging has been performed, by checking global C&M PAC’s Open wound with suspicion/ likelihood of embedded radio- opaque foreign body, removable within the Nurse Practitioners parameters of care. (Refer to WIC clinical Handbook)

Failed conservative treatment within 48 hours of original injury and the relevant clinical indicators are present.

Consider higher threshold for x-ray in patients with learning disabilities, etc.

Clavicle and upper limb, knee, and lower leg, ankle and foot, where injury has been sustained 14 days ago or less and clinical indicators for x-ray are present. This time frame may be extended as Long as there is a National NHS Response to the Covid Pandemic and that as soon as this occurs it shall triger a review or removal of the amendment.

The Practitioner would also review to ensure that no previous imaging has been performed, by checking global C&M PAC’s Open wound with suspicion/ likelihood of embedded radio- opaque foreign body, removable within the Nurse Practitioners parameters of care. (Refer to WIC clinical handbook) Failed conservative treatment within 48 hours of original injury and the relevant clinical indicators are present.

Uncomplicated crush injuries to phalanges Consider higher threshold for x-ray in patients with learning disabilities, etc.


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Exclusions All the following are excluded from treatment at

the WIC and must be referred onto AED or

their GPs:

Children under 16 years, refer to criteria for X-ray at Smithdown Children’s Walk- In Centre or refer to Alder Hey Children’s Hospital AED

Injuries over 10 days old unless patients been on holiday then 14 days.

In jury’s above knee, upper leg in any age

Do not X-ray the following and refer to AED:

Injuries which require immediate

orthopaedic intervention e.g. Clinically

extensive compound/ complicated

fractures

Evidence of altered motor and or

sensory power to

affected limb

Circulatory impairment to affected

limb

Injuries outside of the inclusion

criteria

All the following are excluded from

treatment at the WIC and must be

referred onto AED or their GPs:

Children under 16 years, refer to criteria for X-ray at Smithdown Children’s Walk- In Centre or refer Alder Hey Children’s Hospital AED

Injuries over 10 days old unless patients been on holiday then 14 days.



Injuries which require immediate

orthopaedic intervention e.g.

Clinically extensive compound/

complicated fractures

• Evidence of

altered motor and

or sensory power

to affected limb

• Circulatory

impairment to

affected limb

Injuries outside of the

inclusion criteria

Children under 1 year or 16 years and over

Injuries which require immediate orthopedic intervention e.g. Clinically extensive compound/ complicated fractures

Injuries over 14 days old



Evidence of altered motor and or

sensory power to affected limb

Injuries to the skull, spinal injuries, ribs, pelvis, femur

Injuries outside of the inclusion criteria


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Appendix 2 Clinical Indicators for X-ray

Clavicle & upper limb. above KNEE

History of significant injury likely to cause fracture below elbow

History of significant injury like

to cause fracture to shoulder or clavicle

Falls onto outstretched hand

Pain, swelling, bruising and bone tenderness to local area

New Deformity on examination

Lacerations involving glass opaque

foreign body

History of significant injury likely to cause fracture to lower leg/ankle and foot

History of significant injury likely to cause fracture to knee

Pain, swelling, bruising and bone tenderness to affected area

New deformity on examination

Inability to weight bear - more than five steps on the affected side

History of twisting ankle injury in women over the age of fifty years (increased likelihood of fibula fracture)

Foreign body localization in soft tissues

For women of childbearing age (12 to 55) we use the 28-day rule (Royal College of Radiographers Guidelines 1995) with the exception of extremities

Pregnancy or possible pregnancy is a relative contraindication to x-rays of the distal

limit

It is the responsibility of the nurse practitionerto ask re possibility of pregnancy before

proceeding with the exposure

If pregnancy cannot be excluded the date of the last menstrual period should be

ascertained and recorded on the request form

The operator must then consult with the referrer (Nurse Practitioner) and if in the judgment of the referrer, the clinical need for the x-ray outweighs the minimal risk, the examination should proceed with lead protection of the abdomen and pelvis

This must be documented both on the request form and in the clinical records


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Appendix 3:- LWIC Adults X-ray competency Please refer to Section 9:-Training requirements. Introduction All staff that are required to interpret x-rays on behalf of MCFT LWIC must have completed:

Ionising Radiation (Medical Exposure ) regulations IRMER training on a yearly basis

Staff who have commenced in post after 2009 must have undertaken the Walk in Centre induction that includes sessions on

o History taking and examination o Assessing injuries and wounds o And be able to evidence their competence in these areas

Prior to interpretation, they will have undertaken CPD via The Norwich X-Ray Image Interpretation course which is accredited by the Society of Radiographers. The course is primarily aimed at radiographers who provide a "red dot" service to A&E. This CPD has the appropriate components for ensuring that Nurse Practitioners requesting and interpreting X-Rays within LWIC gain the knowledge and skills in order to provide a quality service to WIC clientele. Course Outline The course is designed to outline:

normal anatomy and normal variants common fractures, including their prevalence and mechanism of injury subtle injuries that are often missed radiologically - but which are clinically significant soft tissue signs in the absence of obvious bony injury fracture classification risk factors, including potential pathological conditions, which may either predispose

to the injury or be an incidental finding other associated injuries following initial diagnosis radiographic projections to aid the non-radiographer in diagnosis

It is hoped that by reading through each module and referring to the associated images provided, the user will become more accurate in their interpretation skills, so giving a high quality service to clinician and patient Modules The four modules the adult WIC staff will be required to complete working in the Adult Directorate are

Hand Wrist Foot Ankle

And can be accessed via the following link


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http://www.imageinterpretation.co.uk/ The Nurse Practitioner will be required to register on the site and following completion of the Modules undertakes the assessment attached to the Module. On successfully attaining the required pass (95%) a certificate will be generated. The Nurse Practitioner will be required to produce these certificates to their mentor and a photocopy must be sent to the Practice Development Mentor. Failure to do so may suspend your interpretation practices. All new interpreters will undertake an interpretation training session agreed by LWIC and be assigned a Mentor and complete 20 practical reviews with their mentor. (Appendix 4) Mentors must be competent in Minor Injury Assessment and experienced X-Ray interpreters- ensuring that they are auditing their own X-rays. Experienced X-Ray interpreters may need to subsequently retake these modules dependent on;

How many x-rays they see within a year ( less than 60 )

To ensure they are updated with the correct terminology

This will be dependent on the locality and frequency of patient presenting for x-rays within their working environment All experienced interpreters will be required to audit their own x-rays against the radiologist’s reports. The following sample is suggested by the Consultant and Clinical Lead for Mersey Care radiology,

20 x-rays every 4 months

An agreement in 95% of cases. (19 out of 20). If you are unable to undertake 60 interpretations of X-Rays a year within your clinical field, i.e. you are part time or have not seen appropriate patient presentations you will be required to complete the 4 Module assessments stated above – yearly, to ensure on going competency. You will also need to show evidence of auditing the X-rays you have interpreted. (Appendix 5) Where the individual is not achieving the appropriate pass mark, they need to undertake the refresher training attached to each module and gain a pass mark before undertaking further interpretation.

http://www.imageinterpretation.co.uk/


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Appendix 4 X-Ray interpretation mentorship log (for new staff developing interpretation skills) Name of Practitioner: Date of last IRMER training: Mentor ………………………………………….

Date ID /DOB

Locality Presenting issue Clinical finding X-ray Your impression

Mentors impression

Radiologist report and date

Comments


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Appendix 5 X-Ray interpretation audit/reflection sheet. (for X-ray Interpreters)

Name of Practitioner Date IRMER training

Date ID / DOB

Locality Clinical presentation Impression of X-Ray Radiologist report and date.

Same findings Yes/No

Comments


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Appendix 6

Authorised signatures of Nurse Practitioners who can request and interpret X-

rays.

Each WIC keep a record in their x-ray file And send copy to the superintendent radiographer at the York center Via FAX 300-8274 /0151 529 2544 & email [email protected] Walk in center:-

Nurse Practitioner Signature



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Appendix 7 Implementation Plan

1. Ensure all staff working within LWICs are aware of the local guidelines

Use forum of staff meeting and via the process of PDR

Ensure all staff are aware of clinical effectiveness website

On-going process

2. Clinical audit of patients attending with minor injuries who require x- ray

Take random sample of clinical notes to review the outcome

Track patients journey from booking in to discharge or referral to other service

Yearly audit

3. Regular review of evidence- based literature in relation to ordering and interpreting x- rays

All staff responsible for searching and sharing information from reputable sources

Review policy if information is relevant

Policy changes to be put before clinical policies group before ratification

4. Work closely with Radiographers, Trauma reporting Radiographers and Radiologist

Link in with Consultant Radiographer to report on x-rays from Liverpool CH WICs and be involved in any formal/informal teaching sessions

All staff to attend bi yearly sessions with Consultant Radiologist/ Radiographer

On-going process

5. All staff to engage in regular Clinical supervision as per Trust guidelines

Clinical supervision to form part of team meetings

All staff to contribute and be involved in clinical supervision process

On-going process


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Appendix 8 – Walk-In Centre Framework for Ordering and Interpreting X- Rays

Competency Comments/evidence Date Achieved

1:-First level nurse employed by MCFT on a permanent basis at LCH Walk-In Centre’s.

2. To attended authorised Training session one interpretation and complete the Norwich online training

3. To complete IR(ME)R training on a yearly Via IRME(R) e-learning.

4. Proven experience / knowledge of minor injuries.

5. Participate in Clinical supervision. Identify any learning needs through process of PDR.

Name of Nurse Practitioner:

Signed: Date: Name of Assessor: Signed: Date


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Appendix 9 - Nurse Led WICs Clinical Guidelines Acute Wounds Table 1: Classification of wounds based on degree of microbial contamination

Criteria Classification

Contaminated Contaminated wounds are open (avulsive), fresh, traumatic wounds< 4 Hours old or wounds from surgical operations involving major breaks in sterile technique or gross spillage from the gastrointestinal tract.

Dirty Purulent inflammation (e.g. abscess); preoperative perforation of Respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma or open traumatic wounds >4 hours old.

Adapted from Robin Chard AORN Journal 2009

A wound classification system formula used by surgical team used for grading the extent of microbial contamination, has four categories which is then used to indicating the chance that a patient will develop an infection. All traumatic wounds that constitute a breech in the skin integrity fall within the last two categories presenting at the Liverpool WIC making them either contaminated or dirty (Table1).

The object of cleaning the wound is to remove both organic and inorganic debris to create an optimum healing wound environment and is an essential part of the wound management. Cleansing and removal of foreign bodies and devitalised tissue has been shown to reduce infection. Dead tissue, foreign debris, devitalised tissue and haematomas must be Removed to reduce the number of contaminating bacteria and deprive any remaining of their breeding environment by doing so you ensure that the remaining tissue is viable with a Good blood supply. If there is extensive devitalized tissue or the repair of the wound is beyond competencies of the practitioner to repair then they should be referred appropriately.

Deeper structure involvement such as muscles and tendons should be referred prior to any wound closure for further assessment.

Embedded foreign debris should be removed as soon as possible. Removal of embedded foreign particles requires either local or regional anaesthesia. A sterile scrub brush soaked in saline may be used to removes the embedded debris from wounds especially gravel from abrasions preventing a ‘tattoo’ effect making a more cosmetically aesthetic wound. If glass or a radio opaque material is the suspected foreign body an x-ray of the wound should be ordered if access to x-ray is not available then the patient will need to be referred to a service where this is available.

0.9% Normal saline is regarded as the most appropriate and preferred cleansing solution within the WIC because it is a nontoxic, isotonic solution that does not damage healing tissues it is also versatile as it is dispensed in pods for accurate irrigation if required.

Clinical Policy WIC v3 (Page: 111 of 132).


Appendix 10 - Flow Chart for Following up Fractures Identified by Nurse Practitioners.

Patient is treated as per

Nurse Led WIC Clinical Guidelines

and

referred to next available Fracture Clinic for further assessment.

X –ray Radiologists report reviewed in WIC and entered onto patient notes.

If Radiologist report states no fracture

reported as a fracture in the WIC –

Nurse Practitioner will converse with radiology team for clarification of report and for

further education re normal variant.


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Appendix 11 - WIC Clinical Competencies for Referring for and Interpreting X-rays

Competency Descriptor KSF Evidence

x-ray Referral/Interpretation

Band 5

Band 6

Band 7

CNM / Band 7 team leader

Has the ability to refer patients for x-ray within MerseyCare and departmental guidelines.

1. Demonstrates awareness of the IR(ME)R guidelines and the legal requirements for completing x-ray referral forms.

2. Identify the surface and skeletal anatomy relevant to area of x-ray:

i) ADULTS

a) Lower leg from knee to foot b) Upper Limb from Clavicle/shoulder to

hand c) Foreign body localization

ii) CHILDREN

a) Upper Limb from Clavicle to hand b) Knee to foot c) Foreign body localization

HWB 6,7

HWB 6, 7. C5 C1

C1- C5 C3

Attendance at Ir (me) r training on a yearly basis. Completed x-ray referral forms

Clinical audit. Reflective diary. Direct supervision.

Audit of notes. Reflective diary. Direct supervision.

Access to clinical guidelines. Audit of notes.

N/A

N/A

Pro

I

Pro

I

Pro

I

Competencies for Referring for and Interpreting X-rays

Use Descriptors – p -participative, s - supervised, I - independent, Pro- proficient

3. Demonstrate knowledge of the process for referring patients for x-rays.

4. Demonstrates appropriate justification for x-ray to be performed.

5. Demonstrates the appropriate referral of patients for x-ray.

Audit of notes. Direct observation. Patient log.

N/A

N/A

N/A

I

I

I

I

I

I

I

I

I

Competency Self- assessment

Mentor / preceptor assessment

Review Review Review Review Review Review Review Review

1 2 3 4 5

Date and Signature:

policy for requesting and interpretation of x-rays by … · 2020. 9. 16. · policy 49 - request...

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