Audit of access to Imaging Referral Guidelines [QSI Ref:XR-501]

Imaging referral guidelines are of proven value in reducing inappropriate examinations but can only work if accepted and used to support justification by referrers, radiologists and those to whom the task has been delegated. This audit aims to show that referrers are aware of these guidelines and can access them.

Imaging referral guidelines are required by the Euratom BSS Directive and national legislation, the Ionising Radiation (for Medical Exposures) Regulations, IR(ME)R [1,2]. Providing access to referral guidelines is the responsibility of local NHS organisations and is an essential part of clinical governance. It is acknowledged that some guidelines may not be applicable to all cases, but mechanisms should be in place to ensure that practice is reviewed against the guideline recommendations and the reasons for any differences assessed and where appropriate, addressed. Imaging referral guidelines “iRefer: Making the best use of clinical radiology services” [3] are advisory and intended to inform decisions not as a mandatory protocol and work best as part of clinico-radiological dialogue possibly through a computerised Clinical Decision Support system (CDS) [4]. Guidelines assist ICRP level 2 justification when ionising radiation examinations are used [5]. It is accepted that in individual cases there may be deviation from the indicated investigation due to the patient’s age or co-morbidity or to availability of an investigation locally. Studies show that compliance is achievable at 80-90% [6,7]. Implementation and improvement may be done by a variety of means including patient-specific reminders, continuing education and training and clinical audit [7-11]. In order for audit of guidelines to be efficient the information used should be derived from routinely collected data. PACS or Radiology Information Systems may be searched to provide data. The use of stand-alone systems is discouraged, as they require double entry of data.

The standard: 

1. All referrers should be aware of imaging referral guidelines

2.Imaging referral guidelines such as RCR Referral Guidelines “iRefer: Making the best use of clinical radiology” or guidelines embedded in Clinical Decision Support should be available to all referrers, including non-medically qualified referrers

Target: 

1. For the awareness standard, the aspirational target is 100% but a realistic target will be determined locally and typically would be 90%

2. For the Guidelines availability standard, the target is 100% as this is a legal requirement under IR(ME)R [2]

Indicators: 

1. The percentage of referrers who are aware of the presence of imaging referral guidelines

2. The percentage of referrers who have access to web-based or print copies of the guidelines

Data items to be collected: 

1. Awareness of referral guidelines - at least 30 referrers.
2. Successful access to Referral Guidelines or CDS - 30 referrers.
3. Referral groups with access to Referral Guidelines or CDS eg General Practice, Hospital practitioners and non-medically qualified practitioners.

An open invitation to referrers to complete a simple web-based survey eg. Survey Monkey or similar email questionnaire including the following questions:

1. What is your role? Consultant / GP / SAS / Junior doctor / Non-medical referrer (eg Nurse Practitioner, Physiotherapist, Chiropractor etc)
2. Are you aware of any imaging referral guidelines or clinical decision support systems for radiology? Y/N
3. RCR Imaging referral guidelines, iRefer may be available through the healthcare intranet, digital requesting system or through Clinical Decision Support (CDS). Are Imaging Guidelines accessible to you? Y/N
4. If so, are they available in print/pdf format, on the healthcare intranet, open internet, or through Clinical Decision Support systems? (Tick all that apply)

Suggested number: 

At least 30 respondents are needed for target 1 and as many as possible for target 2 [12]

This audit may be targeted to a particular referral group, particularly for follow-up. A mailshot of a select group of referrers such as local GPs or emergency care physicians would be preferred where the total number (denominator) is known

Discussions with the Director of Technology in the Trust (Board) or Integrated Care System as to how best to address distribution problems. Options might include:

• Ensuring local NHS intranet does provide access to RCR referral guidelines

• Screen saver reminders – with permission from local IT and Communications departments

• Inclusion of imaging referral in medical induction programmes

• Electronic link to guidelines when using referral systems eg ICE

• Electronic link to guidelines on local PACS system

• Clinical Decision Support systems working through electronic requesting systems

Email or web-based questionnaire

Audit staff assistance to compile and analyse results

Analysis may be automated using a web-based system such as (Survey Monkey® https://www.surveymonkey.com/user/sign-up/)

1. Euratom. Council Directive 2013/59/Euratom laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, 2014. https://ec.europa.eu/energy/sites/ener/files/documents/CELEX-32013L0059-EN-TXT.pdf

2.  UK Department of Health. Ionising Radiation (Medical Exposure) Regulations. Her Majesty’s Stationery Office, London. 2017. http://www.legislation.gov.uk/uksi/2017/1322/pdfs/uksi_20171322_en.pdf (accessed 6.2.18)

3. Royal College of Radiologists. iRefer: Making the best use of clinical radiology. RCR iRefer Guidelines v. 8. 2017. https://www.irefer.org.uk/  (accessed 1.4.22)

4. RCR iRefer CDS https://www.rcr.ac.uk/clinical-radiology/service-delivery/rcr-referral-guidelines/irefer-cds(accessed 1.4.22)

5. ICRP 103. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Annals of the ICRP, 2007. 37(2-4): p. 1 - 332.

6. Anja Almén, Wolfram Leitz and Sven Richter. The National Survey on Justification of CT-examinations in Sweden, February 2009. http://www.stralsakerhetsmyndigheten.se/Global/Publikationer/Rapport/Stralskydd/2009/SSM-Rapport-2009-03.pdf (accessed 6.2.18)

7. Remedios D,  Drinkwater K, Warwick R, On behalf of the Clinical Radiology Audit Committee (CRAC), The Royal College of Radiologists, London.  National Audit of appropriate Imaging, 2014; 69: 1039–1044. https://www.rcr.ac.uk/sites/default/files/docs/radiology/pdf/appropriate_imaging_audit.pdf  (accessed 6.2.18)

8. Royal College of Radiologists Working Party. Influence of Royal College of Radiologists' guidelines on referral from general practice. BMJ. 1993 Jan 9;306(6870):110-1. http://www.ncbi.nlm.nih.gov/pubmed/8435606 (accessed 6.2.18)

9. Oakeshott P, Kerry SM, Williams JE. Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. Br J Gen Pract. 1994 Sep;44(386):427-8. http://www.ncbi.nlm.nih.gov/pubmed/8204331 (accessed 6.2.18)   

10. Eccles M, Steen N, Grimshaw J, Thomas L, McNamee P, Soutter J, Wilsdon J, Matowe L, Needham G, Gilbert F, Bond S. Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial. Lancet. 2001 May 5;357(9266):1406-9. http://www.ncbi.nlm.nih.gov/pubmed/11356439 (accessed 6.2.18)

11. Ramsay CR, Eccles M, Grimshaw JM, Steen N. Assessing the long-term effect of educational reminder messages on primary care radiology referrals. Assessing the long-term effect of educational reminder messages on primary care radiology referrals. Clin Radiol. 2003 Apr;58(4):319-21. 

12. R Godwin, G de Lacey and A Manhire, Editors, Clinical Audit in Radiology; 100+ Recipes, The Royal College of Radiologists, London (1995).

D Remedios, updated by D Remedios 2012, 2015, 2018 and 2022