4 January 2019
Training and governance requirements for Non-Medical Referrers to Radiology (NMR)
Over the past 15 years nurses and allied health professionals have extended their roles to help improve the service delivered to patients. Included in this development is the role of Non-Medical Referrer (NMR) to radiology. This paper gives guidance on the training and governance arrangements required for a NMR to ensure compliance with Ionising Radiation (Medical Exposure) Regulations IR(ME)R 17 and patient safety.
Who can be a Non-Medical Referrer (NMR)?
A NMR must be a registered health care professional. I.e., they must be a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002(a).
Types of NMR
1. NMR referring as part of a clinical team where they will be acting on a radiology report as opposed to evaluating the image itself.
2. NMR referring as part of a clinical team where a doctor will do an initial review (clinical evaluation) of the imaging prior to radiology issuing a formal report.
3. NMR referring as an autonomous practitioner who will be reviewing the images (clinical evaluation) and making a decision on patient treatment prior to the radiology report being issued.
Note: Clinical evaluation is an operator function under IR(ME)R. Where NMRs act on the images prior to the formal radiology report, e.g. emergency department or minor injuries, IR(ME)R17 requires that they are appropriately trained and entitled to act as an operator under IR(ME)R17. Employers should define the training requirements in the procedures which entitle the NMR.
What training should the NMR receive?
It is strongly recommended that all NMR’s should receive appropriate training prior to being entitled as a referrer. The training may be delivered in-house, via an educational institution, e-learning or a combination but must include:
• Principles of radiation protection
• Benefits and risks of the examinations being referred for. This should include an understanding of the ionising radiation dose levels for the type of examinations to be request and can identify if there is a safer alternative to the requested exam.
• Ionising Radiation Regulations 2017 and the Ionising Radiation (Medical Exposure) Regulations 2017 IR(ME)R17 Regulations
• Responsibilities of NMR in relation to patient safety and clinical governance
• Spending time in the appropriate imaging modalities
• Overview of local referral pathways, including the use of electronic referral systems where appropriate
• Professional and legislative responsibilities.
• The entitlement of staff to be NMR’s is the responsibility of the employer under IR(ME)R 17. This should be delegated in the written procedures to a suitable body within the organisation, for example the radiology department or the radiation protection committee
• A NMR must be formally entitled and logged on a register held by the radiology service
• All NMR’s must be appropriately trained in their area of clinical expertise
• All NMR’s should receive training in radiation protection. This could include e-LFH (e-Learning for Health) and face-to-face training together with spending time in the appropriate modalities in Radiology.
• Each NMR must have a defined scope of practice
• There must be an annual audit of NMR practice under the IR(ME)R regulations
• NMRs should complete update training at appropriate intervals, for example: every three years (this could be via e-LFH)
• The NMR must engage in continuing professional development appropriate to their scope of practice and functions as a referrer
• There must be a doctor, either Consultant or General Practitioner, who is responsible, for providing mentorship, advice, guidance and patient care in any team who have NMRs
• There must be processes for mitigating the risks of failure to act on diagnostic results for both results acknowledgement and clinical management handover, as identified by NPSA Safety alert 16: Early Identification of failure to act on Radiological Imaging Reports
• When a NMR is referring to another employing organisation both organisations should agree the entitlement before the NMR’s employer confers entitlement
• Entitlement must be given in writing
• The radiology department must ensure that the appropriate feedback of learning is fed back to the NMR in response to Radiation Incidents or Near Miss reports.
• The radiology department must ensure the employer’s procedures under IR(ME)R17 are accessible to the NMR
• The radiology department must ensure local referral guidelines are available to the NMR
• In the interests of patient safety, the employer must take enforcement action if the NMR is referring ‘out of scope’ or audit activity is inadequate i.e remove NMR access to referral processes.
High Dose Examinations
High dose examinations such as CT and PET/CT should only be made as part of a multi-disciplinary team or consultant led care pathway.
Referrals for MRI & Ultrasound
Although there are no statutory regulations covering referrals to MRI and ultrasound, best practice is to follow the principles set out for referrals for examinations involving radiation.
The Medicines & Healthcare products Regulatory Agency (MHRA) recommends in the Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use (March 2015) that referrals should only be accepted from a registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with the employer's procedures to refer individuals for MRI.
A NMR undertaking MRI referrals should undergo training in MRI safety to ensure they are aware of the hazards associated with MRI imaging. So that all NMR MRI referrals include the relevant clinical information to the accepting clinician, enabling them to decide on whether there is a safety hazard associated with the examination.
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