Nurse Ordering of X Ray Examinations

Stepherunie

Just wondering what peoples feelings are on the increase in the number of ANPs/Senior Nurses who are now allowed to order xray examinations.

In the radiography community there seems to be a very much mixed reaction about it. All the research shows that radiographers are better equipped to correctly identify the required examination required and any pathology/ injury on the corresponding radiograph. Indeed there is very little research out there to prove that nurses have been adequately trained to properly report and order x rays.

From a personal perspective working in an xray dept, I often get requests from the tone of which you can tell quite clearly the person ordering doesn't know what they should be ordering. I've assessed patients myself and realised the too many or the wrong exams has been ordered, then had my jugement called into question for taking the decision to not do all of the xrays (to be fair to ANPs, it's not only them, I've had SHOs do likewise).

By the same token I'm wondering are doctors seeing it as a loss of some of there job role that they will no longer be the one to have the final say as to the need for xrays, particularly in a ward situation where nurse ordering is beginning to be introduced.

drzhivago

Stepherunie wrote: »

Just wondering what peoples feelings are on the increase in the number of ANPs/Senior Nurses who are now allowed to order xray examinations.

I think it is progressive

Stepherunie wrote: »

In the radiography community there seems to be a very much mixed reaction about it. All the research shows that radiographers are better equipped to correctly identify the required examination required and any pathology/ injury on the corresponding radiograph. Indeed there is very little research out there to prove that nurses have been adequately trained to properly report and order x rays.

I think you are being very selective in your quote about ALL the research as I do not believe that is the case

To the best of my knowledge radiographers are not trained in Ireland to report xrays yet you are suggesting that somehow nurses have not been adequately trained yet they do receive training as part of the Advanced Nurse practitioner program

To finish off from above even if a radiographer was trained to identify the required examination for a particular injured part and to interpret the xray they are not trained to examine the patient or to treat the injury, cannot prescribe medications or reset fractures that they have correctly identified afterwards so it is only one part of the overall management of the patient, an important part yes but not a solution of itself to running minor injury units.

Stepherunie wrote: »

From a personal perspective working in an xray dept, I often get requests from the tone of which you can tell quite clearly the person ordering doesn't know what they should be ordering. I've assessed patients myself and realised the too many or the wrong exams has been ordered, then had my jugement called into question for taking the decision to not do all of the xrays (to be fair to ANPs, it's not only them, I've had SHOs do likewise).

I agree with you there steph in part though
You obviously have been working in an A&E for some period of time
Think back to your 1st year of work, would you have been so confident in your interpreting skills at that stage. SHO is 1 year out of college often working alone at night in A&E departments with very little experience. effectively they are learning from their exposures and many of them will learn from you, however were you to go into the resus room you would similarly learn from them how to reduce a shoulder joint or how to suture a wound or worse still how to intubate a patient who cannot breathe for themselves

ANP may also still be in the learning phase of their own career development and thus is also learning in practice

similarly steph I have worked in many A&E departments, have also been in them as a patient, once with a neck injury in a collar. On that occasion brought to hospital on a stretcher in an ambulance, reviewed by a doctor, left in a collar and had the collar removed by the radiographer at the time who did not think it was necessary, a difficult clinical call to make for a doctor at times and in my experience not one that should be made by a radiographer off their own bat without any other clinical person around.

Stepherunie wrote: »

By the same token I'm wondering are doctors seeing it as a loss of some of there job role that they will no longer be the one to have the final say as to the need for xrays, particularly in a ward situation where nurse ordering is beginning to be introduced.

I dont think ordering xrays is progressing that quickly

where I think this is relevant is in relation to all the proposed new minor injury units to be set up
In these my understanding is there will be no doctors and thus I am unsure what happens when the ANP who is there needs support for a difficult clinical call regarding treatment and possibly also regarding xrays

That is my worry

Stepherunie

DrZhivago wrote:

I think you are being very selective in your quote about ALL the research as I do not believe that is the case

To the best of my knowledge radiographers are not trained in Ireland to report xrays yet you are suggesting that somehow nurses have not been adequately trained yet they do receive training as part of the Advanced Nurse practitioner program

To finish off from above even if a radiographer was trained to identify the required examination for a particular injured part and to interpret the xray they are not trained to examine the patient or to treat the injury, cannot prescribe medications or reset fractures that they have correctly identified afterwards so it is only one part of the overall management of the patient, an important part yes but not a solution of itself to running minor injury units.

Firstly just to clarify, I didn't say all. I did a fairly extensive lit review on this myself as did a lecturer of mine and one of the huge issues we both found were the lack of studies looking at nurse reporting. Most studies compare Interns to Radiographers and Interns to Nurses, I think we only found 1 study that looks at all 3 and that was doing a fairly extensive literature review.

I've researched ANP training, and like anything it takes time to find your feet when it comes to ordering. As you say about SHOs, they're a year out of college and if I'm questioned by any Doctor or Nurse as to why I didn't take a particular xray I'm more than happy to explain why I didn't.

Where I know we've noticed it particularly is when it comes to extremity imaging. Patients will often be sent around for ankle and foot when they've had a blow to the toes with no swelling or loss of movement in the ankle. At that point to a radiographer it is a radiation protection issue. There is no clinical indication for xraying the ankle in that situation, and you are subjecting the patient to an unnecessary dose.

DrZhivago wrote:

similarly steph I have worked in many A&E departments, have also been in them as a patient, once with a neck injury in a collar. On that occasion brought to hospital on a stretcher in an ambulance, reviewed by a doctor, left in a collar and had the collar removed by the radiographer at the time who did not think it was necessary, a difficult clinical call to make for a doctor at times and in my experience not one that should be made by a radiographer off their own bat without any other clinical person around.

I'm not going to lie, I'm shocked by this. I would never make that call myself, god knows if I get a patient around for ?Cspine fracture, I'll do everything in my power to keep them still, even those who don't have collars on them. I've been asked my opinion on occasion, particularly when it's a case of if they're questioning whether or not to send them to CT, and in those cases I'd give my opinon, but taking off a collar is shocking.

DrZhivago wrote:

I dont think ordering xrays is progressing that quickly

One of the major teaching hospitals will have nurses on wards who've completed a course ordering x rays from August.


Like I said, I'm only looking for other peoples views on xray ordering in general tbh. I see the ANP role as a great move forward in trying to alleviate the huge waiting times so often seen in A&Es, though I see your point about nurse led minor units.

drzhivago

Stepherunie wrote: »

Firstly just to clarify, I didn't say all. I did a fairly extensive lit review on this myself as did a lecturer of mine and one of the huge issues we both found were the lack of studies looking at nurse reporting. Most studies compare Interns to Radiographers and Interns to Nurses, I think we only found 1 study that looks at all 3 and that was doing a fairly extensive literature review.

Apologies have re read and accept you didnt say all

And just to put this in perspective again Interns are the very first year out of college and depending on when the particular study was done could be 1st week out of college with little or no practcial experience of ordering or interpreting xrays

A nurse (Nurse practitioner) who is doing this would have many years of experience and specific training in interpreting xrays so in describing the results of such a study it is quite biased to say that the nurse performs better than the doctor because it is not comparing like with like.

However there is a subtlety here, the ANP who orders the xray, interprets this for their own clinical perspective but they DO NOT report it.

in my mind the report is the final document that gets appended to the record/the Xray packet and the Radiology Information system

Again to best of my knowledge radiographers dont do that in Ireland but i am aware it is a developing practice in UK

Stepherunie wrote: »

I've researched ANP training, and like anything it takes time to find your feet when it comes to ordering. As you say about SHOs, they're a year out of college and if I'm questioned by any Doctor or Nurse as to why I didn't take a particular xray I'm more than happy to explain why I didn't.

I am 16 years out and do still get questions on this from radiographers and occasionally radiologists who dont have the same training I do and often have to justify myself. Unfortunately if people live and work in silos too long they become over protective of their own patch at times.

Stepherunie wrote: »

Where I know we've noticed it particularly is when it comes to extremity imaging. Patients will often be sent around for ankle and foot when they've had a blow to the toes with no swelling or loss of movement in the ankle. At that point to a radiographer it is a radiation protection issue. There is no clinical indication for xraying the ankle in that situation, and you are subjecting the patient to an unnecessary dose.

see your point but to be honest the extremity xray dose is quite small and equivalent to a flight across the atlantic (that was an analogy given to me by a radiologist once)

In a hospital i worked in previously they developed a set of codes for extremity xrays and this cut down significantly he number of inappropriate films and indeed films overall after a period of time

Upper Limb had 7 codes I think UL1-7 and ULX, 1-7 described particular joints and injuries sustained ULX was something that didnt come within the others

ULX were audited regularly and led to UL7 being put on the list but also identifying who and why xrays were being performed. This led to targeted training on xray interpretation and also limb examination which ended up improving quality for patient on two sides

Stepherunie wrote: »

Like I said, I'm only looking for other peoples views on xray ordering in general tbh. I see the ANP role as a great move forward in trying to alleviate the huge waiting times so often seen in A&Es, though I see your point about nurse led minor units.

ANP work great when in A&E with docs around and good division of labour
Often times they will come across a case which starts as minor but turns major and they hand over to a doc, on other hand a case which may have looked major to receptionist may be minor and case flows the other way

docs and NAP both have role however many departments run without ANP, no A&E at moment runs without docs which is why i am unsure how it will work having ANP or nurse specialists as they said in last report working independently in these cetres

Stepherunie

DrZhivago wrote:

Apologies have re read and accept you didnt say all

And just to put this in perspective again Interns are the very first year out of college and depending on when the particular study was done could be 1st week out of college with little or no practcial experience of ordering or interpreting xrays

A nurse (Nurse practitioner) who is doing this would have many years of experience and specific training in interpreting xrays so in describing the results of such a study it is quite biased to say that the nurse performs better than the doctor because it is not comparing like with like.

However there is a subtlety here, the ANP who orders the xray, interprets this for their own clinical perspective but they DO NOT report it.

in my mind the report is the final document that gets appended to the record/the Xray packet and the Radiology Information system

Again to best of my knowledge radiographers dont do that in Ireland but i am aware it is a developing practice in UK

Oh I totally agree that they're not comparing like with like, I had written that point down but I must have deleted it. The studies did try to address this bias somewhat by grouping the radiographers. One of the studies compared second year radiography students, radiographers will less than 3 years experience and a number with over 10 years experience and interns. Obviously The radiographers with over 10 years experience topped the results which was no great surprise, but if I recall correctly there was very little difference between the second year radiography students and the interns.

With regard to the Nurses Vs Interns, Interns held up very respecively and did score better than some of teh nursing cohorts tested in the research. Both Cohorts were tested against the Gold Standard of a Consultant Radiologist.


Indeed radiographer reporting it is a very well developed practice in the UK. There are now a number of Consultant Radiographers and courses can be completed in CT Brain Reporting, extremity and chest reporting as well as Barium reporting, allowing radiologists in the UK to focus on the more interventional work due to the shortage of radiologists there.

behan29

Nurses have being ordering x-rays from an A/E perspective for years, it has shown clearly that it has reduced waiting times hugely, average waiting times in u.K hospitals from admission to discharge is 4 hours! The guidelines set out for the cousre are extremely clear and concise. Nurses are well aware that x ray prescribing can be a ritualistic task from a medical/surgical perspective. Nusres x ray prescribing will help decrease waiting times as studies have shown that ANPs have the same satisfaction rating as A/E regsistrars. The aim of the cousre is not for the nurse to interpret the xray, it is aimed at ensuring the the right patient recieves the right x rays, how many patients have been x rayed following the ottowa ankle rules in the correct manner. Charging patients 100 euro and they expect to be xrayed is the norm. Drs/ANPs/G/P are afraid in my opinion not to xray patients. I think to reduce the amount of xrays been taken you need to look at the various consultants who x ray everything, ie PFA/CXR and the lovely cervical spines. When the x ray forms do come into your department, i can assure they will have a more concise history and examination than some of the drs(although not all).

tallaght01

behan29 wrote: »

Nurses have being ordering x-rays from an A/E perspective for years, it has shown clearly that it has reduced waiting times hugely, average waiting times in u.K hospitals from admission to discharge is 4 hours! The guidelines set out for the cousre are extremely clear and concise. Nurses are well aware that x ray prescribing can be a ritualistic task from a medical/surgical perspective. Nusres x ray prescribing will help decrease waiting times as studies have shown that ANPs have the same satisfaction rating as A/E regsistrars. The aim of the cousre is not for the nurse to interpret the xray, it is aimed at ensuring the the right patient recieves the right x rays, how many patients have been x rayed following the ottowa ankle rules in the correct manner. Charging patients 100 euro and they expect to be xrayed is the norm. Drs/ANPs/G/P are afraid in my opinion not to xray patients. I think to reduce the amount of xrays been taken you need to look at the various consultants who x ray everything, ie PFA/CXR and the lovely cervical spines. When the x ray forms do come into your department, i can assure they will have a more concise history and examination than some of the drs(although not all).

When I worked in A+E we had some nurses who ordered x-rays. They were good at ordering the right xray for the right person. So, it's quite useful to have a patient and xray waiting for you when yo get to them.

The reason, I would argue, for the better history etc on the xray form is because I would have been juggling 6 or 7 kids at a time, possibly including a case in resus. Whereas our nurses had much more time in minors. It's not something intrinsic.

When you say that ANPs have a similar satisfaction rating as A+E registrars, if you mean in terms of ordering the right xray, then you're probably right. The protocols seem to work pretty well.

I would take issue with you when you say its consultants who cause the problem with over xraying. I would say the more junior the staff member, the more likely they are to do an inappropriate xray. It's ballsy as well to regard a lot of c-spine xrays as excessive. It's risk Vs benefit. It' not all about a high yield. I'd wager a pound to a penny that most people in an RTA would elect to have their c-spine xrayed and take the radiation risk, than face the alternative of a missed fracture.

BTW, the 4 hour waiting time in the UK is an utter utter crock. It has nothing t do with better care. It's a political target. I worked in the UK for a long time under this 4 hour rule. Basically what happened was, the govt announced no one would be in A+E for more than hours at a time. If more than about 3% of patients breeched this time, the head nurse, and the managers got their arse handed to them.

So, this is literally what happens...You're on-call for paeds, say. You've got a sick kiddy up n the wards. But the kid with pretty mild bronchiolitis has been waiting 3.5 hours. The A+E reg wants you to have a look at them. You get paged again and again and again and again. You'll get paged literally every 5 mins, while you're trying to deal with the DKA or the brittle asthmatic on the ward.
THEN.....it's 3 hours 50 mins, so your consultant get called at home!!! And they ring you. They understand, and they don't really care, But they have to ring you, because the hospital manager has called them.

Then you go down and see the kid. 4 hours 20 mins has passed. The A+E nurse hates you. But it's OK. The kid isn't in A+E any more. She's moved him to a bed in a different room in A+E called the "medical admission unit" or some other balls. IN there, he's not observed as well as he would be in A+E. BUt he technically doesn't break the 4 hour mark either. Sometime they just take the wheels off the trolley, so you're now admitted into a "bed". Or if it's busy they won't let the paramedic unload the patient from the ambulance. Because as soon as they do, the 4 hour clock starts ticking.

There's all kinds of nonsense going on the UK to reduce A+E waiting time. All kinds of practitioners being invented, and all kinds of ways to fudge the targets. But it's very very bad fr patient care. Some of the worst stories I've heard have involved that 4 hour waiting target being fudged. We'd be in very dangerous territory basing our own practice on that dire system.

ballsymchugh

IMO if the nurses are trained to do it, then fine. but let's hope they really are trained to do it instead of the union kicking up and looking for more responsibilities that happens every so often. the last one i can remember was nurses wanting the power to prescribe. i've no problem with that either as long as they do the exact same pharmacology and biochem that the med students did.
as what tallaght01 said, the nhs targets are a joke. they also say you can't be on a waiting list for 16 weeks or so, so you're seen at week 15 for your consultation, then you wait as long as you would've before the target was introduced for your procedure. quality.

behan29

The 4 hour waiting times in the U.K are purely a political aspect of the NHS, care is greatly rushed in relation to majors/resus/paeds cases. From a minor injury perspective it works well, i dont think in this day and age patients should wait for 4-6 hours for an x ray and wait another 2 hours for the x ray to be read. The 4 hour waiting times in the U.K were always being altered. I personally dont think that nurse prescribing is entirely useful in certain aspects of the hospital setting, i think it is a waste of money especially when medicataion protocols can be implemented for little or no cost into hospital settings. I do hope that when the x ray prescribing comes on line that as nurses we dont get begging for extra money for providing a better servive for patients. Nurses in triages across the U.K worked within strict protocols for providing x rays and mediactions for minors injuries. In my experiance certain consultants would x ray their cat as Ireland seems to be in a kingdom of fear in relation to litigatation.