Referral Guidelines for Diagnostic Imaging at the Queen Square Imaging Centre

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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.

An IR(ME)R training update is also available to all referrers, practitioners and operators working with us here.

Quick links

Please use the quick links below to explore each section of the guidelines:

Introduction 

Referral Guidelines for Referrers

Responsibilities of the Referrer

Summary and Key Contacts

Relevant Regulations, Policies and Procedures

Introduction

The Ionising Radiation (Medical Exposure) Regulations 2017, referred to throughout this document as IR(ME)R, set out requirements for the protection of individuals undergoing medical exposures involving ionising radiation. The Regulations define the responsibilities of the Employer, Referrer, Practitioner and Operator and require medical exposures to be appropriately justified, authorised and optimised.

For QSE, IR(ME)R applies to examinations involving ionising radiation, principally computed tomography undertaken at the Queen Square Imaging Centre. It does not apply to magnetic resonance imaging. MRI referrals are nevertheless subject to QSE’s clinical-vetting, patient-safety and MRI-safety procedures.

This document provides:

·         an overview of the statutory responsibilities applying to Referrers under IR(ME)R;

·         QSE’s local requirements for CT and MRI referrals;

·         guidance on the information required to enable referrals to be appropriately reviewed, justified and authorised; and

·         practical information about making a referral to the Queen Square Imaging Centre or Chenies Mews Imaging Centre.

Where this document describes a local QSE requirement rather than a direct statutory requirement, this is stated explicitly

A Brief Overview of IR(ME)R 2017

IR(ME)R 2017 (as amended 2024) sets out the statutory duties for those involved in medical exposures to ionising radiation.

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

The Employer

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 (ALARP).  As the CQC-registered provider, the Employer also has overarching governance responsibility for ensuring compliance with the fundamental standards of safety and quality under the Health and Social Care Act 2008.

The Employer is responsible for establishing and maintaining written procedures governing medical exposures. These include procedures for the entitlement of duty holders, the identification of patients, the making and acceptance of referrals, justification and authorisation, pregnancy enquiries, optimisation, clinical evaluation and the management of accidental or unintended exposures.

QSE must ensure that no medical exposure takes place unless it has been justified by an appropriately entitled IR(ME)R Practitioner as producing a sufficient net benefit, taking account of the anticipated diagnostic or therapeutic benefit and the potential radiation detriment.

Every medical exposure must also be authorised before it takes place. Authorisation will normally be undertaken by the Practitioner. Where permitted by QSE’s Employer’s Procedures, an appropriately entitled Operator may authorise an exposure in accordance with written guidelines issued by a Practitioner. The responsibility for justification remains with the Practitioner.

QSE must ensure that a clinical evaluation of the outcome of every medical exposure is recorded. For completed diagnostic examinations, this will normally take the form of a radiology report or other documented clinical evaluation. Where an examination is incomplete or abandoned and no diagnostic images have been obtained, the clinical evaluation must record the outcome of the attempted exposure in accordance with QSE’s Employer’s Procedures.

The Referrer

A Referrer is a registered healthcare professional who is entitled by QSE, in accordance with the Employer’s Procedures, to refer an individual to an IR(ME)R Practitioner for a medical exposure.

Professional registration does not, by itself, confer entitlement to refer to QSE. Referrers must be recognised and entitled by QSE and must practise within their approved scope of referral.

QSE may recognise appropriately registered medical Referrers, including:

• hospital consultants;
• doctors in recognised training or employed medical posts; and
• general practitioners.

QSE may also entitle appropriately registered non-medical healthcare professionals to refer. Before entitlement is granted, the proposed scope of referral must be reviewed and approved through QSE’s governance arrangements.

The documented scope of practice for a non-medical Referrer must define, as applicable:

• the permitted imaging modalities and examinations;
• the clinical indications for which referrals may be made;
• any permitted patient groups;
• any exclusions or restrictions;
• the required training and competence; and
• the arrangements for review and renewal of entitlement.

Referrers must provide sufficient and accurate clinical information to enable the proposed exposure to be justified and authorised. They must also comply with QSE’s referral criteria, information-governance requirements and relevant Employer’s Procedures.

Practitioners and Operators

The Practitioner and Operator are separate IR(ME)R duty holders, although an individual may be entitled to undertake more than one duty-holder function.

The Practitioner is responsible for justifying each medical exposure by deciding whether the anticipated benefits are sufficient to outweigh the potential radiation detriment.

The Operator is responsible for carrying out the practical aspects of the medical exposure for which they have been appropriately trained and entitled.

Every exposure must be authorised before it is undertaken. Authorisation will normally be undertaken by the Practitioner. Where QSE’s Employer’s Procedures permit, an appropriately entitled Operator may authorise an exposure in accordance with written guidelines issued by a Practitioner. Such authorisation does not transfer responsibility for justification from the Practitioner to the Operator.

Practitioners and Operators must act only within the scope of their documented entitlement and must follow QSE’s Employer’s Procedures, examination protocols and written authorisation guidelines.

Where the referral does not contain sufficient or accurate information, the exposure must not be justified or authorised until the required information has been obtained. If sufficient net benefit cannot be established, the exposure must not proceed. The decision and any communication with the Referrer must be documented in accordance with QSE’s procedures.

Justification

Every individual medical exposure involving ionising radiation must be justified by an appropriately entitled IR(ME)R Practitioner before it takes place.

In determining whether an exposure produces a sufficient net benefit, the Practitioner must consider:

• the specific clinical objectives of the exposure;
• the individual characteristics and circumstances of the patient;
• the anticipated diagnostic or therapeutic benefit;
• the potential radiation detriment;
• relevant previous imaging and medical information;
• the availability, efficacy, benefits and risks of alternative techniques that involve less or no ionising radiation; and
• the consequences of not undertaking the examination.

Particular attention must be given to exposures:

• where pregnancy is known or cannot be excluded and the embryo or fetus may be exposed;
• undertaken for health screening;
• undertaken for medico-legal or insurance purposes;
• from which the individual may receive no direct health benefit; or
• involving children or other groups who may be more sensitive to radiation.

Where the Practitioner is unable to establish sufficient net benefit, or where inadequate information prevents proper justification, the exposure must not be authorised or undertaken. The decision must be documented and communicated to the Referrer in accordance with QSE’s Employer’s Procedures.

For MRI referrals, formal IR(ME)R justification is not required. MRI referrals will, however, be clinically vetted for appropriateness and reviewed in accordance with QSE’s MRI-safety and clinical-governance procedures.

Referral Guidelines for Referrers

Requirements for Patient Identification

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
• Address
• Postcode
• 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.

Referrals must be submitted through secure communication channels in accordance with the Data Protection Act 2018 and UK GDPR requirements.

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 and Submitting your Referral

The identity of the Referrer must be clear and verifiable. The Referrer must be appropriately registered and entitled by QSE to make referrals within the relevant scope of practice.

• Paper referral forms must:
• identify the individual Referrer;
• include the Referrer’s professional registration details where required;
• be signed and dated; and
• include an appropriate practice, department or return address.

Electronic referrals must be submitted through a secure, approved account that is attributable to the individual Referrer. Referrers must not submit referrals using another person’s account or permit another person to use their account.

Referral records form part of the patient’s clinical record. They must therefore be accurate, complete, legible, attributable and submitted through an approved secure communication route.

The referral must include sufficient information to enable QSE to:

• identify the patient correctly;
• understand the clinical question;
• assess the appropriateness of the requested examination;
• justify and authorise any medical exposure involving ionising radiation;
• identify relevant patient-safety considerations; and
• return the outcome to the appropriate responsible clinician or healthcare provider.

Assistance with Referrals – “iRefer”

Referrals for examinations involving ionising radiation should be made in accordance with recognised referral criteria. QSE Practitioners use the Royal College of Radiologists’ iRefer guidance, together with relevant professional guidance, local protocols and the individual circumstances of the patient, when considering the appropriateness of a referral.

Recognised QSE Referrers who require access to iRefer should use their organisation’s authorised access arrangements or contact QSE for information about any approved access available to them.

Usernames, passwords and other access credentials must not be included in this document, published on QSE websites or shared through an unsecured communication channel.

Referrers should ensure that they use the current version of iRefer and any relevant up-to-date specialty guidance.

Making 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 which should be submitted through secure communication channels.

QSE’s request forms are available for download using the following links.

• To refer to the Queen Square Imaging Centre, the relevant referral form may be

downloaded or completed online and submitted securely at:

www.queensquare.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, Referrers must communicate any known requirements that may affect the patient’s safe and equitable access to the service. This may include:

• information and communication support needs;
• disability-related reasonable adjustments;
• mobility, cognitive or sensory needs;
• the need for an advocate or carer to attend;
• the need for spoken or signed-language interpretation;
• requirements for longer or specially arranged appointments; and
• other relevant assistance or booking requirements.

QSE will identify, record, flag, share, meet and review disability-related information and communication support needs in accordance with the Accessible Information Standard (DAPB1605), where the Standard applies.

Needs for spoken-language interpretation or translation should also be communicated, although these are not, by themselves, within the specific scope of DAPB1605.

Training, Competence and Entitlement of Referrers

QSE is responsible for defining which registered healthcare professionals may act as Referrers and the scope within which they are entitled to refer.

All Referrers must:

• hold appropriate and current professional registration;
• be entitled by QSE to refer within a defined scope of practice;
• understand the responsibilities of the Referrer under IR(ME)R where referrals involve ionising radiation;
• understand the information required to enable justification and authorisation;
• comply with QSE’s referral criteria and Employer’s Procedures; and
• maintain competence relevant to their referral practice.

Medical registration alone does not demonstrate current knowledge of IR(ME)R or QSE’s local procedures.

Before a non-medical Referrer is entitled, QSE must receive and review evidence of appropriate education, training and competence. The scope of entitlement must be approved through QSE’s governance process and recorded within QSE’s Radiology Information System or other designated register of entitled Referrers.

QSE requires recognised Referrers to refresh relevant referral and IR(ME)R awareness training at least every three years, or sooner where required following a regulatory change, change in scope of practice, governance concern or identified learning need.

Entitlement and scope of practice must be reviewed periodically and may be restricted, suspended or withdrawn where the required competence, registration or governance standards are not maintained.

Responsibilities of the Referrer

The Referrer is responsible for ensuring that the referral is clinically appropriate and that it contains sufficient, accurate and relevant information to enable the examination to be reviewed.

For referrals involving ionising radiation, the Referrer must provide the Practitioner with sufficient information to enable the proposed medical exposure to be justified. Formal IR(ME)R justification is the responsibility of the Practitioner and not the Referrer.

The Referrer must:

• provide sufficient patient-identification details;
• clearly state the clinical history, provisional diagnosis and clinical question;
• identify relevant previous examinations or treatment;
• provide relevant information about known or possible pregnancy;
• identify relevant safety considerations or special requirements;
• ensure their identity and entitlement are verifiable;
• submit the referral securely;
• review and act upon the outcome of the examination; and
• ensure that appropriate arrangements exist for communicating the result to the patient and managing any required follow-up.

Informing the patient about the Examination

Wherever practicable, and before a medical exposure involving ionising radiation takes place, the patient or their representative must be provided with adequate information about the anticipated benefits of the examination and the level of risk associated with the radiation dose.

In the first instance, the Referrer should explain:

• why the examination is being requested;
• how the result may influence diagnosis, treatment or management;
• any relevant alternatives that have been considered; and
• the expected next steps following the examination.

Information about radiation risk should be proportionate to the nature and estimated dose of the examination and should be communicated in a way the individual patient can understand. It should not be assumed that the same general description of risk will be suitable for every examination or every patient.

QSE staff will provide or reinforce examination-specific information as required by QSE’s Employer’s Procedures and consent arrangements.

Where QSE requires the Referrer to document that information has been provided, this must be recorded on the referral form or within the patient’s clinical record in accordance with QSE’s local procedure.

Routine provision and documentation of this information is not undertaken under the statutory Duty of Candour. The Duty of Candour applies separately where the criteria for a notifiable safety incident are met.

Typical Radiation Dose

The radiation dose associated with a CT examination varies according to the clinical indication, the anatomical area examined, the scanning protocol, the patient’s size and individual circumstances, and the equipment used.

The figures below provide approximate comparisons only and must not be regarded as the dose that every patient will receive.

The examination-specific values and equivalent periods of natural background radiation included in this table have been reviewed and approved by QSE’s Medical Physics Expert using:

• current QSE dose data; and/or
• an identified current national source.

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

QSE maintains an IR(ME)R Employer’s Procedure for pregnancy enquiries. Referrers must comply with this procedure when requesting an examination that may result in a clinically significant radiation dose to an embryo or fetus.

For examinations within the scope of the QSE pregnancy procedure, the Referrer must:

• provide any known information about pregnancy or possible pregnancy;
• state the date of the last menstrual period where required by QSE’s procedure;
• clearly identify where the patient is known or suspected to be pregnant;
• provide sufficient information about the clinical indication and urgency of the examination; and
• communicate any other relevant circumstances that may affect justification.

The QSE procedure applies to patient of childbearing potential between the ages of 12-55, for any examination where the field coverage will include the area between the diaphragm and knees.

Where pregnancy is known or cannot be excluded, the Practitioner must undertake and document an individual justification, taking particular account of:

• the clinical urgency;
• the anticipated benefit to the patient;
• the potential radiation dose to the embryo or fetus;
• whether the examination can reasonably be deferred;
• whether an alternative examination involving less or no ionising radiation would answer the clinical question; and
• the consequences of not undertaking the examination.

It is not the Referrer’s role to determine that clinical necessity automatically overrides a known or possible pregnancy. The Referrer must provide the relevant clinical information and urgency so that the Practitioner can undertake the required justification.

Pregnancy testing will be undertaken or requested only in accordance with QSE’s approved Employer’s Procedure. Where QSE requires written consent or additional documentation for an exposure during pregnancy, this must be completed in accordance with that procedure.

All known or possible pregnancies must be clearly communicated to the imaging department before the patient attends wherever practicable.

Recording and Acting Upon the Clinical Evaluation

QSE will ensure that a clinical evaluation of the outcome of every medical exposure is recorded in accordance with IR(ME)R and QSE’s Employer’s Procedures.

For a completed diagnostic examination, the clinical evaluation will normally take the form of a radiology report. Where an examination is incomplete or abandoned, the recorded clinical evaluation will reflect the outcome of the exposure and the diagnostic information, if any, that was obtained.

Where an examination is incomplete or abandoned, QSE will ensure that an appropriate clinical evaluation of the outcome is recorded. Where no diagnostic information has been obtained, the record will state that the examination was not completed, the reason where known, and any recommendation concerning rebooking, alternative imaging or referral back to the responsible clinician.

A conventional radiology report will not necessarily be produced where no diagnostic images or clinically evaluable information have been obtained.

The Referrer is not responsible for producing the IR(ME)R clinical evaluation unless separately entitled by an appropriate employer to undertake that Operator function.

The Referrer, or another clearly identified clinician responsible for the patient’s pathway, is responsible for:

• reviewing the report or other recorded outcome;
• considering the findings in the context of the patient’s care;
• communicating the result to the patient where appropriate;
• acting upon the findings within a clinically appropriate timescale;
• arranging any necessary treatment, further investigation or follow-up; and
• ensuring that urgent, unexpected or significant findings are appropriately managed.

Where QSE is responsible for producing the radiology report, it will be issued to the Referrer or other designated responsible healthcare provider through an approved secure route.

Where QSE has been commissioned only to acquire the images and another healthcare provider retains responsibility for reporting, holding or communicating the report, the report will be produced and managed in accordance with that provider’s pathway. QSE cannot guarantee that it will hold a copy of a report produced by another provider.

Supplementary Information

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.

Referrers should also consider any mobility, cognitive or sensory needs to ensure the patient’s experience is equitable and in line with the Accessible Information Standard.

Risk Management and Incident Reporting

QSE expects all staff involved in medical exposures to understand and comply with the Employer’s Procedures for incident identification, escalation, investigation, learning and statutory notification.

An accidental exposure occurs where an individual receives an exposure in error when no exposure was intended.

An unintended exposure occurs where an exposure was intended but the exposure received was significantly greater than, or different from, that intended. This may include errors involving the patient, examination, anatomical area, modality, technique, timing or radiation dose.

All suspected accidental or unintended exposures, near misses and other radiation incidents must be reported promptly through QSE’s incident-reporting system and escalated in accordance with the relevant Employer’s Procedure.

QSE will undertake an immediate preliminary investigation where an accidental or unintended exposure is suspected. The purpose of the investigation is to:

• establish what happened;
• identify any procedural, human, equipment or system failures;
• assess the actual and intended radiation dose where applicable;
• determine the actual or potential clinical significance;
• identify immediate remedial action;
• reduce the likelihood of recurrence; and
• record and share relevant learning.

The investigation will involve the Medical Physics Expert and other relevant advisers or duty holders as required by the nature of the event and QSE’s Employer’s Procedures.

Where the statutory notification criteria for a significant accidental or unintended exposure, or a clinically significant accidental or unintended exposure, are met, QSE will notify the appropriate IR(ME)R enforcing authority within the required timescale.

Incidents that do not meet the statutory notification criteria will still be investigated, recorded and reviewed locally where required under IR(ME)R and QSE’s governance procedures.

Where an incident constitutes a notifiable safety incident under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, QSE will also comply with its statutory Duty of Candour obligations.

‘ALARP’ and Optimisation

Medical exposures must be optimised so that radiation doses are kept as low as reasonably practicable, consistent with obtaining the information required for the intended diagnostic purpose.

Appropriately entitled Operators must follow QSE’s approved protocols and must take account of the individual patient, the clinical question and relevant diagnostic reference levels.

An exposure must not be undertaken merely because it has been requested. It must first be appropriately justified and authorised. Where the clinical purpose, expected benefit or required information is unclear, clarification must be obtained before the exposure proceeds.

The following question may assist Referrers when considering whether an examination is appropriate:

Will the result of this examination influence the diagnosis, treatment or management of the patient?

Referrers should also check relevant previous imaging and avoid unnecessary duplication wherever this information is reasonably available.

The following quotation is a general clinical decision-making principle and is not itself a statutory test for IR(ME)R justification:

“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.”

Summary and Key Contacts

This guide provides Referrers with an overview of their responsibilities under the Ionising Radiation (Medical Exposure) Regulations 2017 where a referral involves ionising radiation. It also sets out QSE’s local requirements for CT and MRI referrals to the Queen Square Imaging Centre and Chenies Mews Imaging Centre.

IR(ME)R applies to medical exposures involving ionising radiation and does not apply to MRI. Referrers must nevertheless comply with QSE’s clinical-vetting and MRI-safety requirements when referring patients for MRI.

Where further advice is required, Referrers should contact the appropriate QSE service before submitting the referral or before the patient attends.

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 | Email: tsparks@queensquare.com | Phone: 020 7833 2513

Superintendent Radiographer and Deputy Radiation Protection Supervisor: Queen Square Imaging Centre

Ms Eleonora Giankou | Email: egiankou@queensquare.com | Phone: 020 7833 2513

For all MRI and MRI Safety related enquiries:

MR Safety Officer and Superintendent (QSIC)

Ms Eleonora Giankou | Email: egiankou@queensquare.com | Phone: 020 7833 2513

MR Safety Officer and Superintendent (CMIC)
Ms Kim Le | Email: kle@cheniesmews.com | Phone: 020 7833 2513

Relevant Regulations, Policies and Procedures

• Ionising Radiation (Medical Exposure) Regulations 2017, as amended.
• Ionising Radiations Regulations 2017.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• Data Protection Act 2018 and UK General Data Protection Regulation.
• Equality Act 2010.
• Accessible Information Standard, DAPB1605, NHS England.
• Royal College of Radiologists, iRefer: Making the Best Use of Clinical Radiology.
• QSE IR(ME)R Employer’s Procedures.
• QSE Procedure for Entitlement of Duty Holders.
• QSE Procedure for Making and Accepting Referrals.
• QSE Procedure for Justification and Authorisation.
• QSE Procedure for Pregnancy Enquiries.
• QSE Procedure for Clinical Evaluation.
• QSE Procedure for Accidental or Unintended Exposures.
• QSE Patient Identification Policy.
• QSE MRI Safety Policy.
• QSE Local Rules for Radiation Safety.
• QSE Incident Reporting and Escalation Procedure.
• QSE Ionising Radiation Safety Policy.
• QSE Radiation Contingency Plans.