musculoskeletal practitioner referral to radiology at ... - NHS Kirklees

MUSCULOSKELETAL PRACTITIONER REFERRAL TORADIOLOGY AT THE MID YORKSHIREHOSPITALS NHS TRUST OR CALDERDALE ANDHUDDERSFIELD NHS FOUNDATION TRUSTPrepared by:Christopher CreaghanResponsible Area:Approval Information:Lead Director:Patient care and ProfessionsDate Approved:Committee:-Sheila DilksJuly 2007Committee - PECVersion No. Approved:ONEReview Date: June 2009Reference toStandards for BetterHealth DomainDepartment of Health 2004: Standards for Better Health.Second domain: Clinical & cost effectivenessFifth domain: Accessible & responsive careCore/DevelopmentstandardCore Standard C5 C19Performanceindicators1. Reduction of inappropriate referrals to secondary care.History of Document Version 1: May 2007

CONTENTSSection No.PageNo’s1. 0 Introduction 32. 0 Associated Policies and Procedures 33. 0 Aims & Objectives 34. 0 Purpose and Scope 45. 0 Roles and Responsibilities 46. 0 Training and Development 57. 0 Radiology referral agreement 58. 0 Referral Process 69. 0 Clinical Indications for referral 610. 0 Audit and evaluation 7References 8Appendices1) Delegation agreement2) Individual referrer agreement3) Audit toolNICE GuidanceOnce NICE guidance is published, health professionals are expected to take it fully into account whenexercising their clinical judgement. However, NICE Guidance does not override the individualresponsibility of health professionals to make appropriate decisions according to the circumstances ofthe individual patient in consultation with the patient and/or their guardian or carer.Approval Committee:Version No:Date Approved:2

1.01.011.021.031.041.052.02.012.02IntroductionThe Musculoskeletal Service (MSK) is a new initiative operating at the interfacebetween primary and secondary care. Its role is to ensure patients identified withmusculoskeletal dysfunction are assessed and diagnosed, making eithertreatment or onward referrals appropriate by putting the patient on the rightpathway of care for their condition.Patients are referred to the service by any of the General Practitioners operatingwithin North Kirklees. Referrals are typically patients for whom diagnosis isunclear and / or a secondary care referral is a possibility.The MSK Service has developed a working partnership between both GP’s andthe Orthopaedic team at Dewsbury and District Hospital. In order for the MSKteam to make appropriate referrals, diagnosis is essential, as too is recognisingwhich service provider is the most effective at resolving the presenting condition.Should a patient’s condition require an Orthopaedic referral it again is essentialthat this is supported with the appropriate diagnostic imaging.The MSK service employs both advanced and extended scope physiotherapists(Musculoskeletal Practitioners), along with a part-time general practitioner withspecialist interest in musculoskeletal medicine and an orthopaedic consultant,also part-time.For the purpose of this policy it is the Musculoskeletal Practitioners who requireaccess to diagnostic radiology. They will provide the mainstay of clinicalassessment and patient care plans. For a time efficient patient focused service,continuity would be lost if each patient had to be referred back to their respectiveGP in order that radiology be accessed.Associated Policies and ProceduresThis policy should be read in conjunction with the Mid YorkshireHospitals Trust ‘Guidance for medical staff who refers patients to DiagnosticRadiology’.This policy should be read in conjunction with the Kirklees PCT Policy (2007) NonMedical referral to radiology at The Mid Yorkshire Hospitals NHS Trust orCalderdale and Huddersfield NHS Foundation Trust.3.03.013.02Aims & ObjectivesTo ensure that patients who are referred to the MSK Service and attend anappointment with the Musculoskeletal Practitioner and who require furtherinvestigation at the radiology department receive a timely and safe service.To maximise MSK service efficiency by making a prompt and accurate diagnosis,thereby allowing for appropriate treatment or referral to be made.Approval Committee:Version No:Date Approved:3

4.04.01Purpose and ScopeThis document sets out the guidelines for Musculoskeletal Practitioners employedby Kirklees PCT to refer patients for examinations performed by the radiologydepartments at The Mid Yorkshire NHS Hospital Trust or Huddersfield andCalderdale Foundation NHS TrustThis includes acknowledgement of the employer of the responsibility to ensure theindividual Musculoskeletal Practitioner is competent to undertake referral.5.05.1Roles and responsibilitiesMusculoskeletal Practitioners in primary care• The Musculoskeletal Practitioner must ensure they undertake tasks that theyare competent to perform.• The Musculoskeletal Practitioner role is an enhanced role and as such theymust have additional qualifications in courses recognised by the HealthProfessionals Council and Chartered Society for Physiotherapist in the studyof Orthopaedics.• It is essential that a Musculoskeletal Practitioner continues to record in detailany clinical examination undertaken and history that may lead the Practitionerto request an investigation.• Prior to sending anyone for an investigation the Musculoskeletal Practitionermust ensure that the process will add to or alter the diagnosis and isbeneficial and not detrimental to the patient.• The Musculoskeletal Practitioner must ensure:o That the investigation will add to the consultation and managemento Does not investigate too ofteno That any investigation is not unnecessary repeatedo That any request is supported by accurate and appropriate clinicalinformationo That the request is the most appropriate investigation(Royal College of Radiologists 1998)5.2PCT Service Manager• It is the responsibility of the PCT Service Manager to ensure that a list ofapproved referrers in their service is maintained.• Changes or additions to the referrers must be submitted to the Primary CareTrust’s Clinical Governance Lead and Acute Trusts radiology department priorto referrals commencing.• It is the responsibility of the PCT Service manager that appropriate educationand training is undertaken by relevant staff.Approval Committee:Version No:Date Approved:4

6.06.016.02Training and developmentThe referring Musculoskeletal Practitioner should be working towards or should havecompleted a recognised Post graduate Diploma or MSc course in Orthopaedics.The referring Musculoskeletal Practitioner must have received appropriate training inradiation protection as identified by the radiation protection advisor appointed by theAcute Trusts.7.0Radiology referral agreement• A Radiology Referral Agreement must be completed.• This comprises 2 parts, a delegation agreement and individual referralagreement.• A copy of the certificate of competence in radiation awareness should also besent with the completed agreements to the radiology departments.7.1Delegation agreement (appendix 1)• The delegation agreement is between radiology services and the MedicalDirector for the MSK Service.• The agreement will identify the scope of the practice i.e. the professional/situation / examination / area etc. The delegator will be responsible fordelegating the referral process.7.2Individual referrer agreement (appendix 2)• Confirmation must be given that the individual is working to approved clinicalguidelines and has received supervised clinical training from the delegatingclinician.• Confirmation must be given that the individual has received the radiologyprotection training session delivered within the Trust or other equivalenttraining on radiation awareness, if appropriate to the referral.• Responsibility as a referrer cannot be transferred between individuals and anynew appointments must follow the guidelines in place for the speciality and anindividual referrer agreement must be completed and submitted to the ClinicalGovernance Committee. This ensures all staff receives appropriate educationand training relevant to their role.7.21The Radiology Departments can terminate referral rights at any time, either in wholeor for any named individual, for any persistent abuse of the agreement.Approval Committee:Version No:Date Approved:5

8.0 Referral process• Referrers will ensure correct demographical information is entered on therequest form• Referrers will complete relevant clinical information and anatomical area to beviewed on the request card.• The request form is signed, the name written alongside in block capitals and isidentifiable as sent by a Musculoskeletal Practitioner from MSK Service.• Pregnancy must be excluded in female patients and LMP documented on therequest card. All referrals must be in line with the Mid Yorkshire or Calderdaleand Huddersfield Hospitals’ Trust policy related to the irradiation of females ofchildbearing age.9.0Clinical indications for referral9.1Capsular Restriction• Any joint presenting with a restricted capsular pattern whereby underlyingdegeneration is suspected.• Clinical presentation of shoulder capsulitis as part of a screening process toeliminate alternative pathology.9.2Injury / acute dysfunction• Suspected bony lesion9.3Chronic Dysfunction• Clinical presentation suggestive of calcification / bone spur / stenosis /degenerative changes (joint space narrowing)• Suspected previously undiagnosed congenital abnormalities.9.4Pathology• To screen for pathology as and when clinical assessment does not eliminatepractitioners concerns.Approval Committee:Version No:Date Approved:6

10.010.0110.02Audit and evaluationPractice will be audited and evaluated twelve months after the implementation of thisguideline using the audit tool (appendix 3). The report and results will be presented bythe Musculoskeletal Practitioners to the PCT Clinical Governance Group.Any referrals regarded as inappropriate by the radiology department and thereforereturned to the referring Musculoskeletal Practitioner will be discussed at theMusculoskeletal Service meetings.References & BibliographyCollege of Radiographers (2002), Statements for Professional Conduct, College ofRadiographers: London.Core Standards of Physiotherapy Practice (2005). CSP: LondonCSP Rules of Professional Conduct (2002). CSP: LondonDepartment of Health (2000), Ionising Radiation (Medical Exposure) Regulations,Department of Health: London.Department of Health (2000), NHS Plan – A plan for investment, A plan for reform,Department of Health: London.Department of health (2002) Making a difference: Reducing Burdens in Hospitals.Department of Health: LondonDepartment of Health (2003), 10 key roles for Allied Health Professionals, Departmentof Health: London.Mid Yorkshire Hospitals NHS Trust (2002), Guidelines for X-Ray Investigation ofFemales of Childbearing Age.Mid Yorkshire Hospitals NHS Trust (2003), Minimum Technique Protocol.Nursing and Midwifery Council (2004) Guidance for records and record keeping;LondonRoyal College of Radiologists (2002), Risk Management in Clinical Radiology,Royal College of Radiologists: London.United Kingdom Association of Sonographers (1993) Guidelines for ProfessionalWorking Practice London: UKASApproval Committee:Version No:Date Approved:7

APPENDIX 1(to be completed by Medical Director for PCT employed staff)Non-Medical Radiology Referral Agreement forDelegation agreementMUSCULOSKELETAL PRACTITIONERThis agreement is designed to clearly identify for the Mid Yorkshire NHS Trust orCalderdale and Huddersfield Foundation Trust the degree to which appropriately trainednon-medical health professionals will refer patients for examinations.This agreement is recognised by the Trust as appropriate referral practice.Scope of the agreementHealth professionalReferring Practice or TeamExaminations coveredMusculoskeletal PractitionerMusculoskeletal ServicesAppendicular skeletonAxial skeleton (spine and pelvis)Exclusions:Women of childbearing age.Guidelines for LMPPersons under the age of 16 yearsReason why agreement required: To allow clinical impression to be confirmed /disputed by radiological investigation. Therebyhelping to determine diagnosis and enabling thepatient to access the most appropriate care fortheir condition in a timely manner.Approval Committee:Version No:Date Approved:

• Before an individual can participate they must have completed all appropriate training asstated in the individual referral protocol (Appendix 2). Radiation training will beprovided for professionals and dates should be inserted in appendix 2 and signed off bythe trainers when attended.• Only fully completed valid request forms will be accepted, showing the examinationrequired, relevant clinical history and symptoms.• The cards must be signed and it should be made clear that the request is from a nonmedical referrer. In the future radiology will provide an area on the request for thesignature of the non-medical referrer.SignatoriesI, the undersigned, approve the implementation of this agreement as specified above.Clinical Director Radiology Services: …………………………….Print name:Delegating GPor PCT Medical Director:Print name:…………………………….……………………………..……………………………..Agreement Date:Approval Committee:Version No:Date Approved:

APPENDIX 2Individual referrer agreementNon-Medical Radiology Referral Agreement forMUSCULOSKELETAL PRACTITIONERThis protocol is designed to clearly identify the individuals allowed to work within this referralagreement.Part one. To confirm the suitability of the NHS professional with regard to experience andcompetence within their speciality.Name of referrerJob titleReferring Practice Team1.Christopher Creaghan2.Emma JonesMusculoskeletal PractitionerMusculoskeletal ServicesSignature of referrer: 12.Signature of service manager orPractice Manager: ………………………………………………………Print name:Designation:Peter Horner………………………………………………………Approval Committee:Version No:Date Approved:

Part two: Confirmation that the above named individual has attended theradiology services training session or alternative if appropriate.Date attended:………………………………………………APPENDIX 1Signature of trainer: ………………………………………………Print name:………………………………………….......TITLE OF DOCUMENT, FORM, ETC. IN APPENDIXPart three: Confirmation that the above named individual has been providedwith specific clinical protocols to work to AND has received supervised trainingfrom the delegator or nominated alternative where appropriate.Copies of the training package and protocols are available within theirworkplace.Signature of delegator/nominated alternative: ………………………………..Print name:…………………………….....Position: …………………………………… Date: ……………………………….Approval Committee:Version No:Date Approved:

APPENDIX 3Musculoskeletal Practitioner Audit toolMusculoskeletal Practitioner……………………………………………DATE AGE GENDERSIGNS, SYMPTOMS &CLINICAL DIAGNOSISINVESTIGATIONRADIOLOGY REPORTOUTCOMEClinical Diagnosis confirmed?Approval Committee:Version No:Date Approved:

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