The practical imaging aspects of the X-ray procedure

Site: ISRRT e-Learning
Course: International Covid-19 support for Radiographers and Radiological Technologists
Book: The practical imaging aspects of the X-ray procedure
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Date: Saturday, 18 September 2021, 9:11 AM

1. Introduction

Mobile radiography is an extremely useful tool for the diagnosis and monitoring of patients where transfer to the hospital radiology department may be problematic. Undertaking mobile radiography of the thoracic region has been shown to be technically feasible, generating suitable levels of image quality with the added advantage of removing the need for patient transportation1.  There are, however, additional challenges that can present when undertaking mobile radiography and these include differences in radiation protection, communication, infection control and moving and handling to name only a few.  The COVID-19 pandemic2 has also generated additional challenges with regards to mobile radiography ( Figure 1), these include but are not limited to special infection control considerations and managing an increase in the number and range of mobile examinations being requested.

Figure 1.Initial mobile chest X-ray of a 69-year-old female with early radiographic signs of the COVID-19 virus (bilateral, peripheral ground glass and interstitial opacification). Image courtesy of Dr Nick Woznitza, London.

2. Patient identification

One of the primary considerations for any imaging procedure is correct patient identification.  This is an essential element of any radiographic examination but can be especially challenging when undertaking mobile examinations, often patients are acutely unwell and maybe unable to verbally provide the required number of identifiers (e.g. name, date of birth, identification number and address).  Such information can be obtained from ward staff and patient relatives; however, this should be avoided as patients with the same name can exist in the same ward or bay.  This is also the case when checking patient details using written case notes; case notes at the end of a patient’s bed do not necessary equate to the identity of the patient.  In such instances, a successful identity check should use identifiers on the patient’s hospital identity bracelet.  If this is not present, then a request should be made for the ward staff to apply an identity bracelet prior to imaging.  In the future, it is likely that other more sophisticated methods of supporting patient identification will become available, for example digital facial recognition, biometric markers and radiofrequency identification chips3.  To ensure correct identification of the patient it is important that the radiographer / radiologic technologist (RT) has access to the radiology request form.  This was traditionally paper based but is more frequently available only via the electronic radiology information system (RIS) or an electronic patient record (EPR).  If working with digital technology, potentially paperless, then radiographer / RTs should have sufficient means to access such systems (i.e via a tablet device or PDA).  

3. Patient consent

Patient consent is an integral part of the mobile X-ray examination and a legal requirement of practice4. Within general radiographic practice, consent is implied in that a patient would be requested to walk into an X-ray room and carry out instructions from the radiographer / RT. This would be somewhat different for a mobile examination where the radiographer / RT would bring the mobile X-ray unit to the patient.  Every effort should be made to ensure that the patient consents for the examination and that information is communicated to the patient regardless of their condition. Refusal by a patient to undergo an imaging examination should be taken seriously and follow local protocols. A mobile imaging request and a very unwell patient does not prohibit the need to ensure that adequate consent is obtained. A patient is within their rights to refuse an imaging examination if they have the capacity to understand the consequences of their decisions5. For unconscious patients imaging would fall within the care that they are currently receiving. An assumption would need to be made that if a patient was unconscious and being treated in a hospital that mobile imaging would be in the ‘best interests’ of the patient and that the examination can be undertaken.  For COVID-19 patients the monitoring of disease progression or response via chest radiography is likely to encompass a wide range of patients and the justification for imaging should be explained at every opportunity.

Consent information from Society & College of Radiographers

4. Effective communication

Effective communication is an essential element of all imaging examinations and a fundamental skill for radiographer / RTs6,7. Communication with the patient and ward staff are necessary in order to ensure that the examination is delivered in a timely manner whilst acquiring the necessary diagnostic information. Communication is also necessary to ensure that the examination is conducted safely, this being of relevance to patients, visitors and hospital staff. Effective communication with the ward team is necessary for several reasons (see Table 1). On entry to the hospital ward the radiographer / RT should make themselves known to an appropriate member of the nursing team. This will allow the radiographer / RT to ascertain the location of the patient, this is often available on electronic whiteboards or computer monitors. Nursing staff can also provide advice and assistance with regards to patient communication, individual infection control measures and moving and handling issues (Figure 2). Such information is especially important with the COVID-19 pandemic as there can be different PPE requirements depending on the COVID-19 status of the patient and whether any aerosol generating procedures have been undertaken.  

Table 1. Information typically required from ward staff during mobile radiography.
Patient location
Moving and handling requirements
Specific infection control requirements
Additional (relevant) clinical information
Location of adjacent patients / visitors / staff members
Consent & communication issues
Possible pregnancy status of patients / staff members.

Figure 2.Mobile AP erect chest X-ray image of a COVID-19 patient in which the image is rotated (clavicles not equidistant from the spinous process, cardiac silhouette is rotated over right lung field). Such situations cannot be completely absolved but every effort should be made to produce the highest quality image. Image courtesy of Dr Nick Woznitza, London.

It is recommended that positioning a critically ill patient for a mobile X-ray examination should directly involve ward staff. Such individuals will have greater knowledge on the location of catheters, lines and medical devices and will have a stronger understanding of a patient’s needs. It is important that by undertaking mobile radiography there is no detriment to the condition of the patient, i.e. dislodging medical devices or exacerbating pain. Maintenance of patient wellbeing and privacy is important and should be a continual consideration by the radiographer / RT during the examination. Radiographer / RTs should have knowledge of hospital alert systems used by wards, such as the presence of pressure ulcers, epidural catheters or open wounds from which an iatrogenic injury could occur during positioning for the examination.

Effective communication with the patient is also necessary to ensure safety and the optimal diagnostic yield from the examination.  If the patient is conscious and able to respond verbally then the information that they can provide can help deliver an efficient examination (Table 2).



Table 2. Information typically required from the patient during mobile radiography.
Confirmation of a positive identification / justification
History of any recent imaging (supporting justification / procedural awareness)
Moving and handling needs
Understanding of examination specific requirements, i.e. arrested inspiration
Possible pregnancy status.

5. Mobile projectional radiography

Mobile projectional radiography typical requires transportation of a mobile X-ray unit to the patient’s bedside. This generates a number of specific considerations including access to the patient, movement of the X-ray unit within confined spaces (see Youtube video), production of a diagnostic image and maintaining the health and safety of the patient, ward staff and radiographer / RTs. Chest radiography has been recommended in the management of COVID-198,9. In order to restrict the transmission of the COVID-19 virus suspected or proven infections would normally be imaged using mobile X-ray equipment. This will increase the number of examinations being performed and also require mobile radiography in new areas of the hospital. Such situations would more easily be managed within the radiology department, where exposure to ionising radiation can be restricted to designated X-ray rooms. Access to fixed X-ray units can be carefully controlled and additionally are specific elements of an X-ray room designed to minimise patient and occupational exposure to ionisation radiation.