Post examination

1. Image review and reporting

Following acquisition, it is the responsibility of the radiographer / RT to ensure that the resultant image is of diagnostic quality and can answer the relevant clinical question.  If a repeat image is not required, then the radiographer / RT should ensure that the image is made immediately available to the referrer.  This will be commonly undertaken by uploading the image to the hospital Picture Archiving and Communications System (PACS).  In some instances, with DR, the referrer may wish to review the image at the point of acquisition.  There are likely to be differences in image quality between the display screen on a mobile X-ray unit and those assigned for primary review.  Referrers should be advised to check the full image using the designated computer screens and PACS.  Following image review it is the responsibility of the radiographer / RT to appropriately annotate the image (Figure 8).  Protocols for annotations will be at the discretion of local departments but are likely to include an aspect marker (L or R), projection details (mobile AP erect or supine), exposure factors, time of examination and location.  Once the radiographer / RT is satisfied that the image is of sufficient quality and has the necessary annotations then it can be sent to PACS.  Where possible mobile images should be sent for urgent reporting by a radiologist or reporting radiographer / RT.  Mechanisms should be in place for notifying referrers or urgent or unexpected findings.

Figure 8.  Two mobile CXR images from patients with the COVID-19 virus.  Annotations (primary and secondary) are present on the images to provide information about the acquisition conditions.  A primary (at the time of exposure) aspect marker is indicated by the solid blue arrow (left image).  A post-exposure (secondary) aspect marker is indicated by the dotted blue arrow (right image).  Other annotations included on the image include the radiographic projection (dotted rectangular box) and the location of the examination (solid rectangular box).  The post-exposure annotation protocol will be governed by local protocols and may also include exposure factors, examination time and radiographer details.  Images courtesy of Dr Nick Woznitza, London (adapted).      

2. Image storage and retrieval

Images should be ideally stored and retrieved via a hospital based PACS.  Such a system provides a long-term archive for images and allows for comparisons with previous examinations.  Protocols can be built into PACS which will automatically upload the most recent examination for comparison and also apply additional post-processing algorithms (i.e. for line detection).  Clinicians may also have the opportunity to add notes to images for the attention of the reporter, this is useful if they wish to confirm acknowledgement of an unexpected finding or if a feeding tube has since been removed.

3. Equipment decontamination and disposal of PPE

Equipment decontamination and correct disposal of PPE is essential.  Correct removal of PPE and post-procedural handwashing is paramount. Practices must consider the size of the X-ray equipment and also that some components may be sensitive to certain disinfectant agents.  DR computer screens and image receptors can be damaged following prolonged exposure to certain cleaning agents.  It is recommended that radiographer / RTs follow the guidance from the equipment manufacturer with regards to decontamination and cleaning.  It is also important that X-ray unit is appropriate marked to indicate that it has been thoroughly cleaned following an examination and is once again ready for use.  

4. Radiation dose and practitioner recording

Radiation dose monitoring and completion of the radiographic examination is important.  Radiographer / RTs should confirm that the examination has been completed on the relevant hospital / radiology computer system.  In addition, the radiographer / RT should record exposure factors and dosimetric information together with the radiographer / RTs responsible for the examination.  This will facilitate the monitoring of radiation doses acquired outside of the radiology department and also facilitate audit.  

5. Is any additional imaging recommended?

Occasionally, the radiographer / RT may become involved in discussions regarding further imaging of a patient following a mobile examination.  Such situations may result from difficulties in visualising naso-gastric tube position or establishing the presence of free air within the abdomen.  Such situations may require modified views or alternative projections and would commonly warrant discussion between the medical team and radiology.  It may be that such situations are governed by locally available protocols and that imaging will need to extend beyond radiography.  As previously stated there may be an enhanced role for prone imaging in severe cases of COVID-19.  Chest radiography in the prone position may also enhance the visualisation of the posterior lung bases in the presence of a pleural effusion.  A virtual simulation of this technique is provided in the image below (Figure 9).    

Figure 9.  A set of 'virtual' images of a patient undergoing a prone chest X-ray examination.   Images courtesy of Dr Phil Cosson (Shaderware Ltd, UK).  

With respect to COVID-19 there is also a well-established role for CT in the evaluation of the respiratory system (see Youtube video).   Current imaging best practice advises that Chest CT is not used to diagnose COVID-19, but may be helping in assessing complication¹⁵.