Preparation for the procedure

1. Justification of the examination

There are many steps which are needed in order to successful undertake and complete a mobile X-ray examination. Before attending a ward or department it is important to ensure that the requested examination is justified. Justification is two-fold in that there needs to be an appropriate clinical reason for the requested examination but also a reason to justify that the examination should be undertaken outside of the radiology department (mobile).  Referral criteria are available but are not specifically focused for mobile examinations, for example the Royal College of Radiologists iRefer criteria and the American College of Radiology Appropriateness Criteria. Specific criteria for mobile examinations are likely to be governed by local protocols and also discussion with the referrer. Radiographer / RTs should understand local protocols for promptly identifying mobile radiography referrals and ascertaining the appropriateness of such referrals.  Some of these steps may need to involve reporting radiographer / RTs or radiologists. It is also important that the examination remains justified when the radiographer / RT attends the patient’s bedside. By way of an example, when radiography is requested following an intervention (line insertion, drain removal, etc) it is important that the radiographer / RT ensures that these procedures have been completed. It is not unheard of for a radiographer / RT to be requested to perform a mobile chest X-ray on a patient for nasogastric tube position when this has not yet been sited or the patient has removed it.  Justification should also consider repeat referrals, acutely unwell patients are often transported between departments and wards (i.e. A&E, theatre and ITU) and as such referrers may be unaware of previous examinations.  Radiographer / RTs should, where appropriate, make referrers aware of previous examinations as part of the justification process.  It is also good practice for the radiographer / RT to review any prior imaging.  This will provide the opportunity to assess the size of a patient’s chest and whether a portrait or landscape image receptor orientation would be most appropriate.  Review of prior imaging also provides the opportunity to consider exposure factor selection and how the presence of pathology may have an impact on dose optimisation.  Severe cases of COVID-19 may present with a viral pneumonia, as a result there may be significant opacification of the lung fields and an increase in exposure factors may be warranted.  This is important when attempting to demonstrate the exact locations of central venous catheters, endotracheal tubes, chest drains and other medical devices. Additionally, severe cases of COVID-19 have been associated with the presence of existing comorbidities (cardiovascular disease, diabetes, chronic respiratory disease, hypertension and cancer) and being aware of these issues may also help planning radiography10.