An Introduction to Clinical Audit for Radiographers

12. Examples of audits relevant to a mobile chest radiography service

12.3. Technical Aspects

Service Requirement Section C - Technical Aspects
Criteria C1 C2 C3 C4 C5
No. CXR referrals with appropriate clinical information No. CXRs diagnostically acceptable 'right first time' Monitor and act upon any safety concerns raised Monitor and act upon staff dose monitoring indicators Patient doses
Example audit statement All CXRs have sufficient clinical information for justification by the radiographer All CXRs should be diagnostically acceptable No safety concerns should be raised by radiographers undertaking CXRs Staff doses should be <10% of median dose values (* insert local standard) Patient doses should be recorded (e.g. DAP) and remain within acceptable local DRLs and DAP and EI ranges
Purpose Safety: Appropriateness of clinical information to enable justification, and appropriate use of limited PPE. CXRs NOT required for screening or for mild symptoms. Safety and efficiency: the number of CXRs repeated and the reason (reject analysis) should be monitored Safety - e.g. PPE availability; radiation protection issues, lack of available assistance to safely undertake CXR; staff Covid infection Safety: compliance with good practice; rotation of imaging staff into high risk areas; consider ICU staff monitoring and rotation Safety: compliance with good practice in view of some patients receiving multiple imaging examinations: As Low as Reasonably Practicable (ALARP)
Indicator / Standard 100% compliance. Review referrals against justification criteria - all Covid-19 positive patients should be classed as moderate to severe symptoms. 100% Compliance (ideal) Local optimum standard set 100% compliance 100% compliance Review locally - there are no dose limits set.
Audit type Compliance / on-going Compliance / improvement Compliance Monitoring / Compliance (N.B. will be retrospective) Monitoring
Evidence / Previous audits / literature No imaging for screening or mild Covid-19 symptoms: https://pubs.rsna.org/doi/10.1148/radiol.2020201365
 Covid-19 referral criteria available at: https://www.bsti.org.uk/media/resources/files/BSTI_COVID-19_Radiology_Guidance_version_2_16.03.20.pdf
Review against any national Diagnostic Reference Levels and local reject analysis rates. Review CXRs against 10 point plan (Image review and reporting):  https://www.elearning.isrrt.org/mod/book/view.php?id=255
Refer to WHO and subsequent national guidance on PPE: https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf
ISRRT PPE document: https://www.isrrt.org/full-guideline-protective-measures
Refer to local staff dose records and consult with Radiation Protection Advisor if concerns are raised. 
Moloney F et al . Radiation exposure in ICU patients https://www.ncbi.nlm.nih.gov/pubmed/27158429
Patient doses in critical care (McAvoy et al 2019): https://search.informit.com.au/documentSummary;dn=623334492317151;res=IELHEA

Did all exposures have a recorded clinical evaluation (report)? Regulation 12(9) of IR(ME)R, Ionising Radiation (Medical Exposure) Regulations 2017. These regulations implement some provisions of the European Council Directive 2013/59/Euratom. Ref:
The Ionising Radiation (Medical Exposure) Regulations 2017 No.1322 (2017). (Queen’s Printer of Acts of Parliament) Available at: http://www. legislation.gov.uk/uksi/2017/1322/contents/made [accessed 27.06.2019]
European Commission (2013), Council Directive 2013/59/EURATOM. Official Journal of the European Union (2013) Available at: https://eur-lex. europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2014:013:0001:0073:EN:PDF [accessed 27.06.2019].