1. Justification of the procedure.

The International Commission on Radiologic Protection (ICRP) states that “any decision that alters the radiation exposure situation should do more good than harm” (ICRP 103. 2007 p.14). Therefore all imaging requests should confer a net benefit to patients and radiographers/ radiologic technologists are key gate-keepers in this process as they often are the only radiology staff to review referrals prior to exam completion. The radiographer/ radiologic technologists must understand the appropriateness of the examination and be capable of informing and discussing with the referring physician or radiologist if the x-ray exam is not justified. Since the radiographer is defined as a practitioner in many regions, they may also have a legal responsibility for justification of the x-ray procedure. The radiographer must perform a justification for the x-ray procedure prior to the exam. 

Typically, imaging referral guidelines (such as the American College of Radiology Appropriateness Criteria (https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria>), the Royal College of Radiologists iRefer Guidelines (https://www.rcr.ac.uk/clinical-radiology/being-consultant/rcr-referral-guidelines/accessing-guidelines), or the European Society of Radiology iGuide (https://www.myesr.org/esriguide)) can be consulted as high-quality evidence-based advice in this regard. However, such guidelines, although updated regularly, may not include all or even new disease processes, such as COVID-19, so local guidelines or those of professional groups may need to be consulted. The overarching aim should be to only perform imaging (e.g. chest projection imaging CXR) when there is a specific medical indication that imaging can assist in answering. 

With COVID-19 patients, the justification for imaging may include such symptoms as shortness of breath, pneumonia, deterioration of lung function, post-intubation in emergency situations, or correct placement of certain lines. However not all (suspected) COVID-19 patients require imaging and healthcare staff should be mindful of the need to limit staff contact with (potentially) infectious patients.

When considering justification, it can be useful to consider the following questions:

a)      Is this medically indicated? (will it affect the patient’s management).

b)      Is it needed now?

c)      Is this the best investigation? (are there other tests that could answer the clinical question).

d)      Has it been done already? (avoid unnecessarily repeating tests).