Clinical Access Criteria

Midland Region
Community Radiology Access Criteria / 15 July, 2014

MIDLAND Region

Clinical access criteria

for

COMMUNITY referred radiology

FINAL VERSION

Dated 15 July 2014

Contents

Introduction 3

General X-ray

Abdomen 4

Ankle 4

Chest 5

Paediatric Chest 5

Elbow 5

Hand/Wrist 6

Hip 6

Paediatric Hip 7

Knee 7

Shoulder 8

Skull 8

Spine 8

TMJ 8

Ultrasound (US)

Abdomen 9

Carotid Doppler 9

Paediatric Hips 9

Paediatric Renal 9

Renal 10-11

Pelvic 12

Scrotal 13

Neonatal Spine 13

Thyroid 13

Vascular 14

Computed Tomography (CT)

CT Head 15

CT Chest 16

CT Abdomen 16

CT KUB 17

CT Colonography 17

CT Sinus 17

Mammography and Breast Ultrasound

Mammography 18

Ultrasound Breast 19

Prioritisation Methodology 20

Appendix 3 – Midland Regional Advisory Group Members 21

Introduction

The following regional access criteria for primary referred radiology referrals have been developed from a number of sources, including the draft National Community Radiology Access Criteria (Nov 2013).

These criteria have been developed to improve equity of access across the Midland Region. They are a minimum that should be provided and should be read in conjunction with the Prioritisation Methodology detailed in Appendix 2 (when we have redefined this in line with National guidelines).

DHB’s will advise local GP’s where copies of these access criteria are available.

We are unable to accept any patient referral for investigation without the required actions being completed and the results supplied with the referral.

If your patient does not meet the criteria but you think that an investigation is warranted, please phone a DHB Radiologist for advice. If they advise an investigation please document their name as well as all clinical information on the referral form.

Primary Care Nurse Practitioner Referrals

The RANZCR considers that appropriately qualified Nurse Practitioners should be able to refer for diagnostic imaging testing within their particular clinical context as approved by the local radiation licensee.

NPs are expected to apply the practice expectations for public protection set out in the Nurse Practitioner practice standard “Competencies for the nurse practitioner scope of practice 2008”.

GENERAL X-RAY

Abdomen

Standard indications for x-ray referral

·  Diagnosis of constipation where patient history is unobtainable e.g. autism, special needs

·  Follow up of diagnosed renal stones with a KUB x-ray

·  Suspected renal tract stone use local pathway

Referral for x-ray not typically indicated

·  Acute abdomen: Discuss with acute surgical services or emergency services access points

·  Vague central abdominal pain

·  Suspected colorectal neoplasm (refer to colorectal cancer guidelines)

·  Suspected constipation (other than in specific patient groups as above).

·  Suspected abdominal masses refer to ultrasound

Ankle

Standard indications for x-ray referral

Two of the below needed to qualify.

·  The pain has been present for >4 weeks.

·  The pain was sudden in onset and is severe and <4 weeks duration.

·  There is swelling near the joint.

·  There is a palpable mass or deformity.

·  There is limited ROM (range of movement).

·  There is evidence of inflammatory arthritis.

Referral for x-ray not typically indicated

·  Suspected septic arthritis: refer for acute review

·  Acute gout.

Ankle – Trauma

Use Ottawa Ankle Rules

Chest

Standard indications for x-ray referral

The x-ray result will influence patient management.

Referral for x-ray not typically indicated

·  Pneumonia doesn’t require routine CXR follow up unless there are risk factors or red flags including age>50 years or age >40 years if smoker, suspicious radiologic findings on initial CXR or incomplete clinical resolution at 6 weeks (this is a guideline only and there may be local pathways which apply)

·  Routine assessment of hypertension

·  Routine monitoring of known pulmonary sarcoidosis

·  Routine x-ray for asbestos exposure surveillance

·  Follow-up of nodules detected on chest x-ray or CT other than where recommended by reporting or reviewing specialist (consider referral for respiratory specialist review)

·  Initial investigation of heart murmur, unless signs of complications such as heart failure

·  Routine follow-up of asymptomatic patients on amiodarone.

Paediatric Chest

Standard indications for x-ray referral

·  Acute chest infection/sepsis consider acute referral to specialist as per local pathway

·  Recurrent productive cough – if resistant to treatment or additional clinical features i.e. pyrexia

·  Wheeze with additional features such as fevers and localised crackles, chronic heart or respiratory disease and immunocompromised patients

·  Suspected/inhalation foreign body.

Referral for x-ray not typically indicated

·  Incidental finding of a murmur

·  Uncomplicated (afebrile) presentation of asthma/bronchiolitis.

Elbow

Standard indications for x-ray referral

·  Pain has been present for >4 weeks and no response to treatment and/or not reproduced on examination.

·  Unrelenting severe pain <4 weeks.

·  Significant restriction in ROM (range of movement) after 4 weeks.

·  Unexplained deformity/palpable enlarging mass or swelling.

·  There is evidence of inflammatory arthritis.

Referral for x-ray not typically indicated

·  Suspected septic joint: refer for acute review

·  Acute gout

Hand/wrist

Standard indications for x-ray referral

·  Swelling confirmed on examination

·  Deformity

·  Strong history of Inflammatory symptoms >12 weeks with increased inflammatory markers +/- swelling +/- deformity

·  Long (>1year) history of Inflammatory symptoms (without increased inflammatory markers or swelling or deformity)

·  Pain with red flags

Red flags include:

Ø  Persistent deep pain unrelated to activity

Ø  Night pain in the absence of obvious cause.

Referral for x-ray not typically indicated

·  Acute gout

·  Suspected inflammatory arthritis <12 weeks with no significant inflammatory markers or swelling or deformity

Guidance
·  Dedicated wrist views do not typically provide additional information to single PA hand view. Where inflammatory arthritis is suspected consider requesting an AP feet x-ray as well.

Hip

Standard indications for imaging referral

·  Undiagnosed hip pain present for more than 4 weeks where the x-ray is expected to change management

·  Hip pain with red flags and / or history of recent injury

·  Known osteoarthritis where symptoms meet local criteria for surgical consideration (not required if previously x-rayed within 6 months)

·  Pain in previous arthroplasty.

Red flags include:

Ø  Persistent deep pain unrelated to activity

Ø  Night pain in the absence of obvious cause.

Referral for x-ray not typically indicated

·  Suspected septic arthritis: refer for acute review at Emergency Department /Orthopaedic Department

·  Mild symptoms and normal examination findings

·  Follow up of known or suspected osteoarthritis unless development of red flags or meets local criteria for surgery

Paediatric Pelvis/hips

Standard indications for x-ray referral

·  Pain

·  Limp

·  Risk factors/ soft signs or suspected development dysplasia of the hip (DDH) after 5-6 months of age.

Guidance
·  Capital femoral epiphyses ossify on average at 5-6 months of age; DDH can usually be reliably excluded from this age onwards on x-ray.
·  Slipped upper femoral epiphysis require urgent orthopaedic referral.
·  < 5-6 months of age if clinical suspicion of DDH ultrasound is the investigation of choice – refer local pathway

Paediatric Lower and Upper limb

Standard indications for x-ray referral

·  Focal bone pain

Referral for x-ray not typically indicated

·  Osgood-Schlatters, Severs and other apophysitides- x-rays not generally required for diagnosis or management

Knee

Standard indications for x-ray referral

·  Undiagnosed knee pain present > 4 weeks where the x-ray is expected to change management

·  Knee pain with red flags

·  Known osteoarthritis with symptoms meeting local criteria for surgical consideration (not required if previously x-rayed within 6 months)

·  Pain in previous arthroplasty

·  Swelling or deformity

Red flags include:

Ø  Persistent deep nagging pain unrelated to activity

Ø  Night pain in the absence of an obvious cause

Referral for x-ray not typically indicated

·  Suspected septic arthritis: refer for acute review

·  Mild symptoms and normal examination finding

·  Follow up of suspected or known osteoarthritis unless red flags develop or clinically now meets criteria for surgical consideration

·  Suspected meniscal and ligament injury

Shoulder

Standard indications for x-ray referral

·  Suspected bone/joint pathology (>4 weeks) with red flags present

Red flags include:

Ø  Any unexplained deformity, mass, or swelling

Ø  Persistent deep nagging pain unrelated to activity

Ø  Night pain in the absence of an obvious cause

Referral for x-ray not typically indicated

·  Recent onset pain in the absence of red flags

·  Frozen shoulder (unless the condition does not follow its expected natural history)

·  Pre-requisite for a trial of steroid injection (when a reasonable clinical diagnosis has been made and red flags are excluded)

·  Suspected septic arthritis: refer for acute review at Emergency Department /Orthopaedic Department.

Skull

Routine x-ray not indicated

Spine

Standard indications for x-ray referral

·  Unrelenting spine pain > 8 weeks

·  Spine pain with red flags

·  Spine pain and osteoporosis or prolonged use of corticosteroids

·  Significant spinal deformity

Red flags include:

Ø  Persistent deep pain unrelated to activity

Ø  Night pain in the absence of obvious cause

Ø  History of cancer

Ø  Immunosuppression

Ø  Signs of infection : refer for acute review

Referral for x-ray not typically indicated

·  Coccyx pain

·  Acute and chronic uncomplicated spine pain without red flags

Guidance
·  For high clinical suspicion of infection or cancer consider referral for acute review

TMJ

Xray is not indicator for TMJ pain

ULTRASOUND

Abdomen

Standard indications for ultrasound referral

·  Asymptomatic with abnormal Liver Function Test (LFTS) -more than 3 times normal range persisting for at least 3 months

·  Suspected biliary tract obstruction or malignancy (infective causes and medications excluded)

·  Abdominal mass or other palpable abdominal abnormality

·  Painless jaundice without obvious cause

·  Clinical biliary colic/gallstones (not already imaged) or use established pathway

·  Suspected asymptomatic aortic aneurysm (AAA) Radiological report indicates the following maximum measurement of aorta:

¨ Normal < 3 cms No further routine radiology FU

¨ AAA 3 – 3.9 cms Repeat scan 2 years

¨ AAA 4 – 4.5 cms 1 year scan

¨ AAA 4.6 – 5.0 cms 6 month scan

¨ AAA 5.1 – Over URGENT vascular referral

¨ If expansion URGENT vascular referral

> 7mm in 6 months

> 1 cms in 12 months

Required Actions
Please supply appropriate biochemistry and dates with abdominal ultrasound referral

Carotid Doppler

Use local pathways

Paediatric Hips

No direct access; refer local pathway

Paediatric Renal

Refer local pathway

Renal

Standard indications for ultrasound referral

·  Loin pain suggesting renal tract obstruction

·  Haematuria

Ø  persistent isolated microscopic haematuria > 25 year old (defined as 2 or more episodes of positive urine dipstick of 1+ or more i.e. not trace) and infection excluded and renal impairment (as defined below)

Ø  macroscopic haematuria with UTI excluded

Ø  persistent isolated microscopic haematuria >25yo (ontwo or more on MSU; not dipstix) and infection excluded and normal renal function

·  Chronic urinary retention with palpable enlarged bladder

·  Renal Impairment

No prior relevant renal imaging and recheck with good hydration.

Ø  Acute kidney injury (increase in serum creatinine of more than 50% from baseline and/or decrease in eGFR of more than 50% from baseline) ANDConsider direct referral to renal service.

Ø  Progressive chronic kidney disease(> 5 ml/min/year eGFR loss or > 10 mls/min over 3 years)

Guidance
·  Proteinuria >1.0g/24hours or protein/creatinine ratio >100 mg/mmol or albuminuria (albumin/creatinine ratio>65 mg/mmol) - consider referral to renal physician
·  If long term stable elevated creatinine/low eGFR then potential for any reversibility low therefore US findings unlikely to change management.
·  In diabetic with known diabetic complications, ultrasound may not be indicated.

·  AdultUTI

Females:

Ø  > 3 documented UTI's in 6 months, or 6 in a year despite adequate courses of culture specific antibiotics. This pattern implies bacterial persistence rather than recurrence.(Ensure that patient has not previously been investigated with imaging)

Ø  Recurrentpyelonephritis with no previous imaging.

Males:

Ø  Recurrent or persistent infections (if not previously investigated with imaging)

·  Paediatric UTI(please see local guidelines)

Required Actions
Please supply appropriate biochemistry and dates with renal ultrasound referral

Pelvic

Standard indications for ultrasound referral

·  Post menopausal bleeding (bleeding after 1 year of amenorrhoea)

·  Pelvic Mass or uterine size >12 weeks

·  Primary amenorrhoea (delay menarche after age of 18years with appropriate endocrine assay)

·  IUCD not visible

·  Polycystic Ovary Syndrome (PCOS) only if appropriate biochemical signs of hyperandrogensism or oligo- or amenorrhoea. If both present US not required.

·  Chronic Pelvic pain/ suspected endometriosis – persisting symptoms over at least 3 month with PID excluded

·  Heavy menstrual bleeding (heavy cyclical menstrual bleeding over several cycles) and Age > 45years or Age >35years with at least one of the following:

Ø  Weight >90kg

Ø  Risk factors for endometrial hyperplasia (nulliparity, infertility, FH endometrial/colon cancer, use of either Tamoxifen or unopposed oestrogens, P.C.O.S)

Ø  First degree relative less than 60 years old with a diagnosis of endometrial or bowel cancer

Required Actions
All referrers should have completed ALL of the following:
Ø  I have removed a copper IUCD and observed for 3 months, or there is no IUCD present
Ø  I have carried out a pelvic examination, visualized the cervix and taken a smear and STI check if appropriate
Ø  Those patients without risk factors have had no improvement with a three month trial of medical management (hormonal/tranexamic acid/mirena)
Appropriate biochemical profiles to be supplied for PCOS Ultrasound referrals
Local pathways should be followed

Scrotal

Standard indications for ultrasound referral

·  Scrotal masses with concerning features i.e. testicular, painless, nontransilluminating, rapidly growing –(urgent urology referral recommended)

·  Scrotal masses where it is unclear if the swelling is testicular or extra-testicular

·  New hydrocele in adults (may be secondary to testicular cancer).