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4.0 Knowledge and Skills

4.1 Governance

Governance in health and social care is more apparent than ever. All healthcare professionals must act in accordance with the standards of conduct, performance and ethics set by their regulatory body. For radiographers this is the Health and Care Professions Council (HCPC).5 There is a professional expectation that radiographers behave in a way that reflects the Society and College of Radiographers’ (SCoR) Code of Professional Conduct.6 They must develop and work within their own personal scope of practice.7

Radiographers are accountable under national legislation including the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000,8  Ionising Radiation (Medical Exposure) Regulations (Northern Ireland) 20009 and subsequent amendments, 200610 and 201111, the Ionising Radiations Regulations 1999 (IRR’99)12  and Health and Safety at Work Act 197413 as well as local policies and procedures.

4.2 Training and continuing professional development (CPD)

The National Occupational Standards for CT scanning14 represent the basic skills for all radiographers working in CT whether on a rotational basis or as a permanent CT team member. In both cases, the radiographer must have expertise that builds upon pre and post registration education and training to work safely and effectively. In addition to this, radiographers undertake further training and education to Master (MSc) and Doctorate (PhD) level in order to extend their scope of practice to advanced and consultant practitioner standards. The College of Radiographers (CoR) offers an accreditation scheme for advanced15 and consultant16 level practice.

Evidenced CPD is an explicit requirement for registration and is not to be underestimated. The Committee on Medical Aspects of Radiation in the Environment (COMARE) 16th report17 refers to NHS statistics that show an increase of five times in the number of CT scans performed during 2012/2013 when compared to 1996/97. The report highlights the increased average radiation dose to the population. In response to this, the Department of Health (DoH)18 recommends: “the inclusion of the potential risks associated with CT scans should also be part of continuing professional development (CPD), which is essential for accreditation/reregistration for healthcare professionals.” It further advises, in response to recommendation 7 of COMARE 16,17 the development of Imaging Optimisation Teams or radiation protection champions, consisting of a radiologist, a radiographer and a medical physicist to ensure a consistent approach to good practice in CT services. It recognises the need for senior NHS leadership in order to achieve this.

The radiographer has a duty to understand medical terminology and abbreviations in order to produce high quality CT images safely. They will apply their anatomical, physiological and radiographic knowledge to ensure the scan is appropriate, justified and meets the needs of the patient. They must also ensure that the patient is safe and comfortable and treated with respect, compassion and dignity at all times.

Radiographers employ knowledge of, and adhere to, national and local policies on manual handling, basic and immediate life support, infection control, patient identification and record management.

Radiographers require additional training to operate peripheral devices such as Electrocardiogram (ECG) machines and contrast agent delivery systems safely. This may be undertaken by a combination of in-house training and courses accessed via the SCoR website: https://www.sor.org/learning/post-registration-courses/certificate-of-iv-administration

Computer systems enable faster and more effective communication between patient care teams. Electronic requesting of CT examinations means that radiographers must be trained and competent in the use of these systems. Information is stored and managed to facilitate staff training, audit and research and to help improve safety, consistency and reproducibility of techniques.

4.3 Duties of the CT radiographer under IR(ME)R

CT is a high radiation dose technique by comparison to conventional x-ray.19  In order to safeguard the patient and others throughout this diagnostic pathway the CT radiographer must have a thorough understanding of radiation protection and their duties under IR(ME)R8,9,10,11  and IRR’99.12

The radiographer in CT may act as an IR(ME)R operator and/or IR(ME)R practitioner. In both cases they must prove adequate training and be entitled to do so by their employer. They must comply with employer’s procedures.

The Society and College of Radiographers (SCoR), The Royal College of Radiologists (RCR) and the British Institute of Radiology (BIR) have jointly produced a guidance document, with support from Public Health England (PHE) and the Institute of Physics and Engineering in Medicine (IPEM), aimed at employers and staff who provide clinical imaging and interventional radiology services using ionising radiations.20

As the IR(ME)R operator, the radiographer in CT, when entitled, is responsible for any practical aspect of the medical exposure and this may include the authorisation of exposures under agreed and relevant authorisation guidelines.

As the IR(ME)R practitioner in CT, the radiographer, when entitled, is responsible for the justification of the medical exposure.

The radiographer in CT must also ensure compliance with IRR’99 abiding by the Local Rules to ensure occupational exposures are kept as low as practicable.

They must be aware of the national and local diagnostic reference levels (DRLs) and dose constraints established for the examinations they undertake, particularly in relation to children and young adults.21They must work closely with paediatric specialists and take particular care when scanning this age group who are particularly sensitive and vulnerable to cumulative lifetime risks of cell damage caused by radiation. 21,22,23

A fundamental understanding of the physics of CT is a prerequisite. The optimisation of scanning protocols is vital to the safe delivery of radiation and is a responsibility of the radiographer under IR(ME)R. Within this environment, the CT radiographer must ensure they maintain the skills required for appropriate utilisation and management of available techniques. An aptitude to pre-empt and avoid non-intended outcomes is key to safe scanning.

It is crucial to be able to maintain high levels of concentration in sometimes physically and emotionally challenging conditions. The radiographer should ensure the working environment is as free from distraction as possible. Recognition and identification of abnormality are skills that improve with experience. While these abilities are developing, the CT radiographer is encouraged to seek appropriate advice regarding the need for additional information.

Regulations and further guidance is available on the SCoR website: https://www.sor.org/practice/radiation-protection

4.4 Patient-centred care

As previously described, the CT radiographer may be involved in each step of the patient pathway including receiving the referral and justifying or authorising the examination, carrying out the exposure, issuing the results and recommending further investigations or follow up care. At this level of practice, they are likely to be more influential in streamlining patient care.

Patients attend for a CT scan by appointment from home or another healthcare environment, or as an in-patient. As well as the condition under investigation, patients may have other specific needs such as mobility or learning difficulties. They may have visual or hearing impairment, language problems, brain injury, dementia, or social or psychological problems. Patients will have variable understanding and expectations of the procedure and can come from diverse cultural backgrounds. The radiographer must have the ability to work flexibly and provide individually personalised and compassionate care.

Patients may be unware of their potential diagnosis. Radiographers must be mindful of different emotions and behaviours expressed due to uncertainty, fear and anxiety relating to the scan and the results. A CT scan takes longer to perform than an x-ray. A successful, skilled CT radiographer will earn the confidence of the patient in order to establish their consent and compliance.

Very sick and critically ill patients benefit from CT scans. They are required to travel from a relatively safe environment to the scanner. Emergency department physicians, nurses, surgeons and anaesthetists may accompany these patients. The radiographer needs effective communication skills in this multidisciplinary environment. Patients often have to travel while attached to multiple intravenous infusions, they may be immobilised due to injury or have their breathing supported by mechanical ventilation. The CT radiographer must prioritise the timely production of optimum quality images while supporting the team concerned with the intensive care needs of the patient.

4.5 Leadership and teamwork

The jointly published “Team working in Clinical Imaging” document24 details the shared views of the SCoR and the Royal College of Radiologists (RCR).

Radiographers work in CT either as a dedicated member of a specialist team or on a rotational basis. In both cases, it is recommended that there is a core of permanent, experienced senior staff to safeguard standards of training and promote excellence. Effective CT leadership will align technological advancements with staff development to enable the delivery of value-based care through innovation, collaboration and succession planning. 

CT radiographers must embrace teamwork and recognise diversity within the team. They should be experts in efficiency but be able to distinguish this from speed in order to work safely. They should embrace inter-professional working, founded on common respect and reflecting an overarching organisational culture of care and compassion for all staff.

An effective CT team has a common ethos and shared objectives. Radiographers should be instrumental in leading change, be able to adapt to evolving needs in the healthcare environment and be proactive in identifying issues and raising concerns when necessary. The CT radiographer must ensure each examination is performed for the right patient, in the right place and at the right time. In doing so, they become integral to the outcome of the patient experience and to the effective service delivery for the wider community.

The CT radiographer must possess the confidence to challenge decisions they do not consider are in the best interest of the patient. Regular reviews of practice and processes are fundamental to safe service delivery and good governance. Equipment should be fit for purpose. The radiographer is duty bound to raise concern if an individual, process or product is perceived to be failing.

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