RADIOLOGY QUALITY MANUAL
Document No:
S-RAD-RADDOC-QUALITY.032
This is a controlled document. The electronic version of this document is the most up to date and in the case of conflict the
electronic version prevails over any printed version. This document is for internal use only and may not be accessed or relied
upon by 3rd parties for any purpose whatsoever.
TITLE:
RADIOLOGY DEPARTMENT GENERAL INFORMATION
Radiologists
Clinical Support Services Manager
Radiology Manager
Grade MRTs
CT
Fluoroscopy
General
Ultrasound
MRI
Taupo
Radiology Nurse Co-ordinator
Administration RIS/PACS Co ordinator
Appointment Clerks
_____________________________________________________________
Normal Working Hours 0800 - 1630 Monday - Friday
After Hours 1630 - 2230 one MRT on duty for emergency or urgent work only.
2230 - 0800 one MRT on call for emergencies only.
EMERGENCY CALL AND SHIFT SERVICE
The evening, weekend shifts and the on-call services are staffed by 1 MRT only, with
additional staff being called in if it is necessary. These duties are in place to handle
urgent /
emergency examinations only, and cannot be utilised for routine examinations.
Please make direct contact with the on-call or shift MRT.
Pager 6107 between 1630 – 2230 hours daily.
Via Switchboard 2230 – 0800 hours daily.
Lakes District Health Board
Key Word: General Information
File: S-RAD-RADDOC-QUALITY.032
Name of Service Radiology
Authorised by:
Issue Date:
Latest Version Date:
Version: 13
Page 1 of 4
HOD
October 2011
September 2021
:
RADIOLOGY QUALITY MANUAL
Note: Raising an electronic request does NOT negate the requirement to contact the on
call MRT by locator or phone. The MRT on call may NOT be on site.
Staff are paid penal rates for this work and as this reflects on our limited budget, this work needs
to be restricted. We therefore appreciate referrers’ assistance by ensuring that al out of hours
requests are clinically urgent.
Please take note of shift start times and avoid calling the on call MRT if a rostered shift is about
to begin unless in emergency situations.
Out of hours’ Special x-rays, ultrasounds and CT examinations must be requested
only after
consultation with a Consultant. The request must be made directly to the Radiologist on-call
who will arrange appropriate radiographic staff. The Radiologist is available after hours for
acute emergencies only i.e. where patient management will be altered by the outcome of
the test, prior to the department’s next working session.
Any emergency call to a
Radiologist or on call CT MRT or Sonographer must be made by the ED Consultant or
the Specialty Registrar following discussion with the On Call Specialty Consultant.
After hours Radiology reporting may be covered by a remote reporting provider (Everlight
Radiology). When Everlight are rostered on call, referrals are made directly to the CT MRT
by the appropriate Consultant or Registrar following discussion with the on call specialty
Consultant.
The on call Ultrasound Service is available
Monday - Friday
5pm – 10pm
Sat / Sun & Public Holidays
8am – 5pm
There is no after hours MRI service.
REQUESTING AN X-RAY
As request forms, electronic or paper, are a consultative letter from the Clinician to the
Radiologist, they need to be completed fully. Appropriate clinical details must be included.
The preferred method of request is electronically as this ensures patient demographics and
referrer details are accurate enabling the appropriate destination for all printed reports.
Please note: for all urgent, theatre, portable and after hour’s examinations direct contact must
be made with the MRT on duty. Electronic requesting does NOT replace this requirement for
direct contact.
Please ensure you select the correct consultant from the drop down menu as this selection
determines the electronic report destination and acknowledgement.
Requests should be generated as early in the day as possible, to ensure their being
acted upon without delay.
Routine inpatient modality requests will be prioritised and booked in the next available slot.
All urgent requests MUST be discussed with the Liaison Radiologist.
A Liaison Radiologist is available during normal working hours and be contacted on Extension
8912 or is located in the Reporting Office next to CT.
All requests for interventional examinations eg. Biopsies must be discussed with an
Interventional Radiologist – Extension 8913.
Vascular Access Service
All requests for Portacatheter Insertions, PICC Lines. Midlines and US guided cannulations
require discussion. The Vascular Access team can be contacted by Pager 6340 during normal
working hours. This service is not available after hours.
The following examinations require an appointment time to be generated and in most instances
preparation prior to the examination:
Fluoroscopic procedures
Lakes District Health Board
Key Word: General Information
File: S-RAD-RADDOC-QUALITY.032
Name of Service Radiology
Authorised by:
Issue Date:
Latest Version Date:
Version: 13
Page 2 of 4
HOD
October 2011
September 2021
:
RADIOLOGY QUALITY MANUAL
Ultrasound examinations
Special or interventional procedures e.g. drainages, biopsies
CT examinations
MRI
The Dept will arrange the appointments and the preparation of these patients.
For information regarding patient preparation for the above examinations see the
Radiology
Pre & Post Care Manual located in ED and on each ward.
REFERRALS FOR EXAMINATIONS PERFORMED OUTSIDE OF ROTORUA HOSPITAL
These examinations include:
DEXA scans (bone densitometry)
Some Doppler ultrasound studies
Nuclear medicine bone scans
Mammography including hookwire mammography examinations
All these requests
must be paper based and signed by the referring Consultant.
INTRA-OPERATIVE RADIOGRAPHS During normal working hours 0800 – 1630 hours Pager 6105
When an operation is being scheduled, which will require radiographic assistance, the
radiographic staff must be given reasonable warning (30 minutes) so that the necessary staff
and equipment can be available.
It is important to note that there is only one MRT and one Image Intensifier available for Theatre
so care in scheduling examinations is required.
Outside normal working hours1630 – 0800 hours a 30-minute warning is necessary. The MRT
may not be on site or may need to call in back up staff.
PATIENT PREPARATION
A Patient Preparation book (Radiology Pre & Post Care Manual) is available in all the wards in
hardcopy and on EDMS which outlines the preparation for all the procedures done in the
department.
It is important you familiarise yourself with the necessary requirements regarding consent forms
etc. for the various special examinations. All queries regarding patient preparation should be
directed to the Radiology Booking Clerk or Radiology nursing staff during normal working hours.
After hours, all queries regarding patient preparation for urgent CT scans or interventional
procedures should be directed to the on call CT MRT contacted via the Hospital operator.
CT
Patient creatinine and eGFR levels are ESSENTIAL. Depending on the result the patient may
require hydration.
Oral contrast for CT scans is water only – 600mls one hour prior.
In the event positive oral contrast is required the ward will be contacted and the oral contrast
must be charted as per any medications administered. (OMNIPAQUE 300 20mls in 600mls of
water)
Good venous access is required for all CT examinations requiring IV contrast. Please make
contact with the Vascular Access Service, Pager 6340 for patients with difficult IV access
(DIVA).
If the patient preparations are not followed the patient will be returned to the ward and the
examination rebooked for the next available appointment.
Lakes District Health Board
Key Word: General Information
File: S-RAD-RADDOC-QUALITY.032
Name of Service Radiology
Authorised by:
Issue Date:
Latest Version Date:
Version: 13
Page 3 of 4
HOD
October 2011
September 2021
:
RADIOLOGY QUALITY MANUAL
MRI An MRI Safety questionnaire is completed for EVERY patient. This should be filled in ahead of
the scan to expedite the MR safety process, especially regarding patients with ANY type of
implant. This allows the Radiology staff, time to research the safety of the implant prior to the
scan being done. It is ESSENTIAL for the checklist to be filled in with next of kin, power of
attorney should the patient, for any reason, not be able to answer the safety questions. The
Radiology Clinical assistant will support this process prior to the MRI examination being
scheduled for all non urgent examinations.
NOTE: Cardiac Pacemakers are contra-indicated for MRI at Lakes DHB and all patients
with a pacemaker require discussion prior to any referral being made.
Discussion with a radiologist is required should a patient with renal impairment require MR
contrast.
Scheduled Radiologist Meetings with Referrers
Weekly Schedule
Paediatric
1200
Monday
Respiratory
1400
Monday
Medical
0830
Thursday
Orthopaedic
0730
Thursday
Surgical
0815
Friday
Colo-rectal MDM
0800
Wednesday
Medical Interventional
1230
Tuesday
Monthly Schedule
ED
1200
Second Tuesday of the month
ENT
1200
Bi Monthly 2nd Thursday of the month
Gynae
1200
Second Thursday of the month
Authorised by:
Radiology Head of Department
Lakes District Health Board
Key Word: General Information
File: S-RAD-RADDOC-QUALITY.032
Name of Service Radiology
Authorised by:
Issue Date:
Latest Version Date:
Version: 13
Page 4 of 4
HOD
October 2011
September 2021
:
