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Maximizing the benefit–minimizing the risk: the developing role of radiographers in performing intravenous injections

¹Radiology Department, Vale of Leven District General Hospital, Alexandria, Dunbartonshire G83 0UA and ²Health Faculty, City Campus, Glasgow Caledonian University, Glasgow G4 0BA, UK

	Abstract

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
Performance of intravenous (iv) injections as part of radiographer role development has become fundamental to the operational management of diagnostic imaging departments in the UK. Through discussion of appropriate areas, this review aims to highlight current issues pertaining to iv injection. More importantly, the framework described could be transposed to other existing or future areas of role development. Within a validated system of delegation, utilization of radiographers' skills in an expanded role improves allocation of resources and may increase radiographer motivation and provide career enhancement. Professional body accreditation as well as civil and employment law provide clear guidelines on medicolegal implications, valid consent and accountability. Implementation of an iv administration policy, based on Royal College of Radiologists guidelines, includes proper delegation of duties and safe administration of substances. This should help ensure acceptance of vicarious liability by an employer. Failure to adhere to these established guidelines could leave employers and radiographers vulnerable to medicolegal action. Furthermore, evaluation of radiographer performance, facilitated by clinical governance and departmental audits, should ensure effective and safe practice whilst minimizing associated risks. Evidence-based radiography will provide the necessary drive for future changes in practice as well as further expansion of the radiographer's role.

	Introduction

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
It is now accepted that radiography as a profession is developing and changing radically. Many departments have reported a 5% annual increase in their activity [1] and, given the national shortage of radiologists [2], the role of the radiographer has extended in recent years. Increasingly, radiographers are taking on greater responsibilities, previously the domain of radiologists. In particular, there has been a demand forradiographers to perform intravenous (iv) injections [3].

There are innumerable benefits to radiographers keen to advance professionally. Role developments such as iv injecting will greatly enhance personal fulfilment, job satisfaction and prestige [4], which can in turn lead to increased motivation and career enhancement [5].

However, with greater contribution to healthcare provision as well as increased knowledge and personal development there comes an increased professional responsibility and legal liability to achieve and maintain acceptable standards of clinical care. Issues that must be addressed in relation to radiographer-performed iv injections include: appropriate training and assessment of competence; departmental protocols; allocation of responsibility; cost effectiveness; and performance monitoring. All are developed within a framework of audit and research.

	Professional development

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
Role development is a term that has come to the fore in radiography in recent years. Radiographer-performed iv injection is entirely within the development framework outlined by the College of Radiographers (CoR) in the Code of Professional Conduct [6], in which radiographers are encouraged to develop their professional roles. Developing practice means that existing roles must be re-evaluated and present skills fully utilized and further developed. The CoR and the Royal College of Radiologists (RCR) are actively collaborating on aspects of radiographer role extension and have issued a joint document detailing interprofessional roles, individual responsibilities and highlighting the importance of delegation [7].

This change demands high levels of training, expertise and experience, all of which may provide enhanced job satisfaction and increased motivation. Furthermore, skill mix encourages more of a "team approach" within healthcare practice, affording the radiography profession greater respect from medical colleagues.

	Medicolegal aspects

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
Development of the radiographer role prompts consideration of associated medicolegal implications and, more specifically, allocation of radiographer accountability.

Accreditation
Postgraduate radiography courses are now concerned with advanced practice and, subsequently, the conferral of clinical competence upon successful students. The CoR issues a Certificate of Competence in Administering Intravenous Injections [8]. The importance of accreditation by the professional body must be stressed. By ensuring qualified radiographers satisfy the highest professional standard with associated levels of competence, reassurance is provided to radiographers, employers and, most importantly, patients [9]. Furthermore, if the radiographer is accredited by a centralized body in the performance of iv injections, fears of litigation are allayed and the requirement for site-specific training will be obviated [9].

Legal guidelines
The RCR has set guidelines that relate to the proper delegation of responsibility of duties normally outwith the scope of radiographic training and education. It is vital that radiographers involved in iv injecting have thoroughly read, understood and comply with these guidelines [10].

With reference to these guidelines, "if the radiographer acknowledges insufficient skill, capacity or confidence in undertaking an intravenous procedure, it should not be undertaken." Subsequently, the radiographer should demonstrate the professionalism to refer back to the delegating radiologist. Failure to comply could give rise to negligence action and, if death results, ultimately a charge of manslaughter.

There have been two precedent-setting cases in England and Scotland that currently define the standard on clinical negligence action in the UK. Essentially the same, these comprise Bolam v Friern Hospital Management Committee (1957) [11] and Hunter v Hanley (1955) [12], respectively. McNair explained in Bolam, "A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art ... It is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art." Lord President Clyde explained in Hunter, "The true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such a failure as no doctor of ordinary skill would be guilty of if acting with ordinary care."

Although originally applied to doctors, this standard would equally apply to paramedical staff such as radiographers.

The Bolam (and Hunter) principle dictates that a professional or practitioner such as a radiographer has a duty of care and would be liable for any injury sustained to a patient as a result of negligence—defined in law as an act that falls short of a standard expected by "the reasonable man". To apply legal causation to the issue of medical negligence, one must question whether there was a breach of duty of care and if, on the balance of probabilities, that breach caused injury to the patient.

A radiographer would not be held negligent if he acted in accordance with accepted peer practice. This involves following agreed iv injection policies, obtaining valid consent, achieving and maintaining a certified level of competence, and adhering to accepted health and safety protocols.

Policies
It is the responsibility of the radiographer performing iv procedures to ensure the presence of an iv administration policy document—consensus being established between the radiographer and the department manager. The aim of this policy is to ensure proper delegation and the safe administration of substances whilst minimizing the risk to both the patient and the staff. From a medicolegal perspective, it ensures that the employing authority sanctioning the policy acknowledges named individuals undertaking such procedures and accepts vicarious liability. Additional responsibilities in role extension of this kind should be reflected in the individual's job description.

The policy should also detail guidelines outlining safe practice for the radiographer, the patient and the delegating person (i.e. the radiologist). This will avoid uncertainty as to the radiographer's specific responsibilities during a procedure. A copy of this policy must be kept in the departmental "policy and procedures" manual, an example of which is shown in Table 1. Establishment of an iv administration policy should be synonymous with the existence of guidelines that promote its regular review and facilitate future amendments as a result of evidence-based practice.

Every mentally competent adult is entitled to give or withhold consent to treatment [14] and therefore has the legal right to allege negligence or battery if treatment is given in the absence of consent. Consent may be verbal or implied non-verbally, however consent is only valid where a patient's acceptance of the procedure is based on the provision of appropriate information. It is therefore "good practice" to highlight the salient points of the procedure and any concurrent significant risks. Valid consent is most effective when provided in written form, for the future protection of both the radiographer and the patient [15].

If an adult lacks the competence to give valid consent to a diagnostic procedure, it may still be carried out if the radiologist decides that the procedure is in the best interests of the patient [14]. The delegating radiologist should sign a consent form to this effect and may then proceed with the examination.

Radiographers may be required to cannulate a child as part of an iv procedure, prompting further consideration of consent-related issues. In England and Wales, parents of children under 16 years have the right to give or withhold consent providing it is in the best interests of the child. However, the case of Gillick v West Norfolk and Wisbech Area Health Authority (1986) [16] established a precedent for children's autonomy in healthcare. It promoted a "capacity approach" whereby "A child who, in the opinion of a qualified medical practitioner, is deemed to have the appropriate maturity and understanding of the risks involved is recognised in law as being able to give consent." Until the child achieves the capacity to consent, the parental right to make the decision continues except in extenuating circumstances [17]. Where a competent child refuses treatment, a person with parental responsibility or the court may authorize a procedure that is in the child's best interest [18].

The Age of Legal Capacity (Scotland) Act 1991 [19] also recognizes the legal capacity of children under 16 years to consent to medical procedures where, in the opinion of the medical practitioner, the child is able to understand the procedure and the possible consequences. The difference in Scottish law is that parental responsibility cannot authorize procedures that a competent child has refused. Legal advice to assess a child's capacity to understand the procedure may be required [18]. Furthermore, The Children Scotland Act 1995 [20] acknowledges that a child of 12 years or more may display sufficient age and maturity to instruct a solicitor in conjunction with civil matters.

In an emergency situation where consent cannot be obtained, a qualified medical practitioner, i.e. the delegating radiologist, may decide whether to proceed with the examination, provided it is limited to what is immediately necessary in the best interests of the patient [18].

Ultimately, if the radiographer is unhappy about administering an iv injection, there should be referral back to the delegating radiologist—an option that should be reflected in the departmental policy.

	Research and evaluation of radiographer performance

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
With radiographer-performed contrast medium injections becoming increasingly commonplace, it is accepted that the efficiency of radiographer performance should be monitored. As in all areas of healthcare, standards must be applied consistently. This is achievable through the recently implemented system of clinical governance. Clinical governance is a framework for improving and accounting for quality of care in the National Health Service (NHS) [21]. Its essential elements involve: risk management, audit, clinical effectiveness, adherence to policies and the completion of approved training schemes. Although none of these elements are in themselves new, they are now being regarded as central to the core function of health services instead of being considered a peripheral aspect to healthcare.

Departmental audits assessing contrast media reactions and accuracy in cannulation are required to provide evidence of competency and to allow comparison with an identified standard. Venous access should be achieved in at least 90% of patients [22]. Failure to achieve this standard would afford the opportunity for further training to maintain consistently high standards of care.

Patients whose examination involves iv injection may, in extreme circumstances, require resuscitation following a procedure-related complication. It is therefore the responsibility of the injecting radiographer to ensure that the department is equipped with the appropriate functional emergency equipment and that they are familiar with emergency procedures. Regular audit of resuscitation equipment, resuscitation skills and radiographer response to major contrast medium reactions represents sensible risk management [23].

Accredited professional training aids self-evaluation by giving the radiographer confidence to assess the level of knowledge and skill base required to maintain a good clinical standard. This should subsequently allow personal recognition of limitations and prompt the need for further medical assistance or training.

	Resource efficiency

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
Staffing is the most expensive resource in the NHS [24]. Managers are now expected to ensure that services are of a high quality and that deployment of resources is cost effective.

The RCR report in l993 [2] stated that there needed to be a 60% increase in radiologist numbers to cope with the workload that existed in l989. Importantly, it has been acknowledged that radiographers' skills have not been used to their full potential [25]. Given the shortage of radiologists and the utilization of radiographers inan expanded role, improved allocation of resources may be attainable.

Research has identified that finding radiologists to inject promptly is "time consuming and a source of considerable radiographer frustration" [26]. A study of contrast medium injections involving radiographers in CT showed that 10 h of radiology time per week could be saved, increasing patient throughput and reducing waiting times [27]. Furthermore, these benefits are notexclusive to CT departments. MRI, nuclear medicine and iv urography examinations have already gained from having radiographers trained in venepuncture technique. Undoubtedly, radiology departments will ultimately be run more costeffectively as the scope of radiographer practice increases within a proper framework of delegation.

	Health and safety

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 
The health and safety of the patient and the injecting radiographer are of paramount importance. Measures should be implemented to ensure this safety:

• A departmentally agreed safety checklist should be sanctioned. This should provide written documentation demonstrating that patient details and emergency equipment have been thoroughly checked, and that written consent has been obtained following a full explanation of the procedure. It should also highlight patients at an increased risk of sustaining a reaction, and document the strength, volume, type and batch number of the contrast agent used.
  
• The signature of the delegating radiologist must be recorded. This is evidence of procedure approval and availability of the delegating radiologist during cannulation and the ensuing examination.
  
• Injecting radiographers should be aware of the stages of anaphylactoid reactions and be alert to the clinical signs and symptoms of reactions [28] (Table 2).
  
• The delegating radiologist should be summoned immediately an adverse reaction is suspected and, if considered sufficiently severe, the cardiac arrest team should be alerted.
  
• Resuscitation skills rapidly disappear and need to be relearned [23]; injecting radiographers should attend cardiopulmonary resuscitation courses annually.
  
• To minimize patient discomfort, venepuncture should only be attempted twice by the radiographer, after which the assistance of the delegating radiologist should be sought.
  
• Intravenous access should be maintained for at least 15 min post injection to provide instant venous access in the event of a severe contrast medium reaction.
  
• Good aseptic practice should always be employed [29]. This includes handwashing, the wearing of gloves and aprons, and exercising the safe disposal of sharps. Knowledge of the correct procedure to follow in the event of a needlestick injury or spillage is vital, as is knowledge of the procedure for disposal of contaminated waste.
  
• Where possible, the radiographer should be immunized against hepatitis B. In the rare instances that an individual fails to respond to immunization, they may still perform iv injections on the premise that a zero risk policy is always applied.
  
• Use of automated iv pumps requires the formulation of guidelines in relation to safe, effective practice and management of pump-related complications (for example pressure pump extravasation).
  
• Radiographers should be aware of and adhere to RCR recommendations regarding X-ray contrast media as well as diabetic patients receiving metformin (glucophage) [30].
  

	Conclusion

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

CoR accreditation as well as civil and employment law provide clear guidelines on medicolegal implications, valid consent and accountability. Implementation of an iv administration policy based on RCR guidelines, which describe proper delegation of duties and safe administration of substances, should ensure acceptance of vicarious liability by an employer. Failure to comply with established guidelines would leave both employers and radiographers vulnerable to medicolegal action.

Radiographer performance evaluation, facilitated by clinical governance and regular departmental audit, should ensure safe and effective practice. Through optimization of radiographer performance and by undertaking adequate procedure-related risk assessment, the health and safety of patients and staff are minimally compromised.

Radiographer-performed iv injections allow more effective and efficient use of existing resources, providing radiologists with more time for additional procedures, particularly beneficial given the national shortage of radiologists [2]. Furthermore, the framework described could be transposed to existing and future areas of role development, minimizing the risks and maximizing the benefits to staff, patients and radiology departments.

Received for publication January 19, 2001. Revision received April 20, 2001. Accepted for publication April 30, 2001.

	References

Top Abstract Introduction Professional development Medicolegal aspects Research and evaluation of... Resource efficiency Health and safety Conclusion References

 

1. Audit Commission. Improving your image—how tomanage radiology services more effectively. London: HMSO, 1995.
2. Royal College of Radiologists. Medical staffing and workload in clinical radiology in the United Kingdom National Health Service. London: Royal College of Radiologists, 1993.
3. Paterson A. Role development—towards 2000. London: The College of Radiographers, 1995.
4. Fisher F, Pankowski ML. Mandatory continuing education of clinical laboratory personnel. J Con Edu Health Prof 1992;12:225–34.
5. Palmer A. Continuing professional education: individual responsibility, collective consciousness. J Con Edu Nurs 1994;25(2):59–64.
6. The College of Radiographers. Policy for radiographers administering intravenous injections. London: The College of Radiographers, 1996.
7. Board of Faculty of Clinical Radiology, The Royal College of Radiologists and The College of Radiographers. Inter-professional roles and responsibilitiesin a radiology service. London: The College of Radiologists, The College of Radiographers, 1998.
8. Smith P. Continuing professional development—the college role. Synergy 1997;May:51–2.
9. Smith P. The importance of accreditation. Synergy 1998;Nov:4–5.
10. Royal College of Radiologists. Medico-legal aspects of delegation (FCR/2/93). London: Royal College of Radiologists, 1993.
11. Bolam v Friern Hospital Management Committee (1957) 2 All E.R. 118, (1957) 1 W.L.R 582.
12. Hunter v Hanley (1955) SLT 213 at 217.
13. Guidance on consent by patients to examination or treatment in departments of clinical radiology. London: Royal College of Radiologists, 1999.
14. Re T. Consent to medical treatment (adult patient). All England Law Reports 1992;4:649.
15. Diamond B. Principles of consent—issues for the radiological nurse. Nursing Standard 1997;11(40):40–2.
16. Gillick v West Norfolk and Wisbech Area Health Authority and the DHSS. 1986. AC. 112, HL.
17. Davies M. Textbook on medical law (2nd edn). London: Blackstone Press Ltd, 1998:144.
18. Seeking patients' consent: the ethical considerations. London: General Medical Council, 1999.
19. The Age of Legal Capacity (Scotland) Act 1991 section 2(4).
20. Children Scotland Act 1995, Amendment to Section 4(2).
21. Galbraith S. A first class service. London: Department of Health, 1998.
22. de Lacey G, Godwin R, Manhire A. Clinical governance and revalidation. A practical guide for radiologists. London: Royal College of Radiologists, 2000:50–1.
23. Godwin R, de Lacey G, Manhire A. Clinical audit in radiology. 100+ recipes. London: Royal College of Radiologists, 1996:182–5, 280.
24. Nelson MJ. Managing health professionals. London: Chapman and Hall, 1989.
25. Swinbourne K. Pattern recognition for radiographers. Lancet 1971;1:589–90.[Medline]
26. Loughram CF. Intravenous urography: injection of contrast agents by radiographers. Clin Radiol 1993;47:368.[Medline]
27. Gosling C. Intravenous contrast injections by radiographers for computed tomography. Clin Radiol 1993;46:358.
28. Sidhu PS, Dawson P. Resuscitation of patients in an imaging department. Imaging 1997;9:23–31.
29. Guidance for clinical healthcare workers, protection against infection with HIV and hepatitis viruses: recommendations of the Expect Advisory Group on AIDS. London: The Royal College of Nursing, 1995.
30. Royal College of Radiologists' guidelines with regard to metformin-induced lactic acidosis and X-ray contrast medium agents. London: Royal College of Radiologists, 1999.

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