Ionising radiation and the use of X rays

On 1st January 2018, Ionising Radiation Regulations 2017 (IRR17) came into force and replaced Regulations IRR99.  This set of regulations is targeted at ensuring the safety of staff and members of the public which is separate to the regulations concerned with the safety of patients (IR(ME)R17), see below. In order to ensure compliance with these regulations, the Health and Safety Executive (HSE) have begun a rolling program of inspections. We were informed that the chiropractic profession was to be inspected in this regard as part of a planned series of inspections which began with the Veterinary profession. This is not in response to any incident or designed to target our profession for any reason. All professions subject to the new regulations may be inspected to ensure that procedures are safe and compliant. It is important to note that all practices with X-Ray facilities are always subject to inspection.

In October 2018 a statement from the GCC, Chiropractic Professional Associations and RCC was issued regarding planning inspections of Chiropractors with X Ray facilities, which can be viewed here.

The HSE subsequently published a report on their inspections (the full report can be downloaded here) and the professional associations worked together to give guidance back to registrants (you can read the recommendations here).

The Ionising Radiation (Medical Exposure) Regulations 2017 replace the 2000 regulations (including amendments made in 2006 and 2011).

The full regulations are on legislation.gov.uk:

• The Ionising Radiation (Medical Exposure) Regulations 2017
• The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2018

IR(ME)R is regulated and enforced by different organisations within each of the four home nations. These are known within the regulations as the ‘appropriate authorities’.

England: Care Quality Commission

Scotland: Health Improvement Scotland

Wales: Healthcare Inspectorate Wales

Northern Ireland: The Regulation and Quality Improvement Authority

The authorities are interested in compliance with the IR(ME)R 17 regulations and the regulations aim to make sure that ionising radiation is used safely to protect patients from the risk of harm when being exposed to ionising radiation.  More often than not they only get involved when  enquiries are raised by patients or radiology departments who challenge the quality and justification for images brought to them by patients and occasionally whistle blowers. The CQC carried out a short inspection programme of chiropractic clinics around 9 years ago.

Medical ionising radiation is used widely in hospitals, dental care, clinics and in medical research to help diagnose and treat conditions. Examples are x-rays and nuclear scans, and treatments such as radiotherapy.

The regulations aim to make sure that it is used safely to protect patients from the risk of harm when being exposed to ionising radiation.

They set out the responsibilities of duty holders (the employer, referrer, IR(ME)R practitioner and operator) for radiation protection and the basic safety standards that duty holders must meet.

Responsibilities include:

• minimising unintended, excessive or incorrect medical exposures
• justifying each exposure to ensure the benefits outweigh the risks
• optimising diagnostic doses to keep them “as low as reasonably practicable” for their intended use.

The regulations apply to both the independent sector and the public sector (NHS).

What are the purposes for which chiropractors can obtain radiographs?

Chiropractors can use radiography for several purposes following the identification of various history and examination findings. These include:

• excluding underlying pathological cause (red flags)

• confirmation of diagnosis/pathology

• determining appropriateness of care, and

• identifying contraindications or factors that would affect or modify the type of treatment/care proposed.

Radiographs should only be obtained if there is sufficient clinical justification in an evidence based context. Practitioners must weigh the risk against the benefit in deciding to undertake any radiographic investigation.

What is an evidence-based context?

An ‘evidence-based context’ is the integration of the best available evidence with professional expertise to make decisions, in conjunction with patient preference, values and circumstances.

This means that a chiropractor’s decision to undertake radiography should be supported by:

• up to date evidence

• the practitioner experience, and

• the consideration of the values and circumstances of the patient

What is the clinical justification for the use of radiography in clinical practice?

The process for determining whether there is enough clinical reason to undertake a radiographic study on a patient can be simplified into asking the following five questions.

1. Is the potential benefit of the x-ray outweighed by the potential harm?

2. Is there appropriate evidence to support taking an x-ray in this case?

3. Is a decision to take an x-ray in this case supported by my clinical experience?

4. Will an x-ray significantly impact my management of this case?

5. Once informed of the answers to questions 1 to 4 above, does the patient still consent to the investigation?

The Health and Safety Executive (HSE ) full report: Evaluation: Ionising Radiation Targeted Inspections Chiropractors Q4 January – March 2019 

Recommendations by the Chiropractic Professional Associations and The Royal College of Chiropractors following the Ionising Radiation Targeted Inspections by the Health and Safety Executive (HSE) January to March 2019

A statement from the chiropractic professional associations and RCC regarding planned inspections of chiropractors with X-ray facilities, October 2018

HSE Working with ionising radiation. Ionising Radiations Regulations 2017. Approved Code of Practice and guidance  https://www.hse.gov.uk/pubns/books/l121.htm

The Dept of Health and Social Care: https://www.gov.uk/government/publications/ionising-radiation-medical-exposure-regulations-2017-guidance

CQC https://www.cqc.org.uk/guidance-providers/ionising-radiation/ionising-radiation-medical-exposure-regulations-irmer

Health Improvement Scotland  http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/ionising_radiation_regulation.aspx

Healthcare Inspectorate Wales  https://hiw.org.uk/healthcare-organisations-use-ionising-radiation-medical-purposes-eg-x-ray

The Regulation and Quality Improvement Authority  https://www.rqia.org.uk/guidance/guidance-for-service-providers/ionising-radiation-(medical-exposure)-regulations/

Royal College of Radiologists: https://www.rcr.ac.uk/clinical-radiology/being-consultant/rcr-referral-guidelines/about-irefer

IR(ME)R: Implications for clinical practice in diagnostic imaging, interventional radiology and diagnostic nuclear medicine - https://www.rcr.ac.uk/publication/irmer-implications-diagnostic-imaging-interventional-radiology-diagnostic-nuclear-medicine

https://www.irefer.org.uk/