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Reminder About Medical Directives for the ordering of X-rays
Update on Self-Regulation of MR technologists
Suspended Members
Reminder About Medical Directives for the ordering of X-rays
Background
The purpose of this article is to summarize the professional accountability of Medical Radiation Technologists (MRTs) in applying ionizing radiation on the basis of an order for ionizing radiation.
Section 6(1) of the Healing Arts Radiation Protection Act (HARP Act) is specific about who can and cannot prescribe the application of ionizing radiation to human beings. Specifically, no person can operate an X-ray machine for the irradiation of a human being unless the irradiation has been prescribed by:
- a legally qualified medical practitioner
- a member of the Royal College of Dental Surgeons of Ontario
- a member of the College of Chiropodists of Ontario who has been continuously registered as a chiropodist under the Chiropody Act and the Chiropody Act, 1991 since before November 1, 1980 or who is a graduate of a four-year course of instruction in chiropody
- a member of the College of Chiropractors of Ontario
- a person registered as an osteopath under the Drugless Practitioners Act.
Despite subsection (1), a person may operate an X-ray machine for the irradiation of the chest, the ribs, the arm, the wrist, the hand, the leg, the ankle or the foot of a human being if the irradiation is prescribed by a member of the College of Nurses of Ontario who holds an extended certificate of registration under the Nursing Act, 1991.
Despite subsection (1), a person may operate an X-ray machine for the purpose of performing a mammography that has been prescribed by a member of the College of Nurses of Ontario who holds an extended certificate of registration under the Nursing Act, 1991.
Definitions
Key to understanding our roles and responsibilities are two definitions of concepts which come up frequently in our practice.
Medical Directive
“A prescription for a treatment or intervention that may be performed for a range of patients who meet certain conditions. A medical directive includes a specific treatment or range of treatments, the specific conditions that must be met and any specific circumstances that must exist for implementation of the directive.”
Direct Order
“A prescription for a treatment or intervention for a particular patient written by an individual physician for a specific treatment(s) at a specific time(s).”
It has been agreed by our College, the College of Physicians and Surgeons of Ontario (CPSO) and the College of Nurses of Ontario (CNO) with the support of the Ministry of Health and Long-Term Care, X-Ray Inspection Services and Legal Services Branch of the Ministry of Health and Long-Term Care, that an x-ray performed on the authority of an appropriate medical directive meets the requirements of section 6 of HARP.
THE IMPLEMENTATION OF A MEDICAL DIRECTIVE IS NOT ORDERING; THE ACTUAL MEDICAL DIRECTIVE IS THE ORDER.
General Responsibilities
The physician, the nurse and the MRT have specific roles and responsibilities in connection with a medical directive.
Physicians are responsible for:
- developing the medical directive that specifies the particular x-ray to be taken, the specific conditions that must be met, any circumstances that must exist, and any contraindications for implementing the medical directive
- the outcome associated with the implementation of the directive
- ensuring informed consent has been obtained
Nurses are responsible for:
- implementing the medical directive by assessing the patient to determine if the specific circumstances and specific conditions meet the requirements of the medical directive, and
- arranging for the x-ray to be taken
MRTs are responsible for:
- determining whether, from a medical radiation technologist perspective, the requested x-ray is consistent with the MRT's assessment of the patient’s condition
- discussing any concerns about the x-ray request with the nurse who implemented the directive
- contacting the responsible physician if the concerns are not resolved
It is especially important for MRTs to understand the implications of these obligations. Since, as regulated health care professionals, MRTs are "professionally responsible for the outcomes of their professional actions."
An MRT’s Responsibilities
Before an x-ray can be taken on the authority of a medical directive, the MRT must ensure that:
- the directive itself includes the specific components set out in the section The Structure of a Medical Directive
- the requisition includes the specific components set out in the section Information That Needs to be Contained on the Requisition
- the required supporting policies are in place as described in the section Other Policies That Need to be Implemented
The Structure of a Medical Directive
A medical directive which relates to the ordering of an x-ray test or procedure must include:
- the actual name and description of the test(s) or procedure(s) being ordered
- a description of the clinical criteria and the type of patient situation to which the directive applies
- clear identification of the contraindications for implementing the directive
- the identity of the physician by name and signature, who is responsible for the medical directive
- the date and signature of the administrative authority approving the medical directive
Information That Needs to be Contained on the Requisition
The requisition received in the imaging department, whether completed by hand or electronically, needs to include the following:
- the standard name of the x-ray test or procedure
- the name of the person who completed the requisition
- the name of the person who assessed the presence of the clinical criteria
- the name of the physician responsible for the care of the patient ("most responsible physician") and
- identification that the requisition was issued under the medical directive (identified by name and number)
Other Policies That Need to be Implemented
A number of policies must be in place to support the use of a medical directive. If they are not in place, you cannot take the x-ray authorized by the directive. You must ensure that the governing board or employer, in consultation with the medical authority and relevant senior administrative authority, has implemented policies in each of the following:
- identifying the x-rays that may be ordered by means of a medical directive
- identifying the physician responsible for developing the medical directive
- establishing a means of identifying any physician(s) who may choose not to have the directive apply to his or her patients/clients
- identifying who may implement the medical directive, including any specific educational requirements for doing so
- describing an accessible communication network to enable the MRT to consult with the nurse and/or responsible physician in the event that the medical directive is queried
- establishing documentation requirements for implementation of the medical directive
- identifying tracking/monitoring methods for appropriate implementation of the medical protocol
- identifying a mechanism for notifying the Radiation Protection Officer that a medical directive has been developed, and
- identifying the date of next annual review of the medical directive
The expertise required by the health professional implementing the directive must be identified in an associated unit/department/facility policy. For example, medical directives are used as the basis for ordering x-rays in the emergency department of community hospitals. The knowledge and expertise required by emergency department nursing staff who implement the directive need to be clearly identified. The question should be asked whether "any" nurse in the department can implement the directive, or only those who have completed an in-depth assessment module as part of their unit orientation?
The policy should further establish a means to identify the physicians to whom the medical directive applies and any physician(s) who may choose not to have the directive apply to their patients/clients.
Summary
The College in conjunction with the CNO and the CPSO has developed a policy that describes an appropriate medical directive that meets the requirements of section 6 of the HARP Act for ordering x-rays, including all the components required to ensure that the directive is consistent with the jointly developed policy.
It is the responsibility of MRTs to ensure that:
- any medical directive currently in place or developed in the future with respect to ordering x-rays meets the requirements of this joint policy
- any completed requisitions made further to such a medical directive meet the requirements of this joint policy
- each of the supportive policies is in place
If parts of a medical directive or requisition have not been met, or the policies outlined have not been approved by your facility, then it is up to each MRT to seek a direct order from a physician (or from a registered nurse in the extended class for the procedures specified above) before taking an x-ray and to urge that the policy requirements be met.
Copies of the policies regarding Medical Directives for X-Rays and What You Must Know About… Registered Nurses in the Extended Class are available from the College website www.cmrto.org.
Update on Self-Regulation of MR technologists
As you are aware, the former Ontario Minister of Health and Long-Term Care asked the College to regulate magnetic resonance (MR) technologists in Ontario. The necessary regulations under the Medical Radiation Technology Act came into force on May 29, 2003. After June 18, 2004, a person must be a member of the CMRTO (or the College of Physicians and Surgeons of Ontario) in order to be legally authorized to apply electromagnetism for magnetic resonance imaging in Ontario.
The CMRTO has been accepting applications for registration in the specialty of magnetic resonance and assessing whether the applicants meet the registration requirements as set out in the regulations. To date, the College has received approximately 231 applications and 202 MRTs are now registered in the specialty of MR.
On or before June 18, 2004, MR technologists may apply for registration with the College using one of two methods – either through a grandparenting provision or by successfully completing an approved educational program and an approved examination. Please note that in order to qualify for registration under the grandparenting provision (section 4.1(2) of the registration regulation), the CMRTO must receive your application and application fee no later than 5:00 p.m. on June 18, 2004.
As the grandparenting provision applies to all MR technologists who were practising in Canada on May 29, 2003, the College is anxious to inform all MR technologists, both inside and outside Ontario, of this provision. The College is publishing notices in as many of the provincial association journals as possible and the CAMRT journal.
For those MR technologists in Canada who would be relying on the grandparenting provision in order to meet the requirements for registration, it may be to their advantage to apply for registration with the College now, in order to ensure that they can work in Ontario in the specialty of magnetic resonance after June 18, 2004.
All applicants must submit an application fee along with the completed application form. The application fee is $100.00 plus $7.00 GST ($107.00 total). The application form is available on the College’s website at www.cmrto.org or you may request forms from the College by contacting our registration department at 416.975.4353 or 1.800.563.5847.
Election of MR Council Member
It is also important to note that there is an upcoming election of members to the College Council in the Electoral Districts of 1, 4, 7 and 8 in 2004. District 8 has been created for the new specialty of magnetic resonance and includes all of the Province of Ontario. Following the election of a Council member representing the specialty of magnetic resonance, the elected Council member will act as a full voting member of the College Council, for a three year term commencing at the July 2004 Council meeting. Until that time, Hilda Pope, M.R.T.(M.R.), is attending the College Council meetings as a guest. Maida Jeraj, M.R.T.(M.R.), will attend any Council meetings that Hilda Pope is unable to attend. In addition, Jay Neadles, M.R.T.(M.R.), M.R.T.(R.), has been appointed to the College’s Registration Committee. In addition to its role in reviewing applications for registration referred to it, the Registration Committee, with the assistance of Jay Neadles, has been developing policies regarding the registration of the MR technologists.
To be eligible to vote in the May 7, 2004 election in District 8, you must be registered as a member of the College in the specialty of magnetic resonance no later than April 7, 2004.
Suspended Members
The following are the people whose certificates of registration have been suspended effective January 20, 2004, for failure to pay their fees in accordance with section 24 of the Health Professions Procedural Code. A person whose certificate of registration has been suspended is not a member of the College unless and until the suspension is removed.
| 09004 |
Wan, Po Shing |
| 10971 |
Gravel, Carmelle |
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