Communication

All staff need to be aware that requests related to NAI may not specify NAI on the request. Vigilance and insight will be required from all staff to identify such requests. The relevant clinician will preferably directly contact Diagnostic Imaging (DI) to ensure DI are aware the case represents a potential NAI. Contact will be with either the Chief site MIT or with a (preferably paediatric) radiologist.

All Paediatric Skeletal Surveys or other studies suspected of being NAI related must be checked by a paediatric radiologist (or general radiologist if no sub-specialty trained radiologist is available within Southern Health on that day) prior to the patient leaving the department. The same radiologist reports the study in that session. Results (preliminary or final) are to be directly communicated (by phone or in person) to the referring doctor at the time of performance of the exam (i.e. same session). Note of this communication should be made on the report (who and when). This initial report must be left unaltered thereafter.

All studies must then be co-reported (as an addendum to the above) preferably with at least one paediatric radiologist (responsibility of coordinating second opinion is with initial checking radiologist).

Final results are to be available within 24 hours and should be communicated directly to the referring doctor if substantially different to initial communicated interpretation (note of any further communication should be made in the report – who and when).

Same timelines, communication and reporting process for nuclear medicine studies (except nuclear medicine specialists report).

Procedures

In infants and children < 3 years

•  Always do Full Skeletal Survey as detailed below plus whole body bone scan (if latter not available do repeat skeletal survey after 2 weeks).

In children > 3 years it is more difficult to decide regions to be x-rayed

• Usually only x-ray any clinically suspicious sites
• If suspect significant multi-site trauma – do bone scan. X-ray the sites of bone scan abnormality. If these x-rays are negative, may need to consider repeat x-ray in 2 weeks.
• Exceptional cases where there is suspected repeated episodes of widespread violence and hence multiple sites may be involved, may need to consider a full skeletal survey in these older children. Should not be performed without approval from a paediatric radiologist after consultation with the referring doctors from the Victorian Forensic Paediatric Medical Service

Any queries or concerns regarding any cases of NAI should be addressed to Dr. Rachel Evans, (Coordinator of Paediatric Imaging) or in her absence, one of the paediatric radiologists or the site Director of Diagnostic Imaging.

Audit

The above process including reporting times will be audited on an individual case basis by the DI Quality Manager to ensure compliance with above and identify any further issues. Variance from the above timelines or further issues will to be reported immediately to the Director of Diagnostic Imaging. 6 monthly report will be provided to the Director of Medical Services and Quality.

Standard Projections

• AP Chest (for ribs)
• AP Abdomen including Pelvis
• AP Femurs
• AP Tibias and Fibulae
• AP Feet
• AP Skull
• AP Humerii
• AP Forearms
• PA Hands
• Lateral Spine – all regions – cervical, thoracic and lumbarsacral
• Lateral Sternum
• Lateral Skull

Additional Projections (As per Radiologist)

• Coned AP wrists
• Coned AP Ankles
• Coned AP Knees
• Oblique ribs

Other views as requested by radiologist

Technique - Notes

Chief MIT (or delegate) of site to be aware of case to monitor:
    1) Reporting and communication performed within timelines
    2) Appropriately trained radiographer performs/supervises study

All regions to be examined by an adequately trained radiographer according to the prescribed protocol for that region.

Adequate coning is essential.

Do not do 2 views on 1 film.

All imaging for NAI to be performed on DR (if possible).

In infants, where the entire upper and lower limb is examined in one exposure, ensure the elbow and wrist and knee and ankle are in a true AP position.

Ensure that Lead Markers are used on all images.

Image Evaluation

AP Chest – visualize entire bony thorax. Exposure technique for bony detail. Density to clearly demonstrate intervertebral spaces. No rotation.

AP Abdo/Pelvis – Demonstrate from diaphragms to lesser trochanters.

Limbs – each long bone must be in true AP with joint above and below demonstrated.

Approved Southern Health Diagnostic Imaging and Paediatric Services 12/3/09