1 to 1- Clinical prioritisation, patient care Flashcards
You are the sole radiographer working on site. You return from theatre to find 5 A/E patients in the waiting room.
This is the order they arrived in the department
In what order would you x-ray these patients; justify your response- 10 marks
1) Rt wrist – 24 year old man with ? fractured wrist (walking)
2) CXR – 6 month old boy with a 3 week history of night coughing (walking)
3) Pelvis and Lt hip – 79 year old man with ? #NOF (trolley)
4) CXR – 4 year old girl with fever of unknown origin who commenced antibiotic treatment 15 minutes ago (carried)
5) Facial bones – 45 year old lady RTC facial lacerations, ?# (walking)
1) 4 yr old CXR
Potential for sepsis; life threatening
2) NOF
Blood loss, pressure care, risk of morbidity
Either of above first
3) Facial bones
Potential for open # requiring urgent treatment
4) 6 month CXR
Potential for significant illness but not so urgent due to longevity
5) Wrist
Not life or limb threatening
4 and 5 could be imaged in either order
How to work out if something takes priority?
NOF has a high risk of morbidity and mortality
ABCD principle
Age is not normally a consideration
However both the very young and the elderly can deteriorate much more quickly than other patients
How did/will the patient arrive in the department?
Walking patients can often wait
A child being carried may be listed as walking even if they are acutely ill
Open # and dislocations are emergencies
CXR doesn’t necessarily take priority
Sepsis is very important
How quick an examination is to undertake generally doesn’t override clinical need
Clinical prioritisation – in-patients
Multiple in-patient requests can arrive in a short period of time
You are working in the in-patient x-ray department
The following patients are waiting to come down to the department for x-ray
You have porters waiting to bring the patients down to the department
2 patients at a time can be in the department
In what order would you send the porters for these patients; justify your response
1) 63 year old male. CXR for NG tube check. No aspirate. Requested 2 hours ago (bed)
2) 75 year old female. Right knee. Post op TKR. Requested yesterday (bed)
3) 95 year old female. CXR. Pyrexia, SOB, ?HAP. Requested 2 days ago, porters went for patient yesterday but she refused. (bed)
4) 2 year old male. CXR. Cough and dyspnoea, ?infection. Requested 1 hour ago (parents can bring down from ward)
5) 73 year old male. Right shoulder. Fall last week, # proximal humerus. Check position. Requested 6 hours ago. (bed)
6) 63 year old female. Pelvis and left hip. Fall on ward ?#. Requested 1 hour ago (trolley)
7) 58 year old female. CXR. Wedge resection 10/7 ago. Pre-discharge check. Requested 3 hours ago (chair)
1) 63 year old male. CXR for NG tube check. No aspirate. Requested 2 hours ago (bed)
NG tube needs to be used to feed and provide medication
Incorrectly placed tubes cause significant mortality
2) 2 year old male. CXR. Cough and dyspnoea, ?infection. Requested 1 hour ago (parents can bring down from ward)
Parent can carry so porters not needed
Risk of deterioration is more significant in a 2 year old
3) 63 year old female. Pelvis and left hip. Fall on ward ?#. Requested 1 hour ago (trolley)
Urgent treatment needed if fracture detected
Risk of blood loss and morbidity/mortality
4) 58 year old female. CXR. Wedge resection 10/7 ago. Pre-discharge check. Requested 3 hours ago (chair)
Controversial but patient cannot be discharged until x-ray completed so bed is blocked preventing further admissions.
5) 95 year old female. CXR. Pyrexia, SOB, ?HAP. Requested 2 days ago, porters went for patient yesterday but she refused. (bed)
HAP can be a clinical diagnosis. X-ray not essential for this
Treatment probably already started even without x-ray
Previous refusal should not cause further delay
6) 75 year old female. Right knee. Post op TKR. Requested yesterday (bed)
Not clinically urgent but delay may prevent mobilisation and increase recovery time
Leads to bed blocking and increased morbidity
7) 73 year old male. Right shoulder. Fall last week, # proximal humerus. Check position. Requested 6 hours ago. (bed)
Follow up, so not clinically urgent
Can wait until tomorrow if needed
What indications take priority?
Is pre-discharge a “clinical need”? – discuss the implications of bed-blocking on other patients and if this takes priority over other conditions such a ?chest infection.
Are there any missing off this list that you were expecting?
Discuss why they aren’t on there
NG tube position
Post line insertion
?pneumothorax
?sepsis
?perf
?dislocation
?open fracture
?fracture NOF
Other ?fracture (sometimes)
?obstruction
?osteomyelitis
Cellulitis
Pre-discharge…???
In what order would you examination these patients; justify your response
10 marks
1) Rt wrist – 24 year old man with ? fractured wrist (walking)
2) CXR – 6 month old boy with a 3 week history of night coughing (walking)
3) Pelvis and Lt hip – 79 year old man with ? #NOF (trolley)
4) CXR – 4 year old girl with fever of unknown origin who commenced antibiotic treatment 15 minutes ago (carried)
5) Facial bones – 45 year old lady RTC facial lacerations, ?# (walking)
1 mark per examination for correct order and 1 mark for rationale
3) Pelvis and Lt hip – 79 year old man with ? #NOF (trolley)
-because neck of femur has high mortality rate so the sooner it is treated, better chances for the patient.
4) CXR – 4 year old girl with fever of unknown origin who commenced antibiotic treatment 15 minutes ago (carried)
-Potentially could be sepsis because of high fever.
5) Facial bones – 45 year old lady RTC facial lacerations, ?# (walking)
-potential for open fractures which will require urgent care.
2) CXR – 6 month old boy with a 3 week history of night coughing (walking)
-potential for significant illness but might not be due to how long the patient has had the cough
1) Rt wrist – 24 year old man with ? fractured wrist (walking)
-its not limb or life threatening.
How to determine which goes first for clinical prioritisation?
A
NOF has a high risk of morbidity and mortality
ABCD principle
-Age is not normally a consideration
However both the very young and the elderly can deteriorate much more quickly than other patients
-How did the patient arrive in the department?
Walking patients can often wait
A child being carried may be listed as walking even if they are acutely ill
-Open # and dislocations are emergencies
CXR doesn’t necessarily take priority
Sepsis is high priorty
How quick an examination is to undertake generally doesn’t override clinical need
A 25 year old female arrives with a request:
X-ray facial bones with tangential
Assault ?glass foreign body
For 6 marks, describe and explain the infection control measures you would undertake during this examination?
Any reasonable answer, 3 marks for actions, 3 marks for rationale
Wear gloves and apron; to prevent transfer of blood/bodily fluids to your hands and uniform
Clean and cover the IR; to prevent transfer of fomites to the patient
Dispose of PPE and IR cover into clinical waste; to ensure correct management of waste and prevent transfer of infection to wider population
A 25 year old female arrives with a request:
X-ray facial bones with tangential
Assault ?glass foreign body
For 2 marks, describe how you would position the patient for the tangential projection?
For 2 marks, would you use a grid for the tangential projection? Explain your answer.
Turn the patient’s head towards to right and cant/tilt caudally
Use the light from the LBD to visualise the lacerations in profile on the IR
Could get patient to puff cheek out to further bring into profile
No a grid is not needed
The x-ray is looking at soft tissue, so a low exposure will be used therefore only limited scatter/secondary radiation is formed with little or no impact on the image
Using a grid will require an increase in exposure that cannot be justified as the image quality will be satisfactory without the grid
The following 5 in-patients are waiting to come down for x-ray
You are arranging porters to bring the patients down
In what order would you send for these patients to come down to the department; justify your response
10 marks
CXR – 62 year old female; post op, pacemaker insertion (bed)
CXR – 86 year old female; 6/52 post #NOF, not mobilising. Cough ?infection (bed)
CXR – 79 year old male; NG tube check (bed)
CXR – 34 year old female; pneumothorax 4/7 ago, drain clamped this morning. ?resolution (chair)
CXR – 78 year old male; SOB, cough, known Ca lung, ?pleural effusion (bed)
1 mark per examination for correct order and 1 mark for rationale
CXR – 79 year old male; NG tube check (bed)
NGT cannot be used until checked, increased potential for never event if left
CXR – 62 year old female; post op, pacemaker insertion (bed)
Potential for pneumothorax needing urgent treatment. Can often be discharged after x-ray.
CXR – 34 year old female; pneumothorax 4/7 ago, drain clamped this morning. ?resolution (chair)
Potential for harm if PTX not resolved. Drain can be removed if it is.
CXR – 78 year old male; SOB, cough, known Ca lung, ?pleural effusion (bed)
Can be a clinical diagnosis but drain made be needed if significant PE shown
CXR – 86 year old female; 6/52 post #NOF, not mobilising. Cough ?infection (bed)
Chest infection can be diagnosed clinically, treatment can start prior to XR
You are the sole radiographer working on site. You return from theatre to find 5 A/E patients in the waiting room.
This is the order they arrived in the department
In what order would you examination these patients; justify your response
10 marks
Rt elbow – 10 year old female; fall off bunk bed, obvious deformity ?# distal humerus/?dislocation (trolley)
AXR – 62 year old female; abdo pain and distention. ?obstruction (trolley)
Left wrist – 79 year old male; FOOSH, swollen and tender. ?# (bed)
CXR – 1 year old female; cough, pyrexia, SOB. ?infection (walking)
CXR – 90 year old male; Generally unwell with significant deterioration in mobility, confusion. ?chest infection (bed)
1 mark per examination for correct order and 1 mark for rationale
CXR – 1 year old female; cough, pyrexia, SOB. ?infection (walking)
Potential for sepsis, need for urgent treatment
Rt elbow – 10 year old female; fall off bunk bed, obvious deformity ?# distal humerus/?dislocation (trolley)
Potential for ligament or vascular damage
AXR – 62 year old female; abdo pain and distention. ?obstruction (trolley)
Could lead to perf; may need urgent surgical intervention
CXR – 90 year old male; Generally unwell with significant deterioration in mobility, confusion. ?chest infection (bed)
Potential for deterioration and/or skin deterioration if on trolley too long
Left wrist – 79 year old male; FOOSH, swollen and tender. ?# (bed)
Not life or limb threatening, could be treated with backslab until diagnosis if necessary
What does pyrexia mean?
A fever/high temperature
The following 5 in-patients are waiting to come down for x-ray
You are arranging porters to bring the patients down
In what order would you send for these patients to come down to the department; justify your response
10 marks
Rt knee – 79 year old male; fall on ward; painful knee, unable to weight bear. ?# (bed)
Pelvis – 67 year old male; Increasing pain and discomfort, known Ca prostate. ?mets (trolley)
CXR – 67 year old female; SOB, cough ?infection (bed)
Lt knee – 58 year old female; 1/7 post op knee replacement; pre-mobilisation images (bed)
CXR – 84 year old male; increasingly unwell, pyrexia, cough, ?sepsis(bed
CXR – 84 year old male; increasingly unwell, pyrexia, cough, ?sepsis(bed)
Sepsis is a medical emergency, can deteriorate quickly
Rt knee – 79 year old male; fall on ward; painful knee, unable to weight bear. ?# (bed)
Need for treatment if # is identified
CXR – 67 year old female; SOB, cough ?infection (bed)
Whilst can be a clinical diagnosis, has more potential for deterioration than others
Pelvis – 67 year old male; Increasing pain and discomfort, known Ca prostate. ?mets (trolley)
Diagnosis needed quickly but not clinically urgent; pain can be managed more effectively if cause identified
Lt knee – 58 year old female; 1/7 post op knee replacement; pre-mobilisation images (bed)
Not clinically urgent, mobilisation can occur without x-rays if needed
