proc:out_of_hours_mri [RadRegWiki]

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====== Out of Hours MRI ======

Out of hours MRI is largely reserved for MRI ? CES, and is very variable between sites, with Plymouth and Exeter offering overnight scanning, and Truro and Torbay having more limited service. Detailed site by site guides below:

===== Plymouth =====
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Plymouth offers a 24 hour MRI service for neurological presentations, providing certain requirements are met.

==== Suspected Acute Cauda Equina Compression ====

As per the Plymouth PROC guidelines, for suspected cauda equina compression an MRI lumbar spine "is indicated" and can be vetted and arranged overnight by the registrars on-call if any of the following red flag features are present:

  * Bilateral sciatica 
  * Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion 
  * Difficulty initiating micturition or impaired sensation of urinary flow; if untreated this may lead to irreversible urinary retention with overflow urinary incontinence 
  * Loss of sensation of rectal fullness; if untreated this may lead to irreversible faecal incontinence 
  * Perianal, perineal, or genital sensory loss (saddle anaesthesia or paraesthesia) 
  * Laxity of the anal sphincter 
  * Erectile dysfunction

Check with the referrer that the scan is definitely required out-of-hours and cannot wait until the morning list e.g. if the patient’s symptoms have been present for multiple days (>72 hours) at the time of presentation a morning scan may be more appropriate.

Where PROC wants to reject a scan, or where the is any doubt about the justification or timing of a scan, contact the on-call neuroradiology consultant.

There are a couple of areas where the current guidance causes a bit of uncertainty - namely where there is isolated bilateral sciatica, and where symptoms have been stable for > 2 weeks. As per GIRFT guidance these patients do not meet criteria for emergent imaging and there has been communication from Plymouth Neuroradiology to this effect, but strictly a out of hours scan for these patients "is indicated" as per the local guidance document. A reasonable approach would be to suggest to the clinical team that the scan can wait for the morning in these situations, and escalate to the on-call neuroradiology consultant if the clinical team insist.

==== Other Presentations ====

All other neurological presentations where a MRI is requested to be performed overnight need to be discussed with the neuroradiology consultant on call. Check with the clinical team that it is required for overnight, and is going to impact management overnight. Ideally the patient should have been seen by the Neurosurgical team, and you are encouraged to inform the clinicians that the request should be from the Neurosurgical consultant to the on-call Neuroradiologist. Note that radiotherapy is not available overnight, so ? metastatic cord compression imaging is not felt indicated overnight.

==== Arranging Imaging ====

If an out of hours scan is justified **first** complete the MRI checklist:

  * Does the patient have a pacemaker or other cardiac device? 
  * Does the patient have aneurysm clips or a programmable shunt? 
  * Does the patient have any other active implant such as a neuro stimulator, cochlear implant? 
If yes to any of the above the patient cannot be scanned out of hours. 

  * Is the patient ventilated/to be scanned under GA? 
  * Is the patient able to answer questions about their medical history themselves? 
  * Is a translator required? 
  * Is the patient likely to require sedation/additional pain relief and, if so, has this been prescribed? 
  * Does the patient require a log roll? Are staff available out of hours to manage this? 

Please ensure: 

  * The patient is on-site 
  * The request has been discussed with a Consultant Radiologist if required 
  * The request has been vetted 
  * A safety questionnaire has been completed by the referring clinician for those patients unable to answer this themselves 
  * Recent and relevant imaging has been checked to ensure there are no contraindications to MRI 

Vetting is via the vetting module in CRIS, [[proc:ct_vetting|as per CT]]. **Then** contact the on-call MRI radiographer via switchboard. The MRI radiographer is off site and calling them in causes difficulties with the following day's OP lists.

If a request is not felt indicated overnight, and is arranged for the following morning it should be vetted as an urgency 5, and the MR radiographers should be contacted in the morning at 0745 via MRI East (ext. 39385) or a message to the MRI co-ordinator (ext. 32511).

[[https://nhs.sharepoint.com/:w:/r/sites/msteams_e1797f/Shared%20Documents/General/PROCuments/UHP/MRI%20OOH%20Neuro%20PROC%20guidelines%20(Final).docx?d=w04ee79e3eab94a53b87619fbc3bcdb50&csf=1&web=1&e=qd9y42|Derriford Out of Hours MRI Guidance]]
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===== Truro =====
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An on-call MRI service is available to scan suspected CES only between 2000-2200, but Truro does not offer MRI for any indication from 2200 - 0730. If a patient is thought to absolutely require MRI overnight, the patient must be transferred to Derriford and have the scan in Derriford. Dedicated slots exist in the morning in Truro for urgent ? CES scans that can wait.

To arrange a scan from 2000-2200 confirm the patient has no contra-indications to MRI, vet the MRI on CRIS [[proc:ct_vetting|as per CT vetting]], and then contact the MRI team via switchboard. For scans for the morning just check contra-indications then vet. Ambulatory patients should be told to attend MRI for 0730, and ED should be told to contact the MRI at 0730 for non-ambulatory patients.

[[https://nhs.sharepoint.com/:w:/r/sites/msteams_e1797f/Shared%20Documents/General/PROCuments/Truro/Emergency%20MRI%20at%20RCHT.%20PROC%202019.docx?d=wd21c281695104b95858530a828eeed27&csf=1&web=1&e=Iw4j8g|Truro Out-of-Hours MRI SOP]]
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===== Exeter =====
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Exeter offers a 24 hour MRI service, with strict patient selection out of hours. From 2100-2400 MRI cover is available for all scans with an emergency indication as determined by the radiology registrar on. From 2400-0700 only scans to be performed are those for suspected acute CES, planned for intervention overnight, and directly sanctioned by the on-call spinal consultant.

MRI is carried out by the on-call CT radiographer where trained, and they should have a back up radiographer if they are not trained in MRI. Vetting and arranging is the same as for [[proc:ct_vetting|CT Vetting]] - write a comment, set as urgency code 2 and request received, and contact the radiographer.

[[https://nhs.sharepoint.com/:w:/r/sites/msteams_e1797f/Shared%20Documents/General/PROCuments/Exeter/SOP%20for%20CT.MRI%20On%20Call%20Service.docx?d=w7494aa55578549f9ba62e6d22351290f&csf=1&web=1&e=ylD0Ba|Exeter On-call CT and MRI Guidance]]

[[https://nhs.sharepoint.com/:w:/r/sites/msteams_e1797f/Shared%20Documents/General/PROCuments/Exeter/Process%20for%20on%20call%20MR%20requests%20for%20cord-cauda%20equina%20compression.docx?d=w97763303a38c4b75a264a42cc69bb0fa&csf=1&web=1&e=zeGLf6|Exeter On-call MRI protocol]]
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===== Torbay =====
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Out of hours MRI in Torbay is only offered for suspected CES, and is not available 24 hours a day.

Referrals made prior to 2200 that are accepted but the PROC registrar should have vetting completed and MRI contra-indications checked, and then promptly called through to the MRI radiographer on-call via switchboard.

Referrals accepted after 2200 will be scanned the following day at 0800 - in order to arrange this, the scan should be vetted, then the referrer should be instructed to complete the safety questionnaire and called the MRI answer phone on 01803 655654. The referrer should arrange for the patient to come to MRI for 0800 the following morning, but cannot be left unattended in the MRI department.

[[https://nhs.sharepoint.com/:w:/r/sites/msteams_e1797f/Shared%20Documents/General/PROCuments/Torbay/Torbay%20overnight%20MRI%20process%20for%20PROC.docx?d=wa7ef2b2717bf44ae981f90a56d05d309&csf=1&web=1&e=r7Zvzd|Out of hours MRI for corda equina at Torbay]]

[[https://nhs.sharepoint.com/:w:/r/sites/msteams_e1797f/Shared%20Documents/General/PROCuments/Torbay/Torbay%20overnight%20MRI%20process%20for%20PROC.docx?d=wa7ef2b2717bf44ae981f90a56d05d309&csf=1&web=1&e=6U3eXF|Summary of Torbay overnight MRI process for PROC]]
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===== Barnstaple =====
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Barnstaple does not offer out of hours MRI.
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===== Useful Links =====

[[https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/10/National-Suspected-Cauda-Equina-Pathway-October-2023-version-3.drawio.html|GIRFT Guidance on Suspected Acute CES]]