Introduction

Why are guidelines needed?

A useful investigation is one in which the result - positive or negative - will alter clinical management and/or add confidence to the clinician's diagnosis.  A significant number of radiological investigations do not fulfill these aims and may add unnecessarily to patient irradiation [7, 16].  The chief causes of the wasteful use of radiology are:

1. Repeating investigations which have already been done: e.g. at another hospital, in an outpatient department, or in an accident and emergency department.  HAS IT BEEN DONE ALREADY?  Every attempt should be made to get previous films.  Transfer of digital data through electronic links will assist in this respect when available.

2. Investigation when results are unlikely to affect patient management: because the anticipated 'positive' finding is usually irrelevant, e.g. degenerative spinal disease (as 'normal' as grey hairs from early middle age) or because a positive finding is so unlikely.  DO I NEED IT?

3. Investigating too early:  i.e. before the disease could have progressed or resolved or before the results could influence treatment.  DO I NEED IT NOW?

4. Doing the wrong investigation. Imaging techniques are developing rapidly. It is often helpful to discuss an investigation with a specialist in clinical radiology or nuclear medicine before it is requested.  IS THIS THE BEST INVESTIGATION?

5. Failing to provide appropriate clinical information and questions that the imaging investigation should answer.  Deficiencies here may lead to the wrong technique being used (e.g. the omission of an essential view).  HAVE I EXPLAINED THE PROBLEM?

6. Over-investigating.  Some clinicians tend to rely on investigations more than others.  Some patients take comfort in being investigated.  ARE TOO MANY INVESTIGATIONS BEING PERFORMED?

What advice is available?

In some clinical situations firm guidelines have been established.  Guidelines are:

systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances... [8].

Just as the term implies, a guideline is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient can be considered.  So while there have to be good reasons for ignoring them they are not absolute rules.  No set of recommendations will command universal support, and you should discuss any problems with your radiologists.

The preparation of guidelines has become something of a science, with numerous papers emerging within the evolving guidelines discipline.  In particular, experts have provided a detailed methodology as to how guidelines should be developed, produced and appraised [9-15, 17].  Using such a methodology, the development of a single, scientifically robust guideline represents a major piece of academic endeavour.  For the 331 clinical problems in this booklet, such expenditure of time and resources is somewhat impractical.  Nevertheless, increasing effort has been made to ensure that the methodology for the preparation of guidelines has been followed during the preparation of these recommendations.  In particular, there has been expert development of a search strategy, extensive systematic literature review, and critical appraisal by relevant special interest groups.  The Royal College of Radiologists holds an archive of references upon which statements within the text are based.  Every opportunity has been given to workers in other disciplines and those representing patients to put forward their views.  Many societies and groups across Europe have been encouraged to comment on points of fact, local policies, and other related matters.  There has been extensive dialogue with other professional groups, including patients' representatives, European professional associations and specialist societies, and all the Medical Royal Colleges (see Appendix).

In some clinical situations (e.g. the role of ultrasound in normal pregnancy) there are conflicting data within a large body of excellent scientific reports.  Thus no firm recommendations are given ' and the evidence is graded C. It should be noted that there are very few randomised trials comparing different radiological procedures - they are difficult to perform and ethical approval may be denied.

What images are taken?

All imaging departments should have protocols for each common clinical situation.  Therefore no definite recommendations are given about this aspect.  Suffice it to say that all examinations should be optimised to obtain maximum information with the minimum of radiation.  It is important to be aware of this, as the imaging performed may not be what the referring clinician expects.

For whom are the guidelines designed?

These Guidelines are intended to be used by all 'referrers', including in particular general practitioners.  In the hospital setting they are likely to be of most use to newly qualified doctors, and many hospitals give a copy to each newly appointed junior doctor to stimulate good practice.

The range of investigations available to different health professionals must be determined in consultation with local specialists in radiology and nuclear medicine, bearing in mind the available resources.  The recommendations are also of value to those interested in audit of a department's referral pattern and workload [7,16].

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