Referral Guidelines

Referral Guidelines for Imaging

The objective of this EC-funded tender project was to review the situation in the EU Member States regarding the fulfilment of their obligations under the Medical Exposure Directive Article 6.2 (97/43/EURATOM), which requires Member States ‘to ensure that recommendations concerning referral criteria for medical exposures, including radiation doses, are available to the prescriber of medical exposures’.
The project started in December 2011 and finished in February 2013. The professional organisations involved include the European Society of Radiology (ESR) as coordinator, the Royal College of Radiologists (RCR), the Société Française de Radiologie (SFR), the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the European Society of Paediatric Radiology (ESPR). In addition, an advisory board was composed of representatives from the relevant disciplines, as well as experts from the World Health Organization, the International Atomic Energy Agency and various national authorities.

The activities of the project focused on three main tasks:

  • Conducting an EU-wide study on the availability, development and implementation of referral guidelines for radiological imaging in the EU Member States. This web -based survey took place in the spring of 2012. (Work Package 1)
  • Organising a European Workshop with relevant representatives from the EU Member States. This workshop was held in Vienna on 20-21 September 2012. (Work Package 2)
  • Formulating conclusions and recommendations for national and community action. (Work Package 3)

Conclusions and recommendations are based on a survey of 30 European countries carried out in the spring of 2012, the European Workshop in Vienna on 20-21 September 2012 and decisions reached at meetings of the Steering Committee, taking into account information from expert advisors, feedback from stakeholder organisations and further correspondence with national organisations participating in the survey.

Recommendations and survey conclusions:

  • Development and integration of Clinical Decision Support (CDS). There is strong support for the concept of integrating Guidelines into clinical decision support systems and, as a future development, provision of guidance through existing electronic requesting systems.
  • Clearer and stronger European measures to encourage both availability and use of referral guidelines. Such measures should be made centrally or through European competent authorities.
  • European Guidelines. These may be produced initially by a combination of existing national Guidelines, developed using accepted methodology, under the auspices of a European professional organisation. European Guidelines must contain dose information and must include separate advice for children, and the pregnant woman/ unborn child.
  • Encouragement of educational initiatives. Educational initiatives are highly favoured to improve implementation, followed by involvement of referring clinicians in guidelines development.
  • External audit and local internal audit. External audit has been addressed in EC guidelines on clinical audit, but further measures to promote local internal audit are needed.


Workshop conclusions and findings:

  • Agreement that reinforcement for use of imaging referral guidelines is essential. Recommendations are to use educational initiatives and to consider clinical decision support systems.
  • Broad agreement that European imaging referral guidelines are essential and should include specific advice for imaging children. The recommendation is for amalgamation of existing, rigorously-developed national referral guidelines rather than duplicating efforts through developing Guidelines de novo.
  • The results of the survey carried out by the project consortium indicate that imaging referral guidelines are available in two thirds of the EU Member States with legal requirement for Guidelines and in only one third of those countries who do not have a legal requirement for Guidelines. As the situation in many European countries is rapidly changing, participants agreed that a re-audit should be performed by the project organisers prior to making recommendations for Community action.
  • Agreement and recommendation for monitoring through clinical audit, preferably external but also local internal audit.


Two articles were published in Insights into Imaging in December 2013:


The Referral Guidelines document was published in the radiation protection series of the European Commission (No 178).