Who Does What: Patient Prioritisation by Role

Your seat

Every referral enters through you, and you see the whole river — so you’re the first person positioned to notice an urgent request in the wrong queue. Three jobs, with a hard line around them: route by the category, flag what looks wrong, never adjust a category yourself — in either direction. Nothing here asks for clinical judgement; recognition and routing is the job, and it is one of the most protective in the building.

Job 1 — route by the code

Job 2 — walk it over, don’t queue it

You will sometimes flag things that turn out to be nothing. That is the system working — a false alarm costs a radiologist two minutes; a queued red flag can cost a spinal cord. Good-faith front-desk escalation is never criticised, and if it ever is where you work, that itself belongs with your manager.

Job 3 — never adjust a category, either direction

• Never downgrade — not “they’ve waited so long it can’t be urgent”, not “that referrer marks everything urgent”. A wrong-looking code goes back up as a question.
• Never upgrade — including under pressure. Log who called, when, what they said, and move it upstream; new information is real triage data, and only a radiologist can act on it.
• Calls are not urgency. Escalate content when it’s new; never re-order the queue for the loudest phone.

The one-line record

“14:10 GP rang, pt worse, told duty MIT J.S. 14:12.” Twelve words — closes the loop, protects the patient, protects you. An escalation that isn’t written down is hard to prove happened.

Your seat

By the time a request reaches your list, it’s been coded and booked. You hold the two things nobody upstream can see: the room as it is right now, and the patient as they are right now — who may be nothing like the referral written three weeks ago. You don’t set categories; you decide order of execution inside the day, and you’re the last person positioned to notice a category no longer fits the human in front of you.

Running the list when the day goes sideways

• Statutory clocks first. The cauda equina pathway is MRI within 4 hours of request, 24/7 — a request that took 45 minutes to reach you is a 3¼-hour request. Know which studies on today’s list carry a clock and how much is already spent.
• Between categories, category wins; within a category, chronology wins. Re-ordering within a category for positioning/coil efficiency is fine when the gain is real and the swap is visible — silent swaps are invisible queue-jumping.
• “Inpatient” is a location, not a priority. The porter at the desk is pressure, not information. (Inpatient deconditioning and discharge delay are real harms — but they argue through the radiologist’s category, not past it.)
• Slippage is announced, never silent. When an add-on displaces booked patients, tell the desk what moved and why, so waiting patients hear it honestly.

The four re-triage moments only you will catch

Same move each time: pause, escalate the observation to the duty radiologist, let the category be re-decided. You’re not diagnosing — you’re reporting that reality and referral no longer match.

Pressure, and the sentence that survives it

• Verbal urgency changes nothing without a category. You never downgrade — query up, don’t quietly demote.
• One RIS comment line per deviation: what moved, who decided. Tomorrow’s “who changed the list?” becomes a record, not an argument.
• Absorbing unmanaged pressure is the burnout pathway, not a professional duty. The ladder exists so conflict lands with the seat paid to adjudicate it — use it early, not heroically late.

Your seat

You are the only checkpoint that assigns or changes a clinical category — everyone else flags to you, and the accountability is yours. That makes vetting clinical work: a vetting queue two days deep is a patient-safety backlog in the same mental category as an unreported trauma CT, because it may contain tomorrow’s cauda equina.

The four vetting questions, in order

• 1 · Justified? The IR(ME)R question, answered by iRefer / ACR Appropriateness Criteria. Urgency never launders justification.
• 2 · Right test and protocol? Wrong-test-fast is slower than right-test-tomorrow — it buys a second wait. Contrast, anaesthetic support or gating change the realistic timeline; recognise that at vetting, not on the morning of the scan.
• 3 · What harm accrues while this patient waits — by the hour, day or week? That answer is the category. Statutory pathways remove the discretion: cauda equina — MRI within 4 h of request, 24/7 (GIRFT/RCR); MSCC — whole-spine MRI within 24 h with neurology, 1 wk pain only (NICE CG75/QS56); head-injury CT within 1 h high-risk / 8 h anticoagulated GCS 15 (NG232); CT KUB within 24 h (NG118).
• 4 · What did the referrer not write? “Urgent — worsening back pain” with no neurology documented is an information gap, not a P3. Two minutes on the phone converts it into a routine spine or today’s 4-hour pathway. When the category turns on missing information, obtain the information — and document the call.

Changing categories — the defensible rules

• Upgrade freely on anyone’s flag, from any seat. Thank the flagger; that reflex is what keeps the flags coming.
• Downgrade in writing — documented reason, and a referrer conversation where the timeline materially changes. “Downgraded, no neurology documented, discussed with GP” survives audit. Silence does not.
• Re-triage is legitimate. A waitlist is not a filing cabinet; new information reopens any category — and the department needs a route for that information to reach you.

The reporting worklist is also a triage queue

• Statutory and time-critical studies first, then harm-from-delay, then chronology. “Inpatient” is still a location.
• Wet reads: the corridor quick-look that never becomes a report is a known discrepancy generator. If you looked, report it — or hand it, explicitly and documented, to someone who will.
• Actionable findings (incidental PE, pneumoperitoneum): direct communication to the referrer, documented with time and name, per the ACR communication parameter and local equivalents.

Registrar overnight rules

• Your escalation threshold is lower than the consultant’s by design. The 3 a.m. call about a possible cauda equina that proves benign is the system working, not failed independence.
• Seniority never sets a category. The fourth phone call and the consultant’s “just do it” are pressure, not clinical information — triage what’s documented and escalate the conflict rather than absorbing it.
• Provisional decisions are decisions. The overnight downgrade you meant to check gets the same documentation as a final one, plus the actual morning conversation.