Evaluating Adherence to iRefer Guidelines and Barriers to Implementation Among Non-consultant Hospital Doctors in a Model 3 Hospital: A Mixed-Methods Study

BackgroundThe Royal College of Radiologists' (RCR) iRefer guidelines are an established evidence-based clinical decision support tool intended to optimise diagnostic imaging referrals, reduce unnecessary radiation exposure, and improve radiology workflow efficiency.In Ireland, imaging referrals also carry statutory weight: Statutory Instrument (S.I.) No. 256 of 2018 places defined duties on referrers regarding the justification of medical exposures, and Health Service Executive (HSE) guidance requires referrers to have access to iRefer or an equivalent decision support tool.Awareness and use of iRefer among non-consultant hospital doctors (NCHDs) in smaller, high-turnover hospital settings are poorly described. AimTo evaluate awareness, utilisation, and accessibility of the iRefer guidelines among NCHDs in a Model 3 hospital and to identify the systemic, technological, and cultural barriers preventing routine use. MethodsA sequential explanatory mixed-methods design was employed.Phase 1 comprised an in-person, anonymous cross-sectional audit questionnaire developed by the authors for this study, administered to NCHDs to assess awareness, decision-making sources, and guideline concordance across three clinical scenarios.Phase 2 comprised semi-structured, one-to-one interviews with a purposive sample of nine NCHDs across five specialties (emergency medicine, orthopaedics, general surgery, general practice, and general medicine).Interview transcripts were analysed using Braun and Clarke's reflexive thematic analysis framework.Ethical approval was granted by the institutional research ethics committee, and written informed consent was obtained from all interview participants. ResultsQuestionnaires were distributed in person to 90 NCHDs, and 70 completed forms were returned (70/90; 77.8%).No awareness of iRefer was reported by 51/70 respondents (72.9%), and only 1/70 (1.4%) reported being fully aware; 44/70 (62.9%) were unaware of their legal responsibilities as referrers under S.I.No. 256 of 2018.When managing a complex case, 49/70 (70.0%) relied on advice from senior colleagues, and only 1/70 (1.4%) consulted iRefer or an equivalent decision support tool directly.Across three clinical scenarios, guideline-concordant responses ranged from 12/70 (17.1%) to 43/70 (61.4%), and only 4/70 (5.7%) answered all three scenarios concordantly.Qualitative analysis of nine interviews identified six major themes: an almost universal absence of awareness of iRefer and any formal induction to it; reliance on alternative, informal, or specialty-specific decision-making sources; time and workload pressure; information technology and systemic access barriers; recurrent interdepartmental conflict with radiology; and a consistent set of participant-generated recommendations. ConclusionsNCHDs in this Model 3 hospital demonstrated minimal awareness of, and no formal induction to, iRefer, relying instead on clinical judgement and informal or alternative sources.This represents a gap between current practice and both clinical best-practice standards and the referrer duties set out in national radiation protection legislation.The findings support mandatory radiation protection and referrer training at induction, embedding indication-based prompts into the imaging ordering system, and formalising communication pathways between ordering clinicians and radiology.