Emergency Imaging in Flux

 Digital image management processes and advanced imaging systems are changing imaging across the enterprise. The trend is particularly apparent in the emergency department (ED). For starters, digital x-ray expedites patient care, helping clinicians improve throughput. And more departments are turning to other modalities, specifically clinician-based ultrasound, to achieve the common goal of all EDs—efficient, high-quality patient care. Others continue to fine-tune digital processes, developing systems to help manage discrepancies between ED and radiology image interpretations. The ED is not exempt from the explosion in imaging volume. In fact, volumes are increasing, particularly in the data-intense modalities: CT and MRI. On one hand, advanced imaging systems provide data key to accurate diagnosis and rapid treatment. On the other hand, however, increased use of CT and MRI can create backlogs and delay care. The upshot? Digital acquisition and review systems can improve the ED environment, but real progress requires training and planning.

Digital x-ray and the ED

Christiana Care Health System operates two hospitals in the Wilmington, Del., area. Christiana Hospital is a 780-bed acute-care hospital in Newark, Del. It houses a busy ED that sees approximately 80,000 patients annually. The 250-bed Wilmington Hospital has an ED volume in the 20,000 range. Last year, the health system outfitted both sites with Philips Medical Systems digital x-ray systems including two Digital Diagnost Dual Detector DR VMs and 23 computed radiography (CR) systems. ED physicians view images on Philips iSite PACS workstations located throughout the department.

“Digital imaging has improved our ED turnaround. Physicians can see images quicker and thus make [informed and accelerated] treatment decisions,” exp-lains Robert Garrett, administrative director of radiology. Christiana Hospital also has invested in complementary systems to boost efficiency and enhance patient care. For example, three years ago the ED deployed Patient Care Technology Systems EDTracker. The project entailed placing 300 infrared and radiofrequency (RFID) sensors throughout the ED and radiology departments. Now, all ED staff and patients wear a small RFID badge, so they can be tracked throughout the system.

Physicians and other care providers know exactly where patients are located and no longer need to chase patients to transport them to or from radiology. In addition, a stoplight feature monitors the number of patients arriving in the ED. That means when ED volume is high the radiology department can pull staff accordingly to better meet ED needs and maintain patient flow, says Garrett. Ultimately, the combined solutions produce an efficient ED with fluid imaging and patient treatment processes.

Still, Christiana Care plans to squeeze the last drops of efficiency out of its systems. The hospital plans to create an interface between iSite PACS and EDTracker to improve communication between the ED and radiology. “Right now, clinicians know when a patient has returned from radiology, but they don’t know when the radiologist has read CT or MRI studies,” explains Garrett. The interface will alert the clinician to the report, which is expected to expedite care.

Automated discrepancy tracking

The ED at The George Washington University Hospital in Washington, D.C., is primarily digital. The 35-bed ED sees 65,000 patients annually; it’s equipped with two PACS workstations where ED clinicians provide initial x-ray interpretation 24/7. Radiologists read CT, ultrasound and MRI studies; and clinicians read reports in the EMR.

One of the primary challenges in the ED, says Neal Sikka, MD, medical director of Outreach Programs at the George Washington University Department of Emergency Medicine, is the time lag between the initial ED interpretation of film study and the final interpretation in radiology. The lag may be six to 24 hours, which can make it challenging to resolve discrepancies between the initial and final interpretations. Sikka estimates that about 20 of the 200 images read daily contain discrepancies, but the majority of the discrepancies lack proper documentation and are not true clinical discrepancies. “True discrepancies that require follow-up represent only about 2 percent of studies,” Sikka says.

Technology helps remedy the issue. “Every interpretation is documented in the Picis ED PulseCheck record. Radiologists can notify the ED of a discrepancy via phone and maintain a documentation trail through the PulseCheck system. Every morning a resident collects the discrepancies and determines which require a callback,” explains Sikka.

Christiana Care uses a similar automated process to streamline discrepancy tracking. iSite incorporates a discrepancy worklist; if the radiologist’s interpretation differs from the clinician’s, the data drop into a discrepancy folder and an ED provider reviews the discrepancies for appropriate follow-up. “It’s faster, and nothing is lost,” sums Garrett.

Volume explosion

The ED, like other image-intense departments, also bears the weight of imaging advances. Five years ago, a physician might order a cervical spine x-ray for a patient after a car accident and the imaging process concluded with the single study. Today, physicians are more likely to order MRI or CT studies, too. “We have access to the scanners, and it’s easier to order through computerized physician order entry [CPOE]. There’s also a fear of litigation,” explains Sikka. Consequently, some EDs have seen 20-fold increases in CT volume. “CT and MRI studies can slow the process of moving people through the ED,” admits Sikka.

At the George Washington University Hospital, emergency physicians read the studies in real-time, but the configuration is not ideal. “There’s ambient light and noise, and our monitors are not the same quality as in radiology,” says Sikka. Plus, with increasing use of advanced imaging such as CT and MRI physicians are more likely to detect incidental findings such as nodules and benign masses on CTs than on x-rays. “It’s a challenge to determine how to handle all of the additional information,” notes Sikka. The current protocol is similar to discrepancy processes. That is, when a clinically significant incidental finding is noticed on the overread, the ED contacts the patient or patient’s doctor to arrange outpatient follow-up.

The final issue is radiation dose. “There is a risk/benefit ratio. Usually in the ED, the benefit of ruling out a condition outweighs the risk of radiation dose. But I will bring up the issue of radiation dose if the exam seems questionable,” says Sikka.

Clinician-based ultrasound

Ultrasound, specifically clinician-based ultrasound, promises to accelerate ED decision-making, says Patrick Hunt, MD, director of the emergency ultrasound fellowship at Palmetto Health Richland in Columbia, S.C. Instead of the traditional ED ultrasound model where a sonographer acquires a scan for the radiologist to review, clinician-based ultrasound taps into ED physicians to acquire and read the scan.

About 30 to 35 percent of EDs have access to an ED-owned scanner, says Hunt, and departments use ultrasound to assess a variety of conditions including: hemothorax, pneumothorax and abdominal aortic aneurysms. Other applications include kidney, gallbladder and OB studies and central and peripheral vascular access. 

Hunt says the clinician-based ultrasound model can improve care in an array of situations. Take for example the 80-year-old patient who presents with hypotension and back pain. “A two- to three-minute ultrasound [exam] can determine an abdominal aortic aneurysm. The patient avoids CT and can be transferred to the OR in minimal time,” explains Hunt. An ultrasound also can quickly identify cardiac tamponade in a patient stabbed in the chest, and a follow-up scan can assess whether or not the problem is fixed.

Hunt uses seven different ultrasound systems in the ED, including the GE Healthcare Logiq e. The ideal setup, he says, is a cart-based portable unit that can be rolled through the department as needed. He offers advice for sites looking to implement the model:

  • Identify the needs and resources in the ED.
  • Look at a variety of systems and obtain several quotes. Top criteria are image quality, ease of use and data flow and management.
  • Invest in training. A two-day course introduces physicians to basic applications.
  • Follow American College of Emergency Physicians (ACEP) guidelines for post-course applications. That is, a clinician’s first 150 scans should be overread by a radiologist.

The ED and cardiac CT

In September 2006, Kootenai Medical Center, a 246-bed community hospital in Couer D’Alene, Idaho, became the first community hospital to install Siemens Medical Solutions Somatom Definition Dual Source CT scanner. The scanner sits adjacent to the hospital’s ED; the department’s 50,000 annual visits make it the busiest in the state.

The dual-source scanner operates 12 hours a day, seven days a week and scan volume sits at five scans weekly. The ED selectively uses the scanner, referring about one patient per week for a scan. “We use it for specialized and all-around applications, including triple rule outs and CT coronary angiography,” says Chief of Radiology David Moody, MD. Moody attributes the current volume to the less than favorable reimbursement environment, but projects volume increases later this year as a major insurer plans to initiate a pilot program that pays select sites, including Kootenai Medical Center, for cardiac CT.

“We’re trying to lay the groundwork for the future. I see the day when we’ll need 24-hour cardiac CT and advanced imaging coverage,” Moody says. The hospital recently undertook the first step and agreed to 24-hour CT technologist coverage for the dual-source CT and a second Siemens Somatom Sensation 16-slice scanner. The next prerequisite, says Moody, is well-established national reimbursement for scans. Finally, the hospital needs to make sure its teleradiology provider can offer excellent interpretation on overnight dual-source scans.

Fine-tuning ED imaging

ED imaging is complex. Stat studies are the norm, and multiple physicians may be involved in the interpretation process, which can lead to discrepancies and communication challenges. But departments across the country have tapped into a variety of solutions to improve imaging processes and patient. Digital x-ray, clinician-based ultrasound and PACS promise to speed imaging and treatment. Cardiac CT represents one of the next leaps in ED imaging. It promises to speed diagnosis and treatment in emergent cardiac cases. Hospitals that lay the groundwork for emergent cardiac CT including scheduling, training of techs and radiologists and image review processes should be well-poised for the future.