Digital radiography (DR) allows radiologists to quickly get excellent images using a low dose of radiation. For sick, traumatically injured patients, the ability to move the equipment around them is crucial. And, rapid access to the images can help doctors make life-saving treatment decisions as quickly as possible. Space, training and physician buy-in are some of the challenges facilities face when implementing DR.
Erlanger Health System, based in Chattanooga, Tenn., installed two Kodak 9000 DR systems earlier this year. The organization was ready for DR and decided on the Kodak 9000 for several reasons, says Blaine Morris, RTR, CRA, MBA, administrator of radiology services. “The DR 9000 is designed specifically for the ER,” he says. It has electric tables that can be moved in and out of rooms easily and it is battery operated so no one has to step over wires when working on critically-injured patients at the level I trauma center. And, the physicians can more easily get images that used to involve carefully positioning the patient — a challenge when there might be tubes and suction in place.
Erlanger rebuilt its emergency department specifically to accommodate DR. The facility already had Kodak CR systems installed in several locations. However, the emergency department had two x-ray suites originally built in the 1960s. The remodel made the space more efficient. The radiologists were moved out of a large reading room and into the main department so the space could be used for DR.
Sticking with one vendor
Morris says they went with Kodak DR because “the Kodak interface with the CR is real simple. It looks the same so training the techs was a lot more effective. And, the fact that we could process CR plates at the DR console was very nice.”
DR has satisfied Erlanger’s trauma residents’ desire to see images immediately. “They want to see images even while the procedure is going on,” says Morris. That speed has increased efficiency to the point that many inpatients are now brought to the ER for imaging procedures. “We have extra capacity there and we take advantage of it,” Morris says.
Moving to DR with the same vendor already providing CR is a popular strategy. Geisinger Health System in Danville, Pa., installed Fuji’s Velocity DR more than a year ago, says Sally Womer, coordinator of quality improvement and business development for radiology. The system already used Fuji CR and Womer went with Fuji DR because “they could guarantee that the images would be identically matched to the CR images.”
The primary goal was speed, she says. And, they wanted a room specifically designed for the sickest of the sick so they could get any image without having to move patients. DR provides both.
The quick image processing also makes DR more dose efficient, says Morris. Rather than spending time processing plates, clinicians can look at an image in less than 60 seconds. “If you need to repeat something because of positioning, you know it right away,” he adds.
Perfect for pediatrics
One patient population that really benefits from the lower radiation and excellent images offered by DR is children. Children’s National Medical Center (CNMC) in Washington DC recently installed flat-panel direct digital radiography from Swissray International—across from the emergency department and within orthopedics, two of the facility’s busiest areas. Although users are just wrapping up their learning curve now, Technology Manager Bruce Dietrich says he expects to see “greater throughput as we progress with more use.”
CNMC chose Swissray for its unit specifically designed for pediatrics. And so far, the radiologists are very happy with the images.
DR offers double the resolution at half the exposure, says radiologist Raymond Sze, MD, which is “a big deal for children as we’re always looking for opportunities to reduce radiation dose.” Another plus is the improvement in workflow since technologists don’t have to use cassettes and go back and forth between different pieces of equipment.
The most problematic areas for both CR and DR, Sze says, are images of baby hands and ribs, particular premature babies. “Those are areas for which we need the best possible technique.” In tiny patients, it can be difficult to get the resolution needed to see tiny fractures.
For a facility with very busy pediatric imaging population and service, child abuse is a major concern. “Oftentimes, radiologists are the first to raise the flag,” Sze says. “Looking out for child abuse is one of our biggest responsibilities and we need the best possible equipment to confidently make that diagnosis.” A patient with soft tissue trauma or failure to thrive might raise suspicions among clinicians, but excellent images of subtle fractures can help providers advocate for children, he says.
Although it offers several advantages, DR will never replace CR, Sze says. If a child can be positioned properly, DR is superior. However, if a child is too sick to come to the unit, the portability and greater versatility in positioning in CR makes it superior, he says. “We see the two as complementary.”
Sze says there are a lot of opportunities for applying modern shape recognition to conventional radiography. He hopes that research in the acquisition and analysis of DR images will help to create a package of analytic tools specific to pediatric radiology. “There are many studies we interpret as pediatric radiology specialists, such as bony dysplasia, leg length discrepancies, and club feet that adult radiologists often feel uncomfortable with.” A diagnostic package would help in the interpretation of pediatric studies where pediatric imaging specialists aren’t available.
Better quality, faster throughput
Whatever the study, DR has the edge over CR, considered by some to be an old-fashioned technology. Trillium Imaging Inc., a four-site radiology practice in Toronto, has been using DR from Imaging Dynamics since January. CR is an obsolete technology for general purpose radiography, says Murray Miller, MD. He says that DR image quality is terrific and the techs love it. Because of that, he is able to retain technologists and produce more volume with fewer people—an important benefit in Canada where there is a technologist shortage.
Stuart Mirvis, MD, director of emergency radiology/trauma radiology at the University of Maryland Medical Center’s Shock Trauma Center, is a relative veteran of DR. The facility installed DR back in 2003. The Shock Trauma Center sees lots of polytrauma cases, including gunshot and other penetration wounds. “We need to survey the whole body in one shot,” Mirvis says. That one shot replaces the 10 to 14 separate x-rays the technologists used to do which was extremely labor intensive and time consuming.
Despite the differences from other systems the techs were used to, they grasped DR really quickly, Mirvis says. The bigger challenge was getting the surgeons and nonradiologists to use the PACS to read images. “It took a long time for them to accept it,” he says. Although, once they gave it a try, they quickly saw for themselves the benefits.
One change the physicians did have to make was adjusting for the fact that DR provides a compilation of x-rays which they tend to read as one big x-ray. “They need to take a body part and view it separately — magnify the image and make appropriate adjustments. Radiologists don’t learn to read images in that fashion. Now they need to read everything there.”
The increased throughput was the driving factor for installing DR, says Mirvis. As the only level I trauma center in Maryland, the facility treats a lot of severely injured patients and needs to get as much information about injuries as possible quickly. Although administration “puts a jaundiced eye on any purchase, it wants to have the best possible equipment,” he says. The decreased time needed to image patients along with the decreased dose needed was significant enough to provide a clinical justification for the investment in DR.
UMMC recently began using an adaptor for the DR system that allows for higher resolution of something of concern seen in the survey mode. The physician can focus in on the region of interest and adjust the views and angles to get the most accurate information.
Another veteran, Todd Stanley, director of radiology at Indiana University Hospital, has been using Siemens DR for two years. Stanley says the image quality is better than CR and better than he was expecting. “I strongly recommend DR,” he says. “It’s much more efficient and effective.”
The faster throughput means images can be viewed within six seconds. And, the technologists don’t have to work with cassettes. Stanley says the facility went with the robotic option so that they wouldn’t have to invest in two digital plates, which are expensive to maintain. “We could get what we needed with no CR reader to maintain,” he says. The facility has eliminated one of the four rooms dedicated to radiology thanks to the increased efficiency and staff has decreased from five technologists to three. Meanwhile, volume has stayed the same but the turn-around time for the average imaging appointment has gone from 50 to 60 minutes down to just 21 minutes.
The lower dose DR requires is good for pediatric patients and women who are pregnant or might be pregnant, Mirvis says. It also allows for good bone surveys instead of much more time-consuming, high-dose studies. Radiologists also can perform digital angiograms right on the table, following the contrast bolus right down a leg, for example.
One growing challenge is imaging obese patients. “Trauma has always had a tendency to see more of the larger population,” Mirvis says. Certain areas are particularly difficult to image in the obese, such as the chest, stomach, and spine.
“We’re almost always trying to see a C7 and shooting through giant shoulders for critical information,” says Morris. “CR is just not adequate. DR lets us get better images of large patients.”
Components for successful DR
Once you’ve decided to migrate to DR, plan your implementation wisely, warns Womer. She recommends establishing a conversion date and sticking to that date.
And get your administration to support the implementation, she says. Physicians “need to hear from the top that this is going to happen.”
Successful DR implementation also requires a strong IT staff, says Womer. When Geisinger is going to “flip the switch” in an area that’s heavily into imaging, she deploys all 10 IT staff members to that area. “It’s a handholding session for the most part. You almost need to have IT people there to hold clinicians’ hands.”