Preparing Your CT Workflow for the Multislice Data Deluge

hiit040402.jpgMultislice CT scanners provide un-precedented imaging capabilities but unless you change your workflow to accommodate the exponential increase in data, you’ll drown in post-processing work.

So says Jay Cinnamon, MD, neuroradiologist and director of 3D imaging at Quantum Radiology Northwest in Marietta, Ga. The organization is equipped with more than a dozen CT scanners, with four Philips 64-slice scanners soon to be installed.

“In the early days of CT, it took a lot of time to generate a limited amount of data,” he says. “It wasn’t much of a challenge to blend technology with human resources workflow.” Multislice CT, however, puts facilities in a situation where the scanners are turning out huge amounts of data in a much shorter period of time. “We need to think innovatively about how to maximize human resources. Workflow and optimized human resource utilization are absolutely critical to handle the deluge of data coming out faster than we ever expected.”

Put PACS in place

A PACS is an essential first step on the road to multislice CT, says W. Daryle Heath, BS, RT(T)(CT), CT supervisor at St. Dominic Jackson Memorial Hospital in Jackson, Miss. “If you don’t have a PACS, you’re putting the cart in front of the mule,” he says. There’s no point in investing almost $2 million on a scanner just to produce films, he says. Hospitals need to develop an appropriate infrastructure before investing in a multislice CT scanner. “If you don’t have a profitable way of managing the data you’re collecting, there’s going to be a problem.”

Without a PACS, facilities are archiving data either on rewritable DVDs or magneto-optical disks (MODs) which is extremely expensive, Heath says. That might result in changing MODs four to six times a day. “At $60 or $70 a pop, that’s a lot of money a day.” And a lot of inefficency, too.

That’s the situation Duane Ronholm, administrator and director of imaging services at Passavant Area Hospital, Jacksonville, Ill., faced last year. The facility installed a Siemens SOMATOM Sensation 64 last June but, despite the best laid plans, its PACS wasn’t up and running for another six months. Although Ronholm tried to time the two installations better, his staff downloaded images onto a MOD and stored them until the PACS was installed.

The purchasing team at Passavant was originally considering a 16-slice scanner but decided that 64 slices would better help them tap into the market for cardiac work. Patients were going 30 miles away for procedures such as angiography. “We’re able to handle just about anything they can throw at us nowadays,” Ronholm says. “We still have room to add more volume.”

Tap tailor-made techs

One way Cinnamon has handled the new flow of information is by employing “super techs” — technologists who understand disease processes at a higher level than the typical technologist with a CT or MRI background. They also understand post-processing. “You need a fairly intimate understanding of how the software works to pull out as much information as possible from the studies as efficiently as possible,” he says.

Radiology educational programs are devoting some time to teaching advanced post-processing skills, Cinnamon says. But, “the jury is still out on what you need” for a good multislice CT technologist. He has found that, more important than experience in CT, MRI or vascular radiology, is someone who is very focused, meticulous about details and self-motivated to learn this new area including the disease processes, software, and working environment. An ultrasound tech with these skills could do as well in this arena as someone experienced in CT, Cinnamon says. But you need someone with the drive for this niche. “You can’t force somebody into this position who is used to working with patients,” he says. “This type of work has to be stimulating to them.”

The CT staff at Passavant has responded very well to the new 64-slice scanner, Ronholm says. He sent four technologists and a radiologist to Siemens’ training for the basics. Then, two techs learned post-processing through Siemens and the other two spent some time working one-on-one with technologists at another facility using the same equipment. “That worked out really well,” he says.

Since installing the 64-slice scanner last June, Ronholm has added a technologist to the day shift and expanded the department’s hours. The facility used to have 24-hour coverage five days a week and 16 hours on Saturdays and Sundays. Now, scanning staff is available 24 hours a day, seven days a week.

“The best advice I could give is to train your staff” ahead of the installation, says Ronholm. Despite another, nearby facility installing the same scanner one month earlier, Ronholm’s team is doing better with the increase in data and number of procedures. In fact, the number of CT scan requests has increased 20.8 percent since the  move to 64 slice. “We’re doing better work than they are,” he says. Although the training was “a little costly,” it has paid off in the long run, he says.

Heath purposely doesn’t hire technologists with a lot of CT experience. Although that experience may be coveted by most facilities, Heath finds that a CT technologist with 10 years of experience is going to be hard for him to train to his liking. “Human nature is to resist change,” he points out. “I found that it is easier to find a young person six or eight months out of school who wants the knowledge and wants to be trained and for me to train them over six months into the way that we scan.” That makes the technologist more loyal to Heath and more likely to stay longer.

Consider centralized 3D

Another step to successful multislice CT workflow is establishing a centralized 3D lab. Most of the work is done here at Cinnamon’s facility, which cuts down the time per study to about 10 minutes. The technologist does the majority of the work in the 3D lab, leaving about 10 percent for the radiologist to perform. Cinnamon started working in a 3D lab years ago in an academic center with lots of resources. But, as hardware, software and connectivity have improved, the 3D model is now “ready for prime time,” he says.

Cinnamon teaches a course about radiovascular imaging to radiologists and cardiologists, and has found that most don’t have a full grasp of what is required of them to make multislice CT scanning work well. “I get the feeling that the first response is shellshock. Multislice CT is more complicated than they anticipated. They don’t understand the value and need for post-processing. They think the scanner will do it all. They have no understanding of the time and workflow issues involved.” In fact, Cinnamon says many bought advanced scanners expecting to launch new clinical applications. But without a thorough understanding of post-processing procedures, they can only handle one or two studies a day. “Once their volume picks up, they drown in post-processing work.”

For example, many facilities are conducting CT angiograms of the head and neck the “old way,” Cinnamon says. The CT technologist does the study, and generates about 400 images which are sent to the workstation. The radiologist processes all the images, sends some to the PACS archive and then dictates the study. The radiologist spends about 45 minutes on one procedure.

The 3D lab also helps temper the variable computer skills among the 39 radiologists and six neuroradiologists at Cinnamon’s facility. Since not everyone can sit at the workstation and work with the same level of efficiency, there is no guarantee that the results will be the same, he says. “The studies could be processed differently.” But, with everything coming through the centralized 3D post-processing lab, the two technologists level the playing field. “Everything is funneled through them, guaranteeing that the end product will look the same. That cuts out the radiologists’ variable interpretation skills,” he says. And that means the results are consistently high quality.

Change the scanning mindset

Heath’s facility served as a beta testing site for GE Healthcare’s LightSpeed VCT. He noticed that radiologists were generating much more data but still scanning in the same mindset that CT has always been done — axially. They are scanning faster but still axially. “Radiologists are used to seeing images axially. They’re moving toward reading in a volume, reading the scans sagittally and coronally. The thinner slice profiles generate information and the slices were being archived to PACS or produced for interpretation. “Once you’re scanning above 16 slices, you’re utilizing the scanner to its fullest capacity but still axially.” Heath doesn’t archive that data but uses them to reconstruct sagittal and coronal images of that data set. It only stays on the scanner’s hard drive until it gets full after a couple of days and the data are dumped to clear up space. Heath only archives axial slice protocols that the radiologists are used to seeing.

“With 16 slice [CT], radiologists would read everything through the axial images and use whatever sagittal or coronal reformats that were produced for problem solving. As they become more accustomed to reading, radiologists are probably going to move to reading everything in a volume. They will make their diagnosis through sagittal and coronal reformats.” That’s the complete opposite of past procedure, Heath says. And it creates workflow challenges. “If we’re going to supply that information to radiologists, we’re going to have to devise a way to make as much of the process automated as possible.” That includes multiplanar reformats and software that you can designate to automatically build sagittal and coronal images off of the submillimeter dataset you’ve acquired.

Automate & standardize

Heath also uses GE Healthcare’s Xtream FX workflow technology, which helps his team keep up with the large volume of data generated by routine sub-millimeter scanning. The company developed the technology because they learned that radiologists’ biggest challenge is getting both the high resolution needed for increased diagnostic confidence and having time to read the increased volume of thin-slice images. Xtream provides thin-slice reconstruction 3.7 to 6.9 times faster than other industry standard platforms. Heath can start scanning the next patient while the previous study is still being reconstructured without losing any of the reconstructing data.

That is very important, he says, because the last thing you want is an empty table. “Any time the scanner is empty, money is being lost.” Sixty-four slice scanners allow facilities to perform more detailed CTAs, neurological CTAs, peripheral runoffs, and cardiology CTAs — procedures that help them recoup their investment dollars. “As much automation as you can get will enable your workflow to move through. The last thing you want is a department with the capability to do these exams but it is bogged down with manually doing sagittal and coronal reconstructions.” Heath set up Xtream FX to automatically build sagittal and coronal images from the sub-millimeter data set already acquired. Those images are then sent directly to the PACS. “You can effectively control your workflow if you use the software to its fullest capacity.”

This process has ensured that Heath has zero backlog. And, even though the scanner schedule is full, Heath can still accept add on procedures throughout the day. “If a referring physician calls and wants a scan today, he or she gets it today. You’ve got to be able to offer that.”

Test software for standardization

Heath recommends that you thoroughly test any software you’re considering. Try to use all of the tools, he says. “If it’s not easy or you’re not able to set up and standardize your procedures, then it won’t be utilized.” Xtream FX allowed him to link features to each protocol to establish standardization. So, anyone reading images has the same set protocols for a given diagnosis. “Whether we’re conducting a study today or a follow up in six months, we’ll get the exact same scan. That’s very important for the disease process,” Heath says. Standardized protocols aid productivity which helps your workflow. And the better your workflow and productivity, the happier your administration, radiologists and referring physicians are. You’re also providing better patient care, Heath says.

He admits that standardizing his department was an arduous process. But, doing so made it much easier to transition to a 64-slice scanner. “Basically, all we had to do was see what kind of capabilities the 64-slice scanner had.” Heath was ahead of the curve because he was already doing thin-slice profiles on a 16-slice scanner to evaluate the software. When the 64-slice scanners came online at Heath’s facility, he only had to download the protocols he’d already built, and tweak some table speeds and other scan protocol issues. “It was pretty seamless but that is not the norm industry wide.” Many CT departments are going from a 4-slice to a 64-slice scanner — a quantum leap, says Heath. Those going from a single helical scanner to 64 slices are making an unfathomable change, he says.

But whatever the increase in slices, Heath says there are several requirements if you want to be productive, profitable, progressive, and offer exemplary patient care. Those include standardization, supportive administration, the willingness to invest in all the necessary technology, progressive radiologists, and a CT staff who is willing to be progressive and accept new things. “If you have a department that’s always done something a certain way and always will, it doesn’t matter what kind of scanner you give them. If they’re not willing to embrace the new technology, you’re not going to get anything out of it.”


Why are we counting slices?

A big challenge for radiologists and cardiologists when it comes to multislice CT is moving away the concept of slices, says Jay Cinnamon, MD, neuroradiologist and director of 3D imaging at Quantum Radiology Northwest in Marietta, Ga. “The whole paradigm has changed. For 30 years, we’ve been thinking of CT as slices.” Now we’re talking about computerized volumetric data rather than slices.

Clinicians are no longer interested in any single slice — they’re not going to declare a diagnosis based on one 0.756 slice. The technology that creates thinner slices can be processed into more meaningful clinical images.

Cinnamon says we should move away from the term “CT.” That term conjures up the idea of images and slices, he says. “We’re interrogating a body part volumetrically. We can now get 5,000 pieces of data but that’s not what we’re interested in.”

The transition from 64-slice to 256-slice scanning won’t be a big transition, Cinnamon says. 256-slice scanners are ready to go but haven’t been rolled out because the computing ability doesn’t yet exist. By the time they appear on the scene, Cinnamon thinks radiologists and cardiologists will no longer be thinking about slices but “computerized volumetric imaging studies.”