Radiologists, clinicians and IT professionals agree - PACS is an enterprise solution. A truly successful implementation not only meets the needs of radiology but also benefits departments across the enterprise. One of the departments that can reap significant gains with digital image management is the emergency department (ED).

''Our ED was a strong proponent of PACS from day one because they could see what it would do for them," reports Susan Johnson, operations director/PACS administrator for Mercy Medical Center on Des Moines, Iowa. Hospitals that carefully account for the needs of the ED during the PACS implementation process realize substantial clinical and productivity gains.

For starters, the real-time, on-demand viewing enabled by PACS can accelerate the clinical decision-making and treatment processes. PACS enables virtual consultations among multiple clinicians and sub-specialists to improve and speed clinical decision-making. Finally, the ED is not immune to the lost film plague, and PACS eliminates the issue.

"ED demands on PACS differ dramatically from other areas of the hospital," says Thomas Egglin, MD, chief of emergency radiology at Rhode Island Hospital and associate professor of radiology at Brown University in Providence, R.I. Successful image management in the ED hinges on a number of factors, and the needs of the ED should be addressed during the selection and implementation process. The hospital needs to determine optimal processes, which can vary by the type of ED and even within a single ED. Questions to answer include:

• How many workstations are needed? What are the optimal locations?
• What types of workstations and monitors are ideal?
• What are the procedures for PACS downtime?
• Is web distribution appropriate? How and where should it be implemented?
• How will ED physicians be involved in the process? What type of training is necessary for optimal use?
• Is the network solid enough to push images to the ED?
• How can complementary components such as voice clips benefit the ED?

This month, Health Imaging & IT visits with several hospitals across the country that have successfully tackled image management in the ED.

Trimming turnaround times

One of the primary drivers for PACS is reduced turnaround time; STAT turnaround is essential in the ED, and PACS can facilitate dramatic drops in turnaround time.

"Turnaround times have substantially improved with PACS," confirms Linda Womack, regional manager for imaging systems for Sutter Health in Sacramento, Calif. Womack oversees imaging systems for five Sutter Health hospitals, including Sutter-Roseville, a regional trauma center. In the film world, wet-read turnaround to the ED averaged 15 to 30 minutes. Now, images are instantly available via Siemens Medical Solutions Magic Web, and most are read by radiologists within 10 minutes. The interim steps of prepping jackets, completing paperwork and locating prior images are eliminated with digital image management.

The immediate availability of images to both the radiologist and the emergency physician can accelerate care. For example, in some cases like simple fractures, the emergency physician no longer needs to wait for the radiologist's interpretation to begin treatment. "Some cases don't require a radiologist, which helps workflow, especially at night," notes Womack. In addition, consults are facilitated by PACS. "Physicians can remain in their own areas and consult with third-party specialists like neurosurgeons or orthopedic surgeons by phone," explains Womack. And each clinician can view the same set of images during the consult. What's more, priors are universally available. That is, prior images acquired at all Sutter-Novato emergency rooms are available across the five-hospital enterprise. In addition, the written radiology report is displayed with the images on Magic Web.

Mercy Medical Center has seen turnaround time to the ED drop to five minutes since implementing a Kodak PACS in August 2002, says Johnson. Yet the Level 2 trauma center aims to clip that time even further. The site may place a large, flat-screen monitor on a wall or boom arm at its two-bay trauma room using a video splitter to achieve a dual push to PACS and the monitor. The dual push, coupled with digital portable x-rays, could eliminate the brief delay that occurs as the tech runs CR images.

Turnaround time is one component of image management. Another factor is length of stay. Imaging can shorten length of stay in the ED, says Egglin. When Rhode Island Hospital implemented a GE Healthcare Centricity PACS, it established a nominal target of a three hour length of stay in the ED. "Before [PACS], that was almost unattainable," claims Egglin. Now, it's within reach. What's more, Rhode Island Hospital has seen patient satisfaction increase from 30 percent to 90 percent since its ER redesign this spring - with filmless image management as a key redesign component.

Location, location, location

The ED, unlike radiology, may not have a central reading area for image review. In some cases, it does not make sense to require physicians to leave patients to view images. At the same time, it may not be financially feasible to equip each ED room with a PACS review station.

Hospitals can determine optimal placement and viewing conditions by involving ED staff in the PACS process. Michael Cloutier, manager technical services, systems analyst RIS/PACS for Catholic Medical Center in Manchester, N.H., says, "We met with ER leadership during the PACS selection process. We wanted to understand the current film workflow and how PACS could improve that workflow. We also wanted to get a handle on potential adverse effects from PACS." The list of projected PACS benefits for the full-service, 24-room ED included immediate availability of images, elimination of lost films and consultative viewing.

But PACS can have a downside, says Cloutier. "With film, clinicians can bring an image anywhere within the ED," he says. "This option is not available with PACS except with a high dollar investment." Most Catholic Medical Center departments rely on a GE webserver for image viewing, but this was not considered a viable option for the ED as key functions like Exam Notes, an essential communication tool, would not be available. It also was cost-prohibitive to equip each ED treatment room with licensing for the core application.

Catholic Medical Center circumvented this potential obstacle with careful placement of PACS workstations. One is located in the main area of the ED, and a second is housed in the fast-track area. The hospital plans to add a third workstation to improve workflow. The newest workstation will be placed in an area that is accessible to the clinicians on the 'other' side of the ED to allow multiple clinicians to view images in an area close to where they are working.

Similarly, ED clinicians at Arkansas Children's Hospital in Little Rock were very involved in equipment placement, says Keith Smith, RT, senior project manager, IT applications department. "The ED wanted access to images in every acute care room, so that physicians would not have to leave a critical patient and walk across the department to look at a lateral cervical spine image," explains Smith. Every computer in the ED has access to DR Systems PACS web server via a single Meditech login. There also are six dedicated PACS review stations in acute-care rooms and the ED physicians' work room. The review stations have dual-monitor setups, allowing physicians to easily compare prior studies if needed.

The whats of PACS review stations are just as important as the wheres. "Don't force ED physicians to make do with the minimum," Smith says. "Give them what they need to do their jobs. I sleep soundly knowing that they are making critical decisions in the middle of the night using the equipment we provide. The ED needs better monitors and workstations than just your average PC and off-the-shelf monitor."

Arkansas Children's Hospital placed two DR Systems LAN ambassadors and four licensed CSLAs (customer-supplied LAN ambassadors) in its ED. Each of the ED PACS review stations at Arkansas Children's Hospital is equipped with dual-display, two-megapixel LCDs.  "I have yet to hear one complaint from any of our physicians that they can not see what they need to see on an image using the two-megapixel LCDs," says Smith.

The hospital improved the ED reading area by providing an area for physicians to review films outside of the flow of the busy department.  It added adjustable lighting to aid in viewing images by cutting down screen glare and sound-absorbing panels to help reduce the ambient noise inherent in an ED.

Johnson of Mercy Medical Center says improper lighting is often the culprit when ED physicians complain about resolution. "Resolution on high-end, off-the-shelf hardware is great-as long as the fluorescent lights are dimmed," she explains.

Lighting is not the only factor that can disrupt reading. Rhode Island Hospital focused on the flow of people in the ED reading area and implemented paperless processes to limit the number of times techs enter the ED reading area.

Implementing PACS in a trauma center can be more difficult than a standard implementation, says Womack. Physicians need to see images on demand; sometimes they need to view images as the technologist is taking them. The trauma rooms at Sutter-Roseville are equipped with dual-display, three-megapixel monitors, and the system is configured for a dual push from modalities to PACS and the trauma rooms, which allows physicians to view live images. The system streamlines consults among trauma physicians, radiologists and subspecialty physicians. "All three can discuss a case by phone while viewing the same images. This enables immediate decision-making," explains Womack. The hitch, says Womack, is to make sure that techs know where to transmit images.

Behind the scenes: Driving digital image management

Sutter Health relies on a 100 megabyte network to transmit images within its hospitals. Most ED physicians view images on one-megapixel, dual-display monitors; enhanced video cards are used to drive the monitors and boost the workstations' one gigabyte memory. "The enhanced video cards help with CT studies," shares Womack. A one gigabyte network runs between the hospitals and a data center that houses the brains of the PACS. Arkansas Children's Hospital has a one gigabyte network backbone, but plans to boost it to a 10 gigabyte backbone.

Another challenge is handling downtime. "The ED requires very robust downtime procedures," says Egglin. "The flow of patients doesn't stop if the PACS goes down. You can't divert patients away from the ED, so downtime procedures must be defined in advance." ED clinicians at Rhode Island Hospital can turn to 3D workstations for CT viewing and Fujifilm CR QA workstations for plain film viewing to continue reading if the PACS goes down.

Sutter Health set up dual servers for dual redundancy. The live hot-spare configuration has two benefits. The hospitals can balance loads among the two servers, and they also can disable one side for maintenance without any impact on end users. The upshot? "Magic Web is up 99.99 percent of the time; the technology is virtually never down," says Womack.

Doing it right: Training

A successful PACS deployment depends on human factors in addition to technical and practical issues. "Most obstacles are not physical or technical, they're mental," reports Cloutier. When Catholic Medical Center installed PACS, it did not want a lack of training to become an obstacle for clinicians to not using the system.

The hospital relied on a one-on-one approach to training, scheduling a technical and radiology rollout before the actual go-live date. During this period, every time an untrained physician needed to review cases, a trainer went through the case on film and PACS. "This approach was very labor-intensive, but was worthwhile because clinicians were more relaxed and willing to ask questions in a one-on-one environment," explains Cloutier.

Catholic Medical Center divided training into two sessions. In the first, clinicians were introduced to the basics - window/level tools and accessing the next image. In a few weeks, a trainer revisited the physician to introduce the rest of the PACS toolbox.

Solo sessions need not consume vast quantities of precious physician time. Sutter Health relies on formal trainers for ED physicians and other staff. Magic Web is very intuitive, and users can learn the system in less than 10 minutes, says Womack. Johnson points out, "Hospitals need user-friendly solutions in the ED. If a training session takes one hour, it won't fly in the ED."

Even with user-friendly, intuitive PACS, training the right users at the right time is critical. Johnson of Mercy Medical Center stays in close contact with the hospital's ED director so that she knows when new staff need training or experienced users require a refresher. "ED staff can't wait a few weeks for training when they need help. I send the PACS trainer in on nights or weekends if it's needed," notes Johnson.

The extras

There are a variety of tools that can enhance digital image management in the ED. Arkansas Children's Hospital implemented DR Systems' Instant Reporter with its PACS. The digital dictation system allows the radiologist to save an impression of a study as a voice clip, and the ED physician can listen to this "reader's digest" version of the interpretation as results are sent to transcription. The combination of PACS and digital transcription has dropped turnaround time from 24 to 48 hours to four to five hours at Arkansas Children's Hospital.

Catholic Medical Center relies on GE's ExamNotes to facilitate communication. Cloutier describes ExamNotes as the equivalent of an electronic Post-it that can be used to relay information like the preliminary reports by either the ED clinician or the radiologist to other users. The ExamNotes tool also documents contrast materials and communicates miscellaneous information.

Conclusion

PACS can bring substantial benefits to the ED, improving clinical care and turnaround times. These benefits, however, are not necessarily a given. Hospitals that pay close attention to the needs of the ED before, during and after PACS implementation are most likely to realize results. This usually entails a collaborative effort between departments and requires an analysis of ED workflow and image viewing needs to devise an optimal solution. Image management components to consider include the types of workstations and monitors, viewing locations and conditions, training and tools to facilitate communication between radiologists and clinicians.