Image Workflow in the ED

 Emergency medicine professionals working in trauma centers must deliver prompt diagnosis and treatment to critically or acutely injured patients. Radiology has always been an integral part of emergency medicine. That’s why PACS and the streamlined image workflow it offers is having a huge impact on the way multidisciplinary trauma teams handle their most critical of patients.

The 343-bed Bronson Methodist Hospital in Kalamazoo, Mich., which is part of Bronson Health-care system, operates a Level 1 Trauma Center. At its pediatric intensive care unit, Bronson’s ED treats adult traumas as well as children. Nearly 230,000 medical imaging procedures are performed annually throughout the hospital and ED patients account for nearly a third of that volume, says Brook Ward, executive director of clinical and ambulatory services at Bronson.

“The bulk of the work that gets done on a trauma patient has to happen very timely, and in some cases, immediately,” explains Ward. “Physicians need radiology services to help diagnosis and determine what is wrong with their patient so they can take care of them either back in the trauma unit or directly in surgery. Radiology has to partner with the ED and be ready when a patient arrives to be able to provide images and interpretation as quickly as possible.”

Bronson moved operations to a brand new facility in 2000. For efficiency, Bronson constructed its inpatient radiology department adjacent to the ED (out patient radiology is right across the hall). Technologists will perform portable x-rays in the ER, but most trauma patients are quickly transported and imaged directly in radiology. For an extra dose of efficiency, Bronson installed PACS, Fusion Matrix PACS from Merge eMed. 

The advantages of having PACS in an emergency setting are many, says Ward. The radiology staff saves time because they do not have to handle film. Technologists no longer wait for films to be processed nor do they have to physically bring them to the radiologists’ reading room. Once the technologist completes a sequence of exams, the images are automatically saved in the PACS; ready to be viewed by the physicians. A physician also saves valuable time when needing to view historical films because they are now online.

In the past, trauma surgeons would ‘follow’ the films to the radiologist reading room for a consultation. With PACS, the trauma surgeon stays with the patient in the ER and calls the radiologist if he or she has a question on a diagnosis or treatment. “Physicians now expect to see radiology images within seconds of exam completion,” adds Ward. “I think PACS has changed the way physicians practice emergency medicine because their expectations have changed.”

CT in the ED

Norman Regional Health System serves healthcare needs throughout south central Oklahoma. Its flagship, 337-bed hospital recently opened a new ED equipped with state-of-the-art trauma equipment, on-site ultrasound, a new CT scanner, new x-ray rooms and a mini C-arm for orthopedic physicians. 

Norman’s busy ED treats approximately 60,000 acutely ill or injured patients annually. Physicians rely on advanced technologies, such as digital image capture and Philips Medical Systems’ iSite PACS, to improve workflow and deliver the highest level of care to trauma patients. According to Alana Praytor, RT, senior clinical application analyst (PACS), eliminating film — and the time and steps involved in delivering film to multiple doctors — greatly improves image workflow.

Superb image quality and faster scanning times have made CT a very popular modality in emergency medicine. A large amount of information can be acquired quickly with CT, says Praytor, and images can be reconstructed to get different views of anatomy without actually moving the patient. Head CT’s are performed frequently in the ED. With PACS in place, ED physicians, radiologists and a neuroradiologist can sit down at any PACS workstation or web-enabled PC and simultaneously view a patient’s history and images to confer about the case over the phone.

Norman’s new CT scanner is located adjacent to the ED. Praytor says about 12 to 14 CT scans are performed during the night, and even more patients are scanned during the day. The hospital’s CT staff has experienced a more streamlined workflow with PACS and especially since films do not have to be printed. “The CT technologists really appreciate having PACS because multislice CT scanners produce so many images,” says Praytor. “If you print all these images, it becomes almost impossible for a radiologist or other physicians to review all the images — not to mention the time saved when physicians do not have to wait for images to be printed.”

The old versus the new

From a nationally recognized cancer center to a brand new breast care center, Alamance Regional Medical Center (ARMC) in Burlington, N.C., offers a full range of medical services. Its busy ED sees 56,000 patients annually, and almost all patients undergo an imaging exam, says Chris DeAngelo, RIS/PACS administrator.

ARMC combines technology to provide the best possible patient care, including advanced applications such as an integrated RIS/PACS and CPOE. The installation of the image management system and a digital archive coincided with radiology’s upgrade in which new imaging modalities were installed, such as CR, DR, digital fluoroscopy, MR, ultrasound and SPECT. The new technologies have had a major impact on the ED. “A hospital needs to be able to give the best patient care it can by getting the patient in quickly so treatment can be administered quickly,” says DeAngelo. “But at the same time, [medical images] also have to be displayed quickly so that interpretation can be completed. I think that we have met this and exceeded these expectations with the system we have installed and the workflow that has improved.”

ARMC implemented syngo Suite, a RIS/PACS from Siemens Medical Solutions. The technology helps physicians better share and transmit critical information needed to treat ED patients.

Workflow and report turnaround time have changed drastically thanks to PACS — from about a day to just a few minutes. DeAngelo says that once a technologist completes an imaging study, it is instantly displayed on a worklist for the ED physician. “In most cases, the ED physician is reviewing the exam before the patient returns,” says DeAngelo. Once the ED physician finishes looking at the images, he or she inputs a preliminary diagnosis electronically. The study then appears on the radiologists’ worklist and a final diagnosis is created. If there is a discrepancy in findings between the ED physician and the radiologist, a note is made in PACS that automatically alerts the ED physician. “Now you are looking at a turnaround time for a final report that is down to just a few minutes,” says DeAngelo.

Technology advancing care

Level 1 Trauma Centers provide a high level of specialty expertise and meet strict national standards. Carl Chudnofsky, MD, is chairman of the department of Emergency Medicine at Albert Einstein Medical Center, a 440-bed acute care hospital in Philadelphia that has a Level I Trauma Center and a Level III Neonatal Intensive Care Unit. With more than 60,000 annual ED visits, AEMC serves an urban patient population with a mix of medical-, surgical-, and trauma-related pathology. The hospital uses Fujifilm Medical Systems’ Synapse PACS, which is also integrated with the facility’s ED information system.

“Advanced imaging is an integral part of emergency medicine,” says Chudnofsky. “PACS has only made this aspect of care even better.” In addition to its complete range of imaging modalities in the radiology department, the facility’s imaging staff operates two DR rooms and a 16-slice CT scanner directly in the ED. Chudnofsky says PACS has streamlined the physicians’ ability to diagnose patients. The system provides physicians with online tools to manipulate the images to better pick up subtle findings. PACS allows emergency doctors to quickly consult with remotely located specialists on complicated trauma cases. In addition, smaller hospitals that do not have in-house specialists or even in-house radiologists can use PACS and nighthawk services to read urgent care images.

“From my experience, the diagnoses we make are far simpler with PACS due to the [lack of] steps we need to go through,” says Chudnofsky. “Our interaction with consultants is better because of PACS. Our ability to teach is better because of PACS.”

When a hospital implements PACS in radiology and extends its functionalities to other departments such as the ER, Chudnofsky advices that the hospital considers a few key elements. “There needs to be real good communication between the radiology department and the other departments that are going to be involved,” he offers. “It is imperative that you get buy-in [for PACS] from the rest of the institution. When you go live, you have to have a very strong go-live support team. This is particularly true in critical-care areas and areas that function 24 hours a day.”