Rushed, But Ready

Equipping your ED with imaging technology can save lives without costing you an arm and a leg.

It?s 3:37 am and the majority of the city is sound asleep. Suddenly, the screech of a siren. An ambulance delivers a trauma patient to a busy urban hospital. A middle-aged man presents with a number of injuries and severe abdominal pain. He?s hemodynamically unstable. The ED physician knows this could mean bleeding in the abdomen and possibly around the heart. In the old days, the patient would be rushed to surgery. But on this particular morning, there is a CT scanner available as well as an ultrasound. The ED physician has access to both modalities and makes the best decision. Either way, he avoids what could be unnecessary surgery.

No, it?s not George Clooney in a rerun of ER. Rather, the above (fictional) scenario is just an example of what might occur on a typical day in the life of David T. Schwartz, MD, associate professor of emergency medicine at New York University School of Medicine and attending ED physician at Bellevue Hospital and New York University Medical Center in New York City.

ED utilization is on the rise nationwide, and that fact is keeping people like Dr Schwartz quite busy. According to a report published in 2008 by the US Department of Health and Human Services (HHS) titled ?National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary,? from 1996 through 2006, the annual number of ED visits increased from 90.3 million to 119.2 million?a rise of 32%. There were, on average, about 227 visits to US EDs every minute in 2006.

Schwartz estimates approximately 35,000 annual patient visits to the ED at New York University Medical Center and nearly 90,000 annually at Bellevue Hospital. ?Visits to the ED are on the upswing,? said Schwartz. ?That?s due to several factors including hospital closures and insurance issues.?

Traffic may be increasing, but is patient care getting any better? And is imaging equipment making a positive difference in emergency care outcomes?

Schwartz is a veteran in the rough and tumble world of emergency medicine. With 24 years of in-the-trenches experience, he says imaging is critical.

Asked to explain the biggest changes in emergency medicine today as opposed to when he started out, Schwartz noted two key factors. ?There have been so many advances in the field of emergency medicine itself. It?s a relatively new field, only 35 years old. Now, it?s a specialty; there are more research studies, and there is a genuine curriculum and well-established residency training programs as opposed to the early days,? said Schwartz. ?The other big change is the improved ability to handle a wide spectrum of emergency problems in an efficient and precise way. Some of that is due to technology and imaging plays a big role.

?Over 40% of ED patients undergo diagnostic imaging, with conventional radiography being by far the most commonly performed study,? said Schwartz. ?In addition, there is now within radiology a specialty of emergency radiology with radiologists who are devoted to the specific concerns of ED patient care.?

In fact, according to the HHS data, some 44.2% of emergency department visits (in 2006) included imaging exams of some kind. The report goes on to break down usage in the ED by modality including x-ray at 34.9% of visits; CT scan at 11.6%; ultrasound at 3.1%; MRI at 0.5%; and other imaging at 1.3%.

Clearly, today?s EDs are finding imaging equipment to be valuable, life-saving tools. But with tight capital budgets, not every hospital can afford to outfit its ED with a cross-section of dedicated imaging modalities. However, with carefully planning, there are several smart steps you can take to maximize your resources and keep your ED ready for every rush.

Seek Efficiencies

Michael Foley, RTR, director of radiology services at Tufts Medical Center and Floating Hospital for Children, Boston, says looking for efficiencies is the name of the game. His institution has two x-ray rooms in the ED, and the ED has both an adult and a pediatric side.

Originally, the rooms were equipped with computed radiography (CR), but after 14 years the equipment was wearing out and the repairs began to cost more than it was worth to maintain. Ultimately, Foley chose to replace his CR with DIRECTVIEW DR 7500 systems from Carestream Health.

?The reason we went digital was that we were trying to pick up efficiencies,? said Foley. ?During the evening, when the pediatric emergency room was at full tilt and the adult emergency room was also at full tilt, we started getting into some delay issues on imaging. So I was looking, number one, for efficiencies, and number two, I had to replace the equipment.? In addition, Foley notes that the new technology helped him reduce radiation exposure. ?When we went to digital radiography, we went back to the same speed and radiation exposures we were using with conventional film, which was a good thing,? said Foley.

Finally, the Carestream DR units offered another advantage. ?We currently have Carestream CR products throughout the institution,? said Foley. But the user interface on Carestream?s DR products is the same as the one on their CR systems. ?So for the technologists, they knew how to run the machine from day one.?

Efficiency was critical in Foley?s choice. ?I?m into making sure that every technologist is at the same level of competency and excellence. If you give them the same tools to use throughout departments, it helps,? said Foley. ?At the institution, we have 17 x-ray rooms and staff rotate all through the different departments. So why give them 17 different interfaces??

The Big Thing ? and the Next Best Thing

Schwartz showed no confusion when asked about the most important life-saving modality ED physicians require. ?CT is a key tool,? said Schwartz. ?CT plays a substantial role in the management and care of our ED patients. It?s an essential element to the practice of emergency medicine today because you can diagnose many diseases accurately and quickly with CT.?

For example, noted Schwartz, abdominal pain can be quickly and better assessed with CT. ?When looking to evaluate the source of abdominal pain, you?d be stymied without a CT scan,? said Schwartz. ? In the old days?before CT?about 20% of the time you?d be wrong in your evaluation, and the patient would wind up with unnecessary surgery, or there were diagnostic delays that adversely affected patient outcome.?

Indeed, CT scans play a critical role in treating trauma patients as well as those with a variety of emergency neurological and thoracic disorders.

Schwartz counts himself among the fortunate, as both his ED facilities are equipped with CT scanners. At Bellevue, he and his team have a dedicated 64-slice scanner in the ED; at NYU Medical Center, the ED is presently equipped with a 16-slice machine and the institution plans to upgrade in the near future.

But we?re talking about the Big Apple. What about all those community hospitals in rural America? The cost of a dedicated CT scanner for the ED is often prohibitive.

?Availability to CT is key,? said Schwartz. ?The scanner doesn?t have to be physically located in the ED, but it must be available for emergency cases.?

Schwartz notes that almost every hospital in America has a CT somewhere in the institution. The goal is to ensure that technicians and the equipment are available for emergency cases?24/7, if possible.

So if budget doesn?t allow your institution to purchase an ED-dedicated CT, what can you do? Hospitals nationwide are borrowing the mantra of the real estate industry: location, location, location.

?Over the last 20 years, as hospitals have reduced infrastructure, they?ve reconfigured, too,? said Timothy Myers, MD, chief medical officer at NightHawk Radiology Services. ?They are building the facilities in such a way as to put the ED, radiology department, and surgery as close together as possible. Having these three entities close together minimizes the problems of patient transport and equipment access.?

With radiology adjacent to the ED, access to the CT scanner is greatly enhanced. Myers notes another example. ?If a hospital has a limited number of C-arms, it can be problematic. Say the C-arms are needed in the ER and the OR simultaneously. Being physically nearby means you can move them back and forth quickly. It can save the institution from buying unnecessary units.?

For ED departments, access to imaging equipment is vital. ?My radiology department is two buildings over from the emergency room, and four flights up,? said Foley. ?You will find some institutions, when they?re newer institutions, when they build out hospitals, put the radiology suite right next to the emergency room on purpose.?

Asked about his ?wish list? for imaging equipment in his ED, Foley had this to say, ?So, in an institution where radiology is not right next to the emergency room?we have three x-ray [units] there now?I?d like to have a CT scanner, I?d like to have ultrasound there. Those are the three modalities we would need in the emergency room, if I were to rebuild my ER.?

Choices and the Bottom Line

No doubt, CT scanners are the big ticket item on the wish list of ED departments everywhere. When Axis Imaging News asked Schwartz what advice he would give to any ED department with a limited purchasing budget, he said, ?No question, invest in CT over MRI for your ED.?

Both economic factors and patient care come into play. ?Most considerations about emergency room imaging are quality of care. ? because every campus is going to have a CAT scanner somewhere in their campus,? said Foley. ?So, if I put a CAT scanner in the emergency room, that?s a cost plus. It?s never going to have a better ROI on it because if the radiology department can do that?if the patient gets on the elevator, comes up four flights?we can do the CAT scan there.?

Experts seem to agree. ?The most important thing for cost containment and patient care is when the ED and radiology work together,? said Myers. ?You don?t want to duplicate efforts and you do want to have a good rapport, You can put the departments back-to-back so the ED doesn?t have to buy its own CT scanner. Smart planning can lead to a significant improvement in costs.?

But when your ED is not adjacent to radiology, Foley offers these words of caution. ?You?ve got to look at the quality. So, if a patient comes into the emergency room and they?re unstable ? do you want to take the risk of that patient getting on an elevator and going to a different building? Or are you safer in the emergency room; the physicians are there, the nursing staff is there, and you do the CT scan right there??

Ultimately, says Foley, the purchase of a dedicated CT scanner for the ED would not be about building the bottom line. ?So, it won?t be for reimbursement reasons; it?s going to be closer to quality of care for the patient. And, obviously, patients are under the gun when they come through the door; they?re unstable, and time is a factor.?

Who Gets the Portable?

Ultrasound is ubiquitous in EDs nationwide and is performed by both radiologists and emergency clinicians. This modality helps emergency medicine professionals diagnose and treat trauma patients as well as look for gallstones, abdominal aortic aneurysms, appendicitis (especially in children where a CT would mean radiation exposure), and gynecological problems. In addition, ultrasound is used in the ED to assist with specific procedures, for example, ultrasound guidance for IV lines.

Schwartz says his emergency departments at both facilities purchased several units, and they have to be portable.

Portability can mean cost savings, too. At many hospitals, ultrasound units are often shared across departments. But like kids with the remote control, portable?and limited ?units can lead to a struggle for ownership.

Foley says that portable, shared equipment ?short-changes the emergency department.? Moreover, portability can lead to profitability challenges. ?There?s a lot of sharing that goes on, I do have to say ? this is a political problem that we always have to deal with in imaging,? said Foley. ?Imaging has pretty decent reimbursement ? it does produce a lot of good revenue. And physician practices, whether in hospitals or outside hospitals, see this, and so they start buying their own ultrasound machines or they start buying their own x-ray machines?to pick up the revenue. So what happens is, it becomes a little tug of war at times.?

Schwartz, on the other hand, says that ED physicians are not reimbursed for imaging at the New York City institutions where he works. Performing an ultrasound, for example, is ?part of the patient workup.? But he does acknowledge that his are academic institutions. ?At a community hospital, this could be an issue,? said Schwartz.

Still, Schwartz emphasizes that ultrasound performed in the ED is used in a different manner than radiologists would use it. ?We?re doing it to quickly answer a specific question; it?s for a focused purpose. For example, is this unstable trauma victim bleeding into his abdomen or pericardium? Does a woman in early pregnancy have an intrauterine gestation? Or does an elderly patient with abdominal pain have an abdominal aortic aneurysm?? said Schwartz.

Even so, Foley sees things differently. At his hospital, the ED also has its own ultrasound unit. ?The physicians in the emergency room go through a little competency test, and they go through some testing to use the ultrasound machine. But you know what? They don?t use it day in and day out. And up in our regular ultrasound department, our radiologists are doing 50 or 60 cases a day. So, who do you think is going to make the better diagnosis?? said Foley. ?I can?t tell you how many times my techs get called in at 2 o?clock in the morning because they had an ultrasound in the emergency room, but they couldn?t read it. So, they had to call it in to repeat the study.?

Ready to Read

Access to imaging equipment is clearly critical. But it is of little use if your ED is not ready for fast, accurate reads of the images.

Schwartz says a key advance in emergency medicine in recent years is the availability of PACS in the ED. ?We can see everything immediately because we have PACS in our EDs,? said Schwartz. ?We can also call up previous imaging of that patient, if it?s in our system, and that?s a substantial advantage. PACS also allows us to discuss imaging findings with the radiologist since we can both view the images concurrently.?

Teleradiology providers, too, are filling a void for EDs across the country. NightHawk Radiology serves some 1,500 institutions across the United States, with the bulk of its business volume being emergency departments. Myers says teleradiology is helping to save lives every day. ?We get the read back to the ED in 15 to 20 minutes. We?re very precise with stoke protocols, for example, where time can mean brain tissue. ? When minutes count, we have the answer back to the ED.?

Fast, accurate reads translate into cost savings, too. As Myers explains, if a stroke victim in the ED is quickly diagnosed and treated, that patient is less costly in the long run as he avoids a long hospital stay and rehabilitation. ?The care of a stroke victim uses a huge amount of hospital resources.?

Decision Making and Purchasing for the ED

Whether it?s the acquisition of, in many cases imaging equipment or the use of a teleradiology provider, emergency departments are not the group that makes the final buying decision.

At most institutions, a team of people are involved in the assessment of imaging equipment. Foley says that at his institution the process includes an administrator, a physician (or several) who know what to look for in terms of quality of a CT scan, for example, and the purchasing department. ?And we?ll get technologists involved, too?the CAT scan technologists to look at the user interfaces.?

Foley believes the radiology group should make the final buying decision. ?You can?t leave it up to other folks to tell you anything about radiology equipment.?

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Marianne Matthews is editor of Axis Imaging News.