|Walter Eisman, MD (background), chairman of radiology, and James Roebker, MD (foreground), vice chairman, consult in the reading room.
Much ink has been spilt on the trials and turf skirmishes of hospital-based radiology, but this story is not one of those. It is instead a story of collegiality and cooperation, and of successful partnerships that have resulted in positive outcomes for patients, hospital, and physicians.
Consider this scenario: A man enters the emergency department complaining of chest pains. His ECG is normal and he has no history of heart disease. The pain persists: Nuclear medicine and cardiology are notified. A SPECT myocardial scan is performed. The test is negative. Further observation proves the man is not having a heart attack. Relieved, but with an appointment for a cardiac stress test, he is discharged. The entire episode is over in 6 hours, resulting in a satisfied patient and the timely movement of the patient through the emergency department, averting the cost of an admission.
This scene of nuclear medicine collaborating with the emergency and cardiology departments is the result of cooperative relationships between those departments and radiology at St Elizabeth Medical Center, Covington, Ky.
The 24-member Radiology Associates of Northern Kentucky provides a full range of radiological services-from radiography to ultrasonography-to each of St Elizabeth’s three hospitals and the population of northern Kentucky’s Covington, Edgewood, and Grant counties. Radiological procedures total about 180,000 a year. Radiology staff and services are available 24 hours a day, 7 days a week.
In the past 10 years, the hospital has seen its nuclear capabilities grow from one camera, which performed 2,000 procedures per year, to six cameras and 15,000 procedures. The growing demand for nuclear medicine services has come from a variety of departments, but most particularly from cardiology.
For the past 3 years, the nuclear medicine department has participated in the emergency department’s rapid evaluation cardiac unit (RECU).? Conceived by LaRoy Kendall, MD, St Elizabeth’s director of emergency medicine, the RECU program is based on a similar program at the University of Cincinnati, Kendall’s alma mater. It did not take much persuasion to sell the cardiology department and James Roebker, MD, vice chairman of radiology, on the idea. “It didn’t hurt that Dr Kendall was my brother-in-law and next door neighbor,” Roebker remarks. “In this case it was good for everybody.”
The cardiologists accepted the idea, says Kendall, because it would help lighten their load by limiting unnecessary cardiac admissions-admissions they subsequently had to evaluate. Roebker liked the idea because it fits his interests. “I have an interest in nuclear cardiology, and the potential ways to use it in an acute care setting,” he says. “The radiologists did realize this was a very positive thing to do.”
|James Roebker, MD (background), and LaRoy Kendall, MD, director of emergency medicine, review a nuclear cardiac scan performed for a patient in the rapid evaluation cardiac unit at St Elizabeth Medical Center, Covington, KY.
Kendall says that the program was easy to set up and Roebker concurs. “Once we got the program on its way, it wasn’t terribly burdensome,” he says. “It was another example of the service radiology provides to different departments.”
Lloyd Gill, administrative coordinator of radiology, says that the RECU program also made financial sense. “Admitting is an? expensive proposition,” he notes. “This sort of unit can be treated like an outpatient procedure, [yielding] more insurance dollars. Bottom line, it was a program that served a lot of needs.”
Patients have responded enthusiastically to the program since its inception 3 years ago, according to Kendall Strong patient satisfaction is due, in part, to the rapid turnaround the RECU program has been able to achieve, cutting the average length of stay from 3 days to 6 hours. Kendall says that the majority of RECU patients-75% to 80%-go home.
This has translated into significant efficiencies for the emergency department and the rest of the hospital. If a patient enters the emergency department complaining of chest pains, the patient is taken to one of the 28 regular emergency examining areas and attached to an ECG machine that takes a reading every 20 seconds. An alarm sounds if there are any significant changes. A set of cardiac enzymes are obtained, and if these tests are normal or near normal, and the patient indicates they have had no history of heart trouble, they will be moved to one of the two RECU beds. “We’re mainly interested in the low risk group,” Roebker explains. “This is the sub-group you can most safely triage and send home.”
If a patient is in pain when they arrive, but has a normal ECG, a SPECT scan is performed. If the pain is relieved immediately, the patient will receive a cardiac nuclear injection, be observed for 6 hours, and then administered a stress test by the cardiology department. “Both pathways lead to nuclear [procedures],” says Kendall.
Current personnel shortages on the cardiology side make full 24-hour staffing of the RECU infeasible, according to Roebker. It also is not realistic from a practical standpoint to have nuclear technicians on call around the clock in light of the fact that the RECU unit conducts about 15 tests a week. “There’s a limit to how far you can push the techs,” Roebker notes. SPECT scans are performed until 11 PM during the week. Cardiac stress tests are performed until 8 PM. Most of the tests performed are SPECT. If patients arrive after those times, they will be held in the RECU for observation until 7 AM when the cardiologists come on duty.
If the RECU SPECT or stress test is normal, the patient will be sent home. “What these tests do-if they are normal-is send them home, and the patients love it,” explains Walter Eisman, MD, chairman of the radiology department. “It doesn’t mean that they don’t have heart disease. It just means the pain is not caused by a heart attack.” After being sent home, the RECU patients usually return for a follow up cardiac examination, which will include a stress test.
Patients are called within 24 hours after their release for a follow up interview. The follow up has been a way to gauge the success of the program. “You can’t just start this and assume that it’s working,”? Roebker notes. According to statistics kept by St Elizabeth’s, less than 1% of the RECU patients sent home have a heart attack in the 12 months following their release.
The success of the RECU at the medical center’s South unit has brought interest from St Elizabeth’s other two campuses, but staffing and equipment limitations preclude any expansion at this time. Though St Elizabeth’s reputation is built on its cardiac care, the nuclear medicine department is not limited to just performing cardiac scans. Eisman says about 70% of his group’s nuclear work is cardiac. In the emergency department, lung scans are also performed to detect pulmonary embolisms.
Growing Oncology Demand
Oncology is contributing a growing percentage of radiology’s nuclear work load. The nuclear department has performed a handful of attenuated positron emission tomography (PET) scans with a mobile gamma PET scanner. [Reimbursement for gamma PET is currently under evaluation by HCFA.] The hospital plans to purchase a new camera to fill those needs. Radiology’s primary service to oncology-which makes up 20% of its nuclear work-is bone scans.
Radiology Associates of northern Kentucky has been serving St Elizabeth’s since 1958. Three members have specialized training in nuclear medicine-one in all of nuclear medicine and two in nuclear cardiology. But Eisman stresses that the entire group is a team whose members are capable and expected to do a little of everything. The reading of MRI scans is the only work Eisman’s group does outside St Elizabeth’s.
This efficient, cooperative team approach is reflected throughout the radiology department. “Teamwork is one of our values,” says Leanne Williams, manager of nuclear medicine and ultrasound. “It takes the whole team to know the goal is to help the patient, and give the individual the best examination possible. There’s a lot of give and take all over this hospital. [We’re] all customers of each other.”
Strong Service Ethic
Delivering timely results to the ordering physician is a key component of the group’s service to the hospital. “They want their results,” says Gill. “It’s a case of access and turning a report around quickly.”
Most priority reports can be delivered in 2 to 3 hours, indicating that radiology has? been quite effective in this regard.
More often than not, the request for a priority report comes from the cardiology department. “Multiple times a day, a cardiologist needs a test done quickly,” says Roebker. “We’re available immediately.”
When a nuclear-or any radiological-procedure is ordered, it is assigned a priority. Inpatient tests get higher priority because, Roebker says, the results of the test will determine whether or not the patient is discharged. Once the test is done, nursing personnel on the floor floor and the physician are notified, so the specialist can evaluate the results. “Those you need to do first, you do first,” says Eisman. “This whole business is a cooperative effort.”
It is not just the doctors and administration who have a commitment to being efficient. “[All department] personnel understand the significance of what they’re doing; why they’re doing it,” Eisman explains. “They have pride in what they’re doing. If you don’t have a cooperative program, it falls apart.”
Technology is also serving radiology’s move toward greater efficiency. Nuclear? medicine, CT, and ultrasound are in the first stage of implementing a picture archiving and communication system. By June, all nuclear scans will be available on computer workstations. Currently all scans done at the North and South campuses are read in one location at South. All of the radiologists are able to receive studies 24 hours a day in their homes via teleradiology.
Lobbying For The Cause
When the occasion arises, the radiologists will roll up their sleeves and perform public relations on behalf of new procedures and technology they wish to add, though many of these new products are as readily accepted as RECU. “Generally, physicians here are willing to do what is right,” Eisman says. Much of the lobbying is one-on-one, and the current project is promoting PET.
Sometimes another department will ask radiology to take on a new procedure. This happened when the urology department requested a new nuclear test for prostate cancer. Roebker says the test, as far as he can tell, has yet to prove profitable, but that will not stop him or his fellow radiologists from performing it. “It’s not pure altruism, but you do what you have to do for the institution,” says Roebker.
While the radiologists are forging ties with the other departments, the nuclear technologists are promoting the cause of nuclear radiology to the patients directly.? “Patients need to be informed, need to cooperate,” explains Williams. “If they won’t go along, then either we’ll get bad results or they won’t follow through with the test. People are our biggest challenge and our biggest joy.”
Williams says that much of the public relations she and her team of 10 technologists engage in involves allaying patients’ fears. “They’re concerned that their hair will fall out, that they will get sick,” says Williams. “We try to put [the test] in terms that make it more comfortable-why should I do this-the cost/benefit.”
While soothing the fears of their patients, the technologists also carefully monitor the nuclear tests, which must be accurately timed to get the best results. Williams says there is satisfaction that goes with the job, along with the challenges, particularly if a test uncovers a problem before a patient has a serious health issue.
The commitment to building and being part of a community extends beyond St Elizabeth’s walls. The radiology staff-most of whom are under 40-are from the local community, and are friends as well as colleagues. “It’s a way of life, and a dedication to the community,” Eisman says. “It builds trust.”
This trust in the radiology group is reflected in growing volume. “Our business keeps growing, so we must be doing something right,” says Gill.
Christopher Wolski is associate editor of Decisions in Axis Imaging News.