Radiographic images taken in the setting of an intensive care unit can be among the most difficult to acquire simply because of the condition of the patients occupying beds there. Those in the most critical shape, as one example, can only lie helplessly while the technologistwith or without assistancestruggles to properly position them for imaging. Other patients whose status is less serious may be able to cooperate to some extent with efforts at positioning, but the technologist still faces a challenge in getting a good shot because of the presence of multiple catheter insertions and an overlay of delivery tubes and sensor lines.

As such, the retaking of images tends to occur with far greater frequency in the ICU than almost any other section of a typical hospital. The result is inefficiency that adversely impacts throughput, productivity, and even quality of care.

Nowhere, though, is efficiency of operations more essential (or more prized and, for that matter, insisted upon) than in the hospitals administered by the armed forces of the United Statesand at the Naval Medical Center in San Diego, efficiency has increased thanks to the addition of CR imaging in that facility’s intensive care unit.

“We’re getting images from the ICU with fewer retakes now that we’ve made CR our primary ICU imaging modality, and that improvement means we’re able to make treatment decisions sooner and with greater confidence,” says Lt Cmdr Tim Duncan, MD, staff radiologist and director of PACS.

Duncan explains that CR makes this possible by permitting the electronic window and leveling of images. Accordingly, some marginal-quality images can be corrected after the fact at a workstation. This, he indicates, eliminates any need to retake images in about a third of the cases where positioning was a problem.


Not only has CR in the ICU proven a boon for Naval Medical Center efficiency at acquiring images, but also for interpreting them and then making them accessible to attending clinicians.

“The radiologists are much more efficient in reading as a result of CR,” Duncan says. “The images are digital, so we can get to them and begin reading more rapidly. A click of the workstation’s mouse and the image is almost immediately there on the screen in front of you, no matter who else has previously seen it or where it was last looked at. And because of that, the clinicians in the ICU can receive our reports sooner.”

The way the hospital has set up the CR system, attending clinicians can view images displayed on a view station in the ICU at the same instant the interpreting radiologist is reviewing them on his workstation in the radiology department three floors up.

“The ICU clinicians have the ability to pick up the phone and talk to the radiologist while everyone has the same set of images in front of them,” says Duncan. “Answering physician questions about images is now a simple matter. With everyone on the same page, so to speak, care decisions are made at earlier junctures, which, of course, can have a dramatic effect on outcomes.”

ICU doctors also possess the ability to electronically summon prior CR images dating back several years for comparison with current images.

“Before, they didn’t have this kind of ready access to prior comparisons, and that was a major problem for the ICU,” Duncan adds.

HM1 (hospital corpsman, first class) Ed Doorn, RT, ARRT, radiology department leading petty officer, says CR in the ICU has eliminated the problem of lost or misplaced film.

“The ICU is one of those environments where you have the greatest potential for losing or misplacing film,” Doorn observes. “You have one piece of x-ray film on a patientif it becomes lost, that’s pretty much the end of it. But that loss then creates two problems: either you have to go back and reshoot the image or, if that isn’t feasible, you then have to provide care as best you can without the image.”

Doorn agrees with Duncan that it was a smart move to install CR in the ICU, if for no other reason than it cut down on the back-and-forth transiting of technologists between the floors.

“It used to be the technologists would take their plain film x-rays in the ICU, then bring them back upstairs for processing and reading, run the films back downstairs to deliver them with the radiologist’s report to the ICU doctors, then bring them back upstairs for archiving in the film library when the ICU doctors were done with them,” he says. “Each trip from the ICU to the radiology department could take anywhere from 5 to 10 minutes, one way. There were more productive ways the technologists could have been using their time.”


Naval Medical Center in San Diego is a facility with capacity for 539 beds, currently with active beds totaling 265. Constructed in 1988 on a 79-acre site in the city’s Balboa Park area, the 2.5-million-square-foot hospital cost $263 million, with equipment alone accounting for $90 million of that figure. It remains the largest and most technologically advanced military health care complex in the world, according to Navy claims.

“The hospital replaced a smaller facility that went up in 1922,” says Doug Sayers, public affairs officer. “Back in those days, it was known as the Pink Palace; now it’s known as the pride of naval medicine.”

Actually, the Navy was providing medical services there prior to 1922. In 1914, it set up tents in that vicinity to serve as a field hospital in support of an encampment of Marines on North Island across San Diego Bay. In 1917, the field hospital made way for a more permanent establishment not far from that site. It was formally christened as the United States Naval Hospital in 1919.

During World War II, the Navy gained crucial experience at evacuating its wounded personnel from seagoing and land-based combat zones and delivering them for treatment in San Diego. Between 1941 and 1945, approximately 173,000 sailors and other Navy personnel passed through the portals of the Pink Palace. With the outbreak of fighting in Korea in the 1950s and, a decade later, in Vietnam, the Navy refined its medical evacuation methods to the point that personnel in overseas hot spots who required hospital services of the kind found only in San Diego could be admitted 30 hours or less after becoming wounded, injured, or ill.

Today, Naval Medical Center in San Diego offers a full gamut of health services to an eligible beneficiary population of nearly 261,000 officers and personnel, plus their dependents. Among the departments most central to the success of the hospital’s modern-day mission is its intensive care unit. CR technology was introduced there 5 years ago, and represented the hospital’s first big step in moving toward the goal of a digital radiology environment.

“CR, being a digital modality, fit right in with our overall plan to go filmless,” says Duncan. “CR worked so well for us in the ICU setting that it convinced us to move quickly to convert our entire radiology enterprise to digital. Currently, we’re about 90% completed with that conversion process. With the exception of one department, we have our entire main hospital filmless now. Within the next year, we hope to bring the rest of the hospital online, including all of our outlying branch clinics.”

At this time there is only one CR in the ICU. The department has no plans to add a second device. No need, Doorn reports.

“The one CR we have in there meets our requirements perfectly, given the volume of ICU imaging, which is about 4,500 CR images annually,” he says. “Two years ago, we installed a reader in the ICU. This further improved work flow. Prior to installing that reader, the technologists would bring the CR’s image cassette to the main radiology department area and process the images there, just as they would with plain film. Now, they never have to leave the ICU for that.”

Even though the hospital is a military installation with a spit-and-polish hierarchy of administration, the process of deciding to bring CR aboard for the ICU environment was in some regards similar to that which might be employed at a civilian facility.

“In the Navy system, you do have to go through proper channels and high up through the chain of command for approvals to lease or purchase capital equipment like this,” says Lt Cmdr Donna Davis, MS, radiology imaging physicist. “However, our decision-making process and economic model compare in some ways to what you find in a large HMO where there are a number of hospitals under the umbrella of a parent organization.”

Once the necessary clearances were granted, the radiology department acquired a CR system for 6 months of ICU testing and evaluation, and deployed a view station in the most centrally accessible part of that unit. In short order, the ICU team became very invested in the technology, Davis tells.

“When the testing and evaluation period had ended, they told us in the ICU that they did not want to lose the CR,” she says. “So we then arranged a lease of that CR system, with an option to buy. When the lease period ended 3 years later, we assumed ownership of the product.”


The ready acceptance of CR in the ICU encouraged the modality’s champions in radiology. Still, CR represented a paradigm shift for operators and users alike, a very different way of doing business. Old work habits had to yield to change in order that the benefits of CR could be fully realized. That meant attending clinicians, radiologists, and technologists all had to undergo training in use of the technology as well as learning how to use re-engineered work-flow patterns.

“For the clinicians and radiologists alike, there was a certain learning curve in getting accustomed to viewing images on a display monitor after spending years seeing them on film at a viewbox,” says Duncan. “There was some initial discomfort with this change, but the advantages in being able to electronically window and level images quickly overcame that.”

In a by-gone era, the top brass of the hospital could have solved this simply by ordering everyone in the lower ranks to buy into the new technology and like it (or else end up in the stockade). But this is the modern military, and things do not work that way today.

“We promoted buy-in through the training process,” says Doorn. “By providing thorough training, we were able to right up front give the staff a real appreciation for what this equipment could accomplish. The staff’s primary interest is in benefitting the patients, and we were able to help them quickly understand the various ways in which this equipment could help them achieve that objective.”

Training, in fact, must be provided on an ongoing basis, since the hospital has a somewhat higher rate of turnover among personnel than is the case in civilian hospitals. The difference here is that staff do not come aboard and depart of their own choosing but, rather, as transfers arranged for them by Navy command in Washington, DC. Duncan, however, indicates that the frequency of turnover is probably little different from that which occurs at teaching hospitals in the civilian sector.

“Ours also is a teaching hospital, so we have young physicians coming through and rotating in and out on a regular basis,” he says. “This is why it’s necessary for us to have a strong, continuing CR training program, so that those who are unfamiliar with this modality can be quickly brought up to speed.”

Network considerations

A good omen was the fact that physical implementation of CR in the ICU proceeded fairly smoothly and relatively worry-free, Doorn notes.

“Our biggest concern centered around mapping out the image distribution network,” he says. “As part of that process, we gave a great deal of consideration to what we would do in the event the network were to go down. So, we made sure we had ample redundancies built into it. We also had to make sure the network infrastructure was sufficient to handle the size of image files we would be generating and to move them around the network without slowing things down because of traffic volume.”

The network infrastructure, not long ago upgraded, consists of a 1-gigabit fiber-optic Ethernet backbone. To this backbone the department has run fiber-optic cable direct from the ICU view station and the radiology department workstation, Doorn describes.

“We also had a radiology information system already in place, and we had no difficulties establishing an interface with it via a broker,” he says. “The RIS feeds to the broker the demographics that are needed to run Worklist for many of our modalities, CR included.”

Additionally, the radiology department crafted a quality control program for the CR system.

“We recognized that CR would require more maintenance than our x-ray machines,” says Davis. “CR is more sensitive to accumulations of dustit picks up artifact more easily than does x-ray. For that reason, we once a month perform a very thorough QC on the CR. We have a program where the technologists clean the system so as to prevent the accumulation of dust and other foreign debris that can affect image quality.”


The benefits of CR in the ICU at Naval Medical Center include a certain amount of cost savings.

“The savings come mainly from the elimination of the need for film and chemicals,” says Davis. “Over time, these should add up to noticeable savings. However, at this point, we haven’t yet seen a huge windfall.”

Another source of savings is the potential for reducing staff size. Says Davis, “With CR, you no longer have the need to hang films or to physically archive images, so the personnel formerly required for these tasks can be reassigned to other, more productive duties or, as attrition occurs, their vacant positions are not refilled.”

Duncan agrees, but believes some savings are not easily measured, even though their impact certainly is felt.

“There are quite a few intangibles that make it difficult to put a dollar figure on the savings CR can represent,” he says. “For example, there is a clear-cut improvement in patient care as a result of CR, but that’s something you can’t very well measure in terms of precisely how much it’s saving the hospital. We assume there are savings that occur from improved quality of care, such as would result from a reduction in utilization of resources as a result of having patients get better faster and be discharged sooner. And if there’s one thing that can be said about CR in the ICU, it is that the technology clearly is helping us deliver better care a lot more efficiently than ever before. b

Rich Smith is a contributing writer for Decisions in Axis Imaging News.