Marty Schotten, Yuma Regional Medical Center, Yuma, Az

Yuma, Ariz is a popular winter destination for visitors eager to flee the cold, rain, and snow of the Pacific Northwest and Canada. Ordinarily, Yuma’s population stands at about 80,000, but in January and February, it swells to around 175,000. This influx of temporary residents consists mainly of retirees. Some have vacation homes in Yuma, but most live in recreational vehicles (RVs) parked at campsites on the outskirts of the city. During their stay, many of these elderly visitors find it necessary to make at least one trip to the emergency department.

The same is true of younger outdoor-adventure enthusiasts, who likewise flock to Yuma in the pleasant winter months and on holiday weekends throughout the year. For these hardy souls, the vast, open desert spaces surrounding Yuma are a perfect place to race around in dune buggies and all-terrain vehicles. These dangerous activities too frequently involve rollover crashes and other varieties of accidents.

The only emergency department available to treat these diverse cases is found at 247-bed Yuma Regional Medical Center. The nearest other hospital is 97 km away, across the California state line. To obtain emergency services comparable to those available at Yuma Regional Medical Center, patients would have to travel 290 km to Phoenix. It is not surprising, then, that Yuma Regional Medical Center’s emergency department is Arizona’s third busiest.

Until recently, that emergency department also had a reputation for being one of the slowest in the state to deliver care. The cause of the problem was not a mystery: often, the emergency department had so many patients that work-flow bottlenecks invariably materialized, forcing patients to endure long waits for attention. The place where those bottlenecks formed most routinely was the radiography room.

“All that we had to work with in our emergency-department radiography room was an 8-year-old, plain-film chest radiography machine,” Marty Schotten, RT(R)(N), CNMT, reports. Schotten, who is clinical resource coordinator for Yuma Regional Medical Center’s diagnostic Imaging department, says, “This one machine was responsible for covering 15 patient-care rooms within the emergency department. It just could not keep pace with the volume of cases during peak periods.” Schotten adds that a big part of the problem was the analog nature of the equipment. Each time an image was made, the technologist had to step away from the room to process the film, and then carry it to the appropriate emergency-department physician. “Too much staff time was tied up in the handling of the films,” he explains.

The bottleneck in the emergency department’s radiography room was so significant that patients with less serious injuries or ailments had to be transported a lengthy distance to the radiology department where they then could undergo examinations in whichever of its eight radiography rooms might, at that time, be available. Still, this was, at best, a stopgap solution. Transporting the patients to and from the radiology department wasted time, and it certainly contributed nothing to either improved productivity or enhanced profitability, Schotten notes.


In late 2000, Yuma Regional Medical Center found the answer to its problem. It eliminated the bottleneck in the emergency department’s radiography room completely and permanently by replacing its analog machine with a state-of-the-art direct digital radiography (ddR) system. As its name implies, ddR is a 100% electronic modality that uses no film and requires no image processing or handling. The particular type of ddR now owned by Yuma Regional Medical Center employs an x-ray detector system containing four charge-coupled device cameras aimed at a scintillator that converts radiation to digitally recordable light. Beyond producing an ultra?high-quality image, the detector charges and relaxes almost immediately, which permits technologists to take exposures at the rate of once every 5 seconds.

Those exposures are then viewable less than 10 seconds later and can be electronically manipulated on the spot to enhance desired characteristics or features of both bone and soft tissue. The images are delivered, in electronic format, using an internal telecommunications network that links the radiography room with the emergency department’s physicians, the radiology department, other parts of the hospital, and even the outside world.

The system was purchased from Swissray International, Inc, a pioneer and worldwide leader in ddR technology and a provider of medical imaging informatics. Yuma Regional Medical Center acquired Swissray’s standard system package, which included a multifunctional mobile table. “We have since ordered two additional tables so that we could further reduce the potential for bottlenecks whenever we had a bad trauma case mixed in with our other emergency department work,” Schotten says. “The additional tables make it possible to place the trauma patient on one dedicated table and lets us avoid having to move him or her off of it at any point simply in order to perform less complicated imaging work that also requires the use of a table.”

Schotten indicates that ddR has enabled his staff to complete each emergency-department examination in a fraction of the time that it previously took. “That translates to extremely high throughput,” he says. “We estimate that we are now handling up to three times as much patient flow in the emergency department’s radiography room without the need for additional staff time. In fact, we have entirely stopped sending emergency-department patients to the radiology department. There is no need. The emergency department’s radiography room is so efficient that it is not even operating at capacity-and we are now providing coverage to 36 emergency patient rooms, not the 15 that we covered the past.”

By Schotten’s reckoning, the ddR system also is proving to be a cost saver. The elimination of film expenses associated with emergency-department radiography reduced the radiology department’s outlays by $166,000 in the first 6 months alone. “That is not counting the savings on chemicals that are no longer needed now that there is no film to process,” Schotten adds.


It was the radiology department’s desire to convert to a filmless environment that prompted consideration of ddR as a work-flow solution in the first place. “Since the mid 1990s, we had been looking at going filmless as a way to affect favorably not only the department’s bottom line, but also the entire hospital’s,” Schotten says. “The costs of film and chemicals were just too high. We also wanted better ways of accomplishing tasks in order to increase productivity and drive down the need for staff time. We felt that going filmless would help us achieve these objectives.”

To commence the journey to filmless operation, the department acquired a picture archiving and communications system (PACS), which it implemented in economically manageable bites. “Phase one was teleradiology,” Schotten says. “This entailed digitizing images and then sending them to the radiologists at night. Phase two was the acquisition of reading stations, followed by integration of modalities, beginning with ultrasound. All modalities are in use here in the department; currently, every one of them other than radiography is 100% digital and connected to PACS. Our PACS project, however, is still only about two thirds of the way to being completed. Since we are still in transition, we continue, at this time, to print film.”

The department was not initially planning to buy a ddR system from Swissray because, by the time it became aware of Swissray’s offerings, it had already made arrangements with another vendor. That deal fell through, however, when the vendor informed Yuma Regional Medical Center that it would be unable to deliver and install the machine by the department’s deadline of December 15, 2000. “We had set December 15 as the date when the unit had to be operational because, within a week or two after that, the city of Yuma would begin its annual mushrooming of population. The hospital’s emergency department would, as a result, become swamped with cases once again,” Schotten says. “We did not want to be embroiled in a conversion process in the middle of all that.”

That is when the Swissray system was chosen. “Had we known at the beginning what we knew at that point, we would have made Swissray our first and only choice,” Schotten says. “We learned that Swissray’s system was unlike anything else: fast, affordable, and based on a superior type of detector technology. The Swissray ddR product had great appeal for us. What clinched it was the fact that Swissray’s system was versatile enough that a single detector could be used for both upright chest imaging and supine table work. By having one detector handle both types of work, it eliminated the need to have two detectors in the same room; right there was a cost savings.”

Schotten continues, “Also important to us was the reliability and serviceability of the Swissray ddR. Yuma is considered a remote location, so it was imperative to us that the system we acquired be one that we could depend on to stay up, and for which, if it should need servicing, we could find technical support locally.”

Convincing the hospital’s financial decision makers to allocate capital for the acquisition of the Swissray ddR was a fairly straightforward proposition, since they were already committed to supporting the radiology department’s conversion to a filmless environment. “The powers that be had caught our vision from the beginning, and that was key,” Schotten says.


Installation of the Swissray ddR posed little in the way of challenges. This was a surprise to Schotten. “With every new equipment installation, you always expect to have bumps in the road,” he says, “but, compared with other installations, this one had fewer bumps than any. I was amazed.” There were some daunting moments when it came to interfacing the ddR system with the PACS, the radiology information system, and the hospital information system. “We were dealing with four different systems, so we had to deal with four different vendors,” Schotten says. “There was the matter of allocating responsibilities and accountability as we set about the task of achieving compatibility among the systems. That required a lot of thought, because this installation represented the first time that the PACS vendor and the ddR vendor had ever attempted to link their two systems. They were breaking new ground every step of the way.”

Schotten adds, “Fortunately, the Swissray product was designed to facilitate connectivity. We would not have purchased it otherwise.” He explains that the hospital had previously decided that any piece of equipment brought in as replacement for an older, analog system had to adhere to the Digital Imaging and Communications in Medicine (DICOM) standard. “This was a lesson that we learned the hard way, because we had ended up, previously, with a few modalities that had to be run through an output translator in order for the PACS to receive and understand the signals emanating from those machines. That is not a terribly efficient way to do things. That is why we appreciated the fact that Swissray used protocols and standards developed by DICOM and the Radiological Society of North America’s Integrating the Healthcare Enterprise initiative,” Schotten says.

Once the system was up and running, the next step was to train the technologists in its use. “There was a bit of a learning curve involved,” Schotten notes. “Some of the technologists were able to master the system sooner than others, simply because of differences in their skill sets and previous training.” Training was also extended to the radiologists. “Reading a digital image is not quite the same as reading an analog film,” Schotten says. “We had to spend some time familiarizing the radiologists with the ins and outs of doing that, along with explaining how to manipulate the images in accordance with their preferences.”

The images are read at four-monitor workstations located in the radiology department proper. None of the interpretation takes place in the emergency department When emergency-department physicians want to see a ddR-produced image, however, they can do so by pulling it up at any of the five viewing stations deployed around the emergency department.


In 2001, Yuma Regional Medical Center was ranked among the nation’s most technology-visionary hospitals in a USA Today survey. The hospital is now contemplating the addition of a ddR unit for deployment in the core of the radiology department. “One of the appeals of ddR is that it can help us consolidate radiography rooms,” Schotten says. “That is very important to us because the radiology department has no space to grow. Therefore, being able to replace an outdated general radiography room with a ddR system is a very attractive solution; the efficiency of ddR is such that one room can free up two or three others. That is why, when it comes to considering what we would want to put inside a general radiography room, Swissray’s ddR tops our list every time.”

Yuma Regional Medical Center has already placed an order for a Swissray ddR system that will be installed in an outpatient facility about 20 minutes’ drive from the hospital. That outpatient center had been underutilized because too many patients were, instead, electing to have their studies done at the hospital whenever imaging procedures had been ordered for them. Patients who made that choice did so because they were aware that delays in receiving medical services at the hospital would be incurred if they had imaging work performed at the outpatient center. The reason for the delay was that the only way that the outpatient facility could get requested images to the hospital was to have them carried there by hand.

“At the time, we had to maintain a film file room and an archive at the outpatient center, as well as a file room and archive here at the main campus, because we did not have PACS,” Schotten says. “Now, with PACS in place, everything is stored in one common archive and is accessible immediately, no matter where the images were produced. This capability has helped in our efforts to convince patients that they will now find it much more convenient to have their images produced at the outpatient center. We even initiated an internal and external marketing campaign to communicate this to patients and the public. It was very successful, and it did a lot to drive business back out to that remote facility. Since we started emphasizing the outpatient center, volume there is up 133% over the previous year’s volume. It is getting busy enough, now, that it could use a ddR system.”

Meanwhile, another outpatient imaging center is under construction elsewhere in the Yuma market, and a Swissray ddR system is likely to be installed there, as well. The newest facility is being located near the major winter campsites where visitors park their RVs. A number of primary care physicians and other specialists have, in recent months, been opening offices in close proximity to those vacation havens.

“The physicians are locating themselves there to capture business from a patient-rich area more easily,” Schotten says. “Our newest imaging center is being sited there in order to support those medical providers. It is also there to offer convenience to the patients; they have driven 1,600 km to get to an RV park, and they should not have to drive another 24 km to come into town for medical attention or imaging. Neither should they have to wait. Thanks to ddR, they no longer do.”

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