The emergency department has always presented a huge challenge to radiologists. Not only must the images tell the physician what he or she needs to know, they must do so quickly, often after being obtained under less-than-ideal conditions. Manufacturers seem constantly to be introducing new modalities, such as multidetector-array CT, that can provide reams of useful informationif the hospital can afford them. Experts offer advice on selecting patients for particular modalities, such as contrast echocardiography and gated single-photonemission CT, which are said by a team from the Cardiovascular Imaging Center at the University of Virginia to offer “substantially greater diagnostic and prognostic information” 1 about early cardiac events in patients with chest pain and no ST-segment elevation. Perhaps, instead, one should choose ultrasonography, popularized by its portability, multiplanar capability, and real-time features for diagnosis of many conditions and for the guidance of interventional procedures. 2 Adding color Doppler capabilities makes it easier to plan a needle trajectory that avoids large blood vessels. MRI is finding a growing place in the imaging of trauma patients 3 and children, 4 the latter being a population in which avoidance of radiation is particularly desirable. Increasingly, too, radiology departments face the “variety of logistical and medical challenges” 5 presented by the morbidly obese.

With all these options and advisories, perhaps it is not surprising that a reading of recent publications might give the impression that plain radiography is a technique whose time has past, but that would not be true, especially since the introduction of digital radiography (DR) and its many desirable features. For example, in patients with musculoskeletal injuries, DR has the advantages of optimizing image quality and radiation dose, with a wider dynamic range and the ability to carry out postprocessing as required to avoid retaking images. 3 Optimization of imaging parameters with DR can reduce the radiation dose, making it a desirable modality for use in children. 4 Capturing the images digitally also facilitates teleradiology. Several physicians can then view the images simultaneously if there is a need to consult on the findings. In orthopedic trauma, teleradiology improves diagnostic accuracy, speeds the disposition of patients, assists in surgical planning, and potentially reduces the risk of incorrect diagnosis and litigation. 6 Some observers expect that it soon will be possible to transmit the digital images to handheld devices such as cellular telephones, making teleradiology even more appealing for emergency cases. 6

Renco Scheper is manager SEH in the emergency department at Medisch Centrum Leeuwarden Hospital northeast of Amsterdam, Netherlands. The department sees about 20,000 patients a year, roughly half of whom require imaging. Generally, Swissray’s direct digital Radiography ddR is used, although those with neurological problems may have a CT scan in the radiology department. The emergency department has been using the Swissray ddR Combi Plus for 18 months. The system was designed with input from Scheper’s team.

Scheper says, “Formerly, we often had to move patients quite a bit. They had to be stabilized, taken for imaging with all their supportive apparatus, moved onto the radiography table, and rearranged so that the necessary views (of sufficient quality) could be obtained. We then had to keep the patient close to the equipment until the images were available for review. Sometimes, the patient had to be moved back to the table to obtain images of better quality or to acquire views from a different angle.” He continues, “With an emergency department patient, you do not want to do that, so we worked with Swissray to create a ddR system that allows us to perform whatever procedures are necessary to stabilize the patient while we are taking the necessary images.”

Scheper adds, “We can obtain images from any angle, with the patient in any position, and those images are available almost immediately, so we can decide if we need additional views and then start dealing promptly with the patient’s problems. If the patient is admitted to our hospital, we can send the images to the appropriate department; if the patient is transferred to another hospital, we can send the images with them (or by mail) on a CD-ROM.”

Those images, Scheper reports, are of high quality. He says, “We do not have problems with poor-quality films, as we often did with a conventional system. We have not documented the time savings exactly, but we know that the ddR system has speeded up patient processing. We seem to be saving 15 to 30 minutes per patient.”

Two teams of researchers, one in Australia and one in the United States, have attempted to quantify the benefits of DR. For 5 weeks, researchers at Flinders Medical Centre of the Royal Adelaide Hospital 7 collected time and motion data for ddR and conventional radiography studies of patients in the emergency department who required chest radiographs. There were 30 patients in each group. The physicians of the emergency department and intensive care unit also were asked about their experiences with, and preference for, the two options. What the investigators found was that the time required for a clinician to obtain the requested images was 70% less with DR. Although the clinicians expressed the same degree of satisfaction with the two modalities, most of them noted that DR offered significant advantages in that it was possible to modify the images as needed to improve their diagnostic utility.

St Luke’s Episcopal Hospital, 8 Houston, reported on the productivity gains in the radiology department attending installation of DR. With conventional radiography, it was not unusual for the department to have six to 10 patients waiting for radiography. Part of this backlog was attributable to the unpredictable nature of admissions to the emergency department, although inefficient work flow was the largest contributor. After the hospital installed DR, the avoidance of film processing reduced the backlog even before a picture archiving and communications system (PACS) was installed. Moreover, the department found that it could handle a significantly larger number of patients without compromising image quality. The hospital estimated that the DR system would pay for itself in less than 3 years. 8

For emergency departments considering DR, Scheper’s advice is, “Do it tomorrow, for the whole hospital. It is true that it costs more to purchase a ddR system. If, however, you do not have logistical problems in obtaining your images, and you do not have to chase them around the hospital or carry them from place to place, you save money. You do not need staff to move the images, and you do not need storage space. Since we put in our ddR system, we have been able to do the same work with fewer people.”

References:

  1. Kaul S, Senior R, Firschke C, et al. Incremental value of cardiac imaging in patients presenting to the emergency department with chest pain and without ST-segment elevation: a multicenter study. Am Heart J. 2004;148:129-136.
  2. Nakamoto DA, Haaga JR. Emergent ultrasound interventions. Radiol Clin North Am. 2004;42:457-478.
  3. Bohndorf K, Kilcoyne RF. Traumatic injuries: imaging of peripheral musculoskeletal injuries. Eur Radiol. 2002;12:1605-1616.
  4. Scharitzer M, Hormann M, Puig S, Prokop M. Imaging techniques and examination protocols in the pediatric emergency [in German]. Radiologe. 2002;42:146-152.
  5. Grant P, Newcombe M. Emergency management of the morbidly obese. Emerg Med Australas. 2004;16:309-317.
  6. Ricci WM, Borrelli J. Teleradiology in orthopaedics. Clin Orthop. 2004;421:64-69.
  7. Pathi R, Langlois S. Evaluation of the effectiveness of digital radiography in emergency situations. Australas Radiol. 2002;46:167-169.
  8. Sack D. Increased productivity of a digital imaging system: one hospital’s experience. Radiol Manage. 2001;23:14-18.