· CT Accord: More Education Needed
· Case History: SVAMC Reopens ED with Telemedicine

CT Accord: More Education Needed

Sal Martino, EdD, RT(R), FASRT

In 1967, Godfrey Hounsfield developed the first head CT scanner based on x-ray computed tomography (CT), and in 1979, he won the Nobel Prize in Physiology of Medicine for this work. A year later, in 1980, approximately 3 million CT examinations were performed, a number that grew to more than 68 million in 2005. Estimates in recent years suggest that roughly 13% of all radiologic procedures are CT exams.

As CT use has expanded, more data on its effects has been gathered, and studies suggest that perhaps the wild growth should be tamed: CT exams may make up 13% of all radiologic procedures, but they are responsible for 70% of the radiation exposure of patients.

With utilization and concern increasing, it seemed the perfect time to address the use and proliferation of CT. “We decided that it might be the right time to get everyone in same room and ask, ?Where are we? Where are we going? And what kind of recommendations do we want to make?’ ” said Sal Martino, EdD, RT(R), FASRT, executive vice president and chief academic officer of the American Society of Radiologic Technologists (ASRT), Albuquerque.

To foster this aim, 32 experts in health policy, CT manufacturing, clinical practice, and education gathered in August 2007 and April 2008 to produce a consensus document addressing the evolution of CT and its impact on the future of radiologic science education and practice. Sponsored by the ASRT and the American Registry of Radiologic Technologists, the panel developed nine consensus statements focusing on patient safety, regulations, and reimbursement; education and practice; CT in diagnostic radiology; CT in radiation therapy; and CT in nuclear medicine.

Nine Statements
Their first conclusion, and perhaps the one with the most overarching impact, is that “medical imaging and radiation therapy professionals need more education in CT technology, including operation, application, and dose optimization, to ensure patient safety.” The viewpoint was agreed upon unanimously.

“Patient safety and reducing radiation dose already are core principles in the educational curriculum for the radiography, nuclear medicine, and radiation therapy disciplines, as well as for the CT curriculum.” But more education, including that beyond dose reduction, is needed. The panel concludes that when medical imaging and radiation therapy professionals thoroughly understand CT operation, techniques, and protocols, they can minimize dose and perform safer examinations. “More education will ensure patient safety and increase exam quality,” Martino said.

He believes that simply by making practitioners think about the importance of additional education, certification, and radiation dose, the statement will have an impact on clinical practice.

Similarly, the third statement addressing entry-level graduate curriculums will also benefit medicine and patient care. The panel writes, “Entry-level graduates of radiography, radiation therapy, and nuclear medicine programs should have both didactic and clinical education in basic CT procedures.”

“In some respects, CT is considered a specialty, but some employers are hiring entry-level grads and oftentimes require that some of what they do include basic CT exams, so we want to make sure they get CT education in school as well,” Martino said.

The panel suggests this will require course additions and curriculum changes for students in the related disciplines: radiography, radiation therapy, nuclear medicine, and technologists. But most professionals working in the field believe it is necessary.

A survey by the ASRT (the ASRT Computed Tomography Educational Needs Assessment) found that “68% of technologists agreed or strongly agreed that ?entry-level programs should increase their emphasis on computed tomography.’ ”

The remaining statements address:

  • Regulatory quality assurance;
  • Staffing needs, impacted by a technologist shortage and rising volume;
  • Education for CT-certified technologists (more programs are needed to meet demand); radiographers (more education is needed to operate CT equipment); and radiation therapists, who “should not perform diagnostic CT procedures without additional education in diagnostic CT”; and
  • The role of CT in radiation therapy (a core skill) and nuclear medicine (also a core skill).

Access the full document at www.asrt.org/CTconsensus or www.arrt.org/CTconsensus.

—Renee DiIulio

Case History: SVAMC Reopens ED with Telemedicine

NightHawk attracts US radiologists with opportunities throughout the world, ranging from home-based offices in the US to locations in Sydney, Australia, and Zurich, Switzerland.

More than 22,000 veterans are served by the Spokane VA Medical Center (SVAMC), located in Spokane, Wash. During the tenure of center director Joseph M. Manley, the number of patients seeking care at the facility has grown at a rate of more than 10% annually, as Manley testified before the United States Senate Committee on Veterans? Affairs in 2007. The growth in patient volume presented too big a challenge for the center, and in 2006, it was forced to close its emergency department (ED) and urgent care doors.

The SVAMC treats veterans in the northeast region of Washington State through its main center, three community-based outpatient clinics, and a mobile clinic outfitted with two exam rooms. The organization focuses on providing primary and secondary care, emphasizing preventive health and chronic disease management. The center offers 46 hospital beds, 38 rehabilitation-oriented nursing home beds, and a full menu of services spanning all disciplines, including cardiology, gastroenterology, general surgery, neurology, pulmonary, renal, and urology.

It is a main source of care for area veterans, and the center did not want to shutter its ED permanently. Reopening was a priority, but first the hospital needed to deal with the issues that had caused the closure.

The Challenge
One of those issues was staffing. As a VA facility, the structure of the SVAMC differed from traditional hospitals and impacted budget and staffing. Physicians employed by the center accepted less pay than they could garner elsewhere and worked long days with few lifestyle benefits. Radiologists were particularly difficult to recruit.

In addition, when the ED reopened, the administration expected the patient volume to jump even further—by as much as 20%, making the workload even more unmanageable. The CT scanner would need to run around the clock, but finding radiologists to complete the reads would be a challenge. The facility currently employs four radiologists who work the daytime shift (8 am to 4 pm).

“As soon as we reopened the ED, I knew that we would have to cover the CT in-house after hours. But placing radiologists on call was not a cost-effective, desirable option,” said Joel C Sim, MD, chief of diagnostic imaging, SVAMC, in a case study presented by NightHawk Radiology Services, a telemedicine service headquartered in Coeur d’Alene, Idaho.

Instead, the SVAMC set up a fee-per-read structure to handle overnight reads (those needed between 4:30 pm and 8 am). But the solution was neither cost-effective nor timely. Scan prices were high, and reports could sometimes take 2 to 3 weeks to turn around.

The Solution
The center turned to telemedicine, hiring NightHawk to handle its overnight reads. The center now has its own virtual private network in place to NightHawk’s reading center in Austin, Tex.

NightHawk employs US radiologists around the world to meet 24/7 needs, but in the case of the VA facility, the exams and patient data needed to remain in the continental United States. The timing for such a setup was perfect, according to NightHawk’s director of marketing, Scott Giordanella. “We had to make sure all the images for Spokane VAMC are kept here in the US, a direction we were moving in already,” Giordanella said.

Time was needed to properly credential the radiologists for reads at the SVAMC, but the center now has access to experienced, credentialed subspecialists 24/7, 365 days per year. The SVAMC ED reopened in 2007.

The Results
As more NightHawk radiologists have become credentialed, turnaround times in the SVAMC ED have improved. Patients are no longer transported off-site for CT exams, and reports are routinely returned within 30 minutes.

The solution leads to savings not only in the long term through improved care, but also in the short term. The SVAMC estimates it would spend an average of $270,000 to bring a radiologist on board. “The SVAMC needed two or three radiologists to cover their volumes,” Giordanella said, a cost that would run $540,000 to $821,000. At roughly $400,000, the NightHawk contract is significantly less, Giordanella suggests.

In addition, current SVAMC staff are happier (and therefore, easier to retain). The on-site radiologists no longer have to be on call. “With preliminary reports on file, they can reread those exams and either concur or not concur with the findings the next morning. By having NightHawk Radiology handle all after-hours readings, our radiologists go home and are well rested for the next business day,” Sim was quoted in the case study.

The solution has been so successful that the SVAMC is already expanding its use of NightHawk services. Telemedicine now handles MR subspecialty reads in addition to the after-hours CT service, and the organizations are in talks regarding CT final reads.

Since reopening the emergency and urgent care departments, SVAMC has had a successful track record, meeting the growing needs of the 22,000-plus veterans it serves.

—Renee DiIulio