|Charles Mueller, MD (left), and Richard Davis, PhD, administrative director of diagnostic services, Ohio University Medical Center, Columbus.|
While most hospital emergency departments can depend on the radiology department for speedy interpretation of studies during daylight hours, only a relative few are able to expect such alacrity once the sun goes down. Cost is one reason radiology coverage for the emergency department customarily stops at nightfall; radiologist unhappiness with working swing and graveyard shifts is another.
Ohio State University Medical Center in Columbus? ran up against both drawbacks, but let neither deter it from producing a top-notch, ’round-the-clock, emergency radiology service. For its effort, the two-hospital enterprise now enjoys rewards in the form of improved quality of emergency care, faster discharge of patients from the emergency department, shortened length-of-stay for inpatients admitted via the emergency department, and greater satisfaction from all quarters-patients, emergency department physicians, and, of course, the radiologists.
“Only about 10% of hospitals offer total coverage in the emergency department, and that’s partly because it’s very expensive to do so,” observes Charles Mueller, MD, professor of radiology at OSU, a champion of the medical center’s emergency radiology service. “Here’s why it’s expensive. If you’re going to offer emergency radiology 24 hours a day, 7 days a week-24/7, as they say-that means you must have at least one radiologist on emergency department duty each shift. Since there are three shifts each day, that means you’ve got 90 shifts per month to fill. In our experience, we found that 90 monthly shifts translates into a need for six radiologists full time (FT). The cost of that many FTs will easily exceed $1 million a year.”
And that is not counting the cost of technologist and clerical support-perhaps another quarter of a million dollars per year, Mueller speculates. Nor does it factor in the costs arising from the need to build redundancy into the emergency radiology service, cautions Dimitrios Spigos, MD, chairman of OSU’s Department of Radiology.
“Unlike in a radiology clinic setting, patient visits cannot be scheduled, and there is no way to synchronize their arrivals so that caseload can be comfortably spread out,” Spigos explains. “By the same token, the amount of time each patient spends in the emergency department-along with how much emergency radiology service they will require during their visit-cannot be easily predicted. Consequently, you can have frequent instances where tremendous stress is placed upon the system. To prevent overload and enable the system to absorb the stress, it requires that you have two or more of every modality needed for emergency department work, and that by itself can be a very expensive proposition.”
On the logistics side, hospitals desiring to provide 24/7 emergency radiology invariably find it difficult to recruit radiologists to fill the time slots at night.
“It’s a challenge convincing radiologists accustomed to working only by day to stay up all night performing image interpretations and providing consultations,” Spigos acknowledges.
Who can blame them? Pulling an all-nighter in the emergency department can leave a radiologist sleep-deprived, which hampers his ability to work efficiently and with accuracy. Worse, it can adversely impact his circadian rhythms to the point where he cannot easily fall asleep at a decent hour for several subsequent days until his internal clock becomes recalibrated, suggests Mueller, who adds that working through the night is harder for some radiologists than it is for others, depending on age, sleep needs, and sleep habits.
A well-conceived and executed emergency radiology program exhibits several characteristics.
1. It should be set up to operate as a satellite of the hospital’s radiology department and located either within or immediately adjacent to the emergency department.
“This satellite unit would have to offer enough physical space for a minimum of two rooms: one for consultation, the other for interpretation of images,” says Charles Mueller, MD, professor of radiology at Ohio State University in Columbus. “If there is one room, the radiologist assigned to reading will constantly find himself interrupted. That’s a situation not at all helpful to productivity or to the quality of care the patient will receive.”
2. The emergency radiology service needs to function within an electronic environment, supported by PACS with full integration to a radiology information system (RIS) and hospital information system (HIS).
“These systems need to be capable of very fluid and seamless exchanges of images, patient demographics, medical histories, charts, and billing information,” says Mueller. “The emergency radiology service needs to be capable of instantly distributing these data throughout the emergency department and beyond so that the various clinicians and support personnel can quickly come to the right diagnosis and initiate the right care interventions.”
3. The imaging modalities themselves must be state-of-the-art and encompass, at minimum, conventional radiography, helical CT, and ultrasound, all placed in or immediately near the emergency department.
“Traditionally, the emergency department was the place where the radiology department’s old, outdated equipment was sent prior to retirement,” Mueller explains. “That is not acceptable in an emergency radiology program aimed at improving the quality of care.”
In addition to the above-mentioned modalities, the emergency radiology program also should seek to deploy within or near the emergency department modalities such as angiography, fluoroscopy, and nuclear medicine if the institutional radiology department is physically so far removed that the emergency department patient cannot be easily or safely transported to the radiology department, Mueller notes.
4. The emergency radiology program must acquire and retain highly trained personnel.
“The emergency radiology section should have four to six dedicated radiologists, with one in fellowship training, plus residents,” Mueller says. “If you have residents in the section, they must have a veteran radiologist working alongside to provide protection, because a resident in the emergency department alone at night can be severely buffeted by intense demands he or she is not prepared to handle.”
Still, as far as Mueller, Spigos, and their OSU radiology department colleagues are concerned, 24/7 emergency radiology is a noble undertaking-very much do-able and eminently rewarding.
“We provide to the night-shift emergency department physicians timely interpretations of images so they can initiate correct treatment very quickly,” says Spigos. “This puts their patients on the path to an earlier discharge, with a substantially reduced potential need to recall or readmit them later.”
Secondarily, the radiology department is generating-and billing-more studies than ever. Mueller reports that emergency department-generated examinations for all modalities are up by 15% from this same time last year, with CT alone rising by 19%.
“We’re seeing a tremendous increase in utilization, and to an extent it is because of our increased accessibility by the emergency department physicians,” Mueller says. “But it’s also because we’re offering those physicians a facile means of confirming their diagnostic suspicions: for example, CT studies of the sinus to verify a preliminary diagnosis of sinusitis.”
Spigos interjects that the escalation of emergency radiology studies by no means represents overutilization.
“Because we are there, we convert unnecessary studies to appropriate studies,” he insists.
Another benefit of OSU’s 24/7 emergency radiology program is the heightened sense of esteem radiologists have gained from working more closely more often with other specialists in the emergency department.
“The emergency department physicians soon enough came to see our radiologists as key players in the delivery of trauma care, and now have a new, much deeper respect for them,” Mueller says.
Ohio State University Medical Center initiated its 24/7 emergency radiology coverage in late 1994. The impetus was a letter of complaint from an emergency department patient unhappy about being charged for radiologist interpretation services that had no bearing on the course of treatment she received because they were delivered late.
“Back then,” Spigos says, “we were routinely performing interpretations of emergency radiological studies, but not after regular business hours. When the patient presented herself to the emergency department with a complaint of chest pains, it was 11 o’clock at night. Not until the next morning was the radiograph reviewed by a radiologist. But by that time, the patient had since been discharged: the attending physician in the emergency department relied on his own training and experience to make a diagnosis, render treatment, and then send the patient on her way.
“Nevertheless, a bill was sent to the patient for the radiologist’s read. She wrote back to the hospital and asked that the charge be removed since the interpretation didn’t provide any meaningful information with regard to her diagnosis and treatment. Her complaint had validity, so we honored her request. However, for us, this was eye-opening. It pointed out to us a fundamental weakness in our then-existing emergency department coverage. I decided we had to do something about that. That’s when we began developing a plan to extend our emergency department coverage to include nighttime hours. Our goal was to make sure that all our interpretations were contemporaneous with the delivery of care and while the patient was still in the emergency department.”
Implementing the Service
To facilitate this objective, the radiology department over the course of time outfitted the emergency department with technology such as dictation systems and PACS (with clean interfaces to RIS and HIS). The department also established imaging protocols for the most frequently encountered conditions in the emergency department, such as gallstones, appendicitis, pulmonary embolism, and aortic injury. Further, a strategy for scheduling radiologists to attend the emergency department at night was fashioned after much experimentation.
The Demand Factor
Demand for emergency radiology is growing in part because demand for emergency department care is growing.
“Several factors have pushed emergency departments into prominence of late,” says Charles Mueller, MD, professor of radiology at Ohio State University. “Patient attitudes have changed, that’s number one. They are accustomed to instant everything, so it’s understandable that they now expect instant health. Also, local primary-care physicians’ attitudes have changed. They’ve decided they don’t want to endure the ordeal of nighttime practice on top of a full day’s schedule, so they’re routinely sending patients who call with complaints of aches and pains after regular business hours to the hospital emergency department for attention.
“Another element is that payors have been reimbursing for emergency department visits more readily and reliably than they have emergency, after-hours visits to physician offices. This is especially true of HMOs.
“And it’s impossible to overstate the growing and justifiable fear of lawsuits. This has prompted hospitals to invest in state-of-the-art imaging technology for their emergency departments, which serves to ease their vulnerability to allegations that their emergency departments failed to deliver all reasonable and appropriate care for the patient who showed up after, say, a car crash. Among other things, plaintiff’s lawyers like to try to argue that the emergency department botched the diagnosis and subsequent intervention; showing deficiencies in radiology equipment and coverage is one way to prove that.”?
“We tried different approaches to scheduling, such as having each radiologist spend several consecutive nights of emergency department duty each quarter,” says Spigos. “But we found that particular approach unworkable. What happened was the radiologists’ circadian rhythms would change by the third night to the point that they would experience about a week of trouble returning to a diurnal work routine.”
The approach that worked, says Mueller, was to have each of the department’s 20 radiologists take turns doing a 1-night solo stint in the emergency department. That way, each radiologist would be only obliged to forego his regular bedtime once every 3? weeks. To make it even less disruptive, the department instituted a policy of giving to the radiologist scheduled for emergency?? duty that night the morning and afternoon off for napping before starting the shift, and a full day off immediately afterward to catch up on any sleep lost.
“It plays out well,” Mueller assures. “When you return to your regular day shift, you’re bright-eyed and feel little or no after-effects.”
Radiologist participation in OSU’s 24/7 emergency radiology service was at first voluntary, but we had to have broader participation, approximately once every 2-3 weeks, for the system to work. Despite that, it remained an imperative to secure buy-in among the radiologists, Spigos admits.
“We secured the support of the radiologists by emphasizing to them the financial and quality of care benefits of the emergency radiology program,” Spigos tells. “All of the radiologists in the department belong to one practice group. So, it came as welcome news that the reimbursements for nighttime coverage in the emergency department would come directly to our group.”
MAKING IT BETTER
Now that the 24/7 emergency radiology program has been up and running smoothly for some time, OSU is exploring ways to further improve it.
“It has been suggested that it may be advantageous to locate the emergency? radiologists elsewhere in the hospital, far enough removed from the emergency department so that the radiologist who is on duty that night will be able to work in quieter surroundings where lighting can be better controlled,” Spigos says. “One suggested location is the radiologist’s home. That would be feasible, technologically, since we have installed high-bandwidth lines to off-campus locations and to several of our radiologists’ homes. Our PACS implementation also includes an intranet Web site, which would further facilitate the ability of our radiologists assigned to emergency radiology coverage to access from home all the radiographs, CTs, ultrasounds, and other studies performed in the emergency department.”
Mueller agrees that the technology certainly exists to support such a deployment, but is not eager to see it happen.
“I can get the same sharp, clean, clinically useful image on my Pentium III desktop at home as I can in the hospital at my PACS workstation,” he says. “I might, of course, have to manipulate the image on my home PC, but quality will nevertheless be the same as in the hospital.
“However, I know I’m not alone in saying that I’m not anxious to begin using home PCs for night emergency radiology coverage,” Mueller notes. “Emergency radiology is much more than just the reading of images. It is also being available to consult with the clinician about the precise location and severity of the patient’s pain in order to focus our interpretation on the likely source of the problem. It is doing image planning and informing the emergency department clinicians as to the significance of the findings. It’s clueing the clinicians in about the time frame in which they need to respond.
“If we were to work from home, providing these extras would become a difficult matter.”
All things considered, Spigos and Mueller express confidence that emergency radiology at OSU-and elsewhere across the nation-can only gain in stature and importance.
“When you consider that 30% to 40% of inpatient admissions arrive from out of the emergency department, most hospitals are sooner or later going to recognize the need to make sure emergency radiology is properly supported and its utilization encouraged,” says Mueller.
Numbers Must Grow
|From left, Charles Mueller, MD, professor; Bruce Lauer, MBA, technical director, diagnostic radiology; Dimitrios G. Spigos, MD, radiology chairman; and Richard Davis, PhD, administrative director of diagnostic services; comprise the management team for emergency radiology services, Ohio State University Medical Center.|
Yet, he concedes, emergency radiology’s future may well depend on the ability of institutions to convince some radiologists that they ought to subspecialize in emergency radiology.
“The number of emergency radiology-subspecialized radiologists is going to have to grow in order for this kind of service to deliver maximum benefit, but that won’t be easy because, at present, there are only five fellowship programs in emergency radiology to be found in the United States,” Mueller laments. “And most of these programs are going begging for inductees. As a result, we’re producing only a small fraction of the emergency radiologists we now need and will need in the future.”
Mueller ventures an explanation: a dearth of emergency radiology-specific radiologists exists because the overwhelming majority of radiologists participating in emergency radiology programs have “day jobs” they love and would never think of abandoning, such as being a chest subspecialist or a nuclear medicine practitioner. Then, too, there is the not-small matter of emergency radiology lacking recognition as an official subspecialty.
On this last point, however, there is hope for a remedy. According to Mueller, the American Society of Emergency Radiology (ASER)-an organization he cofounded in 1988-recently sent a letter to the American Board of Radiology (ABR) proposing that official subspecialty status be conferred upon emergency radiology. The ABR seemed receptive to at least the possibility of this step, but made no promises in its written reply, Mueller states.
“What we wanted was for the ABR to include emergency radiology as one of the subspecialty categories in its examination protocols,” Mueller shares. “But I think the only way the ABR will agree to it is if we have an outpouring of support from people dedicated to the practice of emergency radiology as a subspecialty. Given our current low numbers, that means we have to encourage residents and post-residents to become more interested in emergency radiology. We need more fellowships. We need more satisfaction from among the radiologists who are engaged in the delivery of emergency radiology-and that, in turn, will encourage more residents to choose emergency radiology as their subspecialty.”
Not that emergency radiology is bereft of adherents even now.
“Already the ASER, which started with just seven members, today has over 500 and holds an annual meeting that is attracting a growing audience each year,” Mueller says. “I consider our own experiences here at OSU. In the beginning, there was skepticism among the radiology faculty concerning the wisdom of providing extended emergency department coverage. Today, most of those who were skeptical believe our extended coverage in the emergency department to be worthwhile. I don’t think anyone would disagree with that.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.