While the use of mobile imaging is nothing new in the health care field, PET/CT is currently fueling its growth.
A typical mobile PET/CT client usually falls into one of the following categories: facilities without the volume to sustain a full-time commitment for a $2-million-plus piece of equipment; those that want to test the relatively new modality before committing to purchasing it; or those with PET in place, but wishing to give PET/CT a trial.
|Marquette General Hospital, Marquette, Mich, created an addition that serves as a docking station for its mobile PET/CT unit. The facility includes a registration desk, waiting area, nurses’ station, and restrooms.|
Those who use mobile PET/CT services say there are many things to consider when determining whether to use such a service. Initially, a potential customer must assess the needs of the community it serves, decide whether to go with PET or PET/CT, whether to use a mobile service or purchase a fixed unit, and determine where to house the service when it comes to the site.
MODEL #1: THE SUBURBAN SITE
“Mobile services are a really good way to build a business, to start you out,” says Gary Fedo, CMT, a registered nuclear medicine technologist and director of imaging services at Ridgeview Medical Center, Waconia, Minn. “A lot of small hospitals like us just don’t have big, deep pockets for capital equipment, so we’re limited in what we can do. Here’s a way to provide that service, and build the business before you actually spend the capital. It’s a wiser way of using your capital.”
Ridgeview Medical Center is an independent, 129-bed, acute care community hospital about 28 miles from downtown Minneapolis. Before the hospital began using mobile PET/CT, referring oncologists and radiation oncologists sent patients elsewhere for PET scans.
Fedo credits Ridgeview’s CEO, Bob Stevens, with the vision to keep that business at the hospital.
Ridgeview already had a site available on its campus for mobile imaging, as well as power and communications capabilities to get images to the hospital. The hospital used mobile CT and MRI before bringing MRI in house about 6 years ago.
Fedo says Ridgeview’s consulting radiology group, Consulting Radiologists, Ltd, advised the hospital to opt for a PET/CT combination scanner, instead of a PET scanner solely. Ridgeview started offering PET/CT in July 2004 for a half-day per week, but switched to a full day at the end of June this year. On average, the hospital performs about 15 to 20 scans per month—up from one or two when the service was first offered. “There were some days that we didn’t have any patients when we started,” Fedo says.
Offering PET/CT on site is a convenience for referring physicians and their patients. “We’re right on the edge of city life and rural life,” Fedo says. “People around here, especially those who live further west from us, don’t like driving downtown. So, besides the time [consideration], it’s a cultural thing too; they just don’t go downtown, particularly older people. That’s another reason why we provide the service here.”
The same holds true for Allina Mercy Hospital, Coon Rapids, Minn, a 271-bed facility about 15 to 20 miles from downtown Minneapolis. “Most of the patients who come to Mercy Hospital are community-based, and they prefer to stay in the community, and do not want to travel to a downtown location or another hospital,” says Geri Heilman, BS, RT, radiology manager for Allina Mercy Hospital.
Heilman says Allina’s referring oncologists and radiologists were the driving force pushing for PET.
Promoting the Service
In order to promote their mobile PET/CT service, hospitals use traditional and creative methods to identify potential referrers, such as educational conferences, including tumor boards involving PET; coverage and advertisements in local and regional media outlets; luncheons with physicians and their staff; newsletters and fliers; and marketing calls, especially to oncology and pulmonary departments. “The other thing is simply word-of-mouth, physicians talking to physicians,” says Geri Heilman, BS, RT, radiology manager, Allina Mercy Hospital, Coons Rapids, Minn.
“PET/CT has a pretty narrow referral list,” says Gary Fedo, CMT, director of imaging services, Ridgeview Medical Center, Waconia, Minn. “Whereas with something like MRI, every family practice physician out there can send you referrals, most of your referrals in PET/CT are going to come from oncologists, radiation oncologists, and some pulmonologists, so you’re pretty limited to whom you can push it.”
Having a strong physician champion can also help promote the new modality and educate the referring community on its capabilities. At Marquette General Hospital, Marquette, Mich, Steve Min, DO, and Todd Bostwick, MD, both radiologists trained in PET, act as physician champions for the mobile unit, and help identify potential referrers. “It’s a slow process,” says Andreas Koutouzos, CNMT, director of nuclear medicine/ultrasound/PET. “The initial support was sought from key physicians, including oncologists, pulmonologists, neurologists, and cardiologists.”
Riverside also uses the expertise of its staff PET specialist as the mobile unit’s physician champion. “He has given talks on it, and gets the word out to all of his colleagues,” says Cynthia Herring, CNMT, MHA, imaging coordinator, Riverside Regional Medical Center, Newport News, Va.
Because the hospital did not have the capital to make an outright purchase, it contacted the company with which it already had a contract for previous mobile imaging services to see what services it had to offer, and began using mobile PET in 2002, 1 day per week, averaging 27 PET patients per month. “The business was just so-so,” Heilman says. “We never really got a strong business.”
When PET/CT emerged as a viable clinical tool, Heilman began to lobby for the combined modality. The company with which the hospital was working was switching all of its trailers to PET/CT, and by the end of 2004, Allina contracted for a mobile PET/CT unit, which it shares with another hospital. Allina offers PET/CT service on Monday afternoons and Friday mornings and, as of July 2005, added all-day Wednesdays, as well.
The hospital now averages about 43 patients per month on the PET/CT unit.
While business has increased with the PET/CT mobile service, “we’re still in the process of trying to grow that business,” Heilman says.
Allina already had a mobile dock in place by its radiology department from the days when it offered mobile lithotripsy and MRI. “We were very lucky that we did not have to do an initial cost setup because we had the dock; we had everything that was required. We had the phone set up already. We had nursing staff available. The only costs we had were what we had agreed with on the contract,” Heilman says.
The hospital uses an umbilical balloon that extends from the hospital to the truck’s entryway, so that patients walk directly into the truck from the hospital.
At Allina, images are networked to the hospital radiologists’ workstation to be read. For Ridgeview, however, the interpretation of scans posed another challenge.
The three radiologists who cover the hospital do not routinely read the nuclear scans, so they are sent to a partner downtown who reads them at an imaging center site.
While it takes longer to get results read, Fedo says, “It is still a lot easier than having the patients drive all over.”
MODEL #2: THE RURAL SITE
For Marquette General Hospital, Marquette, Mich, mobile PET/CT provides the means to serve the population of what Andreas Koutouzos, CNMT, director of nuclear medicine/ultrasound/PET, calls a “very remote” area.
Marquette General is a regional medical center located on the Upper Peninsula of Michigan and services a population of about 317,000. From tip to tip, the Upper Peninsula is more than 300 miles.
|Gary Fedo, CMT|
When PET was originally approved by CMS, Michigan, a certificate of need (CON) state, established eight regions; Marquette was placed in Region 8, which includes the entire Upper Peninsula and about one third of the Lower Peninsula.
Koutouzos says the state decided to permit one PET scanner for Region 8, in which there are five hospitals that desired PET. Marquette is about 250 miles from the nearest of the other four.
Initially, the five hospitals agreed to share a mobile service that would stop at one of the sites each day, but Koutouzos says that would have posed quite a logistical challenge because of the hospital’s remoteness, a further challenge due to an annual 260 inches of snow that can hit the area hard in wintertime.
Koutouzos says Marquette also realized that the use of PET was going to expand, meaning that 1 day a week of mobile service would probably not be enough.
Marquette was eventually allowed to solicit a mobile service from Wisconsin to service the Upper Peninsula, and began offering PET 1 day per week, in the beginning of 2004. “Within 6 months, our volumes became pretty significant,” Koutouzos says.
Six months into the process when PET/CT became available, Marquette was interested. “Prior to that, we were fusing CT scan images on top of the PET study,” Koutouzos says, adding that initially the PET service began with four or five patients 1 day a week.
Marquette averages about 80 to 90 patients per month at its mobile PET/CT, doing imaging 3 days per week. “It’s been a steady progression,” Koutouzos says.
Interpretations are handled by two radiologists, both of whom specialize in nuclear medicine, one with specific training in PET.
|Marquette General Hospital provides PET/CT imaging via a mobile unit 3 days a week.|
When Marquette decided to use the mobile service, “we wanted to create an environment where our patients could come to have a PET scan and not know that they’ve left the building,” Koutouzos says. The hospital built a $250,000 addition to its existing MRI suite, complete with a waiting room, holding area, restrooms, storage, and nurses’ station, that connects to the mobile unit via an umbilical balloon. The facility serves as a docking station for the mobile unit, and was constructed primarily to provide shelter from the weather for patients. “Instead of an eight-foot hallway that would just take you to the unit, we actually created a room, where patients could recover and use restroom facilities, and so on. The last two feet where you cross over from the hospital into the PET scanner is the only thing that would even give you a clue that you’ve left the building,” Koutouzos says. “The patient is never outside. They’d be pressed to even know they’ve left the building.”
MODEL #3: ENTREPRENEURIAL
Riverside Regional Medical Center, a 450-bed facility in Newport News, Va, saw mobile PET as the answer to not just its own but its region’s need for the modality; in 2002, it purchased its first mobile unit, later trading it in for a PET/CT in December 2003. Since Virginia is a CON state, Riverside was required to obtain a CON before purchasing the equipment.
“We have sister hospitals and an outpatient center; we wanted to be able to own our unit and work it within all of our locations,” says Cynthia Herring, CNMT, MHA, imaging coordinator at Riverside Regional Medical Center.
The mobile PET/CT unit services the medical center, as well as sister hospitals Riverside Walter Reed Hospital, in Gloucester, and Riverside Tappahannock Hospital, in Tappahannock; as well as an outpatient center, Riverside Diagnostic Center, in Williamsburg. Scanning is done at Riverside 3 to 4 days a week, and at the other facilities on the remaining days.
The dual-slice CT portion of the mobile PET/CT unit is used only for attenuation correction, not for diagnostic purposes. Riverside does not have an in-house PET unit within its imaging department, but does have 16-slice CT units.
Staff members at Riverside’s nuclear medicine department, including registered nuclear medicine technologists trained in PET, run the mobile unit on a rotating basis. “We were trained initially when we bought the equipment on applications, and some of us were sent to a training program that the company we bought the equipment from provided,” Herring says. “Anybody new coming on board as a nuclear medicine tech will go through an orientation and training before they are allowed to work on that alone.”
The mobile unit sees about 100 to 120 patients per month between all of the sites. Scheduling is handled through an off-site service. Referring physicians call the service to schedule appointments for their patients, but Riverside follows up with the patient directly the night before the appointment. “We order the FDG [fluorine 18-labeled deoxyglucose] from a pharmaceutical company the night before,” Herring says. “Hopefully, we use all our doses the next day. That’s why we call to remind the patients. That way, if they can’t make it, we call to cancel the dose that night.”
The unit utilizes a mobile pad, which is stationed at each facility, that hooks up to an enclosure, creating a direct electrical connection from the facility to the mobile unit. At Riverside, the mobile unit is connected directly to the MRI department, and all patients come through that department’s reception area. After injection on board the mobile unit, patients wait for an hour in a separate reception area in the hospital. “We have enough room to keep one of them on board [the mobile unit] waiting in a reclining chair,” Herring says. “We also have another area set up with another reclining chair, where a family member can sit with them.”
Riverside provides separate bathroom facilities for patients to use after injection, before they undergo the PET scan.
A radiologist who specializes in nuclear medicine/PET on staff at Riverside—which is filmless—oversees the process, and reads all of the studies. A dictated report is sent to the referring physician within 2 or 3 days.
Use of the mobile PET/CT has increased since Riverside started offering the service, and Herring foresees a time when the hospital will need to have more than one mobile unit. “It would be nice to have a stationary unit, and then this unit would just be mobile,” she says.
|Andreas Koutouzos, CNMT|
Most PET/CT trailers are between 48 feet and 53 feet long, and approximately 10 feet wide, some with slide-outs that extend the sides a few feet. They are usually completely self-contained units with an operator console, hot laboratory, patient waiting area, scanning room, and other work areas.
There are several contract options for pricing, including a fixed fee per scan on a daily, weekly, or monthly rate; sliding scale; and built-in minimums.
Mobile imaging providers usually supply a nuclear medicine technologist to perform the injection and scan, as well as an aide/driver to assist with the patient. “The rest of it just flows into our regular routine,” Fedo says. “They’re in our radiology information system; reports go out, and so on. We don’t have any extra people in the department for this service, and that’s one of the beauties of the deal.”
Scheduling appointments is handled by the hospital using the mobile unit. At Ridgeview, scheduling is cut off at 3 PM the day before the mobile service provider is scheduled to arrive so that the company is prepared with the radiopharmaceuticals needed for the following day’s patients.
Upon arriving at a hospital, patients are registered by a hospital staff member. The aide then brings the patient to the trailer, where the technologist injects the patient with a radioisotope, typically FDG, which has an approximately 2-hour half-life. Patients must sit quietly for 45 minutes to 1 hour for uptake before being scanned. Some hospitals, such as Allina and Marquette, have a dedicated “hot” toilet for patients to use after injection and before the scan, to protect other patients from unnecessary exposure.
A no-show can be more costly than usual due to the radiopharmaceutical, so providers are well advised to take extra precautions. Depending on the specific service contract, in the event of a cancellation, the radiopharmaceutical that is not used is usually billed to the hospital, which may or may not pass on that cost to the patient.
The staff and administrators at Marquette work to be “more proactive than reactive” when dealing with no-shows, Koutouzos says. “We work very closely with the physicians’ offices, as well as with the patients, to [help them] understand the magnitude of what a PET scan really involves,” he says. “We do have this phenomenon called winter, and it is not unlikely that we get two feet of snow. We ask that patients who live beyond 75 miles come to Marquette the night before their PET scan.” The hospital has hospitality facilities to accommodate those patients.
While mobile PET/CT is serving its purpose for Ridgeview, Allina Mercy, and Marquette General, each hopes to eventually be able to offer the service in-house.
“It’s going to take a little more time to grow that business because, again, you’re limited to the number of people you’re going to scan,” Fedo says. “When you look at MRI, you’re looking at spine, knee, shoulder, hand work; there’s a ton of patients out there for that sort of scan. With PET/CT scanning, you’re limiting yourself to a smaller number of potential customers.”
Heilman says it will probably take a couple more years before PET/CT moves in-house at Allina, as well. “I would love to bring it in-house, but I don’t envision that will happen until we really have the volume,” Heilman says. “I’m hoping that just adding this Wednesday service will make a big difference because where we were running into problems was that Friday is the end of the week, Monday is the beginning of the week, and there was that long lull in between.
“I’m hoping that with being able to offer the service every other day, we can really start growing the business,” Heilman says.
Words of Wisdom
The interviewees for this story have these words of advice for providers considering use of mobile PET/CT:
Danielle Cohen is associate editor of Decisions in Axis Imaging News.