Pediatric patients in the ED require special consideration when it comes to imaging equipment and protocols.

It?s no secret that the latest imaging technology means better patient outcomes for emergency departments (ED) across the country?which is where nearly 23 million children under the age of 15 are treated every year.1

?We?ve advanced our ultrasound machines, our MRI machines, and our CAT scan machines so that we can see more pathology,? said Michael Foley, RTR, director of radiology services at Tufts Medical Center and Floating Hospital for Children in Boston. ?So, the outcomes will be better because we now can diagnose earlier stages of diseases that we may have missed 15 years ago.?

Of course, excellent outcomes depend on the proper use of the equipment and good judgment, especially when it comes to radiation doses for these young patients. Investing in low-dose technologies and performing imaging based on medical necessity are two steps that go a long way toward both reducing radiation exposure for young children and improving efficiency for the littlest patients in the ED.

The Wiggle Factor

Young patients come into the ED for all types of reasons?but the main cause is injury.

?When you?re looking at the data for pediatric emergency room visits, the number one reason is accidents, meaning falls, trips, motor vehicle accidents, bumps, bruises, and scratches,? Foley said. In 2005 to 2006, falls accounted for 38% of ED visits for children between the ages of 1 and 4. For children ages 5 to 14, falls?usually due to sports injuries?accounted for 27% of initial visits to the ED.2

Imaging is often a key element in diagnosing and treating these young patients. ?Plain films for extremity injuries are extremely common,? said Steven J. Davidson, MD, MBA, FACEP, FACPE, chairman of the Department of Emergency Medicine at the Maimonides Medical Center in Brooklyn, NY. He adds the second most common imaging application is for chest x-rays, when the concern is infection, pneumonia, or the less common case of a foreign body.

While the same imaging equipment is used for both adults and children, younger patients usually require some type of restraining device?such as sandbags or belts?to restrict their movement during the scan. If a child moves during a scan, the case has to be repeated?which translates to more radiation exposure for the child.

?You have to really work with the children to make sure they hold still, and you have to work with the parents,? Foley said. ?Parents get scared when you start putting sandbags or belts on children to hold them down?they think that we?re torturing them. So, you have to be an ambassador with the parents and the child to get them calmed down, because motion will cause a repeat.?

The wiggle factor is particularly challenging during MR scans, which are increasingly being used for scans of the head and of soft tissue in pediatric patients. For children under age 6 who typically have difficulty holding still for the hour-long scan, this means being put under general anesthesia.

?MR can be a challenge in the young kids because of the need for sedation, and the difficulty in organizing the team to both manage the sedation and do the imaging,? Davidson said.

The sedation factor can also be alarming for both patients and their parents, which is why the pediatric radiology staff at Tufts is trained to walk them through it. The hospital also runs regular competency checks to ensure that the staff is comfortable working with children and their parents.

?Children and parents can sense people who were nervous performing scans on children,? Foley said. ?So, it?s probably not the most efficient way for me to use my staff, but the outcomes at the end are better. We get the best images we possibly can with a fully trained staff.?

Ultrasound: A Noninvasive Option

For the littlest patients, ultrasound has many advantages. It is both fast and noninvasive?meaning no medications, no injections, and no radiation.

The pediatric ED at Maimonides Medical Center has a dedicated ultrasound machine, and the department staff is increasingly performing bedside ultrasonography on younger patients. The hospital also employs a full-time pediatric emergency physician, who has an ultrasound fellowship.

?Bedside ultrasonography is a big deal in the emergency medicine world, but its uptake in pediatric emergency medicine is much less,? Davidson said. ?I think there?s a great opportunity in pediatric emergency medicine for bedside ultrasonography, particularly because you?re mostly working with smaller patients, and the opportunity to get the kind of penetration to see deeper structures is perhaps a little better.?

The purpose of emergency bedside ultrasonography is different from that of traditional diagnostic ultrasonography, Davidson adds. ?When one orders a diagnostic ultrasound from radiology, the radiology approach is to undertake a protocol to examine a portion of the body in response to a clinical indication,? he said. ?For emergency bedside ultrasonography, we?re typically trying to answer a narrowly focused clinical question?for example, is there urine in the bladder? You put a probe on, and you have the answer in seconds.?

While radiation exposure is a concern for patients of any age, it is especially important to keep doses low for children?which is another reason why ultrasound is a preferred modality for treating pediatric patients.

?Ultrasound can reduce the number of CT scans you need,? said Foley, who adds that bedside ultrasound is a staple in the hospital?s 50-bed NICU. ?If you?re suspicious that a child has hydronephrosis or even kidney stones, you can do that by ultrasound, which is safer for the child.?

Davidson notes that while a CT scan may be more reliable when looking for issues with an appendix, an ultrasound probe can sometimes provide the needed information without the extra radiation. It?s also useful when treating a dehydrated child.

?We can look at their state of hydration by tracking the diameter of the inferior vena cava over time as we hydrate them,? Davidson said.

There are many other applications for ultrasound in emergency situations. For menstruating girls under age 18, ultrasound is used to detect free fluid, intrauterine pregnancies, and other intra-abdominal issues. In the rare situations where clinicians need to see a child?s heart, ultrasound can perform that task as well.

CT: Limiting Exposure

While CT scans are almost routine for some adult emergency medical care situations, it is not usually the first line of defense for children. The use of CT technology in pediatric emergency situations is a double-edged sword. On the one hand, CT provides a tremendous amount of information very rapidly. On the other, it exposes a child to significantly more radiation than other modalities.

This is why the pediatric emergency departments at both Maimonides and Tufts have protocols in place to make sure that CT is used only when medically necessary.

?We?re very careful here,? Foley said. ?The pediatricians and the pediatric radiologists review a lot of cases before they go ahead and order the imaging.?

Part of this is recognizing which types of situations require CTs and which do not. Currently, Davidson?s department is working with pediatric surgeons to reduce the number of CTs ordered to rule out appendicitis, and the team has successfully scaled back on head CTs as well.

?In our environment, we have been very attuned for a number of years to the low yield of CAT scans of the brain after a minor injury,? Davidson said. ?And we generally don?t do very many.? He adds that CTs are obviously performed if hard neurological signs are present in the child.

When CTs are required, the dosing is scaled to the weight and size of the patient. Newer scanners also have more built-in features to help reduce radiation exposure. Last year, Davidson?s department purchased a new dual-source 64-slice detector from Siemens. An added benefit is the speed of the scan, which improves workflow as well.

?As a consequence, you spend less time with nursing and support staff supervising the child out of the department,? Davidson said. ?So, that has improved efficiency.?

Orders for CT scans from clinicians have increased significantly over the past decade?but as questions about the utility of certain scans are raised, there is growing concern about performing unnecessary scans. In addition to the exposure issues for patients, the scans are costly. But while reducing the number of CT scans could help hospitals cut costs, this is very rarely the primary motivation.

?We wouldn?t restrict our imaging for saving costs, per se,? Foley said, ?but I think it?s more for radiation safety for the patient. We do a good medical necessity check before we just run to that x-ray room with the kids.?

One way for hospitals to keep tabs on CT utilization is through benchmarks.

?I think the way the hospital looks at it is less a bottom-line calculation than a combination of overall utilization on the one side, and expenditures per patient,? Davidson said. ?I think we now look to benchmarking how our utilization is compared to other populations. In comparison with other ED benchmarking alliance members that are comparable types of organizations, our CT utilization is right in the middle of the pack. And I feel pretty good about that.?

Improved Efficiency

At Tufts Medical Center and Floating Hospital for Children, the ED has separate adult and pediatric emergency rooms. For most EDs, imaging delays are most common after regular workday business hours, which is when 63% of adults and 73% of children younger than 15 arrive in the waiting room.3 So, when it came time to replace the aging imaging equipment in the ED, the department went with a dual-detector DR option?the DIRECTVIEW DR 7500 from Carestream.

Fewer Visits for Colds Frees up EDs for Acute Cases

Until recently, this was an all-too familiar story: A parent without medical insurance brings her sniffling, sneezing child to the emergency department (ED) of her local hospital for care. Using the ED as a medical clinic to treat mild illnesses such as the common cold was a routine enough practice that visits to the ED jumped 32% between 1996 and 2006.1

?People didn?t have primary care pediatricians, and a lot of people didn?t have insurance, so they would just use the ER as a clinic,? said Michael Foley, RTR, director of radiology services at Tufts Medical Center and Floating Hospital for Children in Boston. ?Their child would have an upper respiratory infection, and they?d bring them to the ER.?

With this influx of nonemergency patients, the worry was that those with acute conditions would be forced to wait for hours while the emergency medical team tended to minor issues such as runny noses and coughs. However, Foley notes that about a year and a half ago, the practice of using the ED as a clinic began to subside.

?Some of the health care providers are charging patients pretty substantial co-pays to go to the ER,? he said. ?You?re starting to see these patients go back to physician?s offices to pay a $5 co-pay versus a $50 co-pay.?

This is a win/win for emergency department staff and patients. The EDs can focus their resources on acute cases, while primary care physicians handle more routine issues and provide that all-important continuity of care.

The bottom line? Better patient outcomes. ?It?s better for the real acute patients who need the ED care,? Foley said. ?And it?s also better to establish your medical treatment with a primary care physician versus an ED, where you?re never going to see the same doctor two days in a row.?

?A. Carlson

?The reason that we went digital versus going analog with CR was that we were trying to pick up the efficiencies during the times that the pediatric emergency room was at full tilt and the adult emergency room was at full tilt,? Foley said.

Not only does the DR system eliminate the hassle of post-processing cassettes, but it also offers less radiation exposure than CR models.

?When we went to digital radiography, we went back to the same speed and radiation exposures we were using with conventional film, which was a good thing,? Foley said.

At Maimonides Medical Center, PACS has been instrumental in streamlining workflow.

?I think the single biggest contributor has been the availability of PACS,? said Davidson, adding that all images except for those generated by the bedside ultrasound units are in the PACS system. ?Because with PACS, we?re able to have experienced clinicians and experienced radiologists look at the images with us without them having to be at the bedside. And I think that?s a big help because it helps drive decision-making earlier into the course of care.?

Davidson notes that his department has also been working on ways to improve MR efficiency for pediatric patients in the ED. ?We look to bunch our MRs that require sedation and patients that can be followed and have the MR study electively,? he said.

Although MR use is growing in pediatric emergency medicine, having an MR suite in or adjacent to the ED is a luxury that not all departments can afford. The seven-figure price tag is one barrier?lack of space is another.

?An MR suite is a pretty fair chunk of real estate, and this is Brooklyn, not the middle of the country,? Davidson said. ?So, real estate here is extremely precious and extremely tight. I have friends elsewhere around the country who have MRs in or adjacent to the ED, and I think it?ll be a long time coming for us in Brooklyn.?

The hospital is, however, in the early stages of ?carving out? a room dedicated to plain imaging for pediatric patients, Davidson said. This could turn out to be less of a ?real estate? issue, as the smaller size of pediatric patients will likely be a determining factor in the size for the generator, the patient table, and even the room itself.

?You don?t need as big a machine to do kids, because they aren?t as big,? Davidson says, ?so that can give you some flexibility.?

Ann H. Carlson is a contributing writer for Axis Imaging News.

References

  1. Emergency Care of Children. American College of Emergency Physicians. Available at: www.acep.org/patients.aspx?id=26130. Accessed September 3, 2009.
  2. Child Injury and Mortality. ChildStats.gov. Available at: www.childstats.gov/americaschildren/phenviro6.asp#87. Accessed September 3, 2009.
  3. Arvantes J. Emergency Room Visits Climb Amid Primary Care Shortages, Study Results Show. AAFP News Now. August 27, 2008. Available at: www.aafp.org/online/en/home/~. Accessed September 3, 2009.