Past, Present, And Future Of Emergency Radiology

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Canadian Association of Radiologists Journal 64 (2013) 85e89www.carjonline.orgTrauma and Emergency Room Imaging / L’imagerie des urgences et des traumatismsPast, Present, and Future of Emergency RadiologyGarry Choy, MD*, Robert A. Novelline, MD, FACRDivision of Emergency Radiology and Teleradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USAKey Words: Emergency radiology; Acute radiology; Emergency department radiologyIn the past 2 decades, emergency radiology has emerged asan important subspecialty of medicine. Although relativelynew, the growth of this subspecialty has been rapid andparallels the growth of the specialty of emergency medicine.As a subspecialty of radiology, emergency radiology is definedby the imaging and imaging management of patients who areacutely ill and injured. The primary responsibility of theemergency radiologist is not only the imaging of patients in theemergency department (ED) at all times but also off-hoursemergency imaging of all patients in the medical centre.The founding of the major professional societies ofemergency medicine and emergency radiology also occurredin parallel. Aiming to improve the quality of emergency care,emergency physicians founded the American College ofEmergency Physicians in 1968 with the goal ‘‘to educate andtrain physicians in emergency medicine.’’ The first emergency medicine residency was created in 1970, and thespecialty was recognized as the 23rd medical specialty in1979 with the first board examination in 1980. Currently, theAmerican College of Emergency Physicians represents morethan 28,000 physicians and publishes the journal Annalsof Emergency Medicine.Radiologists who wished to improve the imaging care ofemergency patients founded The American Society of Emergency Radiology (ASER) in 1988. The mission of ASER is to‘‘advance the quality of diagnosis and treatment of acutely illor injured patients by means of medical imaging and toenhance teaching and research in emergency radiology.’’ASER membership comprises more than 700 national andinternational members, and the society has hosted annualscientific and educational meetings on emergency radiology* Address for correspondence: Garry Choy, MD, Division of EmergencyRadiology and Teleradiology, Department of Radiology MassachusettsGeneral Hospital, 55 Fruit Street, Founders House 210, Boston, Massachusetts 02114, USA.E-mail address: gchoy@partners.org (G. Choy).since 1990. ASER publishes the journal Emergency Radiology, which has chronicled numerous innovative scientificand clinical developments of the field of emergency radiology.The academic, clinical, and professional footprint ofemergency radiology has grown significantly over the years.To date, emergency radiology has achieved recognition overthe years by numerous other institutional and academicentities (Table 1). Publications in the field of emergencyradiology have grown significantly as seen with searches fortitles and abstracts with the keyword ‘‘emergency radiology.’’ In this review, we will highlight the past, present, andfuture of the specialty of emergency radiology.Emergency Radiology: PastBefore cross-sectional imaging, emergency radiologymainly consisted of radiography and fluoroscopy. Dailypractice included radiographs of the chest, abdomen, skeleton,and occasional intravenous urograms, upper gastrointestinalseries, and barium examinations. Patients with acute centralnervous system and vascular conditions were examined withemergency angiography. Many patients were unable to havecompletion of imaging examinations in the ED. Patients withdiagnostic uncertainty were usually admitted to the hospitalfor preparation of fluoroscopic procedures or for angiographicexaminations.Growth of Imaging and ED VisitsSeveral factors have made a significant change in the practiceof emergency radiology. These include the development ofcross-sectional imaging, an increase in volume of ED patientvisits, increased emergency physician imaging expectations,and cost-containment initiatives from health care reform. Theintroduction of emergency computed tomography (CT),magnetic resonance imaging (MRI), and ultrasound haverevolutionized the practice of emergency radiology.0846-5371/ - see front matter Ó 2013 Canadian Association of Radiologists. All rights 002

86G. Choy, R. A. Novelline / Canadian Association of Radiologists Journal 64 (2013) 85e89Table 1Selected highlights: emergency radiology is recognized by multipleinstitutional and academic entitiesRSNA refresher course trackARRS instructional course trackRSNA/ARRS scientific paper sessionsEmergency radiology editors of radiologyEmergency radiology editors of radiographicsABR required emergency radiology trainingFifteen emergency radiology fellowship positions at 8 medical centresABR ¼ American Board of Radiology; ARRS ¼ American Roentgen RaySociety; RSNA ¼ Radiological Society of North America.The increase in emergency imaging expectations has beensignificant. Emergency physicians have demanded the rapidavailability of all imaging modalities, high-quality imagingexaminations, short waiting times, immediate reporting,real-time postprocessing (3-dimensional, perfusion imaging),and 24 hours, 7 days a week service and/or coverage.Although overutilisation of advanced imaging modalities arenot cost effective, advanced imaging in the ED can lead tobenefits such as a decrease of unnecessary admissions anddecrease in length of stay in both the ED and the hospital.Emergency medical care has been in high demand bypatients, which results in a significant increase in ED utilisation [1]. According to the 2008 Emergency DepartmentSummary of the National Hospital Ambulatory Medical CareSurvey, the number of annual ED visits totaled 123.8 million,with the volume of ED visits increasing at 2%-5% per year[2]. Between 1991 and 2006, ED visits increased from 88million to 120 million, whereas the number of EDs decreasedfrom 5100 to 4600 due to facility closure. At our institution,ED visits increased annually, with the busiest months in Junethrough September.Medical imaging initially outpaced the trends of overallED visits and has only most recently stabilized, and is nowparallel to the growth of ED visits. At our institution, our EDpatient-visit volume increased 2%-3% per year, from 55,000patients in 1996 to 110,000 patients in 2009. From 19972003, image utilisation growth was greater than growth inpatient visits. Although there still is growth in imaging,image utilisation growth has stabilized with parallel growthwith patient ED visits between 2003 and 2009. In the pastyear, from 2011-2012, this has increased by 6%.Cross-Sectional Imaging GrowthExplosive growth of cross-sectional imaging, particularlyCT, has characterized the most recent history of emergencyradiology, having currently grown to approximately 33% oftotal ED imaging volume at our institution. There were 8000CTs performed in 1996 compared with 36,000 CTs performed in 2009 (98 CTs/d). Commonly ordered CT examinations have been increasing steadily over the years and mostrecently stabilized. The highest volume of CT studiesincludes imaging of the abdomen and head experiencing thefastest growth in the past 2 decades. In thoracic imaging inthe ED, since 2001, there has been a significant growth in CTused for evaluation of pulmonary embolism.Emergency medicine practice has been improved by theadvances in emergency radiology. In the past, patients in theED were admitted to the hospital for diagnostic evaluation.Today, advanced real-time diagnostic imaging and onlineinterpretation are performed and completed while the patientis in the ED, 24 hours a day, 7 days a week, and 365 daysa year. Results often determine if an admission occurs, towhich service the patient is admitted, and if there is anyimmediate emergency or surgical intervention. Real-timediagnostic imaging of the patient in the ED can expeditepatient care and ultimately reduce costs.Emergency Radiology: PresentThe emergency radiology facility has become the hospital’sacute diagnostic imaging centre. The emergency radiologydivision of today is unique in its physical design, equipment,staffing, information systems, and operations.Facility Design and EquipmentDesigning the emergency radiology facility today requiresproper planning to optimize workflow, as summarized inTable 2. For example, radiology should be centrally located(Figure 1) for maximal accessibility to physicians andpatients from multiple clinical services. The selection ofimaging equipment is important to best accommodate theexpected volume unique to one’s ED. At our institution, wehave optimized our imaging equipment to meet volumedemands of acute care (Table 3).Multidetector CT scanners in the ED enable total bodytrauma scans, including CT angiograms of the head, neck, andextremities. The latest technologies for dose reduction wouldalso be beneficial and essential. Dual-source and dual-energyCT scanners would be advantageous for emergency cardiacimaging.The convenience of an magnetic resonance (MR) scannerwithin or adjacent to the ED dramatically improves the levelof patient care. In our institution, we also have an MRIscanner available to evaluate stroke, complex head trauma,musculoskeletal injuries, and acute conditions in pregnantpatients or in children. MR safety basics must be adhered.Proper training of individuals must be performed beforeallowing access to the MR scanner area. Controlled accessTable 2Designing an emergency radiology facility for todayDetermine location of radiology in the emergency departmentReview imaging statistics and trends to determine type and volumeof examinations in emergency radiologyPrepare a comprehensive architectural program based on examinationstatistics and predictionsSelect proper imaging equipment: radiography, computed tomography,ultrasound, magnetic resonanceAssign spaces for image interpretation, reception, patient waiting,technology staff, and on-site managers

Emergency radiology / Canadian Association of Radiologists Journal 64 (2013) 85e8987would also enhance learning and image review by teams(Figure 4).StaffingFigure 1. Location of the emergency radiology facility should be centrallylocated. Emergency department physicians and patients must travel toemergency radiology. ED ¼ emergency department; Med/Surg ¼ medicalsurgical; Ortho ¼ orthopaedics. This figure is available in colour online athttp://carjonline.org/.must be maintained to ensure safety and security.For example, access to the MRI suite and control room mightbe controlled with electronic key card entry (Figure 2).Reading Room ConfigurationThe emergency radiology reading room should alsoincorporate various key components. For example, thereading room should be equipped with sufficient workstations for both interpretation by radiologists and the reviewof cases by referring physicians. All workstations shouldideally have Picture Archiving and Communication System(PACS) and word-recognition dictation systems. The availability of 3-dimensional workstations for maximum intensityprojections (MIP), volumetric, and perfusion image analysiswould also be beneficial (Figure 3). Furthermore, the spaceshould be physically large enough for physicians and teamsto review imaging studies and for educational conferences.At our institution, the availability of a flat-panel displayTable 3Sample equipment in emergency radiology facility at our institutionThree digital radiographic rooms (1 dedicated chestunit and 2 multipurpose rooms)Two multidetector computed tomography scannersOne magnetic resonance scannerOne ultrasound roomLarge consultation and/or reading roomStretcher and/or ambulatory patient waiting spacesTechnologist computer work spaceReception and/or scheduling deskOn-site manager’s officePhysician and nonphysician staffing is also crucial to anefficient emergency imaging facility. Emergency radiologistsshould be available to provide interpretations of imagingaround the clock, including all off-hours shifts. Managersand/or supervisors, technologists, receptionists, schedulers,patient transport, and information technology support staff(on-call) are also critical at all times. Staff in the emergencyradiology facility should be aware of the unique workflowand demands of emergency imaging. For example, emergency technologists should have the technical skills to imagemultiple body parts and perhaps even cover multiplemodalities. In addition, technologists should be well versedin patient care with the ability to manage patients who areacutely ill, pregnant patients, and all age ranges, and, technologists should also be highly skilled at workflowmanagement and operational efficiency given the highvolume and urgency of ED cases.Decision SupportDecision support via appropriate communication, informatics, and active radiologist involvement in protocoling iskey to any emergency radiology facility. Tracking of studiesand protocols can be accomplished via informationtechnology dashboards via the radiology information systemor any other electronic dashboard. The decision supportconversation incorporates communication of the clinicalpresentation, physical examination, and laboratory tests,which permits the confirmation of examination appropriateness and selection of optimal examination protocol. Theconversation also permits an inquiry regarding possiblepregnancy, contrast allergy, and renal function impairment.Maintaining Quality in Emergency RadiologyThere are multiple strategies for maintaining quality in thepractice of emergency radiology. Maintaining qualityrequires maximizing communication, documentation, peerreview, and development of collaborative relationships withreferring clinical services such as emergency medicine andtrauma service.All emergency radiology procedures and protocols arecurrently documented and readily available to all staff24 hours a day 7 days a week online and in hard copy. Crosssectional imaging protocols are also loaded into scanners. Allstaff are trained and familiar with emergency radiologyprocedures and protocols. Radiologists are also responsiblefor correct protocol implementation and adherence. Monitoring of all cross-sectional imaging studies in our institutionhas been effective. An emergency radiologist monitors allCT, MR, and ultrasound examinations. By having continuousround-the-clock coverage, CTs on multiple trauma patients

88G. Choy, R. A. Novelline / Canadian Association of Radiologists Journal 64 (2013) 85e89Figure 2. Restricted entry to the magnetic resonance imaging suite with electronic card access. This figure is available in colour online at http://carjonline.org/.are performed with the radiologist present in the CTcontrol room. Monitoring ensures that the examination is ofdiagnostic quality and is complete. Monitoring also ensuresrecognition for the need of postprocessing or if anyadditional imaging acquisition is needed.Technologist feedback is also critical for quality assuranceand improvement of standards. At our institution, we use aninformation system , Qatchall, created at our institution, whichallows radiologists to report quality assurance issues. Peer-topeer feedback is also a practice that can result in qualityimprovement. For example, at our institution, we use a system,Grapevine, created at our institution, that facilitates radiologyreport peer review in a conference setting.availability of such systems can decrease reimaging, reducecosts, and limit unnecessary exposure to excess radiation.CD import availability for patients transferred to theemergency department reduces rates of subsequent imagingutilisation by 17% overall and reduces CT utilisation by16% [3].Management of Transfer Patient Imagingand CD-ROM ImportAging PopulationEmergency Radiology: FutureFuture trends in emergency radiology will includeresponse to an aging population; health care reform; newimaging modalities, such as cardiac CT; the need for radiationdose reduction; and increasing demand for MRI.Currently, many trauma centres and EDs will care forpatients who are transferred in with imaging from otherfacilities on a CD-ROM. There are a multitude of variousvendors that facilitate image sharing and CD-ROM importinto a local PACS system. There also is evidence that theThe percentage of residents in the United States older than65 years of age was 11% in 1900 and was 21% in 2010 [4].Patients older than 65 years of age are hospitalized morefrequently and stay in the hospital longer if admitted.Patients older than 65 years of age also visit the ED moreoften and use 30% of health care funds [5,6].Figure 3. The reading room at our institution has 6 workstations anda 3-dimensional workstation. This figure is available in colour online athttp://carjonline.org/.Figure 4. Large Picture Archiving and Communication System (PACS) wallmonitor for emergency radiology daily conferences and clinical rounds. Thisfigure is available in colour online at http://carjonline.org/.

Emergency radiology / Canadian Association of Radiologists Journal 64 (2013) 85e89Health Care ReformWith health care reforms and access to care, it is expectedthat there will be increased use of EDs, which results inincreased volumes in the emergency radiology facility.To reduce costs, emergency imaging will play a role inidentifying patients who do not require admission, andquicker diagnoses will lead to shortened hospital stays.New Imaging Techniques: Coronary CT AngiographyCurrent strategies to rule out acute coronary syndromeinclude serial enzymes, electrocardiogram, and stress testing)are inefficient, which results in ED delays, ED overcrowding,and unnecessary admissions. The finding of normal coronaryarteries will obviate the need for additional tests and expeditepatient discharge. The availability of 64-slice multidetectorCT scanners and dual energyedual source CT scanners willenable coronary CT angiography in the emergency radiologysetting. Coronary CT angiography, therefore, may enableearlier and safe triage, which reduces hospital admissions andlength of stay compared with the standard ED evaluation.Dose Reduction of Radiation Exposure in the EDA significant number of CTs are performed on patients inthe ED. More than 70 million CTs are performed annually inthe United States. As a result, CTs account for a growing andsignificant proportion of medical radiation exposure. Ina National Center Institute led study, CTs in 2007 alone mayhave contributed to 29,000 new cancer cases and 15,000cancer deaths. There are multiple causes for unnecessary CTexposure in patients in the ED (Table 4), therefore, reductionof radiation dose in CT imaging in the emergency settingwould be critical; this can be accomplished via improveddecision support and use of low-dose CT techniques. Decision support can serve as a gatekeeper to reduce commoncauses of unnecessary CT radiation exposure in patients inthe ED. For instance, decision support can avoid repeatingCTs already performed (often at referring hospitals) andlimit excessive utilisation of CT. CT techniques that reducethe radiation dose include iterative image reconstructionalgorithms.Table 4Causes of unnecessary computed tomography (CT) exposure in patients inthe emergency departmentRepeating CTs that have already been performed (often at a referringhospital)Performing CTs when results are unlikely to affect patient managementInvestigating CTs too frequently (eg, repeated CTs to follow passageof a renal stone)Performing the wrong imaging examinationPerforming incorrect CT protocol from communication failure of trueclinical presentation, resulting in a repeated CTOver investigating via medical imaging (eg, unnecessary noncontrastand delayed scans)89Increased Demand for MR Scanning of Patientsin the EDThere is a growing demand for MRIs of patients in the ED.An MRI holds clinical utility in evaluation of traumatic aswell as nontraumatic central

ABR ¼ American Board of Radiology; ARRS ¼ American Roentgen Ray Society; RSNA ¼ Radiological Society of North America. Table 2 Designing an emergency radiology facility for today Determine location of radiology in the emergency department Review imaging statistics and trends to determine type and volume of examinations in emergency radiology Prepare a comprehensive architectural program .

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