OPERATIONS MANAGEMENT COMMITTEE
Radiology Intervention: Improving Throughput For Imaging Studies in the Emergency Department Akiva Dym, MD FAAEM and Anthony Rosania, MD MHA FAAEM
A
s Emergency Department (ED) patient volumes and crowding continue to increase nationwide, every aspect of ED operations has come under renewed scrutiny. The ED is a complex environment where multiple services, including clinical and ancillary, converge and impact the care of our patients. When combined with the inherent nature of ED volume—one with no control or limit on the input into the system—it is no wonder that emergency departments feel the impact of every inefficiency or operational problem in the hospital or system. While all ancillary services such as environmental, transport, lab, and radiology are important to the efficient functioning of an ED, there is perhaps none that impacts our patients and their outcomes as intimately as radiology. Radiology is perhaps unique among the ancillary services in that it is also, quite clearly, a clinical service as well. While the same may be said of laboratory services, the complexity and very human-dependent nature of radiology services makes them stand out as a prime service which is ripe for improvements and innovation. Radiology is uniquely important to all emergency departments as well as overall hospital operations. Many clinical pathways, such as stroke and trauma, rely heavily on the rapid, accurate, and efficient delivery of advanced imaging services. At the same time, the ED is a source of a plethora of less emergent, but still urgent, forms of imaging, both basic and advanced. When a stroke patient who is potentially a thrombolysis candidate enters the ED, literally every minute to imaging counts. At the same time, the “golden hour” of trauma relies upon the prompt recognition of injuries that may only be discernable through computed tomography (CT) imaging. As may often be seen at many large institutions, these services and their needs for finite resources often end up in direct conflict—putting ED and radiology leaders at the center of difficult triage decisions regarding the use of imaging for critical and/ or potentially critical patients. Radiologists and emergency medicine (EM) physicians, in particular medical directors and those is operational leadership, are important partners in the development of efficient and timely radiology processes. All too often, EM physicians may end up at odds with our radiology colleagues regarding clinical operations. Worse yet, there are times when 36
COMMON SENSE JANUARY/FEBRUARY 2023
EM may not be involved at all in the development of ED radiology policies and processes. Due to the critical relationship between the ED and radiology, it is essential that emergency department leadership is deeply involved in such decisions and in improvements related to these processes. What is it that makes radiology processes so complicated and difficult to improve upon? In considering this, it may be helpful to make a comparison to laboratory services. In contrast to what many of us may believe, lab services are often not a major problem nor major bottleneck in the system. When looking closely at the impact of lab turnaround times and processes on ED operations, there is likely far less variability than as compared to radiology services. To understand this, one merely needs to understand the nature of lab services—while they involve humans, they are for the most part automated. They also involve a logistics chain that does not involve transporting a patient, thus eliminating the added complexity that such processes bring. The use of pneumatic tube transports, automated lab scanning and processing, and the automated nature of many modern analyzers allows for fairly tight control of laboratory turnaround times with limited bottlenecks or interruption. Indeed, the major portion of the overall lab process involving the most human influence, and thus variability, is the actual collection activity in the ED. In contrast, radiology processes are by their very nature human depen-
Contrary to popular belief, there is more to obtaining CT imaging than merely pushing a button.
dent from beginning to end. First, we are transporting a human patient— one who may be critically ill, and thus requires dedicated equipment and personnel to be transported to the study. In addition, their medical needs, such as ongoing infusions or airway management, must be constantly tended to. Furthermore, the very act of transferring a patient >>