As the ED has evolved, the role of advanced diagnostics has exploded in the evaluation and management of our patients. Beginning with simple roentgenograms and basic labora-tory analysis, our diagnostic capabilities have expanded to include advanced non-invasive imaging that has largely replaced exploratory surgery and the “wait-and-see” approach com-monly used in the absence of diagnostics. The concept of housing imaging within the ED had gained popularity, though at differing rates. The most readily available data from the United States and other advanced systems has shown a steady increase in imaging utilization. For example, data from the United States has demonstrated a five-fold increase in CT studies ordered in paediatric cases from 1995 – 2008 (Larson). Flattening and even declining utiliza-tion trends are also beginning to exhibit them-selves for adult patients in advanced systems where CT scans have been readily available for many years (Levin, Menoch). Part of what has driven increased use of imaging can be attributed to increased availabil-ity and practice in high-liability environments. While there is limited peer-reviewed data to suggest a correlation between availability of imaging in-department and utilization rates, links between liability concerns and utilization have been demonstrated (Smith-Bindman).

Bringing ItIn House

All images ©2013 Cannon Design

fig. 1: ED design with x-ray immediately adjacent to triage

Emergency Medicine News & Articles

In-ED imaging can improve efficiency, raise the quality of care

and even help the bottom line. Dr. Manuel Hernandez explains how to design it right from the

ground up.

TABLE 1 – Treatment Stations Required to Support Table 1 —Diagnostic Imaging by Imaging Demand

ED #1 ED #2 ED #3

Number of Annual Imaging Cases 15,000 15,000 15,000

Imaging Turnaround Time 48 min. 36 min. 20 min.

Total Care Time 12,000 hrs. 9,000 hrs. 5,000 hrs.

ED Treatment Stations Required 1.8 1.4 0.8 to Support Imaging Demands1 stations stations stations

1. Assumes 75% exam room occupancy target

The Case for In-ED Imaging Planning for In-ED imaging begins with developing the business case for why invest-ment in such expensive technologies will enhance performance, be it clinical quality, operational effi ciency, fi nancial performance or any combination of the three. Table 1 demon-strates the impact of imaging turnaround times

on overall ED performance. Looking at the cost of construction of un-necessary capacity and annual staffi ng costs to support patient care, the case for developing design solutions to reduce imaging turnaround times is clear. Building on the information in Table 1, Table 2 further explores the business case for in-ED imaging services.

Based on the information presented in Table 2, an investment in an in-ED x-ray unit would achieve break even on the investment within 2-3 years of implementation, while a CT scanner would break even on the investment within 5-7 years, depending on the technology purchased. Other studies have looked at the cost effec-tiveness of use of advanced imaging modali-ties as a part of the ED evaluation phase as a strategy for reducing the overall cost of care. For example, use of coronary CT angiography in the ED as a part of an in-ED cardiac rule-out pathway has been shown to reduce overall length of stay for low-risk chest pain patients while also signifi cantly reducing the total cost of care for the patient encounter (Goehler). In situations such as this, the investment in an

fi g. 2: Imaging Location in High Volume ED

TRIAGETREATMENT

IMAGING

TREATMENT

TREATMENT

TREATMENT

TREATMENT

fi g. 4: CT Scanner Immediately Adjacent to High-Acuity Zone

TABLE 2: Cost Analysis of Imaging Turnaround Times TABLE 3: ED Minimum ImagingVolumes By Modality to JustifyIn-ED Imaging Investment ED #1 ED #2 ED #3

DESIGN & CONSTRUCTION COSTS

Stations Required to Support 1.8 1.4 0.8Imaging Costs stations stations stations

Average ED Design & Construction Costs €3,375/m2 €3,375/m2 €3,375/m2

Recommended Treatment Station Size 13.3 m2 13.3 m2 13.3 m2

Costs Attributed to Imaging €80,798 €62,843 €35,910Turnaround Times

STAFFING COSTS

Total Care Time 12,000 hrs. 9,000 hrs. 5,000 hrs.

Annual Care Hours / RN FTE1 6,240 hrs. 6,240 hrs. 6,240 hrs.

RN FTEs Required to Support 1.92 1.44 0.80Imaging Turnaround Time

Annual RN Salary €70,000 €70,000 €70,000

Annual Nursing Labor CostsRequired to Support Imaging €134,400 €100,800 €56,000Turnaround Time

1. FTE = Full Time Equivalent

MODALITY RECOMMENDED TRESHOLD VOLUME

Fixed X-ray Standard Requirement

Portable X-ray Standard Requirement

Portable Standard Ultrasound Requirement

CT ~ 13,000

MRI ~ 4,400

in-ED CT scanner could yield a quick return on the investment in the technology.

Imaging Modalities to Consider Selecting the proper imaging technologies can have a direct impact on speed to diagnosis, initiation of definitive management and overall length of stay in the ED. The selection criteria for what imaging to include within the borders of the ED should, at a minimum, include the following: 1. Annual imaging volumes (by modality) performed in the ED 2. ED acuity and special patient populations 3. Distance of ED from main diagnostic imaging services (immediately adjacent, distant, remote) 4. Availability of diagnostic imaging staff 24/7 or on-call 5. Potential impact on total cost of care 6. Annual ED Imaging Volumes The addition of diagnostic imaging technol-ogy in the ED is no small investment. Because of this investment requirement, it is important to consider whether or not the demand for imaging services justifies the investment. While there is no industry-wide benchmark for imaging volumes that justify investment in imaging, this author considers the information in Table 3 as a useful guideline.

ED Acuity and Special Patient Populations As EDs develop more and more specialty services, the speed to diagnosis and definitive management becomes evermore important. Similarly, as patient acuity levels increase in

Table 4 – ED Minimum Imaging Volumes By Modality to Justify In-ED Imaging Investment

SPECIAL PATIENT X-RAY US CT MRIPOPULATION / DESIGNATION Paediatrics X X +/-1

Trauma X X X

Acute Stroke X X +/-2

Chest Pain Center X X3

1. Frequent use of CT in the paediatric population is a topic of much debase in EM. As of the time of this publication consensus on In-ED CT except for high-volume / high-acuity paediatric centers does not exist.

2.EarlystudiesatadvancedacademicmedicalcentersareindicatingbenefitofearlyMRIinacutestrokepatients, Asofthetimeofthispublicationconsensusonthevalueofin-EDMRIdoesnotexist.

3. StudiesinvestigatinguseofcoronaryCTangiographyasapartofarapid“triplerule-out”inlowriskpatients isshowingbenefit.ThisrequiresadvancedCTtechnology,typically64-slicedualsourcescanningcapabilityofbetter.

the ED, it can be expected that more and more demand for imaging services will develop. With this understanding in mind and based on current and future standards of care, this author consid-ers Table 4 to be a useful guideline for in-ED imaging planning.

Distance of ED From Main Diagnostic Imaging Services Studies analyzing the root causes of delayed ED imaging have indicated that order processing and patient transport times, along with imaging location, can all impact imag-ing turnaround times. A study of three urban Canadian EDs demonstrated that turnaround times for plain x-ray studies were shortened in the ED with an imaging unit within ED, while turnaround times were over 50% longer when the x-ray unit was located remote to the ED (Worster).

Availability of Diagnostic Imaging Staff 24/7 or On-Call Staffing the imaging areas of the ED is another important consideration for in-ED imaging services. Clearly, a CT scanner in the ED is of no benefit if there is no staff to run it. Once an imaging modality is located within the borders of the ED, it is expected the service will be available 24/7 through either an in-house or on-call staffing model.

Potential Impact on Cost of Care Throughout this article, examples of how diagnostic imaging has impacted the overall cost of care have been presented. Bending the cost-curve of emergency care and the total cost

of care are important considerations that can be meaningfully impacted by careful imaging planning in any ED design. For example, select-ing advanced CT technologies with subsequent elimination of oral contrast preparation for abdominal CT scans has shown to reliably decrease length of stay by as much as two hours or more without compromising quality (Leven-son, Hopkins, Hlibczuk, Anderson).

Designing the ED for Optimal Imaging Services While previous ED designs typically cen-tered on placing in-ED imaging services deep within the ED and clustered together, newer designs are experimenting with decentralization of imaging services, placing each modality clos-est to its area of greatest demand. This said, as illustrated in Figure 1, extremely large ED (an-nual census > 100,000 visits) may benefit from centrally locating in-ED imaging relative to all treatment stations by reducing travel distances for patients and staff. Varying the location of the imaging modali-ties within the ED can have a significant impact on overall speed to imaging and length of stay for all but the largest EDs. One ED that moved its fixed x-ray unit from deep within the ED to be adjacent to triage noted a 25% reduction in length of stay for patients requiring x-ray stud-ies (Horton). The logic of this design approach is that lower acuity, ambulatory patients tend to rely on the fixed x-ray unit, while higher-acuity

Figure 3 – X-ray Immediately Adjacent to Triage

Reprinted with permission from EPi Fall 2013

REFERENCES

Anderson B, Salem L, Flum D. A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults. Am J Surg. 2005;190:474-478.

Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health information exchange reduces repeated diagnostic imaging for back pain. Ann Emerg Med. 2013 Jul;62(1):16-24.

Bamberg F, Marcus RP, Schlett CL, Schoepf UJ, Johnson TR, Nance JW Jr, Hoffmann U, Reiser MF, Nikolaou K. Imaging evaluation of acute chest pain: systematic review of evidence base and cost-effectiveness. J Thorac Imaging. 2012 Sep;27(5):289-295.

Goehler A, Ollendorf DA, Jaeger M, Ladapo J, Neumann T, Gazelle GS, Pearson SD. A simulation model of clinical and economic outcomes of cardiac CT triage of patients with acute

chest pain in the emergency depart-ment. AJR Am J Roentgenol. 2011 Apr;196(4):853-61.

Hlibczuk V, Dattaro JA, Jin X, et al. Diagnostic accuracy of noncontrast computed tomography for appendicitis in adults: a systematic review. Ann Emerg Med. 2010; 55:51-59.

Hopkins CL, Madsen T, Foy Z, Reina M, Barton E. Does limiting oral contrast decrease emergency department length of stay? West J Emerg Med. 2012 Nov;13(5):383-7.

Horton E. Personal interview. Apr. 2012.

Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995 – 2008. Radiology. 2011;259(3): 793-801.

Levin DC, Rao VM, Parker L. The recent downturn in utilization of CT: the start of a new trend? J Am Coll Radiol. 2012 Nov;9(11):795-8.

Levenson RB, Camacho MA, Horn E, Saghir A, McGillicuddy D, Sanchez LD. Eliminating routine oral contrast use for CT in the emergency depart-ment: impact on patient throughput and diagnosis. Emerg Radiol. 2012 Dec;19(6):513-7.

Menoch MJ, Hirsh DA, Khan NS, Simon HK, Sturm JJ. Trends in computed tomography utilization in the pediatric emergency department. Pediatrics. 2012 Mar;129(3):e690-7.

Shuaib A, Khan K, Whittaker T, Amlani S, Crumley P. Introduction of portable computed tomography scanners, in the treatment of acute stroke patients via telemedicine in remote communities. Int J Stroke. 2010 Apr;5(2):62-6.

Smith-Bindman R, McCulloch CE, Ding A, Quale C, Chu PW. Diagnostic imaging rates for head injury in the ED and states’ medical malpractice tort reforms. Am J Emerg Med. 2011 Jul;29(6):656-64.

Sodickson A, Opraseuth J, Ledbetter S. Outside imaging in emergency department transfer patients: CD import reduces rates of subsequent imaging utilization. Radiology. 2011 Aug;260(2):408-13.

Worster A, Fernandes CM, Malcolmson C, Eva K, Simpson D. Identifica-tion of root causes for emergency diagnostic imaging delays at three Canadian hospitals. J Emerg Nurs. 2006 Aug;32(4):276-80.

patients tend to receive a higher number of portable x-rays in many EDs. Figure 2 demon-strates an ED design depicting a decentralized imaging model with x-ray located proximate to triage and lower acuity areas while CT is located closer to the trauma bays. Figure 1 shows an ED design with x-ray im-mediate adjacent to triage. This design solution creates a patient flow that, where clinically-ac-ceptable, allows the triage team to identify and order the appropriate imaging study with the patient receiving the x-ray prior to being placed in a treatment station with a resulting decrease in travel distances for the patient and staff. Figure 4 illustrates an ED design with the in-ED CT scanner located immediately across the corridor from the major resuscitation stations, reducing travel distances for the most critically-ill patients receiving care in the ED. Portable imaging technologies have also been shown to add value and should be planned for appropriately. A 2010 Canadian study assessed the impact of a portable CT scanner in rural community hospitals linked to larger referral center via a tele-stroke program resulted in increased ability to deliver thrombolytics to patients presenting with an acute ischemic stroke (Shuaib). When planning for portable imaging mo-dalities, the primary concerns in ED design are proximity and size. First, storage space for the portable units should be in close proximity to the staff using the technology and the patients

most frequently requiring the corresponding imaging study. Second, ED treatment stations should be designed large enough to accommo-date entry of the portable imaging technology into the room with the ability to easily access the patient from at least three sides. Other important ED design considerations with respect to imaging focus on ensuring imaging staff have adequate workspace in proximity to where imaging services will be performed. Similarly, equipment necessary to process images should be immediately adjacent to where imaging studies will be per-formed to reduce overall staff travel distances and delays in study turnaround times. Equally important, locations where ED physicians and staff can view images should be readily avail-able throughout the ED. This is most easily accomplished by ensuring adequate viewing monitors or, more recently, through the use of high-resolution portable tables with wireless connection to the imaging viewer. An important non-facility design consid-eration is how linking EDs across a com-munity can help reduce overall utilization of imaging modalities, particularly for patients being seen in multiple EDs or having multiple visits for the same complaint. One commu-nity developed a health information exchange that allowed all EDs to access the results of imaging studies performed at other EDs in the community. Access to previously-completed imaging studies resulted in a 64% decrease in

repeat imaging studies for patients complain-ing of back pain (Bailey). Similarly, designing ED imaging services to support image import capabilities for patients being transferred to another ED for ongoing management has been shown to reduce reimaging (Bamberg, Sodickson). This would have the obvious benefit of reducing unnecessary radiation exposure and lowering the total cost of care. Figure 5 illustrates the design of a common imaging view room that can support both in-house and uploaded images.

Summary Through careful planning, business case development and design, EDs can be devel-oped to support best-in-class design features while enhancing the standard of care, improv-ing overall efficiency and productivity of the ED, lowering length of stay and reducing the cost of care for multiple patient groups. Facili-ties planning new, renovated or expanded EDs are wise to carefully consider how diagnostic imaging will evolve and, based on this, what imaging should be considered for inclusion within the physical borders of the ED.