Better Throughput, Better Care: Models for Smarter Emergency-department Imaging

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Helen LidholmManaging emergency-department volume is a perennial challenge for hospitals, and at St. Mary’s Regional Medical Center (SMRMC) in Reno, Nevada, emergency-department volume is only expected to grow, according to Helen Lidholm, CEO. “We’re assessing what our emergency-department volume is going to look like, based on what we know about our community and how our local patient population will be affected by the Patient Protection and Affordable Care Act,” she says. “Every community is different, but we’re anticipating higher volume in the emergency department.”

Currently, the emergency department at SMRMC sees about 56,000 patients a year, Lidholm says. Around 80% of those patients are discharged without being admitted to the hospital, thanks (in no small part) to the imaging technology being used in the facility. “There’s a patient category that we call backs and bellies: patients who come in with diffuse pain in those areas and require imaging to diagnose or rule out one thing or another,” Lidholm says. “We’re able to discharge a larger number of patients because of our use of imaging, while appropriately admitting those who need hospital care.”

The Two Throughputs

Lidholm looks at emergency-department throughput in two ways. The first is the patient flow of those who will be admitted to the hospital, or admitted throughput; the second is the flow of patients who will ultimately leave without being admitted, or discharge throughput. For both groups, Lidholm says, expedience is critical to optimal care. “Timing is everything,” she notes. “We want to make sure the patient spends as little time in the emergency department as possible, to allow faster access for other patients.”

For instance, she says, “If you have parents with a kid with an earache who need to know if it needs treatment, they just want to get home.” On the other hand, for patients who will need to be admitted, she says, “They aren’t as comfortable on a gurney as they would be in a bed. We need to get everyone through as quickly as possible to provide the best possible care, and that’s where the imaging department is key. The vast majority of patients who come through the emergency department are going to have some kind of imaging done.”

As imaging utilization in the emergency department increased, the team at SMRMC faced challenges in radiologist availability due to technology issues, and it anticipated potential difficulty during spikes in patient volume, as well as at night. “We have an excellent group of on-site radiologists, but when we experience technology or network challenges, or when we’re managing patients at night, we need their response time on studies to be as quick as possible—within half an hour,” Lidholm says. “It’s very important to have on-site radiologists, but it’s also important to be able to manage that volume.”

Consultation and Collaboration

To address this issue, four years ago, SMRMC entered into a relationship with Virtual Radiologic (vRad), which provides remote subspecialty service to the hospital during busy and nighttime hours. “We’re all used to using night-coverage services that come on when the regular radiology group goes home, but vRad takes it to another level. It adds a layer of support. Even if we’re completely slammed during the day, if our on-site radiologists can’t keep up, vRad is there to back us up,” Lidholm says.

Lidholm notes that the role of the on-site radiologists includes spending time with other physicians at the hospital—meaning that meeting strict turnaround-time requirements both cannot and should not always be their top priority. “They’re not just in the reading room,” she says. “There’s communication happening all day long between the radiologists and our physicians.”

She continues, “It’s very common for the physician from the emergency department to come look at the images with the radiologist and discuss the case, because the radiologist has seen something and the emergency-department physician might have an opinion. They can have those collegial, face-to-face discussions with the images right in front of them.”

With remote subspecialty radiologists to cover the workload for them, SMRMC’s on-site radiologists can better fulfill this role. “Imaging is a powerful triage tool in the emergency department,” Lidholm says, “and both our emergency-department lengths of stay and the percentage of patients who can be discharged have improved. I’d urge anyone with throughput issues in a hospital