Welcome to theEmergency Teleradiology

Workshop Operations – Arjun Kalyanpur

Clinical Applications – M. Srinivasa Rao3D postprocessing – Roy D’Souza

Reporting Standards and Quality – Carl Aschkenasi

Medicolegal - Leonard BerlinTechnology – Firoz Latif

Workflow - Srinivas

Emergency Teleradiology: Operations and Clinical Applications

Arjun Kalyanpur MDM. Srinivasa Rao, DNB

Roy D’Souza, MD

Rationale for Emergency Teleradiology

• Global Radiologist shortages– Most radiologists concentrated in metros– Emergencies/remote areas most affected – Catastrophic outcome of delay

Radiologist to Population ratios

US – 1: 10,000Singapore – 1: 20,000Japan – 1: 35,000India - 1: 100,000Bangladesh – 1: 1,000,000

Evolution of Emergency Radiology• Increase in emergency imaging utilization– Dependence on imaging for rapid DX– Technical evolution of CT – speed,

resolution– CT now the primary modality for • Vascular occlusion• GI bleed• Perfusion imaging in acute setting

CJEM 2013;15(3):161-166

Operations

• Scale – Multisite, multiradiologist• Smooth workflow and process in Virtual Environment • Seamless Coordination/Communication

Between Hospital and radiologist Between Coordinator and radiologistBetween radiologist and radiologist

The Team

• Operations Manager• Coordinator• IT• Call center• Radiologist• Support team – Transcriptionist, Data entry

The Process

• Hospital- Telerad Image Transfer• Case assignment workflow• Review and Dictation process• Communication of findings• Peer Review• Addendums and Errata

Concepts

• Turnaround time

• Critical Values

• Standard Protocols (Stroke , polytrauma)

Turnaround time

• SLA – based on clinical scenario• Stroke – 15 min• Stat – 30 min• Inpatient, MRI – 60 mins

• As Low As Reasonably Achievable• Mean and Outlier TAT• Verbal communication for complex cases

Critical Values• Life threatening condition

• Tension pneumothorax• Ruptured Ectopic Pregnancy

• Physician to physician communication• Documentation/Tracking

Standard ProtocolsStrokeTakes priority over all others (Time is brain)15 – 10 mins

MultitraumaFocus on traumatic findingsPrioritize reviewImmediate communication

International Nighthawk Model

• Day-night time difference allows for• Better performance – biorhythms• Increased productivity• Enhanced service levels • Commensurate accessibility

Challenges

• Insufficient Clinical Data • Large Image Datasets • Spikes in volume • Outages • Evolving client expectations

Synergy between Teleradiology and Emergency Radiology

• The greatest impact of Teleradiology has been in the emergency radiology space

• Teleradiology is now an integral part of the delivery paradigm for emergency radiology services

• The increasing adoption of teleradiology benefits the subspecialty of emergency radiology by further enhancing its relevance and giving it greater visibility

Dr. Srinivas Meka.Sr. Consultant

Clinical applications

Emergency radiology or nighthawk coverage

American College of Radiology's 1999 survey. AJR Am J Roentgenol 2005;185:24–35. Emergency department image interpretation services at private community hospitals. Radiology 2004;231:190–197.

Clinical ApplicationsEmergency radiology or nighthawk coverage:

Trauma Stroke Acute Abdomen- stone, diverticulitis, AAA, SBO Acute Thorax – PE, Aortic dissection Sonography – Torsion, ectopic NM - VQ, GI bleed Pediatric Emergencies – intussusception, appendicitis

Trauma1. Decrease need for transport

(Emerg Med J 2007;24(8):550-552)

2. Rapid triage – aortic injury, burst fracture

3. Vascular injuries

Stroke Shorten time to thrombolysis Early detection of subtle findings – dense

MCA, insular ribbon Immediate detection of contraindication

for thrombolysis – bleed, large infarct, aneurysm, mass etc

Early detection of complications – herniation, hemorrhagic conversion of bland infarct

Acute thorax Aortic dissection – Early diagnosis and

detection of complications Intramural hematoma- Atypical form of

aortic dissection Surgical management if ascending aorta

is involved.

Acute thoraxPulmonary thromboembolism:Rapid diagnosisIdentification of complicationsAid in early initiation of thrombolytic therapy.

Acute abdomen:

Teleradiology aids in rapid and accurate diagnosis of several acute abdominal and pelvic pathologies.

Helps in initiation of appropriate therapy – Surgical versus non surgical.

Acute abdomenRapid diagnosis of acute appendicitis and bowel pathologies.Identification of complications.

Bowel pathologies

Nuclear medicineExtremely helpful in diagnosing acute conditions such VQ scan for PE.HIDA scan for acute cholecystitis.GI bleed scan

Vascular emergencies Aids in rapid diagnosis of

several vascular emergencies.

Aortic aneurysm rupture: Vascular injuries

SonographyTeleradiology plays a major role in diagnosing potentially life threatening and organ salvaging conditions with a quick turn around time (TAT).

Role of Emergency Teleradiology

• Immediate image review and turnaround• High report quality– Comfort level with all imaging modalities– Experience in all emergent scenarios– Speak the language of the ER – Peer review and QA

Continuing Education and Training

Necessary in telerad environment

Continuous quality improvement

Knowledge update

Stimulate research

Research  Research into quality and process,

Teleradiology helpful

Night radiology coverage Shortage of manpower (radiologists).Subspecialty reads. Catering to rural and semi-urban areas.Vacation coverage.Second opinions.For efficient radiology services.

Summary