CR and DR inspire changes in workflow

Hospital sees impact of technology right from the start of move to filmless imaging

BY ANNE PILEGGI, R.T.

MS. PILEGGI is administrative director for the department of radiology at Saint Joseph's Hospital in Atlanta.

Medical imaging plays such an important role in the diagnosis and treatment of hospitalized patients that most other departments are held captive by the radiology department's ability to respond to their needs in a timely fashion. Computed radiography (CR) and digital radiography (DR) are vital to maximizing efficiency in patient care throughout the hospital.

The radiology department at Saint Joseph's Hospital in Atlanta uses three Fuji AC3CS CR units and one GE DR chest unit, Revolution XQ/i, to handle radiographic needs in the ICU/CCU, emergency department, and preadmission testing as well as in the main radiography area itself. Although staff working in these areas have been affected by digital technologies, their full potential for enhancing workflow has not yet been realized. The original plan has suffered from reduced capital equipment budgets. Even so, the introduction of digital x-ray has expedited the diagnostic process by improving efficiency and streamlining workflow for technologists, radiologists, and other physicians.

The first step was the introduction in 1990 of a Fuji AC1 CR unit in the ICU/CCU. Besides gaining workflow efficiencies, we were looking to obtain more consistent quality in portable chest x-rays. This technology, which was cutting-edge in 1990, had a profound impact. First, the technologist no longer needed to go back to radiography to develop a film. Second, CR provided the ability to print two originals, rather than a second film of questionable quality produced by double-loading a cassette or making a duplicate.

A ripple effect became apparent. The referring physician and radiologist started making their decisions more quickly, and staff on the unit acted on the physicians' treatment decisions sooner. There was a steep learning curve, however. Referring physicians and radiologists had to learn how to look at and interpret minified images with spatial and contrast resolution different from what they were used to. The technologists had to master the technology of CR to understand not only the implications of positioning part of the body being imaged, but also the orientation of the imaging plate relative to the body part.

Soon after this first implementation, a Fuji 7501 CR chest unit was introduced in radiography. A preview monitor was installed in the x-ray room, which allowed the technologist to view the image after the exposure was made and assess patient positioning. Although the image on the monitor was not good enough to assess overall exposure factors and image quality, the patient could be released if the positioning was adequate, because CR usually could make up for any other deficiencies. Given the number of chest x-rays done in the department on any day, this change alone vastly enhanced workflow. Patients could be back in their rooms before the actual film was developed and hung on the rolloscope light board.

SUCCESSES AND SETBACKS

But there was an unexpected adverse result. Technologists began to act as though the exam was done as soon as the patient left the chest room. Films were not being matched with the requisitions and brought in a timely manner to the film librarians for hanging. Radiologists were getting films in batches, which ultimately delayed reports to the referring physicians. Workflow and duties had to be reassessed as a separate issue. This discussion presented an opportunity to review staffing practice and ultimately resulted in the film librarians assuming more responsibility, allowing the technologists to spend the majority of their time on patient care.

Continued success with digital x-ray led us to upgrade and expand our dependence on digital technologies. The Fuji AC1 in the ICU/CCU was replaced with a Fuji AC3CS, and two other Fuji AC3CS units were added, one in the emergency department and another in preadmission testing.

In 1999, we purchased a GE digital chest unit, Revolution XQ/i, to replace the Fuji 7501 CR chest unit in radiography. Again, improvements to workflow occurred. This system features automated digital acquisition preprogrammable techniques. The quality control monitor provides image quality equivalent to printed films. Image parameters can be manipulated or changed to optimize the final outcome. Typically, electronic images are printed using a laser camera. If the laser camera used for printing the image is malfunctioning, the DR unit stores the images on its own hard drive until the printing capability is available.

Introduction of this unit allowed chest x-rays on ambulatory patients to be completed in less than five minutes. Its use directly affected the workflow design, expediting filming, collation, and matching of films with paperwork. This is extremely important, because the technologists, who are in short supply, can use their time more effectively.

We have more work to do, but we believe that establishing the basis for electronic image management by using CR and subsequently DR provided a solid foundation, while incrementally improving workflow.