Our study was designed as prospective,
multicentric,
controlled and open.
It compared workflows for 6 months between two hospitals for emergency room patients undergoing CT scans read either by an on-call radiologist coming on request in one hospital or by a teleradiologist receiving requests and interpreting exams from a dedicated center in the other.
All patients were informed of the study by ER physicians and a written form.
Population
We included 478 patients undergoing CT scans,
referred by the ER physicians of two hospitals: 224 from Croix-Rousse Hospital (Lyon) and 254 from Saint Joseph-Saint Luc Hospital (Lyon),
for the following pathologies:
• Neurological disorders
• Head traumas
• Thoracic disorders
• Surgical abdomen.
Age and sex of patients were as follows: age,
61 years (p<0.01); male/female 48%/52%.
Working hours being 24/7 in one hospital and from 8.00 to 18.30 in the other one,
and to avoid bias caused by programmed exams,
only patients undergoing exams between 8.00 and 18.30 on weekends and holidays were included.
The emergency room departments of the two hospitals selected both featured:
- An emergency care hospitalization unit
- An intensive care unit within the hospital.
Workload when compared to opening hours and the number of working physicians appeared similar.
In Saint Luc – Saint Joseph ER department,
26 physicians and 8 residents worked 24h/24 and 7d/7 with 36000 patient registrations/year.
In Croix Rousse Hospital,
15 physicians and 5 residents worked from 8.00 to 19.00 24h/24 and 7d/7 with 20000 patient registrations/year.
Both hospitals were located downtown,
with a similar range of pathologies,
and no Emergency Medical Services (EMS) unit.
Teleradiology workflow( Fig. 1 )
- The referring physician sends a complete online radiology requisition to the teleradiologist,
all information asked in the form being mandatory to be able to send it.
The requisition is immediately transferred to the teleradiologist.
- The teleradiologist accepts the requisition,
sends back an online exam protocol to the radiology technician (in the radiology department).
- The radiology technician and the referring ER physician agree on a time to do the exam.
- The referring physician supervises the exam.
- Images are sent to the teleradiologist who interprets the exam.
- The teleradiologist sends back an online report to the ER physician.
If needed,
all written steps (requisition form,
exam protocol) can be dealt with on the phone,
at the discretion of either radiologist,
ER physician or technician.
However,
all reports,
even if transmitted on the phone,
will then be properly written.
All online exchanges go through a secure server.
Teleradiologists work from a dedicated center,
where they are able to respond immediately to any exam requisition they receive,
actually working as an emergency radiology department.
It is equipped with a Radiology Information System (RIS),
specialized computer monitors and an optical fiber internet connection.
Exam protocols are available online for all technicians.
A log of all steps from request to report is being kept and saved on a secure server.
As ultrasound exams cannot be performed remotely,
ultrasound requisitions were examined by the teleradiologist.
Then,
either exam modality was changed to CT scanner,
delayed until business hours after a discussion between teleradiologist and ER physician or performed by an on-call radiologist from the referring hospital coming from home on demand.
On-call radiology workflow( Fig. 2 )
- The referring physician gives a phone call to the on-call radiologist.
- The radiologist comes from home to the radiology department (distance is different for each radiologist and the radiologist is sometimes already on site when receiving exam requisition).
- The radiologist gives a protocol to the radiology technician and supervises the exam
- The radiologist interprets the exam,
writes and gives back a written report to the physician.
Reports can also be given on the phone as needed.
On call radiologists had at their disposal a RIS,
a picture archiving and communication system (PACS),
specialized computer monitors,
a CT scanner and an echograph.
Collected data
The main study criterion was the delay between patient registration in the ER and reporting.( Fig. 3 )
Secondary criteria were:
- Delay between registration and referring
- Delay between referring and protocol
- Delay between referring and exam
- Delay between referring and report
- Quality of exam requisition
- Radiation exposure
- Physicians satisfaction
Statistical analysis
We calculated averages (non parametric Mann-Withney test,
5% significance threshold) and alpha risk for each delay and for radiation exposure.
We also analyzed the number of exams for each anatomical location and for each type of indication.
We then analyzed the difference between delays as a function of exam indication if the number of exams for the designated location appeared significant.
Quality of exam requisition was evaluated through health care quality indicators: we used French HAS « IPAQSS » criteria (« Indicateurs Pour l'Amélioration de la Qualité et de la Sécurité des Soins » de la Haute Autorité de Santé,
Indicators for improvement of quality and security of care of the High Health Authority).
Physician satisfaction was assessed through a survey.