HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mueller, C. F. Articles by Yu, J. S. Search for Related Content PubMed PubMed Citation Articles by Mueller, C. F. Articles by Yu, J. S. Social Bookmarking                      What's this?

The Concept of a Dedicated Emergency Radiology Section: Justification and Blueprint

¹ Both authors: Department of Radiology, Ohio State University Medical Center, Means Hall 165, 1654 Upham Dr., Columbus, OH 43210.

Received February 26, 2001; accepted after revision May 10, 2002.

 
Address correspondence to C. F. Mueller.

Introduction

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 
Today's competitive medical arena has brought a constant search for optimal reorganizational strategies that add stability and quality to hospital departments while enhancing the financial status of the medical enterprise as a whole. The typical emergency department often provides between 40% and 70% of admissions to a hospital. Radiology plays an integral part in the care of patients seen in the emergency department. Yet although imaging findings often determine the disposition, workup, and treatment of a patient both during and after the emergency department encounter, hospitals appear to attach little importance to this diagnostic step and assign emergency department imaging to residents or to imaging specialists who view the work in the emergency department as an appendix to their duties. The emergency department in many hospitals has no dedicated radiology specialist, and this lack of coverage is not merely an oversight, for it is a daunting task to commit the time and personnel necessary to provide both generalist and specialist expertise around the clock.

The presence of a dedicated attending radiologist in the emergency department is a relatively recent development in academic medical centers and a few large hospitals [1]. We recognize that local needs determine variations in coverage, and we direct our comments to those institutions that see a need for change in their radiology coverage in the emergency department. Many training programs use residents for emergency department coverage during both night and day shifts; the radiologic studies that the residents perform may be "batch-checked" after a delay of a few hours. On holidays and weekends, imaging interpretations may be performed according to a schedule intentionally designed to increase the time required to produce a final report. At institutions without residents, the radiology department often schedules technologists to work around the clock to perform emergent imaging studies, but the time at which a radiologist interprets the images is based on the perceived acuteness of need. Many radiologists use teleradiology (especially CT and other cross-sectional imaging studies) to cover emergencies from home; however, a final interpretation frequently requires review of a patient's actual emergency department images and previously obtained images as well as access to the hospital dictation system. Inappropriate care given as the result of an interpretation by an emergency department physician that must be reversed because of findings on the final radiology report only opens both the emergency and radiology departments to liability.

The aim of this article is to discuss the justification for and feasibility of establishing an emergency radiology section as a specialized department of radiology. What is the goal of such a conversion? Can it be practically achieved? How would we do it? The benefit of an emergency radiology section would be elimination of a rotating call schedule that now requires the participation of most of the radiology staff. The establishment of an emergency radiology section might standardize radiology's presence and operations in the emergency department and stabilize operations of the radiology subspecialties that are disrupted when a member of subspecialty section is scheduled for night duty.

Historical Background

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 
Before cross-sectional imaging became commonplace, radiology service was limited to conventional radiography. An emergency department physician often would perform the initial interpretation of images. In our institution, the number of major discrepancies between initial interpretations and final reports was acceptably low, and protocols for handling the discrepancies ensured that patients received proper treatment with little delay. In practice, this arrangement allowed the flexibility that emergency department physicians require to administer treatment without necessitating provision of in-house coverage by radiologists around the clock. It was an amicable relationship when disagreements in interpretations were few, but many contentious moments arose when the final radiology reports altered the therapy rendered. The advent of cross-sectional studies only magnified this dilemma.

The relationship between emergency physicians and radiologists continued to evolve, as did the specialty of emergency medicine. Increased use of cross-sectional imaging such as CT and sonography forced more timely integration between the findings of final radiology reports and the clinical services provided by the emergency department physicians. The policy of the emergency department at our institution was that the interpretations of conventional and cross-sectional imaging performed by radiology residents at night and on weekends became the property of the emergency department physicians, who billed for these interpretations. Radiologists also billed for these services, unaware that the patient had already been billed for a similar, but not equivalent, service by the emergency department.

In December 1995, the Health Care Financing Administration (HCFA) published in the Federal Register its final ruling on payments to providers of services for ECGs and radiographs obtained in the emergency department [2], warning that HCFA would pay only once for these interpretations and giving priority approval to contemporaneous interpretations. Both oral and typed interpretations were deemed acceptable when performed contemporaneously, which allowed interpretations to be rendered from a remote site via teleradiology. Hospitals had to guarantee that only one bill would be submitted for radiology services and that a final written report would be rendered. If the primary interpretation was performed by a nonradiologist, HCFA would reimburse the radiology department for only a quality assurance fee.

The concern of HCFA was that Medicare fraud (double billing) was occurring—a correct assumption. HCFA also deemed it proper that patients receive an official interpretation of imaging studies in time for the findings to have an impact on their initial treatment. Therefore, when the emergency department physicians began to bill for interpretations of cross-sectional studies performed in the emergency department, the relationship between emergency department physicians and radiologists became strained, but this circumstance also increased awareness of the importance of the radiologist's function. Radiology in the emergency department could no longer be viewed as peripheral as it once had been.

The escalating use of cross-sectional imaging in the emergency department after hours (i.e., the period between the end of the usual day's work and the beginning of the work day the next morning) and the increased diagnostic confidence that cross-sectional imaging afforded made clear the need for not only these studies but indeed all radiologic studies to be interpreted expeditiously. These factors created the milieu that forced the radiology departments in institutions like ours to add extended hours (in our case, in 1994) and eventually to convert to overnight in-house coverage.

Considerations for Implementing 24-Hr Coverage

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 
Both HCFA and the American College of Radiology in its communications standard [3] have stated that any hospital operating an emergency department should have a physician who can provide radiologic interpretation of images available 24 hr a day, either in-house or at home. Many radiologists cover the emergency department through teleradiology and do not remain in-house 24 hr.

Several methods of providing after-hours radiology coverage of the emergency department exist. The most desirable may be the creation of a section dedicated to emergency radiology. Such a section provides uninterrupted radiology service throughout the day and night. The primary responsibility for the emergency radiology specialist is imaging emergency patients, necessitating his or her full-time presence in the emergency department [4]. This radiologist, in essence, functions as an integral part of the department of emergency medicine, in contradistinction to being a visitor there, as is now the case in many institutions.

The insufficient number of radiologists who specialize in emergency radiology requires that there be another way to provide constant emergency department coverage: enlisting radiology specialists from other sections, such as musculoskeletal radiology or neuroradiology, as part of the night call rotation in the emergency department. The major difference between emergency radiologists who provide dedicated service and radiologists who provide coverage is that radiologists who are "borrowed" from other subspecialities have little or no vested interest in the emergency department and consider emergency coverage an onerous task that takes them away from their chosen work. This sentiment is further ingrained by the lack of exposure of radiology subspecialists have to other facets of radiology once they begin to practice. For instance, a radiologist whose practice is limited to nuclear medicine may find that interpreting an angiogram obtained in the emergency department in a patient with a suspected aneurysm may not be as easy as interpreting a ventilation—perfusion scan obtained in a patient with a possible embolism. Radiology has many subspecialties, and far too few radiologists are proficient in all of them. This fact presents the dilemma for the radiology subspecialists who are expected to cover the emergency department at night.

Other solutions have been tried. A common one is nighthawk coverage. The nighthawk is a radiologist who contracts to work after hours. Because these hours are not routine, nighthawk work often involves longer, and sometimes slower, hours of work in exchange for a shorter work week or longer weekends. Nighthawks rarely remain in their positions for long.

A fourth option is to not cover the emergency department after hours. In some hospitals, an emergency medicine physician still interprets imaging studies performed at night, and the radiologists render their interpretations the next day. Foremost among the significant risks of this practice is that the untrained physician will miss a finite percentage of important diagnoses, likely less than 5%. Encouraging emergency physicians to interpret radiographs after hours implies that they also can interpret radiographs during working hours. If radiologists condone after-hours interpretations by emergency medicine physicians, why not give interpreting privileges to other specialists as well? Many other physicians might readily accept such a policy. Governmental spokesmen [5] have suggested that if a radiologist interprets studies long after the service or treatment has been given, he or she should earn only the departmental quality assurance fee.

How Can an Emergency Radiology Section Be Developed?

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 
Several models exist that could assist in the development of an emergency radiology section within an institution. One possible model to use is the one that led to the development of emergency medicine as a discipline. In the 1960s, internists and surgeons who were beginning their practices responded to the need for emergency department coverage in busy institutions. As the body of knowledge unique to the practice of emergency medicine grew, academic medical centers developed emergency medicine programs with astonishing speed. By 1997, 60 medical schools had begun residencies. During the last decade, the number of emergency department trainees has nearly doubled to 3595, and the residency positions in emergency medicine have routinely been filled [6]. Jobs are available for trained emergency department physicians (65% of whom are trained in medical centers and 35% are trained in nonacademic centers) in more than 5000 hospitals. The emergency medicine trainees like the excitement and the defined responsibilities of their work. This proven path could be applied to emergency radiology and entice potential emergency radiology trainees into the specialty.

A second model emphasizes specialty training in fellowships. This educational experience is currently being standardized by the American Society of Emergency Radiology using a draft document entitled "A Core Curriculum in Emergency Radiology" (Novelline RA, unpublished work, 2001; available at www.erad.org; accessed May 15, 2001) and surveys provided by sites that teach emergency radiology in their radiology curriculum.

To promote the optimal environment, the dedicated emergency radiology section should have radiologists who by training and choice have elected to provide only emergency imaging service. Because other radiology sections have more defined and traditional working hours, emergency radiology must be made more attractive if it is to compete with other subspecialties in radiology. The emergence of this specialty will require vision, time, money, and cooperation with our emergency medicine colleagues. The incentives and rewards will need to balance the challenges of a different type of specialization that would engage in a gamut of radiology services—from conventional radiography to angiography.

A Hypothetic Blueprint for Emergency Radiology Coverage

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 
How do our colleagues in emergency medicine cover the emergency department? Their schedule design is based on shifts, three shifts per day each lasting 8 hr. One month (30 days) requires 90 8-hr shifts for the emergency department to be fully staffed by only one emergency department physician per shift. These 90 8-hr shifts are apportioned to each emergency department physician, who averages slightly more than 13 working shifts per month. The rotation requires a minimum of six full-time employees to cover the emergency department, each rotating serially through the first, second, and third shifts. The shift progression changes after an agreed-upon length of time, with all emergency department physicians taking a turn on each shift. In the course of 1 month, each physician works approximately 14-15 shifts. These figures indicate that a minimum of six additional radiologists would be needed to staff a dedicated emergency radiology section. The principal disadvantage of the emergency radiology section is its requirement for 24-hr coverage.

Because institutions cannot spare six radiologists to staff the emergency radiology section, we propose that four emergency radiologists provide daytime emergency department coverage 1 day each week, with two radiologists from other subspecialties covering on 2 of the remaining 3 days. The emergency radiology section rotations would be based on three shifts, each lasting 10 hr, and the work week would last from Sunday at 4 P.M. to Friday at 6 P.M. For example, shift 1 could begin at 4:00 P.M. and end at 2:00 A.M. Shift 2 would overlap the first shift, beginning at 12:00 A.M. and ending at 10:00 A.M. Shift 3 would begin at 8:00 A.M. and run until 6:00 P.M. A radiologist would rotate through shift 1 in week 1, shift 2 in week 2, and shift 3 in week 3 and would then have a week off. Coverage for each work week would require three radiologists. In our plan, the other members of the department would be responsible for emergency department coverage from Friday at 6:00 P.M. to Sunday at 4:00 P.M. (46 hr), when shift 1 would begin again.

The prerequisites for our hypothetic emergency radiology section would be that each radiologist in the section be able and willing to interpret all emergency department imaging studies (i.e., CT, MR imaging, and angiography) and make a long-term commitment to the endeavor of emergency radiology. Increasing the staff of the emergency radiology section to five would allow the length of each shift to be reduced to 8 hr and still retain some overlap of the shifts.

Conclusions

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 
Hospitals have a tremendous need for quality emergency radiology service. Currently, little or no emphasis is placed on emergency radiology, particularly in establishing a pathway that will promote its growth and encourage the recruitment of residents into the subspecialty. We need to encourage residents who might be so inclined to go into emergency radiology, which will help to ensure its growth, and we must continue to develop fellowships that are dedicated to emergency radiology.

Our analysis sought to describe the gap between emergency radiology coverage and the requirements for the development of a dedicated emergency radiology section staffed with radiologists who practice emergency radiology as their primary responsibility. The transition from emergency department coverage to a dedicated emergency radiology section will be a challenge, especially in an era when many fellowships go unfilled. Yet emergency medicine is growing faster than any other specialty. A new spirit of cooperation among all those providing emergency care will provide rewards not only to our patients but also to the advancement of medicine. A fundamental change in the way in which we approach emergency department radiology service will be required if we are to achieve those goals.

References

Top Introduction Historical Background Considerations for Implementing... How Can an Emergency... A Hypothetic Blueprint for... Conclusions References

 

1. Spigos D, Freedy L, Mueller CF. 24-hour coverage by attending physicians: a new paradigm. AJR 1996;167:1089 -1090[Free Full Text]
2. Health Care Financing Administration. Medicare program: revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1996. Federal Register 1995;60:63124[Medline]
3. American College of Radiology. ACR standard for communication. In: Standards 2000-2001. Reston, VA: American College of Radiology, 2000: 1-3
4. Mueller CF, Spigos DG. Wakeup call: the importance of being there. Emerg Radiol 1995;2:259 -260
5. Office of Inspector General, Department of Health and Human Services. Medicare's reimbursement for interpretation of hospital emergency room x-rays. (memorandum) Washington, DC: Department of Health and Human Services; 1993. Publication OEI-02-89-01490
6. Baker SR, Hart B. Emergency medicine: the growth of training programs and residency positions 1971-2001. Emerg Radiol 2001;8:246 -249

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				D. D. Saketkhoo, M. Bhargavan, J. H. Sunshine, and H. P. Forman Emergency Department Image Interpretation Services at Private Community Hospitals Radiology, April 1, 2004; 231(1): 190 - 197. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mueller, C. F. Articles by Yu, J. S. Search for Related Content PubMed PubMed Citation Articles by Mueller, C. F. Articles by Yu, J. S. Social Bookmarking                      What's this?