Hand-held ultrasound serving three EDs

Technologists take readings at bedside overnight

The EDs at three Toronto area hospitals — Mount Sinai, Toronto Western, and Toronto General — now are able to perform beside ultrasounds using a hand-held device. The medical imaging department at Mount Sinai provides services to the other two hospitals, one across the road and one a mile away, through an ultrasound technologist who is on duty seven nights a week for the three sites. The technologist stays at the two neighboring hospitals and takes a taxi to Western when necessary.

Explaining why ED physicians do not perform the scans, Howard Ovens, MD, director of the Schwartz/ Reisman Emergency Center at Mount Sinai, says, "Our imaging department felt a technologist could fill the main gap where we were not providing this service easily — at night. We felt the geography was such that they could move between three sites using one device." Since the scanner (which costs about $70,000) and the salary of the technologist came out of the imaging budget, he adds, there was no impact on the ED budgets. The scanner is from SonoSite in Bothell, WA.

Much faster and complete

While the technologist may not be quite as fast as a physician, Ovens concedes, "It's still much faster than the traditional on-call model and provides a more experienced scanner doing a more complete report."

Besides, he says, where in the past it might have taken several hours to get a nighttime ultrasound done, it now is often done within an hour. "And where in the past we might have done only a couple of ultrasounds a week at night, we now do 15-20 a week," he adds.

All of this has had a positive impact on quality of care, notes Brian Goldman, MD, MCFP(EM), FACEP, an ED physician at Mount Sinai. He notes that in the past, if a patient needed an ultrasound, what he did depended on the urgency of the problem. If the patient needed an urgent ultrasound, he had to call the radiology resident on call and try and persuade the resident to agree to ask the on-call ultrasound technician back to the hospital to do the study. "Unless I suspected an ectopic pregnancy, more often than not the resident would persuade me to hold the patient overnight to do the ultrasound the following day," he says. "Thus, fairly urgent patients had to wait hours before I could refer them to appropriate services and admit them if needed."

Speeding the process

One of the reasons the scanner was purchased was to cut down on the long delays that were occurring under the system that was then in place, says Ovens. "When the physician does it himself, he also has to cover many other duties," he explains. "Plus, since they really only used ultrasounds for dire emergencies, sometimes there were several hours' delay depending on clinical conditions." Having the scanner, he says, enables a lower threshold of indication.

Goldman recounts a recent case where he saw a young woman with suspected appendicitis at night. Due to the risk of radiation from CT scans, most radiologists recommend doing an ultrasound first, he notes, but the problem with ultrasounds is that they sometimes fail to visualize the appendix. "I ordered one at night, and it showed a tubular structure in the right lower quadrant that was suspicious for appendicitis but wasn't definitive because the structure couldn't be visualized to the tip," Goldman recalls. Still, based on those findings, he was able to persuade the surgeons to accept the patient. "In the past, such patients would have had to hang around until the day for a CT scan before the surgeons would have even seen the patient," Goldman notes.

Boosting patient safety

To further streamline the process, the ED physician calls the technologist directly, rather than going through a resident, Ovens explains. "If the tech is faced with multiple calls, she does her best to set priorities with the ED physician," he says. Most of the time, he notes, there are not competing requests or long delays. "I can diagnose them faster and refer [patients] faster," adds Goldman. "There's no question that a faster diagnosis improves patient safety."

There are benefits for less urgent patients as well, he adds. "In the past, for example, if I suspected a deep vein thrombosis, I would anticoagulate the patient and bring them back the next day for an ultrasound," he notes. "That placed a burden on staff the next day to follow up with the patient." Now that he can obtain ultrasounds at night, he can diagnose or rule out a deep vein thrombosis, thus saving the patient a trip back to the ED, he says.

While the device is currently being used only for diagnostics — i.e., full-body scan — Ovens says, "We are also interested in exploring using the device ourselves for initiating lines, assisting with incisions, drainage of abscesses, and so forth."

Sources

For more information on improving patient satisfaction rates, contact:

  • Howard Ovens, MD, CCFP(EM), FCP, Director, Schwartz/Reisman Emergency Center, Mount Sinai Hospital, Toronto. Phone: (416) 586-4800, ext. 8226.
  • Brian Goldman, MD, MCFP(EM), FACEP, Mount Sinai Hospital, Room 206, 600 University Ave., Toronto, ON M5G 1X5. Phone: (416) 822-5044.

For more information on portable ultrasound equipment, contact:

  • SonoSite, 21919 30th Drive S.E., Bothell, WA 98021-3904. Phone: (888) 482-9449. Web: www.sonosite.com.