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EDs speed care, improve images with new CT scans
More rapid diagnosis avoids unnecessary admits
EDs that are using the latest technology in computed tomography (CT) scanning devices are finding numerous benefits in patients with chest pain. First, these speedier machines allow them to more quickly determine which patients may have a serious condition and which can be discharged, which statistics indicate are the vast majority of such patients. In addition, they say, the scans also are more accurate.
"We are achieving more effective accuracy, similar to what you get with cardiac catheterization, and we can discharge the patient earlier if there is no disease," reports David Bello, MD, director of cardiovascular imaging at Orlando (FL) Regional Medical Center. The facility's ED introduced a new 64-slice CT scanner from Siemens Medical Solutions USA in Malvern, PA, in early 2007.
"Most people who come to the ED [with chest pain] end up being discharged ultimately because they are not having a heart attack," Bello observes. "This essentially rules it out; 90% of these people don't have acute cardiac syndrome and do not need to be here."
Bello says the new scanner has helped reduce length of stay (LOS) significantly. Before its introduction, he reports, the average LOS for all chest pain patients was 32 hours; it now is down to 17. It would be even lower, he adds, if the department had more than one reader. (Bello is the only person qualified to read the scans.) "I'm only here in the daytime, during which the average LOS has dropped to six hours," he says. "If we could read them at night, the LOS for that shift would be probably be eight hours."
A recent abstract presented at a Radiological Society of North America meeting by researchers from the University of Pennsylvania School of Medicine in Philadelphia showed similar results. The study looked at a total of 202 patients, older than age 30, who came to the ED at the Hospital of the University of Pennsylvania between October 2005 and February 2007, and whose primary complaint was chest pain. They were given an electrocardiogram and a specialized CT scan: either 64-slice or an even newer technology, called "dual definition" or "dual source," which uses two X-ray machines.
The study showed that patients who came into the ED during "on" hours (when the scans could be read) spent a total of nine hours and 39 minutes in the department before being discharged. Patients who came to the ED during off-hours spent a total of 12 hours and 15 minutes in the unit. Patients who were referred to the Clinical Decision Unit (CDU), which provided the CT scan, as well as additional evaluation and observation, spent 21 hours and 50 minutes in the hospital if they came during off hours and 18 hours and 38 minutes if they came during on hours.1
They used 16-slice, 64-slice, and dual definition, says Judd E. Hollander, MD, professor of emergency medicine, an ED physician at the Hospital of the University of Pennsylvania in Philadelphia and one of the researchers. "Now, we use dual definition mostly; when it's down we use the 64-slice, because you get the same quality pictures faster," he explains.
There's no question in Hollander's mind why EDs should be using this latest technology. "What you really want to do is save admissions," says Hollander, while echoing Bello's concern about readers. "As long as you are doing tests, you want radiologists available who can read them at any time of the day."
At his facility, he says, there are three individuals who can read the scan, and the department soon will have six or seven at night. "The real way we will improve patient care is when we have someone who can read the scans at any time," Hollander says.
These new scanners will help to solve the problem of boarding, he says. "There are too many ED patients waiting for beds," he says. "The best solution is to figure out which of them can avoid being admitted on chest pain."
Hollander cites statistics similar to Bello's. "For every 100 chest pain patients admitted, only 15 turn out to have an important cause," he says. "If we can identify them and skip admission, we not only help the patients we send home, but also those waiting to come in, because those beds are no longer being blocked."
Cost may be one reason more EDs don't have these more advanced scanners. "Our [Siemens Somatom Sensation 64] scanner cost about $1.5 million," notes Bello. (The University of Pennsylvania also uses Siemens products. The cost of the Somatom Definition Dual-Source CT is about $2.2 million. ) The ED staff at Orlando Regional were very excited about getting the new scanner, and that reaction to its performance "has been very positive," Bello says.
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