PACS in the Emergency Department

PACS in the Emergency Department... - An interview By Hussein AlSayiegh
Dr. Anwar AL-Awadhi anwar.alawadhi@q8health.org	· PACS in the Emergency Department is a crucial tool. · PACS in ER provides speed, accuracy, availability, cost effective health care access, management, delivery and quality improvement. · Generally; X- Rays in the trauma slots can be obtained within 20-30min from request time. · PACS: is moving towards, and should be more user-friendly.
A crucial tool in the ER. PACS in the Emergency Department is a crucial tool in the daily practices of an Emergency Physicians. "Time = Tissue". Tissues could be heart, brain or skeletal muscles and so on in Emergency Medicine. Thus, PACS in the last few years has shifted the speed of availability of the studies, accuracy, and the reduction in costs on the long run, for imaging in the ED. Patient walk in to the ED, gets evaluated by and EM physician, decision is made on what radiological studies to be performed. The patient is then sent immediately to the X-Ray, CT, MRI or Nuclear Medicine Department. Results get uploaded to the radiologist screen whether in the hospital or off the medical campus, and then he/she will view, dictate and upload their results in PACS so the ED physician could view them on the spot. This led to more accurate and swift access to imaging and their results, which in turn has lead to the improvement in the quality of patient treatment and care.			PACS lead to more accurate swift access to images and results in ER.
Do you make requests for imaging procedures electronically? Yes, but if the system goes down, then it is back to paper requests.			Plan (B) if eReq. Is down, paper requests are ready.
How do you get notified if your patient images are available and ready for you to read from PACS? Only if there are significant abnormalities, like bleeding, pneumothorax (air in the lungs) and so on, the Radiologist calls over the phone to the ER or pages the physician over head and documents in PACS the name and title of the ER physician who has received the abnormal results so as the date & time too.			In significant cases, ER physician is contacted on the phone and is noted on PACS.
How is the PACS setup in the emergency room? Some ERs had the mobile viewers and others that I've worked at, had the Viewing PCs. Both off which worked as well. Actually, The viewer PC lasted longer and was easier to be maintained.			Viewing desktop PCs lasted longer than mobile viewers and were easier to be maintained.
Is your viewing PCs having medical quality monitors? So and so. Most are Dell, Siemens, Philips and General Electric. Dell predominates and I think it is one of the best and most user friendly monitors.			Diagnostic quality monitors are available in the ER.
Do you often use processing tools on your viewer? What are you still missing from that? Yes all have been used, so as comparing old and new pictures on side to side screens. Organ windows are used too, like bone window lung window and so on. Some has the 3-D recon, which is the new state of the art imaging, but some don't have it.			In ER, physicians use preset windows levels In ER, you can find 3D recon. Workstations.
What is the expected time until image ready in ER (i.e., for Trauma cases)? Depends on how many traumas are received and how critically their conditions are, which will lead to how many tests are needed to be done and uploaded to PACS. In general the X-Rays in the trauma slots are within 20-30 min and other images like CTs are within 60-90mins to get the final diagnosis.			Expected time for CT images are within 60-90mins from request time.
What is the effect on patient's safety if images from PACS where delayed? Delayed images might lead to the mixing of results with other patients and ultimately some patients might receive the wrong treatment. Some times EM physicians have to look and interpret the results themselves without waiting for the final report from the radiologist, so they use the ones already uploaded in PACS or hard copies if available.			Some patients might receive wrong treatment due to the delays in the delivery of images into PACS.
How the delay in the upload of images, might lead to the mix up in patients ultimate care? Delayed images might compromise patients safety when, for example: 1. A patient might have an image before for hip or knee reduction for dislocation in the ER, and another image post reduction. When there is a delay, the ER Physician might have to go back to repeat the procedure if some of the images were uploaded as post reduction time, but in fact were the pre-reduction ones. 2. Injection of a contrast to rule out J-tube or G-tube leaks in the ER. Images pre and post contrast injection are taken, but the inaccurate timing and sequence of taking those images might lead to the non confirmation and/or the inaccurate interpretation of whether there is a leak or not. 3. Bowel perforation. STAT (immediate) orders in the ER are placed in the computer, but the requests that are being printed in the radiology department might be performed few hours later due to miscommunications or other technical issues, which in turns might lead to the delay in treatment, quality of care and ultimately; the patient disposition in the ER. Those delays can be avoided by better communication methods between the ordering the performing departments and staff.			Examples issues leading to patient safety concerns. · Mixing pre and post condition images. · Delayed Images can pose life threat.
As an ER physician, what are the difficulties you are facing with PACS? 1. PACS should be more user-friendly, i.e. can search a patient through their names, medical records, Civil I.D or other identifiable data as much as possible and not to restrict the search to one or two identifiable. 2. Images should be easily uploaded to the radiologist screens both at the medical campus and at their offices. 3. Online access, so when physicians are not at the medical center, they could login and follow up their patients from a remote access point. 4. Improve the security of those data. 5. Innovation in the security and the confidentiality of the retrieved images when used for medical conferences and meetings. NO patient identifiable data could be allocated. This can be done by removing the name, I.D and other identifiable data, so the meant to be used images protect the confidentiality of the patients and his/her records.			Difficulties, · No search flexibility. · No access for ER from home. · Not enough data security.

Further Readings.

1. J Accid Emerg Med 2000;17:180-184 doi:10.1136/emj.17.3.180

2. PACS Powers the Emergency Department

3. PACS Under Pressure

PACS During Holidays

Medical Imaging 24x7 service

Healthcare is one of many services which run around the clock specially at emergency rooms where patient is in high need of medical intervention on the spot. 

Medical imaging is not an exclusion! In fact, requests for imaging procedures for emergency patients is very frequent due to the fast and the non-invasive nature of some imaging procedures like CT scans, ultrasonography, and even general x-rays which existed in emergency rooms for decades.

High end procedures like PETCT, MR, and SPECT scans are done as well for some emergency patients. For that reason, imaging departments in any general hospital are on service for 24x7 including national holidays.

During holidays and non-working hours, imaging departments usually provide services by assigning technicians on shifts and physicians on call trying to help emergency patients to save their lives and to prevent further medical complications.

 

Absence of PACS admins

Now and after transforming most of imaging services to digital, those services are in hands of a new technology called PACS/RIS. If that system is down, or out then the whole department is usually on hot plate. Due to lack of clear policies and weak technology implementation, PACS/RIS operation is almost impossible without an administrator. In fact, running PACS/RIS without an administrator at any time means threatening lives of many patients.

There are many examples were administrator interference is needed. One example is merging or rejecting wrong images which require administrative access rights to the system. In fact, wrong patient information is; in many times, a serious threat to patient's safety. See FDA similar reported event . The role of PACS admin cannot be substituted by any one. 

One more example of tasks assigned to PACS admins, is the follow up of consistent backup handling. It's beyond changing the backup tape, it's about consistency. Backup logs should be verified for a successful backup job. Thus, role of PACS admin is continuum.

PACS Admins 24x7

Now and after knowing that PACS admin's job is continuous, that doesn't mean that a PACS admin should be available in the hospital all the time!  Yes, a PACS admin should be available in the hospital at least during working hours where regular appointments are scheduled. However, PACS admin should be available on call 24x7 just like any other IT service. In fact, many Internet technologues can help in providing remote support from outside hospital without imposing any threat to data security. 
Thus, PACS administration has to be treated according to the field of information technology standards in both payment scale and team organization to co-op with the demand for the PACS admins.

PACS admin team restructuring

Moreover, to be able to adopt a new PACS team organizational structure and payment scale, a job description for this post has to be defined. In fact, the best resource I have came across about forming PACS team and defining job description accordingly is a document written by Herman Oosterwijk and Janet Skinner from OTech Inc. and Skinner Associates (PACS Admin and IIP Resource Guide 2008, PDF Format). In last guide, authors discussed development, training, career tracks, job Descriptions, titles, salary of PACS professionals and more. 

 

Recommendations

To solve the issue of absense of PACS admins during PACS operation hours I will recomend the following actions.

1. PACS (imaging IT) Team should be formed with proper team members in terms of quality, quantity and good work environment to cover the operation hours (24x7).

2. PACS admins should be on call during after working hours and during holidays with proper job dispatching and compensation system.

3. PACS admins should have access to hospital network using secure VPN connections to help reaching the system everywhere at any time.

4. For smooth operation with minimum down time, service level agreement (SLA) should include an explicit agreement for support during "after working hours" and public holidays.

5. Service agreement should assure 24x7 monitoring of log traps (logs send to vendor's support team) which is the only way to assure optimal down time.

6. Call management system has to be implemented to help PACS administration team managing this heavy job. This system will provide PACS team with ability to schedule jobs and organize support efforts.

 

Conclusion

Above discussion is not inclusive. It's actually a second call for a dialogue within Kuwait imaging community. That dialogue was already started before in the early days of Q8PACS by Mr. Ahmed Al-Mutairi (former senior PACS admin at AlSabah hospital, Kuwait) and was presented earlier to the Radiology & Nuclear Medicine council at that time.

This dialogue will be neccessary to start reform in PACS operations and thus in leveraging medical imaging services in Kuwait.

 

I think this is the time to start the dialogue Again!!