1. Emergency Medicine News & Articles
Bringing It
In House
In-ED imaging can improve
efficiency, raise the quality of care
and even help the bottom line.
Dr. Manuel Hernandez explains
how to design it right from the
ground up.
As the ED has evolved, the role of advanced
diagnostics has exploded in the evaluation and
management of our patients. Beginning with
simple roentgenograms and basic laboratory analysis, our diagnostic capabilities have
expanded to include advanced non-invasive
imaging that has largely replaced exploratory
surgery and the “wait-and-see” approach commonly used in the absence of diagnostics.
The concept of housing imaging within the
ED had gained popularity, though at differing
rates. The most readily available data from the
United States and other advanced systems has
shown a steady increase in imaging utilization.
For example, data from the United States has
demonstrated a five-fold increase in CT studies
ordered in paediatric cases from 1995 – 2008
(Larson). Flattening and even declining utilization trends are also beginning to exhibit themselves for adult patients in advanced systems
where CT scans have been readily available for
many years (Levin, Menoch).
Part of what has driven increased use of
imaging can be attributed to increased availability and practice in high-liability environments.
While there is limited peer-reviewed data to
suggest a correlation between availability of
imaging in-department and utilization rates,
links between liability concerns and utilization
have been demonstrated (Smith-Bindman).
fig. 1: ED design with x-ray immediately adjacent to triage
TABLE 1 – Treatment Stations Required to Support Table 1 —
Diagnostic Imaging by Imaging Demand
ED #1
ED #2
ED #3
Number of Annual Imaging Cases
15,000
15,000
15,000
Imaging Turnaround Time
48 min.
36 min.
20 min.
12,000 hrs.
9,000 hrs.
5,000 hrs.
Total Care Time
ED Treatment Stations Required
to Support Imaging Demands1
1.8
1.4
0.8
stations stations stations
1. Assumes 75% exam room occupancy target
All images ©2013 Cannon Design

2. TRIAGE
TREATMENT
IMAGING
TREATMENT
TREATMENT
TREATMENT
TREATMENT
fig. 2: Imaging Location in High Volume ED
fig. 4: CT Scanner Immediately Adjacent to High-Acuity Zone
TABLE 2: Cost Analysis of Imaging Turnaround Times
ED #1
ED #2
ED #3
TABLE 3: ED Minimum Imaging
Volumes By Modality to Justify
In-ED Imaging Investment
MODALITY
Stations Required to Support
Imaging Costs
1.8
stations
1.4
stations
0.8
stations
€3,375/m2
€3,375/m2
13.3 m2
13.3 m2
13.3 m2
Costs Attributed to Imaging
Turnaround Times
€80,798
€62,843
€35,910
Fixed X-ray
Standard
Requirement
Portable X-ray
Standard
Requirement
Portable
Ultrasound
Standard
Requirement
~ 13,000
MRI
~ 4,400
€3,375/m2
Recommended Treatment Station Size
RECOMMENDED
TRESHOLD
VOLUME
CT
DESIGN & CONSTRUCTION COSTS
Average ED Design & Construction Costs
STAFFING COSTS
Total Care Time
12,000 hrs.
9,000 hrs.
5,000 hrs.
Annual Care Hours / RN FTE
6,240 hrs.
6,240 hrs.
6,240 hrs.
RN FTEs Required to Support
Imaging Turnaround Time
1.92
1.44
0.80
Annual RN Salary
€70,000
€70,000
€70,000
Annual Nursing Labor Costs
Required to Support Imaging
Turnaround Time
€134,400
€100,800
€56,000
1
1. FTE = Full Time Equivalent
The Case for In-ED Imaging
Planning for In-ED imaging begins with
developing the business case for why investment in such expensive technologies will
enhance performance, be it clinical quality,
operational efficiency, financial performance or
any combination of the three. Table 1 demonstrates the impact of imaging turnaround times
on overall ED performance.
Looking at the cost of construction of unnecessary capacity and annual staffing costs to
support patient care, the case for developing
design solutions to reduce imaging turnaround
times is clear. Building on the information in
Table 1, Table 2 further explores the business
case for in-ED imaging services.
Based on the information presented in
Table 2, an investment in an in-ED x-ray unit
would achieve break even on the investment
within 2-3 years of implementation, while a CT
scanner would break even on the investment
within 5-7 years, depending on the technology
purchased.
Other studies have looked at the cost effectiveness of use of advanced imaging modalities as a part of the ED evaluation phase as a
strategy for reducing the overall cost of care.
For example, use of coronary CT angiography
in the ED as a part of an in-ED cardiac rule-out
pathway has been shown to reduce overall
length of stay for low-risk chest pain patients
while also significantly reducing the total cost
of care for the patient encounter (Goehler). In
situations such as this, the investment in an

3. Table 4 – ED Minimum Imaging Volumes By Modality
to Justify In-ED Imaging Investment
SPECIAL PATIENT
POPULATION / DESIGNATION
Paediatrics
X-RAY
US
CT
MRI
X X +/-1
Trauma
X X X
Acute Stroke
X X -2
+/
Chest Pain Center
X
X3
1. Frequent use of CT in the paediatric population is a topic of much debase in EM. As of the time of this publication
consensus on In-ED CT except for high-volume / high-acuity paediatric centers does not exist.
2. Early studies at advanced academic medical centers are indicating benefit of early MRI in acute stroke patients,
As of the time of this publication consensus on the value of in-ED MRI does not exist.
3. Studies investigating use of coronary CT angiography as a part of a rapid “triple rule-out” in low risk patients
is showing benefit. This requires advanced CT technology, typically 64-slice dual source scanning capability of better.
in-ED CT scanner could yield a quick return on
the investment in the technology.
Imaging Modalities to Consider
Selecting the proper imaging technologies
can have a direct impact on speed to diagnosis,
initiation of definitive management and overall
length of stay in the ED. The selection criteria
for what imaging to include within the borders
of the ED should, at a minimum, include the
following:
1. Annual imaging volumes (by modality)
performed in the ED
2. ED acuity and special patient populations
3. Distance of ED from main diagnostic
imaging services (immediately adjacent,
distant, remote)
4. Availability of diagnostic imaging staff
24/7 or on-call
5. Potential impact on total cost of care
6. Annual ED Imaging Volumes
The addition of diagnostic imaging technology in the ED is no small investment.
Because of this investment requirement, it
is important to consider whether or not the
demand for imaging services justifies the
investment. While there is no industry-wide
benchmark for imaging volumes that justify
investment in imaging, this author considers the
information in Table 3 as a useful guideline.
ED Acuity and Special
Patient Populations
As EDs develop more and more specialty
services, the speed to diagnosis and definitive
management becomes evermore important.
Similarly, as patient acuity levels increase in
the ED, it can be expected that more and more
demand for imaging services will develop. With
this understanding in mind and based on current
and future standards of care, this author considers Table 4 to be a useful guideline for in-ED
imaging planning.
Distance of ED From Main Diagnostic
Imaging Services
Studies analyzing the root causes of
delayed ED imaging have indicated that order
processing and patient transport times, along
with imaging location, can all impact imaging turnaround times. A study of three urban
Canadian EDs demonstrated that turnaround
times for plain x-ray studies were shortened in
the ED with an imaging unit within ED, while
turnaround times were over 50% longer when
the x-ray unit was located remote to the
ED (Worster).
Availability of Diagnostic Imaging Staff
24/7 or On-Call
Staffing the imaging areas of the ED is
another important consideration for in-ED
imaging services. Clearly, a CT scanner in the
ED is of no benefit if there is no staff to run it.
Once an imaging modality is located within the
borders of the ED, it is expected the service will
be available 24/7 through either an in-house or
on-call staffing model.
Potential Impact on Cost of Care
Throughout this article, examples of how
diagnostic imaging has impacted the overall
cost of care have been presented. Bending the
cost-curve of emergency care and the total cost
Figure 3 – X-ray Immediately Adjacent to Triage
of care are important considerations that can
be meaningfully impacted by careful imaging
planning in any ED design. For example, selecting advanced CT technologies with subsequent
elimination of oral contrast preparation for
abdominal CT scans has shown to reliably
decrease length of stay by as much as two hours
or more without compromising quality (Levenson, Hopkins, Hlibczuk, Anderson).
Designing the ED for Optimal
Imaging Services
While previous ED designs typically centered on placing in-ED imaging services deep
within the ED and clustered together, newer
designs are experimenting with decentralization
of imaging services, placing each modality closest to its area of greatest demand. This said, as
illustrated in Figure 1, extremely large ED (annual census > 100,000 visits) may benefit from
centrally locating in-ED imaging relative to all
treatment stations by reducing travel distances
for patients and staff.
Varying the location of the imaging modalities within the ED can have a significant impact
on overall speed to imaging and length of stay
for all but the largest EDs. One ED that moved
its fixed x-ray unit from deep within the ED to
be adjacent to triage noted a 25% reduction in
length of stay for patients requiring x-ray studies (Horton). The logic of this design approach
is that lower acuity, ambulatory patients tend to
rely on the fixed x-ray unit, while higher-acuity

4. patients tend to receive a higher number of
portable x-rays in many EDs. Figure 2 demonstrates an ED design depicting a decentralized
imaging model with x-ray located proximate
to triage and lower acuity areas while CT is
located closer to the trauma bays.
Figure 1 shows an ED design with x-ray immediate adjacent to triage. This design solution
creates a patient flow that, where clinically-acceptable, allows the triage team to identify and
order the appropriate imaging study with the
patient receiving the x-ray prior to being placed
in a treatment station with a resulting decrease
in travel distances for the patient and staff.
Figure 4 illustrates an ED design with the in-ED
CT scanner located immediately across the
corridor from the major resuscitation stations,
reducing travel distances for the most criticallyill patients receiving care in the ED.
Portable imaging technologies have also
been shown to add value and should be planned
for appropriately. A 2010 Canadian study
assessed the impact of a portable CT scanner
in rural community hospitals linked to larger
referral center via a tele-stroke program resulted
in increased ability to deliver thrombolytics
to patients presenting with an acute ischemic
stroke (Shuaib).
When planning for portable imaging modalities, the primary concerns in ED design are
proximity and size. First, storage space for the
portable units should be in close proximity to
the staff using the technology and the patients
most frequently requiring the corresponding
imaging study. Second, ED treatment stations
should be designed large enough to accommodate entry of the portable imaging technology
into the room with the ability to easily access
the patient from at least three sides.
Other important ED design considerations
with respect to imaging focus on ensuring
imaging staff have adequate workspace in
proximity to where imaging services will be
performed. Similarly, equipment necessary
to process images should be immediately
adjacent to where imaging studies will be performed to reduce overall staff travel distances
and delays in study turnaround times. Equally
important, locations where ED physicians and
staff can view images should be readily available throughout the ED. This is most easily
accomplished by ensuring adequate viewing
monitors or, more recently, through the use of
high-resolution portable tables with wireless
connection to the imaging viewer.
An important non-facility design consideration is how linking EDs across a community can help reduce overall utilization of
imaging modalities, particularly for patients
being seen in multiple EDs or having multiple
visits for the same complaint. One community developed a health information exchange
that allowed all EDs to access the results of
imaging studies performed at other EDs in the
community. Access to previously-completed
imaging studies resulted in a 64% decrease in
repeat imaging studies for patients complaining of back pain (Bailey). Similarly, designing
ED imaging services to support image import
capabilities for patients being transferred to
another ED for ongoing management has been
shown to reduce reimaging (Bamberg,
Sodickson). This would have the obvious
benefit of reducing unnecessary radiation
exposure and lowering the total cost of care.
Figure 5 illustrates the design of a common
imaging view room that can support both inhouse and uploaded images.
Summary
Through careful planning, business case
development and design, EDs can be developed to support best-in-class design features
while enhancing the standard of care, improving overall efficiency and productivity of the
ED, lowering length of stay and reducing the
cost of care for multiple patient groups. Facilities planning new, renovated or expanded EDs
are wise to carefully consider how diagnostic
imaging will evolve and, based on this, what
imaging should be considered for inclusion
within the physical borders of the ED.
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Reprinted with permission from EPi Fall 2013