Emergency Teleradiology: Operations and Clinical Applications

1. Welcome to the
Emergency Teleradiology Workshop
Operations – Arjun Kalyanpur
Clinical Applications – M. Srinivasa Rao
3D postprocessing – Roy D’Souza
Reporting Standards and Quality – Carl Aschkenasi
Medicolegal - Leonard Berlin
Technology – Firoz Latif
Workflow - Srinivas

2. Emergency Teleradiology:
Operations and Clinical Applications
Arjun Kalyanpur MD
M. Srinivasa Rao, DNB
Roy D’Souza, MD

3. Rationale for Emergency
Teleradiology
• Global Radiologist shortages
– Most radiologists concentrated in metros
– Emergencies/remote areas most affected
– Catastrophic outcome of delay

4. Radiologist to Population ratios
US – 1: 10,000
Singapore – 1: 20,000
Japan – 1: 35,000
India - 1: 100,000
Bangladesh – 1: 1,000,000

5. Evolution of Emergency Radiology
• Increase in emergency imaging utilization
– Dependence on imaging for rapid DX
– Technical evolution of CT – speed,
resolution
– CT now the primary modality for
• Vascular occlusion
• GI bleed
• Perfusion imaging in acute setting
CJEM 2013;15(3):161-166

6. Operations
• Scale – Multisite, multiradiologist
• Smooth workflow and process in Virtual Environment
• Seamless Coordination/Communication
Between Hospital and radiologist
Between Coordinator and radiologist
Between radiologist and radiologist

7. The Team
• Operations Manager
• Coordinator
• IT
• Call center
• Radiologist
• Support team – Transcriptionist, Data entry

8. The Process
• Hospital- Telerad Image Transfer
• Case assignment workflow
• Review and Dictation process
• Communication of findings
• Peer Review
• Addendums and Errata

9. Concepts
• Turnaround time
• Critical Values
• Standard Protocols (Stroke , polytrauma)

10. Turnaround time
• SLA – based on clinical scenario
• Stroke – 15 min
• Stat – 30 min
• Inpatient, MRI – 60 mins
• As Low As Reasonably Achievable
• Mean and Outlier TAT
• Verbal communication for complex cases

11. Critical Values
• Life threatening condition
• Tension pneumothorax
• Ruptured Ectopic Pregnancy
• Physician to physician communication
• Documentation/Tracking

12. Standard Protocols
Stroke
Takes priority over all others (Time is brain)
15 – 10 mins
Multitrauma
Focus on traumatic findings
Prioritize review
Immediate communication

13. International Nighthawk Model
• Day-night time difference allows for
• Better performance – biorhythms
• Increased productivity
• Enhanced service levels
• Commensurate accessibility

14. Challenges
• Insufficient Clinical Data
• Large Image Datasets
• Spikes in volume
• Outages
• Evolving client expectations

15. Synergy between Teleradiology and
Emergency Radiology
• The greatest impact of Teleradiology has been in the
emergency radiology space
• Teleradiology is now an integral part of the delivery paradigm
for emergency radiology services
• The increasing adoption of teleradiology benefits the
subspecialty of emergency radiology by further enhancing its
relevance and giving it greater visibility

16. Dr. Srinivas Meka.
Sr. Consultant

17. Clinical applications
Emergency radiology or nighthawk coverage
American College of Radiology's 1999 survey. AJR Am J
Roentgenol 2005;185:24–35.
Emergency department image interpretation services at private
community hospitals. Radiology 2004;231:190–197.

18. Clinical Applications
Emergency radiology or nighthawk coverage:
 Trauma
 Stroke
 Acute Abdomen- stone, diverticulitis, AAA, SBO
 Acute Thorax – PE, Aortic dissection
 Sonography – Torsion, ectopic
 NM - VQ, GI bleed
 Pediatric Emergencies – intussusception, appendicitis

19. Trauma
1. Decrease need for transport
(Emerg Med J 2007;24(8):550-
552)
2. Rapid triage – aortic injury, burst
fracture
3. Vascular injuries

20. Stroke
 Shorten time to thrombolysis
 Early detection of subtle findings – dense
MCA, insular ribbon
 Immediate detection of contraindication
for thrombolysis – bleed, large infarct,
aneurysm, mass etc
 Early detection of complications –
herniation, hemorrhagic conversion of
bland infarct

22. Acute thorax
 Aortic dissection – Early diagnosis and
detection of complications
 Intramural hematoma- Atypical form of
aortic dissection
 Surgical management if ascending aorta
is involved.

23. Acute thorax
Pulmonary thromboembolism:
Rapid diagnosis
Identification of complications
Aid in early initiation of thrombolytic
therapy.

25. Acute abdomen:
Teleradiology aids in rapid and
accurate diagnosis of several
acute abdominal and pelvic
pathologies.
Helps in initiation of
appropriate therapy – Surgical
versus non surgical.

26. Acute abdomen
Rapid diagnosis of acute
appendicitis and bowel pathologies.
Identification of complications.

27. Bowel pathologies

29. Nuclear medicine
Extremely helpful in diagnosing acute
conditions such
VQ scan for PE.
HIDA scan for acute cholecystitis.
GI bleed scan

30. Vascular emergencies
 Aids in rapid diagnosis of
several vascular
emergencies.
 Aortic aneurysm rupture:
 Vascular injuries

31. Sonography
Teleradiology plays a major role
in diagnosing potentially life
threatening and organ salvaging
conditions with a quick turn
around time (TAT).

32. Role of Emergency Teleradiology
• Immediate image review and turnaround
• High report quality
– Comfort level with all imaging modalities
– Experience in all emergent scenarios
– Speak the language of the ER
– Peer review and QA

33. Continuing Education and
Training
Necessary in telerad environment
Continuous quality improvement
Knowledge update
Stimulate research

34. Research
 Research into quality and process,

35. Teleradiology helpful
Night radiology coverage
Shortage of manpower (radiologists).
Subspecialty reads.
Catering to rural and semi-urban areas.
Vacation coverage.
Second opinions.
For efficient radiology services.
Summary