In this new era of health care reform, hospitals are under pressure to cut costs and at the same time, improve patient outcomes. Manufacturers are working hard to design equipment and develop programs to cater to these new demands. The diagnostic imaging equipment both inside emergency vehicles and within the emergency department now allows for faster and more accurate diagnoses. Programs that leverage telemedicine and streamline physician communication are helping hospitals increase their efficiency and save money.

Ultrasound to the rescue
In early July, paramedics at Dallas/Fort Worth Fire Services in Texas had a patient in their emergency vehicle with an undetectable pulse, yet there was a rhythm on the monitor. The rhythm wasn’t enough to determine whether the patient’s heart was still contracting, so the team used their Samsung PT60A tablet-based ultrasound and were able to get confirmation. Once they got confirmation, they made every effort to try to resuscitate the patient.

“This is all to preserve the golden hour—give the patient definitive care from the time we make contact with them,” said Dr. Roy Yamada, EMS medical director. In the past, before the paramedics had the ultrasound, they had to call Yamada to ask whether they should start or stop resuscitation efforts. With the upgrade though, the team can also wirelessly transmit the ultrasound images through Trice Imaging’s mobile encryption and image management system to the receiving hospital in real-time so that hospital staff can better prepare for the patient’s arrival.

Samsung is currently conducting a trial to investigate this new technology and the full results will be released next year. So far, the ultrasound has been deployed in 91 callouts to diagnose trauma, internal bleeding, acute abdominal pain and cardiac arrest cases in the Dallas and Fort Worth metropolitan areas.

But for now, ultrasounds inside of the ED are still the most common way to diagnose patients. At the RSNA conference two years ago, Siemens Healthcare unveiled ACUSON Freestyle, the first-ever ultrasound with wireless transducers.

It‘s useful when a physician in the ED wants to perform a quick procedure, explained Jeffrey Bundy, CEO of Siemens Healthcare Ultrasound. Since there aren’t any cables, the physician doesn’t have to reposition that ultrasound to get better access to the patient.

Last month, Siemens released the 3.5 version of Freestyle that features improved needle visualization and a new user interface with a larger clinical image display. They also created a new mobile link application that connects the system to a Microsoft Windows tablet on a shared wireless network.

Bundy doesn’t know of any hospital with the system in an emergency vehicle, but he thinks it would be of great use. “I would imagine that in the small confines of that type of environment, having another cable draping across the fluid bags and everything else that’s connected to a patient on the way to the hospital having the wireless transducers would be an advantage,” he said.

Meanwhile, GE Healthcare released the dual-probe version of their pocket-size Vscan ultrasound in early August, which is designed to look like a flip phone. The company claims that it’s the only portable ultrasound on the market with two transducers in one probe.

“In the emergency department it’s all about being fast,” said Ajay Parkhe, general manager of primary care ultrasound at GE. According to GE, Vscan saves the physician time since they don’t have to change the probes and only takes 30 seconds to start-up.

Since most of the staff members in the department are not sonographers, GE designed the Vscan’s user interface so that someone without much ultrasound knowledge can use it. “If you’re not a sonographer, you can pick it up in 15 minutes and figure out the methodology,” said Parkhe.

GE has sold about 17,000 units globally and Parkhe believes that the pocket-sized ultrasound will become even more popular in the future, but he doesn’t think it will take over the larger console ultrasounds. Vscan is mainly designed for triage—when a patient comes into the ED with shortness of breath, the physicians can use it to determine whether their condition is serious or minor.

However, the console ultrasounds are preferred for the more complicated cases. “Once you come to the hospital, you want to do more complicated things—you need different probes and different measurement packages—and for that, you will have a place for the consoles,” said Parkhe.

CT in its prime
Even though there is a decline in overall imaging utilization right now, there appears to be an increase in imaging in EDs, according to a recent study published in the Journal of the American College of Radiology.

Researchers at Thomas Jefferson University used Medicare Part B Physician/Supplier Procedure Summary Master Files from 2002 to 2012 to analyze imaging rates. They found that CT use per 1,000 scans increased 159 percent.

CT first started out exclusively in the radiology department, but hospitals soon realized that the technology can serve an important role in their EDs, according to Siemens. It can be argued that many patients get admitted to the hospital because they need a CT scan.

Today, in most large hospitals, there will be a CT both in the radiology department and the ED.

Two of Siemens’ CTs — SOMATOM Definition Edge, which got FDA approval in 2012, and SOMATOM Force, which got approval earlier this year — have found a place in some hospitals’ EDs. Physicians in the ED are more likely to perform more image reconstructions than in other settings because they usually don’t have any information on the patient’s condition. The Definition Edge was designed with refined image reconstruction so it can provide the physician with more of that information.

Most CT take upwards of 10 seconds to image a patient but the Force is capable of performing sub-second scans. That generates better image quality when scanning patients who are unconscious or confused and aren’t able to follow breathing instructions. GE Healthcare’s Revolution CT, which received FDA approval in April, is another unit designed to diagnose challenging patients in the ED. It also reduces breath hold times because it can scan entire organs including the brain, heart, liver and pancreas in one .28 second rotation.

It can acquire a scan of the heart in one beat even at high heart rates because of its wide area 160 millimeter coverage detector and new cardiac protocols available on the GE’s Clarity user interface.
The system also has built-in software called SnapShot Freeze that can capture coronary motion independent of gantry rotation speed so the physician can image the heart motion free.

Changing protocol
The biggest challenge that the physicians at Beaumont Health System in Michigan face is the volume of patients that come into their ED. Over the past three months, they have seen a record high number of patients admitted.

“These volumes are going up, we’re seeing sicker and sicker patients and the hospital has been full for quite some time,” said Dr. Terry Kowalenko, chief of emergency medicine at Beaumont. “Obviously, we have a challenge of getting our patients who are admitted upstairs.”

In an effort to solve the problem, Beaumont is going to convert some of their office space into hospital beds and they are also working on creating a discharge lounge area so that patients won’t have to wait in their rooms for a ride.

Beaumont doesn’t know the reason why they have seen a recent increase in ED volume, but it’s not something that’s just isolated to their health system.

About 25 percent of patients who go to the ED don’t need to be there, according to a Medicare Payment Advisory Committee report from 2012. Since many of them don’t have primary care doctors, they are using the ED are their drop-in clinic.

In response to this issue, Philips Healthcare is working with hospitals to develop community paramedic programs. Hospitals are starting to leverage their paramedics and emergency vehicles to treat patients in their homes instead of transporting them to the ED.

“The model has traditionally been very binary, which is, you either get treated in a hospital or doctor’s office or you call someone to transport you to a hospital. There has never really been a reliable middle ground,” said Dr. Anthony C. Jones, vice president and chief marketing officer of patient care and monitoring solutions at Philips. “But the incurred cost of too many people going to the emergency department is problematic and hospitals are now being held financially accountable to manage people’s care and not just the treatment.”

The programs are designed to try to find the best way for each facility to combine Philips’ EMS products including portable defibrillators, ventilators and patient monitors with telehealth solutions to communicate information back to the hospital.

“We’re looking at it from the solutions side and the technology side and our customers are looking at it from the workflow, financial and care side to really figure out the right mix and how to better equip those paramedics and improve the movement of data from them to the hospital,” said Jones.

In October, Philips got FDA approval for two of their telehealth applications called eCareCompanion and eCareCoordinator. The first application, eCareCompanion, works as a patient portal where patients can answer questions to monitor their health and request measurements from their physicians. It can also connect to medical devices including blood pressure machines.

The second, eCareCoordinator, provides physicians with population health management by providing a daily review of each of their patients. They also have real-time access to health data including vital signs and blood pressure and the responses to their patients’ health questionnaires. “That technology gives us the ability to spot a problem sooner before it gets out of control,” said Jones. “If you can do that and deploy a paramedic to actually stabilize the patient and not transport them, it has tremendous cost savings.”

This approach is a major paradigm shift for the industry. Instead of focusing on how quickly they can transport a patient to the hospital, they’re now focusing on developing solutions to avoid the trip altogether. “That is really where the industry is looking,” said Jones.

Crushing wait times
Overcrowding in the ED often leads to longer wait times and more patient walkouts, but some hospitals are starting to implement a comprehensive communications platform called PerfectServe to curb that. The platform is used to alert key staff members in the hospital and EMS teams that they are needed when ED wait times get too high.

St. John Hospital and Medical Center in Michigan has an annual ED census that has risen 15 percent in two years to over 108,000 patients. In order to quell overcrowding, they developed ED-managed Clinical Decision Units (CDUs) that connected the ED and their inpatient services.

Patients cannot stay in the CDUs longer than 24 hours otherwise they will be billed as outpatients so it’s imperative that they have error-free clinical communication. To do that they implemented PerfectServe to make sure that any calls and messages for the physicians are sent to them based on their preferences and schedules. “What we have seen is that by speeding those communication cycle times, you’re not only able to improve throughput, but you’re able to reduce the number of patients who leave against medical advice and also increase the number of those who are being seen,” said Terry Edwards, founder and CEO of PerfectServe.

After implementing the program, the hospital was able to reduce the CDU length of stay for patients who were later admitted to inpatient beds by 40 percent and 10 percent for patients not admitted. Currently, more than 100 hospitals in the U.S. are using the program and about 70 are in the process of deploying it.

Edwards thinks that in the future, all hospitals will have some type of program in place to streamline communication. “As we start connecting these information systems with these communications systems, we’re able to make people aware of things that we couldn’t in the past,” he said. “By making them aware of the right things in the right way, they can take action and deliver better care.”

As the payment model shifts from fee-for-service to value-based, solutions that improve patient outcomes and satisfaction are going to become more popular.

“I think the health care systems and hospitals that are recognizing that they need to transform and continue to innovate and grow will all be adopting tools like this,” said Edwards.