Patient-Centered Radiology

January 2017

​Safety First at University of Colorado Hospital

In radiology, the gold seal of approval is accreditation as a Diagnostic Imaging Center of Excellence (DICOE). This designation, awarded by the American College of Radiology, recognizes best-quality imaging practices that emphasize efficiency, safety and quality. 

The radiology department at University of Colorado Hospital is one of just 54 in the country to have achieved this status. Over the last year the team has developed three multidiscplinary quality and safety initiatives that show they have earned their place as one of the top radiology centers in the country.

Jim Borgstede, MD​, vice-chair of radiology at UCH, explained that the patient is at the heart of each initiative.

“We want to provide safe, effective and efficient exams for our patients, and reduce the chance of delays,” he said. “Each of these initiatives show that we are committed to patient-centered radiology.”

Improving magnetic-resonance safety

The first initiative focuses on improving the safety of magnetic resonance imaging. Justin Honce, MD​, assistant professor of neuroradiology, (pictured on right) explained that most people are not aware of the dangers of MR scans.

“MR safety is a complex topic,” he said. “Within the MRI suite patients are exposed to a number of different electromagnetic forces. Each of these carries separate risks, such as heating or burns, damage to or movement of implanted devices and, in rare cases, even arrythmias or seizures. The use of intravenous contrast in patients also brings its own set of risks. We developed the MR safety program to address these issues.”

Since the program’s inception in 2015, the focus has been on patients fitted with internal devices, who comprise 10–15% of the patient population.

“The challenge in preparing these patients for an MR scan is knowing which device they are fitted with and whether they can be scanned safely,” Dr. Honce said. “We recently incorporated MagResource, a device database tool, which dramatically increased the speed and accuracy with which we can obtain the information we need.”

The team, which includes MR-specific schedulers and lead technologists, has also improved the way the scheduling team and MR technologists coordinate imaging for these patients, to reduce the chance of accidents or of patients being sent home because of devices the team didn’t know about. But obtaining device-specific information was only the first step in providing quality care for this population.

“These patients also require a lot of coordination between the referring physician, the patient and the MR team, with appointments before and after their exam to check their device settings,” Dr. Honce explained. “In the past we had patients come in who were not prepared and unfortunately we had to delay their exams.”

To improve the patient experience and the overall efficiency of the department, Dr. Honce and the MR Safety Initiative team identified a set of common devices—vagus nerve stimulators, deep brain stimulators and programmable shunt valves—and created the role of “device champion” for each device.

“Device champions follow the patient through the process, making sure they have all the right appointments and calling the patient to ensure they attend the right appointment at the right time,” Dr. Honce said.

Alongside these process improvement efforts, Dr. Honce and the team also improved their MR safety education by expanding their intern orientation and providing focused training for staff who work with intraoperative MRI, such as the anesthesia and neurosurgery teams.

Improving magnetic-resonance quality

The second initiative, MR Quality, focuses its efforts on improving image quality, which is also key to patient-centered care in radiology. The team, led by Sajal Pokharel, MD, PhD​, assistant professor of radiology at UCH, worked to optimize MR protocols and reduce scan times to benefit patients and improve overall efficiency. The team also provided education to residents and technologists, further improving the patient and provider experience.

Optimizing the radiation dosage for CT scans

The kernel of the third initiative, CT dose optimization, began in 2011 when Dr. Borgstede worked with the American College of Radiology to set up a national CT dose index registry. This registry required radiology departments to upload dose measurements for each exam to a national database. This data was then used to create quarterly reports. Though it started with just eight other institutions across the country, the registry now receives data from more than 24 million exams annually, from 1200 imaging sites.

Ann Scherzinger, PhD​, is professor of radiological science and chair of the physics section of UCH’s radiology department. She explains that for the last few years UCH has been conducting independent studies comparing their data to the national registry.

“In 2015 we noticed that our doses were at the high end on a number of abdominal studies, compared to the national average,” she said. “In order to optimize patient safety, we needed to find out what was causing that.” With a multidisplinary team including physician leader Thomas Suby-Long, MD​, who is an assistant professor of radiology, along with the manager of CT and a CT radiology quality specialist at UCH, the team discovered that one area of opportunity lay with how the patient was positioned in the CT scanner.

“Originally, technologists were taught that they had to center the patient perfectly in the middle of the ‘donut’ of the scanner,” Dr. Scherzinger said. “This was normally done by doing two x-ray images: one from the top and one from the side, so you could see whether the patient was centered correctly.”

“Over time this approach fell from favor due to fears the two x-ray images created unnecessary radiation. This led to people skipping the second image, with the consequence that it was difficult to determine whether the patient was centered correctly.”

However, the position of the patient is critical when it comes to radiation dosage for modern scanners with sophisticated dose-reduction capabilities. Dr. Scherzinger and the team performed several phantom studies to confirm this, using plastic objects in the scanner to simulate the patient’s body. This allowed for experimentation without risk to the patient.

“As we moved the objects around we determined that the location of the patient did indeed affect the dosage,” she said. “Further, the systems that scanners use to adjust the radiation—dose modulation techniques—don’t work correctly when the patient isn’t centered.”

When UCH reintroduced the two initial “scouting” x-rays for positioning into abdominal imaging scans, they managed to achieve an overall dose reduction of 51%, proving that including the additional scout led to far less radiation exposure.

A commitment to patient-centered radiology

For Dr. Borgstede, the ongoing CT dose optimization initiative is a success because the lower dose was achieved without degrading the diagnostic quality of the images.

“We were not simply trying to drive the dose down,” he said. “Dr. Scherzinger’s work has shown that we are able to optimize the dose without reducing quality.”

Each of these initiatives demonstrate that the radiology department at UCH is leading the way in patient safety, patient satisfaction and examination quality. Dr. Borgstede believes this is only possible by putting the patient at the heart of everything they do.

“Everyone, from our leadership to our process improvement team to the sincere work of our physicists, technologists and radiologists, is dedicated to patient-centered care,” he said. “Our radiology department is at the cutting edge, and to large extent that is due to the caliber and integrity of our team.”