Portable Wireless DR: Ready for Prime Time?
Portable wireless digital radiography (DR) has tried to muscle into the imaging market for three years. After some growing pains, systems have matured from clunky, barely usable iterations to sleeker units seemingly well-suited for the challenges of portable imaging. Are these new systems ready for prime time? What strategies are required to operationalize the investment? A pair of pioneers shares their experiences.
“Portable wireless DR is the first advance in x-ray since digital that is a game changer,” says Mary-Theresa Shore, MSM, RT, director of clinical operations department of radiology, at Massachusetts General Hospital (MGH) in Boston. In fact, Brigham and Women’s Hospital (BWH), also part of the Partners HealthCare network in Boston, recently revised its radiography equipment purchasing specifications to require wireless DR for all new purchases.
The reasons behind the enthusiastic acceptance of the technology correlate with the basics of radiography: image quality and efficiency.
At MGH, 85 percent of portable studies are chest exams, which are notoriously complex to interpret owing to anatomic challenges presented by bone, lung and soft tissues. Another factor is the increasingly minute diameter of inserted lines, which can be lost in the haze of multiple lines. “A study by Foos [et al in the September 2010 issue of Clinical Imaging] showed that providing the edge-enhanced companion view increases the diagnostic accuracy of radiologists and intensive care physicians to determine the position of tubes and lines, a common indication to obtain a portable chest radiograph in the intensive care setting,” says Florian J. Fintelmann, MD, a MGH radiologist.
The image quality improvement is critical in portable imaging, says Michael Delvecchio, RT, technical director of radiology at BWH. An initial preoperative chest x-ray for a surgical patient typically is acquired on a fixed DR system at BWH. But follow-up studies on patient floors use CR. “The image quality is not as crisp. Comparing daily films from the preoperative DR image to the post-operative CR exam can be challenging,” says Charles David Healy, RT, manager of inpatient diagnostic radiology at BWH.
“Portable DR standardizes image quality and eliminates the question of an actual finding versus image quality discrepancies,” he continues.
However, it might be 20 to 30 minutes before the images are available for radiologists and referring physicians, because the technologist needs to trek back to the department to expose the cassette. In the wireless model, images are transmitted directly from the detector to PACS, and they are available for physician review in less than four to five minutes, says Shore.
The second efficiency factor stems from the ability to immediately assess image quality on wireless systems. In a CR model, if a technologist clips a bit of anatomy or the patient moves, the problem is not recognized until the tech exposes the cassette in the department, which instigates a return trip to the hospital floor, where the nurse may or may not acquiesce to a second exam.
“With DR, the technologist can see the image at the bedside, which provides an opportunity to repeat the exam,” says Shore. On the plus side, it’s a potential efficiency gain as the return trip to the floor is bypassed. Shore and her MGH colleagues, however, recognize that the technology may be associated with an unintended consequence. The hospital plans to complete repeat analyses to ensure that the techs are not unnecessarily repeating exams to acquire better images. “Technologists understand that a second study doubles radiation exposure, but we plan to monitor it too,” she says.
The newest systems are easy to drive, stop, turn and park, says Shore. “We are going into rooms that are not very large, where a great deal is going on. Our objective is to get in and get out quickly without causing any issues for patients.” Current systems meet that bar. But no matter how sleek the model on the tradeshow floor looks, early adopters recommend a thorough test drive in the hospital environment to understand how the system travels and fits into various hospital rooms.
Parking is another consideration. The portable DR systems used at BWH require a parking space of approximately 12 square feet. “We worked closely with physician teams, particularly the thoracic surgeons, to convince them that we are a major player on their team,” says Healy.
The lobbying paid off, earning the portable systems a designated parking alcove complete with electronic power and connectivity to the thoracic unit. Parked in the alcove, the DR systems are safe from being bumped by stretchers, carts and other mobile equipment.
Previously, BWH had limited portable DR to the emergency department and realized high uptime and longevity. However, the unit only traveled along a 50-foot route on a single floor. Sending a unit to the hustle and bustle of hospital floors via a jam-packed elevator is analogous to an off-road venture. “We may not realize the same longevity with this use,” notes Healy.
Another problem with first-generation portable wireless DR concerned ergonomics. Early detectors weighed in at a hefty 10 to 12 pounds, which presented an unwieldy ergonomics issue for technologists. Newer detectors have trimmed down considerably, with weights in the six-pound range. Some replicate the configuration of a CR cassette, making for a more straightforward transition from CR cassettes to DR detectors. Others include a handle for easier carrying. Plus, techs may have been more prone to drop CR cassettes as they needed to carry eight to 10 cassettes. With DR, they carry a single digital detector.
Despite the more lightweight versions, MGH plans to evaluate the ergonomic implications of wireless portable DR. “Our technologists complete 40 to 50 studies in a shift. We want to avoid overuse injuries,” says Shore. Currently, the hospital uses a one-tech portable imaging model. Although nurses can assist with portable exams, MGH may explore the two-technologist model or pair technologist assistants with portable technologists.
The final items on the portable wireless DR checklist relate to the connectivity factor. “Nothing is quite plug-and-play,” says Shore, who worked extensively with the hospital’s wireless group to ensure connectivity, security and HIPAA compliance. The analysis paid off, as the group detected a few weak spots in specific buildings that will require additional bandwidth.
Similarly, the BWH team took its loaner unit for a thorough test drive across the entire campus, evaluating maneuverability and wireless connectivity.
Sites also need to assess the graphical user interface and RIS/PACS connectivity; workflow should be straightforward as technologists should not be hamstrung by a complex interface or navigating through multiple applications to transmit exams to PACS.
Portable wireless DR promises to provide image quality and efficiency improvements. However, a thorough assessment of wireless infrastructure, ergonomics and repeat studies are essential for a successful deployment.
“Portable wireless DR is the first advance in x-ray since digital that is a game changer,” says Mary-Theresa Shore, MSM, RT, director of clinical operations department of radiology, at Massachusetts General Hospital (MGH) in Boston. In fact, Brigham and Women’s Hospital (BWH), also part of the Partners HealthCare network in Boston, recently revised its radiography equipment purchasing specifications to require wireless DR for all new purchases.
The reasons behind the enthusiastic acceptance of the technology correlate with the basics of radiography: image quality and efficiency.
At MGH, 85 percent of portable studies are chest exams, which are notoriously complex to interpret owing to anatomic challenges presented by bone, lung and soft tissues. Another factor is the increasingly minute diameter of inserted lines, which can be lost in the haze of multiple lines. “A study by Foos [et al in the September 2010 issue of Clinical Imaging] showed that providing the edge-enhanced companion view increases the diagnostic accuracy of radiologists and intensive care physicians to determine the position of tubes and lines, a common indication to obtain a portable chest radiograph in the intensive care setting,” says Florian J. Fintelmann, MD, a MGH radiologist.
The image quality improvement is critical in portable imaging, says Michael Delvecchio, RT, technical director of radiology at BWH. An initial preoperative chest x-ray for a surgical patient typically is acquired on a fixed DR system at BWH. But follow-up studies on patient floors use CR. “The image quality is not as crisp. Comparing daily films from the preoperative DR image to the post-operative CR exam can be challenging,” says Charles David Healy, RT, manager of inpatient diagnostic radiology at BWH.
“Portable DR standardizes image quality and eliminates the question of an actual finding versus image quality discrepancies,” he continues.
The Efficiency Connection
The connection between image quality and efficiency is clear in the portable wireless model. In the conventional CR model, the technologist preps for rounds by stacking a cassette for each patient and traipses to the floor to acquire the studies, with most exams completed in minutes.However, it might be 20 to 30 minutes before the images are available for radiologists and referring physicians, because the technologist needs to trek back to the department to expose the cassette. In the wireless model, images are transmitted directly from the detector to PACS, and they are available for physician review in less than four to five minutes, says Shore.
The second efficiency factor stems from the ability to immediately assess image quality on wireless systems. In a CR model, if a technologist clips a bit of anatomy or the patient moves, the problem is not recognized until the tech exposes the cassette in the department, which instigates a return trip to the hospital floor, where the nurse may or may not acquiesce to a second exam.
“With DR, the technologist can see the image at the bedside, which provides an opportunity to repeat the exam,” says Shore. On the plus side, it’s a potential efficiency gain as the return trip to the floor is bypassed. Shore and her MGH colleagues, however, recognize that the technology may be associated with an unintended consequence. The hospital plans to complete repeat analyses to ensure that the techs are not unnecessarily repeating exams to acquire better images. “Technologists understand that a second study doubles radiation exposure, but we plan to monitor it too,” she says.
Details & Driving
One of the problems plaguing first-generation portable wireless DR was the poor driving experience. Systems were heavy and difficult to maneuver. With some, tires were insufficient and went flat.The newest systems are easy to drive, stop, turn and park, says Shore. “We are going into rooms that are not very large, where a great deal is going on. Our objective is to get in and get out quickly without causing any issues for patients.” Current systems meet that bar. But no matter how sleek the model on the tradeshow floor looks, early adopters recommend a thorough test drive in the hospital environment to understand how the system travels and fits into various hospital rooms.
Parking is another consideration. The portable DR systems used at BWH require a parking space of approximately 12 square feet. “We worked closely with physician teams, particularly the thoracic surgeons, to convince them that we are a major player on their team,” says Healy.
The lobbying paid off, earning the portable systems a designated parking alcove complete with electronic power and connectivity to the thoracic unit. Parked in the alcove, the DR systems are safe from being bumped by stretchers, carts and other mobile equipment.
Previously, BWH had limited portable DR to the emergency department and realized high uptime and longevity. However, the unit only traveled along a 50-foot route on a single floor. Sending a unit to the hustle and bustle of hospital floors via a jam-packed elevator is analogous to an off-road venture. “We may not realize the same longevity with this use,” notes Healy.
Another problem with first-generation portable wireless DR concerned ergonomics. Early detectors weighed in at a hefty 10 to 12 pounds, which presented an unwieldy ergonomics issue for technologists. Newer detectors have trimmed down considerably, with weights in the six-pound range. Some replicate the configuration of a CR cassette, making for a more straightforward transition from CR cassettes to DR detectors. Others include a handle for easier carrying. Plus, techs may have been more prone to drop CR cassettes as they needed to carry eight to 10 cassettes. With DR, they carry a single digital detector.
Despite the more lightweight versions, MGH plans to evaluate the ergonomic implications of wireless portable DR. “Our technologists complete 40 to 50 studies in a shift. We want to avoid overuse injuries,” says Shore. Currently, the hospital uses a one-tech portable imaging model. Although nurses can assist with portable exams, MGH may explore the two-technologist model or pair technologist assistants with portable technologists.
The final items on the portable wireless DR checklist relate to the connectivity factor. “Nothing is quite plug-and-play,” says Shore, who worked extensively with the hospital’s wireless group to ensure connectivity, security and HIPAA compliance. The analysis paid off, as the group detected a few weak spots in specific buildings that will require additional bandwidth.
Similarly, the BWH team took its loaner unit for a thorough test drive across the entire campus, evaluating maneuverability and wireless connectivity.
Sites also need to assess the graphical user interface and RIS/PACS connectivity; workflow should be straightforward as technologists should not be hamstrung by a complex interface or navigating through multiple applications to transmit exams to PACS.
Portable wireless DR promises to provide image quality and efficiency improvements. However, a thorough assessment of wireless infrastructure, ergonomics and repeat studies are essential for a successful deployment.