The Role of Teleradiology in Interpretation of Ultrasounds Performed in the Emergency Setting

Аннотация

Abstract

Background: Teleradiology has become an important tool in the field of emergency medicine, particularly in the area of emergency ultrasound interpretation. In emergency situations where time is of the essence, rapid diagnosis and treatment can mean the difference between life and death. Teleradiology is an innovative alternative to augment the staffing and fill the gaps of the on-site radiology personnel in emergency departments of the hospitals or during off-hours.

Aim: To assess the impact of Teleradiology in Emergency Ultrasound interpretation.

Methods: A retrospective study is carried out between January to December 2022 for a cohort of 33,616 patients from 86 hospitals across the United States. The study involves radiological interpretations of 37253 Ultrasonograms (USG) performed in the emergency setting by American Board Certified Radiologists empanelled by a teleradiology service provider, headquartered in Bangalore, India.

Results: The telehealth model proposed in the study was seen to provide timely and quality reporting of 37253 scans of patients with a mean turn-around-time (TAT) of 35.71 minutes 95% CI (35.50-35.91).

Conclusion: Our study demonstrates that a structured telesonography program with defined protocols for image capture, transmission and clinical communication can allow for successful immediate reporting of ultrasound examinations in the setting of emergency care.

Полный текст

Introduction

Teleradiology epitomizes healthcare innovation and efficient healthcare delivery, and represents a success story within the wider field of telemedicine [1]. This rapidly expanding field involves the transmission of radiological images from one location to another for interpretation by a radiologist [2]. It is an indispensable tool in the field of emergency medicine, significantly improving patient care. The value of prompt interpretation and reporting of radiologic examinations by a teleradiologist in the evaluation of specific emergent complaints renders it a significant part of the emergency medicine diagnostic paradigm [3].

A notable escalation in emergency cases within emergency departments (EDs) has been observed over the past couple years, strongly associated to population growth, and further heightened during the COVID pandemic [4]. Emergency departments are also vulnerable to be crowded in catastrophic disasters such as earthquakes, tsunamis, cyclones, urban floods etc [5]. According to National Hospital Ambulatory Medical Care Survey: 2020, the total number of visits to emergency departments of the hospitals in the US was 131.3 million [6] which is a matter of concern. In India, a study conducted by the NITI Aayog in 2021 reported the percentage of emergency and injury cases to be 16% of all patients presenting to a health facility and 19%-36% of admissions in district hospitals annually [5]. Further to this, a report released by Department of Emergency Medicine, AIIMS, on Emergency and Injury Care at Secondary and Tertiary level centres in India revealed that the number of beds available at emergency departments to cater to the emergency patients, represents only 3 to 5 % of the total beds available in the country [7]. With a yearly rise in the number of people who visit emergency departments (EDs), nearly half of all EDs operate at or exceeding their capacity. This trend is very concerning and needs to be addressed [8]. Moreover, there is an acute shortfall of physicians specially radiologists i.e., about 22,000 radiologists for a large population of over 1.2 billion, resulting in a skewed ratio of 1:100,000 [9]. Considering the severity of trauma, stroke and other critically ill patients presenting to the emergency department of the hospital, delays in diagnosis and treatment can lead to serious consequences for patients. The timely and accurate interpretation of the patients’ imaging is pivotal. But the availability of in-house trained radiologists is limited in emergency departments, particularly after hours or on holidays. The challenge is to work towards efficiency and quality despite the rising workload and the shortage of medical personnel [10]. Under such circumstances, teleradiology is an obvious alternative to augment, assist, and fill in the gaps of the on-site radiology personnel in order to fulfil the rising demand for imaging in trauma and acute illnesses in an emergency setting with limited radiology workforce [8].

Emergency ultrasound is a diagnostic imaging technique that utilizes high-frequency sound waves to create images of internal organs and structures in the body [12]. It is a fast and non-invasive way to evaluate a wide range of clinical conditions, including trauma, abdominal and pelvic pain, inflammatory conditions such as appendicitis and cholecystitis, acute kidney dysfunction, abscess, complications of pregnancy, complications of organ transplants etc [13]. Doppler ultrasound is a real-time imaging technology which plays pivotal role in emergency radiology for quick evaluation of vascular conditions and blood flow. It makes it possible to identify potentially fatal conditions such deep vein thrombosis (DVT), arterial blockages and insufficient organ perfusion. By diagnosing vascular damage, it facilitates timely surgical intervention in trauma cases [14].

The major benefit of teleradiology in emergency sonography is not just the ability to provide timely diagnosis and treatment but also providing adequate after hour and specialist coverage including support for onsite ultrasound technologists/sonographers. In addition, teleradiology in emergency ultrasounds can also lead to cost savings for hospitals and patients [15]. The benefits of teleradiology for patients have been well documented by several studies [1, 11, 16, 17] and the current study aimed to evaluate the benefits of teleradiology in emergency ultrasonographic interpretation.

The advent of digital imaging technologies, Picture archiving and communication systems (PACS) and radiology information systems (RIS), high-speed internet connections and artificial intelligence have further improved the value proposition of teleradiology in providing timely radiological services under emergency settings, even to remote and underserved areas [11, 18, 19]. Moreover, stringent service level agreements between the hospital and the teleradiology service guarantee very quick report turnaround, which is advantageous to the patient and the attending emergency physician. The standard for clinical service in the field of emergency care has thus been enhanced thanks to teleradiology [1, 20].

Aim The purpose of this retrospective study is to evaluate the role of teleradiology in outcomes of ultrasounds performed on a cohort of patients in the emergency settings.

Methods

A retrospective study was carried out between January to December 2022 for a cohort of 33,616 patients from 86 hospitals across the United States. The study involves analysis of radiological interpretations of Ultrasonograms (USG) performed in the emergency setting, by American Board Certified Radiologists empanelled by a teleradiology service provider, headquartered in Bangalore, India. The DICOM static images as well as the cine-series of the ultrasounds of the patients were uploaded onto the telereporting workflow platform “RADspa”, a cloud-based Radiology Information System (RIS)/ Picture Archival and Communication System (PACS) system over a high-speed internet connection. In addition to uploading the images, the technologists at the hospitals also provide their observations in the form of a worksheet submitted along with the images. The worksheet is typically a combination of an annotated graphic image with measurements and free text comments. The images (static images and cine-series) and worksheets are reviewed by the radiologists and the reports were transmitted back to the hospitals over the same workflow platform, as well as conveyed verbally/telephonically in cases with critical findings. Other information such as prior images and reports, patient clinical and surgical history records, etc. are also uploaded to the RIS so that they were available to the radiologists along with the images.

A breakdown of studies for different procedures performed in the emergency setting was conducted. The mean reporting turn around time (TAT) from the time when the DICOM images of emergency ultrasound studies were received in the worklist up until the reports were uploaded in RADspa or verbally communicated to the referring physician was calculated. Approval has been taken from the institutional review board for this retrospective study.    

Results

A total of 37, 253 USG scans of 33,616 patients from 86 hospitals across the US were evaluated in this study. The hospitals were categorized on the basis of bed size and number of images received (Table 1).

Among all hospitals under study, 28 hospitals had in-house technologists to perform ultrasonography scans for the patients, out of which 4 hospitals had on-call technologists on weekends. 51 hospitals had on-call technologists while in one hospital, radiology residents report ultrasonography cases. In six hospitals, technologists do not perform sonograms after 11pm.

In a teleradiology practice, there are three ways by which technologists communicate and provide brief description of the cases to the teleradiologists. The technologists create worksheets with case observations and upload in the RADspa either as pdf or jpeg file or may convert them into DICOM or may write down their comments or notes directly into the textbox available in RADspa. During our study, out of 37,253 USG scans, the technologists had provided notes for 27,138 (72.84%) cases and for rest of the cases, worksheets were attached.

The information about the demographics such as gender and age of the patients was also loaded into the cloud-based server. Out of 33,616 patients in our study, 70.56 % were females and 29.44% were males. The mean age of the patients was 40.95 years 95%CI (40.73-41.17). The maximum number of patients in the study belonged to age group 21-40 years (Figure 1).

To help diagnosis and treatment decisions, USG scans of different body parts were performed on the patients (Table 2). Among different procedures performed, Lower and upper extremities USGs comprised 26.28% (9792), abdomen USGs 18.62% (6937), obstetrics 17.41% (6488) and pelvis 15.62% (5820). Out of 33616 patients, 9496 cases had followed up with Computed Tomography (CT) scan also.

Teleradiology services were provided to the patients under different clinical situations. Patient clinical texts were categorized based on patient presenting symptoms and analysis was done using a systems-based approach (Figure 2). The majority of presenting symptoms were categorized as; reproductive (35%), gastrointestinal (31%), cardiovascular (9%) and musculoskeletal (6%). Other categories, shown in figure 2, make up smaller proportions of the overall study cohort presenting symptoms.

Cine-series of 4025 patients were also uploaded into the cloud server for interpretation by teleradiologists. Out of 4025 cine-series, 1731 (43%) were done for reproductive system related issues, 1048 (26.03%) for gastrointestinal system related problems and 655 (16.27%) for cardiovascular system issues (Figure 3).

In our study, a total of 1262 cases had undergone doppler ultrasound. Out of these, 569 cases having clinical history of scrotal or testicular pain, swelling, torsion and hydrocele underwent scrotal Doppler. Further 497 cases having cyst, suspected ovarian torsion, pelvic pain, cramps, vaginal bleeding during pregnancy, post-menopausal bleeding, lower abdominal pain had pelvic doppler. Additionally, 152 patients with numbness, vertigo, slurred speech, syncope, CVA, transient ischemic stroke and stenosis underwent carotid Doppler. 28 patients with abnormal gallbladder, liver or spleen, hepatic encephalopathy, liver failure, cirrhosis, hepatic vein thrombosis, liver transplant history underwent liver doppler while 16 cases with renal failure had renal Doppler (Figure 4).

The mean reporting TAT for all emergency ultrasound studies was 35.71 minutes 95% CI (35.50-35.91).

All of the USG scans were peer reviewed under quality assurance (QA) program to assess diagnostic accuracy and clinical performance. Out of 37,253 USG scans, 99.9 % studies showed accurate and concurrent interpretations. Only 39 (0.1%) studies showed discrepancies. Among these 39 cases, majority of the cases (24) had non- clinically significant discrepancies while 15 were clinically significant ones.

Discussion

Emergency care is the provision of immediate interventions required to prevent death and disability, wherein delays over hours may worsen prognoses or reduce the efficacy of care [21]. With the development of emergency radiology as a distinct radiology specialism, a unique set of expertise is essential to diagnose critically unwell or traumatized patients, promptly and accurately [11]. Teleradiology is an innovative solution which provides quick interpretation of imaging and accurate diagnose of critically injured or ill patients requiring immediate resuscitation, intensive care, or emergent surgery, allowing emergency physicians to make informed decisions about patient care and treatment plans. Further, the emergency teleradiology model proposed in the study, where night-to-day teleradiology services are leveraged i.e. emergency scans performed at night in the US can be reported from India during the day by appropriately certified radiologists, and vice versa, could be a front-line driver in healthcare. There has been a lack of emergency radiology subspecialty training or dedicated emergency radiology positions.  A number of emergency radiology and medicine societies, namely, the Society of Emergency Radiology (SER) European Society of Emergency Radiology (ESER), American Society of Emergency Radiology (ASER), Society for Emergency Medicine India (SEMI), and Indian Society for Trauma and Acute Care (ISTAC) have been founded to promote exchange of best practices in the area and enable integration of clinical care and imaging [22].

The current retrospective study involves evaluation and interpretation of imaging of the emergency patients, transmitted from 86 hospitals across US. According to the information obtained from the Annual Survey of Hospitals (AHA), the total staffed beds in all U.S. hospitals is 919,649 [23]. The hospitals are broadly categorized on the basis of bed size as follows: a) Small hospitals: Fewer than 100 beds b) Medium hospitals: 100 to 499 beds c) Large hospitals: 500 or more beds. In our study, the hospitals were categorized on the basis of bed size and number of imaging received as shown in table1. The majority of the studies (79.7%) were transmitted by 54 medium size hospitals while 13% of the studies were transmitted by 3 imaging centers. Our study demonstrates that hospitals of any size may benefit from telesonography.

Telesonography may be effectively practiced in either model (in house or on-call technologist). Out of 86 hospitals, 28 hospitals had in-house technologists which helped in establishing better communication of results as compared to the hospitals having on- call technologists.

Of all USG scans, 17333 (35%) of studies were from patients presenting reproductive related issues, followed by 15653 (31%) gastrointestinal/biliary issues, 4295 (9%) vascular issues and 2952 (6%) musculoskeletal related issues which required immediate medical attention. Other smaller categories included 1531 skin related cases, 1398 studies of urinary system, 365 neurologic and 280 respiratory related problems (Figure 2). Hence, teleradiology in the realm of ultrasound covers the entire gamut of organ systems as well as clinical presentations to address emergent clinical needs.

The mean turn-around-time (TAT) is the time interval between when the DICOM images of emergency ultrasound studies were received in the worklist till the reports were uploaded in RADspa or verbally communicated to the referring physician / results sent to hospitals. The mean reporting TAT for all emergency ultrasound studies was 35.71 minutes 95% CI (35.50-35.91). Previously published study by Szabo et al reported the mean TAT for ultrasounds within the ED of a hospital system with in-house radiologists to be around 58.27 minutes [24]. The current study shows that mean TAT using Teleradiology is quite reasonable and satisfactory compared to the mean TAT for ultrasounds recorded by other published study with the on-site radiologist, thus displaying the impact teleradiology can have on patient care under the emergency setting.

Our study also demonstrates that static images of standard views accompanied by the sonographer’s observations in the form of a worksheet are adequate for the interpretation of ultrasound studies via telesonography in the majority of cases. Additional cine sequences can be used in complex cases to provide additional detail.

With reference to communication of findings, in the case of critical findings requiring immediate patient management, referring physicians were informed either by direct telephonic communication with the radiologist or the call centre team of the teleradiology service provider [25]. In our study, a total of 752 calls were made to communicate with the hospitals. Out of these, 49 direct calls were made between the radiologist and the referring physician while 70 calls were made by support staff to relate positive finding and 47 calls to communicate negative findings. Additionally, 619 calls were performed for the verbal communication of important findings to physician assistants at hospitals who ensured further actions.

Peer review plays an indispensable role in a radiology interpretation quality assurance (QA) program. A QA program is the most common method for assessing diagnostic accuracy and clinical performance. In our study, a very high accuracy (99.9%) was observed during the peer review process. Only 39 (0.1%) studies showed discrepancies. Among these 39 cases, 24 were non- clinically significant discrepancies while 15 were clinically significant ones. In a published study by Iyer et al (2013), 85.9% cases had concurrent interpretations. Some of the discrepancies analysed during peer reviewing in our study were under-reading, faulty reasoning, failure to provide appropriate differential diagnosis, overcall, typographical error, failure to consult prior imaging studies and failure to suggest further imaging or follow-up.

Conclusion

Teleradiology has become an important tool in the field of emergency medicine where time is of the essence, and rapid diagnosis and treatment can mean the difference between life and death. Many emergency departments do not have a radiologist on site to interpret ultrasound images, which can lead to delays in diagnosis and treatment. Under such circumstances, the deployment of teleradiology services can be a game changer with its ability to provide quick and accurate diagnoses, further leading to expedient and safer disposition of patients. Our study demonstrates that a structured telesonography program with defined protocols for image capture, transmission and clinical communication can allow for successful immediate reporting of ultrasound examinations in the setting of emergency care. The findings of the telehealth model proposed in the study seeks to provide a platform for constructing a similar telesonography model in developing countries of the world.

Table 1 Breakdown of hospitals on the basis of bed size and imaging

Hospital bed size	Number of hospitals	Number of cases
Small hospitals (Fewer than 100 beds)	22	1621
Medium-size hospitals (100 to 499 beds)	54	29692
Large hospitals (500 or more beds)	7	981
Imaging centres	3	4959
Total	86	37253

Table 2 Breakdown of studies for different procedures

Procedures	Number of cases
Venous Doppler (Lower Ext/ Upper Ext)	9792
Abdomen	6937
Obstetrics/ bio-physical profile	6488
Pelvis (non-pregnant female)/ Transvaginal /Endo-vaginal	5820
Gallbladder/Right Upper Quadrant /Appendix /Live/ Right Lower Quadrant	3965
Scrotal/Testicular/Scrotum Doppler	1977
Renal/ Retroperitoneal	1393
Breast	184
Carotid Doppler	152
Neck	115
Soft Tissue	79
Intussusception	69
Carotid Duplex	60
Groin	35
Chest	29
Urinary Bladder	24
Extracranial Arteries Both	19
Fistula graft	18
Head	18
Thyroid	18
Transplant Kidney	12
Other Procedures	49

Figure 1. Age group categorization of the patients

Figure 2. Distribution of cases based on patients’ clinical presentation and symptoms using a systems-based approach.

Figure 3. Distribution of cases with cine-series using a systems-based approach.

Figure 4. Breakdown of cases for doppler ultrasound