A Physician’s Perspective Lisa A. Laurent, MD Advanced Radiology Consultants Park Ridge, Illinois Fellow Institute of Medicine of Chicago Medical Director.

A Physician’s PerspectiveLisa A. Laurent, MD

Advanced Radiology ConsultantsPark Ridge, Illinois

Fellow Institute of Medicine of Chicago

Medical Director Body CT

Medical Director Ultrasound

Advocate Lutheran General Hospital

Park Ridge, Illinois

Unless otherwise indicated, all trademarks are owned by MEDRAD, INC. or licensed for its use.

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Current Situation

• Advocate Lutheran General Hospital – 638 bed hospital– 5 CT suites– 22 technologists (all registry certified)

• Upgraded 16 GE slice to 64-slice GE Discovery™ CT750 HD

• Commenced implementation of Adaptive Statistical Iterative Reconstruction (ASIR)

• Located in busy Level I ED trauma center

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Implementation Issues

• Creation of contrast protocols for the new scanner with ASIR technology

– How do you create protocols as you change radiation dose?– How do you increase image quality?– What are tools to ensure continuous improvement?

• Partners in development– Contrast company– OEM scanner – Injector company

• Identified PE studies as a potential challenge

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CT Pulmonary Angiography (PA) Challenges

• Gold standard for diagnosis of pulmonary embolism• High percentage of sub-optimal diagnostic studies

– University of Pittsburgh Medical Center 27%*– University of Albany 30%†

– Kelly AM, Patel S, Kazerooni EA. CT pulmonary 24%angiography for accurate pulmonary embolism in ICU patients clinical experience (abstr.) Radiology. 2002; 225(p):385

• Sub-optimal studies have been shown to result in additional*– Imaging studies– Medical therapy – Hospital admission

*A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism.  Christopher R Deible MD, PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis MD1. Society of Thoracic Radiology 2008. E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.†Patient Outcomes and Resource Utilization for Emergency Department Patients with Suspected Pulmonary Embolism and Initial Chest Computed Tomography Angiography Studies Deemed Suboptimal for Interpretation; Annals of Emergency Medicine; VOLUME 54 NUMBER SEPTEMBER 2009; Weinstein J, Burton J, Katz B/Albany Medical Center, Albany, NY

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P3T® PA Clinical Trial*

• “Higher percentage of exams ranked as diagnostic without limitation…”

• “Better contrast enhancement of pulmonary arteries…”

• Note: at a slightly higher contrast dose than standard scan protocol at 80 mL

*A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism.  Christopher R Deible MD, PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis MD1.  Society of Thoracic Radiology 2008. E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.

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Qualitative Assessment of CTs Obtained With P3T® vs Standard Protocol*

P3T® PA Results: Pulmonary CTA

(Lacomis, Deible, Federle) University of PittsburghPresented at Society Thoracic Radiology 2008, Submitted to AJR in 2010

• 60 patient (prospective and randomized design) study, ED patients suspected of PE

• 64-slice VCT (GEHC)

• Omnipaque 350 mg/ml

• August 2006 to March 2007

*Used by permission.

Advocate Lutheran General

Hospital Experience

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Implementation Plan

• Invest in Certegra™ software package from MEDRAD– P3T® PA – weight-based dosing software for PA– Connect.PACS™ Application– Manage.Report™ Application– Significant training plan

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P3T® Software

P3T® calculates the appropriate dose for each patient by computing custom injection protocols,

enabling personalized care and patient care while maintaining efficient workflow

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P3T® Software

P3T® calculates custom injection protocols as well as scan timing for each patient using 4 primary components• Patient and procedure data gathered by health care

personnel• P3T® algorithm for protocol generation• DualFlow technology (the simultaneous injection of

contrast and saline)• Use of a transit or timing bolus

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PE Exam Challenge and Process

• The challenge: to perform diagnostic quality PE exams in a consistent fashion for all patient body habitus types, regardless of age and clinical presentation

• The process: to implement P3T® Software– Retrospectively reviewed all adult PE studies performed since

May 1, 2011– Used software tracking processes– Determined best practices for coaching technologists, educating

radiologists, and developing a team approach to create total departmental engagement

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How Is This Analysis Made Possible?

• Data– Accurate– Accessible– Automated

• Connect.PACS™ Application – Point-of-care decision– Provides a way to retrospectively analyze data– Real-world proof as opposed to assumption

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Using the Data to Drive Results

Easily able to identify reasons behind PE limitations• Technologist adoption• Flow-rate—limiting issues• Contrast efficiency

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Using the Data to Drive Results

Building a Team

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Protocol Adherence: First 6 Weeks

May 4th May 11th May 18th May 25th June 2nd June 9th0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Other PE

Abd P3T

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Protocol Adherence: Last 6 Weeks

Sept 10th Sept 17th Sept 24th Oct 1st Oct 8th Oct 15th0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OtherPEAbdP3T

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PE Exam Analysis Breakdown

• 199 PE exams completed (May 1, 2011, through July 31, 2011)

• 23 exams deemed nondiagnostic (11.6%)– 14 of these exams, the technologist did not use P3T® (7.0%)– 9 nondiagnostic exams used P3T® (4.5%)

• 3 caused by motion artifact• 1 caused by the use of Isovue® 300 vs Isovue 370• 5 caused by flow-rate-limiting issues due to catheter restrictions

CT Chest Pulmonary Embolism Suboptimal Analysis

199 Total StudiesMay 1st – July 31st

110 with P3T 89 without P3T

9 Sub-Optimal 14 Sub-Optimal

23 Total Suboptimal Studies

45%55%

8% 16%

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PE Exam Analysis Breakdown

• 219 exams reviewed (August 1, 2011 through October 19, 2011)

• 17 exams deemed suboptimal (7.8%)– All exams used P3T® software

• Cross referenced Certegra™ data vs RIS• Data-mining capabilities identified that 8 of the 17 exams were

performed during a certain time of the day• Facilitated focused education and coaching to improve results

in the future

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Non-diagnostic/Suboptimal PE Exams

PE Exam Analysis Breakdown

• ALGH results and progress since May 1st Certegra™ implementation

Kelly AM et al UPMC Albany ALGHMay 1st to

Jul 31st

ALGHAug 1st toOct 19th

0%

5%

10%

15%

20%

25%

30%

35%

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Snapshot of Data

Gender Study Time Study Description Brand Concentration LotLoaded (mL)

Delivered (mL)

Female 2:54CT CHEST PULM EMBOLISM

Isovue 370 -- 96.51 95.43

Female 1:24CT CHEST PULM EMBOLISM

Isovue 370 -- 92.5 73.61

Male 21:00CT CHEST PULM EMBOLISM

Isovue 370 -- 96.51 95.44

Female 11:12CT CHEST PULM EMBOLISM

Isovue 370 -- 74.45 49.59

Female 5:00CT CHEST PULM EMBOLISM

Isovue 370 -- 100.61 73.35

Female 0:33CT CHEST PULM EMBOLISM

Isovue 370 -- 92.54 91.68

Female 11:53CT CHEST PULM EMBOLISM

Isovue 370 -- 74.55 73.14

Female 18:14CT CHEST PULM EMBOLISM

Isovue 370 -- 96.59 95.24

Female 1:12CT CHEST PULM EMBOLISM

Isovue 370 -- 120.78 119.45

Male 17:04CT CHEST PULM EMBOLISM

Isovue -- -- 92.54 90.78

Female 23:34CT CHEST PULM EMBOLISM

Isovue 370 -- 68.55 67.15

ACR Guidelines for Communication of Diagnostic Findings

Procedures and materials • The report should include a description of the studies

and/or procedures performed and any contrast media and/or radio-pharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere.

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Documentation Gaps

• Analysis of Documentation Accuracy– RIS (Manual Capture)– PACS (Manual Capture)– Injector (Automated)

• Methodology– Pulled 102 accounts and reviewed documentation across 3

different documentation techniques

Examples

Study Date Study Description A Loaded (ml) A Delivered (ml) RIS Volume RIS Volume Variance PACS Volume PACS Variance Saline in PACS8/14/2011 11:04 CT CHEST PULM EMBOLISM 71.49 70.14 200 129.86 51 19.14

Study Date Study Description A Loaded (ml) A Delivered (ml) RIS Volume RIS Volume Variance PACS Volume PACS Variance Saline in PACS8/28/2011 0:05 CT CHEST, ABDOMEN AND 150.55 149.75 97 52.75 97 52.75

Results of Documentation

• Deviation from Actual Injection Record

RIS Differential PACS DifferentialGreater than 5 mls 75% 22%

Greater than 10 mls 61% 14%Greater than 20 mls 35% 7%

Other Observations on Manual Data

• No Saline Delivery Information Captured

• No Flow Rate Information Captured

• Protocol Information Not Captured

Vision – Offer Closed Loop Contrast Dose Management

Ref Physician

Contrasthistory

HIS/EMRPHR

RIS- Pharma

cy- Billing

SpeechRecognition

PACS

Certegra

Stellant

CT scanner

Radiology

Hospital

ISI

ProtocolManagement

Reporting

ModalityUtilization and Analytics

DICOM

DICOM

HL/7

HL/7

MEDRAD Confidential, Internal Use Only

Appendix

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Pressure Related to Contrast Flow Rates with 22 g Catheters for CT Exams

1.06 1.31 1.37 1.57 1.66 1.69 1.79 1.8 1.9 1.9 1.91 1.97 2.23 2.33 2.42 2.62 2.850

50

100

150

200

250

300A Peak Pressure (psi)

PS

IFlow Rates and Pressures

Flow rates with Isovue® 300 concentration (mL/s)

Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco and none should be implied.

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Flow Rates and Pressures

Pressure Related to Contrast Flow Rates with 20 g Catheters for CT Exams

Flow rates with Isovue® 370 concentration (mL/s)

4.76 4.76 4.77 4.77 4.78 4.79 4.8 4.95 4.97 5.24 5.26 5.26 5.3 5.37 5.410

50

100

150

200

250

300A Peak Pressure (psi)

PS

I

Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco and none should be implied.

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Using the Data to Drive Results

Contrast Efficiency

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Contrast Efficiency

For the past 219 PE exams:

ALGH averaged 79.3 mL of contrast

Compared to 100 to 125 mL of contrast without P3T® software

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Contrast Waste Per Month

May June July August0

200

400

600

800

1000

1200

1400

1600

1800

2000

2011

Co

ntr

as

t m

L

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Conclusions

• Delivering contrast has become more challenging with the faster scanners

• CT suites need more tools to customize the dose per patient and manage results

• Using P3T® PA for PE exams, ALGH improved diagnostic outcomes while lowering contrast volumes

• Connect.PACS™ tools allowed for accurate quality analysis of PE exams and established action plans for further improvement

THANK YOU

Questions?

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