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  • Look Ahead - The Evolution of Emergency Radiology — Past and Future

    Learn how acute care imaging has created a new model of care in emergency departments. By Susan D. John, MD

    August 1, 2018

    Emergency radiology is relatively young as a subspecialty of diagnostic and interventional radiology compared to other imaging subspecialties. Although acute care imaging has been an integral part of radiology from the beginning, emergency radiology was not recognized as a distinct discipline until the 1980s. Changes in the ways that emergency care is practiced have escalated over the past 20 years, fueled by rapidly developing imaging and information technologies and changes in health care policy and reimbursement.

    In response, radiology developed dedicated emergency radiology services, creating a new model of care in imaging practices and altering the way that imaging is provided beyond the emergency department. The practice of emergency radiology continues to evolve and faces new challenges and opportunities ahead.

    Creating an Identity for a New Subspecialty

    Accurate and prompt imaging is necessary to ensure the best outcomes in diagnosis and treatment of emergent and potentially life-threatening conditions of patients seen in our emergency departments and trauma centers, which creates a close working relationship between emergency medicine, trauma surgery and emergency radiology. As with all relationships, there have been growing pains and controversies. Emergency medicine was organized in the 1970s, spurred by rapid improvement in emergency care and renewed interest in improving public health.

    Many parallels can be drawn between the development of the specialty of emergency medicine and the subspecialty of emergency radiology. Emergency departments were usually staffed by rotating staff physicians until emergency medicine residency programs were implemented beginning in 1970.

    As advanced treatment methods emerged for life-threatening conditions such as trauma, acute myocardial disease and stroke, a need arose for physicians with more focused training in such emergent conditions. Similarly, emergency radiology services were originally provided by rotating general and subspecialty radiologists, and this practice continues in some facilities. John H. Harris Jr., MD, co-authored the first comprehensive textbook on emergency imaging in 1974. Dr. Harris is one of the radiologists instrumental in creating the American Society of Emergency Radiology (ASER) in 1987, which now has more than 1,500 members. Soon after, emergency radiology fellowship programs began to emerge at institutions with Level I trauma centers, and today there are at least 15 such fellowships.

    Technological advances have contributed significantly to the reliance of emergency services on diagnostic imaging. The use of CT in emergency departments (EDs) increased dramatically over a period of 10 years, with a compound annual growth rate of 16 percent between 1995 and 2007, according to the 2011 Radiology study, “National Trends in CT Use in the Emergency Department: 1995-2007.”

    The value of ultrasound (US) for rapid diagnosis of conditions such as acute cholecystitis, hydronephrosis, ascites and abscesses was recognized early in radiology, along with the special advantages of US for children and patients who cannot be transported to a CT scanner. Emergency medicine adopted US as a screening tool for fluid collections in trauma patients and has gradually incorporated other point-of-care US skills into their practices and training programs. As the volume of patient visits to EDs increased (141.4 million visits in 2014 with 8 percent resulting in hospital admission according to Centers for Disease Control), the need for rapid patient throughput became more urgent, enhancing the need for fast diagnostic tools.

    The importance of contemporaneous interpretation of imaging during evaluation of patients in the ED became increasingly evident, requiring practices to expand radiologist staffing. Widespread implementation of PACS and the development of teleradiology provided some relief, but resident coverage of after-hours ED imaging in academic practices predominated until recent years. In 2007, only 10 percent of academic medical centers had in-house attending radiologists. These were exciting times for radiology, with some dark clouds lurking on the horizon. Radiologists and hospital administrators alike began to question the value of an onsite radiologist, diminishing the visibility of the emergency radiologist as a team member and promoting the commoditization of the specialty as a whole.

    Expectations and Opportunities in Emergency Radiology

    Emergency radiologists are poised to lead medicine into a future in which radiologists are key participants and leaders within clinical care teams. The current focus in medicine on quality and standardized care demands that imaging specialists have depth of knowledge and experience in more focused areas of clinical care. The American College of Surgeons Committee on Trauma provides guidelines for Level I Trauma certification, which include 24/7 availability of radiologists. Emergency radiology must continue to increase the number of fellowship positions to meet this growing demand.

    The precise skill set required of an emergency radiologist is still not well-defined. ASER is working toward a more standardized curriculum in emergency radiology fellowship programs and has produced a comprehensive online core curriculum. As the number of radiologists who practice predominantly in emergency settings increases, the American Board of Radiology should ensure that certifying examinations are designed that reflect the distinct discipline of emergency radiology. We also must recognize that other imaging subspecialties will continue to play an important role in emergency imaging and will be expected to meet the same reporting standards. Some busy trauma centers are staffing neuroradiologists and body imagers 24/7 in addition to emergency radiologists, and others are hiring radiologists with dual subspecialty training to meet this need. Pediatric emergency imaging presents special challenges that need to be considered as after-hours care becomes more subspecialized.

    Stephen Ledbetter, MD, MPH, current president of ASER, eloquently outlined the complexity that characterizes the practice of emergency radiology in a keynote speech at the 2011 ASER meeting. Each day, the emergency radiologist is responsible for patients with acute life-threatening conditions in an intense care environment. Volumes are sporadic and unpredictable, making appropriate staffing challenging. Emergency radiologists must deal with frequent interruptions and multiple communications and patient handoffs while working with little prior history and no comparison imaging. Patients referred from other hospitals often arrive with imaging studies, requiring clear policies on second interpretations and formal reporting of outside imaging. We must also be prepared for the growing threat of mass casualty events that can overwhelm usual workflow in emergency imaging facilities without well-planned surge protocols. (See “Including Radiology in Emergency Plans is Critical on Page 10).

    New Technology Presents New Challenges

    Advances in artificial intelligence (AI) and image-guided interventions will undoubtedly change the landscape of emergency radiology, and radiologists must play a role in the development of AI tools to ensure that they provide the needed support. AI programs are being developed that will identify imaging studies with potential life-threatening pathology such as intracranial hemorrhage or infarcts, facilitating prioritization of those examinations over less urgent exams. Computer-based detection of injuries that should be reported but will not change patient management (e.g., exact number of rib fractures) will improve the efficiency and effectiveness of emergency radiologists. Emergency physicians and trauma surgeons will assume more direct responsibility for procedures that require a rapid response, including bedside US. Trauma surgeons will become more engaged in minimally invasive post-traumatic hemorrhage control as more emergency department hybrid OR/angiography suites emerge. Interventional radiologists will need to modify staffing and workflow to meet the expectation of rapid hemorrhage interventions in the ED.

    Emergent MRI indications will become standard of care as the technology becomes faster and more widely available in emergency departments. A growing body of evidence confirms the value of MRI for diagnosis of emergent conditions such as acute appendicitis in vulnerable populations such as pregnant women and children and acute spine and musculoskeletal conditions that require emergent intervention. CT angiography, already a vital tool for diagnosis of traumatic vascular injuries, will be used more broadly for acute vascular occlusive disease in the heart and brain. Perfusion imaging and other functional imaging techniques have the potential to improve stroke therapy in the acute setting.

    A Unique Opportunity

    Emergency radiologists have the opportunity to reframe the image of radiologists as active and caring participants in life-saving care of patients. Many incidental abnormalities are identified on imaging studies performed for non-related reasons in the ED. The emergency radiologist is the best physician to document such abnormalities and may be the only physician who can ensure that such findings are addressed once the patient leaves the ED. Emergency radiologists must actively participate in and even lead multidisciplinary collaborations to develop accurate and cost-effective diagnostic imaging protocols in the ED. More research is needed to validate the pivotal role that emergency radiology plays in improving patient outcomes in emergency care.

    Susan D. John, MD, is professor and chair of the Department of Diagnostic and Interventional Imaging at the University of Texas (UT) McGovern Medical School at Houston. She serves as chief of Adult and Pediatric Imaging Services at Memorial Hermann Hospital TMC, Children’s Memorial Hermann Hospital and Lyndon B. Johnson General Hospital in Houston. Dr. John has held the John S. Dunn Distinguished Chair in Radiology at UT McGovern since 2004. She is past president of the American Society of Emergency Radiology (ASER) and received the ASER Gold Medal in 2015. Dr. John chairs committees for the Society for Pediatric Radiology and the Society for Chairs of Academic Radiology Departments. She serves on the RSNA Public Information Committee (PIC)/Public Information Advisors Network (PIAN) and is currently the PIC vice chair.

    The complexity and intensity of the emergency center environment requires a different approach from radiologists.


    Figure B
    Advanced imaging techniques, such as ultrafast MRI for appendicitis (A) and vascular and brain perfusion imaging for stroke (B, C), are becoming increasingly important for emergent diagnoses in emergency departments, leading to greater need for subspecialized radiologists. Images courtesy of Susan D. John, MD.