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Tuesday, April 11, 2006
Visit to Massachusetts General Hospital ER
MRI Image from General Electric Healthcare
Interview with Dr. Gonzalez, Chief of Neuroradiology at the Massachusetts General Hospital and Associate Professor of Radiology at Harvard Medical School.
QUESTIONS
1. How do patients transfer to specialists in two hypothetical situations?
a. Clear-cut situation such as a broken limb
b. Less obvious situation: how many steps before radiological imaging is called for?
2. What is the head radiologist's dream ER and how would it function?
3. How does the ER interface with other departments within the hospital (such as the psych dept)?
4. What are the major security issues and patient privacy issues?
5. What is the actual protocol for triage?
6. Is the head radiologist more of a clinical or administrative position at the hospital?
7. How much interaction does the radiology department have with the ER?
8. What types of comments come back from staff and patients?
9. How are patients physically transferred between departments?
10. What are the time constraints? What are the time limits to treatment options?
11. How much does the clinical staff rely on patient questionnaires vs. observation?
12. What is the protocol for repeat patients?
13. How does MGH's ER compare to ER's in other hospitals?
KEY RESPONSES
TRIAGE
MGH - patient arrive mainly by ambulance rather than as walk-ins, but the ER caters to both.
The EMT makes decision where the patient should go, and assesses the situation. After the patient arrives at the ER, the Triage nurse evaluates the patient, determining whether the problem is routine or critical.
If further investigation is necessary, the patient will undergo CT scans and/or MR studies.
A hypothetical situation illustrates the breadth of response: a patient comes in with a headache, after an accident. After triage: the patient is sent home having been evaluated and given some painkillers, or will be sent to have a CT scan which may show an aneurysm and will then have to be treated. The patient will be admitted to the appropriate part of the hospital.
ISSUES OF COMMUNICATION
There is no substitute for talking face-to-face; it is the best means of communication in the ER. This includes both doctor-to-patient and especially doctor-to-doctor communication.
Transfer of information is done face-to-face.
ISSUES OF OWNERSHIP OF THE PATIENT
The ER is the entryway to the hospital. If the patient is admitted, then - for example - neurosurgeons and other specialists will take over management of the patient from the ER. The patient will not return to the ER, but will be transferred around other parts of the hospital as necessary.
ISSUES OF LEGACY OF BUILT FORM
One of the main problems is that the ER inhabits an old building. The ER is a hybrid system, which has evolved over a century, but is becoming more streamlined. The built form however, creates issues of legacy. How do you fit new machines, new ways of treating patients etc into the existing shell, whilst continuing functional operation of services within the hospital?
CARING FOR THE PATIENT IN THE ER
The main business of the ER is vital care.
Support systems: a problem is all the extra kit following patients around: trolleys and wires with IV/machines etc that have to be maneuvered individually whilst still connected to the patient.
Scanning/Docking CT/MRI procedures now take only a few minutes (CT scan possible in just 5 minutes), but the whole process can take an hour to get the patient onto and off the scanner.
The scanning machines are in use 24/7. On average, 2 patients per hour on the CT scanner, 1 per hour on the MRI scanner. Patient has to change cart due to the magnets, all needles etc have to be changed so that there is no ferrous material in the scanning room.
Issues with CT/MRI machines– placement in building, special building materials etc.
Overflow spaces (staging areas) for scanning. Scanners constantly in use.
The ER at MGH has an ER Radiology Department within the ER which is one part of a larger radiology department.
THE DREAM ER
Easier interventions and upgrades.
Patient focus/patient-centric platform
Vertical connection to the rest of the hospital from the ER.
Communications systems: face-to-face, paging, telephone instant access is important in the ER. The ideal would be to have instant video conferencing, however, this is still not a substitute for face-to-face communication, and would only be useful if was instantaneous.
GENERAL ISSUES AT MGH'S ER
Bottlenecks and tight corners. Legacy issues in every ER.
Control rooms scanning reading room (very dark).
Issues of cross-talk– privacy screen in tight spaces such as CT control rooms.
Issues of getting lost and mobility
ER's are not 'designed', at the most, they are space planned. How quickly do they go out of date? How do you upgrade them? Should equipment rooms such as scanning facilities be placed around the edges for easy upgrading of large equipment? Are things already out of date by the time they are built and start to be in use?
Trolleys that automatically cart medical supplies/medical records etc around follow coloured lines on floor.
Patient exposure to other patients in the entryway.
Problems with bringing in new machinery to the new Stroke Department on the 2nd floor. New machines had to delivered by helicopter in after part of the ceiling was removed, the building had to be strengthened.
Security? Privacy?
THE TECHNOLOGICAL REVOLUTION IN THE ER
Revolution in radiology (Computers, then CT and MRI) has completely changed the way problems are diagnosed and the ability to diagnose. It is rare to have an MRI scanner in the ER.
Everything is digital now, even X-Ray no longer uses film.
Speed of information transfer 15 mins, can take longer, so radiologist will be present to look at the results as they appear on the screen as an initial check to make sure nothing serious is happening there and then.
In 1975, MGH installed the second CT scanner in the country (?), which was able to scan 4 slices per hour, and then took 1 hour to reconstruct the data. We saw the scanner processing and displaying enormous amounts of detail of the entire body in around 1 minute.
We thought about issues of power and also issues of server space and information storage. With its 6 CT scanners alone working 24/7, MGH must require extraordinary IT systems as well as the generators etc required by all hospitals. What happens if these go down?
The entire ER area has been rebuilt in the last 5 years in stages, (what complexities and compromise does an ongoing upgrade system like this entail
Future advances: biopsy– digital intervention, data/biological instead of cutting patients open to examine. How will this affect the ER of the future?
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