Consultation Paper Distributed Medical Imaging in the new Royal Adelaide Hospital Central Adelaide Local Health Network Issued: April 2016
TABLE OF CONTENTS TABLE OF CONTENTS 2 1. INTRODUCTION 3 2. PURPOSE 3 3. CURRENT MODEL 4 4. RATIONALE FOR CHANGE 5 5. FUTURE MODEL 6 5.1 Scope of the Future Model - Distributed Medical Imaging 6 5.2 Physical design 8 5.3 Implementation of the Future Model 12 5.4 Workforce Considerations 13 5.5 Benefits of the future model 13 5.6 Implementation of the future model 14 5.7 Related change processes 14 5.8 Implications for not undertaking the change 14 6. FEEDBACK 15 7. REFERENCES 15 Page 2 of 15
1. Introduction The Central Adelaide Local Health Network (Central Adelaide LHN) is one of five Local Health Networks (LHNs) in South Australia. The population of the Central Adelaide LHN is estimated to represent 27% of the total State s population. According to the recent Department of Planning and Local Government projections, the population is likely to increase to approximately 471,000 by 2016, to 488,000 in 2021 and 503,000 in 2026. The Central Adelaide LHN brings together four hospitals: Royal Adelaide Hospital (RAH), The Queen Elizabeth Hospital (TQEH), Hampstead Rehabilitation Centre and St Margaret s Rehabilitation Hospital, and a significant number of Mental Health (including Glenside Campus) and Primary Health Care Services. Central Adelaide LHN also governs a number of state-wide services including SA Dental, BreastScreen SA, DonateLife SA and Prison Health Care Services. The Central Adelaide LHN is committed to delivering the highest quality health care possible and taking active steps to continuously review and improve its services. Since the release of South Australia s Health Care Plan 2007-2016 (SA Health Care Plan), it has been widely acknowledged by the Central Adelaide LHN that we would need to change some key aspects of our day-to-day business and service delivery to ensure that we can continue to provide services to our community into the future. Increasing pressures that Central Adelaide LHN is faced with as part of the public health system include: - an ageing population with growing health care needs - rises in chronic disease - pressure to ensure we have enough clinicians and support staff to deliver services effectively - delivering sustainable services with a limited health budget resource. The Central Adelaide LHN is committed to achieving the vision set out in the SA Health Care Plan and in particular ensuring that we provide the best services possible to patients and that we find innovative ways of achieving this. Given the pressures we are facing and the need to make sure we can continue to provide services to the community, we have no choice but to change. To this end, and consistent with the vision articulated in the SA Health Care Plan, Central Adelaide LHN has embarked on a journey to change its approach to health care and the way it delivers health care services into the future. SA Medical Imaging (SAMI) is a Statewide service, under State-wide Clinical Support Services which is responsible for the provision of all medical imaging services at SA Public Hospitals within metropolitan and country South Australia across SA Health. 2. Purpose The purpose of this paper is to describe Distributed Medical Imaging as available on Day One of operation for the new RAH. It starts the next part of the consultation process about this function. The Distributed Medical Imaging model will streamline the patient journey with improved access to appropriate services distributed throughout the hospital to increase the availability and accessibility to Page 3 of 15
diagnostic and interventional procedures. 3. Current Model The Medical Imaging Department at the RAH delivers a Level 6 diagnostic imaging and interventional service for the Central Adelaide LHN. It provides general X-ray, CT, MRI, ultrasound, mammography, fluoroscopy and angiography and imaging guided intervention. The RAH Medical Imaging Department is an important support service to the RAH and is integral to efficient patient flows. The RAH s Medical Imaging Department is currently structured as a centralised model with all patient flows (Emergency, Outpatients and Inpatients) scheduled through its current equipment model. The RAH Medical Imaging service is structured as follows: Level 3 Emergency, Inpatients and Outpatients Hospital service for emergency, inpatient and outpatient activity. - General X-ray (& Mobile) and OPG - CT scanning - Ultrasound - Angiography - Fluoroscopy Level 2 - MRI (3T) - MRI scanning (3 T) Level 4 Theatres - Mobile X-ray - Fluoroscopy (Portable Image Intensifiers) Level 6 MRI and CVIU - MRI scanning (3 T) - CVIU Other service areas include Women s Health Centre, Hampstead Centre and the Chest Clinic. Page 4 of 15
Figure 1: Current model of Medical Imaging at the RAH Imaging services are best provided using multi-disciplinary teams of imaging professionals. The imaging workforce comprises both specialist clinical and technical staff. Specialist medical staff include radiologists and radiology registrars and other medical specialists with an interest in imaging such as vascular surgeons who have undertaken additional training in imaging. Radiologists participate in all stages of the imaging cycle including the imaging examination, interpretation of images in the relevant clinical context and communication of results to the patient s requesting doctor. Radiologists are also responsible for the medical care of the patient while in the imaging department. There are also radiology nurses who assist with radiology procedures and radiographers who are predominantly involved in image acquisition. Other technical staff include sonographers. Medical Imaging is supported by other professional groups, including biomedical engineers, medical physicists and information communication technology staff (who manage the radiology information system, storage and access to medical images). Non-clinical support staff include clerical staff (who under general supervision of the clinical staff and in accordance with established policies and procedures, greet patients; answer phones and direct calls appropriately; and perform clerical and service duties necessary to register, schedule and log patients coming to the department for tests. At the RAH, radiology assistants support the operations within the clinical setting by assisting with the movement of patients within the department, on and off the examination table, as well as undertaking tasks to support patient flow and patient transport.. 4. Rationale for Change There is a growing appreciation and understanding that the key to attaining good healthcare outcomes is getting the correct diagnosis in a timely manner. This has already put significant pressure on medical imaging services in terms of the volume of examinations carried out, the increasing complexity of imaging investigations and the speed with which these examinations need to be delivered. This pressure will continue to increase as diagnostic and interventional services play a crucial and integral part in the comprehensive assessment and Page 5 of 15
treatment of most patients. The efficient scheduling of patients through medical imaging is critical to ensure safe, patient-centred care is delivered. Health reform activity across SA has also informed the development of the Distributed Medical Imaging model. This reform activity includes: - Changes to the clinical profiles of major and general hospitals. - Implementing the new model of care which includes reshaping patient care areas based on the nature of the patient journey. - Improving the timeliness of patient care in Emergency Departments to achieve discharge or admission within a 4 hour timeframe. - Reducing the inpatient length of stay (LOS); emergency patients often have clinical priority over inpatients for images meaning the latter stay longer in hospital. - Outpatient and Ambulatory Care service reforms to ensure timely access to and discharge from the Outpatient Specialist Clinics. - The development of treatment pathways by clinical networks where imaging is needed in very specific timeframes e.g. Stroke. Implementation of care planning models that increasingly uses multi-disciplinary teams which include imaging specialists in clinical decision. making. 5. Future Model 5.1 Scope of the Future Model - Distributed Medical Imaging The Distributed Medical Imaging model is based on the clinical profile for major teaching hospitals which includes: - Providing a full range of major complex, surgical diagnostic and support services for the state. - Increased focus on surgery required for the treatment of trauma, cancer, cardiac, neurological and vascular disease. - Referral hospitals for all other hospital and health facilities. - Being responsive to the needs of clinical services e.g. if more ambulatory care is provided out of hospital, hospital imaging services will have to be flexible and respond appropriately. At the new RAH, Medical Imaging will be distributed in the following patient areas: - Emergency - Outpatients - "Hot Floor" Imaging servicing ICU and Technical Suites - Inpatients Page 6 of 15
Figure 2: Distributed Medical Imaging new RAH The Distributed Medical Imaging design at the new RAH is conducive to effective and safe care, minimising delay in diagnosis and treatment and saving time in patient transfer as the service is in close proximity and dedicated to each patient flow. It is anticipated that the current issues of access delays to diagnostic and interventional services will be removed, as each patient flow will have a dedicated imaging service designed to meet its clients needs. Key Features: Key features of each Imaging area are as follows: Emergency Imaging: The design of Emergency Imaging is to: - Provide immediate access for resuscitation and trauma patients to diagnostic imaging services (X-Ray and CT). - Provide streamlined and direct access for Diagnostic Assessment Unit, Observation and Treatment Area patients to diagnostic imaging services (X- Ray, CT, MRI, Ultrasound). - Minimise delay in diagnosis. - Minimise patient travelling by being in close proximity to all Emergency Service areas. - Provide emergency clinicians with ready access to radiologists, located at Reporting Rooms within Emergency Imaging, for image interpretation and communication of results. Outpatients Imaging: Outpatients Imaging will work with the new RAH Outpatient Specialist Clinics to ensure that booking processes and workflows will support the timely access of patients to Radiology. Unlike the current RAH, where the centralised equipment model for all patient flows (Emergency, Outpatients and Inpatients) means that Outpatients bookings are scheduled after more urgent patient flows such as Emergency and Inpatients, Outpatients will have improved access to diagnostic imaging services. Outpatient imaging will be planned and scheduled according to the imaging needs of the particular clinical specialities holding clinics on particular days e.g. vascular, breast and orthopaedics. This will allow patient visits to the hospital to be co-ordinated with all their care needs being planned for the same day. Page 7 of 15
The design of Outpatients Imaging is to: - Provide a streamlined and single point of access for outpatients to diagnostic imaging services (X-Ray, CT, MRI, Ultrasound and Mammography). - Minimise delay in diagnosis or reviews through the efficient scheduling and queuing of outpatient diagnostic imaging services. - Provide responsive and ready access to urgent outpatient diagnostic assessment as required to avoid a hospitalisation. - Minimise patient travelling by being in close proximity to Outpatient Clinics. - Minimise the length of time for image interpretation and communication of results to Clinicians. - Provide an integrated approach to ambulatory services. Technical Suites and ICU Imaging: The design of Technical Suites and ICU Imaging is to ensure the priorities of the different specialties are met, e.g. cardiology, radiology and interventional imaging. The Technical Suites and ICU Imaging service must manage and prioritise a range of complex patients, from the clinically unstable and critically ill to those who are stable and undergoing elective and often time consuming interventional procedures. It is designed to: - Support critical and high acuity care flows for Technical Suites and ICU. - Minimise patient travelling by being in close proximity to Technical Suites and ICU. - Provide direct access for ICU patients to CT. - Provide ready access for Technical Suites patients to Angiography, Mobile Fluoroscopy, Mobile X-rays and CT. - Provide ready access for ICU patients to Mobile x-rays. Inpatients Imaging: The design of Inpatients Imaging is to: - Provide streamlined and ready access for Inpatients to diagnostic imaging services (X-Ray, Fluoroscopy, CT, MRI and Ultrasound). - Minimise delay in diagnosis or reviews. - Minimise patient travelling by being in close proximity to all Inpatient areas. - Provide Inpatient Clinicians with ready access to Radiologists, located at Reporting Rooms within Inpatient Imaging, for image interpretation and communication of results. 5.2 Physical design The physical distributed design of the Medical Imaging at the new RAH enables medical imaging to be provided in close proximity to the point of care. The physical model is described for each level with each modality identified. Legend: Imaging modality and patient flow: Ultrasound MRI CT Fluoroscopy Mammography X-Ray/OPG Inbound patients Outbound patients Emergency: Medical Imaging is co-located within the Emergency Department between the areas of Resuscitation, Treatment Area and the Diagnostic Page 8 of 15
Assessment Unit. Medical Imaging will be notified of the requirement for imaging of a Resuscitation patient by the Resuscitation Team. Emergency patients requiring CT, MRI and Ultrasound will be pulled into these areas following the receipt of an electronic request and calling for the patient using the patient transport system. Medical Imaging will review all electronic requests to prioritise patients dependent on their clinical acuity and ensure that they are imaged in a timely manner. Emergency patients requiring plain films will be pushed into Imaging from Emergency. Emergency will electronically send the examination request and organise for transportation of the patient to the Imaging Bed-bay. This will enable increased through-put of patients requiring plain films. Figure 3: Emergency Medical Imaging US MRI CT Lift Lift Lift lobby BED BAY/ RECEPTION Lift RESUS Outpatients: Outpatients Medical Imaging is dedicated to the scheduling and imaging of Outpatients to provide a service that will meet Outpatient specialist patient flows. Communication between the Outpatient Clinics and Outpatient Imaging will enable patients to be scheduled for their imaging examinations efficiently and ensuring the synchronisation of future appointments with examination results. The standardisation of modality protocol information will enable Outpatients Imaging to print information for patients. Co-location of Imaging with the Outpatient Clinics will enable same day examinations where possible. Page 9 of 15
Figure 4 Outpatient Medical Imaging WAITING/ RECEPTION US MRI CT X-Ray US Figure 5: Womens Health Outpatient Medical Imaging Store Utility Treatment Treatment Waiting Staff hub WC Utility Treatment Staff hub WC Cystoscopy US Change Steno MAMMO WC WC WC Report WC Waiting Reception Technical Suites: Two CTs on the Technical Suites level will be dedicated to scanning patients located on this Level for example ICU patients and pre and post-operative patients. To increase streaming of patients through CT and to minimise the delay of access to a CT, diagnostic and therapeutic patient flows will be separate. Scheduling of patients will be coordinated through Inpatients CT. Scheduling of Interventional Suites procedures will be managed through the receipt of electronic requests and the scheduling of Suites using the Theatre booking system. Page 10 of 15
Figure 5: Technical Suites - CT CT Figure 6: Technical Suites - Interventional Suites Scrub Scrub Scrub Scrub Scrub Exit Bay Exit Bay Exit Bay Exit Bay Exit Bay Equip TS 8 TS 13 Equipment TS 14 TS 15 Equipment TS 16 Exit Bay Scrub Scrub Exit Bay Exit Bay Scrub Scrub Exit Bay TS 21 Equipment TS 22 TS 23 Equipment TS 24 Inpatients: Inpatients Medical Imaging is dedicated to the scheduling and imaging of Inpatients. Through being able to schedule and scan Inpatients with greater predictability, inpatient staff will be able to ensure that a patient is present and ready at the time of transport for their examination. Medical Imaging will review all electronic requests to prioritise patients dependent on their clinical acuity and ensure that they are imaged in a timely manner. Page 11 of 15
Figure 7: Inpatients Medical Imaging BED BAY/ RECEPTION US US CT MRI 5.3 Implementation of the Future Model The Distributed Medical Imaging model will start at the new RAH on Day One, as soon as the hospital opens. On Day One, the following components will be in place: - Fixed and mobile equipment for CT, General, MRI, Fluoroscopy, Angiography and Ultrasound will be in place and operational on each level of the new RAH. - The Enterprise System for Medical Imaging (ESMI) will interface with the new RAH Patient Administration System (PAS). ESMI is a comprehensive patient management system for medical imaging incorporating a radiology information system (RIS), a commonly configured picture archive and communication Page 12 of 15
system (PACS), voice recognition (VR) reporting software and billing revenue collection components. ESMI provides access and visibility of patient images and results across SAMI, resulting in consistent and coordinated patient care. - Ordering of examinations will be available through the new RAH PAS. - Access and viewing of patients examinations (images) and completed reports will be accessible through the new RAH PAS. - Facility management services will be in place to support Medical Imaging provide a responsive service by efficiently moving of patients throughout around the facility. 5.4 Workforce Considerations Medical imaging is a highly technologically driven service, and delivery of these services requires continuous training and upskilling of staff. In order to implement the Distributed Medical Imaging in the new RAH, radiographers employed by SAMI will be required to work across more than one modality This will require additional training to support radiographers develop their practice into specialist areas such as CT, MRI, Ultrasound and Angiography. These specialty training pathways are internally managed and supported by each modality with links to tertiary and professional organisations. At the new RAH Medical Imaging staff will be rostered to a modality on a level. To deliver a mobile service, staff will be required to undertake imaging across different levels. For example staff rostered to mobile will be required to perform mobile x-rays in multiple settings such as an Inpatient room or Technical Suites. Supervision of staff will be the responsibility of the modality supervisor for each area or after hours, the Shift Supervisor. This is the same supervision model as at the RAH. A 24/7 diagnostic imaging service (CT and X-ray) will be delivered in the new RAH Emergency Imaging with MRI and Ultrasound available. A rostered diagnostic and interventional service will be delivered in Technical Suites, Inpatients and Outpatients. Hours of service are yet to be determined, and will be the subject of separate consultation should there be a change from existing arrangements. 5.5 Benefits of the future model The distributed medical imaging model enables rapid access to services for patients and communication of imaging reports; benefiting both referring clinician and patient. In the distributed imaging model, imaging services are spread across patient care areas, placing imaging services closer to inpatient areas, outpatients, the emergency department and technical suites. Key opportunities of a Distributed Medical Imaging model are: Quality & safety Evidence based guidelines and Quality and safety processes to be implemented through development of key performance indicators (KPIs), audit programs, staff performance monitoring, benchmarking activity, sentinel event reporting and risk management activities. Investment in the development of evidence based practice, guidelines and protocols with standardised clinical referral Page 13 of 15
protocols Patient Flow ICT (ESMI and EPAS) protocols / pathways for imaging and technical protocols. Flexibility to be built in for less common protocols and specialised procedures. Dedicated patient imaging areas to provide streamlined and direct access for patients. Minimise patient travelling by being in close proximity to patient areas. Structured report templates to improve efficiency, communication, quality, safety, consistency of reporting and referrer prompts for the appropriate clinical information. Minimise delay in diagnosis or reviews. Access and visibility of patient images and results across SAMI, resulting in consistent and coordinated patient care. 5.6 Implementation of the future model The distributed design at the new RAH will require a change to how Medical Imaging will function. Medical Imaging patient flows will change to reflect the new RAH s physical environment as well as the implementation of the Enterprise System for Medical Imaging (ESMI) and the Enterprise Patient Administration System (EPAS), queuing system support and the use of communication technologies. To help achieve this and to further develop the detail of a Distributed Medical Imaging model, work has commenced to refine the future processes required to meet service obligations. Medical Imaging is working with Clinical Directorates to develop a common understanding of key patient flows. By identifying the key steps and the end-to-end processes of different flows, the foundations in defining future work flows is being developed. 5.7 Related change processes The implementation of ESMI and EPAS and ensuring staff (clerical, nursing and medical) are trained in the use of ESMI and EPAS will be important for the implementation of Distributed Medical Imaging. Other changes resulting from Transforming Health reforms and the SA Health response to the review by KPMG to assess the efficiency, effectiveness and financial performance of SA Medical Imaging January 2016, will result in separate consideration and consultation as required. SAMI will lead these processes. 5.8 Implications for not undertaking the change The new RAH is designed to ensure that the environment will enable all care provided to be patient centred. The Distributed Medical Imaging model is fundamental to this concept. By streaming patients through medical imaging areas designed to meet the needs of different patient flows, the availability and accessibility to diagnostic and interventional procedures will increase. Page 14 of 15
If Distributed Medical Imaging is not implemented at the new RAH, it will create delays in accessing diagnostic and interventional services for all patient flows. For example, no dedicated Emergency imaging flow will create a bottle neck in Emergency, as patients wait to be imaged. This in turn will delay time to receive appropriate diagnostic or treatment interventions. This will have flow-on delays for the scheduling of Inpatients and Outpatients scans and procedures. 6. Feedback This Consultation Paper provides more detail in relation to Distributed Medical Imaging model. There are still details that need to be determined and your feedback, suggestions and questions will assist in further refining the Distributed Medical Imaging model is welcome. Feedback can be provided via survey monkey https://www.surveymonkey.com/r/newrahmedicalimaging or in writing to Workforce Workstream, new RAH Program, Level 8, Emergency Block, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000. Feedback is due by 6 May 2016. In particular we are seeking responses to the following questions: 1. What do you believe will be the key to the successful implementation of the Distributed Medical Imaging model in the new RAH? 2. What do you believe may be the challenges to implementing the Distributed Medical Imaging model? 3. What else would you like to know about the Distributed Medical Imaging model? 4. Do you have any further feedback about the Distributed Medical Imaging model in the new RAH? 7. References Model of Care for Major Hospitals, SA Health, 2008. South Australia s Health Care Plan 2007 2016 Central Adelaide Local Health Network, Commitment to Care Our Change Journey, Version 8, May 2014 Central Adelaide Local Health Network, Single Service Multiple Sites Service Delivery Model Australasian Health Facility Guidelines, Part B - Health Facility Briefing and Planning, 440 - Medical Imaging Unit, Revision 5.0, 15 October 2013 Observations and Impressions of Medical Imaging Practice in the USA - A field trip by a team from South Australia to attend a radiology conference and visit several hospitals in the USA, SA Medical Imaging Advisory Committee, December 2008. Page 15 of 15