In 2008, an alliance of radiology organizations was formed to launch the Image Gently campaign, emphasizing the importance of child sizing radiation dose to image pediatric patients more safely. The renewed focus on improving the safety of imaging for children has prompted hospital radiology departments and imaging centers to reexamine every aspect of their pediatric care. By reducing exam times, eliminating the need for follow-up exams and providing automated dose protocols for a range of weights and sizes, the right imaging technology can help facilitate safer imaging for the youngest patients.

Robb Young, senior manager of the CT business unit at Toshiba America Medical Systems, Inc., asks, “What are the greatest challenges in imaging small children? Children, especially young children, have a hard time taking instructions, and they tend to be a little squirmy. That’s the main challenge in pediatric imaging versus adult imaging: How do you get the diagnostic image you need so you don’t have to re-image?”

Young says that Toshiba’s Aquilion^® ONE 320-detector row, dynamic volume CT scanner is optimal for pediatric imaging in terms of both speed and dose. “With this technology, we can image children so quickly that we need less – sometimes even no – sedation, and often without them having to hold their breath.” he says. “You can image 16 cm in 0.35 seconds, whereas on a conventional CT it could take four or five seconds.”

 The Aquilion ONE’s automated dose protocols take the guesswork out of imaging children by automatically child sizing dose, so the technologist can focus on the patient, not the control board. “This is a real issue,” Young says. “Should the technologists be focused on the scanner or the patient? Our design philosophy has always been to automate everything so they can focus on the child.”

Sometimes pediatric imaging goes beyond the diagnosis, and physicians are faced with performing interventional procedures where imaging plays a key role in the care delivered. Allan Berthe, product manager for Toshiba’s X-ray vascular business unit, notes that in some pediatric hospitals, cardiac imaging is performed alongside surgery to repair congenital heart defects. While this can help minimize disturbance to patients, it also creates unique challenges in the cardiac-catheterization suite. Toshiba’s Infinix-i™ C-arm addresses this issue with a unique five-axis positioner, enabling multiple clinicians to work around the patient while gathering high-quality images.

“There’s always a challenge with maneuverability around the room because the patient doesn’t give you any cooperation,” Berthe says. “It was paramount that the entire system design philosophy was changed to accommodate greater patient access and coverage. The five-axis positioner enables us to park the C-arm in a position that, when combined with the ceiling C-arm, gives 180° open head-end access while maintaining the C-arm coverage you want, the motion in various directions, the speed and the right angles.”

The Gentler Approaches

Ultrasound is often used as the frontline modality in imaging children because it is noninvasive and emits no radiation. Erin Owen, senior manager for Toshiba’s ultrasound business unit, says, “If they can diagnose it with ultrasound, they’re going to do that first.” Toshiba’s ultrasound technology facilitates rapid, high-quality pediatric imaging through a multitude of proprietary features. One such feature is differential tissue harmonic imaging (D-THI), which offers superior penetration at the high frequency needed to maintain image quality. “The higher the frequency, the better the image quality,” she says. “D-THI gives us image quality throughout without losing the penetration and while maintaining the resolution.”

Toshiba also offers two transducers that are ideal for pediatric imaging. One condition often experienced by infants in the neonatal ICU is bleeding in the brain; Toshiba’s neonatal head transducer offers high-frequency imaging in a nickel-sized package designed to fit the smallest patients. Another transducer, the 745 BTV, is “a very small convex transducer that is good for neonatal heads and also for looking at the livers or kidneys of very tiny babies,” Owen says. “For some of these babies, a regular transducer would be too powerful, and that would negatively affect image quality.” Precision Imaging, a feature available on most TAMS transducers, also enhances image quality by providing superior definition of lesions. “It helps us get a clearer understanding of what’s going on, and might help eliminate a more costly or frightening exam,” Owen says.

Pediatric MRI represents a multitude of challenges.  Most MRI exams are lengthy and children might require sedation to keep still.  Additionally, anyone who has experienced an MRI exam can testify to the loud noise, which can frighten young patients. Joel Urick, product manager in Toshiba’s MRI business unit, explains how the company’s MRI technology addresses these issues by shortening exam length and improving image quality. “Our coils are integrated into the table.  Therefore, instead of having to go into the MRI room to reposition the child, you can continue the scan without stopping.  This not only makes the exam faster when performing multiple exams, but also makes the exam more comfortable for the patient,” he says. “You landmark the patient ahead of time and the table moves from location to location.”

Toshiba’s non-contrast MRI techniques can eliminate the need for an IV for a child prior to a scan, enabling users to perform contrast-free imaging for full runoffs down the legs, renal exams, pulmonary embolism and more. The manufacturer’s proprietary JET™ sequence offers motion correction, a valuable benefit with imaging patients who have a hard time holding still. “Even if a patient turns his or her head to the side, JET can extrapolate the data where the patient wasn’t moving and produce a detailed image,” Urick says. “Even if a child moves during a scan, it might not be necessary to repeat it.”

Improving the safety of pediatric imaging yields benefits across the board, Young notes. “If you are able to image children at the lowest possible dose, you can image everyone that way,” he says. “If it’s safe for kids, it’s safe for everyone.”

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Imaging can be intimidating for patients of all ages, but for children in particular, the technology poses a unique challenge. To image young patients safely, it is crucial to minimize the number of scans needed for fast and accurate diagnosis. To minimize the number of scans performed, it is equally crucial that patients be as comfortable as possible during their exams. “The whole objective is to achieve a gentle experience,” Robb Young, senior product manager, CT business unit, Toshiba America Medical Systems, Inc., explains.

To that end, Toshiba has developed a series of innovations to boost the comfort of pediatric imaging. These include a miniature CT scanner designed to help educate children about the procedure and help them exert a degree of control over the process. Prior to undergoing their own scans, children can watch a favorite toy go into the miniature CT. The mini-CT will be introduced at this year’s RSNA meeting, alongside a dedicated version of the Aquilion^® ONE unit designed for pediatric imaging and decorated with a playful jungle theme. “If a child is more comfortable, it’s going to be a better patient experience and ultimately a higher quality scan,” Young says.

With MRI, noise reduction is a key element to helping children relax and feel more comfortable during the scan process. Toshiba’s groundbreaking noise-reduction technology, Pianissimo™, and the short, open-bore design of all MRI units raise the pediatric comfort level. Joel Urick, product manager, MRI business unit, says, “Our Pianissimo technology makes our scanners much quieter than standard MR scans – up to 90 percent quieter with many sequences. Reducing the noise makes it much less scary. It allows us to make working with kids a little easier, and if they do need to be sedated, the odds of them waking up are reduced.” Bore design reduces the level of intimidation children feel; in many cases, kids can be imaged feet first. “That way, their parents can be at the front part of the scanner, holding their hands and doing whatever else is needed to make them more comfortable,” Urick notes.

In the case of ultrasound, often considered the frontline technology in pediatric imaging, room design can go a long way toward reducing the intimidation factor. Erin Owen, product manager in Toshiba’s ultrasound business unit, says, “Children will fuss with ultrasound, like anything else, but the transducers are designed to be comfortable, they have warm gel, and there’s usually a television where children can choose what they want to watch during exams.” Toshiba will also showcase a decorated pediatric ultrasound unit at this year’s RSNA meeting.  The unit will be decorated in a manner similar to that of the pediatric Aquilion ONE.

“Lowering dose is of utmost importance, but it’s also important to make imaging comfortable, fast, and the best experience it can be,” Young says. “These children deserve it.”

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Whatever form the health care legislation under debate in the House and Senate takes, one priority is shared by lawmakers from both sides of the aisle: improving quality and safety. President Obama’s proposed 2010 budget includes a recommendation to implement a hospital quality-incentive payment program; the budget projects that such an initiative could result in savings of $11 billion over the next decade. In addition, the Medicare Payment Advisory Commission has recommended that Medicare revise its payment-system incentives to adjust provider payment based on quality of care, and has suggested that Congress create a wide-reaching quality-incentive payment policy for hospitals and physicians.

With quality and safety in the spotlight on a national level, hospitals across the country are renewing their commitment to ensuring that their services meet or exceed the core measures for quality set by the government. For many facilities, this is a massive, daunting undertaking, requiring a comprehensive reexamination of even the simplest daily processes to ensure that all members of hospital staff are enforcing the common goal: improving patient care.

Memorial Hermann Healthcare System (MHHS), Houston, Texas, embarked on a new quality initiative in 2003. The hospital began by developing a brand promise that Michael Shabot, M.D., chief medical officer, describes as striking at the health care system’s core mission: “That the system provide the highest possible quality and safe health care combined with an outstanding patient experience.”

Shabot, who came onboard in January 2007 as chief quality officer, was hired, in part, to reinforce this renewed commitment to patients. “Everyone talks about differentiating themselves on the basis of quality care and safety,” he says. “Our commitment was actually to do it and demonstrate it. It required real dedication.”

Shabot was instrumental in implementing the second wave of the system’s new initiative, which became known as the Breakthrough in Patient Safety campaign. One idea that set the Breakthrough campaign apart was that it took cues from what Shabot calls high-reliability industries, such as nuclear power and naval aviation, which conduct specialized training for every single employee. “We brought in consultants from other industries to retrain all of our employees, including the kitchen staff, the maintenance staff—everyone who works for MHHS,” Shabot says. “We even train our volunteers to speak up when they think something’s not right. It’s everybody’s job to make every patient safe.”

All MHHS facilities honor a safety hero of the month (an individual who has intervened to ensure patient safety); the system has also designated 600 employees as safety coaches, who perform safety-monitoring services on work areas other than their own. In addition to meeting or exceeding safety and quality standards set by the government, MHHS ensures total transparency by publishing its own core measure data on its Web site.

In May 2009, the National Quality Forum presented MHHS with its 2009 National Healthcare Quality Award. By that time, the health system had been recognized by the New York Timesfor having the best heart-attack care in the city of Houston, averaging less than 90 minutes from the door to percutaneous coronary intervention. The system has revolutionized triage for both stroke and pneumonia, leveraging top-of-the-line imaging and PACS equipment to create what Shabot calls “a true culture change for everyone involved.”

“Our imaging capabilities are crucial to ensuring rapid, quality care,” Shabot says. “Modalities like CT angiography, CT, and MRI are crucial for rapid diagnosis of trauma. If a patient comes into the emergency department with chest pain, he or she gets an immediate ECG, and if there’s any evidence of an ST-elevation myocardial infarction, the catheterization laboratory is immediately activated.” In some cases, ECGs are actually read wirelessly from ambulances, meaning that the catheterization laboratory is ready by the time the patient arrives at the hospital. “It’s like a ballet,” Shabot says. “We have to make sure all of our staff is committed to this, on call, and available.”

Shabot and the team have also implemented a comprehensive program for appropriate dose in pediatric imaging. “In retrospect, we were often using more radiation than was necessary, like the rest of the country,” he recalls. “At appropriate lower doses, you can get the same quality images, and in the past few years, the need to attenuate these doses for children has become a priority.”

Though the Breakthrough campaign has already cost MHHS around $18 million, Shabot expects the investment to pay big dividends down the line. “We’ve made these improvements because it’s the right thing to do, but reimbursement is very important,” he says. “If we’re able to take a patient who was going to have a heart attack and literally reverse it—so that instead of spending days in critical care, clinging to life, he or she can go home in 48 hours or less—we’ve done the right thing for the health care economy. In our day-to-day operations, quality saves money and it saves lives. It’s a win–win situation.”

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A study spotlighting the opinions and concerns of chief executive officers, financial officers, and operating officers (C-suite) of U.S. hospitals reveals their top initiatives for 2009. Commissioned by Toshiba and conducted by an independent research company, the survey includes interviews with 60 leading executives throughout the country.

Patient care and safety, improving patient satisfaction and recruiting and retaining leading physicians are the group’s top three concerns today. Another top concern is accessing capital funds to invest in facilities and equipment, not surprising in today’s economic environment.

Carrying on with the theme of improving patient care, most of the institutions surveyed have or will expand or modify their patient safety and quality programs and they have or are increasing administrative time to educate their staff on compliance with safety measures.

When it comes to diagnostic imaging, the C-suite views having state-of-the-art imaging equipment as an important component of their ability to recruit physicians and technical staff and very important to their overall success. They also believe these technologies have improved the speed of diagnoses for heart attacks and stroke.

Other topics addressed in the study include issues related to reimbursement. For instance, have they seen a drop in reimbursement due to the implementation of Medical Severity Diagnostic Related Groups (MS-DRGS)? Nearly 80% said “No.” Or do they plan to increase their percentage of on-staff physicians if MedPAC’s (Medicare Payment Advisory Commission) recommendation regarding restructuring hospital payments based on “Episode of Care” is implemented? (Episode of Care would provide one fixed payment for the treatment of a specific illness and combines the technical fee with the professional fee.) Fifty-seven percent said “Yes, they would consider hiring more staff physicians.”

The study was completed in December 2008. A copy of the complete results of the study are available for customers by contacting Mary Kienstra, senior research analyst, Toshiba, at mkienstra@tams.com.

“The versatility of Toshiba’s Kalare R&F system coupled with its high-quality images resulted in immediate improvements in patient care, increased overall workflow and eliminated the need for conventional film,” stated Freddie Gibson, director, Medical Imaging Services, Nacogdoches Memorial Hospital.

In addition, the system allows clinicians flexibility to obtain images from virtually any position without moving the patient for improved comfort and faster exams. This makes it ideal for imaging ambulatory, wheelchair and stretcher patients. This flexibility also dramatically increases room utilization and overall operational efficiency.

“The Kalare has saved my department time by helping us complete most of our studies twice as fast as we used to,” said Gibson. “The Kalare is extremely user-friendly, making it comfortable for technologists to perform multiple exams a day with little fatigue. Some exams, which used to require two technologists, can now be performed by one. The chief technologist now has more time to oversee the entire department and work one-on-one with staff.”