meeting the demand for 24/7 emergency radiology coverage...
TRANSCRIPT
Meeting the Demand for 24/7 Emergency Radiology Coverage in Academic
Medical Centers
Aaron Sodickson MD, PhD [email protected]
Section Chief, Emergency Radiology Director, Brigham NightWatch Program
Medical Director of CT, Brigham Radiology Network Associate Professor, Harvard Medical School
Brigham and Women’s Hospital Harvard Medical School
Objectives: • Describe the Brigham and Women’s Emergency
Radiology approach to 24/7 coverage
• Highlight pros, cons, and tradeoffs in our coverage model as they relate to: - Teleradiology as the means for expansion - Staffing, scheduling, compensation - Clinical coverage - Trainee education - Academic productivity
Overview of our Practice: • Academic, tertiary care, level 1 trauma center
• 24/7/365 dedicated Emergency Radiology section
• BWH ED coverage & regional after-hours teleradiology coverage of other Massachusetts hospitals and urgent care centers
• 10 FTE’s, 12 staff radiologists
• Trainees: 2 resident shifts per day 2 Emergency Radiology fellows
Attending Shifts FTE’s 12a 3a 6a 9a 12p 3p 6p 9p 12a
2004 6.5
< 2004 3.5
2006 10
8a-4p 4p-11p
11p-8a
6p-3a
Benefits of Teleradiology Expansion:
• Growth largely enabled by added outside teleradiology work
• Additional volume and revenues to support new staff salaries
• Increased attending presence at BWH
• Extend emergency radiology expertise beyond BWH to enhance care at sites where after hours radiologist availability was limited
• Build regional reputation and relationships [email protected]
60 yo, mesenteric hematoma Pancreaticoduodenal aneurysm Emergent coil embolization
Syncope, SOB 2 wks p Achilles repair Saddle embolus, R heart strain Surgical embolectomy Extracted clot the length of the leg [email protected]
Challenges of Teleradiology Model:
• Adds complexity: - Workflow: competing demands, priorities - IT: additional systems, reliance on remote support - Business: program administration, finances,
customer service
• Adds risk: - A lot of competition, downward price pressure - Reliance on telerad business success to maintain
group size, compensation
Staffing – who works which shifts?
Model 1: Separate night and day crews
• Night crew prone to: - Burnout: 3-7 yr expected longevity on nights - Academic disengagement
• Potentially divisive: 2 parallel practice groups with limited interaction, group cohesion “Us vs them”
• Potential for misunderstanding, conflict over compensation, shift hours, scope of work
Staffing – who works which shifts?
Model 2: Everyone works all shifts equally • Physiologically easier on the “night crew”
• Physiologically harder on the “day crew”
! Everyone becomes (MORE / LESS): happy, engaged, productive
• More difficult to schedule rationally - Transitions between nights / days - Preserve recovery time after night blocks
• Hard to switch from Model 1 to 2 [email protected]
Staffing – who works which shifts?
Model 3: Hybrid • Attempt to accommodate individual preferences
within the constraints of covering the schedule
• Scheduling complexity increases further
• Ideally, everyone works at least some of each shift to understand the breadth of practice, improve group cohesion, break down “us vs them”
Compensation – Time and/or Money • Compensation model has changed over time, and
partly drives preference for shift distribution • What is a full FTE?
• 1:3 pure nights (1:2 not sustainable, could split the difference in a purely clinical model)
• 180 “day shifts,” other shifts between these • Schedule each person based on their mix of shifts • 2/7 of shifts on weekends
12a 3a 6a 9a 12p 3p 6p 9p 12a
180 “day” 122 “night” 165 145
Compensation – Time and/or Money • Because of telerad revenues, we have some
autonomy in how we compensate our shifts
• Points system - “Daytime hours” 8a-4p - “Evening hours” 4p-midnight - “Overnight hours” midnight-8a
• So later shifts are compensated both in time and $$
Increasing hourly differential
Clinical Coverage • We read (almost) all imaging performed on BWH ED
patients, and all emergent imaging (ER or inpatient) at our NightWatch sites.
• Our staff have various fellowship backgrounds: Abdominal/Body (4), MSK (3), Thoracic (2), Neuro (2), ERad (1), None (2)
• It would take a much larger program to always have specific fellowship expertise available.
• Everyone is experienced in ER imaging, with consultants available within and outside our section for later secondary case review as needed. [email protected]
Neuroradiology • We read all ER head, spine CT • Since 2004: neuro CTA, brain & spine MRI on
ER patients 11pm -8 am - covered by neuroradiology at other hours
• Starting an “Emergency Neuroradiology Clinical Practice Unit” in collaboration with Neurorad - All CTA read contemporaneously by ERad for
acute care decisions. Immediacy adds value.
- Later Neurorad review for QC, new data available, added value for subsequent management
Trainee Education
• Need to balance 24/7 attending presence with graded responsibility for resident
• Growth through autonomy, without sacrificing patient care
• Adjacent reading room: - Resident is first line overnight in our ER - Teleradiology remains efficient
- Frequent sign-outs, immediate availability for clarification or hyperacute situations
Trainee Education
• In practice, most formal teaching occurs on the day shifts – more interaction, didactics, research activities
• Night shifts allow greater trainee autonomy, volume for more senior residents
• Target sign-out intervals ~1 hr during day, ~2-3 hrs overnight
Night Work is the Enemy of Academic Productivity
• Academic engagement is naturally variable
• Pure night work sets people up to fail - Disconnected, sleep-deprived, jet-lagged - Mentality that the clinical shifts are the whole job - Tremendous drive, discipline needed to make this work
! Transitioned to a hybrid model - 3/12 work no overnights, 3/12 work no days - 6/12 do some of everything, in different proportions [email protected]
Is is Possible to Meet the Academic Mission in a 24/7 Environment?
• It’s not easy, but it is possible ! Need to hire highly motivated people!
• Each FTE gets 45 academic days - Variable activity / academic engagement with that time
• Academic incentive plan: Withhold 3% of sectional comp $$, distribute by academic effort - Recognition of effort, unlikely to drive behavior
• RSNA 2014: - 5 RC talks (3 speakers), 10 scientific, 10 educ exhibits [email protected]
Meeting the Demand for 24/7 Emergency Radiology Coverage in Academic
Medical Centers
Aaron Sodickson MD, PhD [email protected]
Section Chief, Emergency Radiology Director, Brigham NightWatch Program
Medical Director of CT, Brigham Radiology Network Associate Professor, Harvard Medical School
Brigham and Women’s Hospital Harvard Medical School