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Meeting the Demand for 24/7 Emergency Radiology Coverage...
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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
Transcript of Meeting the Demand for 24/7 Emergency Radiology Coverage...
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
