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187
Perspective
How Many Radiologic Technologists Are Necessary Image Patients Efficiently in a Pediatric Radiology
to
Department? Candace
D. Carver1
and
Thomas
L. Slovis
No standards
currently exist to determine the time required to perform radiologic examinations of infants and children. In the absence of such standards, the determination of the number of technologists required in any department is often capricious and at the whim of the chief of pediatric radiology, complaints of the referring physicians, or financial interests of the hospital administration. The technolfor technologists
ogist’s
time
when this
per
examination
evaluating information,
patients
arriving
is the
departmental
first
variable
to
efficiency.
Once
armed
all the variables
at the same
(e.g.,
time,
portation)
that go into the total
radiologic
examination
can
registration,
equipment
assess
with
number
failure,
time a patient
waits
of
trans-
for a
be determined.
Because having the patient wait for a radiologic examination the shortest time possible is a major departmental priority, we evaluated the minimal number of technologists necessary to image 46,2i 6 patients who received plain film examinations during 1 year on the day shift at Children’s Hospital of Michigan. Information gathered on these patients included (i) time required to perform each examination (technologist’s time), (2) time each examination room was used (room utilization), and (3) waiting time in the department. At the onset, we arbitrarily set a goal of 20 mm total time for a patient to be in the department. Because the number of radiologic suites was fixed (four rooms), we tried to decrease examination time by (1) having “float” technologists aid with immobilization and fill in during lunches and breaks, (2) using a loading/unloading daylight system to increase our efficiency, Aeceived September 1
Both authors:
AJR 155:187-189,
and (3) having one technologist responsible for quality control. In an attempt to meet our goal, we altered patient flow patterns, coordinated these patterns with our staffing, used specific radiology transporters, and decreased the time necessary
Patients
for registration.
and Methods
For simplicity, patients were classified according to the radiologic suite, emergency or main department, in which they had their examination. Patients from the emergency department and the orthopedic clinic were imaged in the emergency department’s radiologic suite (ER patients). The diagnostic suite in the main department was used for all other clinic patients and those referred by private physicians (outpatients) and for all inpatients. This classification of ER patients, outpatients, and inpatients is important because each group had its own variables regarding total departmental time. A total of 1 30-1 50 patients between the ages of 3 days and 21
years were examined
each day. Fifty-five
percent
were examined
25, 1989; accepted after revision March 13, 1990.
Department
of Radiology,
Children’s
July 1990 0361-803x/90/1551
Hospital
of Michigan,
-0187 C American
3901
in
the emergency department’s suite and 45% in the main department. Each suite consisted of two rooms with a three-phase generator, a circa-1972 table, and a ceiling-mounted tube. The emergency department’s suite had wall-mounted daylight unloading equipment, whereas the main department’s suite had a loading/unloading cornpact daylight system. Most of the common plain film studies were performed (Table 1), but the two-view chest radiograph was the one done most frequently, accounting for more than 6O% of the total number of examinations. Whenever possible, one technologist was assigned to a room (two per suite), and two floaters were used to cover lunch and break
Beaubien
Roentgen Ray Society
Blvd.,
Detroit,
MI 48201
.
Address reprint requests to T. L. Slovis.
i 88
CARVER
TABLE 1: Time Main Department
Required
for Radiologic
Examinations
in the
Examination
Performed
Downloaded from www.ajronline.org by 110.84.188.238 on 10/12/15 from IP address 110.84.188.238. Copyright ARRS. For personal use only; all rights reserved
Examination
Time (mm) Mean
Chest Skull Sinus Bone age Scoliosis Foot
± SD
Fingers Hand Tibia/fibula Femur Elbow Shoulders (bilateral) Sacroiliac joints Orbits Abdomen Forearm Shunt survey Ankle
2 5 3 2 4 4 4 4 4 3 3 5 6 5 6 3 3 4 4
9515 414 579 203 31 8 416 53 258 158 464 455 109 45 10 94 707 393 74 1 85
Wrist
4
113
Clavicle
3 4 4 4 5 1
74 124 74 64 38 74
5.4 8.2 1 5.7 1 3.0 23.3 4.9±
2
174
12.0±2.3
45 235 86 66
16.6 20.3 9.0 20.0
Toes
Knee Facial bones Nasal bones Mandible Pelvis Hips
Complete spine Cervical spine Thoracic spine Lumbar/sacral spine Note-Examination ing, quality control,
12 5 2 5
time includes time required and repeat examinations.
4.7±0.8 9.3 ± 2.9 10.1 ± 2.4 3.6 ± 0.5 6.2 ± 0.3 6.5±0.8 5.7± 0.3 4.8 ± 0.3 5.7±1.3 7.5 ± 0.4 5.6± 1.1 5.1 ± 0.9 1 1 .0 ± 0.7 4.0 ± 1.8 8.8 ± 2.8 7.5 ± 3.4 6.7 ± 1.5 12.0 ± 2.8 5.5 ± 1.6 5.4±0.9
for immobilization,
± ± ± ± ±
± ± ± ±
1.2 0.4 4.2 3.2 3.8 1.3 2.8 5.3 1.9 4.5
AND
SLOVIS
total departmental time for 1 9,306 mm per patient. Of this, an average
outpatients was 24 ± 6 of 7 mm was devoted to registration. The average total departmental time for i 3,427 ER patients was 16 ± 3 mm per patient. This time is equivalent to their examination time because they did not require registration or transportation. In addition, we found that for 58% of the time available in the main department and for 68% in the emergency department’s suite, the radiologic examination rooms were occupied by patients. The total time spent by patients in the department in relation to the number of technologists available is shown in Figure 1.
Discussion The basis of an evaluation of a radiology department’s efficiency is the actual time required for an examination. As the number of examination suites is fixed, the first variable is the number of radiologic technologists. In pediatric radiology, technologists perform their role by gaining the child’s confidence, reassuring the patient, and in younger infants, by immobilizing the patient. Clearly, two technologists working in one suite are more efficient than one. Examination time, which includes processing, quality control, and, when necessary, immobilization and repeat examinations, is kept to a minimum by using a dedicated quality control technologist and rapid loading/unloading daylight processing systems. In the first quarter of our study, the values of all variables indicated the need for six to seven technologists on the day shift in order to come close to our goal (Fig. i). This was determined by calculating how much time was required for an examination and the total time spent in the department
process-
periods and to help with immobilization of patients and so forth. Each technologist had a total of 1 hr off during his or her shift. One additional technologist was assigned to the quality control station in the main department. This staffing pattern was not always possible, and the impact of having fewer technologists was evaluated with regard to patient flow. Times recorded were when patients arrived in the radiology department; when they entered an examination room; when they were discharged; and in the case of inpatients, when transport was called and when the patient left the department.
30
25 Tiin DWt
1usivs
of
20
ort (am)
13
10
Results In all three categories (inpatients, outpatients, and ER patients), the average time required for an examination was similar (1 5, i 7, and 1 6 mm, respectively), but extraneous factors such as time required for transportation, unscheduled
patients,
AJR:155, July 1990
and registration
greatly
influenced
5
the total amount
of time patients were in the department. Examination times and number of examinations performed in the main department in 6 months are listed in Table 1. We found that the average total departmental time (±SD) for 1 3,483 inpatients was 30 ± 8 mm per patient, half of which (1 5 ± 5 mm) was spent waiting for the transportation service to return patients to their hospital rooms. The average
0....4....5....6....7....8
Yu11-Tii
Fig. 1.-Number plotted
against
Equivalents
of full-time equivalent radiologic total time (exclusive of transport)
per
Day
technologists all patients
per day spent in
radiology department shows that a minimum of 5.8 technologists is necessary to accomplish a standard of 20 mm total time. With seven technologists,totaltime can be reduced to 15 mm.
AJA:155,July
when
perform
EFFICIENT
1990
different
numbers
the examinations.
IMAGING
of technologists
were
In addition,
we identified
available
IN PEDIATRIC
to
specific
Downloaded from www.ajronline.org by 110.84.188.238 on 10/12/15 from IP address 110.84.188.238. Copyright ARRS. For personal use only; all rights reserved
problems related to each group of patients that hindered our efforts to reach our goal of 20 mm total time in the department. Although the goal of 20 mm or less was achieved for ER
patients
(i 6 mm), the time required
for inpatients
was 30 mm,
half of which (1 5 mm) was spent waiting for transportation. The cost of employing an additional full-time person to provide patient transportation must be balanced against the negative aspects of keeping patients in the department the extra iS mm. Although these patients are inpatients, they are stable; unstable patients are examined at the bedside. Special ar-
rangements
are made for examination
of infectious
patients.
The only detriment associated with keeping inpatients in the department the additional time is that supervision in the waiting room is minimal, and often the parents are not present. The main reason times in the department were prolonged for outpatients was the wide variation in the number of patients referred for radiologic procedures from the outpatient clinic at any given time (two thirds of the patients came between 1 1 a.m. and 2 p.m.). Another reason for increased times was that some of these patients (5%) needed to register, which takes an average of an additional 7 mm. Inadequate technical staffing was minimal, and mechanical downtime was 1 1 %. As a result, the suite in the main department was in use only 58% of the time. In comparison, the emergency department’s suite was in use 68% of the time; the flow of patients was fairly constant, and downtime for this suite was 1.5%. During the second through fourth quarters, major changes were made in the main department. These included (1) conversion to the daylight system for loading/unloading, (2) reorientation of the clinics to distribute their patient flow more
equally,
and (3) adjustment
of our technologist
staffing
pat-
terns. With these changes, we were able to decrease the percentage of patients waiting more than 30 mm from 3% to 0.8% and the percentage of those waiting more than 45 mm
from 2.8% to 0.5%. Several authors [1 -7] have presented measurements of work loads productivity standards, and surveys of general
radiology
189
RADIOLOGY
department
staffing
related to the number
of radio-
logic examinations performed. These reports, however, have not included imaging of infants and children and have not considered how long it should take to perform radiologic procedures in a radiology department. Little consideration has been given to the amount of time radiologic suites are in use, a crucial determinant of productivity [3, 5]. Our study addresses these problems and provides initial standards for departmental efficiency and for assessing the number of radiologic technologists necessary in a children’s hospital setting. The goals of radiology staffing need to be reconciled with the goals of the hospital, for it is inconsistent, in terms of patient service, for a patient to wait 3 hr in a clinic and 20 mm in radiology. The hospital administration and referring physicians need to be partners in this dialog so that expectations of the time necessary for imaging are appropriate.
ACKNOWLEDGMENTS We thank our technologist and clerical staff who helped compile the data. We also thank Thomas Aozek and Ingrid Whipple for providing support and wise counsel.
REFERENCES 1 . MacEwan diagnostic
OW, Snigurowicz 0, Trypka L. Radiology workload radiology. J Can Assoc Radiol 1982;33: 183-1 96
system
for
2. Trisolini MG, Boswell SB, Johnson 5K, McNeil BJ. Radiology work-load measurements reflecting variables specific to hospital, patient, and examnation: results of a collaborative study. Radiology 1988;166:247-253 3. Janower ML. Productivity standards for technologists: how to use them. Radiology 1988;166:276-277 4. McNeil BJ, Sapienza A, van Gerpen J, et al. Radiology department management system: technologists’ costs. Radiology 1985;1 56:57-60 5. Janower ML. Radiology department management system: technologists’ costs (letter). Radiology 1986;159:566 6. Kirschner LB. Survey results: department staffing related to examination volume. Part III. 1988 AHRA Member Survey on Salary and Other Characteristics. 7. Calandrino
Radiol Manage 1989;1 1:46-48 C, O’Ambra P. Nonmedical personnel
atric radiology department.
Pediatr
Radiol
requirements
1989;19:321-324
for a pedi-
187
Perspective
How Many Radiologic Technologists Are Necessary Image Patients Efficiently in a Pediatric Radiology
to
Department? Candace
D. Carver1
and
Thomas
L. Slovis
No standards
currently exist to determine the time required to perform radiologic examinations of infants and children. In the absence of such standards, the determination of the number of technologists required in any department is often capricious and at the whim of the chief of pediatric radiology, complaints of the referring physicians, or financial interests of the hospital administration. The technolfor technologists
ogist’s
time
when this
per
examination
evaluating information,
patients
arriving
is the
departmental
first
variable
to
efficiency.
Once
armed
all the variables
at the same
(e.g.,
time,
portation)
that go into the total
radiologic
examination
can
registration,
equipment
assess
with
number
failure,
time a patient
waits
of
trans-
for a
be determined.
Because having the patient wait for a radiologic examination the shortest time possible is a major departmental priority, we evaluated the minimal number of technologists necessary to image 46,2i 6 patients who received plain film examinations during 1 year on the day shift at Children’s Hospital of Michigan. Information gathered on these patients included (i) time required to perform each examination (technologist’s time), (2) time each examination room was used (room utilization), and (3) waiting time in the department. At the onset, we arbitrarily set a goal of 20 mm total time for a patient to be in the department. Because the number of radiologic suites was fixed (four rooms), we tried to decrease examination time by (1) having “float” technologists aid with immobilization and fill in during lunches and breaks, (2) using a loading/unloading daylight system to increase our efficiency, Aeceived September 1
Both authors:
AJR 155:187-189,
and (3) having one technologist responsible for quality control. In an attempt to meet our goal, we altered patient flow patterns, coordinated these patterns with our staffing, used specific radiology transporters, and decreased the time necessary
Patients
for registration.
and Methods
For simplicity, patients were classified according to the radiologic suite, emergency or main department, in which they had their examination. Patients from the emergency department and the orthopedic clinic were imaged in the emergency department’s radiologic suite (ER patients). The diagnostic suite in the main department was used for all other clinic patients and those referred by private physicians (outpatients) and for all inpatients. This classification of ER patients, outpatients, and inpatients is important because each group had its own variables regarding total departmental time. A total of 1 30-1 50 patients between the ages of 3 days and 21
years were examined
each day. Fifty-five
percent
were examined
25, 1989; accepted after revision March 13, 1990.
Department
of Radiology,
Children’s
July 1990 0361-803x/90/1551
Hospital
of Michigan,
-0187 C American
3901
in
the emergency department’s suite and 45% in the main department. Each suite consisted of two rooms with a three-phase generator, a circa-1972 table, and a ceiling-mounted tube. The emergency department’s suite had wall-mounted daylight unloading equipment, whereas the main department’s suite had a loading/unloading cornpact daylight system. Most of the common plain film studies were performed (Table 1), but the two-view chest radiograph was the one done most frequently, accounting for more than 6O% of the total number of examinations. Whenever possible, one technologist was assigned to a room (two per suite), and two floaters were used to cover lunch and break
Beaubien
Roentgen Ray Society
Blvd.,
Detroit,
MI 48201
.
Address reprint requests to T. L. Slovis.
i 88
CARVER
TABLE 1: Time Main Department
Required
for Radiologic
Examinations
in the
Examination
Performed
Downloaded from www.ajronline.org by 110.84.188.238 on 10/12/15 from IP address 110.84.188.238. Copyright ARRS. For personal use only; all rights reserved
Examination
Time (mm) Mean
Chest Skull Sinus Bone age Scoliosis Foot
± SD
Fingers Hand Tibia/fibula Femur Elbow Shoulders (bilateral) Sacroiliac joints Orbits Abdomen Forearm Shunt survey Ankle
2 5 3 2 4 4 4 4 4 3 3 5 6 5 6 3 3 4 4
9515 414 579 203 31 8 416 53 258 158 464 455 109 45 10 94 707 393 74 1 85
Wrist
4
113
Clavicle
3 4 4 4 5 1
74 124 74 64 38 74
5.4 8.2 1 5.7 1 3.0 23.3 4.9±
2
174
12.0±2.3
45 235 86 66
16.6 20.3 9.0 20.0
Toes
Knee Facial bones Nasal bones Mandible Pelvis Hips
Complete spine Cervical spine Thoracic spine Lumbar/sacral spine Note-Examination ing, quality control,
12 5 2 5
time includes time required and repeat examinations.
4.7±0.8 9.3 ± 2.9 10.1 ± 2.4 3.6 ± 0.5 6.2 ± 0.3 6.5±0.8 5.7± 0.3 4.8 ± 0.3 5.7±1.3 7.5 ± 0.4 5.6± 1.1 5.1 ± 0.9 1 1 .0 ± 0.7 4.0 ± 1.8 8.8 ± 2.8 7.5 ± 3.4 6.7 ± 1.5 12.0 ± 2.8 5.5 ± 1.6 5.4±0.9
for immobilization,
± ± ± ± ±
± ± ± ±
1.2 0.4 4.2 3.2 3.8 1.3 2.8 5.3 1.9 4.5
AND
SLOVIS
total departmental time for 1 9,306 mm per patient. Of this, an average
outpatients was 24 ± 6 of 7 mm was devoted to registration. The average total departmental time for i 3,427 ER patients was 16 ± 3 mm per patient. This time is equivalent to their examination time because they did not require registration or transportation. In addition, we found that for 58% of the time available in the main department and for 68% in the emergency department’s suite, the radiologic examination rooms were occupied by patients. The total time spent by patients in the department in relation to the number of technologists available is shown in Figure 1.
Discussion The basis of an evaluation of a radiology department’s efficiency is the actual time required for an examination. As the number of examination suites is fixed, the first variable is the number of radiologic technologists. In pediatric radiology, technologists perform their role by gaining the child’s confidence, reassuring the patient, and in younger infants, by immobilizing the patient. Clearly, two technologists working in one suite are more efficient than one. Examination time, which includes processing, quality control, and, when necessary, immobilization and repeat examinations, is kept to a minimum by using a dedicated quality control technologist and rapid loading/unloading daylight processing systems. In the first quarter of our study, the values of all variables indicated the need for six to seven technologists on the day shift in order to come close to our goal (Fig. i). This was determined by calculating how much time was required for an examination and the total time spent in the department
process-
periods and to help with immobilization of patients and so forth. Each technologist had a total of 1 hr off during his or her shift. One additional technologist was assigned to the quality control station in the main department. This staffing pattern was not always possible, and the impact of having fewer technologists was evaluated with regard to patient flow. Times recorded were when patients arrived in the radiology department; when they entered an examination room; when they were discharged; and in the case of inpatients, when transport was called and when the patient left the department.
30
25 Tiin DWt
1usivs
of
20
ort (am)
13
10
Results In all three categories (inpatients, outpatients, and ER patients), the average time required for an examination was similar (1 5, i 7, and 1 6 mm, respectively), but extraneous factors such as time required for transportation, unscheduled
patients,
AJR:155, July 1990
and registration
greatly
influenced
5
the total amount
of time patients were in the department. Examination times and number of examinations performed in the main department in 6 months are listed in Table 1. We found that the average total departmental time (±SD) for 1 3,483 inpatients was 30 ± 8 mm per patient, half of which (1 5 ± 5 mm) was spent waiting for the transportation service to return patients to their hospital rooms. The average
0....4....5....6....7....8
Yu11-Tii
Fig. 1.-Number plotted
against
Equivalents
of full-time equivalent radiologic total time (exclusive of transport)
per
Day
technologists all patients
per day spent in
radiology department shows that a minimum of 5.8 technologists is necessary to accomplish a standard of 20 mm total time. With seven technologists,totaltime can be reduced to 15 mm.
AJA:155,July
when
perform
EFFICIENT
1990
different
numbers
the examinations.
IMAGING
of technologists
were
In addition,
we identified
available
IN PEDIATRIC
to
specific
Downloaded from www.ajronline.org by 110.84.188.238 on 10/12/15 from IP address 110.84.188.238. Copyright ARRS. For personal use only; all rights reserved
problems related to each group of patients that hindered our efforts to reach our goal of 20 mm total time in the department. Although the goal of 20 mm or less was achieved for ER
patients
(i 6 mm), the time required
for inpatients
was 30 mm,
half of which (1 5 mm) was spent waiting for transportation. The cost of employing an additional full-time person to provide patient transportation must be balanced against the negative aspects of keeping patients in the department the extra iS mm. Although these patients are inpatients, they are stable; unstable patients are examined at the bedside. Special ar-
rangements
are made for examination
of infectious
patients.
The only detriment associated with keeping inpatients in the department the additional time is that supervision in the waiting room is minimal, and often the parents are not present. The main reason times in the department were prolonged for outpatients was the wide variation in the number of patients referred for radiologic procedures from the outpatient clinic at any given time (two thirds of the patients came between 1 1 a.m. and 2 p.m.). Another reason for increased times was that some of these patients (5%) needed to register, which takes an average of an additional 7 mm. Inadequate technical staffing was minimal, and mechanical downtime was 1 1 %. As a result, the suite in the main department was in use only 58% of the time. In comparison, the emergency department’s suite was in use 68% of the time; the flow of patients was fairly constant, and downtime for this suite was 1.5%. During the second through fourth quarters, major changes were made in the main department. These included (1) conversion to the daylight system for loading/unloading, (2) reorientation of the clinics to distribute their patient flow more
equally,
and (3) adjustment
of our technologist
staffing
pat-
terns. With these changes, we were able to decrease the percentage of patients waiting more than 30 mm from 3% to 0.8% and the percentage of those waiting more than 45 mm
from 2.8% to 0.5%. Several authors [1 -7] have presented measurements of work loads productivity standards, and surveys of general
radiology
189
RADIOLOGY
department
staffing
related to the number
of radio-
logic examinations performed. These reports, however, have not included imaging of infants and children and have not considered how long it should take to perform radiologic procedures in a radiology department. Little consideration has been given to the amount of time radiologic suites are in use, a crucial determinant of productivity [3, 5]. Our study addresses these problems and provides initial standards for departmental efficiency and for assessing the number of radiologic technologists necessary in a children’s hospital setting. The goals of radiology staffing need to be reconciled with the goals of the hospital, for it is inconsistent, in terms of patient service, for a patient to wait 3 hr in a clinic and 20 mm in radiology. The hospital administration and referring physicians need to be partners in this dialog so that expectations of the time necessary for imaging are appropriate.
ACKNOWLEDGMENTS We thank our technologist and clerical staff who helped compile the data. We also thank Thomas Aozek and Ingrid Whipple for providing support and wise counsel.
REFERENCES 1 . MacEwan diagnostic
OW, Snigurowicz 0, Trypka L. Radiology workload radiology. J Can Assoc Radiol 1982;33: 183-1 96
system
for
2. Trisolini MG, Boswell SB, Johnson 5K, McNeil BJ. Radiology work-load measurements reflecting variables specific to hospital, patient, and examnation: results of a collaborative study. Radiology 1988;166:247-253 3. Janower ML. Productivity standards for technologists: how to use them. Radiology 1988;166:276-277 4. McNeil BJ, Sapienza A, van Gerpen J, et al. Radiology department management system: technologists’ costs. Radiology 1985;1 56:57-60 5. Janower ML. Radiology department management system: technologists’ costs (letter). Radiology 1986;159:566 6. Kirschner LB. Survey results: department staffing related to examination volume. Part III. 1988 AHRA Member Survey on Salary and Other Characteristics. 7. Calandrino
Radiol Manage 1989;1 1:46-48 C, O’Ambra P. Nonmedical personnel
atric radiology department.
Pediatr
Radiol
requirements
1989;19:321-324
for a pedi-
