Five years ago, the notion of 24 x 7 coverage was cutting edge. Today, the idea of 9-to-5 radiology is quaint. The issue of report turnaround, however, is a mounting problem as radiology fields the growingand frequently unrealisticexpectations of an increasingly demanding clientele.

A case in point is circumstances surrounding the tragic death 1 year ago of a 16-month-old child who entered UCLA Medical Center for corrective surgery on a cleft palate. According to a recent report in the Los Angeles Times, the child had the first of several planned corrective procedures to repair head and facial malformations caused by Treacher Collins syndrome and afterwards was taken to the pediatric intensive care unit because of difficult breathing. A chest x-ray was ordered around 8:50 pm after the child's mother, herself a registered nurse, noticed that the breathing tube moved when an attendant turned to check the breathing apparatus. The attending resident ordered another radiograph 3 hours later because the mother, who had noticed that the child's stomach was hard, believed the breathing tube was pumping air into the stomach. The resident concluded both times that the tube had not been moved, according to the article.

What actually happened is unclear and even a bit mysterious. But, according to the coroner's report, the article noted, the cause of death was a misplaced breathing tube. There is no room here to catalog the series of mistakes detailed in the report by inspectors from the California Department of Health, but, according to the article, "the hospital's radiology department, which typically reviews doctors' x-ray readings, didn't examine the records for more than 12 hours after the first one was taken, a delay criticized by state health inspectors." The health department report notes that the formal report from radiology was available at 5:15 pm the following day.

I have no doubt that in a fine radiology department such as the one at UCLA Medical Center, radiologists are available 24 x 7 if they are called. Portable radiography equipment, however, is on hand in many ICUs in medical centers throughout the country,  and it is general practice for the ordering physician (in this case a resident) to provide the initial read, whether it is 8 pm or 8 am. The inspector's report stated, "Representatives of the facilities indicated that there was no formal policy for the immediate interpretations of x-ray films obtained in the PICU, and that when such a policy was discussed with Department of Radiology physicians, these physicians stated that they were too busy' to provide immediate interpretations for radiographs obtained in the intensive care unit for airway placement verification." The Times article noted that among the system improvements promised by UCLA administrators is a policy calling for radiologists to be available at all hours to immediately review x-rays for patients in the intensive care unit.

It has become standard practice for physicians of all stripes to read radiographs. Most radiologists would concur that about 95% of radiographs are fairly routineincluding airway placement verificationand 5% are extremely difficult. But one instance like the above underscores the importance of proper training and/or experience in assessing whether a nasotracheal tube is in the esophagus or the bronchi. When members of the American College of Radiology meet this month in Washington, DC, they will consider the role that practitioner's assistants can play in alleviating the problem of a workload that is escalating faster than the workpool is growing. The college is expected to consider whether PAs should be licensed to interpret radiographs.

Radiology must act decisively to meet the rising tide of scans generated by their colleagues' referrals. It is equally important, however, to establish standards of what can be reasonably expected of a radiology service. While the outcome of that debate in Washington is uncertain, one thing is clear: The noose is tightening on the turnaround issue.

Cheryl Proval
Cproval@medpubs.com

PS. Please take a minute to log onto www.imagingeconomics.com and answer a few questions about turnaround time and stat policies at your institution. We will publish the results in an upcoming issue.