A Physician’s Perspective Lisa A. Laurent, MD Advanced Radiology Consultants Park Ridge, Illinois Fellow Institute of Medicine of Chicago Medical Director Body CT Medical Director Ultrasound Advocate Lutheran General Hospital Park Ridge, Illinois Unless otherwise indicated, all trademarks are owned by MEDRAD, INC. or licensed for its use.

Current Situation Advocate Lutheran General Hospital 638 bed hospital 5 CT suites 22 technologists (all registry certified) Upgraded 16 GE slice to 64-slice GE Discovery™ CT750 HD Commenced implementation of Adaptive Statistical Iterative Reconstruction (ASIR) Located in busy Level I ED trauma center

Implementation Issues Creation of contrast protocols for the new scanner with ASIR technology How do you create protocols as you change radiation dose? How do you increase image quality? What are tools to ensure continuous improvement? Partners in development Contrast company OEM scanner Injector company Identified PE studies as a potential challenge

CT Pulmonary Angiography (PA) Challenges Gold standard for diagnosis of pulmonary embolism High percentage of sub-optimal diagnostic studies University of Pittsburgh Medical Center 27%* University of Albany 30%† Kelly AM, Patel S, Kazerooni EA. CT pulmonary 24% angiography for accurate pulmonary embolism in ICU patients clinical experience (abstr.) Radiology. 2002; 225(p):385 Sub-optimal studies have been shown to result in additional* Imaging studies Medical therapy Hospital admission CTPA is gold standard for ruling out PE CTPA has been shown to have a high percentage of sub-optimal studies And sub-optimal studies have repeat exams or other exams ordered. Sometimes with admission & therapy given because they just can’t tell. *A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism.  Christopher R Deible MD, PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis MD1. Society of Thoracic Radiology 2008. E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center. †Patient Outcomes and Resource Utilization for Emergency Department Patients with Suspected Pulmonary Embolism and Initial Chest Computed Tomography Angiography Studies Deemed Suboptimal for Interpretation; Annals of Emergency Medicine; VOLUME 54 NUMBER SEPTEMBER 2009; Weinstein J, Burton J, Katz B/Albany Medical Center, Albany, NY

P3T® PA Clinical Trial* “Higher percentage of exams ranked as diagnostic without limitation…” “Better contrast enhancement of pulmonary arteries…” Note: at a slightly higher contrast dose than standard scan protocol at 80 mL Implementing P3T to rule out PE in a clinical trial at UPMC (GE64, 350 concentration, 60pt) P3T demonstrated higher percent of diagnostic studies Going back to what happens with sub-optimals… this is potentially reducing radiation exposure to patients due to possibly lower repeat rate Better contrast enhancement It did have a slightly higher dose vs the standard protocol *A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism.  Christopher R Deible MD, PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis MD1.  Society of Thoracic Radiology 2008. E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.

P3T® PA Results: Pulmonary CTA Qualitative Assessment of CTs Obtained With P3T® vs Standard Protocol* (Lacomis, Deible, Federle) University of Pittsburgh Presented at Society Thoracic Radiology 2008, Submitted to AJR in 2010 60 patient (prospective and randomized design) study, ED patients suspected of PE 64-slice VCT (GEHC) Omnipaque 350 mg/ml August 2006 to March 2007 *Used by permission.

Advocate Lutheran General Hospital Experience

Implementation Plan Invest in Certegra™ software package from MEDRAD P3T® PA – weight-based dosing software for PA Connect.PACS™ Application Manage.Report™ Application Significant training plan

P3T® Software P3T® calculates the appropriate dose for each patient by computing custom injection protocols, enabling personalized care and patient care while maintaining efficient workflow

P3T® Software P3T® calculates custom injection protocols as well as scan timing for each patient using 4 primary components Patient and procedure data gathered by health care personnel P3T® algorithm for protocol generation DualFlow technology (the simultaneous injection of contrast and saline) Use of a transit or timing bolus

PE Exam Challenge and Process The challenge: to perform diagnostic quality PE exams in a consistent fashion for all patient body habitus types, regardless of age and clinical presentation The process: to implement P3T® Software Retrospectively reviewed all adult PE studies performed since May 1, 2011 Used software tracking processes Determined best practices for coaching technologists, educating radiologists, and developing a team approach to create total departmental engagement

How Is This Analysis Made Possible? Data Accurate Accessible Automated Connect.PACS™ Application Point-of-care decision Provides a way to retrospectively analyze data Real-world proof as opposed to assumption

Using the Data to Drive Results Easily able to identify reasons behind PE limitations Technologist adoption Flow-rate—limiting issues Contrast efficiency

Using the Data to Drive Results Building a Team

Protocol Adherence: First 6 Weeks

Protocol Adherence: Last 6 Weeks

PE Exam Analysis Breakdown 199 PE exams completed (May 1, 2011, through July 31, 2011) 23 exams deemed nondiagnostic (11.6%) 14 of these exams, the technologist did not use P3T® (7.0%) 9 nondiagnostic exams used P3T® (4.5%) 3 caused by motion artifact 1 caused by the use of Isovue® 300 vs Isovue 370 5 caused by flow-rate-limiting issues due to catheter restrictions

CT Chest Pulmonary Embolism Suboptimal Analysis 199 Total Studies May 1st – July 31st 110 with P3T 89 without P3T 55% 45% 9 Sub-Optimal 14 Sub-Optimal 8% 16% 23 Total Suboptimal Studies

PE Exam Analysis Breakdown 219 exams reviewed (August 1, 2011 through October 19, 2011) 17 exams deemed suboptimal (7.8%) All exams used P3T® software Cross referenced Certegra™ data vs RIS Data-mining capabilities identified that 8 of the 17 exams were performed during a certain time of the day Facilitated focused education and coaching to improve results in the future

PE Exam Analysis Breakdown ALGH results and progress since May 1st Certegra™ implementation Non-diagnostic/Suboptimal PE Exams

Snapshot of Data Gender Study Time Study Description Brand Concentration Lot Loaded (mL) Delivered (mL) Female 2:54 CT CHEST PULM EMBOLISM Isovue 370 -- 96.51 95.43 1:24 92.5 73.61 Male 21:00 95.44 11:12 74.45 49.59 5:00 100.61 73.35 0:33 92.54 91.68 11:53 74.55 73.14 18:14 96.59 95.24 1:12 120.78 119.45 17:04 90.78 23:34 68.55 67.15

ACR Guidelines for Communication of Diagnostic Findings Procedures and materials The report should include a description of the studies and/or procedures performed and any contrast media and/or radio-pharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere.

Documentation Gaps Analysis of Documentation Accuracy Methodology RIS (Manual Capture) PACS (Manual Capture) Injector (Automated) Methodology Pulled 102 accounts and reviewed documentation across 3 different documentation techniques

Examples

Results of Documentation Deviation from Actual Injection Record

Other Observations on Manual Data No Saline Delivery Information Captured No Flow Rate Information Captured Protocol Information Not Captured

Vision – Offer Closed Loop Contrast Dose Management history Hospital Ref Physician HL/7 Radiology HL/7 ISI Protocol Management HIS/EMR PHR CT scanner DICOM Stellant RIS Pharmacy Billing Reporting DICOM Certegra Speech Recognition PACS Modality Utilization and Analytics MEDRAD Confidential, Internal Use Only

Appendix

Flow Rates and Pressures Pressure Related to Contrast Flow Rates with 22 g Catheters for CT Exams Flow rates with Isovue® 300 concentration (mL/s) Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco and none should be implied.

Flow Rates and Pressures Pressure Related to Contrast Flow Rates with 20 g Catheters for CT Exams Flow rates with Isovue® 370 concentration (mL/s) Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco and none should be implied.

Using the Data to Drive Results Contrast Efficiency

Contrast Efficiency For the past 219 PE exams: ALGH averaged 79.3 mL of contrast Compared to 100 to 125 mL of contrast without P3T® software

Contrast Waste Per Month

Conclusions Delivering contrast has become more challenging with the faster scanners CT suites need more tools to customize the dose per patient and manage results Using P3T® PA for PE exams, ALGH improved diagnostic outcomes while lowering contrast volumes Connect.PACS™ tools allowed for accurate quality analysis of PE exams and established action plans for further improvement

THANK YOU Questions? 35