Als, Claudine

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LETTER TO THE EDITOROptimizing patient throughput in nuclear medicine:a semi-quantitative tool for scheduling bone scintigraphyClaudine AlsPublished online: 10 October 2007# Springer-Verlag 2007Dear Sir,A busy nuclear medicine department may be defined by ahigh patient throughput and a high number of data acquisi-tions in relation to the number of gamma cameras at disposal.Hence, optimizing camera occupation while preservingconstant quality standards is mandatory. This is especiallytrue in case the unit is part of a hospital setting, whereappointment planning for out-patients has to face up everyday with urgent demands concerning hospitalized patients. Asin a small country such as Luxembourg, where the nuclearmedicine market is commercially speaking insignificant,another reality that dedicated computer programmes tailoredto our national needs and covering administrative as well asscheduling purposes do unfortunately not exist.The problem in scheduling is that some scintigraphicprocedures require a constant camera acquisition time perpatient independently of the clinical indication and thatsome others do not. Protocols with a rather stableacquisition time per patient are, for instance myocardialperfusion, thyroid uptake and imaging, pulmonary ventila-tion and perfusion, static and dynamic renal scans.Appointment schedules are then rather easily organized.The situation is, however, different with bone scintigraphy,as camera acquisition time varies substantially with theclinical indication, spanning theoretically from someminutes to some hours. Therefore, scheduling constantacquisition times per bone scan would result in undesiredpatient waiting as well as in blank camera periods. As bonescintigraphy is a frequent exam in any department ofnuclear medicine, the question is quite relevant. We haveenhanced the efficiency of scheduling bone scintigramswith a semi-quantitative approach.In our department, all scintigraphic orders (‘ordonnances’)by referring physicians, and especially orders for bone scans,are evaluated by the medical doctor (MD) specialist in nuclearmedicine before attributing an appointment to the patient.Depending on the clinical indication, the MD decides upon thenecessity of mono- vs bi-sequential acquisitions, of earlyimages, of late phase planar and/or SPECT images. To describethe scheduled camera sequences per bone scan, we developeda standardized semi-quantitative code (Tables 1 and 2) withthe following aims:1. to have the cameras busy as much as possible perworking day and to avoid blank periods,2. to facilitate communication within the medico-technicalteam concerning patient scheduling and throughput,3. to have patients wait as little as possible in the waitingroom upon arrival,4. to provide patient appointments with a delay as short aspossible.The semi-quantitative code consists of two numbers. Thefirst number defines the necessity or not of an early(vascular) phase acquisition (Table 1). The second numberroughly defines the duration of late phase acquisitions(Table 1). Some clinical examples are given in Table 2.From a practical point of view and according to Tables 1and 2:Eur J Nucl Med Mol Imaging (2007) 34:2145–2146DOI 10.1007/s00259-007-0596-xC. Als (*)Department of Nuclear Medicine, Clinique Ste Thérèse,36, rue Ste Zithe,2763 Luxembourg, Grand Duchy of Luxembourge-mail: claudine.als@cst.luC. AlsInstitute of Clinical Chemistry, University of Bern, Inselspital,3010 Bern, Switzerland1. theMD allocates the relevant semi-quantitative code to thebone scan order,2. the reception team is thereafter able to efficiently allocatepatient appointments related to the available cameras,3. the camera programme is more efficiently ‘filled up’due to standardized communication and thereby patientthroughput is increased,4. as an example, late phase images of three consecutivepatients with an injury of the foot may, for instance beacquired on one camera while within a similar timespan, images of a patient with a set-up for polyarthritisare acquired on another camera,5. if necessary, in case of an equivocal or uncertainsituation, additional acquisitions may be ordered at theend of the scheduled protocol and after clinicalexamination, so that the system is flexible,6. the code is probably as well applicable to a nuclearmedicine unit with one as with several gamma cameras,7. in a unit with more than one camera, last-minuteflexibility is nevertheless higher, as additional imagesmay be acquired on another camera than the one in usefor the initially scheduled acquisitions,8. be it only for patients coming late for their appointment orcancelling their exam at the last minute, the system anywayhas to deal with delays and, thus anyway, is flexible.In conclusion, and in absence of a dedicated nationalcomputer programme, we tried to resolve the schedulingproblems of our medico-technical team, generated byhighly variable acquisition times with bone scans, spanningfrom some minutes to hours (Table 2). We thereforeinvented and implemented the above-described standard-ized code. The code is of course free of charge. Introduc-tion and acceptance of the code in our department gave noproblems. The higher the part of bone scans performed witha ‘non-basic’ protocol (i.e. basic protocol=whole body lateimages), the higher the impact of timing on fluidity ofpatient throughput. Camera planning and patient throughputbecame more convenient and more efficient. Patientsatisfaction increased due to lesser waiting times. Feelingof stress within the team greatly decreased. All concernedactors—patients, staff and MDs—considered theseimprovements as relevant and as highly satisfying. Werecommend this convenient and cheap tool to any busydepartment of nuclear medicine interested in efficiency andin an improved cost-benefit relation.Table 2 Practical clinical examples of the bi-numbered code applied to bone scans in our departmentClinical indications(examples)Vascular phaseimages necessary?Osseous phase, type of imageacquisitions and scheduledduration (min)Total durationosseousphase (min)Bi-numberedcodeLumbar backpain (yes) 1 static image (5’) 25–30 1–2Lumbar SPECT (20’)Loosening of hip prosthesis? Yes 1 static image (5’) 25–30 1–2Hip-femur SPECT (20’)Osseous metastases? None Whole body planar (20’) 20–25 0–2Algodystrophy? Yes 3–5 static images of limb (à 5’) 15–30 1–1(2)Injury of foot? Yes 2–3 static images of feet/ankles (à 5’) 10–20 1–1Polyarthritis or other rheumatic condition? Yes Whole body planar (20’) 45 1–3Feet+hands/wrists (4 images à 5’)Spondylarthritis? Yes Whole body planar (20’) >6 1–4Feet+hands/wrists (4 images à 5’)Thoraco-lumbar SPECT (20’)The scheduled duration includes patient installation/handling under the camera. Thereby patient throughput and efficiency of the department areincreased.Table 1 A semi-quantitative code derived from the indication forbone scintigraphy roughly defines the scheduled duration of cameraacquisition per patientDefinition of the bi-numbered code for bone scintigraphy (×-×)First number (defines necessityor not of early/vascular phase)Second number (indicates roughduration of late/osseous phaseacquisition)0=no early phase acquisitionsrequired; 1=with early phaseacquisition(s)1=±15 minutes2=±30 minutes3=±45 minutes4=±60 minutes2146 Eur J Nucl Med Mol Imaging (2007) 34:2145–2146

Optimizing patient throughput in nuclear medicine: a semi-quantitative tool for scheduling bone scintigraphy

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Optimizing patient throughput in nuclear medicine: a semi-quantitative tool for scheduling bone scintigraphy

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