Mobile x-ray room service rolls into Oslo's nursing homes

In an everyday occurrence in Norway's nursing homes, a frail patient becomes dizzy or stumbles and takes a fall. The outcome is also predictable. If a fracture clearly results, the patient is sent to the hospital for treatment. On the other hand, if there is uncertainty about whether a fracture has occurred, the normal response is watchful waiting for some days-a practice that can lead to delay in diagnosis and treatment. The patient might finally be sent to the hospital by ambulance or taxi for a simple x-ray examination. This can be time-consuming and expensive, as well as distressing for the patient.

An alternative to this familiar scenario is emerging. Mobile services offer a more convenient, clinically efficacious, and less expensive approach, according to research conducted at the University of Oslo in collaboration with Ulleval University Hospital, also in the Norwegian capital.

Since September 2004, we have been testing the demand for and use of a lightweight digital radiography system at the patient's bedside in Oslo nursing homes. With the mobile system, images can be acquired and preliminarily assessed in just seconds. Images are delivered on a CD-ROM to a central reporting facility for diagnosis or transmitted directly via wireless broadband Internet.

The need for mobile services in the care of geriatric patients seems clear. In Western countries, the elderly population is set to grow dramatically by 2015, with a particularly large increase in the number of people over 85 years of age. More resources, including radiology services, will certainly be required. This trend is already pronounced in Norway. We have about 36,000 nursing home beds-three times the number of all of Norway's somatic hospital beds combined. The Oslo region has one of the highest hip fracture rates in the world.

Geriatric patients often seem to be accorded low priority and medical prestige, however. They may be confused and typically have more than three chronic diseases. In comparison with other patient groups, they are more vulnerable to environmental and social changes. Transporting nursing home patients to hospitals for radiology and other medical services is challenging. It requires complicated logistics, since ambulance transports or taxis are required to get to the hospital and back to the nursing home after the examination. A person from the nursing home must follow each patient, which is cumbersome for short-staffed institutions.

Yet the nursing home population as a patient group has not been a focus in radiology. In general, commercial vendors have not addressed the potential equipment necessities for this group. At the time we began our research some years ago, the commercially available mobile x-ray systems were extremely heavy, weighing about 400 kg to 500 kg. Considering that staff would need to travel over snow and ice to nursing homes to deliver the x-ray service and roll the equipment in and out of vehicles, the need to find a lightweight system was clear.

We decided to create a prototype by combining a lightweight conventional x-ray system from Sedecal of Spain with a high-tech digital flat-panel detector made by Canon Europe. Our prototype system weighed 94 kg and cost about Pound Sterling 140,000 (about +205,700). Since we started our research, this combined system has become commercially available.

TESTING OUR THEORIES

A series of research projects at the University of Oslo sought answers to several questions:

- How well does the prototype lightweight digital x-ray system function and how easy is it to use?

- What is the quality of digital radiography at the bedside in nursing homes, compared with heavyweight stationary systems in a hospital radiology department?

- How common are changes in chronic disease or trauma-"health events"-that require physician consultation among nursing home patients?

- What is the effect of transport to the hospital on nursing home patients?

- How does the expense of a mobile digital x-ray service compare with a hospital-based service?

As part of our research, we launched a pilot project in 2004 and 2005 serving six Oslo nursing homes with conventional x-rays on our prototype mobile system. Since we launched the pilot project, we have expanded to serve more than 30 nursing homes in Oslo and have funding to continue the service at least until the end of 2005.

The digital x-ray system is transported into the nursing home by a radiographer from a car equipped with a wheelchair ramp. The radiographer typically requires the help of one nursing home staff member to move and support the patient while he or she obtains the digital x-rays in the patient's room. Images appear on the screen within three seconds, and they can be corrected on the spot for wrong projections of the region under examination or suboptimal exposure parameters.

If no pathology is clearly evident, the images are burned onto a CD-ROM, which is then physically delivered to a central reporting facility for evaluation by a radiologist. The central reporting facility has been in the process of reinstalling its PACS, and this changeover process is the reason we have mainly been delivering the images by CD-ROM rather than transmitting them electronically. We have, however, successfully experimented with transmitting images via broadband Internet networks at gasoline station wireless hot spots to the central reporting facility.

If the radiographer notices something on the DR screen that is obviously pathologic and requires hospitalization, he or she burns a copy of the images onto a CD-ROM, which is then sent with the patient to the local hospital.

We tracked developments in our pilot project during a six-month period in 2004 and 2005. In this time, 195 examinations were performed on demand from about 30 nursing homes. To assess the use and value of the mobile digital x-ray service, we asked nursing home physicians to complete a questionnaire. We received 135 completed questionnaires that showed the mobile x-ray exam had consequences for therapy in 111 cases and for nursing care in 96 cases. Most of the exams (100) were skeletal x-rays.

Throughout the study period, the equipment was easy to use and reliable, and the quality of the studies was consistently good. We compared the images taken by the mobile digital equipment in nursing home rooms with images from heavyweight stationary equipment in a hospital department with the highest volume of conventional x-ray examinations in Norway. Images taken on the stationary equipment were slightly better, but the difference was not significant. Our research suggests that quality improves rapidly as the radiographer gains experience with the mobile DR system.

ASSESSING UTILIZATION

In a separate study, we assessed the frequency of referrals for physician consultations among patients in six nursing homes in Oslo. A population of 714 patients was followed prospectively for eight weeks. The patients ranged from 35 to 107 years of age, with a mean age of 85 years.

During the research period, more than half of the patients had a health event that required an immediate consultation with a physician. There were 453 health events, of which 114 required specialist care. Of these specialist consults, 59 called for a radiologist, and 19 of these patients had access to the mobile digital x-ray system.

Most of the demand was for conventional x-rays, typically skeletal x-rays after a fall. Older people are the sickest people in our society, but our research suggests they may actually be less likely to have conventional x-rays because it is so hard for them to get to the hospital for care. Data from our study suggest a utilization rate of 500 exams per 1000 nursing home patients per year, compared with 700 exams per 1000 patients per year in the general population.

We also believe more advanced imaging services were underutilized in our study group. Older patients living in nursing homes are prone to having strokes as well as abdominal disorders-conditions that would normally lead to referrals for more advanced imaging services. Yet only one ultrasound and two CT scans were performed on the population of 714 during the eight-week study period.

TRACKING THE TRAVEL-WEARY

Those patients who do go to the hospital may have an exhausting and disorienting experience. They are collected by an ambulance or taxi and taken away from the environment and people they know. Patients wait in hospital corridors to have a fairly simple x-ray done and then wait for the pickup. If they are traveling by ambulance, they need to be slotted into the schedule, further delaying their return home.

Our research quantified the amount of time spent in transit for a radiology exam and, in some cases, a surgical consultation. The time away depended on the type of transport. It took from one to 11.5 hours with an ambulance, with an average time of five hours. Taxis were easier and more accessible for obvious reasons, and the time out of the nursing home ranged from 1.5 to 6.5 hours, with an average of 3.4 hours.

Assessments of patients upon return revealed a highly significant tie between the time away from the nursing home and the degree of patient exhaustion. Among those who had a digital x-ray exam on a mobile system at the nursing home, there were no reports of exhaustion.

FINANCIAL OUTLOOK

Our research shows that transporting a patient to the hospital also consumes more staff and financial resources than does a mobile x-ray service. With ambulance transport, in addition to the radiologist making a diagnosis, five to seven people might be involved in getting an exam done, including the driver and codriver of the ambulance and the person riding in the back with the patient. As nursing home patients tend to be uncooperative, it might take two radiographers to move the patient for a simple x-ray exam at the hospital radiology department. A different ambulance team might take the patient back.

In contrast, with mobile digital radiography, aside from the radiologist making the diagnosis, only one or two people are involved-the radiographer and a member of the nursing home staff to help move and support the patient.

Another advantage of mobile digital x-ray services is the ability to serve more than one patient at a time. Often, when a mobile service goes to see one patient who has an immediate radiological need, other patients at the same nursing home location have a less urgent need for an x-ray. The cost of mobile services decreases if more than one patient per stop is served.

An analysis conducted by an economist at the Norwegian School of Management showed that mobile digital x-ray services could save 30% of the current costs if one patient per stop is served. If two patients per stop are served, the savings rise to 60%. Most of these savings come from cutting ambulance and taxi transport costs.

While the per-study costs would be lower, however, the introduction and promotion of mobile x-ray services could stimulate demand and utilization of radiology. In theory, this could increase overall costs, given that our research suggests nursing home patients receive 20% to 25% fewer conventional x-ray exams than the general population. We need to see how the market will react and how the health system will respond to increased x-ray availability. On the other hand, society has a strong ethical obligation to provide palliative treatment and to improve function for nursing home patients. Technical developments have made it possible to change and reorganize the way such patients can be serviced.

Results so far have been promising, and the value of performing x-rays at the bedside of nursing home patients is now well understood by most people in touch with our research project. Our data suggest that mobile DR services are better for the patient, less expensive for society, and of good diagnostic quality. We are now seeking support from Norwegian health authorities to offer mobile x-ray services on a broader scale, beyond nursing homes in Oslo. It is very important to try to make this available for the whole population-not only in the big cities but also in the less densely populated areas. In the future, we hope to see these services spread across Norway.

Prof. Laerum is a professor of medicine (experimental radiology and internationalization) at the University of Oslo in Norway.