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For other articles and previous issues click here. March 7, 2005 Turning
Up the Volume Volumetric studies may poise ultrasound for a major expansion in applications, use, and productivity. The conventional way ultrasound scans are done: The patient lies on the examining table as the sonographer positions the transducer above the organ or area of interest. The sonographer tells the patient to hold his or her breath, freezes each image, and takes the necessary measurements. “You need to repeat these steps multiple times with conventional ultrasound,” said JP Moreland, RT(R)(CT), RDMS, RVS, a senior sonographer at Celebration Health, part of the seven-campus Florida Hospital system. Depending on the exam type, it takes between 20 and 40 minutes to complete. The patient must wait in the exam room while the radiologist reviews the images on a workstation. If the radiologist sees something questionable, additional images must be obtained. Then the patient must get back onto the table while the sonographer rescans the area in question. “This is often inconvenient, time-consuming, and costly,” Moreland said. New Paradigm “You need one breath hold, one sweep and one button push, and you’re done in that plane,” Moreland said. “You move 90° to that plane, sweep again, and you’re done with that organ.” Acquiring the exam in volume and archiving the information to an offline workstation frees the patient to get dressed and leave the department—generally in less than eight minutes. The radiologist reviews the images on a flat-screen, high-resolution workstation with the capability to manipulate the volume of raw data to reconstruct a 3-D image of any organ or area of interest. If the physician sees something of interest, he or she can virtually rescan by reexamining that volume of information, looking at different slices as if the doctor were in the room scanning the patient. “There’s no need to repeat any part of the sonogram. The radiologist can phone the ordering physician and report the results,” Moreland said. A sonographer for 15 years, Moreland has done ultrasound conventionally for most of his career. Over the last four to five months, Moreland has become a champion of volume imaging protocol (VIP), the process developed at Celebration. No Return The use of volumetric ultrasound has really exploded
over the past several years worldwide, said Jim Brown, senior director,
clinical marketing for Philips Medical Systems’ ultrasound
business. As data-acquisition and postprocessing capabilities evolve,
“we’re seeing more and more of our customer base start
to embrace this,” Brown said. One reason for the growth in usage is cost. As with any new technology, the cost of volumetric ultrasound equipment has also decreased over time, making it more affordable, says William J. Carrano, vice president of marketing for Siemens Medical Solutions’ ultrasound business. “We’re seeing faster and faster computer processing speeds at lower and lower costs to manufacturers,” Carrano said. “So we can look at incorporating this faster computer power into an ultrasound system and not substantially raise the price of that ultrasound system where it’s out of reach for hospitals and imaging centers. Add to that the fact that ultrasound transducer technology is advancing rapidly in the area of high-resolution, four-dimensional imaging and you have a paradigm shift in the way ultrasound is going to be practiced in the future.” The marketers believe it still will take some time for volumetric ultrasound to become routine—protocols are still being written, and some technical challenges remain. For example, standards for archiving 3-D digital ultrasound images have yet to be approved. Also, it’s not possible to collect Doppler information with volumetric ultrasound as of yet. However, the marketers are convinced that volumetric ultrasound has such potential that it could make sonograms the imaging modality of first choice in many diagnostic areas where it had never even been considered. Terri Bresenham, vice president of diagnostic ultrasound for GE Healthcare, believes this to be “a really exciting time to be in the ultrasound world because of the changes underway. It’s all very positive for the patient and the caregiver.” She believes the potential of using ultrasound equipment to gather a volume set of raw data and being able to manipulate that data on offline workstations brings the modality in line with what’s been happening in CT and MRI. Cardiology and Breast Cancer Brad Uricchio, MD, medical director for imaging at Celebration, found that volumetric acquisitions vastly improved diagnostic confidence with pelvic and breast sonograms. “But it proved beneficial in all exams,” he said. The only area where Celebration did not use volumetric ultrasound was obstetrics—although it expects to soon. Ultrasound has always had the advantage of being fast, noninvasive, nonradioactive, and relatively inexpensive compared with CT and MRI. Volumetric ultrasound takes advantage of those benefits and adds more. Because volumetric ultrasound scans are fast, they can improve workflow. Because the sonographer has to sweep the area of interest only one time vs. obtaining multiple images manually, volume scans should decrease the incidence of work-related repetitive stress injuries among sonographers. And by providing more precise, dynamic information—along multiple planes—volumetric ultrasound should also make physicians more confident in their diagnosis and treatment plans. Celebration Health recently found that volumetric ultrasound scans could be completed approximately 60% faster than conventional ultrasound. Boosting Productivity As reimbursements continue to stagnate or decline, providers must make up for lost revenues by increasing patient volume, Bresenham said. Volume sonography allows providers to accommodate a growing number of studies without the need for additional staff or equipment. It could even help the facility attract more patients because it offers faster exam and report turnaround, she said. With conventional ultrasound, Bresenham said, the physician looking at 2-D images on his workstation sometimes says, “‘I’m not quite sure’ or ‘I would like to see a different view of that organ.’ In that case, his only option is to go back and rescan the patient.” Rendering the images in 4-D on a GE LOGIQworks workstation, “he can change the orientation and get the information he is looking for. There is no need to rescan, which is one of the key elements of productivity gain.” Additionally, volume scanning also helps reduce unnecessary patient anxiety, Bresenham said. “Instead of sitting half-naked in a cold room waiting for them to decide if they can release you, you have the scan done and are released. The answer is forthcoming.” The physician wanting to see another angle and ordering a rescan can frighten the patient. Often the physician needs to see another plane only to confirm that nothing is abnormal. Under the new paradigm, the physician gets his second look without the patient ever knowing it, thus avoiding that unnecessary anxiety, Bresenham said. Volumetric sonography is not a costly investment
for imaging centers. Sonographers can use their conventional 2-D
transducer to do a manual sweep. “You could purchase an electronic
3-D or 4-D probe and the software that runs them, which is about
$15,000 to $20,000,” Bresenham said. GE’s LOGIQworks
workstations cost approximately $30,000. Sonographers do have to learn how to scan differently. “There is a learning curve,” Grady said, “though not a steep one.” Some sonographers, Moreland said, may be wary of the new volume protocols, “but when they experience the diagnostic power and overall advantages volume imaging provides, like my colleagues have, I am certain they, too, will embrace this scan technique wholeheartedly.” Between July and November of last year, Carrano spoke with more than 2,500 potential customers in different cities across the country. “And whenever I talk about it,” he said, “I get a very positive response from sonographers. They’re all very excited about it, so I don’t think there will be a lot of resistance.” Sonographer Acceptance Bresenham said sonographers who have used GE’s volumetric technology have said it makes their job much more gratifying because they can spend more time talking to patients. Ordinarily, “when sonographers are in a scanning mode, they’re not as interactive with the patient because they’re concentrating on their work.” When a sweep takes only a few seconds, it’s not as limiting. Also, volumetric ultrasound could help a major problem in the profession: work-related repetitive stress injuries. Studies have shown that as many as 80% of sonographers scan in pain and as many as 20% have injuries serious enough for them to have to leave their jobs. Reducing Repetitive Stress “One of the benefits of [volumetric] ultrasound is that sonographers will spend less time on probes, and that’s likely to prevent some of the repetitive stress injuries that we see,” Bresenham said. Those who have used it say volumetric ultrasound improves study quality and accuracy. The quality is higher because radiologists get a dynamic look at what they’ve historically had to evaluate with static images. “It’s much easier to put your trust in the sonographer’s impressions if you are watching the data acquisition in real time, which is what volume imaging protocol does,” Grady said. Now the radiologists look at images from the study as if they were scanning themselves. “That obviously elevates diagnostic confidence,” Grady said. Volumetric studies can also make the sonographer more confident, Carrano says. When taking conventional 2-D slices, “you always have the question, ‘Did I fully interrogate the region of interest? Do I know if I indeed got all the suspected abnormal tissue or pathology?’ With volumetric ultrasound, it’s easy for the sonographer to walk away from the data knowing you got the right volume of data.” CAD Assistance Most volumetric systems in use today are at leading-edge institutions. “We’re still several years away from this being widespread use,” said Philips’ Brown. However, manufacturers expect that because of the many advantages, this technology may be adopted faster than some others. Carrano said the interest level, particularly among radiologists and cardiologists, “is ramping up pretty quickly.” He suspects that its adoption may be fairly rapid because healthcare providers are under enormous pressure today to scan more patients in less time and optimize workflow, and volumetric ultrasound offers them the opportunity to do both. Florida Hospital is planning to set up VIP rooms where patients undergo volumetric scans at all of its facilities. Patients will be scheduled 10 minutes apart, where as now it’s closer to one hour, Grady said. Bresenham believes that within three to five years, the technology will be so improved—the Doppler and DICOM archiving issues will be solved—that volumetric ultrasound will completely replace 2-D scanning. “I think it’s that revolutionary,” she said. — Beth W. Orenstein is a freelance health writer who lives in Northampton, Pa. She is a frequent contributor to Radiology Today. |
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