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Since 2010, radiologist assistants (RAs) in the interventional radiology department at Memorial Sloan Kettering Cancer Center (MSKCC) have assisted with more than 10 000 procedures. To investigate the influence of RAs on productivity and efficiency, the authors performed a retrospective analysis of the department’s procedure durations and start times for Mediport placements, with and without the aid of RAs, between 2010 and 2014. The authors also reviewed overall caseloads. Analysis revealed that the duration of procedures were, on average, 6 minutes shorter with the involvement of an RA in the procedure room. Further, in procedure rooms staffed with an RA, the average start time was on time, vs delayed without an RA. The findings suggest that RAs can increase efficiency, productivity, and even patient satisfaction by ensuring punctual start times and shorter procedure times.
High-quality care and minimal wait times are the expected standard in the health care setting. With the assistance of RAs, it is possible for medical centers to balance this expectation with ever-increasing patient volumes by improving productivity and efficiency.
Unlike other midlevel health care providers, RAs are specialized within the field of radiology and function under a radiologist’s supervision. Radiology departments have employed midlevel staff members as far back as the 1970s. By the 1990s, the U.S. Department of Defense revitalized the use of midlevel radiology staff because of a radiologist shortage in the military.1 In 1996, Weber State University introduced the first radiology practitioner assistant (RPA) program to help meet the demand for radiology physician extenders.1,2 In 2003, the American College of Radiology, the American Society of Radiologic Technologists, and the American Registry of Radiologic Technologists introduced the registered radiologist assistant (R.R.A.) position as an advanced-level radiographer, and the country’s first RA students graduated from Loma Linda University in 2005.2–4 Today, the ARRT recognizes 9 RA education programs in the United States.5
Before starting an RA education program, students will have learned about the effects, safety, and proper use of ionizing radiation.5 To be accepted into an accredited program, candidates must have completed approximately 2000 clinical hours as a radiologic technologist. RA clinical training encompasses virtually all radiology-based procedures, such as fluoroscopy-guided gastrointestinal, genitourinary, musculoskeletal, and interventional procedures.5 Candidates for R.R.A. certification and registration must fulfill ARRT’s education requirements to be eligible to take the R.R.A. exam. Because of their rigorous clinical training, RAs do not require extensive on-the-job training. According to Ten Napel et al, one study tied RAs’ strong technical and imaging background to their ability to work immediately with minimal additional training.6
As an extension of the radiologist and radiologic technologist, the RA is an integral part of the medical care team. Radiology departments can modify the RA’s responsibilities to meet their unique needs. MSKCC employs 4 RAs who perform a broad range of medical procedures, but they are involved most extensively with venous access procedures. The Table provides a list of the procedures RAs perform and assist with in the department. The ARRT has defined the entry-level clinical activities of the R.R.A. to include reviewing the patient’s chart to determine the appropriateness of an examination or procedure, explaining the procedure to the patient and family members, obtaining informed consent, and performing procedures.4
May described a similar workflow in which the RA has a leading role in patient management and assessment, including3:
Ten Napel et al found that the more satisfaction patients experienced, the more likely they were to return to the same provider and to refer others.6 The researchers also found that long wait times were a leading contributor to patient dissatisfaction in the radiology department.6 Similarly, McLeod and Montane cited long wait times as well as lack of communication and insensitivity to the patient’s needs as primary reasons for patient dissatisfaction.7
Providing excellent patient care has become a determining factor for reimbursement payments. As a result, patient satisfaction has moved to the forefront in health care organizations, requiring improved efficiency and shorter wait times. May inferred that RAs can relieve the workload burden of radiologists and increase productivity and efficiency.3 Ten Napel et al suggested that this boost in productivity can lead to decreased length of stays.6 Shorter visits could mean that patients receive treatment sooner, which might increase the likelihood of treatment success and decrease time spent in the hospital overall. In turn, patients’ improved clinical outcomes could reduce health care costs.
Patient care is the RA’s first responsibility. Taking time with each patient and decreasing his or her wait time is important to the patient and his or her family, and the quality of care they receive is a reflection of the medical center and its staff. RAs help interventional radiologists with the high volume of radiology procedures and demands for prompt treatment by thoroughly explaining procedures, answering patients’ questions, and spending time with patients and their family members. Assistance from RAs frees radiologists to attend to other duties after a procedure, such as completing postoperative orders or calling the referring physician to discuss next steps or critical findings.
As procedure volumes increase, the interventional radiologist’s time will be pressed further, especially because of the documentation that procedures require. RAs can take on administrative duties, perform select procedures, and assist with other procedures. This translates into effective patient care because RAs become proficient in the procedures they perform. Skilled RAs also are helpful aids when radiologists are performing complex procedures. In addition, as May suggested, RAs can spend more time with patients while radiologists focus on interventional procedures and interpretations.3
Since MSKCC hired its first RA in 2008, RAs have helped improve efficiency, productivity, and patient care in the cancer center’s interventional radiology department. As the interventional radiology department expanded, its need for RAs grew, too, just as May predicted: “The ranks of RAs will eventually expand and be commonplace alongside radiology nurses to provide quality patient care.”3
RAs rotate through several procedure rooms in the interventional radiology department at MSKCC. RAs primarily are responsible for operating these procedure rooms and looking up laboratory reports for patients to ensure they are in laboratory value range for the referred procedure. RAs also review the patient’s procedure order and pertinent imaging studies for appropriateness, and they identify correlations with the associated disease.
As part of their didactic education, RAs spend hundreds of clinical hours learning from radiologists. They are trained to recognize preliminary findings across all imaging modalities. Their radiologist-driven clinical training and education as radiologic technologists give RAs a competitive advantage. RAs are the only midlevel provider licensed to administer ionizing radiation and, as radiologic technologists, are trained to reduce radiation exposure to patients and health care professionals. Providing radiologists with initial image observations is one unique ability of RAs.6 When reviewing medical images, RAs can bring discrepancies to the attending radiologist’s attention. RAs also can complete paperwork and notes before and after procedures. This reduces administrative work for the attending radiologist and reduces delayed procedures.
Another important role RAs can perform is the case briefing. Before a procedure begins, RAs discuss the case with the physician and then communicate procedure details to the entire team. Details include what equipment will be used, the type of sedation required, positioning of the patient, and expectations for the procedure. This type of communication strengthens procedural safety and efficiency for the patient and the health care team. When the patient arrives, the RA educates him or her about the procedure. The attending radiologist verifies that the patient’s questions were answered and that informed consent was obtained
Once the patient and family have consented, the patient is placed on the procedure table. The RA helps the nurse and technologist situate the patient. While the nurse helps the patient get comfortable and the technologist sets up the tray, the RA can assist with other tasks to start the procedure. For example, he or she might localize the area with image guidance or help remove a dressing. The RA also can aseptically prepare the patient for the procedure and prepare the instrument tray. This assistance improves the efficiency of the procedure preparations and the overall procedure. The attending radiologist is present for the time-out and procedure. Once the procedure is complete, the RA can provide the attending radiologist with a preliminary report, schedule follow-up appointments if needed, and talk with the patient’s family.
When an RA is present to verify orders, review images, and follow up with the patient’s family, the attending radiologist has time to answer phone calls, reply to emails, or assist a colleague with a different case. The radiologist also is free to devote his or her attention to procedures at hand. Because RAs can perform routine examinations, radiologists also have more time to attend to complex cases. RAs also can serve as a department intermediary between physicians, technologists, and administrators.
MSKCC employs 24 interventional radiologic technologists with 2 supervisors; 19 interventional radiologists, including 3 neurointerventional radiologists; and 26 nurses. Two RAs manage the majority of venous access procedures. The third RA works with the neurointerventional radiologist, and the fourth RA rotates through the outpatient clinic. The 4 RAs prepare and perform the venous access procedures in the same fashion. The RAs take leading roles in training fellows, technologists, and residents. Training primarily consists of procedural knowledge, preparation, performance, and postprocedure care. The fundamentals established in training allow for department-wide continuity. Standardization minimizes errors, improves patient and employee safety, reduces radiation dose, and improves efficiency.
At MSKCC, the RA’s scope of practice recently expanded to include the neurointerventional radiology department and the body interventional clinic. Within the clinic, RAs meet with patients, schedule procedures, and attend to clerical paperwork. The RA also is involved in all stages of a patient’s procedure. This allows for continuity of care as well as a familiar face to help the patient and family throughout the process.
Because of their experience performing procedures, RAs are an exceptional addition to the interventional radiology clinic and neurointerventional radiology department. Their knowledge enables them to educate patients about the procedures, assist with simple clinical procedures, and prepare appropriate paperwork. As trained medical imaging professionals, RAs also can perform preliminarily reviews of medical images. While the attending radiologist discusses a procedure with one patient, the RA can gather the patient’s image studies, laboratory reports, and medical history for the radiologist’s review. Again, this type of assistance can increase efficiency throughout the interventional radiology department.
When MSKCC hired its first RA, the position’s main scope of practice focused on the interventional radiology department. Because of the value the RA brought to the team, the department hired 2 more between 2010 and 2013 and a fourth in 2015 after continued growth. In a study of patient satisfaction with RAs, Sanders called for further assessment of wait times, pace of procedures, and overall effectiveness of RAs in the radiology department.8 In this retrospective analysis, the authors reviewed the efficiency of procedures with and without the assistance of RAs in the cancer center’s interventional radiology department. Specifically, data was collected on procedure start times, procedure durations, and room turnover rates.
The analysis, focused on Mediport placements because the RA is the most involved in this procedure and it is consistent regardless of the room in which it occurs. Figure 1 displays the RAs’ involvement in Mediport placements between 2010 and 2014. Figure 2 shows that the average duration of procedures was 6 minutes shorter, on average, when an RA was involved. Figure 3 shows that procedure start times were on schedule when RAs were present. Data in Figure 4 reveals that procedures were delayed consistently when RAs were not involved. The correlation between increasing procedure volume and room completion data suggests the vital role RAs play in improving efficiency and productivity.
A daily caseload in the interventional radiology department at MSKCC is approximately 6 patients per room. This demonstrates a time savings of 30 to 65 minutes per procedure room with an assigned RA, translating to earlier patient treatments and closing procedure rooms on time. Patients typically are satisfied when their procedure starts at the scheduled time, promoting improved patient care. Making sure employees leave within their scheduled work hours also increases efficiency because it can help prevent employee burnout.
Between 2001 and 2015, the volume of all procedures in the department increased (see Figure 5). The authors did not collect data regarding room use, and RA involvement did not begin until 2010. Between 2010 and 2015, the increase in procedures appears to correlate directly to the added involvement of RAs in the procedure rooms. Further, it was found that approximately 10 250 cases were performed with the involvement of an RA. Our findings suggest that productivity and efficiency can continue to improve by adding more RA staff members. This implication aligns with McLeod and Montane’s assertion that patient turnaround times will decrease and patient interactions will increase with the addition of RAs to health care teams, and therefore improve patient satisfaction in the radiology department.7
Several factors limited this retrospective review. The staff interventional nurses perform the sedation for patient cases in some procedure rooms, and anesthesia services performs the sedation of patients in the other rooms. Although this factor does not influence the duration of procedures, it could affect procedure start times and room turnover. As mentioned earlier, the authors chose to review the Mediport procedure in their analysis because the RA is most involved in this procedure. Based on the findings regarding this procedure, it is hypothesized that all procedures involving an RA will decrease procedure time and increase productivity.
As patient volumes continue to increase, radiology departments will need to address the growing demand for shorter wait times while continuing to provide quality patient care. With the assistance of its RAs, the radiology department at MSKCC is able to increase efficiency and productivity while enhancing patient care. Other radiology departments might wish to explore the option of hiring RAs to improve their own workflows as they balance higher patient volumes with quality patient care.
Wesley Shay, MS, R.R.A., R.T.(R), has been a registered radiologist assistant for 6 years. He is employed at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, New York, and worked previously for New York University Langone Medical Center.
David Silva, MS, R.R.A., R.T.(R), is a registered radiologist assistant and manager of interventional radiography for MSKCC.
Heeralall Mohabir, MBA, R.T.(R), is senior manager of operations in interventional radiography, computed tomography, magnetic resonance imaging, ultrasonography, mammography, and regional interventional radiography for MSKCC.
Joseph Erinjeri, MD, PhD, is an interventional radiologist for MSKCC.