Rethinking ED Imaging

Neuroradiologist Encourages EDs to Consider MRIs Over CTs

By Megan Headley

There’s one leading priority for clinicians working in emergency departments (ED): Find a fix, fast. But that priority doesn’t always align with health systems’ growing attention to the cost of care.

Clinicians willing to reexamine traditional ED care processes are looking for new ways to provide greater value to patients. Consider, for example, CT scans. They have become embedded in trauma workflows primarily for the speed with which they turn around images. But Dr. John Karis, a neuroradiologist and director of MRI and brain imaging at Barrow Neurological Institute at St. Joseph’s Hospital & Medical Center in Phoenix, suggests that MRIs might ultimately provide better value for patients in a number of ways.

The time versus certainty tradeoff

CTs have been the standard in the ED for years because they help physicians get to a definitive answer fast. Quickly addressing issues means speeding up patient throughput.

“Ordering an MRI in most hospitals would take many hours, including moving the patient to another department, setting up the exam, conducting the exam, and addressing any follow-up needs,” Karis acknowledges. “This means any incentive for a physician to use MRI over CT is against them, even if it might be a more fitting or accurate test for the patient’s condition.”

Yet, Karis points out, CT isn’t always the best solution for an individual’s problem, and uncertain or inaccurate diagnoses can actually lengthen the amount of time needed for patient care. This is particularly true when it comes to effectively diagnosing certain types of neuro-related cases, he says. For example, an MRI exam could potentially produce more informative diagnostic images of spinal cord damage, disc protrusions, soft tissue injuries, and stroke precursors.

“When a patient receives a CT in the ED, it’s common that they’ll inevitably need an MRI afterwards, leading to wasted resources and time,” Karis says. And, as he points out, there are long-term cost savings associated with administering the appropriate tests. Plus, Karis says, “If a physician is more confident about their diagnosis, this could potentially reduce the number of admissions in cases of doubt. With strong imaging quality at the start, EDs will realize improved workflows and eliminate the need for repeat or follow-up scans.”

There’s also the matter of radiation. By turning to MRI scans rather than CT, EDs can reduce an individual’s radiation exposure. In fact, this was one of the main reasons St. Joseph’s Hospital and Medical Center introduced MRI in its neurologic ED.

Karis offers an example of this value in action: “If a patient comes into the ED with numbness, this could be a symptom of either an ischemic event or multiple sclerosis. The CT workup of this clinical question typically involves obtaining a CT of the head and a CTA of the head and neck. CTA of the head and neck includes the thyroid gland in the field of view, thus exposing a gland with increased radiation sensitivity to potentially unnecessary radiation. By contrast, the availability of dedicated ED MRI eliminates unnecessary radiation, improves diagnostic accuracy, consolidates workflow, and streamlines patient care, providing patients with the most direct route to treatment.”

Obstacles to making the switch

Based on his experience, Karis has found that transitioning to a more MRI-friendly ED requires a cultural shift and an adjustment to new routines. He points to three potential obstacles to overcome in making this switch.

  1. Efficiency

An MRI in the ED is only practical if its turnaround time is similar to that of a CT scan. Any solution would have to address the efficiency concerns that are top of mind for EDs. Fortunately, equipment manufacturers are focused on meeting this challenge.

St. Joseph’s uses an MRI scanner that has shortened the total exam time to less than 10 minutes. While this is still longer than a typical CT, which may take two to five minutes, Karis finds that the difference becomes insignificant when looking holistically at the patient journey and the diagnostic confidence gained in those 10 minutes.

  1. Location

MRIs are not usually located in the ED and are often on a different floor, making transport and logistics harder. Ideally, an MRI scanner would be in close proximity to the ED, eliminating the need for staff to leave for extended periods of time to accompany a patient to another department or floor. However, this is particularly challenging for EDs in urban areas, which are often short on space or logistical capacity to renovate. Siting MRIs in EDs can also be complicated because of their weight, quench pipe, and costs. Addressing this early in facility design is one clear solution.

  1. Non-targeted exams

Karis notes that EDs have a tendency to perform non-targeted MRI exams, more commonly observed among less experienced staff. This makes ongoing education for newer staff critical in establishing the MRI exam as an ED test.

“Experienced neuroradiologists know the value of MRI and, in our case, adapt quickly with full confidence in the approach,” Karis says. “However, because of the quality of MRI images, it’s tempting to ask for a variety of tests. Making this a habit can make an exam much longer than 10 minutes.”

Physicians should only request MRI exams for a selected set of exam protocols, Karis says. This requires referrers to think clearly about what they want to test. It also requires a true commitment to the shorter time frame to prevent a backlog for the ED-dedicated MRI scanner.

The best-value approach

As health systems increasingly prioritize cost reduction, all departments will have to get on board. While the ED has drastically different needs and priorities than other disciplines, it still has areas where improvements can be made.

As Karis puts it, “We owe it to our patients to image most appropriately, providing the best value with the least harm.”

Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at