Wada et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine(2018) 26:17
https://doi.org/10.1186/s13049-018-0484-3

COMMENTARYOpen AccessFirst installation of a dual-room IVR-CT
system in the emergency room
Daiki Wada1*, Yasushi Nakamori1, Shuji Kanayama1, Shuhei Maruyama1, Masahiro Kawada1, Hiromu Iwamura1,Koichi Hayakawa1, Fukuki Saito1 and Yasuyuki Kuwagata2

Abstract
Computed tomography (CT) embedded in the emergency room has gained importance in the early diagnostic phaseof trauma care. In 2011, we implemented a new trauma workflow concept with a sliding CT scanner system withinterventional radiology features (IVR-CT) that allows CT examination and emergency therapeutic intervention without
relocating the patient, which we call the Hybrid emergency room (Hybrid ER). In the Hybrid ER, all life-saving procedures,
CT examination, damage control surgery, and transcatheter arterial embolisation can be performed on the same table.
Although the trauma workflow realized in the Hybrid ER may improve mortality in severe trauma, the Hybrid ER canpotentially affect the efficacy of other in/outpatient diagnostic workflow because one room is occupied by one severely
injured patient undergoing both emergency trauma care and CT scanning for long periods. In July 2017, we implemented
a new trauma workflow concept with a dual-room sliding CT scanner system with interventional radiology features(dual-room IVR-CT) to increase patient throughput. When we perform emergency surgery or interventional radiology
for a severely injured or ill patient in the Hybrid ER, the sliding CT scanner moves to the adjacent CT suite, and we canperform CT scanning of another in/outpatient. We believe that dual-room IVR-CT can contribute to the improvement ofboth the survival of severely injured or ill patients and patient throughput.
Keywords: Whole-body computed tomography, IVR-CT, Hybrid ER, Dual-room IVR-CT

Background
Knowledge on whole-body computed tomography fortraumaWhole-body computed tomography (WBCT) has gained
importance in the early diagnostic phase of trauma care.
Huber-Wagner et al. [1] and Yeguiayan et al. [2] have suggested benefits of WBCT for patient survival. Although amulticentre randomised study by Sierink et al. showed thatdiagnosing patients with an immediate total-body CT scandoes not reduce in-hospital mortality compared with thestandard radiological work-up, they suggested that improvement in the selection of patients who may benefit fromimmediate total-body CT should be the subject of future research [3]. We have shown that CT performed before emergency bleeding control might be associated with improved
survival, especially in severe trauma patients with a Trauma* Correspondence: dk0116-w@live.jp
1
Department of Emergency and Critical Care Medicine, Kansai Medical
University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507,
Japan
Full list of author information is available at the end of the article

and Injury Severity Score probability of survival of < 50%[4]. Huber-Wagner et al. also showed that WBCT during
trauma resuscitation significantly increased survival in
haemodynamically unstable patients with major trauma [5].
CT scanner installation within the emergency room

CT installed in the emergency room (ER) has also become
important for early diagnosis in trauma care. Several studies
have shown time and patient benefits in ER management byinstalling a CT gantry [6–8]. Although this concept substantially diminishes delays in transferring patients to the CTscanner, patient transfer to specialised departments fordefinitive therapy remain as one rate-limiting step in achieving maximum therapeutic workup.
Introduction of IVR-CT into trauma workflow

We initially implemented a new trauma workflow concept
with a sliding CT scanner system with interventional radiology features (IVR-CT) that allows CT examination andemergency therapeutic intervention without relocating thepatient, which we call the Hybrid ER (Fig. 1). All workup© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Wada et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:17

Page 2 of 4AFCDEBFig. 1 Photograph showing our IVR-CT system in the emergency room. All life-saving procedures including airway management, emergency surgery, andTAE can be performed on the table without relocating the patient. (A) Sliding CT scanner, (B) CT examination and intervention table, (C) moveable C-arm,(D) 56-in. monitor screen, (E) ultrasonography equipment, and (F) mechanical ventilator

times including time to CT initiation and start of bleeding
control procedures (transcatheter arterial embolisation[TAE] and definitive surgical therapy) with our new protocol were significantly shorter than those with the conventional protocol [9]. Presently, eight trauma centres in Japan
have a Hybrid ER. We previously revealed by retrospective
cohort study at a tertiary hospital that this novel trauma
workflow, comprising immediate CT diagnosis and rapid
bleeding control without patient transfer, may improvemortality in severe trauma [10].
Introduction of dual-room IVR-CT into trauma workflow

Being a one-room solution, the Hybrid ER can potentiallyaffect the efficacy of other in/outpatient diagnostic workflow
because one room is occupied by one severely injured patient undergoing both emergency trauma care and CT scanning. Recently, Frellesen et al. reported that sliding-gantry
CT embedded in a dual-room solution without IVR features
allows for significant time savings in the diagnostic workupof polytrauma patients, and faster resumption of the regular
in/outpatient CT schedule is possible [11]. Therefore, in July
2017, we implemented a new trauma workflow concept witha dual-room IVR-CT to increase patient throughput.

Main text
Before the introduction of the dual-room IVR-CT in ourHybrid ER trauma workflow concept, a multislice IVR-CTsystem (Aquilion PRIME, TSX-303B; Toshiba Medical Systems Corp., Tochigi, Japan) was installed in our ER. In ourHybrid ER workflow, when a patient is admitted to our ER,
all life-saving procedures including airway management,
CT examinations, emergency surgery, and TAE can be
performed on the same table (Fig. 1). The primaryadvantage of our Hybrid ER workflow is the ability to initiate emergency bleeding control procedures after completion of the diagnostic workup without transferring thepatient to the radiology department or operating room.
The obvious disadvantage of this workflow is that the Hybrid ER can be occupied for long periods during bleeding
control procedures.
Approximately 2000 patients are admitted to our emergency department per year. In 2016, we treated 380 (20%)
trauma patients, which included 120 patients with severe
trauma (Injury Severity Score > 16) and 1370 (73%) patientswith severe illnesses such as sepsis, cardiovascular disease,cerebrovascular disease, gastrointestinal disease, and cardiopulmonary arrest. We have recently needed to cope withthe diversifying needs of emergency medicine in Japan because of the important problem of elderly emergency patients as Japan’s society ages.
At that time, we had two conventional resuscitation
rooms and the Hybrid ER. The Hybrid ER is available toboth severely injured patients requiring definitive therapy
and to severely ill patients such as those with acute myocardial infarction requiring percutaneous coronary intervention
supported by veno-arterial extracorporeal membrane oxygenation (ECMO) or with acute interstitial pneumonia andacute respiratory failure requiring veno-veno ECMO. However, because such procedures occupy the Hybrid ER forlong periods, we cannot perform CT examination in the Hybrid ER. This resulted in an economic problem in that theefficacy of other in/outpatient diagnostic workflow was reduced when the Hybrid ER was occupied.
In July 2017, we implemented a new workflow concept
with a dual-room IVR-CT. We installed one Hybrid ER
and one new CT suite that has a radiolucent table (Fig. 2).

Wada et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:17

Page 3 of 4Fig. 2 Photographs showing the dual-room sliding CT scanner system with interventional radiology features. The new CT suite has another radiolucent
table. When we perform emergency surgery or interventional radiology for a severely injured or ill patient in the regular emergency room, the sliding CT
scanner is moved to the new adjacent CT suite with the radiolucent table, and we can perform CT scanning of another in/outpatient

These two rooms are separated by moveable door, and thesliding CT scanner moves between these two rooms depending on need. When we perform emergency surgery
or IVR procedures for a severely injured or ill patient in
the Hybrid ER, the sliding CT scanner is moved to thenew CT suite, and we can perform CT scanning of another in/outpatient. Actually, while one severely injured
patient is being treated in the existing Hybrid ER, if another moderately severe patient is admitted, the patient
can be brought into the new CT suite for CT examination.
After a diagnosis is made, the diagnostic room is rapidly
vacated and readied for further use. If no patients are admitted to the Hybrid ER, intensive care unit patientsscheduled for CT can be also brought into the new CT
suite and scanned. To further reveal the efficiency of oursystem, we need to collect and evaluate the number of admitted in/outpatients and definitive interventions
performed, especially of patients undergoing CT scans.
There are several limitations in this study. First, this is aretrospective historical control study and not a randomized control study. Second, this study is conducted in asingle institution. Third, the sample size is small. Thus,
further study is required to evaluate the value of thisworkflow concept, including adverse events such as
wound infection or sepsis that could be related to the performance of surgical procedures in the ER. We believethat this system may have a positive impact on the survivalof severe trauma and seriously ill patients and improve patient throughput. In particular, we would like to see thissystem introduced to major trauma and tertiary care hospitals in urban areas and to local core hospitals in rural

areas that treat trauma and seriously ill patients along withmany moderately ill patients. However, there may be important limitations in terms of the 24-h availability of
trauma surgeons, radiologists, and radiology technicians
to take advantage of this system.

Conclusion
We report a new workflow concept using a dual-room
sliding CT scanner system with interventional radiologyfeatures. We believe that this system can contribute toimproving the survival of severely injured and ill patientsand can become the norm for patient throughput inemergency and critical care centres in the future.
Abbreviations
ER: Emergency room; IVR: Interventional radiology; dual-room IVR-CT: Dual-room
sliding CT scanner system with interventional radiology features;
TAE: Transcatheter arterial embolisation; WBCT: Whole-body computed
tomography
Acknowledgements
Not applicable.
Funding
There are no sources of funding for this commentary.
Availability of data and materials
Not applicable.
Authors’ contributions
DW drafted the manuscript. SK, SM, MK, HI, and FS were involved intreatments performed in the novel emergency department. YN, KH, and YK
helped to draft the manuscript. YN had a major impact on critical appraisalof manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.

Wada et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:17

Page 4 of 4Consent for publication
Not applicable.
Competing interests
The authors declare that they have competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Author details
1Department of Emergency and Critical Care Medicine, Kansai Medical
University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507,
Japan. 2Department of Emergency and Critical Care Medicine, Kansai Medical
University Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
Received: 3 October 2017 Accepted: 27 February 2018

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