CASE STUDIES IN CLINICAL PRACTICE MANAGEMENT
Objective Evaluation of CT Time Efficiency
in Acute Stroke Response
Christina L. Brunnquell, PhD, Gregory D. Avey, MD, Timothy P. Szczykutowicz, PhD
DESCRIPTION OF THE
PROBLEM
Timely diagnosis and therapy is
essential in stroke response, because
time-efficient CT imaging in acute
stroke can significantly contribute to
preserved neural circuitry and
improved patient outcomes [1,2].
Streamlining of acute stroke CT
procedures can play an important
role in reducing door-to-needle
times. In addition to rapid imaging,
accessibility of imaging series to
interpreting radiologists before ex-
amination completion is vital for
rapid decision making and patient
management. Because different se-
ries have different urgency (eg, head
without contrast scans should be
acquired and interpreted and results
communicated within several mi-
nutes), series-level measurements are
essential. Existing commercial image
analytics platforms do not typically
address such detailed workflow steps.
A variety of efforts are undertaken
to provide consistently efficient CT
imaging and interpretation in our
radiology department, including
technologist training, protocol and
policy changes, and implementation
of software solutions [3]. However,
neither the baseline performance nor
the effect of these interventions on
imaging efficiency is well understood
in an objective and quantitative way.
Access to quantitative timing
measures of CT imaging workflow
ª 2018 American College of Radiology
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steps and analysis thereof would
facilitate understanding of our
efficiency in acute stroke imaging
and the clinical variables that affect it
[4,5]. Monitoring CT imaging
efficiency in acute stroke can
additionally aid in compliance
with The Joint Commission
Comprehensive Stroke Center
Certification requirement to evaluate
performance measures to improve
stroke treatment. CT image
metadata and image file time stamps
in PACS provide objective and
quantitative series-level information,
and in this work, we applied it to
understand relative performance and
potential improvements in acute
stroke response imaging workflow [6].
WHAT WAS DONE
The purpose of this work was to
establish and evaluate a method to
extract important time stamps from
DICOM image headers and the
PACS database to measure image
acquisition, processing, and transfer
efficiency at an institutional level.
Using this method, we retrospec-
tively analyzed CT imaging
efficiency in acute stroke response.
We provided objective measures
answering important clinical ques-
tions regarding how changes in
stroke imaging protocol, scanner
location, performing technologist,
and image-processing software
variations impact performance. This
approach can be easily adopted at
any institution for objective effi-
ciency monitoring because it uses
easily accessible data that are auto-
matically recorded with every image
slice.
At our institution, a compre-
hensive acute stroke CT examina-
tion consists of a localizer
radiograph plus four series: non-
contrast head, CT angiography
(CTA), perfusion, and head with
contrast (Fig. 1). An overview of
this workflow is illustrated in
Figure 1, including timing for a
single representative examination.
As the examination progresses
through the four imaging series,
each series is ideally sent to
PACS after reconstruction and
interpreted as soon as possible.
After perfusion scans, data are sent
to a workstation or automated
software for processing.
Objective measures of CT
imaging efficiency were gathered
from 494 comprehensive acute
stroke examinations over the course
of 1.5 years. Examinations were
performed at multiple sites of a
single institution. For each image in
each series, we extracted timing
information from DICOM tags
corresponding to the time of series
creation, image acquisition, and
image reconstruction (Table 1).
Extraction of time stamps from
the original DICOM files was
1
Fig 1. (a) Stroke code CT imaging protocol at our institution. Time stamps relating to these events are extracted to quantify the
precise temporal relationship between them and to identify potential areas of improvement for increased efficiency. (b) Time
points of interest in a representative single examination, collected from DICOM metadata (series setup, acquisition, recon-
struction) and PACS file time stamps (PACS availability). CTA ¼ CT angiography.

performed in MATLAB (The maintain objectivity and minimize
MathWorks, Natick, Massachusetts, bias in our analysis, this time was
USA). We additionally collected not included in our analysis.
the time of image availability in the In addition to time stamps, we
PACS system for the interpreting extracted DICOM metadata indi-
radiologist from the PACS cating performing technologist,
database. This time point contains scanner on which the examination
information on how long a CT was performed, date of examination,
technologist takes to send a study time of day, and perfusion process-
to PACS after reconstruction. At ing method. We sorted the exami-
our institution, the radiologist notes nations by these variables to measure
in the imaging report the time the impact of clinical factors and
that findings were communicated workflow parameters. Analysis
to the responding neurologist. To focused on three efficiency measures
Table 1. Time stamp sources for imaging workflow analysis
Event Source Tag
Series setup DICOM (0008,0031)
Acquisition DICOM (0008,0032)
Reconstruction DICOM (0008,0033)
Available in PACS PACS database Image slice file time stamp
in particular: acquisition duration,
time to image availability in PACS
for interpretation, and perfusion
processing time. The first two of
these measures were referenced to
the time of CT localizer acquisition
to minimize the effect of variables
unrelated to CT workflow on effi-
ciency measures and could refer to
either an individual series or the full
examination. Nonparametric tests
were used to investigate differences
in efficiency by time of day (n ¼ 2,
day and night), scan operator (n ¼
37 operators), scanner (n ¼ 4), and
quarter of the year (n ¼ 5 complete
quarters in 1.5 years of data),
including Mann-Whitney U test or
Kruskal-Wallis test and post hoc
Dunn’s test. To investigate correla-
tion between technologist experience
and efficiency, we compared the

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Volume - n Number - n - 2018
Table 2. Overall performance measures for 494 comprehensive acute stroke examinations
Acquisition Available in PACS Delay (Acq to PACS)
Scan 25% Median 75% 25% Median 75% 25% Median 75%
Head without contrast 0.56 0.63 0.77 1.33 1.59 2.25 0.69 0.87 1.51
CTA 2.82 3.80 6.44 5.71 7.44 10.89 2.33 3.02 4.57
Perfusion maps 5.43 6.55 9.17 16.89 21.89 28.83 10.05 14.14 19.21
Head with contrast 6.04 7.49 10.00 10.93 12.91 16.28 3.13 4.97 7.05
All values are times, in minutes, since the CT localizer radiograph acquisition. Acq ¼ acquisition; CTA ¼ CT angiography.

number of examinations each tech-
nologist performed during the study
period to the examination acquisi-
tion time with a Pearson’s correla-
tion test. This study was performed
under retrospective institutional re-
view board approval (patient consent
waived) and was HIPAA-compliant.
OUTCOMES
Extraction of time stamps from
DICOM and PACS proved to be a
feasible and useful method for
objectively monitoring stroke
response efficiency. Analysis of 494
comprehensive acute stroke exami-
nations indicated high-efficiency
head noncontrast acquisition (me-
dian 0.63 min from time of CT
localizer acquisition) and PACS
availability (median 1.59 min) for
initial evaluation of possible
ischemia or hemorrhage. Series-level
timing measures are shown in
Table 2.
A policy change intended to
decrease duration of acute stroke CT
examinations was introduced at the
end of the first quarter from which
examination data were collected.
Instead of waiting for instruction
from the attending neurologist to
proceed to CTA acquisition after
exclusion of hemorrhage on the head
noncontrast examination, technolo-
gists were instructed to proceed
directly to CTA after the
noncontrast scan. Analysis of imag-
ing time stamps from examinations
performed on the emergency
department CT facilitated measure-
ment of the impact of this protocol
change. After this policy change, we
observed a significant reduction in
time from noncontrast head scan
acquisition to CTA acquisition for
scans performed on the emergency
department scanner (median time
reduced from 7.18 min to 2.46 min,
P < .001). This reduction contrib-
uted to overall increased efficiency in
examination completion on emer-
gency department CT over the
period studied (median total exami-
nation time reduced from 12.5 min
to 7.0 min, P < .001, Fig. 2a). The
largest reductions in these two time
measures occurred between Q1 and
Q2, corresponding to the date of
the protocol change, which was
communicated at the end of Q1.
The interquartile range, which can
be used as a measure of
examination length variability,
also decreased to approximately
35% of its Q1 value after the
protocol change. These results
indicate clinically and significantly
improved performance and
increased consistency between
examinations as a result of the
policy change, as acquisition delay
from head noncontrast to CTA
decreased by 66% (4.7 min) and
total examination acquisition time
decreased by 44% (5.5 min).
We further investigated whether
variables such as scanner, time of
day, and operating technologist
influenced efficiency. We observed a
statistically significant increase in the
time to acquire all series (increase of
median acquisition time of up to 2.5
min, 37%, P < .001) and the time
to PACS availability of the entire
examination (increase of median
time of up to 7.7 min, 35%, P <
.001) for scans performed at a sat-
ellite clinic compared with our main
campus (Fig. 2b). These differences
indicate an opportunity for
improved consistency across sites.
In a comparison of examinations
performed during daytime versus
overnight hours, we did not
observe statistically or clinically
significant differences in acquisition
time or PACS availability of all
image series, indicating that rapid
acute stroke response is feasible at
all hours of the day.
Comparisons between anony-
mized CT technologists indicated a
statistically significant and striking
influence of technologist on exami-
nation acquisition time and time to
image availability in PACS (P < .001).
The median time to complete all ac-
quisitions varied between technolo-
gists from 4.75 min to 15.28 min
(Fig. 2c), and the median time for the
full examination to be available in
PACS varied between techs from
15.4 to 51.8 min. Both of these
measures varied by a factor of up to
3 depending on the technologist
performing the examination. This
was the largest effect size we observed
and has important implications for
future directed training. A significant
negative correlation (r ¼ 0.35,
P < .05) between examination

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Brunnquell, Avey, Szczykutowicz n Case Studies in Clinical Practice Management
Fig 2. Relative impact of three clinical variables on time to acquire all series in a comprehensive acute stroke CT examination at
our institution. (a) A marked reduction in acquisition duration was observed over time as a new policy was incorporated and had
its intended effect. Acquisition duration reduced by up to 44% from Q1 (red). (b) Acquisition duration was modestly but sta-
tistically significantly higher at one satellite location (sedct, red). (c) Wide variability of acquisition duration depending on
technologist performing the examination was observed. Box plots indicate performance distributions for each of 37 individual
technologists. The median acquisition time for each technologist varied by more than a factor of 3 among our group of CT techs.
edct ¼ emergency department CT; sedct ¼ satellite emergency department CT.

acquisition time and technologist
experience (indicated by number of
examinations performed during the
study time period) indicates that
increased technologist experience has
a significant correlation with
efficiency of acute stroke
examination completion. The widely
varying performance measures for
individual technologists may provide
indications for further training
needs or clarification of acute
stroke imaging procedures and
policies. Our series-level analytics
approach additionally facilitated the
identification of delays in the CTA
acquisition as the greatest contributor
to increased examination acquisition
time in the lowest-performing techs.
During this study period, two
different perfusion mapping tech-
niques were used in the clinical
workflow. A transition from manual
(Vitrea, Vital Images, Minnetonka,
Minnesota, USA) to automatic
(Rapid, iSchemaView, Redwood
City, California, USA) perfusion
processing occurred during this
period. Vitrea requires the technol-
ogist to process the perfusion images
on a separate workstation, and Rapid
automatically processes the perfusion
images. The examinations in this
study are part of a transition period
from using only Vitrea to create
perfusion maps (100% of examina-
tions processed with Vitrea in Q1) to
typically using both Rapid and
Vitrea for perfusion map processing
(63% of examinations processed
with both, 29% with Vitrea only,
7% with Rapid only in Q5). When
two methods were used, one was
always completed immediately after
acquisition; we only included the

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Volume - n Number - n - 2018
first to arrive in PACS in our tem-
poral analysis. We refer to the time
from perfusion acquisition to perfu-
sion map availability in PACS as
perfusion processing time. Rapid was
found to have a significantly reduced
perfusion processing time compared
with Vitrea (11.7 min versus 14.6
min, P < .05), confirming that its
incorporation into clinical workflow
reduced the wait time for full ex-
amination availability for radiologist
interpretation.
DISCUSSION
Time-efficient CT imaging in acute
stroke is essential for improving pa-
tient outcomes and has been
emphasized in national guidelines
for acute stroke care. In this work,
we retrospectively analyzed CT im-
aging speed in stroke response to
identify institutional trends and op-
portunities for improvement. For
our institution, these results provide
important insight into what clinical
factors significantly impact efficiency
and indicate new areas for quality
improvement. It allows us to eval-
uate the impact of staffing and
protocol decisions, such as changes
in acquisition workflow steps and
perfusion processing methods, and
facilitates directed training and
informed decision making.
We demonstrate an approach for
systematic evaluation of imaging ef-
ficiency in time-sensitive settings,
using series-level DICOM and
PACS time stamps. In evaluation of
CT timing, this approach is appli-
cable to any institution in its use of
universal CT workflow steps (ie,
image acquisition, reconstruction,
processing, and transfer) and
standardized DICOM metadata.
Current efforts in measuring
acute stroke response timing can
include potentially inaccurate and
time-consuming pen-and-paper
methods, and an approach such as
this provides quantitative data
and reduces the burden on compli-
ance teams.
ACKNOWLEDGMENTS
The authors would like to thank
Richard Bruce, MD, Aaron Field,
MD, Gary Wendt, MD, and Wally
Peppler, PhD, for their valuable
insight and feedback in the comple-
tion of this work and preparation of
the manuscript. We also thank Daryl
Belden for facilitating data access
and retrieval, and Peter Wasmund
and Carrie Bartels for providing
insight into details of clinical
workflow.
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Christina L. Brunnquell is from the Department of Medical Physics and the Department of Radiology; Gregory D. Avey is from the
Department of Radiology; and Timothy P. Szczykutowicz is from the Department of Medical Physics Department of Radiology and
the; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin.

All authors are involved in a collaborative project that supplies CT protocols to GE Healthcare. T.P.S. is also a GE consultant, the
founder of protocolshare.org, and on the MAB of iMALOGIX, LLC. G.D.A. and T.P.S. receive equipment support from GE
Healthcare.
Timothy P. Szczykutowicz: 1005 Wisconsin Institutes for Medical Research, 1111 Highland Ave, Madison, WI 53705; e-mail:
tszczykutowicz@uwhealth.org.

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Brunnquell, Avey, Szczykutowicz n Case Studies in Clinical Practice Management