Applied Radiology

Moderator: Welcome to the Applied Radiology Prefilled Syringe Focus Group. This panel has been assembled with people who are interested in and have experience with prefilled syringes. I'd like to thank our host, Applied Radiology, for allowing us to discuss this issue. My name is Dave Enterline and I will serve as the Moderator of this discussion. I'm a radiologist in the Department of Radiology at Duke University Medical Center in North Carolina. I'm primarily a neuroradiologist, and I also perform interventional neuroradiology and head our emergency radiology areas. In our department, we have six spiral CT scanners at our principal hospital. We do approximately 3,000 CT patient examinations per month, so it is a fairly high-volume department. Each of our CT scanners has some variety of injector built in, and we have products from several different vendors. Currently, we don't use prefilled syringes at our primary site, although two of our associated hospitals are using prefilled syringes for CT scanning. At this point, I'd like to have the rest of the panel introduce themselves and briefly comment on their use of prefilled syringes.

CC: Cynthia Caporuscio, I am the Section Head for CT Scanning at Centre Community Hospital, in State College, PA. We are a small community hospital with 200 beds. We do use prefilled syringes. We do a high volume of CT studies for the amount of beds we have in the hospital, so it is a necessity to use the prefilled syringes.

GG: Gary Goble, Chief Technologist from Aston Ambulatory Care Center in Dallas, TX. Aston is an outpatient center, and we do between 1,000 and 1,200 CT exams per month. We've been using prefilled syringes since I came aboard in March 2000. There were financial considerations that led to that decision, but also morale issues with the staff to help keep the technologists happy.

RL: Richard Ligi, Director of Radiology and Imaging Services at St. Francis Hospital and Health Center, Poughkeepsie, NY. We're a Level 2 trauma center. At the present time, we have a very active radiology organization, and prefilled syringes are very necessary in a trauma center, as well as in an interventional setting, where volume is extremely high. We anticipate our yearly volume at around 14,000 examinations in CT, and 3,000 in interventional procedures.

MM: Matt Merical, Department Supervisor at Dickinson County Memorial Hospital in Spirit Lake, IA. For our hospital and for the regional imaging centers for some rural areas in Iowa, we switched to prefilled syringes about 18 months ago when we went from axial scanning to helical. We made the change for reasons of patient throughput and ease of use.

JP: Jeff Pulliam, CT/MRI Supervisor of Summit Medical Center in Nashville, TN. We average about 1,300 to 1,400 CT scans per month, and we've been using prefilled syringes for about 2 years. The change was made for financial reasons and for efficiency of the technologists. We've been extremely happy with the results on both the financial end and on throughput.

RR: Robbin Roberts, CT Scan Technologist at Howard Community Hospital, Kokomo, IN. We've been using prefilled syringes for close to 4 years now, ever since we went from axial scanning to helical scanning. With the increased throughput of patients with prefilled syringes and helical scanning, it's just much better, more efficient and faster.

DR: Dawn Ross, X-Ray Supervisor at Modesto Imaging Center in Modesto, CA. We switched to a helical scanner about 9 months ago. Our technologists were having to come in half an hour earlier to start their shifts to get the Medrad syringes filled to do their patients for the day; and they were complaining about having to do this. At the same time, our patient load increased by about 10 patients a day, so it made more sense to get the prefilled syringes. They're ready to go and you don't have as much set up time, so using prefilled syringes helped us increase our patient volume.

LT: Lanis Taylor, CT Supervisor at Wellmont Holston Valley Medical Center, Kingsport, TN. At Holston Valley we average 2,000 CT scans per month. Switching to prefilled syringes was a throughput issue for us; we're busting at the seams. Once we changed, we more than made back the additional cost. We love it; it cuts down on our time and cuts down on the stress.

CW: Casey Watson, Staff Technologist at Eastern Idaho Regional Medical Center in Idaho Falls. At our facility we probably do an average of 30 to 45 CT scans a day. I think the decision to use prefilled syringes was weighted heavily on time efficiency and ease of use of the product from the technologist's standpoint.

Moderator Presentation

Our principal purpose of this focus group is to discuss CT contrast utilization and to address some of the advantages and disadvantages of prefilled syringes at individual institutions. More specifically, we'd like to hear about the panel members' experiences. How do you feel about prefilled syringes overall, and what are their pros and cons?

Figure 1 is a picture of one of our CT rooms, with a light speed scanner and a Medrad injector system. The conventional equipment we use for CT injection consists of a syringe vial for drawback of contrast, a device to draw back the contrast, and a connection to the patient (Figure 2). The prefilled syringe in essence is a single device, except for the actual connection to the patient. It has an interlocking bottom that's mated to a particular injector (Figure 3). Each of the injectors is optimized for individual patient use.

Medrad-compatible prefilled syringes were first introduced in 1997. Prefilled syringe vendors have teamed with one of the injector companies. The major manufacturers of prefilled syringes offer various contrast concentrations and volumes optimized for different scanning protocols. This has really been a growth area for the contrast companies, reporting growth of 20% to 40% annually. I think it's an area that will continue to grow.

There are some goals I'd like to present for this focus group.

1) To discuss the decision process in each of your departments; how did you get to the point of saying, "that's why I want to use prefilled syringes."

2) Are you using prefilled syringes all the time, or only in selected patient populations or situations? If you are using them selectively, please let us know how (such as for emergency patients, outpatients, combative patients, or patients on weekends, etc.).

3) The initial decision to use prefilled syringes is made based on perceived benefits. Now that you are using them, please share your views on the actual advantages and disadvantages.

4) Have you increased patient throughput? Are you able to schedule additional patients as a result of using prefilled syringes?

5) How has the use of prefilled syringes factored into employee satisfaction? As we're approaching a technologist shortage, does it make a more pleasant environment for technologists to work in?

6) Are there other benefits? Does the fact that the patient sees a single syringe that they know you're loading individually become a benefit to your overall institution?

Transition to prefilled syringes

There are many different considerations in making a transition to or using prefilled syringes, and I've divided them into categories (Table 1).

Technologist ease of use: There is certainly an inherent efficiency and ease of use that comes with prefilled syringes. A technologist can also minimize contact with contrast agents, which is especially a concern in cases of contrast allergy. You can decrease the amount of spillage. These are issues of interest to all technologists.

Safety issues: The safety issues are related primarily to labeling and misadministration. When contrast is drawn into syringes from a bottle, are those syringes labeled? How are you sure what the patient is getting? Needle sticks and glass breakage are also safety issues. In drawing contrast up from bottles, the safety issue is related to removing the cap, and tearing off the actual metal rim.

JCAHO regulations: We should also discuss medication sterility and contamination. Recently, JCAHO came out with compliance issues related to all medications. We know that hospitals are very concerned with JCAHO compliance. Table 2 lists the regulation pertinent to our discussion. There are two points associated with this regulation: 1) All medication must be labeled appropriately, safely, and in a standardized method; and 2) Medications should be dispensed in the most ready-to-administer form possible, to minimize opportunities for error. How do these compliance issues figure into your decision to use prefilled syringes?

Cost effectiveness: Clearly, cost effectiveness is a very complex issue, and is relevant to the decision to use prefilled syringes. Clearly, the prefilled syringes cost more than the cost of a bottle of contrast, since there's more involved in manufacturing the prefilled syringe. So, which factors influenced your decision to use this product? Is it really a cost-effective venture? A time effectiveness study and cost effectiveness study would be valuable in defining if the issue is simply the cost of the prefilled syringe versus the cost of a bottle of contrast and the actual injector. Which factors, if any, offset the overall cost to the institution?

Table 3 lists the direct and indirect costs associated with using prefilled syringes. All of these factors must be accounted for in a cost-effectiveness analysis. Contrast waste is certainly an indirect cost. Are there situations in which contrast is loaded into a syringe and not used for a patient? How many ccs of contrast are wasted in drawing it up into a syringe? These are all indirect costs relevant to cost effectiveness. In addition to the cost and space for the additional supplies that must be purchased and stored, how do you dispose of those additional items? Is there a cost associated with their disposal? Finally, if a product helps you increase efficiency, is that efficiency translated into overall savings? These savings can account for the ability to scan additional patients, but also the ability to use a CT scanner more efficiently. Does it save you from having to order another CT scanner or from having to hire an additional full-time-equivalent (FTE)? Is the additional cost of prefilled syringes offset by increased throughput, patient satisfaction, technologist satisfaction, or any other issue?

Contrast Use and Participant Experience

Moderator: Let's talk about some of the issues relevant to each of your CT Departments and your use of contrast in general. How long have you used prefilled syringes? What is your comfort level with them?

GG: We use prefilled syringes across the board. As far as our examination mix, it ranges from CT head, abdomen, pelvis, and chest, for the most part, with some extremity scans. So, they are not all contrast-enhanced exams. But 75% to 80% of each day's exam mix uses contrast. It becomes a morale issue with the staff when the schedule changes. Throughout the day we have a set schedule written on a dry-erase board, with exams scheduled in 30-minute slots. Once we start getting add-on exams between the 30-minute slots, it ends up stomping on the technologists' mental well being. When they arrive in the morning and they look at that schedule, they say, "Well, at least I don't have to work every single second all day, I'll be able to go to lunch." That evaporates by about 10:30 with the add-ons. But everyone in an American hospital or clinic system knows that, to a great extent, we're handcuffed with what we can do with raises, incentives, or bonuses. So I considered that switching to prefilled syringes would be one of the perks for the staff. It did have to be fought for, because there is a premium attached to using prefilled syringes. But, that premium really shrinks once you start going through the practical applications and its impact on the staff and patients. Then, the premium shrinks to almost an insignificant level.

Moderator: Rich, how do you use contrast in your department and what is your scan mix? Do you use all prefilled syringes?

RL: At St. Francis, the majority of our contrast media is delivered through prefilled syringes, specifically because we're a Level 2 Trauma center. We have one CT scanner at the moment, and the time schedule is very limited. Our situation is similar to what Gary described, you have a half-hour slot, you're trying to get a procedure accomplished, and you don't have the advantage of having additional time slots. We're basically under the gun when it comes to time. In the course of our day with scheduling outpatients and doing inpatients, when a multiple trauma comes in it just throws a wrench into the entire day. When prefilled syringes came into play, and into interventional radiology and CT scanning, I found it to be a benefit, almost like the remote control on a TV. It did an awful lot to the system, and this is important where I am. We deliver Isovue 300 at St. Francis, mostly for our chest and abdomen scans. We usually use 150 mL. But prefilled syringes are a necessity in our environment.

Moderator: Jeff, how do you use contrast at your institution?

JP: Probably 95% of our CT studies are contrast injected, we do very few nonenhanced studies. It's almost all Isovue 300, the 150 mL syringe. For the head studies, we use the 370. But, in terms of the change to prefilled syringes, it came down to efficiency and time management for the technologists. One tech would come in first thing in the morning before we got the prefilled syringes and spend 30 to 40 minutes loading syringes, having to initial the syringes, label what was in the syringes, what type of contrast it is, and date it. It got very time consuming. You had to guess how busy you were going to be, but you filled 5 or 10 more syringes than you knew you needed from the schedule. Now, if something happened during the day and you got busier than that, you had to take time in the room to fill the syringes. Then, that room stopped, you couldn't scan patients in that room and fill syringes at the same time.

Moderator: How long does it take to fill the syringe itself?

RL: For each syringe, including the time to label it in indelible marker, probably 3 to 5 minutes. Then you've got all the bottles and all the syringes that you've opened up laying across the counter. If two techs can do it, it could be a team effort. But, some people don't have that luxury. Then at the end of the day, if you didn't use all that contrast, you just had to toss it, and that is a cost issue. I'd say at the end of the day we would throw away anywhere from 4 to 6 filled syringes, or 600 to 900 ccs of contrast. So, it was a win-win situation all the way around to switch to prefilled syringes. The techs love it; it doesn't matter how busy you are now, you've got plenty on hand. You can reach into the contrast warmer or wherever the syringes are stored, pop it on, and off you go. If you do 50 scans a day, or 75, or just 15 a day, the speed is always there. My techs love it and I love it.

Moderator: Robbin, you've recently moved to a helical scanner and have a very efficient operation. Can you tell us a little bit about that?

RR: Before we started using prefilled syringes, we were just doing axial scanning, and we were only doing 8 or 9 patients a day. It took a little bit of time first thing in the morning just to get all of the supplies lined up and ready. That's time that you don't have patients in the room and you're not scanning. When you're only scanning 8 or 9 patients a day, any time that you could have somebody in there makes a big difference. Now, we're scanning from 25 to 30 or 35 exams a day, and I just can not imagine doing this without the prefilled syringes. Because when you're getting a patient up off of the table, your finger is on the button, and you're rolling the injector down and getting ready for that next prefilled syringe. If you had to take time and draw that contrast up every morning or you have 10 syringes drawn up already, and then you get 3 more add-ons...that's just time wasted and taken away from patients. We use Isovue 300 on all of our studies, and 95% of our studies are contrast-injected studies. For a chest, abdomen, and pelvis combination, we use 150 mL; for a standard scan, like a chest or a head, we use 100 mL.

DR: We've been using the prefilled syringes for about 4 months. Before that we were using the Tri-Paks. We got our injector about 3 or 4 years ago. The technologists had to come in, take the contrast out of the bottle, open the Tri-Pak, and put it in a Medrad syringe. So the chance of contamination was higher by doing that. With filling them up first thing in the morning according to the number of patients you had scheduled, when we had a no show (cancellation), we'd have to throw that syringe away. We'd have 2 or 3 patients a day that didn't show up. Or even if an add-on patient took their place, it might not be a contrast study. So we were wasting contrast on a daily basis. From my viewpoint, since I do the purchasing, it's easier for me to just order that one prefilled syringe instead of having to order the contrast bottles and Tri-Paks. Plus, we had to have a place to store all that, and we're busting at the seams for space. So just having the prefilled syringes and the transfer set made it a lot easier for me in purchasing all our supplies. So I enjoyed the change to prefilled syringes myself, and it also makes the technologists very happy.

Moderator: How do you staff your CT scanners, and has it changed since your transition to prefilled syringes?

DR: Our chief technologist scheduled herself to do the CT patient load everyday and she had to come in early and fill the syringes. For about 4 months, she asked me to "please find some prefilled syringes." When I did, she was very happy, and if you make your chief technologist happy, it works better for me too.

Moderator: Lanis, in your department, how have the issues of contrast and CT injectors panned out?

LT: We've been injecting contrast for years. We had to go through the cumbersome process of filling the syringes, which means risking possible contamination and storing two products instead of one on the shelf. This time is money. When we started using prefilled syringes it was instant gratification, and a big morale boost for everyone. We have improved patient throughput. It gives an employee a little time to give back to the patients, which is a very important in building a network with those patients. Not only have we decreased the use of our FTEs by not having an additional person come in early in the morning to fill the syringes, but the turnaround time, or prep time, in the room has been cut dramatically. Instead of 4 or 5 minutes loading up the syringe, you can re-prep the table, and get ready to go.

We run three machines practically all the time. We run two machines 16 hours a day, and we have one in the ER open 24 hours a day and we've also had to off-load ambulatory patients onto that machine.

We exclusively use the 300 concentration. For brain scans, we use 100 ccs and we still spike a bottle. We're not heavy into arterial scanning right now, but we expect to be soon. We are doing a lot of scanning for PEs.

Moderator: Yes, I think it's a growth area that everyone has seen. Casey, how do you use contrast and your injectors in your department?

CW: Currently, we do three-quarters of our studies using contrast and we've been using prefilled syringes for about 2 years now. We have just the 150 mL Isovue 300 available to us, and that's used for all of our routine studies, with the exception of head scans. We use 75 mL of the 370 for head scans. I think the most dramatic thing that I can think of with regard to using prefilled syringes is, as Richard mentioned, that an outpatient schedule doesn't account for multiple traumas. We're the major trauma center for the region. So any time that we're able to save helps us from keeping outpatients waiting, and I think that is a great benefit for them. In the past, we've had a number of patients walk away because of the wait. So, in terms of the number of patients you can scan, it's a great benefit for the technologist and the patient waiting to get in.

In addition to cutting down patient waiting time, we've also been able to cut down on the technologists' time to turn around a room. As everyone has mentioned, that does wonders for the technologists' morale as well. You don't feel quite as rushed, and you can get an adequate history.

Advantages of prefilled syringes

Moderator: If you had to choose, which are the primary advantages to using prefilled syringes?

CC: We use prefilled syringes exclusively, and we're extremely happy. We've been using them from the beginning, I think since the very first day they came out. For our injector, we used to have empty syringes that we filled, and now with the prefilled it's simple, it's easy. Also, I've noticed less reaction to the contrast.

I've also noticed a big difference in patient throughput. Every month the head of my department has congratulated us for hitting a new total. This is in a 200-bed hospital, and for the last 4 months we've gone from 934 patients to 956, to 1,051, to 1,081 patients per month. That floors us, we don't know how we are doing it; it's just move, move, move. We schedule 35 to 40 patients a day, in 15-minute time slots. That means that abdominal and pelvis exams are 30 minutes each, and head scans are 15 minutes.

With the prefilled syringes, we have more time to actually sit down and talk with the patients while we're injecting them. It also seems that the patient isn't aware as much of that part of the procedure.

Moderator: That makes a big difference to the patients. They're often very anxious, and obviously the more time you can talk with them, it really makes an impact.

CC: Oh, yes. Some of them are really apprehensive and it makes a big difference and puts them at ease, if you can talk with them. You have to remember that this scan is your daily routine, it's just another person to you. But to them this might be the only time in their life they go through this, and they tend to remember the experience.

RL: I'm really happy that Cynthia brought up the issue of patient apprehension, because that's something I really think about. Going back, a radiologist would walk in the room with two 50-cc syringes with needles. For patients, that was quite scary. Now with this system, it makes it a lot easier. I think that's a big plus that hasn't really been considered.

JP: I think it is reassuring to the patients if the tech can stay with them. Everyone who comes in for a CT scan is always sure they've got cancer. It doesn't matter what they're there for; they "know" they're going to find cancer. But if you're in there with the patient when the contrast is going in, I think it has a calming effect. The patient is nervous. You've told them that they're going to feel hot or get a funny taste in their mouth, but if you're able to stand there beside the scanner, they can see you and hear you. It makes the test go that much easier for them.

It also eases the patient's mind to see the tech just walk over to a contrast warmer, grab that syringe, and walk back to pop it on the injector head. For the patient to see you ready to go like that, is so much better than if they see you making what seems to be a witch's brew while you're drawing up the syringe, running back and forth to get the supplies. I think it gives the patient peace of mind, and makes the techs a little more friendly to the patients.

Disadvantages of prefilled syringes

Moderator: We've talked a lot about the benefits, and we'll talk about cost-effectiveness. But have you found any disadvantages of the product?

CW: Quite frankly, I can't think of any disadvantages of the prefilled syringe. If we carried a wider range of volumes, we'd use them even more.

CC: I can't think of any disadvantages, either.

LT: No. At our institution, we have yet to have a prefilled syringe fail. That's pretty remarkable, given the numbers that we've done with them.

JP: I can't think of any disadvantages. As far as the way the syringe is itself, no. But as far as the day-to-day usage, I haven't seen any problems. I think it's as close as you can get to having a safe and effective system.

Moderator: That's a very important point. How many people are aware of any misadministration, either at your own institution or have heard of any at other? I know it happened in our area. This can be aspiration or any other form of misadministration.

MM: We've been lucky in our hospital; that hasn't happened to us.

JP: In my facility, a technologist drew an empty syringe back in the injector, and just failed to take it off the injector head. The next technologist came in with a trauma patient, thought the syringe was loaded up, and injected air into the patient. Luckily the patient was okay, but the technologist was traumatized, when he realized how close he came to killing a patient. In avoiding misadministration, these prefilled syringes are actually lifesavers.

GG: I think most of the people here would agree that, more than any other modality, CT techs are probably the hardest hit individuals for taking call. If you have someone who does their 8-to-10 shift, non stop, with one patient right after the other, and then they're on call until the next morning when they start their next shift, you have someone who is a zombie at times. This is especially a problem when you have a trauma situation. Matt told me that their volume doubles and triples during tourist season in the Spirit Lake area. If the CT tech is called in at night, they still have to perform the next day. When you have someone almost nodding off at the console, you're setting yourself up for problems. You want as error-free a situation as possible.

LT: The procedures can be so monotonous for the tech; you're doing the same thing 30 times a day, and you lock into your routine. It's very easy to make mistakes in that situation.

JP: This is especially a problem with the traditional syringe, if you were loading them through the injector, sometimes the technologist can get distracted, and then he's loaded partial contrast and a big bubble of air in there. So, he's got to take the time to stop and push the air back out. It seems to me that if you sucked room air into those syringes, you've contaminated the syringe and the contrast, to a point. It was an uncomfortable feeling. But, at the same time, you were under such stress to get patients in and get them out, to go so hard and so fast. But, you can't afford to make that mistake.

Moderator: Approximately 60% of the panel are aware of misadministration. I think they're very isolated situations, but they are significant. The consideration is, of course, how many problems like that are tolerable? I think everyone would agree that in safety issues, zero tolerance is certainly the goal. What about the sterility issue; have people had any problems with that? Jeff, you've mentioned drawing back air, and one of the things that all prefilled syringes have is a little bit of air right at the top. To a certain degree, when you tilt the injector down you can see that air bubble move, and that tells you that you're truly loaded.

JP: Yes. All of my technologists are concerned enough to make sure even that air bubble at the top is gone before they turn the injector head. I've seen some facilities where you see the injector at just a slight angle. At my facility, I preach to them to make sure that injector head is turned completely pointing up and down, to make sure there are no air bubbles whatsoever. It's as close to 100% as you're going to get that way and you can eliminate the technologist making a mistake.

Moderator: The small bubbles we see all the time in IVs coming from the patient floor are inconsequential. But what we're talking about are really the dramatic or the multiple cc injections that are extremely detrimental, particularly in precarious patients, or in patients that have right-to-left shunts in the heart. Those are the patients that really get into trouble.

MM: Our facility is small enough that we don't have the luxury of being able to staff a dedicated CT tech, so all of our techs have to take call and cover CT. It can be really stressful for a tech to be in OR one week and CT the next. Just concentrating on the patient, getting the scan right for the radiologist, and doing the MIPs and the MPRs is hard enough, let alone having to worry about contaminating the contrast. So from my standpoint, making the process as easy and foolproof as possible was important just in relieving their stress.

Using the prefilleds has also allowed us to standardize patient contrast dosage. We got the radiologists to agree on dosages and concentrations. We use both 300 and 370 at our facility, and we power inject and use the prefilled syringes for all of our contrast cases. It does ease the techs' anxiety, because they're anxious about being in CT a little bit, especially those that are new to the modality. So, we can relieve a little bit of anxiety in providing the prefilled syringes, and that makes it easier for them. Also, there's only one technologist in that department. When we went from axial scanning to helical, our volume went up about 28%. So, since we are still staffing one technologist, we have to make the workflow as efficient as possible and the prefilled syringes help us do that. From a cost standpoint, using prefilled syringes is a little more expensive, but throughput has increased. If you use the Medrad syringe or power injector, you need to use the Tri-Paks to load your own contrast. The Tri-Paks are not inexpensive, and if you couple that with the cost of a vial of contrast, it's not that much less expensive than buying the prefilleds.

Moderator: Have any of you changed your staffing? Either scheduling or the total number of technologists, since you've made the transition from syringes that you load yourself to the prefilled syringes?

MM: It hasn't really changed our staffing. However, it has allowed us to be able to increase our patient volume and still staff just one technologist.

RL: At St. Francis it was the same. It doesn't reduce the staff, but it increases your volume and just one technologist is pretty much the norm.

GG: We eliminated coming in 30 minutes early before a shift to set up the room. The bulk of prep time was setting up syringes and filling them, and then you had to take the trash out, because you just filled the container with the residue from the set-up. So, in that way, it just trimmed 30 minutes off. But it's a significant 30 minutes, because the techs had to come in before their shift really started.

CC: My radiologists didn't like the fact after we filled the syringes, they would lay on the counter until they were used. The radiologists didn't like the fact that the patients could see them, or that they might think they could be tampered with, or somebody had actually touched them and contaminated them. So, it eliminated a lot of that concern, also.

Moderator: So, now that you've gone to the prefilled syringes, how do the radiologists feel about that?

CC: I've had no complaints. You just snap it off and throw it away, and you put a fresh one on. The patient can see you pulling the sterile top off and getting ready for the next patient, and they know everything is contained and sterile.

RR: With us, our shift starts at 7 am. When we had to draw up our own syringes and fill them in the morning, it took the first 30 to 45 minutes. So, it just took away patient time. Now we get patients in starting at 7:15. By 7:30, we're doing our first patient. As Jeff said, it's an opportunity to get inpatients down that were added on and start your day earlier.

DR: We still have one technologist. But it's cut down on the overtime we had to pay when she had to clock-in early. We're now back to an 8-to-5 schedule for our CT scanner. Even 5 minutes in the medical field is golden, any way that you can cut your time is good. If we can just save 5 minutes here or there, by doing something differently, that might allow you to get up and go to the bathroom or go get a cup of coffee or something.

LT: We have changed the way we staff. We used to have a tech come in at 6 am, and that was to prep the rooms, warm up the scanner, and draw up all the syringes. So, now we've cut out the time to draw the syringes.

Moderator: Casey, as a technologist, what are your perceptions as far as room prep, set-up time, etc.?

CW: I have a really high appreciation for the product because I work a night shift, and I'm there by myself for the majority of my shift. That means I have to take time for transporting patients and getting reports ready. So, with prefilled syringes, I have just one less thing that I have to worry about for the day. So, it's great.

How Prefilled Syringes Are Used

Moderator: Is anyone selectively using prefilled syringes? Is there a mixture of patients in whom you use prefilled syringes and nonprefilled? I know some of you are at or close to 100% prefilled usage now.

RL: I'm pretty close to 100% usage. I would just say pediatric patients would be the only patients that we don't regularly use them for since we need less volume.

JP: Yes. We use 100% prefilled.

Moderator: How quickly was the curve between getting a couple samples, going to selective use, and then going to 100%?

MM: We started off with just the Tri-Paks. We were getting our contrast from another vendor, and thought we would just use the Tri-Paks. But, they were cumbersome, and the Tri-Paks are not inexpensive. So, we tried the prefilled syringes. We probably used the Tri-Paks for 4 or 5 months. Then we switched to prefilleds and never went back. Now I don't think the technologist would let us go back.

Also, I think the technologists know that prefilleds are a little bit more expensive, and they appreciate the fact that we're willing to invest that to make their job a little bit easier.

RL: As an administrator, you have to remember that you need to give your technologist the necessary tools to perform a procedure. By giving them a prefilled syringe, I feel a lot more confident than I used to, because I don't have to worry about all the intangibles and risks involved with measuring volumes by hand. I think prefilled syringes are a much better tool to provide your technologist.

RR: We're 100% prefilled syringes, other than pediatrics. In children, we just draw a syringe from a bottle; we still keep a couple of those on hand, to get the smaller volumes.

Moderator: From a department manager's standpoint, is there an advantage in the transition to prefilled syringes? How do you go about making those transitions?

MM: I think if the techs are used to using the Tri-Paks and filling their own syringes, the transition is relatively easy. It doesn't take much training to learn how to snap a syringe on and flush the air. So, I think it's a fairly easy transition.

Moderator: Does anyone want to comment on the overall scheme of contrast utilization in the department and how they use prefilled syringes versus bottled syringes?

CC: By doing away with the bottles and having to fill syringes, we've gone down almost 100% in needle sticks. It just stops the whole department if someone gets a needle stick. You have to fill out the paper work and send them to the emergency room. Then, you're on your own for a while, and all kind of things can happen while they're getting the needle stick checked. It's done away with that almost 100 percent.

GG: Also, in most medical facilities now, there are two trash cans: the regular trash and the red-bag medical wastetrash. The red-bag trash is expensive to dispose of, because it goes by weight. If someone is filling syringes from bottles and throws the glass bottles in the red-bag trash, even though they shouldn't, that gets very expensive. But not too many people are going to harangue a tech about the trash. He's already sweating bullets trying to keep up with the patient load, not getting lunch, and barely getting a restroom break. So, that's one of those little things you don't really think about, unless you're actually observing the operation of the CT tech. All these intangible things add up to be pretty significant, and that affects your bottom line.

RL: I totally agree. You also don't have multiple bottles anymore. We used to pop the tops all the time and put them into an injector warmer. That also created a problem; it wasn't very safe. Many technologists would get their fingers caught on the rims of those metal bottle tops. Having something that you know is safe to handle, especially with the fears of cross-contamination today, is very important.

JP: With prefilled syringes, you've eliminated a lot of the possibilities of an accident to your technologist and to your patient.

Rationale for the Use of Prefilled Syringes: Presentation by Gary Goble

There were several factors involved in the decision-making process to go to prefilled syringes rather than the multi-component system, as I call it. Primarily, I initiated the decision process in response to several issues. At our clinic we had one CT technologist performing 16 to 24, up to 30 exams per day. This includes a lot of add-on exams, which created a problem, not the least of which was an unsatisfied CT technologist.

I drew up a list of the possible ways to address this problem. 1) Hire an additional technologist. That would be difficult, as well as expensive. 2) Hire a tech assistant, which of course that is still another addition to the staff. 3) Turn down clinicians' requests for add-ons, which is simply not possible in today's environment. 4) Find a way to increase productivity.

I knew our goal had to be to increase productivity to solve this problem. I found that the prefilled syringes have many advantages associated with them, and they don't impact just one aspect of our scanning department (Table 4).

Decreased inventory and storage: One of the biggest impacts was a direct benefit to me personally, because there's decreased inventory. There is just one unit versus three to four units in a multi-component system. So, I spent less time conducting inventory. It's also a lot easier to manage space. With the prefilled syringes, the room inventory is reduced as well. So, you have that storage space allocation that gets freed up for other uses.

Decreased ordering time: There is also the issue of the time spent ordering the multi-component systems. When I came to Aston in March, we had a three-part system. If you notice, the syringes come in a 50-piece unit, the tubing is an 100-piece unit, and the contrast is 10- to 12-piece unit. It's like buying hot dogs, there are 8 hot dogs to a pack, but 12 buns in a pack. That's an exact corollary to the multi-component system, because these people were either very, very smart about how they're packaging their product or they don't have a clue about the practical use of their product. There's no match-up in amounts.

Technologists' time: Of course, the technologist's time has been the prime consideration throughout this discussion. The bulk of the time that can be cut is the daily room prep time. The consensus seems to be that it's a 30-minute allocation to load up the multi-component systems for the day. Granted, that's the techs' quiet part of their day. But that's still a half-hour that could represent one or two more exams.

Cindy mentioned scheduling 15-minute slots. My hat's off to you! I don't think we could accommodate that and deal with add-on exams. As sure as the sun rises in the East, if we went to a full 15-minute slot schedule, we would still be doing add-on exams.

Staff training: Another issue mentioned was orienting staff. Matt rotates his staff through the departments. So, you have someone in CT one week, and in other departments for the next few weeks. So, when they come back to CT, they should be able to come back into an environment where they don't have to remember where the pieces are and how to do each step. With the prefilleds, they just go over, open a pack, and load it up on the injector. It's simpler for the techs to learn and remember.

Time management: We're all being asked to manage our time more efficiently. As managers, we have to manage our staff's time as well as our own time. This can be difficult, to say the least. Using prefilled syringes, we spend less time ordering the multi-component systems and we save time by fewer compliance problems. I personally get informed when the CT technologist gets behind schedule. These delays are usually related to starting an IV or a patient who needed reassurance. It's a human-interaction issue.

With the helical scanners today, the amount of time that the patient's in the room may only be 15 to 18 minutes. So, you have a very narrow window of interaction between the technologist and the patient. Lanis brought up an important point about a lot of the patients' perceptions. They come in to get a CT scan, and almost no matter what the scan is for, they're thinking: cancer. The patient is coming in for what they may consider the most important exam of their life. It's nice to know that the technologist may be able to spend 3 to 4 minutes actually talking to and touching the patient, rather than having their back to them while they hook little plastic pieces to mount into this other strange-looking machine. So, I think that personal touch is very, very important.

Cost factors: It's clear that today a predominant factor is money. Yes, there is a premium associated with using prefilled syringes. But, that premium is offset by the other benefits.

Rationale summary: I didn't begin with the assumption that we would move to prefilled syringes. That wasn't my decision-making process at all. Rather, I considered: what is the problem and how are we going to solve it? The big factors were inventory, the time associated with managing and stocking that inventory, and training. As never before, we're in an environment in which it's very rare to find a radiology department that has been staffed by the same people for the last 10 to 15 years. Many of the longest-term staff is in the 5- to 7-year range. So, when you have that type of revolving staffing, you need to streamline almost everything: your paperwork, your scan protocols, and, especially, your room prep for patient scanning.

Of course, I had to submit my decision to the people with the sharp pencils, and I had to do a little bit of convincing. Basically, I told them we would increase expenses a little bit. But that it could be offset by increased patient throughput, kicking in another two add-ons without that increasing the technologist's overtime. There's always a tradeoff in everything we do nowadays. The decision to switch to prefilled syringes was a positive one, and we have not regretted that decision to this date.

Moderator: Thank you very much, Gary, for the insights into your decision process in converting to prefilled syringes. I'd like to hear some of the factors involved in others' decision process to switch to prefilled syringes. Who was involved in the decision process? What were some of the perceptions you faced from business standpoint? Which factors were involved in the final decision?

CC: The technologists and the chief technologist began the decision process in our hospital. First, we looked at the cost factor. But the ultimate decision finally came down to the technologist and the radiologist.

GG: At our facility, once I collected the information and set up my argument for making the change, I submitted that to my director. Then, I wrote out the criteria I used to make that decision with offsetting points on both sides, and that went to a budget analyst. The increase in expenses had to be approved, not so much with what we would be getting out of this, although that was included in my proposal. Purposely on my part, I did not want to paint us into a corner by saying, "If we switch to this system, you'll see 18 more exam units done per month," because the technologist has no control over what the patient volume is. If you notice, through our entire conversation about prefilled syringes, the consistent theme has been keeping your people happy and keeping them employed at your facility. There's surely direct cost related to losing personnel.

RL: I have to agree with Gary, the points that he touched upon were exactly the points that determined our move to prefilled syringes. Going back to the technologists, I think the greatest consideration is giving them the necessary tools to perform a service that will benefit not only the institution, but also the patient. To me, it's just another state-of-the-art excellence that is necessary to deliver the system to the patient.

Moderator: How did you bring the decision to your boss, to the department, and, finally to the hospital administration, for approval?

RL: Looking at it from an administrative standpoint, they want to see the pros and the cons, to see exactly what the benefits are. Basically, I put all the positives in one category and the negatives in another and looked at the negative that would impact the institution, which was finance, of course. But after someone sees all these positives, I think the financial end of it becomes very trivial and doesn't have much impact.

MM: When we went from axial to spiral scanning about 18 months ago, we looked at injectors. The first thing we looked at was injector ease of use and dependability, and we selected the Medrad injector. So, then we had to make a decision about contrast. Obviously, Bracco makes prefilled syringes for the Medrad. We started off with the Tri-Paks and then switched to the prefilled syringes. I agree that the cost is secondary to ease of use. Luckily, we're an independent hospital, so we can look at all the different contrast vendors and products available. Of course, you have to look at department revenue versus the little bit extra that you're going to spend for the prefilled syringes. I weighed all those things and then went to my director and presented the case and he agreed. I think the issue that finally made the decision was ease of use. We have one technologist, and it's important to make the process as simple as possible, eliminating as many chances for error as possible.

JP: Our process actually started when my chief technologist happened to come in the room when we were stopped between cases and trying to load syringes. Patients were backed up, sitting outside the door waiting, and we were wasting valuable room time. If the table goes cold, you're not making money. But our chief tech mentioned that Bracco had these prefilleds, and would I be interested in them? I said, "Sure." So, the Bracco rep showed up, and after one day of just trying it, I was sold. We were willing to take the hit of however much it added to our costs at that time, because we could bring in more patients. It might be two, four, or six more patients; everybody can give different numbers on their throughput improvement. But it still boils down to ease of use. The technologist was comfortable with it, and it was very safe. It was almost a no-brainer decision to go to that point.

Our radiologists were not involved in the decision-making whatsoever, and, in fact, they didn't even realize that we had changed. We did it strictly for technologists' ease of use and the technologist throughput. It was strictly between the chief tech and myself, deciding it. She was aggressive enough to take it to administration and, even for them, it made perfect sense.

Moderator: Did you have to do a lot of financial analysis?

JP: Not very much. They asked about what we thought we could do, how it would improve throughput. It took me maybe an hour to jot down some numbers to show what I thought we could do. The decision-making process for our hospital probably took less than 2 or 3 days. It's a minor hit to your bottom line, and, even with managed care, you can make up that difference with one or two patients. That's why our hospital looked at it.

RR: Our process to move to prefilleds was actually started by the sales rep. One day, he and my director came in while I was in the process of filling syringes to get ready for the rest of the afternoon. My director said, "Do you have a patient waiting?" I said, "Yes, but I've got to get this done. I've got to get a couple more syringes drawn up." He said, "I think I have something that you're going to be interested in." That's when he and the rep told me they had the prefilled syringes and he arranged to get a box to try them out. As Jeff said, it was just a matter of 2 or 3 days, and we automatically switched over. The radiologists were not involved in the decision at all. As soon as we started using them, we knew we wanted to switch

Moderator: I think it's easy to convince the technologists. It's harder to sell the departmental administrators. How did you bring it to them?

RR: Something that worked to our benefit was that we had just switched from the axial scanner to a helical scanner. So, they knew they were going to be making more money because of our increased patient throughput. We could slip in this extra contrast that we wanted because of eliminating technician time to get that ready. It just made it all a nice transition.

GG: I evaluated our CT scanner's throughput, averaged that out for a week, and then extrapolated that out for a whole year. So, I determined a year's average volume and the revenue generated. Then I took the same figures for the costs to start an IV, and the whole three-part system. Once I had those numbers together, I figured the contrast costs, which was a whole separate column. I ended up with separate columns totaling the cost for us to operate on a yearly basis. I reserved our FTE, because even more than contrast, that's your biggest expense for running the department. Once I looked at those figures, I took a prefilled syringe scenario and figured what the variance would be. I didn't offset that variance with the things that I observed, such as throwing the bottles in the red-bag trash, because that's such a tenuous argument. While I presented those issues informally, they weren't numbers on a sheet for the accounting person to analyze. But it was a close enough variance that once I presented the figures, I addressed the intangibles, such as the tech's time. I said, "I'll let you figure out what it costs me to pay this tech for 30 minutes of straight time or 30 to 45 minutes of overtime to do the add-ons." So, I didn't just present it as "we want to do this; what do you say?" and then it just passed through. There were some hard numbers associated with it, and in a large facility, you're talking huge amounts of money.

I got really close on the dollar margin for the variants and said, "Here's what we're looking at." I even broke it down to dollar per patient, and said, "This is how much more it costs per patient to do it this way." Then, I offset that dollar amount with the advantages and let them figure it in their head. I did not even mention misadministration costs. If you have one misadministration, you potentially blew your whole contrast budget for 3 years.

JP: What sometimes gets left out of consideration is the technologist. You can give them the latest helical scanner and all the latest equipment. But they can still be pushed to the limit. It's important to remember the benefit of eliminating one more stress that they're facing. It's one more thing they don't have to take the time to do. Sometimes that gets lost in all the discussion about money and the bean counters just want three more patients, or ten more. But if you can even give the perception to the people that work for you that you're trying to make their job easier, they're going to be more willing to push to do two or three more patients.

GG: Even those considerations, though, are convertible into financial terms. We're talking retention. If the administration says it costs you $3,000 just to run an ad for a technologist...you're avoiding that by keeping a happy camper here. The techs are getting the message that they are important to us. But, at the same time, we know we'll be able to put some more patients through here. But, the techs are not even seeing that aspect of it. They're just seeing the fact that we shaved some hassle out of the day.

JP: Yes! I don't have to stop if I'm out of syringes, especially if I've got a bad trauma that's came in, with blood everywhere. In that case you really don't want to have to spend 2, 3, or 5 minutes loading the syringe, you can always argue that. That takes that stress off the technologist, they're under the gun to begin with.

MM: Probably the worst time to draw up a syringe is when you're half awake at 3 o'clock in the morning. It's much easier to use the prefilled.

JP: This eliminates so much, and it makes the technologists happier. Then they're going to be willing to do a little more in the department, maybe, to keep the radiologist happy. The films come through quicker; everything goes just a little bit quicker. You've eliminated some time.

Moderator: Dawn, you're in charge of purchasing and medical supplies. What was the decision process that was important in your case in going through those justifications?

DR: Actually, I was pretty lucky because our chief technologist is a working technologist who is scheduled just the way the other technologists are. We put in our new helical scanner about 9 months ago, and she was the first one trained on it. Since we were short on technical staff, she had to do the scanning every day for months until the other techs were trained. Since she's the chief technologist, she wanted to find a way to make the process faster. She asked me about buying prefilled syringes. All we had to do was prove to the medical director that the image quality was going to be the same if we switched to the prefilled syringes, which it was. There were no additional reactions because we switched; it was the same as before.

From my standpoint, the ordering is easier. We don't have a computer system that I use to order, and I don't have anything written down, it's all in my head. I order for the whole facility, the film, the contrast, the needles, everything; and that's for the CT, MRI, mammography, ultrasound, and X-Ray departments. So, it makes a big difference to take one thing off my list that I have to order. I don't have a set time for ordering, I have to supervise the X-ray department all day long. I just have to get away, look at the supplies, write it down, order it, and send out the purchase order (PO). So, if there's one thing that I can take off of that list, it helps me get back to the X-Ray Department quicker and do my job.

MM: That's my point about trusting the people that you have in power in the hospital. I think you have to be accountable for the decision and be ready to account for the increase in the budget.

DR: I was ready to account for it, but I was never asked to. It's been there for us, and there were never any questions asked because we never had any problems since we switched.

Moderator: Great. Lanis, what input do you have as far as the decision process and how it came to pass?

LT: Well, it was an idea that all of the techs had batted around. We crunched the numbers for the system director who is the director of the four hospitals, and we're very lucky to have him on board in our hospital. We knew there was a price difference. Our ultimate goal was to keep the backlog of scheduled patients to 2 days, who otherwise may not get in for 3 to 4 days. With that, even though using prefilleds was going to cost a little more, we felt from the standpoint of our image to the community, it was worth it. Our throughput was worth a few dollars, and that's how we presented it.

Moderator: So, you sold it on reducing the backlog?

LT: Yes, we did. I always said, "You can have the biggest cannon on the battlefield. But if you don't have enough people to get the cannon balls up there, you might as well have a pop-gun." That's the same as the IV contrast issue. You can have the biggest machine. But if you have to fumble around for 5 minutes, and it takes you as long to load the contrast as it does to do a scan, then you have really, really lost.

Moderator: Have you had to cost-justify that time? Have they been happy with the result?

LT: Yes. They questioned us up front, and we have showed them the numbers about every month.

Moderator: Great. One of the issues that's been raised is JCAHO compliance. Was that a factor in anyone's decision for this?

MM: We're a JCAHO-accredited facility, and I think being in compliance is important. It didn't play into our decision-making process, however, because there were so many positives.

Moderator: Now, what about those who don't have a contract with a specific contrast manufacturer? Does it make the transition to a prefilled syringe any easier or more difficult?

LT: We're out of the system. We do have a contract, but it isn't with the company that we presently use for contrast. Everyone likes the contrast that we're presently using, so we went outside the system. We're allowed a certain percentage of the total purchase of that product outside the system.

MM: Our purchasing group doesn't have an exclusive agreement with Bracco. We have arrangements with several different vendors. So, even though our purchasing group had that alliance, we went with the product after looking at different products.

RL: Our facility does not have a purchasing group that has a contract with Bracco. But it wasn't hard to get the approval to get the prefilleds.

Moderator: So, it's a factor, but probably not an overwhelming factor at this point?

RL: As we go down the list of indirect costs, especially those that revolve around the technologists; we've talked about the factors involving efficiency. But I think the actual decision is easier, because I think the benefits of prefilled syringes already outweigh the negatives, including the cost.

Prefilled syringes easily deliver a product, and it's a safe product, number one. With all the fears everyone has with the so-called epidemics of transmittable diseases, I think this is very important. Many times patients do ask about it; they look around and see the equipment that you're using. So, when you come in with a filled syringe, just place it on the injector, and then they're injected, it is easier for them to know that what they're getting has not been given to someone else. You're getting something sterile.

MM: I agree. In these days of competitive health care, patients are much more aware of the medications that they're being given. They're less likely to be completely trusting of any healthcare facility. So, you have to be certain you're doing a good service. But patients do question things more than they used to. I think that's good; it's good to be educated.

CW: With regard to approaching administration with a rationale for prefilled syringes, it's clear there's a direct and indirect increase in patient care and benefit to the patient. I'm sure that everyone's facility has a mission statement and the first sentence talks about wanting to bring a higher standard of care to their patients.

Moderator: Absolutely, that's universal now. Have HMO contracts, or other contracts, gotten in the way of this decision process in any way?

CC: No, not at all. I have noticed that patients are much more educated and knowledgeable, especially in my area, which is a college town. They want to know what's going on, what you're doing step by step. They don't want to just be the patient anymore. They want to be part of it.

Moderator: What advice would you give to people that are about to make this decision process to move from filling syringes for their contrast injector to using prefilled syringes?

CC: I would say it's a no-brainer. When you sit down and study what is really important, technologist safety and the patient benefits, and you realize the exam numbers will go up...even with the extra cost, you almost have to do it. You have no other choice.

GG: I think the process should include the technologists, so you are empowering them and allowing their decision to play a part. In my particular circumstance, one of the CT technologists did not think it was necessary. But, within a month of implementation, if I'd told him we were switching back to a multi-component system, I think he might start crying!

RL: I think that someone who does not use prefilled syringes would just have to take time to think about all the positives, and they're too overwhelming. I think they will definitely dominate any thinking of an administrator or CEO. Maybe not a CFO but, I'm sure, for anyone directly looking at patient care, it shouldn't be a problem.

GG: You can't really associate a dollar amount with the fact that your technologist is going to be happier. So, the variance that I dealt with was specifically related to a lot of the things that the administrator would not even be aware of. They're not going to be thinking of things like misadministration, and you could almost quantify that factor...allocate 20¢ or so to that for that little bit of piece of mind.

But, you can try to account for cost of heavy glass bottles contrast comes in ending up in the medical waste. Every place that I've worked, I've observed those in the red-bag trash. Especially in a hospital setting with multiple scanners set up, all that additional weight is very expensive, since the hospital is charged by weight. So, that certainly needs to be minimized, and there is a penny percentage that you could associate with that. Once I came in within less than a dollar of the cost variance associated with prefilled syringes, then the intangibles that are hard to quantify kicked it over.

It wasn't a decision solely based on keeping that technologist happy and efficient, even though that's been a preponderance of our discussion. To me, there was a direct trade-off in the dollar amount.

JP: But if you had just one misadministration or error, the administrators would have to open up the checkbook and that patient's family would own part of that hospital.

MM: But, that's hard to quantify when you're doing your analysis.

JP: Exactly, but all it takes is one problem, and you've got a black eye that you're never going to recover from, because that family is going to tell its circle of friends, and those friends are going to make the story even worse.

GG: But, the CFO would not know that. So, you have to say it bluntly. "Do you realize that we have an individual that performs exams, works their 8- to 9-hour day, frequently without lunch, and then is on call with the potential for having the 16 hours that belong to them interrupted at 2-hour intervals? Do you realize that person has to come back in the next day and is responsible for starting an IV and administering contrasts into a patient's bloodstream?" Then a light bulb goes on, that we're not just an assembly line putting people in a machine, pushing the button and saying, "Hold your breath," then bringing in the next one. It's a reminder that there is the possibility of human error that wouldn't be quantified exactly.

Moderator: Have you found switching to prefilleds is budget-neutral or an actual cost savings?

GG: We have such a competitive atmosphere and we're a clinic. I know others here are on a 24- or 16-hour schedule in a hospital. We are pretty much limited to 7.5- to 9-hour scanning schedule. Part of that is because you can't inject if you don't have support staff on hand in case of an adverse reaction. We have that little niche of time, and I have not gone back to analyze what we're doing since the switch to prefilleds, how much we've increased patients. But if I were asked, it would not be difficult to do. I have been asked generally "How is that going?" My response has always been, "Well, we're shaving off room prep time. We're able to accommodate add-ons almost without thought." So, it would not be difficult to point out how many exams were directly related to the 20 or 30 minutes of room prep time that we saved by using prefilled syringes. I don't even bring up the savings in storage space or time to count the inventory, because that's my function.

DR: We are owned by such a big corporation, and are one of their highest facilities in patient load. So, I don't think they mind giving us the little extra that we need to keep up our productivity and increase in financial standings for them. Because we are their biggest facility, they give us what we need to keep going, to keep bringing in the patients. So, we haven't had any problem justifying it.

MM: That's our situation, too. As the department administrator looking at prefilled syringes, the first and foremost thing you have to think about is: "Will this benefit our patients?" That's what we're there for, not just "How much money can we make?" Then, you have to look at: "Is the department profitable? Will it continue to be profitable if we use prefilled syringes?" If the answers to both those questions are yes, then you need to try this product. Then you can see if it will benefit your patients, reduce your risk of litigation, and be good for the technologist. We have to keep patient care in mind first.

Moderator: I'd like to thank you all for coming and sharing your experiences, opinions, and insights into the use of prefilled syringes. I think this product will certainly be a wave of the future. Applied Radiology should also be recognized for hosting this panel discussion and recognizing the impact that this product will make in each of our individual practices. Thank you all.