February 18, 2019

Drop the Daily Chest X-Rays for Patients in Intensive Care

How we eliminated this common but unnecessary practice

chest-x-ray_650x450

By Anita Reddy, MD

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Many hospitals obtain chest X-rays (CXR) daily on patients in their intensive care units (ICU), though it has been over a decade since this practice was recommended. The American College of Radiology (ACR) stopped recommending daily CXR in 2008 after much research showed that using on-demand imaging does not impact ICU length of stay, duration of mechanical ventilation, morbidity or mortality, and can negatively affect patients’ sleep and radiation exposure rates. The ACR strengthened its stance on daily CXR to “usually not appropriate” in 2011 and 2014.

But for most clinicians and hospitals, including Cleveland Clinic, daily CXR remained standard practice. We averaged 375 portable CXR per day across the health system in 2018. Given the data supporting on-demand images, we sought to move away from this practice across all Cleveland Clinic hospitals.

Our first step was to meet with all key stakeholders, including intensivists, surgeons, pulmonologists and radiologists. We then altered the options for chest imaging in the electronic health record so that providers could only order daily CXR for patients with cardiac support devices or who had undergone cardiac and thoracic surgery. Providers were also required to indicate a specific reason for the need in this population. We analyzed data from the pre- and post-intervention periods with a two-sample t-test.

Advertisement

Average daily portable CXRs decreased 23.5 percent overall (P < 0.001), and average overnight CXR decreased 36.6 percent (P < 0.001). The CXR volume during rounding hours did not increase in compensation, and actually decreased by 15.8 percent (P < 0.001). The initiative did not result in any reported harm events or delays in care. I presented these results at the 2019 Society of Critical Care Medicine Annual Congress.

Targeting the most appropriate patients

In the next phase of our project, we will continue to provide feedback to ICU directors about which providers are utilizing portable daily CXR. We also plan to reassess the need for daily CXR in cardiothoracic surgery and ICU patients to determine whether certain populations of patients may not benefit from this monitoring, and whether timing can be less disruptive to sleep for those who do need daily monitoring.

This initiative offered a way to improve patient experience, maximize caregiver efficiencies, minimize radiation exposure and standardize practices with no negative impact on patient outcomes.

Advertisement

Dr. Reddy is Quality Officer in the Medical Intensive Care Unit and Associate Director of ICU Operations at Cleveland Clinic.

Related Articles

ARCU
January 2, 2024
How the Acute Respiratory Care Unit Improves Care for Complex Patients

Lessons learned from cohorting patients and standardizing care

23-PUL-4178617-CQD-DM-Stretching-boundaries-ARDS-Hero-1
December 27, 2023
Stretching the Boundaries of ARDS

New tools and protocols to improve care

Prone positioning
June 8, 2023
The Importance of a Multidisciplinary Approach to Prone Positioning in ARDS

Cleveland Clinic pulmonologists share a framework for how to implement effective clinical protocols to standardize evaluation and management of complex acute respiratory distress syndrome

MICU team members
May 22, 2023
How Cleveland Clinic’s Medical Oncology Intensive Care Unit Improves Outcomes

An interdisciplinary team of specialists improves outcomes with effective collaboration, communication and identifying and implementing best practices

22-PUL-3270759 CQD-The respiratory toxicity of opioids in 2022-650&#215;450
December 5, 2022
The Respiratory Toxicity of Opioids in 2022

A public health tragedy with persistent pathophysiological and therapeutic challenges

22-PUL-3153114 CQD-Complex Case 1-DrSimon Mucha650x450
October 10, 2022
Case Study: Severe Toxicity Immunotherapy Highlights Multidisciplinary Oncology ICU Care

Immune toxicity remains a diagnosis of exclusion, and multidisciplinary collaboration remains the cornerstone for early diagnosis and treatment.

650&#215;450-Artificial-Stone-Silicosis-Occupation-Lung-Disease (1)
April 7, 2021
Engineered Stone Silicosis: New Face of an Old Disease

A closer look at risk, clinical manifestations, treatment and prevention efforts

650&#215;450-COPD-Lung-Transplantation (1)
March 3, 2021
When Is Lung Transplantation an Option in COPD?

Refer early, even when patients aren’t yet transplant candidates

Ad