Reducing Daily CXRs in the icu
April 1st, 2022- A systems-based project to reduce unnecessary daily chest x-rays in ventilated ICU patients has been approved with the input and review of McLaren physician leaders on the Critical Care Task Force and HVC Steering Committee.
WHY: In the ICU, CXR ordering strategies may be routine (daily) or on-demand with a clinical indication. Much of the historical justification for routine daily CXRs no longer exists because of monitoring built into modern ventilators and the use of noninvasive monitors including capnography and oximetry. More importantly, point-of-care lung ultrasound has become widely available and may outperform CXR in the diagnosis of certain acute lung pathologies such as pneumothorax. In response to emerging evidence, the American College of Radiology in 2011 changed its rating for routine daily CXRs in the ICU to “usually not appropriate.” As part of the 2014 Choosing Wisely recommendations, the Critical Care Societies Collaborative specifically recommended against ordering CXRs and other diagnostic tests at regular intervals (such as daily) rather than for specific clinical indications.
A number of published studies have now demonstrated that on-demand strategies may safely reduce CXR ordering by 26% to 45%. By eliminating the need to review daily CXRs for each patient, clinicians may also increase time spent at the bedside and focus on higher-value data to inform care. The COVID-19 pandemic further emphasizes the importance of the judicious use of limited healthcare resources. In addition to cost, radiation exposure and false positives, every CXR consumes personal protective equipment and exposes staff to contagious patients, and there simply may not be enough time or staff resources to obtain a CXR for every ICU patient every day.
WHAT: Implement a systems-based project to reduce unnecessary daily CXRs in ventilated ICU patients. Project goals are to support appropriate use of imaging and nursing resources, decrease unnecessary exposure to ionizing radiation and hazards associated with patient positioning, standardize critical care and radiology policies, and improve Imaging Stewardship.
HOW: Use a multimodal approach to include three components:
Education (HVC web site info, posters, pocket cards)
Audit and feedback (HVC teams, attending physicians, radiologists)
Clinical decision support strategies
Remove standing daily CXR orders from Cerner PowerPlans
Duplicate order alert if repeat CXR ordered < 24 hours
EHR order alert
Alert informing of System efforts to decrease the number of unnecessary CXRs and instructing providers to consider SCCM-provided, evidence-based recommendations regarding the effective use of bedside ultrasound to evaluate patients for conditions, such as pulmonary edema, pneumothorax, pleural effusions, and hemodynamic instability.
EHR Hard Stop- Provider must select an indication
Unexplained new cardiopulmonary symptoms or signs; suspected new pneumonia; suspected pneumothorax; suspected new pleural effusion; insertion of endotracheal tubes, feeding tubes, chest tubes or central venous catheters and suspected malposition or malfunction of existing tubes, OTHER.