Reducing Daily CXRs in the icu

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.

Selected References

Choukalas, C. G., & Vu, T.-G. (2020). The Problem of Daily Imaging in the Intensive Care Unit. JAMA Internal Medicine, 180(10), 1369. https://doi.org/10.1001/jamainternmed.2020.2667

Expert Panel on Thoracic Imaging, McComb, B. L., Chung, J. H., Crabtree, T. D., et al (2016). ACR Appropriateness Criteria® Routine Chest Radiography. Journal of Thoracic Imaging, 31(2), W13-5. https://doi.org/10.1097/RTI.0000000000000200

Gershengorn, H. B., Wunsch, H., Scales, D. C., & Rubenfeld, G. D. (2018). Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation. JAMA Network Open, 1(4), e181119. https://doi.org/10.1001/jamanetworkopen.2018.1119

Halpern, S. D., Becker, D., Curtis, J. R., et al (2014). An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: The Choosing Wisely® Top 5 list in critical care medicine. American Journal of Respiratory and Critical Care Medicine, 190(7), 818–826. https://doi.org/10.1164/rccm.201407-1317ST

Keveson, B., Clouser, R. D., Hamlin, M. P., et al (2017). Adding value to daily chest X-rays in the ICU through education, restricted daily orders and indication-based prompting. BMJ Open Quality, 6(2), e000072. https://doi.org/10.1136/bmjoq-2017-000072

Maley, J. H., & Stevens, J. P. (2020). Low-Value Diagnostic Imaging in the Intensive Care Unit: A Teachable Moment. JAMA Internal Medicine, 180(10), 1368–1369. https://doi.org/10.1001/jamainternmed.2020.2681

Sy, E., Luong, M., Quon, M., Kim, Y., et al (2016). Implementation of a quality improvement initiative to reduce daily chest radiographs in the intensive care unit. BMJ Quality & Safety, 25(5), 379–385. https://doi.org/10.1136/bmjqs-2015-004151

Trumbo, S. P., Iams, W. T., Limper, H. M., Goggins, K., et al (2019). Deimplementation of Routine Chest X-rays in Adult Intensive Care Units. Journal of Hospital Medicine, 14(2), 83–89. https://doi.org/10.12788/jhm.3129

Wu, Y., Rose, M. Q., Freeman, M. L., Richard-Lany, N. P., et al (2020). Reducing chest radiography utilization in the medical intensive care unit. Journal of the American Association of Nurse Practitioners, 32(5), 390–399. https://doi.org/10.1097/JXX.0000000000000256