Reducing chest radiography utilization in the medical intensive care unit

Area of Science:

• Critical Care Medicine
• Radiology
• Quality Improvement Science

Background:

• Routine daily chest radiographs (CXRs) were standard practice in ICUs.
• Evidence and technological advancements support on-demand CXRs for improved patient care.
• A significant number of routine CXRs were being ordered, some unnecessarily after patient extubation.

Purpose of the Study:

• To implement and evaluate interventions aimed at reducing the number of routine chest radiographs (CXRs) in an adult medical intensive care unit (ICU).
• To transition from routine to on-demand CXR ordering practices.
• To assess the impact of these changes on patient outcomes, radiation exposure, and costs.

Main Methods:

• A prospective, phased quality improvement (QI) project was conducted in a 19-bed adult medical ICU over 3.5 years.
• Interventions included staff surveys, removal of routine CXR orders, duplicate alerts, visual reminders, and an electronic clinical decision support tool.
• Nurse Practitioners (NPs) led the initiative, providing monthly education on appropriate CXR use and promoting bedside ultrasound.

Main Results:

• The total number of CXRs per patient-day decreased by 36.1%.
• The proportion of routine CXRs dropped from 55.37% to 13.18%, while on-demand orders increased from 44.63% to 86.82%.
• Radiation exposure per census decreased by 27%, and patient charges for CXRs reduced by $7,750 monthly. ICU mortality and ventilator days remained stable.

Conclusions:

• An orchestrated process involving awareness and behavior change effectively reduced routine CXR utilization in the ICU.
• The shift to on-demand CXR ordering was achieved while maintaining patient safety and clinical outcomes.
• This QI project demonstrates the feasibility and benefits of optimizing CXR ordering practices in critical care settings.