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A Quality Improvement Initiative to Reduce Unneeded Screening Chest Radiographs in a Pediatric Cardiovascular ICU
Stefan W Malin1, Anne E McCallister2, Samer M Abu-Sultaneh2
1Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana. malins@iu.edu.
Insights
Reducing daily chest X-rays (CXRs) in a pediatric cardiovascular ICU (CICU) significantly decreased their use by 33% without impacting patient safety. This initiative lowers radiation exposure and healthcare costs.
Area of Science:
- Pediatric critical care medicine
- Radiology
- Healthcare management
Background:
- Current guidelines recommend on-demand chest radiographs (CXRs) for stable, mechanically ventilated adults, but not pediatric intensive care unit (PICU) patients.
- Unnecessary CXRs increase radiation exposure, healthcare costs, and patient disruption.
- The study addressed the lack of specific recommendations for reducing routine CXRs in pediatric ICUs.
Purpose of the Study:
- To decrease the frequency of unneeded daily screening chest X-rays (CXRs) in a pediatric cardiovascular ICU (CICU) by 20% within six months.
- To implement evidence-based criteria for ordering daily screening CXRs in mechanically ventilated pediatric patients.
- To maintain patient safety while reducing radiation exposure and healthcare expenditures.
Main Methods:
- Developed and implemented specific criteria for daily screening CXRs on the daily rounding sheet.
- Increased the frequency of respiratory therapist evaluations of endotracheal tube positioning.
- Monitored the percentage of subjects receiving daily screening CXRs, the ratio of daily to total CXRs, and unplanned extubations.
Main Results:
- The percentage of subjects receiving daily screening CXRs decreased from 67% to 44% (a 33% reduction).
- There was no significant change in the ratio of daily screening CXRs to total CXRs ordered.
- No increase in unplanned extubations was observed, indicating sustained patient safety.
Conclusions:
- Implementing specific criteria for daily screening CXRs is a sustainable method to reduce their use in the pediatric cardiovascular ICU.
- This practice change can be achieved without compromising patient safety or increasing other radiographical imaging.
- Reducing unneeded CXRs optimizes resource allocation, decreases radiation exposure, and lowers healthcare costs.
Background:
Adult critical care and radiographical societies have recommended changing practice from routine screening radiographs to on-demand chest radiographs (CXRs) for stable mechanically ventilated adult patients. There are no similar recommendations for patients in the pediatric ICU. Reducing the frequency with which unneeded CXRs are obtained can decrease radiation exposure and reduce waste, a substantial contributor to rising health care costs. We aimed to reduce unneeded daily screening CXRs in a pediatric cardiovascular ICU (CICU) by 20% in 6 months.
Methods:
Criteria delineating which subjects in the CICU required daily screening CXRs were created and added to the daily rounding sheet for discussion for each subject. The primary goal of this study was to reduce CXRs in mechanically ventilated subjects as our previous practice had been to order daily CXRs. Respiratory therapists increased the frequency of evaluating and documenting endotracheal tube positioning prior to the initiation of this project. The outcome measure was the percentage subjects who received a daily screening CXR. The ratio of daily screening CXRs to the number of total CXRs ordered and unplanned extubations were followed as balancing measures.
Results:
The number of subjects who received a daily screening CXR decreased from a baseline of 67% to 44% over the course of this project. There was no change in the ratio of daily screening CXRs to the number of total CXRs ordered or an increase in unplanned extubations. With an estimated cost of $268 per CXR, a reduction of 33% in routine screening CXRs saves an estimated $250,000 annually.
Conclusions:
A decrease in daily screening CXRs can be sustained through the development of specific criteria to determine which patients need screening radiographs. This can be achieved without an increase in CXRs obtained at other times throughout the day or an increase in unplanned extubations. This eliminates unneeded health care expenditures, improves resource allocation for radiology technicians, and decreases disruptive interventions for patients.
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