A Quality Improvement Initiative to Reduce Unnecessary Screening Chest Radiographs in a Pediatric ICU
Stefan W Malin1, Danielle K Maue2, Daniel T Cater2
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
Implementing chest radiograph (CXR) criteria in a pediatric intensive care unit (PICU) significantly reduced daily screening CXRs. This initiative lowered radiation exposure and healthcare waste without increasing patient harm.
Area of Science:
- Pediatric critical care medicine
- Radiology
- Quality improvement initiatives
Background:
- The Critical Care Societies Collaborative identified reducing routine diagnostic tests as a key Choosing Wisely initiative.
- Unnecessary chest radiographs (CXRs) contribute to radiation exposure and healthcare waste.
- A quality improvement project aimed to decrease daily screening CXRs in a pediatric intensive care unit (PICU).
Purpose of the Study:
- To reduce the frequency of daily screening CXRs in intubated patients within a PICU.
- To achieve a 20% reduction in daily screening CXRs from baseline within 4 months.
- To evaluate the impact of implementing specific CXR ordering criteria.
Main Methods:
- The study included all intubated patients in the PICU, excluding those with tracheostomies.
- Specific criteria were developed to identify patients most likely to benefit from daily screening CXRs.
- Daily CXR orders were discussed during patient rounds, with criteria applied to guide decisions.
Main Results:
- The percentage of intubated patients receiving daily screening CXRs decreased from 79% to 31%.
- No significant increase was observed in unplanned extubations or the number of non-screening CXRs.
- The project resulted in estimated savings of $300,000 in patient charges and $60,000 in hospital costs.
Conclusions:
- Implementing evidence-based criteria for ordering screening CXRs can effectively reduce their utilization in PICUs.
- This approach minimizes radiation exposure and healthcare costs without compromising patient safety.
- Targeted CXR ordering is a feasible and beneficial quality improvement strategy in pediatric critical care.
Background:
The Critical Care Societies Collaborative included not ordering diagnostic tests at regular intervals as one of their Choosing Wisely initiatives. A reduction in unnecessary chest radiographs (CXRs) can help reduce exposure to radiation and eliminate health care waste. We aimed to reduce daily screening CXRs in a pediatric ICU (PICU) by 20% from baseline within 4 months of implementation of CXR criteria.
Methods:
All intubated patients in the PICU were included in this quality improvement project. Patients with tracheostomies were excluded. We developed criteria delineating which patients were most likely to benefit from a daily screening CXR, and these criteria were discussed for each patient on rounds. Patients on extracorporeal membrane oxygenation, on high-frequency oscillatory ventilation, or on high support on conventional mechanical ventilation were included as needing a daily screening CXR. We tracked the percentage of intubated subjects receiving a screening CXR as an outcome measure. Unplanned extubations and the number of non-screening CXRs per intubated subject were followed as balancing measures.
Results:
The percentage of intubated subjects receiving a daily screening CXR was reduced from 79% to 31%. There was no increase in frequency of unplanned extubations or number of non-screening CXRs. With an estimated subject charge of roughly $270 and hospital cost of $54 per CXR, this project led to an estimated $300,000 in patient charge savings and $60,000 in hospital cost savings.
Conclusions:
Adopting criteria to delineate which patients are most likely to benefit from screening CXRs can lead to a reduction in the percentage of intubated patients receiving screening CXRs without appearing to increase harm.
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