Deimplementation of Routine Chest X‐rays in Adult Intensive Care Units

Abstract

Despite increased awareness of Choosing Wisely (CW) ® recommendations to reduce low-value care, 1 there is limited published data about strategies to implement these guidelines or evidence that they have influenced ordering patterns or reduced healthcare spending. [2][3][4][5][6] Implementation science seeks to accelerate the translation of evidence-based interventions into clinical practice and the deimplementation of low-value care. [7][8][9] Based on established principles of implementation science, we used a prospective, nonrandomized study design to assess a CW intervention to reduce chest X-ray (CXR) ordering in adult intensive care units (ICUs). 10 In ICUs, CXR ordering strategies may be routine (daily) or on-demand (with clinical indication). The former strategy's principal advantage is the potential to detect life-threatening situations that may otherwise escape diagnosis. 11 Disadvantages include cost, radiation exposure, patient inconvenience, false-positive workups, and low diagnostic and therapeutic value. 12,13 On-demand strategies may safely reduce CXR ordering by 32% to 45%. [11][12][13][14][15][16][17] Based on this evidence, the Critical Care Societies Collaborative and the American College of Radiology have recommended on-demand CXR ordering. 18,19 Here, we describe the effectiveness of an intervention to reduce CXR ordering in two ICUs while evaluating the deimplementation strategies using a validated framework. METHODS Setting and DesignVanderbilt University Medical Center (VUMC) is an academic referral center in Nashville, Tennessee. The cardiovascular ICU (CVICU) has 27 beds and the medical ICU (MICU) has 34 beds. Acute care nurse practitioners (ACNPs) and two critical care physicians staff the CVICU; cardiology fellows, anesthesia critical

Fasting habits over a 10-year period: An observational study on adherence to preoperative fasting and postoperative restoration of oral intake in 2 Dutch hospitals

“…Furthermore, these future studies can incorporate lessons learned from other studies about how to deimplement old habits. 47,48 This study has some limitations. Estimation of the duration of fasting may have been imprecise.…”

The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives

“…The median baseline chest CXR ordering rate in the CVICU was 1.16 xrays per patient per day. During the intervention period, the rate dropped to 1.07 (p < .001; Trumbo et al, 2019;Oliver et al, 2016). In the MICU, baseline ordering rates were lower at 0.60 per patient per day for the MICU physician care team and 0.39 per patient per day for the APRN teams.…”

“…A year-long APRN initiative was launched to target reducing unnecessary lab and chest-x-ray testing at an academic medical center which demonstrated success in showcasing the role of APRN-led care in promoting high-value health care. A decrease in daily lab testing and chest x-ray use was demonstrated (Kleinpell, Kapu, Witherspoon et al, 2017;Trumbo, Iams, Limper et al, 2019).…”

“…Working in conjunction with an interdisciplinary Choosing Wisely Ò committee, the teams implemented six different year-long projects targeting reducing unnecessary laboratory and CXR use (Kleinpell et al, 2017). In the Cardiovascular intensive care unit (CVICU), and the MICU, a prospective nonrandomized study with historical control data was conducted using provider education, peer champions and weekly data feedback of CXR ordering rates (Trumbo et al, 2019). Two of the lead APRNs served as peer champions to coordinate data feedback and advocate for the intervention among ordering providers.…”

“…Trends in ordering rates during the intervention period were not significantly different than the baseline period. The major facilitators identified in provider interviews included peer champion discussions about CXR ordering on rounds and weekly data feedback (Trumbo et al, 2019). The role of the APRN in this initiative was instrumental in reinforcing mindful ordering practices.…”