Restricting Daily Chest Radiography in the Intensive Care Unit: Implementing Evidence-Based Medicine to Decrease Utilizationt

Abstract

Purpose: In this study, the authors applied evidence-based medicine to decrease the utilization of routine chest radiography in adult intensive care units and used time-driven activity-based costing to demonstrate cost savings.Methods: A multidisciplinary team was formed with representatives from radiology, surgery, internal medicine, and nursing. The process of performing a portable chest radiographic examination was mapped, and time trials were performed by the radiology technologists and radiology resident. This information was used to determine the cost of performing portable intensive care unit (ICU) chest radiographic studies. The clinical team changed resident education, ordering protocols, and workflows to discontinue the use of routine daily chest radiography, emphasizing that it should be ordered only in specific situations, such as on admission or after central line placement. In addition, as a balancing measure, the team tracked complications such as unplanned extubations and ventilator days.Results: Changing ordering practices in the adult ICUs to align with established evidence-based guidelines resulted in a 37% decrease in the utilization of portable chest radiography between June and December, without a concomitant increase in unplanned extubations or ventilator days. In addition, a proportionate cost savings was realized, as demonstrated by the application of time-driven activity-based costing.Conclusions: This performance improvement initiative successfully increased the value of care delivered to ICU patients by aligning institutional clinical practice with evidence-based medicine. This resulted in decreased utilization and the cost associated with delivering care without a concomitant increase in complications.

Imaging in the Intensive Care Unit

“…Subsequent studies, including quality improvement initiatives, have suggested a slow but gradual decrease in the use of daily CXRs, though with substantial variability between hospitals. [16][17][18] The most recent Appropriateness Criteria by the ACR states that CXRs are usually indicated under the following circumstances 19 :…”

“…Such an approach should lead to a decrease in radiation exposure and medical costs without compromising patient safety. 16,18 The Advent of Point-of-Care Ultrasound Point-of-care ultrasound (POCUS) is being used with growing frequency in the ICU, often employed instead of CXRs and chest CTs. [19][20][21][22] POCUS offers several advantages, including the absence of radiation exposure, portability, speed, and ease of obtaining serial studies, particularly when ultrasound devices are readily available in the ICU.…”

“…Subsequent studies, including quality improvement initiatives, have suggested a slow but gradual decrease in the use of daily CXRs, though with substantial variability between hospitals. 16 17 18…”

“…Such an approach should lead to a decrease in radiation exposure and medical costs without compromising patient safety. 16 18…”

Diagnostic Modalities in Critical Care: Point-of-Care Approach

“…The number of studies recommending restrictive application of a routine daily pCXR rule is increasing, as the evidence of impairing outcome, quality of care or patient safety is missing. The American College of Radiology Appropriateness Criteria Expert Panel recommended that the stable ICU patients, including those being mechanically ventilated, should have a pCXR only if there is a clinical indication as they are of low diagnostic contribution, have negligible impact on management decisions, and unexpected relevant findings are scarce [ 148 , 149 , 150 , 151 , 152 , 153 ]. However, the need for daily pCXR is still the subject of discussion and will remain until the further prospective evidence is available [ 154 ].…”