Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes

Tonna, Joseph E.; Kawamoto, Kensaku; Presson, Angela P.; Zhang, Chong; Mone, Mary C.; Glasgow, Robert E.; Barton, Richard G.; Hoidal, John R.; Anzai, Yoshimi

doi:10.1016/j.jcrc.2017.10.003

Cited by 4 publications

(4 citation statements)

References 17 publications

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“…Subsequently, Tonna et al have shown that on-demand CXR ordering can be safely implemented among such patients. 37 Also similar to our study, Tonna et al observed an initial decrease in CXR ordering, followed by a gradual increase toward baseline ordering rates. These findings highlight the need for sustained awareness and interventions and for the careful selection of high-value projects.…”

Section: Discussionsupporting

confidence: 91%

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

Trumbo

Iams

Limper

et al. 2019

Journal of Hospital Medicine

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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

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Section: Discussionsupporting

confidence: 91%

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

Trumbo

Iams

Limper

et al. 2019

Journal of Hospital Medicine

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“…Additionally, compared to sublobar resections, lobar resections may have more post-operative implications with more lung parenchymal removal particularly in patients with poor functional respiratory reserve and comorbidities that would make clinical and diagnostic interpretation more complex. Lastly, we aimed to focus on elective thoracic surgery patients as the majority of current studies are focused on adult patients who are critically ill or those in the ICU [ 14 , 15 ]. Though a baseline, PACU CXR may provide a baseline reference for thoracostomy tube placement, obtaining an additional routine, POD one CXR may have low diagnostic yield in changing management particularly in the absence of abnormal clinical signs and symptoms [ [17] , [18] , [19] , [20] ].…”

Section: Discussionmentioning

confidence: 99%

“…Tolsma et al, found routine, daily CXRs to be helpful in medical decision making but this was limited to patients undergoing cardiac surgery [ 13 ]. For patients in the ICU, Tonna et al, found that CXRs obtained by clinical change, as opposed to a routine basis, did not change Acute Physiology And Chronic Health Evaluation ( APACHE ) II scores, LOS , ventilator usage, or mortality [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

Are routine, daily chest radiographs (CXR) necessary following (VATS and RATS) lobectomies?

Alcasid,

Banks,

Jiang

et al. 2024

Surgery Open Science

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“…They also recognized that the changes we proposed were not only appropriate on the basis of current recommendations but could be easily implemented. Although there is literature suggesting that a simple request from SICU and MICU directors has been shown to reduce imaging rates, without further intervention, ordering rates will begin to increase eventually [11]. The team understood that to sustain any improvements, a more comprehensive, systematic approach will be needed.…”

Section: Discussionmentioning

confidence: 99%

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

Scott

Waite

Napolitano

2021

Journal of the American College of Radiology

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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.

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Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes

Abstract: In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.

Cited by 4 publications

References 17 publications

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

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

Are routine, daily chest radiographs (CXR) necessary following (VATS and RATS) lobectomies?

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

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