Choosing Chest x-rays (CXR) Wisely: A Multifaceted Intervention Targeting Scheduled, Daily Imaging Reduces CXR Utilization in Intensive Care Unit Setting
Sonali Palchaudhuri
Johns Hopkins Bayview Medical Center
Sonali Palchaudhuri is a Hospitalist Fellow at Johns Hopkins Bayview Medical Center, completing a Certificate in Quality Improvement, Patient Safety, and Outcomes Research at Bloomberg School of Public Health. She is also the National Director of Providers for Responsible Ordering (PRO), a growing chapter organization that aims to promote high-value care among providers through culture change, educational activities, and on-ground QI projects. With a background in engineering, she is interested in designing interventions for more efficient and effective care in both high-resource and low-resource settings. She will continue quality improvement research and high-value care projects as a Gastroenterology fellow at the University of Pennsylvania this summer.
Abstract
Background: Daily scheduled chest X-rays (CXR) have been common practice in intensive care units (ICU). Meta-analyses show no observed differences in hospital or ICU mortality, hospital or ICU length of stay, or number of... [ view full abstract ]
Background: Daily scheduled chest X-rays (CXR) have been common practice in intensive care units (ICU). Meta-analyses show no observed differences in hospital or ICU mortality, hospital or ICU length of stay, or number of ventilator days if CXRs are ordered on demand versus preemptively daily. Consequently, ABIM Choosing Wisely Critical Care Recommendations advise against ordering scheduled CXR. We designed a multifaceted intervention to reduce the number of scheduled daily CXR in the medical (MICU) and cardiac ICUs (CICU).
Methods: In January 2015, we implemented a multifaceted intervention to teach and to encourage providers to order CXR in response to changes in clinical status with new symptoms or after specified interventions, and not schedule them daily for all patients. Interventions included sending an evidence-based summary to attending physicians, posting a pocket card with American College of Radiology recommendations for the appropriate and inappropriate indications for ICU CXR, and removing the default CXR order from the rounding order sets in the electronic medical record. We compared the number of CXR ordered and completed in the MICU and CICU post-intervention (January 2015-November 2015) with the baseline frequency during the pre-intervention period (January 2014 – November 2014), both in total and in monthly comparisons to account for seasonal variability.
Results: The total number of post-intervention CXR was reduced by 21% (2044 pre-intervention, 1620 post-intervention, p-value = 0.007). In the MICU, the number of CXR per ICU patient-day decreased from 0.6 to 0.17.
Conclusions: A multifaceted approach, including educational and systems-based interventions, reduced the practice of CXR utilization in the ICU, by targeting scheduled daily CXR. This intervention has the potential to change the ICU practice culture, from a culture of habitual test ordering to a culture that “chooses CXR wisely.” Reduced radiation exposure and cost are principal benefits to patients.
Authors
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Sonali Palchaudhuri
(Johns Hopkins Bayview Medical Center)
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Stephanie Chen
(Kaiser Permanente San Francisco Medical Center)
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Jonathon Thorp
(Johns Hopkins Bayview)
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Jeff Trost
(Johns Hopkins Bayview Medical Center)
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Anthony Accurso
(New York University Department of Population Health)
Topic Areas
Prevalence and drivers of overuse , Harms of overuse (physical, psychological or system-related) , Organizational factors (such as structure and culture) that drive overuse
Session
AS-2A » Abstract Slams: Interventions to Reduce Overuse (13:30 - Friday, 5th May, Salons 1, 2, & 3)
Presentation Files
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