I am thrilled the Choosing Wisely Campaign has looked upon this data. Upon my first foray into the ICU as a PGY-1 many moons ago, we would not be able to go home until we put in orders for all of our patients. Amongst those things that we would order daily included chest x-rays for the patients on the ventilator. Around 5-6am, the radiology techs would come around and venture into all the rooms to obtain the imaging. Not to mention further disturbing the already deranged sleep cycles of our vented patients. During rounds we’d look at all the images and discuss the findings. But did it really change management?

Defending Daily Chest X-Rays

Now, I know you could make the argument where one can see if the infiltrates are better, worse, or the same on the film. And you can see worsening effusions, where the tubes and lines are and all that jazz. Yes, there are many nuances to it like many things in medicine. I’m not a CXR abolitionist, I am, however, an abolitionist of mindless practices that cost a significant amount of money but don’t really change outcomes. The cited papers stated that they did not see an “increase in reported adverse effects”.

When someone is on a vent, I do not order daily chest x-rays. I order films based on the patient, based on their pathology, and what I am looking for. If a patient is volume overloaded, I can see based on the little number on their pulse-ox that the FiO2 cannot be weaned down. If the peak pressures start climbing and I am suspecting a pneumothorax, I whip out the ultrasound device and assess for lung sliding. Same for effusions. The point is that I order a test knowing what I’m looking for, not trying to discover things. This paper states that 2.2% of daily chest x-rays led to a change in management. I agree with all this for choosing wisely.

Changing Culture

The cited paper is from 2017. I guess you can say it’s relatively new. People ask me how they can do things to change practice when the docs don’t want to change their ways. Well, you can print this bad boy out and leave it on someones desk. After all, it’s free to download. The authors looked at their 400 bed hospital and by implementing some rules like removing the “daily CXR” order from the EMR and making the ordering clinicians click on some extra annoying boxes to get the order in. In addition they were trained on the utility (or lack thereof) of daily CXR’s. All in all, they were able to cut down on the imaging ordered and saved the hospital between $191-224k. That’s a lot of management pizza parties for staff!

We can all admit the way we spend money in healthcare needs to be curtailed. It’s quite wasteful. Then when something catastrophic happen, a’hem, then people get furloughed and receive pay cuts. We can do our part to mitigate that as much as possible. This is one step in that direction. If you are not familiar with the Choosing Wisely Campaign, they look at other concepts such as this one. The intention is to provide better care to our patients.
-EJ

This paper has been added to my ICU Pearls collection of articles.

Citation:

Keveson B, Clouser RD, Hamlin MP, Stevens P MSN, RN, Stinnett-Donnelly JM, Allen GB. Adding value to daily chest X-rays in the ICU through education, restricted daily orders and indication-based prompting. BMJ Open Qual. 2017;6(2):e000072. Published 2017 Nov 25. doi:10.1136/bmjoq-2017-000072
Link to FULL FREE Article

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