Are daily routine chest radiographs useful in critically ill, mechanically ventilated patients? A randomized study

Imaging in the Intensive Care Unit

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

Evaluation of the Daily Change in PaO2/FiO2 Ratio as a Predictor of Abnormal Chest X-rays in Intensive Care Unit Patients Post Mechanical Ventilation Weaning: A Retrospective Cohort Study

Background and Objectives: The routine daily chest X-ray (CXR) strategy is no longer recommended in intensive care unit (ICU) patients. However, it is difficult for intensivists to collectively accept the on-demand CXR strategy because of the ambiguous clinical criteria for conducting CXRs. This study evaluated the predictive value of the change in PaO₂/FiO₂ (PF ratio) for abnormal CXR findings in ICU patients after mechanical ventilation (MV). Materials and Methods: A retrospective cohort study was conducted between January 2016 and March 2021 on ICU patients with MV who had at least 48 h of MV, and stayed at least 72 h in the ICU post-MV. Routine daily CXRs and daily changes in the PF ratios were investigated during the three days post-MV. Results: The 186 patients included in the study had a median age of 77 years (interquartile range: 65–82), and 116 (62.4%) were men. One hundred and eight (58.1%) patients had abnormal CXR findings, defined as one or more abnormal CXRs among the daily CXRs during the three days post-extubation. The reintubation rate was higher in the abnormal CXR group (p = 0.01). Of the 558 CXRs (normal = 418, abnormal = 140) and PF ratios, the daily change in PF ratio had a significant predictive accuracy for abnormal CXR findings (AUROC = 0.741, p < 0.01). Conclusions: The change in PF ratio (the Youden index point: ≤−23) had a sensitivity of 65.7%, and a specificity of 79.9%. Based on these results, the daily change in the PF ratio could be utilized as a predictive indicator of abnormal CXRs in ICU patients after MV treatment.

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

The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.

Chest sonography versus chest radiograph in children admitted to paediatric intensive care - A prospective study

There is a paucity of studies on the correlation between chest radiograph and ultrasound (US) in children. Our objective was to study the correlation between bedside chest radiograph and ultrasound findings in 413 children with 1002 episodes of chest radiograph and US enrolled for a prospective, double-blinded observational study in a multidisciplinary paediatric intensive care unit. Weighted κ statistic for agreement was different for right and left lungs and varied from 50% for left pleural effusion to 98% for right pneumothorax. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed by ultrasound alone in a significantly higher number of patients as compared to chest radiograph (P = 0.001). Chest ultrasound is therefore deemed more sensitive than chest radiograph in detection of pleural effusion, pulmonary oedema and pneumothorax.

ACR Appropriateness Criteria® Intensive Care Unit Patients

Chest radiography is the most frequent and primary imaging modality in the intensive care unit (ICU), given its portability, rapid image acquisition, and availability of immediate information on the bedside preview. Due to the severity of underlying disease and frequent need of placement of monitoring devices, ICU patients are very likely to develop complications related to underlying disease process and interventions. Portable chest radiography in the ICU is an essential tool to monitor the disease process and the complications from interventions; however, it is subject to overuse especially in stable patients. Restricting the use of chest radiographs in the ICU to only when indicated has not been shown to cause harm. The emerging role of bedside point-of-care lung ultrasound performed by the clinicians is noted in the recent literature. The bedside lung ultrasound appears promising but needs cautious evaluation in the future to determine its role in ICU patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Prescription practice and clinical utility of chest radiographs in a pediatric intensive care unit: a prospective observational study

Background

Chest radiograph (CXR) prescribing pattern and practice vary widely among pediatric intensive care units (PICU). ‘On demand’ approach is increasingly recommended as against daily ‘routine’ CXRs; however, the real-world practice is largely unknown.

Methods

This was a prospective observational study performed in children younger than 12 years admitted to PICU of a tertiary care teaching hospital in India. Data were collected on all consecutive CXRs performed between December 2016 and April 2017. The primary outcome was to assess the factors that were associated with higher chest radiograph prescriptions in PICU. Secondary outcomes were to study the indications, association with mechanical ventilation, image quality and avoidable radiation exposure.

Results

Of 303 children admitted during the study period, 159 underwent a total of 524 CXRs in PICU. Median (IQR) age of the study cohort was 2 (0.6–5) years. More than two thirds [n = 115, 72.3%] were mechanically ventilated. Most CXRs (n = 449, 85.7%) were performed on mechanically ventilated patients, amounting to a median (IQR) of 3 (2–5) radiographs per ventilated patient. With increasing duration of ventilation, the number of CXRs proportionately increased in the first two weeks of mechanical ventilation. In non-ventilated children, about two thirds (68%) underwent only one CXR. Majority of the prescriptions were on demand (n = 461, 88%). Most common indications were peri-procedure prescriptions (37%) followed by evaluation for respiratory disease status (24%). About 40% CXRs resulted in interventions; adjustment in ventilator settings (13.5%) was the most frequent intervention. In 26% (n = 138) of radiographs, image quality required improvement. One or more additional body part exposure other than chest and upper abdomen were noted 336 (64%) images. Children with > 3 CXR had higher PRISM III score, more often mechanically ventilated, had higher number of indwelling devices [mean (SD) 2.6 (1.2) vs. 1.7 (1.0)] and stayed longer in PICU [median (IQR) 11(7.5–18.5) vs. 6 (3–9)].

Conclusion

On demand prescription was the prevalent practice in our PICU. Most non-ventilated children underwent only one CXR while duration of PICU stay and the number of devices determined the number of CXRs in mechanically ventilated children. Quality improvement strategies should concentrate on the process of acquisition of images and limiting the radiation exposure to unwanted body parts.

Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis

Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I² 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%-72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.

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

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.

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

BACKGROUND

Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns.

OBJECTIVE

We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies.

DESIGN

We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies.

SETTING

The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016.

PARTICIPANTS

The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists).

INTERVENTION COMPONENTS

We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates.

MEASUREMENTS

We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation.

RESULTS

Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities.

CONCLUSIONS

Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

The clinical value of routinely obtained postoperative chest radiographs in post-anaesthesia care unit patients seems poor-a prospective observational study

Background

The clinical value of routinely obtained postoperative chest radiographs (CXRs) in post-anaesthesia care unit (PACU) patients is largely unknown.

Methods

To determine the diagnostic efficacy and treatment impact of postoperative routinely obtained CXRs in a university hospital PACU. Observational study collecting the expectations of attending physicians, the findings on routinely obtained CXRs and actions based on the findings on these CXRs in postoperative PACU patients. A 22-bed PACU in a university hospital in the Netherlands. Patients admitted to the PACU during a 9-month period. The analysis was restricted to CXRs routinely obtained during the first PACU admission, i.e., CXRs obtained during later admissions were excluded. Diagnostic efficacy, defined as the percentage of CXRs showing any unexpected major abnormality; treatment impact, defined as the percentage of CXRs showing an unexpected major abnormality that triggered a predefined change in therapy.

Results

The analysis included 294 postoperative CXRs. Of them 94 showed a new and unexpected predefined major abnormality (diagnostic efficacy of 35%). Of these 94 CXRs, only 10 triggered an intervention (treatment impact of 4%).

Conclusions

The diagnostic efficacy of routinely obtained postoperative CXRs in PACU patients is fair; the treatment impact seems low if we assume that all CXRs that showed an abnormality but were not followed by an intervention and did not require an intervention. Future research should focus on the safety and cost-effectiveness of abrogating routine postoperative CXRs.

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation

IMPORTANCE

Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation.

OBJECTIVES

To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017.

EXPOSURES

Hospital discharge date (quarter of the year) and hospital in which patients received MV.

MAIN OUTCOMES AND MEASURES

The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations.

RESULTS

The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98).

CONCLUSIONS AND RELEVANCE

Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.

Daily routine versus on-demand chest radiograph policy and practice in adult ICU patients- clinicians' perspective

Background

Chest radiographs are taken daily as a part of routine investigations in Intensive care unit (ICU) patients. They are less effective and unlikely to alter the management of the majority of these patients compared to the radiographs obtained when indicated. According to the American College of Radiology (ACR) Appropriateness criteria, only selective ordering of chest radiographs is recommended, including elderly or high risk patients. The aim of this study was to identify and assess the clinician’s perspective in abandoning the current practice of daily routine chest radiograph and replacing with the on-demand radiograph in Saudi hospitals.

Methods

This was a cross-sectional study. A valid self-administered questionnaire was distributed to all clinical staff members working in ICUs in the major tertiary hospitals in Saudi Arabia. The study population was primarily the ICU intensivists (physicians), nurses and respiratory therapists (RT). The data collected were statistically processed using SPSS version 20.0; descriptive and inferential analyses were done.

Results

Out of 730 questionnaires sent, we received only 495 completed questionnaires with a response rate of 67.8%. Majority of them (n = 351) are working at academic hospitals. About half of the respondents (n = 247) are working in an open-format ICUs. Findings showed that the daily routine chest X-ray was performed in almost 96.8% of ICUs patients, which the majority of the clinical staff members (73%) thought that this current daily routine CXR protocol in the ICUs should be replaced with the on-demand CXR policy. Interestingly, the differences in demographic and work-related characteristics had no significant impact on the clinician’s view and supported moving to on-demand CXR policy and practice.

Conclusions

The daily routine CXR is still a common practice in most of the Saudi hospitals ICUs although enough empirical evidence shows that it can be avoided. We observed that intensivists support the change of the current practice and recommend an on-demand CXR policy likely to be followed in intensive care management.

Electronic supplementary material

The online version of this article (10.1186/s12880-018-0248-6) contains supplementary material, which is available to authorized users.

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

PURPOSE

Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied.

MATERIALS AND METHODS

This was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up.

RESULTS

A total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11-19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89-0.96), and 0.73 (95% CI: 0.69-0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS.

CONCLUSIONS

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.

Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment

Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.

Adding value to daily chest X-rays in the ICU through education, restricted daily orders and indication-based prompting

Background

Chest X-rays (CXRs) are traditionally obtained daily in all patients on invasive mechanical ventilation (IMV) in the intensive care unit (ICU). We sought to reduce overutilisation of CXRs obtained in the ICU, using a multifaceted intervention to eliminate automated daily studies.

Methods

We first educated ICU staff about the low diagnostic yield of automated daily CXRs, then removed the ‘daily’ option from the electronic health records-based ordering system, and added a query (CXR indicated or not indicated) to the ICU daily rounding checklist to prompt a CXR order when clinically warranted. We built a report from billing codes, focusing on all CXRs obtained on IMV census days in the medical (MICU) and surgical (SICU) ICUs, excluding the day of admission and days that a procedure warranting CXR was performed. This generated the number of CXRs obtained every 1000 ‘included’ ventilator days (IVDs), the latter defined as not having an ‘absolute’ clinical indication for CXR.

Results

The average monthly number of CXRs on an IVD decreased from 919±90 (95% CI 877 to 963) to 330±87 (95% CI 295 to 354) per 1000 IVDs in the MICU, and from 995±69 (95% CI 947 to 1055) to 649±133 (95% CI 593 to 697) in the SICU. This yielded an estimated 1830 to 2066 CXRs avoided over 2 years and an estimated annual savings of $191 600 to $224 200. There was no increase in reported adverse events.

Conclusion

ICUs can safely transition to a higher value strategy of indication-based chest imaging by educating staff, eliminating the ‘daily’ order option and adding a simplified prompt to avoid missing clinically indicated CXRs.

ACR Appropriateness Criteria® Intensive Care Unit Patients

Portable chest radiography is a fundamental and frequently utilized examination in the critically ill patient population. The chest radiograph often represents a timely investigation of new or rapidly evolving clinical findings and an evaluation of proper positioning of support tubes and catheters. Thoughtful consideration of the use of this simple yet valuable resource is crucial as medical cost containment becomes even more mandatory. This review addresses the role of chest radiography in the intensive care unit on the basis of the existing literature and as formed by a consensus of an expert panel on thoracic imaging through the American College of Radiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Implementation of a quality improvement initiative to reduce daily chest radiographs in the intensive care unit

OBJECTIVE

To reduce the number of routine chest radiographs (CXRs) done in a tertiary care intensive care unit (ICU).

METHODS

Using a quality improvement approach, we measured the number of CXRs done per patient-day before (15 June 2010-15 June 2011) and after (15 June 2011-15 June 2012) a multipronged intervention in a 15-bed medical-surgical ICU in a 350-bed tertiary care teaching hospital. We studied a total of 1492 patients who were admitted to this ICU-738 patients during the preintervention period and 754 patients during the postintervention period. Interventions were education for the ICU house staff, developing indications for routine CXRs on the computer order-entry system, and visual posters/signage to remind ICU staff that there were no indications for routine, daily CXRs. The primary outcome was the number of CXRs per patient-day, but we also measured CTs of the chest, mechanical ventilator days, length of ICU stay and ICU and hospital mortality.

RESULTS

There were 0.73 CXRs per patient-day done during the preintervention period and 0.54 CXRs per patient-day done during the postintervention period, a 26% reduction. There were no differences between the periods in age, sex or severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE) II score) of the patients, number of chest CTs, mechanical ventilator days, length of ICU stay and ICU or hospital mortality.

CONCLUSIONS

A quality improvement that includes education, reminders of appropriate indications and computerised decision support can decrease the number of routine CXRs in an ICU.

Defining indications for selective chest radiography in the first 24 hours after cardiac surgery

OBJECTIVE

In the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only.

METHODS

In this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fisher's exact test or χ(2) analysis.

RESULTS

A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event.

CONCLUSIONS

Defining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.

Implementation of lung ultrasound in polyvalent intensive care unit: Impact on irradiation and medical cost

OBJECTIVE

To determine the effect of implementing a daily lung ultrasound round on the number of chest radiographs and chest computed tomography (CT) scans in a polyvalent intensive care unit (ICU).

STUDY DESIGN

Retrospective study comparing two consecutive periods.

PATIENTS

All patients hospitalized for longer than 48 hours in a polyvalent ICU.

METHODS

Implementation of a daily lung ultrasound round after a short educational program. The number of chest radiographs and chest CT scans and the patient outcome were measured before (group PRE) and after (group POST) the implementation of a daily lung ultrasound round.

RESULTS

No demographic difference was found between the two groups, with the exception of a higher severity score in the group POST. For each ICU stay, the number of chest radiographs was 10.3 ± 12.4 in the group PRE and 7.7 ± 10.3 in the group POST, respectively (P<0.005) The number of chest CT scans was not reduced in the group POST, as compared with the group PRE (0.5 ± 0.7 CT scan/patient/ICU stay versus 0.4 ± 0.6 CT scan/patient/ICU stay, P=0.01). The ICU mortality was similar in both groups (21% versus 22%, P=0.75) CONCLUSION: The implementation of a daily lung ultrasound round was associated with a reduction in radiation exposure and medical cost without altering patient outcome.

The value of routine chest radiographs after minimally invasive cardiac surgery: an observational cohort study

Background

Chest radiographs (CXRs) are obtained frequently in postoperative cardiac surgery patients. The diagnostic and therapeutic efficacy of routine CXRs is known to be low and the discussion regarding the safety of abandoning these CXRs after cardiac surgery is still ongoing. We investigated the value of routine CXRs directly after minimally invasive cardiac surgery.

Methods

We prospectively included all patients who underwent minimally invasive cardiac surgery by port access, ministernotomy or bilateral video-assisted thoracoscopy (VATS) in the year 2012. A direct postoperative CXR was performed on all patients at ICU arrival. All CXR findings were noted, including whether they led to an intervention or not. The results were compared to the postoperative CXR results in patients who underwent conventional cardiac surgery by full median sternotomy over the same period.

Main results

A total of 249 consecutive patients were included. Most of these patients underwent valve surgery, rhythm surgery or a combination of both. The diagnostic efficacy for minor findings was highest in the port access and bilateral VATS groups (56% and 63% versus 28% and 45%) (p < 0.005). The diagnostic efficacy for major findings was also higher in these groups (8.9% and 11% versus 4.3% and 3.8%) (p = 0.010). The need for an intervention was most common after minimally invasive surgery by port access, although this difference was not statistically significant (p = 0.056).

Conclusions

The diagnostic efficacy of routine CXRs performed after minimally invasive cardiac surgery by port access or bilateral VATS is higher than the efficacy of CXRs performed after conventional cardiac surgery. A routine CXR after these procedures should still be considered.

Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey

Background

ICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.

Methods

Web-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.

Results

Of the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization.

Conclusion

The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.

Routine chest x-rays in intensive care units: a systematic review and meta-analysis

Introduction

Chest x-rays (CXRs) are the most frequent radiological tests performed in the intensive care unit (ICU). However, the utility of performing daily routine CXRs is unclear.

Methods

We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay).

Results

Nine studies (39,358 CXRs; 9,611 patients) were included in the meta-analysis. Three trials (N = 870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only one trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% confidence interval [CI] 0.84 to 1.28, P = 0.72; two trials, N = 776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P = 0.91; two trials, N = 259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P = 0.27; three trials, N = 870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P = 0.23; two trials, N = 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P = 0.62; three trials, N = 705). Adding data from six observational studies, one of which systematically screened for missed findings, gave similar results.

Conclusions

This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain.

Patient safety in the critical care environment

Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Obtaining improvement in systems of care is difficult given the reactionary mode physicians tend to enter when dealing with moment-to-moment crises. It will be important to implement quality and safety measures that are already supported by evidence. Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.

Chest radiographs in 104 French ICUs: current prescription strategies and clinical value (the RadioDay study)

OBJECTIVE

To analyze the current practices of chest radiograph (CXR) prescription and their clinical impact.

DESIGN

Prospective snapshot observational study (on RadioDay) combined with a survey.

PATIENTS

Patients who were given a CXR on RadioDay.

SETTING

One hundred four French intensive care units (ICUs).

RESULTS

On RadioDay, 854 CXRs (in 804 patients) were ordered. For the "CXRs morning round," the prescription policy was declared to be "on-demand" (in 63 % of the ICUs), "daily routine only in mechanically ventilated patients (MV)" (30 %) or, less frequently, "daily routine in all patients" (7 %). When analyzing the two main local policies, as compared with "daily routine only in MV" ICUs, in "on-demand" ICUs: (1) fewer CXRs were ordered (0.6 ± 0.3 vs. 0.9 ± 0.2 CXRs/patient, p < 0.001) with no increase in the rate of unscheduled CXRs (i.e., CXRs performed outside the morning round), and (2) individual CXRs were more often followed by a therapeutic intervention (which would not have occurred without the CXR): 34 vs. 25 % of the CXRs (p < 0.05). Last, in case of severe respiratory disease (low PaO(2)/FiO(2) ratio), it is noteworthy that the clinical value of "on-demand" individual CXRs was still markedly higher than that of "daily routine" CXRs.

CONCLUSION

Nearly two-thirds of the participating ICUs adopted the "on-demand" strategy of prescription, which was associated with a lower rate of CXRs with no increase in unscheduled CXRs and was of higher clinical value than a "daily routine in MV" strategy. Importantly, the study design did not allow assessing if the "on-demand" strategy had missed or delayed some diagnoses.

An integrated approach for prescribing fewer chest x-rays in the ICU

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.

Review of a Large Clinical Series: The Value of Routinely Obtained Chest Radiographs on Admission to a Mixed Medical—Surgical Intensive Care Unit

Background and objectives: The efficacy of routinely obtained chest radiographs (CXRs) on admission to the intensive care unit (ICU) is largely unknown. The current study investigated the efficacy of routinely obtained admission CXRs and determined whether the value of this diagnostic test was dependent on patient category. Materials and Methods: Prospective nonrandomized controlled study. including 1081 admission CXRs of 1330 patients admitted to a 28-bed mixed medical—surgical university-affiliated ICU, over a 10-month period. To determine the value of admission CXRs, 2 categories of efficacy were used: diagnostic efficacy (the number of CXRs with a new or progressive major finding divided by the total number of CXRs) and therapeutic efficacy (the number of CXRs resulting in a change in clinical management divided by the total number of CXRs). Efficacy <15% was considered low. Patients were subclassified into subcategories on the basis of type of admission. Results: Of all admission CXRs, 227 were clinically indicated and 854 were routinely obtained to establish a baseline prior to admission to ICU. Diagnostic efficacy of routinely obtained admission CXRs was 11%. The majority of abnormalities were malposition of invasive devices and severe pulmonary congestion. Therapeutic efficacy of routinely obtained admission CXRs was only 5%. Subgroup analysis showed highest efficacy in nonsurgical patients. Conclusions: In our mixed medical—surgical ICU the diagnostic and therapeutic efficacy of routinely obtained admission CXRs is low, though not completely negligible. Highest efficacy of CXRs was found in nonsurgical patients. Prospective studies are needed to determine whether abolishing this diagnostic test is a safe strategy.

Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study

BACKGROUND

Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care.

METHODS

In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672.

FINDINGS

11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001).

INTERPRETATION

Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety.

FUNDING

Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).