Reducing Unnecessary Chest X-rays in the Pediatric Intensive Care Unit- Assessing Baseline Unit Characteristics and Readiness for Change

From the 2021 HVPAA National Conference

Daniel Loeb (Cincinnati Children’s Hospital Medical Center), Kelli Paice, Kathryn Pavia, Conor Merritt, Andrea Maxwell, Edward Cooper, Ranjit Chima, Maya Dewan

Background

The American College of Radiology recommends against routine portable chest radiographs (CXRs) to assess stable adult patients in the intensive care unit (ICU)^1,2. In patients admitted to the pediatric ICU (PICU) evidence is limited, but small studies demonstrate the safety and impact of demand versus routine plus demand CXRs³.

Objectives

Assess the acceptability and feasibility of reducing routine overnight CXRs on intubated patients at a single center PICU.

Methods

This quality improvement initiative was conducted in the PICU at Cincinnati Children’s Hospital Medical Center, a large quaternary care center medical-surgical ICU. The baseline rate of overnight CXRs per ventilator days was retrospectively measured over the prior calendar year. Provider expectations and attitudes around limiting overnight CXRs were gathered via a deidentified unit-wide survey. Rule-in patient criteria for limiting routine CXRs was established via departmental shared decision making.

Results

Extracted electronic medical record data from January 2020 through November 2020 demonstrated an average of 1.5 overnight CXRs performed per ventilator day, with control limits ranging from 1.2 to 2.0 overnight CXRs per ventilator days without any significant seasonal variance [Figure 1]. The division-wide survey illustrated a readiness for change with most staff in agreement that all intubated patients do not require daily CXRs (82%). This agreement improved to 94% for patients > 40 kg and decreased to 59% for patients <10 kg [Figure 2]. The majority of providers were not opposed to increasing the interval between routine CXRs to >24 hours in those patients with stable or improving respiratory failure (82%), uncomplicated post-operative patients (91%), or patients intubated for neurological reasons (91%). In evaluating reasons for routine CXRs, 100% of critical care fellows and 86% of advanced practice nurses (APN) stated that they order daily CXRs due to cultural expectations as compared with only 7% of attending physicians [Figure 3].

Conclusions

Baseline rates of routine overnight CXRs are high and do not have significant seasonal fluctuation. There is broad practice acceptance and readiness to limit daily CXRs in patients >40kg and those without worsening respiratory failure. Motivation for ordering routine overnight CXRs on intubated patients varies greatly between critical care fellows and APN’s compared to attending physicians.

Clinical Implications

A high baseline rate of overnight CXRs juxtaposed with a high degree of readiness for change among PICU providers to reduce the use of routine CXRs on select intubated patients has primed the ICU to begin reduction of the rate of routine overnight CXRs. A multidisciplinary team has been formed and a key driver diagram has been created to assist the team in designing interventions for CXR reduction.

References

1. Amorosa JK, Bramwit MP, Mohammed TL, et al. ACR appropriateness criteria routine chest radiographs in intensive care unit patients. J Am Coll Radiol 2013; 10:170-4. doi:10.1016/j.jacr.2012.11.013
2. Graat ME, Choi G, Wolthuis EK, et al. . The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Crit Care 2006;10:R11 doi:10.1186/cc3955
3. Bafaqih H, Almohaimeed S, Thabet F, Alhejaili A, Alarabi R, Zolaly M, Baqais K, Kasim K, Chehab M. Utility of daily routine portable chest X-ray in mechanically ventilated patients in the pediatric intensive care unit. J Pediatr Intensive Care. 2014 Mar;3(1):29-34. doi: 10.3233/PIC-14082. PMID: 31214448; PMCID: PMC6530738.