Quality Improvement: Reducing Chest Radiographs in the Cardiac Surgery Intensive Care

Abstract

Problem: Daily chest radiographs (CXRs) are a part of routine care for intensive care unit (ICU) patients. The Choosing Wisely campaign is an evidence-based practice initiative by the American Board of Internal Medicine (ABIM) that promotes providers to rethink unnecessary medical procedures without clinical indication. Obtaining daily CXR in the ICU has proven to be costly, exposes patients to unnecessary radiation, and provides a low yield of clinically significant data. Purpose: The purpose of the quality improvement project (QI) was to implement an evidence-based decision algorithm to reduce unnecessary daily chest CXRs in ICU patients. The algorithm encouraged CXRs to be ordered on demand for this population when clinically warranted to investigate a clinical concern. Methods: Following education of unit staff, a decision algorithm was implemented with a practice change bundle if the patient qualified for on-demand CXRs. Pre and post data were collected through chart audits and on data from the Radiology Information System (RIS). Data collected measured staff ICU note adherence to the chest radiograph algorithm, the diagnosis for CXR screening, and the total number of CXR sent in a monthly period. Results: Data collection took place over 15 weeks including three weeks of baseline data. During the implementation period weekly staff adherence to the decision algorithm increased. The findings suggest increasing practice of ordering on demand CXRs based on eligibility. Conclusions: Significant outcomes of the project were twofold. First, health care cost reduction was achieved by reducing the cost of unnecessary CXRs. Second, increased patient safety was achieved by reducing the amount of patient radiation exposure related to routine daily CXRs.