Eliminating Routine Chest XRays in the ICU by Internal Medicine Residents at Mount Carmel West

From the 2019 HVPAA National Conference

Dr. Jessica Weiss (Mount Carmel Health), Dr. Calli Bertschy (Mount Carmel Health), Mr. David Aufdencamp (Mount Carmel Health), Dr. Robert Battisti (Mount Carmel Health)

The Critical Care Societies Collaborative, as part of the ABIM Choosing Wisely initiative, discourages from ordering diagnostic tests at regular intervals (e.g. daily), but rather recommends ordering tests in response to specific clinical questions. Unnecessary chest XRays (CXRs) not only increase healthcare costs and do not benefit patients, but may potentially cause harm.

This quality improvement project was aimed at decreasing the number of routine CXRs performed in the ICU by Internal Medicine residents. Our educational intervention consisted of lectures and posted reminders in the ICU encouraging residents to evaluate each patient daily for the need for a CXR rather than placing standing orders.

This project compared pre-intervention data from 6/2017 through 12/2017 with post-intervention data from 6/2018 through 12/2018. The number of CXRs per days spent in the ICU and the total number of CXRs per patient in the ICU were compared using 2-sample Poisson Rate.  Statistical analysis showed a decrease in number of CXRs per ICU patient days from 1.21 to 1.12 (p=0.001) and a decrease in number of CXRs per ICU stay from 4.47 to 3.91 (p<0.000). Length of stay (LOS) was chosen as a consequential metric to possibly indicate if an undesired effect was made as a result of performing less CXRs. For patient LOS compared to expected LOS per the diagnosis related groups (DRG), 41.78% in the pre-intervention period had a LOS longer than expected compared to 40.53% in the post-intervention period (p=0.615) indicating there was no significant difference in LOS.

The significant difference between the pre-and post-intervention periods suggests residents were critically evaluating patients daily for the need for a CXR.  We are optimistic that with more time and continuing education we will continue to optimize the care we provide our patients and “choose wisely.”