Article Text
Abstract
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.
- computerized decision support
- implementation science
- quality improvement
- critical care
- high value care
- cost-effectiveness
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Statistics from Altmetric.com
Footnotes
Contributors GBA contributed to the study conception and design and data analysis and interpretation; revised and finalised the final figures; contributed to the majority of the manuscript in the form of important intellectual and scientific content; served as the senior author in editing and revising the original draft. BK contributed to the study conception and design and data analysis and interpretation; wrote the original first draft of the manuscript before revision by senior author; helped prepare preliminary findings for presentation at 2015 American Thoracic Society Meeting in abstract/poster format; reviewed and edited final draft. RDC contributed to the study conception and design; helped facilitate project completion in the MICU; helped prepare preliminary findings for presentation at 2015 American Thoracic Society Meeting; reviewed and edited final draft. MPH contributed to the study conception and design; helped facilitate project completion in the SICU and helped to present preliminary findings from the SICU at the 2015 Society of Critical Care Medicine Meeting in abstract/poster format; reviewed and edited final draft. PS contributed to the study conception and design and helped with the majority of data analysis and project facilitation; reviewed and edited final draft. JMS-D contributed to the data analysis and interpretation; produced original versions of figures 1 and 2; contributed significant intellectual and scientific content to the original draft; reviewed and edited final draft.
Funding This study was financially supported internally by the Department of Medicine and by resources provided by the James M. Jeffords Institute for Quality at the University of Vermont Medical Center.
Competing interests None declared.
Ethics approval The project was reviewed and exempted by the UVM Institutional Review Board as a quality improvement project involving nonhuman research subjects’ data.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data were extracted from the electronic health records of patients in our institution. Because of the Health Insurance Portability and Accountability Act in the USA, designed to protect private health information, the authors do not feel comfortable uploading the data to an open source database, even with our own best efforts to remove all identifiers. We would be willing to provide a de-identified .xls file to reviewers on a case-by-case basis.