Education, Teaching, and Quality Improvement |

Quality Improvement Project to Reduce Unnecessary Chest X-ray in a Medical Intensive Care Unit FREE TO VIEW

Jason Filopei, MD; Navitha Ramesh, MD; Samuel Acquah, MD
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Mount Sinai Beth Israel, New York, NY

Chest. 2015;148(4_MeetingAbstracts):475A. doi:10.1378/chest.2268396
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SESSION TITLE: Process Improvement in Obstructive Lung Disease Education, Pneumonia Readmissions and Rapid Response Systems I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Chest radiographs are routinely performed in the ICU for mechanically ventilated patients; however, the utility of this practice remains unclear and is surely not evidence based. Faced with rising costs of modern medicine, intensivists must balance delivering both excellent and cost conscious care. We demonstrate the effectiveness of a quality improvement initiative focused on provider education that dramatically reduced the number of CXR's ordered in our MICU.

METHODS: A quality improvement inititative recommending a restrictive approach to ordering CXRs was implemented at our teaching hospital in January 2012. It consisted of monthly education for MICU providers on more focused indications for CXR use including ICU admission, post procedure, or change in clinical status. We later conducted a restrospective review of all ICU patients from 2011-2014 to examine the effectiveness of the education process and determine if there were any negative consequences.

RESULTS: Total CXR ordered in the ICU was 3093, 2770, 1505, and 1171 from 2011-2014, respectively. Total number of admissions to the MICU and total number of patients on a ventilator was 1269 and 527, 1287 and 575, 1288 and 545, and 1297 and 517 from 2011-2014, respectively. There was a 164% decrease in total number of CXR ordered between 2011 and 2014. We calculated CXR per number of ICU admissions as 2.44, 2.15, 1.16, and 0.90 from 2011-2014. CXR per total patient days on a ventilator were 1.22, 1.19, 0.77, and 0.68 from 2011-2014, respectively. Finally, CXRs ordered per total patients days in the ICU was 0.62, 0.57, 0.33, and 0.26. Percent mortality over the study time frame was 15.3, 17, 15.5, and 13.7 from 2011-2014, average length of ICU stay in days was 3.9, 3.7, 3.6, and 2.9 from 2011-2014, respectively, and percent readmission rate was 2.5, 1.2, 1.2, and 0.9.

CONCLUSIONS: A quality improvement project focused on educating ICU providers to use a restrictive approach to ordering CXR led to large decreases in the total number of CXR's ordered while corrected for both total numbers of patients and ventilator days. Based on our observations, there was no negative impact on total number of patient ventilator days, length of stay, and other outcomes. This restrictive approach will likely result in significant reduction in radiation exposure and ICU operating costs.

CLINICAL IMPLICATIONS: A restrictive approach to ordering CXR's in the ICU appears to be a safe practice that leads to a significant saving of hospital resources.

DISCLOSURE: The following authors have nothing to disclose: Jason Filopei, Navitha Ramesh, Samuel Acquah

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