Critical Care: Imaging in Critical Illness |

Pragmatic Single Intervention for a Sustained Reduction in Portable Chest Radiography (pCXR) in Cardiovascular and Surgical/Trauma ICU and Associated Outcomes FREE TO VIEW

Joseph Tonna, MD; Kensaku Kawamoto, MD; Angela Presson, PhD; Chong Zhang, MS; Mary Mone, BS; Robert Glasgow, MD; Richard Barton, MD; John Hoidal, MD; Yoshimi Anzai, MD
Author and Funding Information

University of Utah; Department of Surgery, Salt Lake City, UT

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):298A. doi:10.1016/j.chest.2016.08.311
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SESSION TITLE: Imaging in Critical Illness

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 25, 2016 at 11:00 AM - 12:15 PM

PURPOSE: Portable chest radiography (pCXR) is used frequently in intensive care units (ICUs), especially for post-operative cardiothoracic surgery and trauma patients. Studies have suggested that “on-demand” radiography testing is equivalent to daily routine testing with regard to adverse events while reducing cost and radiation exposure. Prior to our intervention, routine daily pCXR order placement was standard culture in the cardiothoracic (CVICU) and surgical/trauma (SICU) ICUs at our institution. We evaluated the impact of a pragmatic single time point intervention requesting on-demand testing in our CVICU and SICU.

METHODS: We conducted a pre-post intervention study at a large tertiary academic medical center consisting of two intervention ICUs (CVICU, SICU) and two control ICUs. Our medical directors requested pCXRs be ordered on an on-demand basis via an email and in-person meeting with the attending faculty and daily rounds sheets were modified to prompt the question of pCXR necessity. Data were collected from 9.8 months prior to the intervention (7/1/14-4/24/15) through 10.8 months post (4/25/15-3/20/16). Patient and unit level data were extracted from the electronic health record (EHR), including patient demographics, pCXR use, illness severity (mortality, APACHE II, incidence and duration of mechanical ventilation [MV], ICU length of stay [LOS], unplanned reintubations and case mix). Data summaries were expressed as median (interquartile range, IQR), mean (standard deviation SD) or percent. An interrupted time-series approach using generalized estimating equation poisson regression models were used to test the intervention effect controlling for patient characteristics in the pre-post time periods. Results are reported as rates and 95% confidence intervals (CIs), and statistical significance was evaluated a p<0.05.

RESULTS: There were 11,994 patient days from 1,947 ICU admissions of 1,729 patients (166 patients had more than one admission). Intervention cohort characteristics (combined) were: Age: 56.7(SD: 17.6), 66% male, 96% survival, APACHE II 14 (IQR: 11-19), MV (occurrences) / patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). The average pCXR rate per patient per day before the intervention was 0.93 (95% CI: 0.89~0.96), and after the intervention it was 0.73 (95% CI: 0.69~0.77). After controlling for patient severity characteristics, daily pCXR rate immediately following the intervention decreased by 21.7% (p<0.001). The daily CXR rate following the intervention steadily increased over 10.8 months by about 3% / month (p=0.044) without further intervention. There was no change in APACHE II, mortality, and occurrences of MV, unplanned re-intubations, ICU LOS, or duration of MV.

CONCLUSIONS: We found that a pragmatic single time point intervention to reduce radiography resulted in a significant reduction in daily pCXRs without changes in re-intubation, LOS, or duration of MV. The intervention implemented here could serve as a model for other ICUs.

CLINICAL IMPLICATIONS: A reduction of pCXR can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic single intervention outside of a controlled study.

DISCLOSURE: The following authors have nothing to disclose: Joseph Tonna, Kensaku Kawamoto, Angela Presson, Chong Zhang, Mary Mone, Robert Glasgow, Richard Barton, John Hoidal, Yoshimi Anzai

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