Health Record Change Curbs Daily Chest X-rays in ICUs

Marcia Frellick

February 20, 2019

SAN DIEGO — When electronic health record systems restrict orders for daily chest x-rays, there is a significant reduction in the number of x-rays ordered in intensive care units (ICUs) with no harm to patients, new research suggests.

Because portable chest x-rays — among the most common services ordered in ICUs — are often performed early in the morning so that results are ready for rounding hours, restrictions help eliminate sleep interruptions and minimize radiation, said lead researcher Anita Reddy, MD, from the Cleveland Clinic.

The benefits of fewer sleep interruptions are cumulative and might improve patient satisfaction, she told Medscape Medical News.

"We know from the literature that if patients don't get good rest, they are at higher risk of developing delirium," Reddy explained here at the Society of Critical Care Medicine 2019 Congress. The change improves not just one night of sleep; it wards off the long-term effects of repeated disruptions.

In addition, each chest x-ray exposes a patient to 0.1 mSv of radiation, so exposure is limited, she reported.

Reddy and her team first met with intensivists, surgeons, pulmonologists, and radiologists to review the literature. "The vast majority of stakeholders wanted to do this," she said.

The American College of Radiology and the Choosing Wisely campaign both recommend against daily imaging, but many ICUs, including those at Cleveland Clinic, have been stuck in the habit of daily x-rays to safeguard against missing something, she explained.

Daily x-rays are used mostly as a monitoring tool; "we see this same practice with daily blood work," said Reddy.

The team modified the ordering options for imaging in a multihospital tertiary health system so that daily chest x-rays could only be ordered for cardiac and thoracic surgery patients; in general, for all other patients, chest x-rays could be ordered only on a one-time basis.

Overnight X-rays Dropped by 36.6%

Chest x-rays were compared in two periods: from January 1 to June 11, 2018, before the restrictions were implemented; and from June 12 to December 31, 2018, after implementation.

The restrictions led to a 23.5% decrease in the overall number of portable chest x-rays ordered (< .001) and a 36.6% decrease in the average number of overnight chest x-rays (< .001).

There was no increase in the volume of chest x-rays performed during rounding hours to compensate for those decreases; in fact, volume decreased by 15.8% (< .001).

There was no reduction in staff time related to the decrease in x-rays because of the staffing model used at the Cleveland Clinic, but radiologists were able to dedicate their reclaimed time to reading other types of images, Reddy explained.

And when the team looked at whether there were any written or verbal reports of safety concerns or delays in care related to the intervention, "there was zero in either of those categories," she reported.

The team next plans to assess outcomes — including length of stay, time on a ventilator, and rates of delirium — before and after the changes were implemented.

"We have to overcome this cultural habit and reassure our clinicians that we can do less and still take really good care of our patients," said Reddy.

Inertia Impedes Change

This research could help people break long-established habits, said John Mazuski, MD, PhD, from Washington University in St. Louis.

He said that restrictions are already in place at his institution to discourage the routine ordering of daily chest x-rays — labs and x-rays cannot be ordered more than 24 hours in advance — but added that making institution-wide changes to an electronic health records system is not as easy as it sounds.

"The main reason it's not done is inertia," Mazuski noted. "It's a very tricky issue, when you have multiple practitioners, to get the buy-in you need to enact these reforms."

However, such reforms will be particularly necessary as health systems look for ways to eliminate practices that don't yield much, if any, new information, he said.

Reddy and Mazuski disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 2019 Congress. Presented February 18, 2019.

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