Follow Up on Daily Xray for Intubated Patients Sebastian Benavides 12/10/2012

CHEST September 2007 vol. 132 no Low Value of Routine Chest Radiographs in a Mixed Medical-Surgical ICU * Karin A. Hendrikse, MD, Jan Willem C. Gratama, MD, PhD, Wim ten Hove, MD, Johannes H. Rommes, MD, PhD, Marcus J. Schultz, MD, PhD, FCCP, and Peter E. Spronk, MD, PhD, FCCP+ Author Affiliations * From the Departments of Radiology (Drs. Hendrikse, Gratama, and ten Hove) and Intensive Care Medicine (Dr. Rommes), Gelre Hospitals, Lukas site, Apeldoorn; Department of Intensive Care Medicine (Dr. Schultz), Academic Medical Center, Amsterdam; and HERMES Critical Care Group (Dr. Spronk), Amsterdam, the Netherlands. * Karin A. HendrikseJan Willem C. GratamaWim ten Hove Johannes H. RommesMarcus J. Schultz Peter E. Spronk+ Objective: To determine the diagnostic efficacy (DE) and therapeutic efficacy (TE) of daily routine chest radiographs (CXRs), and to establish the impact of abandoning this CXR from daily practice on total CXR volume, ICU length of stay (LOS), readmission rate, and ICU mortality. Design: Prospective controlled study in two parts. The first part comprised a 1-year period during which attending physicians were blinded for findings on daily routine CXRs and were only informed if something deemed important was seen by the radiologist (predefined major abnormalities) who reviewed all CXRs as usual. The second part comprised a half-year period during which daily routine CXRs were replaced by clinically indicated CXR. Setting: Mixed medical-surgical ICU of a teaching hospital.

Results: Data on 1,780 daily routine CXRs in 559 hospital admissions were collected. Diagnostic efficacy of daily routine CXRs was 4.4%. The most frequent unexpected major abnormalities were new or progressive infiltrates (1.8%) and oropharyngeal tube malposition (0.7%). Therapeutic efficacy of daily routine CXRs was 1.9%. The most frequent intervention was oropharyngeal tube adjustment (0.6%). No relation was found for DE or TE and hospital admission type or intubation and mechanical ventilation. In the second study part, 433 CXRs were obtained in 274 admissions. Abandoning daily routine CXRs did not affect clinically indicated CXRs orders, or ICU LOS, readmission rate, and mortality. A total CXR volume reduction of 35% (which equaled $9,900 per bed per year [US dollars]) was observed after abandoning daily routine CXRs. Conclusion: Diagnostic and therapeutic value of the daily routine CXR is low. Daily routine CXRs can be safely abandoned in the ICU.

UCI MICU 06/ Patients Each had daily CXR (sometimes more) 3 PNA, 5 AIRWAY PROTECTION 11-12/ Patients Almost all had daily chest xrays and many times had much more Most patients were admitted for either PNA, respiratory distress or sepsis

Limitations Line placement xrays not documented correctly Many times residents order xrays rapidly, stating mostly respiratory distress when the exam was actually ordered for daily CXRs Change in clinical status not clear But one must think if daily chest xrays is the best diagnostic tool when clinical status is worsening Other reasons for chest xray orders are also not clear Often times the order states that chest XR are ordered for wither SOB of respiratory distress

Patients in ICU on 06/2012 MICU daysChest X-Rays Ordered Line Placement changes CXR less Line placement studies Change in ETTPneumonia Admissions YES AIRWAY PROTECT AIRWAY PROTECT YES AIRWAY PROTECT AIRWAY PROTECT AIRWAY PROTECT

Patients in the ICU 11/ /2012 MICU daysCXR ordered Line Placement changes CXRs –Line placement changes Xrays ordered due to ETT changes PNA admission Yes Yes Yes 46061No Yes Yes 46062No 46151

Price of CXRs per day 06/2012 MICU daysCXR less Line placement studies CXR /DaysTotal Cost for X-rays Cost per hospital day $3100$ $600$ $500$ $1600$ $3500$ $2900$ $1400$ $3500$125

Price of CXRs per day 11/2012 to 12/2012 MICU daysCXR-line placement studies CXR/dayTotal Cost of CXR Cost Per Hospital Day 22 1$2200$ $1500$ $2600$ $600$ $1000$ $2100$ $600$ $600$150

ANALYSIS 06/2012 ETT changed in 3/177 = 1.7% Cost of Chest X-Ray $100 Each Assuming Daily CXR for one month COST $3,000 ( average 30 days) COST $ 36,500 per year At UCI ICU Average $ 142 spent daily on CXR Average $4,268 monthly Average $ 51,380 yearly $14,880 extra ( Compared to daily CXR baseline)

Analysis 11/12-12/12 ETT changed in 10/111 = 9% (improvement from 06/2102) Cost of Chest X-Ray $100 Each Assuming Daily CXR for one month COST $3,000 ( average 30 days) COST $ 36,500 per year At UCI ICU Average $ 124 spent daily on CXR Average $3,720 monthly Average $ 45,260 yearly $8,760 extra ( Compared to daily CXR baseline)

Analysis In June of 2012, the daily cost of a CXR at UCI was $142. In Nov and Dec of 2012, the daily cost of a CXR at UCI was $124. On a yearly basis, we went from $51,380 to $45,260. Therefore it seems that there has been an improvement. It is Possible that resident influence on awareness is making a difference in the amount of CXRs that are ordered vs. Fellow and attending awareness of the value of a daily CXR. Regardless, work needs to continue on how daily CXRs can be cut down to reduce cost.

How to cut down Proper documentation/clear documentation for indication for chest x-ray. Each x-ray should have a specific purpose or reason for study. Potential screening or reminders by computer of recently ordered CXR. Indications NOT acceptable: Follow-up ETT placement if initial already done and patient continues to remain sedated, follow up pneumonia, follow up respiratory failure on a daily basis ABG VS CXR (Roughly same price, which is more valuable) Use of US for ETT tube placement (current studies are underway) Furthermore, is it necessary to get a CXR every time a patient spikes a fever?