Anita Reddy, MD: Reducing Redundant X-Rays in the ICU

Anita Reddy, MD

A new study from a team of Cleveland Clinic investigators found that alterations to a facility’s electronic health record (EHR) could significantly reduce the rate of daily chest X-rays (CXR) conducted on patients in the intensive care unit (ICU).

The program, which only allows clinicians to order daily CXR for patients with either cardiac support devices or to have undergone cardiothoracic surgery, could significantly improve ICU patient experience (in terms of consistent sleep patterns) and rate of radiation exposure. Clinicians were also able to submit for a patient CXR if they were able to provide specific reason for its necessity in the EHR entry.

At the 48^th Society of Critical Care Medicine (SCCM) Congress in San Diego, CA, author Anita Reddy, MD, an internist at the Cleveland Clinic, presented the EHR study results, showing her team was able to reduce Cleveland Clinic ICU daily portable CXRs by 23.5% overall, and average overnight CXRs by 36.6%.

Despite these drops, CXR volume during rounding hours did not rise due to compensation—instead dropping by 15.8% (P for all < .001). No harm events nor delays in care were reported in reaction to the lessened CXRs.

In an interview with MD Magazine®, Reddy discussed basis and necessity of the trial, the particular burdens of patients undergoing tests in the ICU, and what more follow-up can be done after the CXR reduction results.

MD Mag: How pressing of an issue is limiting the rate of daily chest X-rays on ICU patients?

Reddy: Daily chest X-rays are common practice for ICUs, even though they are no longer recommended by several national societies. There are potential negative impacts including patients sleep being disturbed by nighttime or early morning X-rays. Previous literature has shown that using on-demand imaging compared to daily imaging doesn’t negatively impact ICU length of stay (LOS), duration of mechanical ventilation, morbidity or mortality. At Cleveland Clinic, we felt it was important to reduce the amount of daily chest X-rays being performed across the enterprise, in the ICUs and other patient care areas where these are utilized. This initiative offered a way to improve patient experience, maximize caregiver efficiencies, minimize radiation exposure, and standardize practices with no negative impact on patient outcomes.

The study notes emphasis on the benefits of improved patient sleep and limited radiation burden. Are there any other ICU-related tests that may be done in excess that patients could also benefit from being less exposed to?

Yes, daily blood work is a common occurrence for ICU patients, and we have similar concerns about the usefulness. We have already started undertaking initiatives to reduce these daily labs across all inpatient population.

From your perspective, what were the standout findings from the trial?

One thing that stood out to us was the effectiveness of using the EMR for this initiative. We got tremendous buy-in from colleagues in critical care, pulmonary, cardiology, surgery and radiology to undertake this initiative. There is certainly an education factor, but making the process automatic by working it directly into the EMR was helpful to clinicians and make it successful.

Are there any more new clinical practices, or follow-up studies, to come from the study’s results?

Yes, we are planning follow-up studies for this initiative. We hope to look more in-depth at how these practice affects patients, including length of stay, mortality, morbidity and if it decreases delirium. Delirium is common in the ICU and can be affected by lack of sleep. We’d like to explore if not waking up patients during early morning hours for X-rays has an effect on delirium.