Cost Savings And Decreased Radiation Exposure With On-Demand Chest Radiographs For Mechanically Ventilated Patients

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Main Category: Radiology / Nuclear Medicine
Also Included In: Respiratory / Asthma
Article Date: 05 Nov 2009 - 0:00 PST

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An article published Online First and in a future edition of The Lancet reports that when on-demand radiographs are dictated by the patient's clinical status, the number of radiographs carried out is a third less, without compromising patient care or safety. Current guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. The article is the work of Dr Gilles Hejblum, Institut National de la Santé et de la Recherche Médicale, Paris, France, and colleagues.

A total of twenty-one intensive care units at eighteen hospitals in France were included in this randomised study. They were assigned to either a routine or an on-demand strategy for chest radiographs during the first of two treatment periods. In the second period, units then switched to the alternative strategy. Each treatment period lasted for the time taken for enrolment and study of twenty consecutive patients per intensive care unit. Patients were monitored until discharge from the unit or for up to 30 days of mechanical ventilation, whichever happened first. Units enrolled 967 patients. But 118 were excluded because they had been receiving mechanical ventilation for less than two days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation.

The results indicated that 424 patients had 4,607 routine chest radiographs. The average per patient-day of mechanical ventilation was 1.09. A total of 425 patients had 3,148 on-demand chest radiographs (with a mean of 0.75). This corresponded to a reduction of 32 percent with the on-demand strategy. Significantly, no change was recorded between the routine and on-demand strategies in any secondary outcome measures such as days of mechanical ventilation, length of stay in the intensive care unit, or mortality. But the authors caution that numbers of radiographs are not the only factor to consider. They explain: "Opinions from medical personnel participating in the study about the routine versus on-demand strategies were not recorded before, during, and after the study. This information is potentially important - for example, the physicians' workloads are increased by individual assessment of every patient early in the morning to decide whether a chest radiograph is necessary instead of ordering systematic morning chest radiographs for all mechanically ventilated patients. Such considerations could restrict implementation of the on-demand strategy in daily practice."

But they write in conclusion: "Results from our study strongly support the adoption of an on-demand strategy in preference to a routine strategy to decrease the number of chest radiographs done in mechanically ventilated adult patients without a reduction in patient safety. In view of the large number of patients who undergo mechanical ventilation, these results could substantially benefit clinical practice."

In a complementary comment, Dr Mark D Siegel, and Dr Ami N Rubinowitz, Yale School of Medicine, New Haven, CT, USA, remark: "Hejblum and colleagues have provided persuasive evidence that routine daily chest radiographs are unnecessary in most intubated mechanically ventilated patients, and can be safely replaced by an on-demand approach, reserving studies for clinical indications. Whether an on-demand strategy is appropriate for individual intensive care units needs to be decided locally. In our view, an on-demand strategy should be adopted only if: skilled clinicians are available to promptly identify patients requiring chest radiography; images can be made and interpreted efficiently; abnormalities can be acted on throughout the day. If these conditions are met, an on-demand strategy would seem justified and might lead to cost savings, decreased radiation exposure, and a greater diagnostic and therapeutic yield from the radiography."

"Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study"
Gilles Hejblum, Ludivine Chalumeau-Lemoine, Vincent Ioos, Pierre-Yves Boëlle, Laurence Salomon, Tabassome Simon, Jean-François Vibert, Bertrand Guidet
DOI: 10.1016/S0140-6736(09)61459-8
The Lancet

Written by Stephanie Brunner (B.A.)
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