E. D. Porter1, R. M. Hasson1, T. M. Millington1, D. J. Finley1, C. V. Angeles1, J. D. Phillips1 1Dartmouth-Hitchcock Medical Center,Lebanon, NH, USA
Introduction: Overutilization of radiographic imaging continues to drive up medical costs. In thoracic surgery, patients routinely undergo a chest radiograph (CXR) following surgery and chest tube (CT) removal. However, recent literature has questioned the utility of such practice in the pediatric population. We sought to investigate our institution’s CXR ordering practice following adult thoracic surgery and subsequent CT removal and its impact on clinical decision-making.
Methods: Retrospective cohort study at a single academic center. All adult general thoracic surgery patients with an intraoperative CT placed from April to June, 2018 were selected. Patients discharged with a CT or whom underwent pleurodesis were excluded. Indications for CT removal included absence of an airleak and drainage < 400cc’s in 24 hours. We reviewed patient charts for demographics, comorbidities, procedural data, post-operative CXR orders and results, and 30-day outcomes. Our institution defines a ‘small’ pneumothorax (PTX) as <15% of the hemi-thorax space. For the purpose of this study, any PTX >15% was termed ‘sizable’.
Results: In our study period, 55 patients met inclusion criteria and underwent thoracic surgery with an intraoperative CT placed. Surgical procedures included primary lung or pleura (42), mediastinum (6), diaphragm (5), and esophagus (2). The average number of CXRs performed per day was 2.1 (max 4.0). All patients received a CXR immediately following surgery, with 62% resulting in normal/expected findings, 18% a small PTX, 18% a sizable PTX, and 9% other abnormal results (consolidation or effusion). No patients experienced a change in care secondary to this CXR (Fig. 1). All patients received a post CT removal CXR. These CXRs resulted in 36% normal findings, 44% a small PTX, 5% a sizable PTX, and 15% other abnormal results (effusion and/or hydropneumothorax). A change in care ensued in only 2 patients (4%), which consisted of continued observation with a repeat CXR (Fig. 1). Within patients who had an abnormal finding on their post CT removal CXR, 65% were discharged the same day. Three patients were readmitted, of which two had a CT placed. On review, both patients had abnormal findings on their post CT removal CXR prior to discharge.
Conclusion: Routine immediate post-operative and post CT removal CXRs occurred in all adult thoracic surgery patients at our institution. Despite the majority of CXR’s resulting in abnormal findings, no patient underwent a procedural intervention during initial hospitalization. Routine immediate post-op and post CT removal CXRs without clinical indication are overutilized and interventions to reduce this practice should be further investigated.
