S. A. Hennessy1, T. Hranjec2, K. A. Boateng1, M. L. Bowles1, S. L. Child1, M. P. Robertson1, R. G. Sawyer1 1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA
Introduction: Chest x-ray (CXR) remains the most commonly used imaging modality in the Surgical Intensive Care Unit (SICU), especially in mechanically ventilated patients. The practice of daily, routine CXRs is associated with morbidity for the patient and significantly increased costs. We hypothesized that elimination of routine daily CXRs in the SICU and integration of clinical on-demand CXRs would decrease cost without any changes in morbidity or mortality.
Methods: A prospective comparative quality improvement project was performed over a 6 month period at a single institution. From November 2013 through January 2014 critically ill patients underwent daily routine CXRs (group 1). From February through April 2014 daily routine CXRs were eliminated (group 2); ICU patients only received a CXR based on the on-demand CXR strategy. This strategy advised imaging for significant clinical changes or post-procedure. Patients before and after the on-demand CXR strategy were compared by univariate analysis. Parametric and non-parametric univariate testing was used where appropriate. A multivariate logistic regression was performed to identify independent predictors of mortality.
Results: In total, 495 SICU admissions were evaluated: 256 (51.7%) in group 1 and 239 (48.3%) in group 2. There was a significant difference in the number of CXRs, with 4.2 ± 0.7 in the daily CXR group versus 1.2 ± 0.1 in the on-demand group (p<0.0001). The mean cost per admission was $394.8 ± 47.1 in the daily CXR group versus $129.9 ± 12.5 in the on-demand group (p<0.0001). This was an estimated cost savings of $60,000 over a 3 month period for group 2 compared to group 1. Decreased ICU length of stay (LOS), hospital LOS and mechanical ventilation (MV) was seen in group 2, while mortality and re-intubation rates were equivalent despite decreased imaging (Table 1). After adjusting for age, gender, re-intubation rate, duration of MV and APACHE III score, no difference in mortality was seen between the two groups (OR 2.2, 95% CI 0.7-6.4, p=0.15). To further adjust for severity of illness, patients with APACHE III score > 30 were analyzed separately. Mortality and re-intubation rate, ICU LOS and hospital LOS were similar between the groups, while duration of MV was still decreased (Table 1). In high APACHE III score patients there was also a reduction in number of CXR per admission from 4.5 ± 0.8 to 1.4 ± 0.2 with a cost savings of $316.6 per ICU admission.
Conclusion: Use of a clinical on-demand CXR strategy lead to a large cost savings without associated increase in mechanical ventilation or mortality. This is a safe and effective quality initiative that will reduce cost without increasing adverse outcomes.
