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ICU Patients Do Not Need a Daily Chest Radiograph
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Key Point
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In the ICU, daily chest radiographs demonstrate poor diagnostic and therapeutic efficacy. This strategy can be abandoned without adversely affecting patients’ ICU length of stay, readmission rate, or hospital mortality. |
It is common in the Netherlands to obtain daily chest radiographs (CXRs) for ICU patients regardless of patients’ status, but this practice is unnecessary, according the results of a study by Karin A. Hendrikse, MD, and colleagues. “This is the first blinded study evaluating the efficacy of daily routine CXRs in the ICU,” reported the authors in the September Chest.
TWO-PHASE STUDY
The researchers prospectively evaluated the diagnostic efficacy (DE) and the therapeutic efficacy (TE) of all CXRs obtained in the ICU of a 985-bed, university-affiliated hospital in the Netherlands, during an 18-month period. During the yearlong first phase of the study, chest radiography was performed daily, with additional CXRs ordered if deemed clinically necessary. The attending physicians were blinded to the results of the routine CXRs unless there was a predetermined major abnormality. During the second part of the study (the implementation phase), attending physicians obtained CXRs only when clinically necessary.
During the study period, 1,780 daily routine CXRs and 907 clinically indicated CXRs were obtained in 486 patients (mean age, 71). Among the routine CXRs, new or progressive major findings were revealed in only 79 cases (DE, 4.4%). CXRs prompted a change in clinical management in only 33 cases (TE, 1.9%). There was no association between DE or TE and ventilatory status or admission type (ie, surgical or medical).
During the implementation phase, the investigators evaluated 433 CXRs in 250 patients (mean age, 67); the median number of CXRs ordered per day during this phase was half that of the study period (1.0 vs 0.50). There were no differences between the study and implementation phases in terms of readmission rate (13% vs 9%) or hospital mortality (16% vs 14%). Furthermore, the omission of daily chest radiography had no effect on ICU length of stay or the use of clinically indicated CXRs.
STUDY LIMITATIONS
One of the study limitations was that the decision to order a CXR during the study phase “could have been influenced by the assurance not to miss important findings,” said the authors. “However, we consider this less likely because the number of clinically indicated CXRs did not change in the implementation phase.”
Also, because the study took place at a single center with dedicated and trained radiologists, the findings may not apply to other hospitals with differences in case mix and staffing. However, a similar study from an academic hospital with larger staffing showed comparable results, related the authors.
—Timothy Begany
Suggested Reading
Graat ME, Choi G, Wolthuis EK, et al. The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Crit Care. 2006;10(1):R11.
Hendrikse KA, Gratama JWC, ten Hove W, et al. Low value of routine chest radiographs in a mixed medical-surgical ICU. Chest. 2007;132(3):823-828.
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