Deimplementation of Routine Chest X-rays in Adult Intensive Care Units
BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns.
OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies.
DESIGN: We conducted a prospective, nonrandomized study with control data from a historical period. Qualitative evaluation was guided by the Consolidated Framework for Implementation Research.
SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016.
PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists).
INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates.
MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation.
RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities.
CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.
© 2019 Society of Hospital Medicine
Despite increased awareness of Choosing Wisely (CW)® recommendations to reduce low-value care,1 there is limited published data about strategies to implement these guidelines or evidence that they have influenced ordering patterns or reduced healthcare spending
In ICUs, CXR ordering strategies may be routine (daily) or on-demand (with clinical indication). The former strategy’s principal advantage is the potential to detect life-threatening situations that may otherwise escape diagnosis.11 Disadvantages include cost, radiation exposure, patient inconvenience, false-positive workups, and low diagnostic and therapeutic value.12,13 On-demand strategies may safely reduce CXR ordering by 32% to 45%.11-17 Based on this evidence, the Critical Care Societies Collaborative and the American College of Radiology have recommended on-demand CXR ordering.18,19 Here, we describe the effectiveness of an intervention to reduce CXR ordering in two ICUs while evaluating the deimplementation strategies using a validated framework.
METHODS
Setting and Design
Vanderbilt University Medical Center (VUMC) is an academic referral center in Nashville, Tennessee. The cardiovascular ICU (CVICU) has 27 beds and the medical ICU (MICU) has 34 beds. Acute care nurse practitioners (ACNPs) and two critical care physicians staff the CVICU; cardiology fellows, anesthesia critical care fellows, and transplant and cardiac surgeons are also active in patient care. The MICU is staffed by two critical care physicians who supervise one team of ACNPs and two teams of medical residents who rotate through the unit every two weeks. Each MICU team is assigned a fellow in pulmonary and critical care.
We conducted a prospective, nonrandomized study in these units from October 2015 to June 2016. The VUMC Institutional Review Board approved the intervention as a quality improvement (QI) activity, waiving the requirement for informed consent.
Intervention
Following the top CW recommendation of the Critical Care Societies Collaborative—“Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.”19—the VUMC resident-led CW Steering Committee designed a multifaceted approach to reduce ordering of routine CXRs in ICUs. The intervention included a didactic session on CW and proper CXR ordering practices, peer champions, data audits, and feedback to providers through weekly e-mails (see Supplemental Materials, 1 – Resident Presentation and 2 – CXR Flyer). 20
