Elsevier

The Lancet

Volume 374, Issue 9702, 14–20 November 2009, Pages 1687-1693
The Lancet

Articles
Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study

https://doi.org/10.1016/S0140-6736(09)61459-8Get rights and content

Summary

Background

Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care.

Methods

In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672.

Findings

11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1·09, 95% CI 1·05–1·14), and 425 had 3148 on-demand chest radiographs (mean 0·75, 0·67–0·83), which corresponded to a reduction of 32% (95% CI 25–38) with the on-demand strategy (p<0·0001).

Interpretation

Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety.

Funding

Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).

Introduction

The American College of Radiology recommends routine daily chest radiographs for mechanically ventilated patients, and use of further radiographs if necessary.1 This strategy is controversial: some clinicians are in support,2, 3, 4, 5, 6, 7, 8 whereas others advocate on-demand prescription of chest radiographs when warranted by the patient's clinical status.9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19

Routine chest radiography has two main advantages. First, some potentially life-threatening situations that might otherwise fail to be diagnosed can be discovered and treated.4, 5, 6 Second, the decision to do a chest radiograph is not necessary, and in the case of restricted mobile resources for chest radiography, scheduling of the examinations during morning rounds might be more efficient. By contrast, the on-demand strategy might avoid unnecessary radiation exposure and provides substantial cost savings. Moreover, very few routine chest radiographs lead to therapeutic or diagnostic interventions.12, 15, 16 However, the consequences of the on-demand strategy on the quality of patient care are uncertain, and an increased number of chest radiographs might be needed during the rest of the day to compensate for those not done in the morning.

Findings from a study based on the opinions of 82 physicians working in the intensive care unit have underscored the absence of consensus regarding the need for systematic daily chest radiographs for mechanically ventilated patients.9 Substantial variation was recorded between the physicians' opinions of whether routine chest radiographs were needed for mechanically ventilated patients with different clinical conditions. This absence of consensus results from the lack of conclusive data to guide practice. Therefore, we did a large prospective multicentre study to assess the efficiency and effectiveness of routine versus on-demand chest radiographs for optimum care of mechanically ventilated patients, using a two-period cluster-randomised design.

Section snippets

Intensive care units and patients

21 intensive care units for adults, all of which are part of a Paris network for such units,20 participated in the study: 13 medical, two surgical, and six mixed; 17 units were located in university hospitals. These 21 closed units account for about a third of all intensive care unit beds in the Paris region (ie, Ile de France), and 5% in France. Before the study, only one intensive care unit was operating an on-demand strategy for prescription of chest radiographs; all other units were using a

Results

Table 1 shows characteristics of the 21 participating intensive care units. None of the participating units cared for neurosurgery or cardiac surgery patients, but all other types of patients are represented in the patient sample. Overall and in order, the ten most common diagnoses of patients admitted to the units in 2006 were: acute respiratory failure without underlying pulmonary disease, coma, septic shock, acute kidney failure, acute respiratory failure with underlying pulmonary disease,

Discussion

Results from our study show a substantial reduction in use of chest radiographs with the on-demand strategy in all 21 participating intensive care units, corresponding to a 32% decrease overall compared with the routine strategy. Between the strategies, we recorded similar numbers of chest radiographs that led or contributed to therapeutic or diagnostic interventions, duration of mechanical ventilation and stay in the intensive care unit, and mortality.

We noted that although the routine

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