Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, an Article published Online First (www.thelancet.com) and in an upcoming edition of the Lancet shows that on-demand radiographs, dictated by the patient's clinical status, leads to a third fewer radiographs carried out without compromising patient care or safety. The Article is written by Dr Gilles Hejblum, Institut National de la Santé et de la Recherche Médicale, Paris, France, and colleagues.
In this randomised study, 21 intensive care units at 18 hospitals in France were assigned to either a routine or an on-demand strategy for chest radiographs during the first of two treatment periods. Units then switched to 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.
The team found that 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09), and 425 had 3148 on-demand chest radiographs (mean 0.75), which corresponded to a reduction of 32% with the on-demand strategy. Importantly, no change was recorded in any secondary outcome measures—days of mechanical ventilation, length of stay in the intensive care unit, or mortality—between the routine and on-demand strategies. But the authors caution that numbers of radiographs are not the only consideration. They say: "Opinions from medical personnel participating in the study about the routine versus on-demand strategies were not recorded before, during, and after the study. This information is potentially important—for example, the physicians' workloads are increased by individual assessment of every patient early in the morning to decide whether a chest radiograph is necessary instead of ordering systematic morning chest radiographs for all mechanically ventilated patients. Such considerations could restrict implementation of the on-demand strategy in daily practice."
However, they conclude: "Results from our study strongly support the adoption of an on-demand strategy in preference to a routine strategy to decrease the number of chest radiographs done in mechanically ventilated adult patients without a reduction in patient safety. In view of the large number of patients who undergo mechanical ventilation, these results could substantially benefit clinical practice."
In an accompanying Comment, Dr Mark D Siegel, and Dr Ami N Rubinowitz, Yale School of Medicine, New Haven, CT, USA, say: "Hejblum and colleagues have provided persuasive evidence that routine daily chest radiographs are unnecessary in most intubated mechanically ventilated patients, and can be safely replaced by an on-demand approach, reserving studies for clinical indications. Whether an on-demand strategy is appropriate for individual intensive care units needs to be decided locally. In our view, an on-demand strategy should be adopted only if: skilled clinicians are available to promptly identify patients requiring chest radiography; images can be made and interpreted efficiently; abnormalities can be acted on throughout the day. If these conditions are met, an on-demand strategy would seem justified and might lead to cost savings, decreased radiation exposure, and a greater diagnostic and therapeutic yield from the radiography."
Dr Gilles Hejblum, Institut National de la Santé et de la Recherche Médicale, Paris, France. T) +33 (0) 1 49 28 32 28 E) gilles.hejblum@inserm.fr
Dr Mark D Siegel, Yale School of Medicine, New Haven, CT, USA. T) +1 203-589-6387 E) mark.siegel@yale.edu
For full Article and Comment, see: http://press.thelancet.com/radiographfinal.pdf
Journal
The Lancet