To determine the impact of elimination of daily routine
chest radiographs (CXRs) in a mixed
medical–surgical intensive care unit (ICU) on utility of
on demand CXRs, length of stay (LOS) in ICU, readmission rate,
and mortality rate.
Design and setting
Prospective, nonrandomized, controlled study in a 28-bed ICU. Analysis included data of all admitted ICU patients during 5 months before and after elimination of daily routine CXRs.
Before elimination, 2457 daily routine CXRs and 1437 on demand CXRs were obtained from 754 patients. After elimination, 1267 CXRs were obtained from 622 patients. The ratio of CXRs/patient day decreased from 1.1 ± 0.3 to 0.6 ± 0.4 (p < 0.05). Elimination did not result in a change in utility and timing of on demand CXRs. The absolute diagnostic and therapeutic value of on demand CXRs increased with elimination of daily routine CXRs: before intervention, 147 unexpected predefined abnormalities were found (10.2% of all on demand CXRs in 15.9% of all patients), of which 57 (3.9%) in 6.4% of all patients led to a change in therapy. After intervention, 156 unexpected predefined abnormalities were found (11.6%; p < 0.05), of which 61 (4.8%) in 9.5% of all patients (p < 0.05) led to a change in therapy. The LOS in ICU, readmission rate and ICU, and hospital mortality rate were not influenced by the change in strategy.
Elimination of daily routine CXRs reduced the number of CXRs in a mixed medical–surgical ICU, while not affecting readmission rate and ICU and hospital mortality rates.
Electronic supplementary material
The online version of this article (doi:10.1007/s00134-007-0542-1) contains supplementary material, which is available to authorized users
Daily routine; On demand; Chest radiograph; ICU; Critical care
The clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients.
This was a prospective observational study conducted in a 28-bed, mixed medical–surgical ICU of a university hospital.
Over a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care.
In the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.
Chest x-rays (CXRs) are the most frequent radiological tests performed in the intensive care unit (ICU). However, the utility of performing daily routine CXRs is unclear.
We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay).
Nine studies (39,358 CXRs; 9,611 patients) were included in the meta-analysis. Three trials (N = 870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only one trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% confidence interval [CI] 0.84 to 1.28, P = 0.72; two trials, N = 776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P = 0.91; two trials, N = 259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P = 0.27; three trials, N = 870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P = 0.23; two trials, N = 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P = 0.62; three trials, N = 705). Adding data from six observational studies, one of which systematically screened for missed findings, gave similar results.
This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain.
Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.
Chest radiography (CXR) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care.
To assess the influence of CXR on patient management in general practice.
Design of study
Prospective cohort study.
Seventy-eight GPs and three general hospitals in the Netherlands.
Patients (n = 792) aged ≥18 years referred by their GPs for CXR were included. The main outcome was change in patient management assessed by means of questionnaires filled in by GPs before and after CXR.
Mean age of the patients was 57.3±16.2 years and 53% were male. Clinically relevant abnormalities were found in 24% of the CXRs. Patient management changed in 60% of the patients following CXR. Main changes included: fewer referrals to a medical specialist (from 26 to 12%); reduction in initiation or change in therapy (from 24 to 15%); and more frequent reassurance (from 25 to 46%). However, this reassurance was not perceived as such in a quarter of these patients. A change in patient management occurred significantly more frequently in patients with complaints of cough (67%), those who exhibited abnormalities during physical examination (69%), or those with a suspected diagnosis of pneumonia (68%).
Patient management by the GP changed in 60% of patients following CXR. CXR substantially reduced the number of referrals and initiation or change in therapy, and more patients were reassured by their GP. Thus, CXR is an important diagnostic tool for GPs and seems a cost-effective diagnostic test.
chest radiography; general practice; patient care management
Prior studies demonstrate the suitability of natural language processing (NLP) for identifying pneumonia in chest radiograph (CXR) reports, however, few evaluate this approach in intensive care unit (ICU) patients.
From a total of 194,615 ICU reports, we empirically developed a lexicon to categorize pneumonia-relevant terms and uncertainty profiles. We encoded lexicon items into unique queries within an NLP software application and designed an algorithm to assign automated interpretations (‘positive’, ‘possible’, or ‘negative’) based on each report’s query profile. We evaluated algorithm performance in a sample of 2,466 CXR reports interpreted by physician consensus and in two ICU patient subgroups including those admitted for pneumonia and for rheumatologic/endocrine diagnoses.
Most reports were deemed ‘negative’ (51.8%) by physician consensus. Many were ‘possible’ (41.7%); only 6.5% were ‘positive’ for pneumonia. The lexicon included 105 terms and uncertainty profiles that were encoded into 31 NLP queries. Queries identified 534,322 ‘hits’ in the full sample, with 2.7 ± 2.6 ‘hits’ per report. An algorithm, comprised of twenty rules and probability steps, assigned interpretations to reports based on query profiles. In the validation set, the algorithm had 92.7% sensitivity, 91.1% specificity, 93.3% positive predictive value, and 90.3% negative predictive value for differentiating ‘negative’ from ‘positive’/’possible’ reports. In the ICU subgroups, the algorithm also demonstrated good performance, misclassifying few reports (5.8%).
Many CXR reports in ICU patients demonstrate frank uncertainty regarding a pneumonia diagnosis. This electronic tool demonstrates promise for assigning automated interpretations to CXR reports by leveraging both terms and uncertainty profiles.
Pneumonia; Intensive care unit; Natural language processing; Chest imaging; Electronic tool
The authors designed an automated electronic system that incorporates data from multiple hospital information systems to screen for acute lung injury (ALI) in mechanically ventilated patients. The authors evaluated the accuracy of this system in diagnosing ALI in a cohort of patients with major trauma, but excluding patients with congestive heart failure (CHF).
Single-center validation study. Arterial blood gas (ABG) data and chest radiograph (CXR) reports for a cohort of intensive care unit (ICU) patients with major trauma but excluding patients with CHF were screened prospectively for ALI requiring intubation by an automated electronic system. The system was compared to a reference standard established through consensus of two blinded physician reviewers who independently screened the same population for ALI using all available ABG data and CXR images. The system's performance was evaluated (1) by measuring the sensitivity and overall accuracy, and (2) by measuring concordance with respect to the date of ALI identification (vs. reference standard).
One hundred ninety-nine trauma patients admitted to our level 1 trauma center with an initial injury severity score (ISS) ≥ 16 were evaluated for development of ALI in the first five days in an ICU after trauma.
The system demonstrated 87% sensitivity (95% confidence interval [CI] 82.3–91.7) and 89% specificity (95% CI 84.7–93.4). It identified ALI before or within the 24-hour period during which ALI was identified by the two reviewers in 87% of cases.
An automated electronic system that screens intubated ICU trauma patients, excluding patients with CHF, for ALI based on CXR reports and results of ABGs is sufficiently accurate to identify many early cases of ALI.
Bedside chest radiography (bCXR) represents a substantial fraction of the volume of medical imaging for inpatient healthcare facilities. However, its image quality is limited compared to posterior-anterior/lateral (PA/LAT) acquisitions taken radiographic rooms. We evaluated utilization of bCXR and other chest imaging modalities before and after placing a radiography room within our thoracic surgical inpatient ward.
Institutional review board approval was obtained for this HIPAA-compliant. We retrospectively identified all patient admissions (3,852) to the thoracic surgical units between April 1, 2007 and December 31, 2010. All chest imaging tests performed for these patients including computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound (US), bedside and PA/LAT radiographs were counted. Our primary outcome measure was chest imaging utilization, defined as the number of chest examinations per admission, pre- and post-establishment of the digital radiography room on January, 10th 2010. Statistical analysis was performed using an independent-samples t-test to evaluate changes in chest imaging utilization.
We observed a 2.61 fold increase in the number of PA/LAT CXR per admission (p<0.01) and a 1.96 fold decrease in the number of bCXR per admission (p<0.01) post radiography room implementation. The number of chest CT, MRI and US per admission did not change significantly.
Establishing a radiography room physically within thoracic surgery units or in close proximity can significantly shift CXR utilization from bedside to PA/LAT acquisitions, which may enable opportunities for improvement in efficiency, quality, and safety in patient care.
Chest imaging; workflow improvement; imaging utilization; radiography room; radiology resource optimization
To ascertain current chest radiography practice in intensive care units (ICUs) in the Netherlands.
Postal survey: a questionnaire was sent to all ICUs with > 5 beds suitable for mechanical ventilation; pediatric ICUs were excluded. When an ICU performed daily-routine chest radiographs in any group of patients it was considered to be a "daily-routine chest radiography" ICU.
From the number of ICUs responding, 63% practice a daily-routine strategy, in which chest radiographs are obtained on a daily basis without any specific reason. A daily-routine chest radiography strategy is practiced less frequently in university-affiliated ICUs (50%) as compared to other ICUs (68%), as well as in larger ICUs (> 20 beds, 50%) as compared to smaller ICUs (< 20 beds, 65%) (P > 0.05). Remarkably, physicians that practice a daily-routine strategy consider daily-routine radiographs helpful in guiding daily practice in less than 30% of all performed radiographs. Chest radiographs are considered essential for verification of the position of invasive devices (81%) and for diagnosing pneumothorax, pneumonia or acute respiratory distress syndrome (82%, 74% and 69%, respectively). On demand chest radiographs are obtained after introduction of thoracic drains, central venous lines and endotracheal tubes in 98%, 84% and 75% of responding ICUs, respectively. Chest films are also obtained in case of ventilatory deterioration (49% of responding ICUs), and after cardiopulmonary resuscitation (59%), tracheotomy (58%) and mini-tracheotomy (23%).
There is notable lack of consensus on chest radiography practice in the Netherlands. This survey suggests that a large number of intensivists may doubt the value of daily-routine chest radiography, but still practice a daily-routine strategy.
To describe the spectrum of clinical features and management of community acquired pneumonia in the UK.
Prospectively recorded clinical details for all children with possible pneumonia and chest x ray (CXR) changes in 13 hospitals in the North of England between 2001 and 2002.
89% of 711 children presenting to hospital with pneumonia were admitted; 96% received antibiotics, 70% intravenously. 20% had lobar CXR changes, 3% empyema and 4% required intensive care. Respiratory rate (RR), hypoxia and dyspnoea all correlated with each other and prompted appropriate interventions. Admission in children, not infants, was independently associated with RR, oxygen saturation, lobar CXR changes and pyrexia. Neither C‐reactive protein, lobar CXR changes or pyrexia were associated with severity. Children over 1 year old with perihilar CXR changes more often had severe disease (p = 0.001). Initial intravenous antibiotics were associated with lobar CXR changes in infants and children and with dyspnoea, pyrexia and pleural effusion in children. The presence of pleural effusion increased duration of antibiotic treatment (p<0.001). Cefuroxime was the most often used intravenous antibiotic in 61%. Oral antibiotics included a penicillin in 258 (46%), a macrolide in 192 (34%) and a cephalosporin in 117 (21%). Infants stayed significantly longer (p<0.001) as did children with severe disease (p<0.01), effusions (p = 0.005) or lobar CXR changes (p⩽0.001).
There is a high rate of intravenous antibiotic administration in hospital admissions for pneumonia. Despite lobar CXR changes not being independently associated with severe disease, initial lobar CXR changes and clinical assessment in children independently influenced management decisions, including admission and route of antibiotics.
community acquired pneumonia; childhood pneumonia; lobar pneumonia; severity; antibiotics
A best evidence topic was written according to a structured protocol. The question addressed was whether routine chest radiography is indicated following chest drain removal in patients undergoing cardiothoracic surgery. A total of 356 papers were found using the reported searches; of which, 6 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were mean duration of drains left in situ, timing of drain removal, pathology detected on chest radiographs (CXRs), interventions following imaging and clinical assessment, complications in patients not undergoing routine CXRs and the cost saving of omitting routine CXRs. One large cohort study reported the detection of pathology in 79% of clinically indicated CXRs in comparison to 40% of routine CXRs (P = 0.005). Ninety-five per cent of the non-routine CXR cohort remained asymptomatic and required no intervention. One large observational study reported the detection of new pneumothoraces in 9.3% of patients, 70.3% of which were barely perceptible. Intervention following CXR was required in 0.25% and only one medium-sized pneumothorax would have been potentially missed without CXR. Another large observational study reported intervention following CXR in 1.9% and the presence of relevant clinical signs and symptoms to be a significant predictor of major intervention (P < 0.01). A smaller observational study reported no pathology detected or intervention following CXR in 98% and the cost saving of omitting a single CXR at £10 000 per annum. Another small observational study reported only 7% of CXRs to be clinically indicated with a false-positive rate of 100%, and a false-negative rate of 7% in CXRs not clinically indicated. The smallest study reported no complications in the non-CXR cohort and only one patient undergoing intervention in the routine CXR cohort. We conclude that there is evidence that routine post drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment. The best evidence studies reported the detection of pathology on routine CXR ranging from 2 to 40% compared with 79% in clinically indicated CXRs (P = 0.005). Whilst the rate of intervention following routine CXR was as high as 4% in the smallest study, clinical signs and symptoms suggestive of pathology were a significant predictor of major re-intervention (P < 0.01).
Chest drain; Chest radiography
Metastatic lung disease in Wilms tumor (WT) patients was traditionally identified by chest radiograph (CXR). It is unclear whether patients with small lesions, detectable only by computed tomography (“CT-only” lesions), require the more intensive therapy, including doxorubicin and lung irradiation, given to patients with metastases detectable by CXR.
This study involved 417 patients with favorable histology WT and isolated lung metastases (detected by CXR or CT) who were registered on National Wilms Tumor Study (NWTS)-4 or -5. Outcomes by method of detection (CXR vs. CT only), use of lung radiation, and 2- or 3-drug chemotherapy (dactinomycin and vincristine +/− doxorubicin) were determined and compared using the log-rank test.
There were 231 patients with lung lesions detected by CXR and 186 by CT only. Of the patients with CT-only nodules, 37 received only 2 drugs and 101 did not receive lung radiation. Five-year event-free survival (EFS) was greater for patients receiving 3 drugs (including doxorubicin) with or without lung radiation than for those receiving 2 drugs (80% vs. 56%; p=0.004). There was no difference seen in 5-year overall survival (OS) between the 3-drug and 2-drug subsets (87% vs 86%; p=0.91). There were no significant differences in EFS (82% vs. 72%; p=0.13) or OS (91% vs. 83%; p = 0.46) for patients with CT-only nodules whether they received lung radiation or not.
Our results suggest that patients with CT-only lung lesions may have improved EFS but not OS from the addition of doxorubicin but do not appear to benefit from pulmonary radiation.
Wilms tumor; CT scans; pulmonary metastases; doxorubicin; lung radiation
Accurate interpretation of chest radiographs (CXR) is essential as clinical decisions depend on readings.
We sought to evaluate CXR interpretation ability at different levels of training and to determine factors associated with successful interpretation.
Ten CXR were selected from the teaching file of the internal medicine (IM) department. Participants were asked to record the most important diagnosis, their certainty in that diagnosis, interest in a pulmonary career and adequacy of CXR training. Two investigators independently scored each CXR on a scale of 0 to 2.
Participants (n = 145) from a single teaching hospital were third year medical students (MS) (n = 25), IM interns (n = 44), IM residents (n = 45), fellows from the divisions of cardiology and pulmonary/critical care (n = 16), and radiology residents (n = 15).
The median overall score was 11 of 20. An increased level of training was associated with overall score (MS 8, intern 10, IM resident 13, fellow 15, radiology resident 18, P<.001). Overall certainty was significantly correlated with overall score (r = .613, P<.001). Internal medicine interns and residents interested in a pulmonary career scored 14 of 20 while those not interested scored 11 (P = .027). Pneumothorax, misplaced central line, and pneumoperitoneum were diagnosed correctly 9%, 26%, and 46% of the time, respectively. Only 20 of 131 (15%) participants felt their CXR training sufficient.
We identified factors associated with successful CXR interpretation, including level of training, field of training, interest in a pulmonary career and overall certainty. Although interpretation improved with training, important diagnoses were missed.
education; medical; radiography; thoracic; clinical competence; educational measurement
The aim of this study is to assess the value of chest radiographs (CXRs) and sputum examinations in detecting pulmonary involvement of tuberculosis (TB) in patients with extra-pulmonary tuberculosis (EPTB).
Materials and Methods:
A retrospective analysis was performed among 248 EPTB patients with culture-proven diagnosis of tuberculosis seen between January 2001 and December 2007 at a tertiary teaching hospital, Riyadh, Saudi Arabia. Demographics, clinical, laboratory and radiological findings were reviewed and assessed. This study was approved by the hospital ethics and research committee.
One hundred twenty five of 233 EPTB patients (53.6%) had abnormal CXR findings. There was a significant difference in the occurrence of positive sputum culture results between patients with abnormal CXR findings (30/57) and those with normal CXR findings (4/17) (P = 0.04). Of 17 HIV-negative/unknown HIV-status EPTB patients with normal CXR results, 4 patients (23.5%) had positive sputum culture results. Intrathoracic lymphadenopathy (P < 0.001), pleural TB (P < 0. 001) and disseminated TB (P = 0.004) were associated with an increased risk of abnormal CXR findings. Patients with cough (52.9%), weight loss (41.2%) and night sweats (26.5%) are more likely to have positive sputum culture results.
CXR findings are predictive of positive sputum culture results. However, the rate of normal CXR among EPTB patients with positive sputum culture results was relatively high. Therefore, respiratory specimen cultures should be obtained in TB suspects with a normal CXR to identify potentially infectious cases of TB.
Predictors; pulmonary; extra-pulmonary tuberculosis; radiology
AIM: To compare the reported injuries on initial assessment of the chest X-ray (CXR) in thoracic trauma patients to a second read performed by a dedicated trauma radiologist.
METHODS: By retrospective analysis of a prospective database, 712 patients with an injury to the chest admitted to the University Medical Center Utrecht were studied. All patients with a CXR were included in the study. Every CXR was re-evaluated by a trauma radiologist, who was blinded for the initial results. The findings of the trauma radiologist regarding rib fractures, pneumothoraces, hemothoraces and lung contusions were compared with the initial reports from the trauma team, derived from the original patient files.
RESULTS: A total of 516 patients with both thorax trauma and an initial CXR were included in the study. After re-evaluation of the initial CXR significantly more lung contusions (53.3% vs 34.1%, P < 0.001), hemothoraces (17.8% vs 11.0%, P < 0.001) and pneumothoraces (34.4% vs 26.4%, P < 0.001) were detected. During initial assessment significantly more rib fractures were reported (69.8% vs 62.3%, P < 0.001).
CONCLUSION: During the initial assessment of a CXR from trauma patients in the emergency department, a significant number of treatment-dictating injuries are missed. More awareness for these specific injuries is needed.
Thoracic radiography; Rib fractures; Hemothorax; Pneumothorax; Pulmonary contusion
Chest drain insertion is a common procedure in neonatal care. Routine radiography after removal of chest drains increases radiation exposure, handling and cost, but there are few data proving clinical benefit.
To review current practice and determine the yield of routinely obtained chest radiographs (CXR).
A retrospective chart review of all infants undergoing removal of chest tubes in a single tertiary neonatal unit in New Zealand between January 1998 and July 2004 was performed.
In total, 119 infants were identified, from the database, to have a chest drainage performed. In 19 cases, the procedure was needle aspiration or the drain was removed outside of our unit, hence these were excluded. The remaining 100 patients with 110 episodes of chest drain removal after 174 chest tube insertions were analysed. In asymptomatic infants, routine radiography showed some reaccumulation of air in nine of 35 cases of pneumothorax or of fluid in two of the five cases of pleural effusion, but chest tube reinsertion was not required. In the 12 clinically symptomatic infants, chest tubes were reinserted in five cases (four reaccumulations of pneumothorax and one pleural effusion), and one infant had symptomatic right upper lobe collapse. In the remaining infants, there were no abnormalities on CXR accounting for deterioration.
Given the low yield for routine radiography after chest drain removal, we suggest that close observation is likely to detect clinically relevant recurrence of pneumothorax.
A review of the management of isolated sternal fractures in a regional cardiothoracic unit reveals that, in a 2 year period, 37 consecutive patients were admitted for observation and further investigation, including echocardiography and cardiac enzyme measurements to exclude blunt cardiac injury. Minor blunt cardiac injury was detected in only one patient, and was associated with an acutely abnormal electrocardiogram (ECG). ECG showed acute changes in 8 further patients, whilst 3 patients had an abnormal chest X-ray (CXR) due to widening of the mediastinum (1 patient had abnormal CXR and ECG), but none had evidence of cardiac injury. CXR and ECG were both normal in 23 patients, and were predictive of the absence of significant complications. A survey of 22 other cardiothoracic units around the UK confirms that the management of patients with isolated sternal fractures varies considerably from hospital to hospital. As suggested by previous reports, we believe that patients, who are otherwise fit and have normal ECG and CXR on presentation, can be safely discharged home on oral analgesics. The routine use of echocardiography and creatinine kinase (CK) assays in the assessment of isolated sternal fractures is not indicated. The introduction of these guidelines has resulted in a dramatic reduction in the number of patients admitted with isolated sternal fractures to our unit.
Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.
This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5–1 MHz) followed by the high-frequency (10–5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement.
Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10–5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.
Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10–5 MHz) linear transducer.
To evaluate the effect of the timeliness of asthma diagnosis on chest X-ray (CXR) and antibiotic utilization in children.
Patients and methods
This was a retrospective cohort study of 276 asthmatic children aged 5–12 years from Rochester, Minnesota. From the time when children met our predetermined asthma criteria, the frequency of CXR and antibiotic utilizations for respiratory illnesses were collected from medical records until age 18 years. Using a Poisson regression model, the frequency of CXR and antibiotic utilizations were compared in children with timely, delayed, or no clinician diagnosis of asthma.
Of the 276 asthmatic patients, 97 (35%) had a timely diagnosis, 122 (44%) had a delayed diagnosis, while 57 patients (21%) had no clinician diagnosis of asthma. There was no significant difference in CXR or antibiotic utilization for respiratory illness between these groups. In addition, this was true for the comparison between the timely diagnosed group and the delayed diagnosed group combining both the group with a delay in asthma diagnosis and the group who never had asthma diagnosis.
A delay in the diagnosis of asthma in children is common and overall it may not influence antibiotic and CXR utilization for respiratory symptoms by clinicians. However, its impact on access to asthma-related therapies and other healthcare utilizations could be possible and was not assessed in this study. Given the limitations of our study, a larger prospective study needs to be considered.
adolescent; antibacterial agents; child; health services; radiography; therapeutics; thoracic
Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost.
Our hospital is located in Northern Mississippi and has a 28 bed Medical‐Surgical ICU unit with 95% occupancy. We joined the ICU collaborative with the IMPACT initiative of the Institute of Healthcare Improvement (IHI) in October 2002. A preliminary prospective before (fiscal year (FY) 2001–2) and after (FY 2003) hypothesis generating study was conducted of outcomes resulting from small tests of change in the management of ICU patients.
Key measures for improvement
Nosocomial infection rates, adverse events per ICU day, average length of stay, and average cost per ICU episode.
Strategy for change
Four changes were implemented: (1) physician led multidisciplinary rounds; (2) daily “flow” meeting to assess bed availability; (3) “bundles” (sets of evidence based best practices); and (4) culture changes with a focus on the team decision making process.
Effects of change
Between baseline and re‐measurement periods, nosocomial infection rates declined for ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) and bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), with a downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode. From FY 2002 to FY 2003 the cost per ICU episode fell from $3406 to $2973.
A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs.
intensive care; nosocomial infections; bundles; quality improvement
Postintubation chest X-rays (CXR) are standard practice in emergency department (ED) intubations. In the operating room, it is not usually a standard practice to confirm endotracheal tube placement with a CXR.
We seek to study the utility of postintubation CXR in ED patients.
This was a retrospective case series of 157 adult patients intubated in the ED of an urban academic hospital with an emergency medicine training program. Standardized chart review was performed by two emergency physicians (EP) using a structured data abstraction tool and final radiology attending reads of postintubation CXR to assess placement. Endotracheal tube placement was graded as satisfactory, too high, too low, or malpositioned in the esophagus. Descriptive statistics were used, and 95% confidence intervals (CI) were reported. Hospital Institutional Review Board approval was obtained.
A total of 157 patients were intubated in the ED during the study period: 127 (81%, 95% CI: 74–86) had adequate tube placement by CXR confirmation, 9 (6%, 95% CI: 3–11) endotracheal tubes were judged to be too high, and 20 (13%, 95% CI: 8–19) were judged to be too low with 10 (6.5%, 95% CI: 3–11) of these being right mainstem bronchus intubations. One patient (<1%, 95% CI:<0.0001–4) had a CXR confirming esophageal intubation.
ED intubations were judged to have “satisfactory” placement by CXR in 81% of patients. CXR is able to identify a small subset of patients that likely need immediate intervention based on their CXR. Until further studies refute the utility of postintubation CXR in ED intubations, they should remain a part of routine practice.
Intubation; Chest X-ray; Emergency department
The objective of this study was to establish 1) the performance of chest X-ray (CXR) in all suspects of tuberculosis (TB), as well as smear-negative TB suspects and 2) to compare the cost-effectiveness of the routine diagnostic pathway using Ziehl-Neelsen (ZN) sputum microscopy followed by CXR if case of negative sputum result (ZN followed by CXR) with an alternative pathway using CXR as a screening tool (CXR followed by ZN).
From TB suspects attending a chest clinic in Nairobi, Kenya, three sputum specimens were examined for ZN and culture (Lowenstein Jensen). Culture was used as gold standard. From each suspect a CXR was made using a four point scoring system: i: no pathology, ii: pathology not consistent for TB, iii: pathology consistent for TB and iv: pathology highly consistent for TB. The combined score i + ii was labeled as "no TB" and the combined score iii + iv was labeled as "TB". Films were re-read by a reference radiologist. HIV test was performed on those who consented. Laboratory and CXR costs were used to compare for cost-effectiveness.
Of the 1,389 suspects enrolled, for 998 (72%) data on smear, culture and CXR was complete. 714 films were re-read, showing a 89% agreement (kappa value = 0.75 s.e.0.037) for the combined scores "TB" or "no-TB". The sensitivity/specificity of the CXR score "TB" among smear-negative suspects was 80%/67%. Using chest CXR as a screening tool in all suspects, sensitivity/specificity of the score "any pathology" was 92%, respectively 63%. The cost per correctly diagnosed case was for the routine process $8.72, compared to $9.27 using CXR as screening tool. When costs of treatment were included, CXR followed by ZN became more cost-effective.
The diagnostic pathway ZN followed by CXR was more cost-effective as compared to CXR followed by ZN. When cost of treatment was also considered CXR followed by ZN became more cost-effective. The low specificity of chest X-ray remains a subject of concern. Depending whether CXR was performed on all suspects or on smear-negative suspects only, 22%–45% of patients labeled as "TB" had a negative culture. The introduction of a well-defined scoring system, clinical conferences and a system of CXR quality control can contribute to improved diagnostic performance.
It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain.
PATIENTS AND METHODS
A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospec-tively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care.
A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant.
The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.
Chest radiograph; Acute abdomen
Little information is available on prognosis and outcomes of very long stay intensive care unit (ICU) patients. The purpose of this study was to identify long-term outcomes after hospital discharge and readily available clinical predictors of hospital mortality for patients requiring prolonged care in the ICU.
Clinical data were collected from consecutive patients requiring at least 30 days of ICU care admitted over 3 calendar years (2001 to 2003) to a medical/surgical ICU in a university-affiliated tertiary care centre.
A total of 182 patients met the inclusion criteria, with a mean age of 63 years, median ICU stay of 48.5 days (interquartile range 36–78 days) and ICU mortality of 32%. They accounted for 8% of total admissions and 48% of total occupied beds. Of these patients, 42% died in hospital, 44% returned to their previous place of residence, and 14% were transferred to long-term care institutions. By 6 months after hospital discharge a further 8% of the patients had died, 40% remained at their previous place of residence, and 10% were in long-term care. Predictors of hospital mortality, identified using multivariate logistic regression, included age (odds ratio [OR] 1.45 per additional decade, 95% confidence interval [CI] 1.10–1.91), any immunosuppression (OR 5.2, 95% CI 1.7–15.5), mechanical ventilation for longer than 90 days (OR 4.0, 95% CI 1.3–12.0), treatment with inotropes or vasopressors for more than 3 days at or after day 30 in the ICU (OR 7.1, 95% CI 2.6–19.3), and acute renal failure requiring dialysis at or after day 30 in the ICU (OR 6.3, 95% CI 2.0–19.7).
Patients with very long stays in the ICU appear to have a reasonable chance of survival, with most survivors in our cohort residing at their previous place of residence 6 months after hospital discharge. Prolonged requirement for life support therapies (ventilation, vasoactive agents, or acute dialysis) and a limited number of pre-existing co-morbidities (immunosuppression and, to a lesser extent, patient age) were predictors of increased hospital mortality. These predictors may assist in clinical decision making for this resource intensive patient population, and their reproducibility in other very long stay patient populations should be explored.
Background. Few investigations preoperatively are important for low-risk patients. This study was designed to determine the level of compliance with preoperative investigation guidelines for ASA I patients undergoing elective surgery. Secondary objectives included the following: to identify common inappropriate investigations, to evaluate the impact of abnormal testing on patient management, to determine factors affecting noncompliant tests, and to estimate unnecessary expenditure. Methods. This retrospective study was conducted on adult patients over a one-year period. The institute's guidelines recommend tests according to the patients' age groups: a complete blood count (CBC) for those patients aged 18–45; CBC, chest radiograph (CXR) and electrocardiography (ECG) for those aged 46–60; and CBC, CXR, ECG, electrolytes, blood glucose, blood urea nitrogen (BUN), and creatinine (Cr) for patients aged 61–65. Results. The medical records of 1,496 patients were reviewed. Compliant testing was found in only 12.1% (95% CI, 10.5–13.9). BUN and Cr testings were the most frequently overprescribed tests. Overinvestigations tended to be performed on major surgery and younger patients. Overall, overinvestigation incurred an estimated cost of US 200,000 dollars during the study period. Conclusions. The need to utilize the institution's preoperative guidelines should be emphasized in order to decrease unnecessary testing and the consequential financial burden.