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