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On-Demand versus Routine Radiographs for Ventilated Patients Has Benefits in Clinical Practice

NEW YORK -- November 5, 2009 -- Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, an article published online first 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.

Gilles Hejblum, MD, Institut National de la Santé et de la Recherche Médicale, Paris, France, and colleagues randomised 21 intensive care units at 18 hospitals in France to either a routine or an on-demand strategy for chest radiographs during the first of 2 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.

However, the authors caution that numbers of radiographs are not the only consideration. "Opinions from medical personnel participating in the study about the routine versus on-demand strategies were not recorded before, during, and after the study," the authors wrote. "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."

"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," they concluded. "In view of the large number of patients who undergo mechanical ventilation, these results could substantially benefit clinical practice."

SOURCE: The Lancet

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