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Invited Commentary
Less Is More
July 27, 2020

The Problem of Daily Imaging in the Intensive Care Unit: When You Care so Much It Hurts

Author Affiliations
  • 1San Francisco Veterans Affairs Healthcare System, San Francisco, California
  • 2Department of Anesthesia and Perioperative Care, University of California, San Francisco
JAMA Intern Med. Published online July 27, 2020. doi:10.1001/jamainternmed.2020.2667

As the economic and clinical fragilities of the world make themselves known during the coronavirus disease 2019 (COVID-19) pandemic, the importance of resource use rises to the forefront of health care professionals’ minds. How does one weigh patient safety against cost, especially when dealing with critically ill patients, for whom mistakes can cost lives? In this issue, Maley and Stevens1 present a compelling example of a case where routine diagnostic examinations turned into a near-miss event. They argue that not only are seemingly innocuous care practices, such as daily chest radiographs (CXRs), expensive and inefficient, but also that significant underappreciated harms, including inappropriate interventions based on inaccurate results, abound.

A brief literature review shows support for their position. At their same institution, more than 15 years prior, Krivopal et al2 randomized patients to daily or clinically indicated (nonroutine) CXR. They found that despite fewer CXRs in the nonroutine arm, there was no increase in duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, or mortality. A systematic review3 of 9 studies (including 9611 patients and 39 358 CXRs) also revealed no harm associated with a restrictive CXR strategy. A study of an intervention to reduce routine CXRs in a cardiac surgery ICU showed similar results: nearly 11% of patients had unexpected, clinically relevant findings discovered on routine CXRs,4 although clinical outcomes were not affected. The bottom line seems to be that it is possible to reduce routine CXRs in the ICU, and although a few findings might be missed, it does not seem to alter patients’ outcomes. And yet, as Maley and Stevens1 point out, routine CXRs persist.

Whether out of convention or fear of the missed diagnosis (CXRs actually do change management5), the exhaustive search for data in the ICU is a well-worn path; frequent laboratory tests and studies are a common critical care practice. Expenses in the last year of life are estimated to account for 21% of all Medicare spending, a number that is downtrending but still considerable.6 Costs associated with critical care are often accused of being major contributors to this figure, although waste of this type is difficult to identify in prospect. This association partly misses the mark; patients who come to the ICU, where health care happens to be expensive, are inherently at a high risk of death. Nevertheless, as our understanding of complex disease processes improves over time, we may find room to reduce some current testing and therapies; daily CXRs are a deserving target of quality-improvement initiatives.

The COVID-19 pandemic only emphasizes the importance of the judicious use of finite health care resources. Every CXR exhausts personal protective equipment and exposes staff to contagious patients, to say nothing of cost, radiation exposure, and the very real possibility that, in times of surge, there simply may not be enough time or staff resources to obtain a CXR for every ICU patient every day. The COVID-19 crisis offers an opportunity for reflection on other practices that are common but perhaps not clinically useful, and that reflection must begin with routine laboratory studies. A number of authors have demonstrated that reducing the frequency of laboratory tests in the ICU can be achieved without compromising care (see Kumwilaisak and colleagues7 for a well-done example). Notwithstanding that these trials rarely report patient acuity (patients with more serious illness probably still need frequent laboratory tests), a clear, actionable signal emerges: patients who had laboratory tests in the emergency department do not need another set just because they entered the ICU; most patients with gastrointestinal bleeding do not need a complete blood count every 4 hours; and daily coagulation studies do not heal patients. Such practices take time, effort, and resources; they introduce the potential for error but with limited possible benefit. The COVID-19 pandemic amplifies possible negative consequences of this trade-off. As in the case with CXRs, we may simply not have the ability to maintain the status quo, particularly when doing so would put staff at risk and patients would be no better off. The pandemic should not lower the standard of care, but it may be the impetus that directs our attention back to what really counts, because the costs of caring too much could be staff contracting the virus or exhausting limited supplies of personal protective equipment.

As Maley and Stevens1 describe, it is increasingly important to provide high-value care in the ICU. It is not only possible to change our practices and reduce unnecessary CXRs, but it is also generally safe to do so. The benefit of decreasing cost and increasing efficiency without affecting major outcomes or quality of care is a goal we can achieve, and in these times, for the sake of both patients and staff, one we must achieve.

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Article Information

Corresponding Author: Christopher G. Choukalas, MD, MS, San Francisco Veterans Affairs Healthcare System, 4150 Clement St, San Francisco, CA 94121 (christopher.choukalas@ucsf.edu).

Published Online: July 27, 2020. doi:10.1001/jamainternmed.2020.2667

Conflict of Interest Disclosures: None reported.

References
1.
Maley  JH, Stevens  JP.  Low-value diagnostic imaging in the intensive care unit: a teachable moment.   JAMA Intern Med. Published online July 27, 2020. doi:10.1001/jamainternmed.2020.2681Google Scholar
2.
Krivopal  M, Shlobin  OA, Schwartzstein  RM.  Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.   Chest. 2003;123(5):1607-1614. doi:10.1378/chest.123.5.1607PubMedGoogle ScholarCrossref
3.
Ganapathy  A, Adhikari  NKJ, Spiegelman  J, Scales  DC.  Routine chest x-rays in intensive care units: a systematic review and meta-analysis.   Crit Care. 2012;16(2):R68. doi:10.1186/cc11321PubMedGoogle ScholarCrossref
4.
Mets  O, Spronk  PE, Binnekade  J, Stoker  J, de Mol  BAJM, Schultz  MJ.  Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients.   J Thorac Cardiovasc Surg. 2007;134(1):139-144. doi:10.1016/j.jtcvs.2007.02.029PubMedGoogle ScholarCrossref
5.
Marik  PE, Janower  ML.  The impact of routine chest radiography on ICU management decisions: an observational study.   Am J Crit Care. 1997;6(2):95-98. doi:10.4037/ajcc1997.6.2.95PubMedGoogle ScholarCrossref
6.
Riley  GF, Lubitz  JD.  Long-term trends in Medicare payments in the last year of life.   Health Serv Res. 2010;45(2):565-576. doi:10.1111/j.1475-6773.2010.01082.xPubMedGoogle ScholarCrossref
7.
Kumwilaisak  K, Noto  A, Schmidt  UH,  et al.  Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit.   Crit Care Med. 2008;36(11):2993-2999. doi:10.1097/CCM.0b013e31818b3a9dPubMedGoogle ScholarCrossref
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