Choosing Wisely: Tackling unnecessary X-rays in the ICUs

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Choosing Wisely: Tackling unnecessary X-rays in the ICUs

Toronto, June 24, 2015

By Emily Holton

Dr. Antoine Pronovost reviews an X-ray with Dr. Mazin Tuma and NP Nikki Marks
Dr. Antoine Pronovost, the medical director of the Trauma and Neurosurgery Intensive Care Unit, reviews a chest X-ray with clinical fellow Dr. Mazin Tuma and nurse practitioner Nikki Marks. (Photo by Yuri Markarov)

Just a few years ago, a typical day in the St. Michael’s Intensive Care Units would begin with the arrival of a team of X-ray technologists. They fanned out across the ICUs with portable machines, and over several hours would carefully reposition and scan each patient one by one. Although several studies show that moving from daily X-rays to ordering X-rays only to answer specific clinical questions does not increase ICU patients’ risk of complications, the practice was – and remains – standard practice in most ICUs.

Dr. Antoine Pronovost, the medical director of the Trauma and Neurosurgery Intensive Care Unit and Dawn-Marie King, the director of Medical Imaging and Laboratory Medicine, saw an opportunity to do things differently. They began a project that reduced the total X-rays ordered in the ICUs by more than 50 per cent. As a result, countless patients have avoided unnecessary radiation, discomfort and disruption, and only one tech is needed to cover ad-hoc X-rays in the ICUs. The rest of the technologists are now freed up to help support flow in the ED.

To begin, Dr. Pronovost developed a set of new guidelines for portable X-rays in the ICUs, and King worked with her team to explore how an ad-hoc model might work. For example, if a patient developed a fever or his or her breathing changed, he or she would get an X-ray right away to help determine the cause. Medical Imaging committed to being available throughout the day as these situations arose. However if the patient’s status hadn’t changed since the last X-ray, the guidelines said that he or she should go without.

“Change is always challenging,” said King. “Our physicians were concerned that without daily X-rays, complications might get missed. We needed to show them that our guidelines were sound, and having a physician champion to do that was the key.”

Before implementing the guidelines, Dr. Pronovost and his team used them to audit daily X-rays at morning rounds. For each image, Dr. Pronovost would ask, “According to the proposed guidelines, would this patient have received an X-ray today? And if not, would we have missed something clinically significant?”

Within a couple of weeks King and Dr. Pronovost had the buy-in they needed. Within a year, all three ICUs had moved successfully to an ad-hoc model. New residents and fellows are briefed on the new practice as they arrive on the units, and staff and physicians reinforce the message.

“It was a great quality improvement project because the end result was less work, not more,” said Dr. Pronovost. “It makes intuitive sense – and is more rewarding – to couple testing with specific clinical questions.”

Since this project began, St. Michael’s volunteered to be an early adopter of Choosing Wisely Canada, a campaign to help physicians and patients make smart decisions about potentially unnecessary tests, treatments and procedures. Learn more at

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

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