LAUSR

Objectives: Daily chest radiographs (CXRs) have long been a routine part of care in the intensive care units (ICU). We sought to reduce overutilisation of CXRs obtained in this setting, using a multifaceted intervention to eliminate automated daily studies. Methods: Within a 45-bed multidisciplinary ICU of a tertiary teaching hospital in Brazil, we prospectively applied a three-step intervention from May 2017 to April 2018. Firstly, a partnership formed by physician champions from both ICU and Radiology and marketing coordinators advertised Choosing Wisely recommendations for Critical Care as emails and banners. The aforementioned team educated ICU staff physicians and residents about the low diagnostic yield of automated daily CXRs through didactic sections. Then, formal discussions about CXR need for each patient during morning ICU rounds was adopted. Finally, the programmed daily order option from the electronic health records system was removed. A reeducation lecture was held in August 2018 and partial audit data was shown. Results: From May to October 2018, all CXR images were urgently acquired, and their average time was 43 minutes from order to availability. Before intervention, the median number of CXRs per patient per day was 0.38 (0.36 - 0.40). After, this amount decreased to 0.30 (0.28 - 0.32) [p= 0.0013], representing a 22% reduction on CXR request. Mean length of ICU stay before and after campaign was, respectively, 8.14 (7.79 - 8.71) and 8.45 (8.24 - 9.74) days [p= 0.35]. Mean mortality rate before and after intervention was, respectively, 18.45% (± 3.87%) and 21.58% (± 2.23%) [p = 0.12]. Conclusions: This was the first report of a Choosing Wisely initiative in a Brazilian ICU of a public hospital. Transition to a high value on-demand CXR strategy in ICUs is safe and particularly noteworthy in a low resource public health system.