Reducing Unnecessary Chest X-rays in a Pediatric intensive Care Unit

Introduction: Routine chest x-rays (CXRs) are commonly performed on critically ill patients even when the patient has no changes in clinical status. This can drive up healthcare costs and expose patients to unnecessary risks such as radiation exposure. Our SMART aim was to decrease routine CXRs by 10% over a year.


Methods: We performed a unit-based quality improvement project using the Institute of Health Improvement’s (IHI) model for improvement aimed at decreasing routine Chest X-Rays (CXRs) in the pediatric critical care unit. Routine CXRs were defined as those ordered previous day and completed prior to morning rounds. Rates of all CXRs were tracked as a balancing measure, including those ordered as STAT, Urgent or ordered and completed any time of the day. Drivers for change included general knowledge and inconsistent practice surrounding routine CXRs. Education was provided to faculty, trainees, and advanced practice providers, and barriers were discussed. Data was tracked using Statistical Process Control charts and shared at faculty meetings and displayed in the unit to increase awareness. Overall project outcome was also tied to performance improvement goal for faculty.


Results: At the start of the project in July 2024, the rate of routine CXRs among patients was 0.08 CXRs per patient days. Over the following nine months, this rate declined to 0.03 CXRs per patient days, representing a 62.5% relative reduction in routine CXRs. In addition to the targeted decrease in routine imaging, there was also a broader impact: the overall rate of all CXRs performed, regardless of indication, decreased from 460 CXR per 1000 Patient days to 389 CXR per 1000 patient days.


Conclusions: The reduction in routine CXRs was likely driven by a combination of increased awareness, data transparency, and team engagement around imaging practices. Sharing real-time data and aligning around standardized expectations empowered clinicians to reassess the necessity of routine imaging. These efforts not only reduced unnecessary exposure and resource utilization but also demonstrated how simple, collaborative interventions can lead to meaningful practice change across an ICU team. These results suggests a potential shift in imaging culture.