Introduction: Evidence suggests that routine daily CXR in ICUs rarely changes management (1), but instead increases radiation exposure, cost, & workflow burden (2). Many ICUs continue to have a culture of 'Routine daily CXR' regardless of the patient's change or no change in clinical status. The yearly Greenhouse Gas (GHG) emissions from Low-value radiographs amount to 19 metric kilotons (kT), equivalent to annual emissions of approximately 4,000 cars in the United States (1). Studies have shown that providers' education and change in order protocols can result in 37% decrease in portable CXRs without an increase in unplanned extubations or ventilator days and no harm to patient outcomes (3). Also, there is 36% cost savings and 17 minutes saved per exam (3). This study aimed to assess the extent of the problem and to understand factors influencing the decision-making
Methods: Retrospective study was done at a quaternary medical center of 1020 beds with 138 ICU beds. Along with hospital available data, the Advanced Practice Providers (APPs) survey between January 1, 2025, and May 1, 2025, was utilized. No individual patient profile was accessed.
Results: Total Portable CXRs performed were 17,871, with consecutive days (daily repeat) orders staggering at 93.6%. These patients' mean length of a daily repeated portable CXR was 7.5 days, with a standard deviation (SD) of 8.7 days. Further data analysis from Advanced Practice Provider Survey to evaluate Proportional Ranking of factors influencing portable CXR orders showed that the four top reasons to order CXR in the institution were: 1) confirm central line placement with Average Rank (AR) at 1.77, 2) Intraaortic Balloon Pump (IABP) monitoring with the AR of 2.45, 3) Routine imaging post-procedures with AR of 2.69, and the highest AR with 3.0 was for 4) Routine Daily CXR. The workflow strain is noted to be with r=0.37, with each additional 10 CXRs on a given day adding 7 mins on average for each patient. 27% of patients with > 10 CXRs account for 70% of all CXRs.
Conclusions: With Providers' education, integrating clinical decision support and revising order protocols in Epic, stakeholder Communication, leadership endorsement, and developing standardized ICU & hospital indication guidelines can counter the hard-to-eradicate culture of 'Routine daily CXR'.
