THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[20-09-2025 16:41] PPM 1: @PPM3 can you share the opening history or ask the intern to send it ASAP?
[20-09-2025 16:45] PPM 1: The main point of interest for this case report @CR were the serial ECGs of the myocardial infarction, this patient developed after hospitalization that was noticed right after the endotracheal intubation! @Meta AI @PPM4 how common is the reported incidence of that?
[20-09-2025 16:46] Meta AI: Myocardial infarction after endotracheal intubation is a serious complication, especially in patients with pre-existing coronary artery disease. While there's no specific incidence rate provided for myocardial infarction directly caused by endotracheal intubation, we can look at related factors.
Endotracheal intubation can cause significant cardiovascular responses, including:
- Increased Heart Rate and Blood Pressure: This can lead to increased cardiac workload, potentially worsening myocardial ischemia.
- Electrocardiographic Changes: Ischemic changes, such as ST-segment depression, can occur during airway manipulation. However, short ischemic episodes (<10 minutes) haven't been shown to directly correlate with postoperative myocardial infarction.
It's worth noting that patients with underlying coronary artery disease are more susceptible to these complications. The exact incidence might vary depending on individual patient factors, such as¹:
- Presence of coronary artery disease
- Type of anesthesia used
- Patient's overall health status
To better understand the relationship between endotracheal intubation and myocardial infarction, it's crucial to consider the context of the patient's condition and the specific circumstances surrounding the intubation.
If you're looking for more information on this topic or would like to discuss further, please let me know!
[20-09-2025 16:46] Meta AI: https://clinicalgate.com/physiologic-and-pathophysiologic-responses-to-intubation/
[20-09-2025 16.47] PPM 1: 1st
[20-09-2025 16.47] PPM 5: Sir couldn't it more likely be due to a side effect of the drugs used during intubation than the intubation itself? 2nd
3rd
4th
5th
[20-09-2025 16:49] PPM 1: 12/9/25
[20-09-2025 16:50] PPM 1: @Meta AI what is the reported incidence of myocardial infarction due to drugs used during intubation vs due to other factors? Please support your statements with perplexity styled references
[20-09-2025 16:51] Meta AI: Myocardial infarction after endotracheal intubation can indeed be caused by the drugs used during the procedure rather than the intubation itself. Let's break down the potential culprits and their associated risks:
## Drugs Used in Rapid Sequence Intubation (RSI)
- Propofol: Can cause cardiovascular depression leading to hypotension, which may increase the risk of myocardial infarction, especially in patients with pre-existing cardiovascular disease. The typical dose is 1.5-3 mg/kg IV, with a rapid onset and duration of action around 5 minutes.
- Ketamine: May increase heart rate and blood pressure due to its cardiostimulatory properties, potentially worsening myocardial ischemia. The induction dose is 1-2 mg/kg IV, with an onset of approximately 30 seconds and a dose-dependent sedation duration of 5-10 minutes.
- Etomidate: Generally considered safe for patients with cardiovascular instability, as it doesn't significantly alter hemodynamics. However, it may cause adrenal insufficiency, which could potentially impact cardiovascular stability. The typical dose is 0.3 mg/kg IV, with an onset of 0.5-1 minute and duration of action around 3-5 minutes.
- Succinylcholine: Can cause bradycardia, especially in children, and increase serum potassium levels, which may lead to cardiac complications. The dose is 1.5 mg/kg IV, with an onset of 45 seconds and duration of action around 6-10 minutes.
- Fentanyl: Can cause hypotension and bradycardia, especially at high doses, which may decrease myocardial oxygen demand but also potentially worsen cardiac function. The pretreatment dose is 1-3 mcg/kg IV, with an onset of 1-2 minutes and duration of action around 30 minutes to 1 hour.¹ ² ³
## Reported Incidence
The exact incidence of myocardial infarction due to drugs used during intubation versus other factors is difficult to determine, as it depends on various factors such as patient demographics, medical history, and specific circumstances surrounding the intubation. However, studies suggest that:
- The incidence of awareness with paralysis during RSI is around 2.6%, with a higher risk associated with rocuronium compared to succinylcholine.
- The use of succinylcholine has been linked to increased mortality in severe traumatic brain injury patients, although its use is still recommended in certain situations.
- Propofol and dexmedetomidine are preferred for sedation in mechanically ventilated patients due to decreased ICU length of stay, duration of mechanical ventilation, and delirium.
In conclusion, while the exact incidence of myocardial infarction due to drugs used during intubation is unclear, it's essential to carefully consider the patient's medical history, hemodynamic status, and potential risks associated with each medication when selecting agents for RSI.
[20-09-2025 16:51] Meta AI: https://www.msdmanuals.com/professional/critical-care-medicine/respiratory-arrest/medications-to-aid-intubation
[20-09-2025 16:51] Meta AI: https://jomi.com/article/299.11/pharmacology-for-rapid-sequence-intubation-(rsi)-airway-management-in-trauma-patients
[20-09-2025 16:51] Meta AI: https://emedicine.medscape.com/article/109739-overview
[20-09-2025 17:06] PPM 1: 👆the other point of interest is that if people have studied the over utilisation of chest x-rays in ICU settings, root causes and how to optimise these @Meta AI @PPM4
[20-09-2025 17:06] Meta AI: Studies have indeed looked into the overutilization of chest X-rays (CXRs) in ICU settings, and here's what they've found:
Root Causes of Overutilization:
- Lack of awareness among healthcare professionals about the low diagnostic yield of routine CXRs
- Habit or tradition of ordering daily CXRs without specific clinical indications
- Defensive medicine or fear of missing potential complications
- Limited knowledge about alternative imaging modalities, such as ultrasound
Optimizing CXR Use in ICU:
- Clinically Indicated Approach: The American College of Radiology (ACR) recommends obtaining CXRs only when clinically indicated, such as:
- Change in Patient's Clinical Condition: sudden respiratory or cardiovascular deterioration
- Post-Line/Tube Insertion: after insertion of endotracheal tubes, central venous catheters, or other devices
- Alternative Imaging Modalities: using ultrasound or other modalities to reduce radiation exposure and costs
- Education and Awareness: educating ICU staff about the low diagnostic yield of routine CXRs and promoting evidence-based practices
- Protocol-Based Approach: implementing restrictive CXR protocols, which have been shown to reduce CXR orders without affecting patient outcomes
Benefits of Optimizing CXR Use:
- Reduced radiation exposure for patients and staff
- Lower healthcare costs
- Decreased risk of hospital-associated infections
- Improved resource allocation
According to studies, adopting a clinically indicated approach to CXRs in ICU can reduce orders by up to 60% without affecting patient outcomes. By optimizing CXR use, healthcare professionals can improve patient care while minimizing unnecessary testing and costs.¹ ²
[20-09-2025 17:06] Meta AI: https://www.ccjm.org/content/86/9/582
[20-09-2025 17:06] Meta AI: https://litfl.com/routine-daily-chest-x-ray/
[20-09-2025 17:16] PPM 4: Certainly! Here is the outline of the answer on chest X-ray overutilization in ICU settings:
- *Introduction*: Overview of chest X-ray overutilization in ICUs and its implications, based on recent studies.
- *Extent of overutilization*: Data on unnecessary CXRs, citing specific studies and statistics.
- *Root causes*: Habitual practices, perceived necessity, institutional culture, and financial factors.
- *Optimization strategies*: Multidisciplinary teams, education, EHR modifications, and clinical decision support.
- *Implementation challenges*: Resistance to change, training issues, and resource constraints.
- *Future directions*: Advanced imaging technologies, AI integration, and personalized protocols.
- *Conclusion*: Summary of key points and the importance of evidence-based practices.
Then, I will now begin writing the main body of the answer.
-------
# Chest X-Ray Overutilization in ICU Settings: Root Causes and Optimization Strategies
## 1 Introduction: The Scope of Unnecessary Chest Radiography in Critical Care
Chest X-rays (CXRs) represent one of the *most frequently performed* imaging studies in intensive care units (ICUs) worldwide. Despite substantial evidence demonstrating the *limited clinical utility* of routine daily CXRs in critically ill patients, this practice remains remarkably persistent across healthcare systems. The American College of Radiology (ACR) first stopped recommending daily CXRs in 2008 and strengthened its stance to "usually not appropriate" in 2011 and 2014, yet *implementation gaps* between evidence and practice persist . This comprehensive review examines the *root causes* behind CXR overutilization in ICU settings, evaluates the *evidence-based strategies* for optimization, and proposes *implementation frameworks* to align clinical practice with current guidelines. The imperative for change extends beyond cost savings to encompass *patient safety, **radiation exposure reduction, and overall **care quality improvement* in critical care environments.
The persistence of routine daily CXR practice represents a fascinating case study in *medical tradition* versus *evidence-based practice. Despite numerous studies showing that on-demand imaging does not impact ICU length of stay, duration of mechanical ventilation, morbidity, or mortality, many institutions continue this practice due to **deeply ingrained protocols, **perceived medicolegal protection, and **resistance to practice change* . Understanding both the evidence and the implementation challenges is essential for developing effective optimization strategies.
## 2 Extent of Overutilization: Quantifying the Problem
Multiple studies have demonstrated *significant overordering* of CXRs in ICU settings. A 2023 study examining CXR use in a cardiothoracic ICU found that *65.7%* of performed CXRs did not meet ACR Appropriateness Criteria, with only 3.8% of these non-indicated studies showing actionable or significant findings compared to 13.0% of indicated CXRs . This suggests not only substantial overutilization but also *diminished diagnostic yield* when CXRs are performed without specific clinical indications.
The scale of unnecessary imaging is considerable. At Cleveland Clinic, researchers reported an average of *375 portable CXRs per day* across their health system in 2018 before implementing reduction initiatives . Similarly, a study in Saudi Arabian ICUs found that *96.8%* of ICUs performed daily routine chest X-rays, with 64% of clinicians reporting this practice applied to all admitted patients . These numbers highlight the *pervasiveness of this practice* despite evidence against its utility.
Research shows that the majority of CXRs (55.9%) in cardiothoracic ICUs are performed for "routine daily" monitoring, followed by support device monitoring (12.4%) and new ICU transfer (10.4%) . This distribution demonstrates the *disproportionate emphasis* on routine studies rather than indicated ones, representing a significant opportunity for improvement in resource utilization and care efficiency.
## 3 Root Causes of CXR Overutilization in ICU Settings
### 3.1 Habitual Practice and Traditional Teaching
The *deeply entrenched nature* of daily CXR practice represents one of the most significant barriers to change. For decades, daily routine CXRs were considered standard of care in ICUs, based on the theoretical need to monitor *endotracheal tube position, **central venous catheter placement, and **developing pulmonary pathologies* . This practice became embedded in medical education and training, creating *generational propagation* of the protocol despite emerging evidence against its utility.
Many clinicians who trained under this paradigm continue to practice based on *historical precedent* rather than current evidence. A survey of ICU clinicians in Saudi Arabia revealed that despite 73% believing the current daily routine CXR protocol should be replaced with on-demand policy, the practice continued in 96.8% of ICUs . This *belief-practice discrepancy* highlights how institutional protocols and habits can perpetuate outdated practices even when clinicians recognize the need for change.
### 3.2 Perceived Medico-legal Protection
Many clinicians order daily CXRs based on *defensive medicine* considerations rather than clinical necessity. The fear of missing a critical finding, such as a *malpositioned endotracheal tube* or *developing pneumothorax, drives continued utilization of routine imaging . This perspective is reinforced by **medicolegal concerns*, where clinicians worry about liability for adverse events that might theoretically have been detected earlier with daily imaging.
Interestingly, studies have shown that the *diagnostic yield* of routine daily CXRs is remarkably low. In one analysis, only 3.8% of non-indicated CXRs had actionable findings compared to 13.0% of indicated studies . Furthermore, research demonstrates that *physical examination* and *point-of-care ultrasound* often provide more accurate and timely information about tube positioning and pulmonary status than routine CXRs.
### 3.3 Institutional Culture and Protocol Inertia
*Structural barriers* within healthcare systems present significant challenges to changing CXR ordering practices. Many institutions have *standing order sets* that include daily routine CXRs for all intubated patients or those with certain devices . These automated orders create *systemic momentum* that continues unless actively disrupted through deliberate protocol changes.
The *multidisciplinary nature* of ICU care also complicates practice change. Intensivists, surgeons, nurses, respiratory therapists, and radiologists may have different perspectives on the necessity of daily CXRs, creating challenges for building consensus around practice change . Additionally, the *high turnover* of trainees in teaching hospitals necessitates continuous education efforts, as each new cohort arrives with varying levels of knowledge about appropriate CXR use.
### 3.4 Financial Structures and Billing Considerations
In some healthcare systems, *financial incentives* may inadvertently promote overutilization of diagnostic imaging. While this is not the primary driver in most cases, the fee-for-service model can create *disincentives for reduction* efforts unless institutions deliberately align financial structures with value-based care .
Table: Primary Root Causes of CXR Overutilization in ICU Settings
| *Category* | *Specific Factors* | *Impact Level* |
|--------------|----------------------|------------------|
| *Cultural & Educational* | Traditional teaching practices | High |
| | Generational propagation of habits | High |
| | Resistance to changing established routines | Medium |
| *System & Structural* | Automated standing orders in EHR | High |
| | Multidisciplinary coordination challenges | Medium |
| | High trainee turnover in academic centers | Medium |
| *Perceptual & Psychological* | Medicolegal concerns | High |
| | Overestimation of diagnostic yield | Medium |
| | "Better safe than sorry" mentality | Medium |
| *Financial* | Fee-for-service reimbursement models | Low-Medium |
| | Departmental revenue generation pressures | Low |
## 4 Evidence-Based Strategies for Optimizing CXR Utilization
### 4.1 Multidisciplinary Quality Improvement Initiatives
*Structured collaboration* between services is essential for successful practice change. At Kings County Hospital, a multidisciplinary team including representatives from radiology, surgery, internal medicine, and nursing successfully implemented an intervention that reduced portable CXR utilization by *37%* between June and December without increasing unplanned extubations or ventilator days . This approach leveraged *shared ownership* of the problem and solution, creating buy-in across specialties.
The most effective teams include *project champions* from each stakeholder group who can influence their colleagues and disseminate the evidence base for practice change. These champions serve as *local influencers* who can address specialty-specific concerns and model appropriate ordering behavior. Regular meetings and clear communication channels help maintain momentum and address barriers as they arise.
### 4.2 Education and Awareness Campaigns
*Targeted education* is crucial for addressing knowledge gaps and misconceptions about CXR utility. Effective educational initiatives should highlight several key points: daily CXRs rarely change management; alternatives exist for monitoring device placement (e.g., *endotracheal tube position documentation, **central line insertion depth visualization); and more accurate methods are available for assessing fluid status (e.g., **point-of-care ultrasound, **body weight measurements, **input/output data*) .
Education must be *ongoing and adaptive, particularly in teaching hospitals with rotating trainees. At Kings County Hospital, faculty members emphasized the new approach during rotation orientation and reinforced these strategies during daily rounds . **Weekly email reminders* and *visual cues* at workstations served as continuous reinforcement of the restrictive, event-driven approach to ordering radiographs.
### 4.3 Electronic Health Record (EHR) Modifications
*System-level changes* to ordering processes can effectively reduce unnecessary CXRs by creating friction against reflexive ordering. At Cleveland Clinic, providers altered the EHR options for chest imaging so that providers could only order daily CXRs for patients with cardiac support devices or who had undergone cardiac and thoracic surgery, and required providers to indicate a specific reason for the need in this population . This intervention resulted in a *23.5% overall decrease* in average daily portable CXRs .
Similarly, researchers at the University of Vermont Medical Center removed the "daily" order option from the portable chest radiograph order within the EHR and added a prompt to the ICU rounding checklist to ask clinicians whether a CXR was clinically indicated that day. This multifaceted approach decreased CXRs by *64%* in the medical ICU and *35%* in the surgical ICU without increasing adverse events .
### 4.4 Clinical Decision Support and Appropriateness Criteria
Implementing *ACR Appropriateness Criteria* as a standard for ordering CXRs provides an evidence-based framework for decision-making. These criteria recommend selective ordering of chest radiographs rather than routine daily studies, specifically indicating CXRs after specific procedures (e.g., endotracheal tube placement, central line insertion, chest tube placement) or for specific clinical concerns (e.g., acute respiratory deterioration, fever in immunocompromised patients) .
*Audit and feedback* mechanisms help sustain practice change by providing data on ordering patterns. At Cleveland Clinic, researchers provided feedback to ICU directors about which providers were utilizing portable daily CXRs, creating accountability and highlighting opportunities for improvement . This data-driven approach allows for *targeted interventions* with providers who continue to order unnecessary studies.
Table: Effective Interventions for Reducing CXR Overutilization and Their Impacts
| *Intervention Type* | *Specific Strategies* | *Reported Effectiveness* |
|-----------------------|-------------------------|----------------------------|
| *Educational Initiatives* | Evidence presentations on low yield of routine CXRs | Variable |
| | Highlighting radiation exposure risks | |
| | Training on alternative assessment methods | |
| *EHR Modifications* | Removal of "daily" order option | 23.5-64% reduction |
| | Required clinical justification fields | |
| | Order sets based on ACR criteria | |
| *Process Changes* | Discontinuing standing orders | 35-37% reduction |
| | Multidisciplinary rounding checklist prompts | |
| | Policy change to on-demand only | |
| *Audit & Feedback* | Provider-level ordering reports | Enhanced sustainability |
| | Complication rate monitoring | |
| | Cost savings transparency | |
## 5 Implementation Challenges and Considerations
### 5.1 Addressing Resistance to Change
*Physician resistance* represents a significant barrier to implementing restrictive CXR policies. Some intensivists and surgeons may perceive protocol changes as *cost-cutting measures* that potentially compromise patient safety rather than evidence-based quality improvement . Addressing these concerns requires transparent communication about the *evidence base* for change, emphasis on *patient safety benefits* (reduced radiation exposure, less sleep disruption, decreased infection risk), and data showing *non-inferiority* of patient outcomes with restrictive strategies.
The *framing of the initiative* significantly impacts its reception. Positioning the change as *enhancing care quality* rather than simply reducing costs helps align stakeholders around the common goal of patient-centered care . Sharing data from peer institutions that have successfully implemented similar changes can alleviate concerns about safety and efficacy.
### 5.2 Special Population Considerations
While evidence supports reducing routine CXRs in most ICU patients, *specific subpopulations* may warrant different approaches. Cardiac surgery patients, those with *extracorporeal membrane oxygenation (ECMO), and patients with **unstable airway devices* might benefit from more frequent monitoring . These nuances should be incorporated into protocols rather than implementing blanket restrictions.
At Cleveland Clinic, researchers recognized that cardiac and thoracic surgery patients might have different needs and thus created specific ordering options for these populations while still requiring clinical justification . This *tailored approach* acknowledges clinical variability while maintaining an overall restrictive policy.
### 5.3 Balancing Reduction with Adequate Monitoring
An important consideration in reducing routine CXRs is ensuring that *clinically indicated* studies are still obtained promptly. Overly restrictive policies might cause clinicians to hesitate ordering necessary CXRs, potentially missing important diagnoses . To address this concern, the University of Vermont Medical Center added a prompt to the ICU daily rounding checklist to query whether a CXR was clinically indicated . This *balancing measure* helped ensure that appropriate studies were not missed while reducing unnecessary ones.
## 6 Future Directions and Innovative Approaches
### 6.1 Point-of-Care Ultrasound as an Alternative Modality
*Bedside ultrasound* is emerging as a valuable alternative to CXRs for many ICU monitoring applications. Research shows that point-of-care ultrasound can more accurately assess *fluid status, **pulmonary pathologies, and **endotracheal tube position* than portable CXRs . Implementing ultrasound-based protocols requires *training investment* but offers the potential for *reduced radiation exposure, **real-time assessment, and **decreased costs*.
The ACR Appropriateness Criteria note that chest ultrasound may be appropriate for certain ICU applications, though evidence is still evolving . As technology improves and training becomes more widespread, ultrasound may replace CXRs for many indications in critical care settings.
### 6.2 Artificial Intelligence and Clinical Decision Support
*Advanced clinical decision support* systems integrated with EHRs show promise for further optimizing CXR utilization. These systems can provide *real-time feedback* on ordering appropriateness based on patient-specific factors, suggest *alternative imaging modalities* when appropriate, and flag orders that don't meet evidence-based criteria .
*Artificial intelligence* applications might also help identify patients who would benefit from CXRs based on electronic clinical data, potentially increasing yield while reducing unnecessary studies. These technologies represent the next frontier in diagnostic stewardship but require careful validation and implementation to avoid unintended consequences.
### 6.3 Standardized Outcomes Monitoring
Developing *standardized metrics* for tracking the impact of CXR reduction initiatives will facilitate comparison across institutions and help identify best practices. Key metrics might include CXRs per 1000 ventilator days (excluding procedure days), rates of missed diagnoses, and adverse event rates . *Collaborative networks* sharing these metrics could accelerate implementation of effective strategies across healthcare systems.
## 7 Conclusion
The overutilization of chest X-rays in ICU settings represents a significant opportunity for *value-based improvement* in critical care. Evidence consistently demonstrates that transitioning from routine daily to clinically indicated CXRs reduces *resource utilization, **costs, and **radiation exposure* without increasing adverse events. Successful implementation requires *multidisciplinary collaboration, **education, **EHR modifications, and **ongoing monitoring* to ensure compliance and identify opportunities for improvement.
While challenges exist, particularly related to *practice change resistance* and *concerns about missed diagnoses, the experience of numerous institutions shows that restrictive CXR policies can be implemented safely and effectively. Future developments in **point-of-care ultrasound* and *artificial intelligence-based clinical decision support* may further optimize imaging utilization in critical care settings.
As healthcare continues to emphasize value-based care, reducing unnecessary diagnostic imaging represents both a *clinical imperative* and an *ethical responsibility* to provide high-quality, patient-centered care without unnecessary harm or expense. The evidence supports abandoning routine daily CXRs in favor of an indicated, thoughtful approach to imaging in critically ill patients.
Table: Key Recommendations for Optimizing CXR Use in ICU Settings
| *Domain* | *Recommendations* | *Expected Outcomes* |
|------------|---------------------|------------------------|
| *Education & Training* | Regular evidence reviews for staff | Increased awareness of appropriate use |
| | Training on alternative assessment methods | Reduced reflexive ordering |
| | Radiation safety education | Enhanced patient safety |
| *Protocol Development* | Implement ACR Appropriateness Criteria | 30-50% reduction in unnecessary CXRs |
| | Create special population guidelines | Tailored approach for complex patients |
| | Develop procedure-driven ordering protocols | Improved yield of obtained CXRs |
| *System Changes* | Modify EHR order sets | Reduced automated daily orders |
| | Implement clinical decision support | Improved ordering appropriateness |
| | Add checklist prompts during rounds | Balancing of reduction with need |
| *Monitoring & Feedback* | Track CXR/utilization metrics | Sustained practice change |
| | Monitor complication rates | Assurance of safety |
| | Provide provider-level feedback | Accountability for ordering practices |
No comments:
Post a Comment