2013年1月13日 星期日

A bad hospital habit finally being broken

Patients have long been given daily, routine chest X-rays in hospital intensive care units around the developed world, for no good medical reasons. Just because of decades of habit.

But recent studies have shown they are a waste of time and resources, not to mention being potentially hazardous because of the repeated radiation.

Such X-rays don’t detect more problems, don’t alter mortality rates, the length of stay in ICU, or the number of days patients are hooked up to breathing machines, recent studies have shown.

So when doctors at St. Paul’s Hospital in downtown Vancouver decided to instigate a stop to the practice, they managed to find cost savings of $40,000 annually by ordering 70-per-cent fewer routine X-rays. Each X-ray test costs about $40.

In the process, they spared patients from X-ray radiation and freed up staff time more more proven interventions.

“Not to sound stupid, but it was one of those things we were used to doing out of tradition, because of thinking it was the right thing to do. But it was one of those things for which there was no evidence of benefit,” said intensive care specialist Dr. Peter Dodek. He led a study of the practice as a scientist with the Centre for Health Evaluation and Outcome Sciences at St. Paul’s and the University of B.C.

The American College of Radiology used to recommend daily chest X-rays for patients on ventilators. But the recommendation has now changed because of evidence that such routine tests are not necessary.

Frequent chest X-rays are, however, still necessary for patients with symptoms of heart and lung distress or those freshly hooked up to tubes and catheters that could pose complications.

St. Paul’s began to rethink its policy a few years ago when five residents in internal medicine read about a comprehensive study in France showing that daily chest X-rays of ICU patients were unnecessary. As part of their postgraduate medical training and a project on patient care quality improvement, they decided to launch their own study.

“Our intention was not to eliminate chest X-rays because some patients do need them. After all, we are talking about patients who are intubated, and often on mechanical ventilation. They’re at risk of acquiring pneumonia in hospital so that’s why daily chest X-rays were thought to be useful, to check for those signs,” Dodek said.

But there are other ways and means to look for signs of pneumonia — fever, white blood cell counts and oxygen levels. Doing a chest X-ray on an ICU patient means radiology technicians have to wheel portable X-ray machines to the bedside, nurses have to lift and reposition seriously ill patients, and clear tubes and catheters out of the way of the X-ray beam. Repositioning patients can result in catheters and tubes coming loose.

Once the patient is readied for the scan, nurses and other health professionals must stand back so they’re not exposed to the radiation.

The St. Paul’s project team drew up a list of conditions that still require routine chest X-rays and worked with computer programmers to change the electronic order-entry system so that all requisitions include at least one of the required indicators. They spread the word by putting up posters and giving educational sessions. They also hope to have their work published in a medical journal.

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