Routine Chest X-Rays After Thoracic Surgery Are Unnecessary

Abstract

Background

Routine chest x-rays (CXRs) ordered on thoracic surgery inpatients are common, costly, and of unclear clinical utility. We sought to investigate CXR ordering practices and their impact on clinical care.

Materials and methods

A single-center, retrospective cohort study of adult patients admitted after undergoing thoracic surgery with an intraoperative chest tube (CT) placed was performed over a 1-y period. Our primary outcome was a CXR-driven change in care. We evaluated routine CXR orders immediately after surgery in the postanesthesia care unit (PACU) and after final CT removal. “Routine” was defined as not ordered during a workup for a clinical concern. Patients were excluded if they underwent pleurodesis, were discharged with a CT, or had an immediate post-CT removal clinical change prompting intervention.

Results

A total of 241 patients met inclusion. All patients received a routine PACU CXR, and 48% (117) had abnormal radiographic findings (e.g., pneumothorax, consolidation, effusion, etc). Secondary to this CXR, one patient (0.4%) experienced a change in care: a repeat CXR only. All patients received a routine final CT removal CXR, and 58% (140) had abnormal radiographic findings. After this CXR, 33 patients (14%) experienced a change in care: 32 underwent repeat CXR and one was clinically observed. Overall, no patients experienced a procedural intervention.

Conclusions

Routine post-thoracic surgery CXRs in the PACU and after CT removal have limited clinical impact. Quality initiatives should be pursued to decrease empiric CXR use and reserve ordering for specific clinical concerns.

Introduction

Undergoing multiple chest x-rays (CXR) after thoracic surgery is a common, costly occurrence.^1,2 Although some CXRs are ordered in response to a clinical concern, many are ordered routinely and without clinical prompting.3, 4, 5, 6, 7 In several surgical fields, postoperative pathways have become ubiquitous in providing safe and efficient care.^2,8,9 Routine CXRs are a widely accepted component of standardized postoperative care in thoracic surgery patients. However, if these pathways are not continually revisited, they can lead to redundancy and overutilization.

Reports have challenged the utility of empiric postoperative CXRs in thoracic surgery, but evidence-based guidelines to restrict their use are lacking.^1,2,5, 6, 7^,10,11 Of particular interest are the CXRs ordered immediately after surgery in the postanesthesia care unit (PACU) and, later, after final chest tube (CT) removal. A few studies looking at thoracic surgery patients have demonstrated limited clinical impact after these CXRs,^3,5,10,11 and in other patient populations, a plethora of evidence exists to challenge their utility.12, 13, 14, 15, 16, 17, 18, 19, 20, 21

At our academic institution, all thoracic surgery patients, regardless of clinical status, receive a routine CXR in the PACU and later after final CT removal. Anecdotally, radiographic abnormalities discovered on these x-rays are inconsistently managed in stable patients. This motivated us to formally investigate the utility of these films to serve as a baseline for future quality improvement work to reduce empiric CXR use. We hypothesized that routine CXRs in the PACU and after final CT removal would have limited clinical impact.