Bedside chest radiography as part of a postcardiac surgery critical care pathway: a means of decreasing utilization without adverse clinical impact.

OBJECTIVE: To evaluate the use of bedside chest radiography and patient outcome before and after implementation of a cardiac surgery critical care pathway that included guidelines for bedside radiography.

DESIGN: A cohort observational study.

SETTING: A university hospital in the midwest.

PATIENTS: Three groups, of 100 patients each, undergoing cardiac surgery in 1990, 1991, and 1995.

INTERVENTION: Introduction of a critical care pathway.

MEASUREMENTS: Medical records were retrospectively reviewed in three groups of 100 patients each: before the introduction of the critical care pathway; 2 months after introduction of the pathway in 1991; and 4 yrs after introduction in 1995. Data were analyzed to determine operative risk for each group. Subsequent analyses determined bedside radiography use, total length of hospital stay, and patient outcome (mortality rate, complications requiring intervention, and reoperation) during hospitalization and at outpatient follow-up 15-30 days postdischarge.

RESULTS: Total length of hospital stay was shorter for the 1995 group (7.6+/-6.6 days) compared with other groups (prepathway, 11.1+/-10.3 days; 1991 postpathway, 10.2+/-9.6 days; p<.05). The mean numbers of radiographs per patient were as follows: prepathway, 5.1; 1991 postpathway, 5.2; and 1995 postpathway, 3.3. The mean number of radiographs in the 1995 group was significantly lower (p = .02). More patients had the proposed number of two bedside radiographs described in the pathway in the 1995 group compared with the other groups (prepathway, p<.0001; the two-month postpathway group, p = .01). Twenty-three malpositioned catheters/tubes were found in the prepathway and 1991 groups compared with 11 in the 1995 group (p = .02). No statistically significant difference was found in inpatient complications (mediastinal bleeding, pneumothoraces, and pleural effusions), postdischarge complications, reoperations, or mortality rate.

CONCLUSION: Introduction of a critical care pathway can decrease the use of bedside radiography without adversely affecting near-term patient outcomes.