It’s All in the Approach

Earlier this month, the Johns Hopkins School of Medicine hosted its first High-Value Practice Research Symposium to highlight efforts across the system to reduce unnecessary tests and procedures, including work inspired by the Choosing Wisely^® campaign that has been embraced by training programs.

The symposium featured podium and poster presentations on various research investigations and innovations, including one from Sonali Palchaudhuri, MD, an Internal Medicine resident, who presented on the work she does to reduce daily chest X-ray utilization in the intensive care unit (ICU).

When she started as an intern at Johns Hopkins Bayview in 2013, Dr. Palchaudhuri learned of Providers for Responsible Ordering (PRO), a group with a mission to avoid prescribing unneeded care. She and several other residents and faculty set out to grow the group that year in efforts for culture change, and wrote a pledge so providers can identify their interest in high-value care. Since then, the pledge has helped PRO grow from a local project to a national group with chapters at institutions across the country.

“High-value care is really a team effort,” Dr. Palchaudhuri said. “You need an investment by a group to think more critically about the care we deliver.”

Dr. Palchaudhuri, now the PRO resident director, wanted to start projects that targeted practices that don’t align with evidence and might cause medical and financial harm. She focused on unneeded chest X-rays in the ICU because of the additional harms involved — waking and moving patients during the night and radiation from multiple scans — and evidence that these tests are not indicated.

Her goal was to try to eliminate unnecessary ordering as defined by sources such as the Critical Care Societies Collaborative’s Choosing Wisely recommendation against ordering diagnostic tests, including chest X-rays, at regular intervals. The preferred and recommended strategy is to order them as needed to answer clinical questions.

But first, she and her team had to figure out why daily orders were being placed. They realized that clinicians were ordering more tests in the morning and hypothesized that this could be due to the fact that chest X-rays were included as an item to select in the daily morning ordering set.

“Just the presence of the order suggests that it was appropriate to order every day, so we took it out of the ordering set,” Dr. Palchaudhuri said, adding that physicians can still order chest X-rays separately as needed.

The team’s approach also focused on culture change through education. Discussions were initiated during grand rounds, and presentations were given to residents and ICU attendings. They distributed pocket cards that summarized guidelines and posted them at workstations to put the evidence at the fingertips of providers at the point of care.

To track this work, which began in January 2015, the team collected data from one year before the intervention and eight months after. Monthly and total comparisons showed that morning orders for chest X-rays fell by 28 percent with no impact on ordering of urgent chest X-rays.

“We are on target with our goal to reduce routine morning orders by 30 percent,” Dr. Palchaudhuri said. “We plan to continue to collect data and further refine our interventions to make sure this project is sustainable.”