Routine Chest X-Rays After Thoracic Surgery Are Unnecessary

j o u r n a l o f s u r g i c a l r e s e a r c h  j u n e 2 0 2 0 ( 2 5 0 ) 1 8 8 e1 9 2

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Routine Chest X-Rays After Thoracic Surgery Are Unnecessary Eleah D. Porter, MD,a,* Kayla A. Fay, BS,a Rian M. Hasson, MD,a,b Timothy M. Millington, MD, FACS,a,b David J. Finley, MD, FACS,a,b and Joseph D. Phillips, MD, FACSa,b a b

Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Geisel School of Medicine at Dartmouth, Hanover, New Hampshire

article info

abstract

Article history:

Background: Routine chest x-rays (CXRs) ordered on thoracic surgery inpatients are com-

Received 7 July 2019

mon, costly, and of unclear clinical utility. We sought to investigate CXR ordering practices

Received in revised form

and their impact on clinical care.

19 November 2019

Materials and methods: A single-center, retrospective cohort study of adult patients admitted

Accepted 30 December 2019

after undergoing thoracic surgery with an intraoperative chest tube (CT) placed was per-

Available online xxx

formed 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

Keywords:

(PACU) and after final CT removal. “Routine” was defined as not ordered during a workup

Cost-effectiveness

for a clinical concern. Patients were excluded if they underwent pleurodesis, were dis-

Thoracic surgery

charged with a CT, or had an immediate post-CT removal clinical change prompting

Patient safety

intervention.

Chest x-ray

Results: A total of 241 patients met inclusion. All patients received a routine PACU CXR, and

Thoracostomy tube

48% (117) had abnormal radiographic findings (e.g., pneumothorax, consolidation, effusion,

Postoperative complication

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. ª 2020 Elsevier Inc. All rights reserved.

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.3-7 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

This article was presented at Academic Surgical Congress 2019 Annual Meeting, February 5-7, 2019, Hilton Americas, Houston, TX. * Corresponding author. Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756. Tel.: þ1 603 650 5000; fax: þ1 603 676 4347. E-mail address: [email protected] (E.D. Porter). 0022-4804/$ e see front matter ª 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.12.030

porter et al  cxrs unnecessary after thoracic surgery

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.1,2,5-7,10,11 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.12-21 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.

Materials and methods Study design and patient selection This was a cohort study of a prospectively maintained thoracic surgery database. Consecutive patients who underwent a general thoracic surgery procedure with an intraoperative CT placed at our 400-bed rural, academic quaternary care hospital between July 1, 2017, and June 30, 2018, were screened for eligibility. Our primary outcome was a routine CXR-driven change in care. A “routine CXR” was defined as one ordered from an order set and/or not during a workup for a clinical change or concern. The indication for a CXR was determined by chart review, as providers were required to type in a free text response for an x-ray’s indication. Changes in care were also determined by retrospective review, in which we reviewed progress notes and free text indications for imaging and/or other procedures. A change in care included clinical observation with prolonged hospitalization, serial CXR imaging, repositioning of a CT, or a procedural intervention consisting of reinsertion of a CT. We were not able to determine other changes in care, such as pulmonary toilet, incentive spirometry, diuresis, or a change in the water seal system settings. We selected two time points for monitoring of routine CXRs: in the PACU immediately after surgery and, later, after final CT removal. These two time points were selected based on both previous work in the field3,21 and because it was standard practice for our thoracic surgery service to routinely order CXRs at these times. Any additional CXRs were discretionary. Patients were excluded if they were discharged with a CT still in place or if they underwent pleurodesis. The latter exclusion was secondary to post pleurodesis patients having a unique CXR ordering algorithm that included serial CXR monitoring for clinical response with discrete interventions if none were found. We determined that these films would not be considered routine. Patients were also excluded if their CXR orders were managed by a nonthoracic service or if they had

189

an immediate clinical change or decline after CT removal, as this would have prompted an intervention and nonroutine CXR (Fig. 1). Medical charts were reviewed for demographics, comorbidities, baseline pulmonary function tests, procedural data, routine PACU and final CT removal CXR results and their impact on clinical care, and perioperative outcomes. Surgical procedures were categorized into lung, pleura, mediastinum, esophagus, or diaphragm. Postoperative complications were monitored during the index admission and graded I-IV as classified by Clavien-Dindo.22,23

CT management and CXR results Our standard intraoperative CT is a 28-French tube, and our drainage system is a standard dry suction water seal system. Criteria for CT removal after nonesophagectomy included absence of an air leak and drainage <450 cc in 24 h. Postesophagectomy, the typical pathway included introduction of clear liquids on postoperative day 2, and if no evidence of increased CT output, the CT was removed on postoperative day 3. CT removal technique is standardized at our institution: a patient is asked to take two slow deep breaths, and on full inspiration of a third breath, they perform a Valsalva and a cough maneuver. If there are no bubbles in the chamber, regardless of column motion, then it is considered that there is no air leak. CXR results were categorized based on the radiologist’s documented interpretation. Results were classified into one of four de novo categories that included (1) normal/expected findings, (2) small versus (3) sizable pneumothorax (PTX) as defined by less than or greater than 15% of the hemithorax, respectively, and (4) other abnormal findings (e.g., consolidation, effusion, atelectasis, opacification, hydropneumothorax, etc). Categories were applied such that if multiple findings were present, the most clinically significant/relevant category that may prompt an intervention was assigned. This study was approved by the Institutional Review Board at Dartmouth College and DartmoutheHitchcock Medical Center with a granted waiver of consent.

Results Demographics and perioperative characteristics During the 1-y study period, 241 patients underwent thoracic surgery with placement of an intraoperative CT and met inclusion criteria (Fig. 1). Of note, the three patients who were excluded secondary to having an immediate clinical change after CT removal experienced vital sign changes consisting of either tachycardia, hypotension, or hypoxia. Table summarizes the patient and periprocedural characteristics. The average age was 61  15 y, and 52% were male. The majority of patients had at least one preoperative comorbidity (90%), with hypertension having the highest prevalence (44%). Eighty-two percent of patients had an American Society of Anesthesiologists class 3. The distribution of procedure types varied and included 65% lung (156; 80 lobectomy, 71 wedge resection, one pneumonectomy, and four other), 14% pleura (33; 26 decortication and seven biopsy/mass excision), 14% mediastinum

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Table e Patient demographics and perioperative characteristics. Total (N ¼ 241)

Characteristics Age (y; mean  SD) Age  65 y, n (%)

113 (46.9)

Male, n (%)

125 (51.9)

Comorbidity, n (%)

218 (90.5)

HTN, n (%)

105 (43.6)

DM, n (%)

48 (19.9)

Obesity, n (%)

59 (24.5)

COPD, n (%)

56 (23.2)

Cardiac history*, n (%)

34 (14.1)

CKD, n (%)

Fig. 1 e Patient selection.

8 (3.3)

Preoperative PFTs FEV1 % predicted (median  SD) DLCO % predicted (median  SD)

(35; 20 mediastinal mass excision/biopsy, 13 thymectomy, and 2 others), 5% esophagus (13; 10 esophagectomy and three others), and 2% diaphragm (four imbrication). A minimally invasive surgical approach was used in 215 patients (89%): video-assisted thoracic surgery (VATS) alone (118) and robotic-assisted VATS (97). The median length of stay was 2  3 d. During index admission, 8% (19) of patients experienced a Clavien-Dindo grade III/IV complication. Within 30 d, 9% (21) of patients were readmitted, and there were two patient deaths (0.8%). One patient had stage IV esophageal cancer complicated by esophageal perforation and lung abscess. The other patient had stage IV lung cancer with recurrent pleural effusion.

Routine CXR outcomes

ASA  3, n (%)

All patients received a routine PACU CXR. These resulted in 48% (117) having abnormal radiographic findings. The abnormal findings consisted of 20% (48) a small PTX, 3% (8) a sizable PTX, and 25% (61) other abnormal results (Fig. 2). PACU CXRs led to a change in care in one patient (0.4%), which consisted of a repeat CXR but no procedural intervention (Fig. 3). The CXR result category for this patient was “other abnormal” and consisted of opacification of the left hemithorax and a small pleural effusion. On repeat film, the same results were noted.

77  21 83  21 197 (81.7)

Surgical procedure Lung, n (%)

156 (64.7)

Pleura, n (%)

33 (13.7)

Mediastinum, n (%)

35 (14.5)

Esophagus, n (%)

13 (5.4)

Diaphragm, n (%) Open surgery, n (%) Minimally invasive surgery, n (%) VATS alone, n (%) Robotic assisted VATS, n (%) y

Any complication , n (%)

4 (1.7) 26 (10.8) 215 (89.2) 118 (49.0) 97 (40.2) 62 (25.7)

CD I/II, n (%)

51 (21.2)

CD III/IV, n (%)

19 (7.9)

LOS (d; median  SD)

Postanesthesia care unit chest x-ray

61  15

Readmission Mortality

23 21 (8.7) 2 (0.8)

ASA ¼ American Society of Anesthesiologists; CD ¼ Clavien-Dindo; CKD ¼ chronic kidney disease; COPD ¼ chronic obstructive pulmonary disease; DLCO ¼ diffusion lung capacity for carbon monoxide; DM ¼ diabetes mellitus; FEV1 ¼ forced expiratory volume in 1 s; HTN ¼ hypertension; LOS ¼ length of stay; PFT ¼ pulmonary function test. * Cardiac history includes coronary artery disease, myocardial ischemia, and congestive heart failure. y Clavien-Dindo classification system grade I-IV.

Final CT removal CXR All patients received a final CT removal CXR. Of these CXRs, 58% (140) had abnormal radiographic findings. The abnormal findings consisted of 46% (110) a small PTX, 2% (5) a sizable PTX, and 10% (25) other abnormal results (Fig. 2). These CXRs led to a change in care in 33 patients (14%), all of which experienced either repeat/serial CXR (32) or clinical observation alone (1). No procedural interventions took place (Fig. 3). Within the 33 patients who experienced a change in care, their CXR results consisted of 67% (22) a small PTX, 15% (5) a sizable PTX, and 18% (6) other abnormal results. Notably, of the 140 patients with an abnormal CXR result, 89 (64%) were discharged on the same day as their CXR.

Discussion The utility of routine CXRs after thoracic surgery has been repeatedly challenged, yet national guidelines restricting their use are absent.1,2,5-7,10,11 Our study shows that at an academic center in the United States, empiric use of postoperative CXRs is still a pervasive practice with limited clinical value. Similarly, other authors have found that after lung resection, more than 77% of routine CXRs are unlikely to influence clinical decision-making.11 Postoperative care pathways have been shown to improve efficiency while maintaining patient safety, and they have

porter et al  cxrs unnecessary after thoracic surgery

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Fig. 2 e Results of the routine chest x-ray (CXR) performed in the postanesthesia care unit (PACU) and after final chest tube (CT) removal. demonstrated excellent outcomes in thoracic surgery.2,8,9 Routine CXRs are a widely accepted component of these pathways, but there is limited evidence to support this practice. In this study, we focused on empiric CXRs ordered in the PACU and after final CT removal, as these two times have been identified as having decreased utility for a routine CXR.3,5,10,11 Our data revealed that these CXRs did not lead to a single procedural intervention. It is important to note that we excluded patients with any clinical change after CT removal, as this would have prompted radiographic evaluation and thus would not be considered “routine.” At our institution, the average cost of a CXR is $500 USD. By eliminating just these two routine CXRs from our postoperative pathway in select patients, we could have saved at a minimum $241,000 in 1 y. In fact, almost every patient who experienced a change in care as a result of these routine CXRs underwent a second CXR, further escalating costs. Some may argue validity to routine imaging assessment after thoracic surgery. If re-expansion is not seen on a PACU CXR after pleurodesis or decortication, reintervention may be required.7 Likewise, radiographic documentation of the thorax postsurgery may be an important baseline for future comparison. These are legitimate concerns, and we subscribe that routine imaging for these indications may be necessary. However, after this, it appears that most thoracic surgery patients go on to receive daily routine CXRs during hospitalization.1 Perhaps, one could consider the necessity of obtaining any other routine CXR after a favorable PACU image. Routine CXRs after final CT removal may also be justified in certain scenarios. Not all patients can reliably express clinical distress, and the

Fig. 3 e Change in care secondary to the routine chest x-ray (CXR) in the postanesthesia care unit (PACU) and after final chest tube (CT) removal.

appropriate amount of time spent observing a patient after CT removal before discharge is unknown. In certain regions of the country, patients may be discharged to remote areas, and objective data from a routine CXR may prevent an unsafe discharge. We are currently investigating if travel distance influences CXR orders before discharge at our rural institution. Nevertheless, empiric ordering of postoperative CXRs is simply not supported by our data, and several studies across different disciplines have shown support for the restrictive use of postCT removal CXRs.3,12,14-17 In addition, there is growing evidence for the alternative use of chest ultrasound in lieu of x-ray to reduce both cost and radiation exposure.24 Not all imaging after thoracic surgery is unnecessary, but our study reinforces that the current climate is one of CXR overutilization. There are several limitations to this study. This is a singlecenter, retrospective review and is thus subject to selection bias. We were not able to capture the qualitative factors involved in the decision-making between a patient and clinician. In addition, some changes in clinical care secondary to a CXR were unable to be determined, such as pulmonary toilet, incentive spirometry, diuresis, or a return to suction. These are clinically important and will need to be addressed in a future prospective study. Despite these limitations, our study provides contemporary data at an academic institution that corroborates previous reports and demonstrates continued CXR overutilization. Looking ahead, multicenter prospective and/or randomized controlled trials are needed to support the restrictive use of post-thoracic surgery CXRs. At our institution, since completing this study, we have implemented a quality improvement initiative to reduce empiric CXR use after thoracic surgery. We anticipate results to show that in a hospitalized setting with close clinical observation, the reserving use of post-thoracic surgery CXRs for specific clinical concerns can be safe and efficacious.

Conclusions Routine postoperative CXRs immediately after thoracic surgery in the PACU and later after final CT removal have limited

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impact on clinical care. In this study, routine CXRs at these time points did not lead to a single procedural intervention, but they did lead to additional CXRs. Thoracic surgeons should use clinical judgment to more judiciously decide which patients require empiric CXRs.

Acknowledgment Authors’ contributions: All authors contributed to the study conception and design. E.D.P. and K.A.F. contributed to acquisition of data. The analysis and interpretation of data was performed by E.D.P., K.A.F., and J.D.P. E.D.P., R.M.H., T.M.M., D.J.F., and J.D.P drafted the article and made critical revision of the article.

Disclosure The authors do not have any financial or personal relationships that would influence this work.

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