A CPI approach using radiation awareness and evidence based medicine to achieve appropriate use of medical imaging examinations
A prospective intervention study, using clinical practice improvement (CPI) methodology, was undertaken to reduce unnecessary x-ray examinations in the early management of patients presenting to the Emergency Department (ED). This was achieved through raising the awareness of medical and allied health staff to medical radiation by means of clinical education and implementing evidence based diagnostic imaging requisition. The main study was conducted in the ED of a public hospital located in the western Sydney, Australia. A second hospital within the area health service, with similar bed size, activity levels and demographics, was used as the control site. The first phase intervention raised the awareness of the health professionals to medical radiation. The second phase intervention used CPI methodology to attain efficient clinical practices so as to eliminate unnecessary examinations and requests. A multi-disciplinary CPI Project Team involved in the process of imaging examination requisition was empowered to improve the appropriateness of the requested examination utilisation. This it achieved mainly through the implementation of evidence based clinical decision rules and imaging guidelines. An additional method of validating the outcomes was provided through the simultaneous rollout of the interventions at another hospital within the same area health service. At the completion of the study, unnecessary examinations such as Skull, Ribs, Nasal Bone and Kidney Ureter Bladder (KUB) requests at the intervention Hospital site were significantly reduced by 92.6% (p (less than) 0.0001), whereas at the control site Hospital there was minimal reduction which was found to be not statistically significant (p=0.2110). Other frequently requested examinations such as Ankle, Knee and Spine requests were marginally though significantly reduced at the intervention Hospital by 22.7% (p (less than) 0.001), whereas at the control site Hospital the reduction was similarly found to be not significant (p=0.1055). Most importantly, the overall x-ray requisition for every 100 ED presentations at Hospital ‘B’ was reduced by 27%. The results of this study, demonstrated that Radiation Awareness educational programs, targeting medical and allied health staff, will reduce the unnecessary requisition of examinations found not to contribute to the process of the patient’s clinical management. The use of a CPI project approach was found to be important in the process of establishing, implementing and sustaining the achieved improvements, and in particular, the rules and guidelines of evidence based imaging requisition. Importantly, the study also confirmed that the CPI methodology that had been used for the main intervention was adaptable to other organisations when it was found to have been successfully rolled out at another hospital. This confirmed that the main outcomes of the investigation could be generalised to other health facilities. There was an immediate reduction in the requisition of unnecessary examination similar to the results at the main intervention hospital. The implementation and adoption of the CPI intervention across the health care system in general could significantly reduce unnecessary x-ray examinations, saving significant health care resources, and sparing patients from potential cancer risks associated with avoidable exposure to ionising medical radiation.