Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Date of Graduation


Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing


Erica Lewis


In the cardiovascular service line at an academic medical center in the southeastern United States, obtaining daily chest x-rays still occurred despite evidence that it is unnecessary and possibly even harmful. This quality improvement project was implemented in a 24-bed Cardiovascular Intensive Care Unit and 20-bed acute care unit, together considered to be the cardiac service line. Using the implementation framework of the Model for Improvement and Plan/Do/Study/Act, a guideline that outlines appropriate times to obtain a chest x-ray based on the American College of Radiology’s appropriateness criteria was created. Daily chest x-rays were eliminated and replaced with an on-demand chest x-ray ordering protocol. The project was implemented for two months. The intervention started on May 1st, the first day of the month, and ended on June 30th, the last day of the month. Institutional Review Board approval was obtained. Descriptive data such as patient age, gender, predicted risk of mortality, predicted risk of prolonged ventilation, and predicted risk of a long length of stay was analyzed for descriptive data only. A Mann-Whitney Rank Sum test was used to evaluate the primary outcome of frequency of chest x-rays and the secondary outcomes of hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), 30-day mortality, ventilator hours, and reintubation rates. There was a statistically significant decrease in frequency (p < 0.001) of chest x-rays with an associated significant decrease in patient cost (p < 0.001) and radiation exposure (p < 0.001). There was no change in hospital LOS, ICU LOS, ventilator hours, reintubation rates, or mortality rate. Replacing daily chest x-rays with an on-demand ordering approach is effective and efficient. This will remain a permanent practice change in the cardiovascular service line and open up opportunities for other quality improvement projects.

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