22-Outcomes of a Chest Radiograph De-Implementation Program: An Implementation Effectiveness Study
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Procedures, 2021
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The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Enyo Ablordeppey


Introduction/Hypothesis: Data suggest that point of care ultrasound (POCUS) for central venous catheter (CVC) confirmation may obviate the need for traditional post-CVC chest x-rays (CXR) to confirm catheter position and exclude pneumothorax (PTX), but this practice has had a slow rate of adoption. To facilitate uptake, we developed DRAUP (De-implementation of Routine cxr after Adoption of Ultrasound guided cvc insertion and confirmation Protocol), a program using 6 multifaceted strategies. In this study, we assess implementation and effectiveness outcomes using this program.

Methods: This is an interim analysis (1/1/2020 – 7/31/2020) from a prospective, hybrid implementation and effectiveness study at an urban academic Emergency Department (ED). All patients with POCUS-guided right internal jugular (IJ) CVC placement were eligible. Using Morgan's framework for medical overuse, six implementation strategies were selected, including organizational support, algorithm development, audit and feedback, planned adaptation, education and training, and decision support. This study assessed adoption of POCUS confirmation after right IJ CVC insertion, de-adoption of post CVC CXR in the ED, and fidelity to the protocol. Effectiveness outcomes included feasibility of DRAUP and descriptive analysis (false negative (FN) rates of POCUS to detect malposition and PTX). Feasibility was measured by the number of opportunities to deimplement CXR based on the algorithm. Fidelity was measured by adherence to the protocol through checklist completion.

Results: There were 252 CVCs placed in the ED. Among 89 patients with right IJ catheters, DRAUP was used in 49% (44/89) with no ED CXR performed in 36 (82%) (feasibility). Fidelity of the required POCUS images and deimplementation algorithm was achieved in 86%. The incidence of CVC malposition and/or PTX seen on the next available CXR was 4.5% (2/44) and 0% (0/44) respectively. The FN rate of CVC malposition and PTX by POCUS were 2% (1/ 44) and 0%, respectively.

Conclusions: Multifaceted implementation strategies used in DRAUP can reduce CXRs after POCUS-guided CVC confirmation, thus reducing this evidence-to-practice gap in critically ill patients. Larger studies in other EDs or the intensive care units are needed to measure the implementation reach of DRAUP using multifaceted strategies.


Meta Tag
Content Type Presentation
Knowledge Area Procedures
Knowledge Level Intermediate
Knowledge Level Advanced
Learning Pathway Cardiothoracic Critical Care
Membership Level Select
Tag Radiology
Tag Point of Care
Tag Cardiothoracic Critical Care
Year 2021
Chest X-ray Deimplementation Program
Point-of-care ultrasound
Central venous catheter position
DROP program


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