Background: Choosing Wisely ® is a national campaign aimed at promoting high-value care. Vanderbilt University Medical Center (VUMC) has created a steering committee to direct implementation of select Choosing Wisely (CW) recommendations. Our first initiative successfully reduced unnecessary daily lab testing across multiple hospital services. Our second initiative targets chest x-ray (CXR) utilization in intensive care units (ICUs). 

Purpose: Based on the top recommendation of the Critical Care Societies Collaborative, we aim to achieve a 20% absolute reduction in CXR ordering rates in select ICUs within one year of implementation. The Medical Intensive Care Unit (MICU) and Cardiovascular Intensive Care Unit (CVICU) were chosen due to their high CXR ordering rates, with planned expansion to other ICUs. Secondarily, we aim to promote high-value care and leadership in health system change implementation by providing experiential learning opportunities for medical students, residents, fellows, and faculty. 

Description: Our intervention pairs trainee leadership with real-time data feedback and peer comparison. Before the project’s launch, the Committee recruited faculty and housestaff champions, held didactic sessions, and established the infrastructure necessary for data reporting and visualization in Tableau. Educational activities consisted of 15-minute presentations to clinical teams highlighting the CW campaign, the Critical Care Societies Collaborative recommendations, baseline CXR ordering rates at VUMC, and the model for project implementation. On October 5, 2015, MICU and CVICU teams began receiving weekly emails with CXR ordering rates. During the initial months of implementation, we observed rounds to better understand ICU workflow and CXR ordering practices, and we interviewed stakeholders to determine what factors facilitated or impeded initial intervention uptake. In response, we developed promotional materials, engaged additional physician and nurse practitioner champions, and garnered leadership support for incorporating CXR ordering into rounds. To calculate radiology staff time savings, we will also conduct a time motion study on the process of taking a CXR. 

Conclusions: Preliminary results of the initiative during the first two months show a decrease in CVICU CXR ordering rates (p=0.03); additional evaluation is underway. Lessons learned to date include the importance of understanding the decision-making process for test ordering, competing priorities and barriers to implementation, the value of stakeholder input and peer champions, and differences in approach with physician and nurse practitioner audiences.