Omission of Routine Chest X-Rays After Chest Tube Removal is Safe and Feasible After Thoracic Surgery: A Single Institution Quality Improvement Initiative

Introduction: Postpull chest x-rays (CXRs) are routinely performed following chest tube (CT) removal in thoracic surgery patients even in the absence of clinical concern, but their clinical use and cost-effectiveness have been questioned. Methods: This is a retrospective, quality improvement study that compared clinical outcomes and cost between thoracic surgery patients who underwent routine postpull CXRs (preintervention group) versus selective CXRs (postintervention group) following CT removal. Results: A total of 569 patients were included in the analysis. The preintervention and postintervention group included 433 and 136 patients, respectively, with comparable characteristics and surgical approach. Postpull CXRs were significantly reduced (preintervention versus postintervention; 87.3% versus 5.9%, P ≤ 0.001) without a statistical difference in incidence of CXR abnormalities (33.1% versus 12.5%, P = 0.28). Clinical symptoms after CT removal were comparable between the two groups (3.7% versus 3.7%, P = 1.00). Within 2 wk, CT replacement (3.0% versus 0.7%, P = 0.21) and readmission (9.0% versus 8.1%, P = 0.71) rates were not significantly different. Fewer postintervention patients underwent routine CXR at 2-wk follow-up visit (75.3% versus 17.6%, P ≤ 0.001). The total cost per patient in the preintervention group was $783.18 whereas the postintervention group was $90.35 resulting in an 8.7-fold decrease. Conclusions: Omission of routine CXRs after CT removal in asymptomatic thoracic surgery patients did not impact clinical outcomes while also significantly reducing cost. A selective approach to imaging based on clinical symptoms is safe and feasible.