Drop the Pre Op: reducing unnecessary preoperative chest X-rays

September 23, 2021

Chest x-rays are the most common imaging exam in Alberta. It is estimated that Alberta Health Services performs over 22,000 preoperative chest x-rays annually. Choosing Wisely Canada suggests that routine preoperative x-rays should not be performed on patients undergoing low-risk surgical procedures because the risks outweigh the benefits. Low-risk patients do not have the risk symptoms, or any other problems found in the physical exam or medical history. A preoperative chest x-ray would not likely change their treatment plan, but it could increase their risk of radiation exposure and cause unnecessary delays.

In support of AHS’ commitment to providing the most appropriate care for Albertans, Diagnostic Imaging and the Surgery Strategic Clinical Network have a goal to reduce the number of chest x-rays performed as part of routine surgical practices.

Health care providers have a role to play to ensure that preoperative chest x-rays are requested only when the patient’s clinical condition aligns with Choosing Wisely Canada recommendations. 

Assessment of current AHS practice indicates:

  • Chest x-ray may be included in the pre-surgical work up based on historical practice. 
  • Assumption by physicians that the x-ray is required by anesthesiology and, as such, requested in advance of the surgery out of precaution to avoid surgical delays.

AHS recommendations based on Choosing Wisely Canada 

Anesthesiology

Don’t order a baseline chest x-ray in asymptomatic patients, except as part of surgical or oncological evaluation.

While chest x-rays remain an important part of a surgeon’s evaluation before cancer or thoracic surgeries, it is better if these staging examinations are completed before committing a patient to surgery. Chest x-rays are not indicated in the routine preanesthetic assessment. In the absence of symptoms, chest x-rays yield few diagnoses and many false positives. Chest x-rays do not improve risk prediction or stratification. Chest x-rays in the preanesthetic evaluation should be reserved for patients with symptoms consistent with acute cardiopulmonary illness (dyspnea, wheeze, productive sputum, etc.).

General Surgery

Routine preoperative chest x-rays and baseline laboratory studies, such as complete blood count, metabolic panel, or coagulation studies, should not be obtained in patients undergoing low-risk surgery with no significant systemic disease (ASA I or II) and the absence of symptoms.

Obtaining routine preoperative radiological and laboratory testing offers little value to the perioperative care of asymptomatic patients undergoing low-risk surgery. Evidence suggests that abnormal results within this setting rarely affect management of or change clinical outcomes. Instead, a focused history and physical examination should be performed to identify which preoperative investigations are required. Where preoperative testing may add value is in the setting of symptomatic patients or higher risk surgery where significant blood loss and fluid shifts may be expected. A discussion with the patient, anesthesiologists, and surgical team would help guide decision-making in these circumstances.

Internal Medicine

Don’t routinely perform preoperative testing (such as chest x-rays, echocardiograms or cardiac stress tests) for patients undergoing low-risk surgeries.

Routine preoperative x-rays for low-risk surgeries result in unnecessary delays, potential distress for patients, and significant costs for the healthcare system. Numerous studies and guidelines outline a lack of evidence for benefits in routine preoperative testing (e.g., chest x-ray, echocardiogram) in low-risk surgical patients. 

Nurse Practitioner

Don’t order screening chest x-rays in asymptomatic patients.

This includes periodic health exams, pre-employment health assessments, tuberculosis screening, preoperative and preadmission screening and cancer screening. There is little evidence to indicate that patient outcomes are improved with screening in these populations. Furthermore, exposure to unnecessary radiation may exceed any potential benefits. Chest x-rays on asymptomatic patients may also result in false positive reporting, which may cause undue stress. The decision to order a chest x-ray should be considered on careful evaluation of any patient presentation indicative of respiratory disease or illness.

Medical Radiation Technology

Do not x-ray a patient without a relevant clinical history and a complete requisition in order to prevent unnecessary or redundant studies.

An accurate and comprehensive clinical history improves patient safety and reduces unnecessary repeat examinations. Medical Radiation Technologists (MRTs) are encouraged to engage patients in conversation to fill in gaps in the clinical information available. MRTs should speak with other members of the healthcare team to address any discrepancies with an imaging request.

Questions?

Please email DIClinicalAppropriateness@albertahealthservices.ca

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