Audit of requests for preoperative chest radiography

BMJ 1994; 309 doi: (Published 24 September 1994) Cite this as: BMJ 1994;309:772
  1. D Walker,
  2. P Williams,
  3. J Tawn
  1. Department of Radiology, Royal Bournemouth General Hospital, Bournemouth BH7 7DW.
  • Accepted 20 May 1994

Requests at our hospital for preoperative chest radiography were increasing but radiology staff did not know whether the increase was related to a change in workload or in clinical practice. We determined the rate of requests for preoperative radiography in patients undergoing elective surgery and the impact of such an investigation on subsequent clinical management.

Methods and results

From 12 to 26 June 1992 we audited all admissions in all specialities of patients due to have elective surgery. We put preoperative chest radiographs in labelled envelopes, which were then sealed with staples; these envelopes were put in radiography packets, which the patients took back to the ward. The packets were returned to the radiology department after the patients had been discharged. If the staples on an envelope had been removed we concluded that the radiograph had been reviewed.

We disseminated the results of this study at departmental audit meetings in surgery, anaesthetics, and radiology. After discussion among staff, revised guidelines, based on advice from the Royal College of Radiologists,1 were issued to doctors and displayed on all surgical wards (box). Radiology staff were encouraged to challenge apparently inappropriate requests. We then assessed the rate of requests for preoperative chest radiography from 21 June to 2 July 1993.

Guidelines for preoperative chest radiography

The Royal College of Radiologist's guidelines for preoperative chest radiography among patients admitted for elective non - cardiopulmonary surgery state that routine chest radiography is no longer justified. This investigation may be clinically desirable, however, in certain patients in the following categories:

  • Those with acute respiratory symptoms

  • Those with possible metastases

  • Those with suspected or established cardiorespiratory disease who have not had chest radiography in the past 12 months

  • Recent immigrants from countries where tuberculosis is still endemic and who have not had chest radiography in the past 12 months

Preoperative chest radiography will also be performed in the following categories of patients:

  • Those with a recent history of chest trauma

  • Those whose operation may involve a thoracotomy

  • Heavy smokers who have not had chest radiography in the past 12 months

  • Patients not included in the above categories if the request is made by the appropriate anaesthetist

It should be noted that none of the above categories of request is routine, and therefore the reasons for chest radiography should always be stated on the request card.

The overall rate of requests for preoperative chest radiography fell from 24% (102/430) in 1992 to 7% (54/725) in 1993. The 1992 request rate from the urology department (44% (38/86)) was the highest of all the specialties and fell the most, to 2% (4/169). The request rate from the general or vascular surgery department fell from 32% (49/154) to 11% (23/213), but the rates from the gynaecology and orthopaedics departments changed little (6% (5/90) and 10% (10/100) respectively in 1992; 8% (8/104) and 9% (17/182) respectively in 1993). The request rate from the opthalmology department, transferred to this hospital after June 1992, was 4% (2/57).

In 1992, 77 of the 102 (75%) radiography packets were returned to the radiology department with the staples intact on the envelopes holding the radiographs. These radiographs could not therefore have been reviewed. We assumed that the remaining 25 (25%) radiographs had been reviewed preoperatively; the rate of opened envelopes ranged from 0% (0/5) for the gynaecology department to 40% (4/10) for the orthopaedics department. In 1993 the number of preoperative chest radiographs performed was too low (five a day) for us to repeat reliably the study of the proportion of opened envelopes.


Increasing emphasis on the efficient use of inpatient beds has resulted in a rise in day case surgery and has reduced length of admission for elective procedures. House officers overinvestigate patients before surgery, particularly with respect to chest radiography.2 In our 1992 audit all requests for radiography from the orthopaedics and gynaecology departments were made by senior house officers and those from urology and general or vascular surgery departments by preregistration house officers. The higher request rates for urology and general or vascular surgery (44% and 32% respectively) compared with those for orthopaedics and gynaecology (10% and 6% respectively) suggest that inexperience or inadequate supervision may influence the degree of investigation.

A 1979 study of elective surgical patients found that the rate of requests for preoperative chest radiography at eight hospitals ranged from 12% to 54% (mean 30%), with wide variation among specialties (from 47% in general surgery to 13% in gynaecology).3 Our 1992 findings were similar.

It is surprising that at least 75% of radiographs during the 1992 audit were not examined despite being available on the wards and in theatre. These radiographic investigations did not benefit patients. Radiology staff enforced the guidelines that were issued to other staff in September 1992 and also rejected request cards on which the only information provided was “pre-op.” The rate of requests for preoperative chest radiography fell from 24% to 7% which represents an annual reducation of nearly 3500 examinations. We can monitor the rate of preoperative chest radiography easily, using computers both in the radiology department and in the operating theatres; we intend to keep the rate at or below 7%.

We thank our radiography and clerical colleagues for their essential contribution.


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