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. 2025 Jan-Dec:54:19160216251336681.
doi: 10.1177/19160216251336681. Epub 2025 May 20.

Reducing Unnecessary X-Rays for Nasal Fractures: A Quality Improvement Project

Jess Rhee  1 , Danielle Kelton  2 , Sheena Belisle  3 , Agnieszka Dzioba  1 , Leigh Sowerby  1 , Andrew Simpson  4 , Julie E Strychowsky  1
Affiliations

Reducing Unnecessary X-Rays for Nasal Fractures: A Quality Improvement Project

Jess Rhee et al. J Otolaryngol Head Neck Surg. 2025 Jan-Dec.

Abstract

BackgroundChoosing Wisely Canada recommends against the use of nasal bone X-rays for the evaluation of nasal fractures. The goal of this quality improvement project was to reduce the number of nasal bone X-rays ordered at our institution by 50% by 1 year.MethodsThe Institute for Healthcare Improvement Model for Improvement was used, and a pre- and post-intervention study was conducted. Change ideas included the following: a clinical decision support tool, provider surveys, and education. The number of X-rays ordered monthly was monitored. Financial cost (labor, materials, and overhead) was assessed. Environmental impact was extrapolated based on carbon dioxide equivalent emissions (CO2e). Balancing measures included the use of computed tomography (CT) scans. Analysis included summary statistics, statistical process control charting, and unpaired t-tests.ResultsThere was a 73% reduction in total X-rays ordered from 197 pre-intervention (September 2021-November 2022) to 58 post-intervention (December 2022-February 2024). There was a statistically-significant decrease in difference of means of 2.6 X-rays/month (4.9 vs 2.3, pre vs post; P < .001), an average monthly reduction of 53%. There was special cause variation after implementation. Cost savings was $5534.98, and environmental footprint reduction was 111.2 kg of CO2e. There was no compensatory increase in the number of CT scans ordered.ConclusionImplementation of a clinical decision support tool and education resulted in a significant reduction in the number of nasal bone X-rays ordered for the evaluation of nasal fractures. This Choosing Wisely Canada project ultimately reduces unnecessary investigations for patients, saves health care costs, and reduces environmental impact.

Keywords: choosing wisely medical education; clinical practice guidelines; clinical research; comprehensive otolaryngology; evidence-based medicine; health policy; quality improvement.

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Conflict of interest statement

Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Graphical Abstract
Graphical Abstract
Figure 1.
Figure 1.
Fishbone diagram.
Figure 2.
Figure 2.
Driver diagram.
Figure 3.
Figure 3.
Educational infographic.
Figure 4.
Figure 4.
Clinical decision support tool.
Figure 5.
Figure 5.
Timeline of change ideas and PDSA cycles.
Figure 6.
Figure 6.
Initial survey results to emergency department physicians in adult and pediatric departments at LHSC.
Figure 7.
Figure 7.
T-test analysis of nasal bone X-rays ordered from December 2021 to September 2022 compared with those from December 2022 to September 2023.
Figure 8.
Figure 8.
Pre- and post-intervention analysis between September 2021 and April 2024.
Figure 9.
Figure 9.
Final survey results to emergency department physicians in adult and pediatric departments at LHSC 1 year after the implementation of change ideas.
Figure 10.
Figure 10.
Balancing measures of facial/head CT scans ordered from September 2021 to April 2024.
See this image and copyright information in PMC

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References

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