Close
Enter your
text here

Improving Neonatal X-Ray Quality Through Standardization

Improving Neonatal X-Ray Quality Through Standardization 1024 683 Pam Georgiana
Baby in a NICU bed with nasal canula. Swaddled in white blanket with health care worker's hand gently resting on the baby.

Pre-X-ray Safety CHECK reduces repeat imaging, radiation exposure and diagnostic variability in the NICU.

Portable radiographs are necessary for diagnosing disease and evaluating position of medical devices in neonatal intensive care units (NICUs). However, repeat imaging due to poor-quality radiographs exposes vulnerable infants to additional radiation and unnecessary handling, disrupting their environment and potentially compromising developmental care.

“Neonates are particularly vulnerable to radiation exposure because their tissues are rapidly growing and developing,” Roopali V. Bapat, MD, MSHQS, neonatologist and director of Quality Improvement for the Neonatal Network at Nationwide Children’s, explains. “Every repeat film adds to a lifetime cumulative exposure. Our goal was to create a reliable and consistent approach that improved diagnostic quality and supported frontline staff.”

A new quality improvement project led by researchers at Nationwide Children’s and published in Pediatric Quality & Safety demonstrates that a simple, standardized pre-X-ray process can boost diagnostic film quality and reduce the need for repeat imaging.

“The project began because I noticed more and more films that were difficult to interpret for various reasons. Either the baby was not lying flat, the X-ray beam was not positioned correctly or equipment obscured the image,” Debra L. Armbruster, PhD, APRN-CNP, nurse practitioner in Neonatology at Nationwide Children’s, adds. “Over time, turnover and variations in training meant that staff were not using the same techniques for positioning infants during X-rays.”

The project evaluated whether a standardized Safety CHECK process would increase the frequency of high-quality neonatal radiographs by 15%. The team defined a high-quality radiograph as one with no infant rotation, flat positioning, no visual artifacts and accurate collimation of the X-ray beam.

They examined radiographs in three groups: all chest, abdominal and baby gram films; films of infants with a peripherally inserted central catheter (PICC); and films of infants with an endotracheal tube (ETT). Some X-rays were included in multiple groups.

Positioning inconsistencies were particularly problematic for infants with PICCs and endotracheal tubes. In these instances, even small changes in positioning can affect image interpretation and assessment of device placement.

The multidisciplinary team implemented three sequential interventions: a Safety CHECK pre-X-ray process, increased provider presence during imaging procedures and simulation-based staff education. The checklist was reinforced through staff meetings, visual reminders and documentation tools. Project leaders were frequently present during imaging procedures to offer support and answer questions in real time.

“Having champions at the bedside made a significant difference,” Dr. Armbruster says. “When nurses, physicians, respiratory therapists and radiology staff worked toward the same goal, it built buy-in and helped the changes become part of everyday workflows.”

The team evaluated 2,067 radiographs, including 1,461 unique films. The percentage of high-quality radiographs increased from 19% to 65% across all films. Improvements were even greater in the device-specific groups, increasing from 2% to 81% in the PICC group and from 1% to 74% in the ETT group.

To determine whether the improvements would persist, the research team evaluated outcomes across Baseline, Intervention and Sustain periods. They discontinued active interventions three months before the Sustain period.

“A key challenge in quality improvement is distinguishing temporary gains from true practice change,” Dr. Bapat says. “By evaluating Baseline, Intervention and Sustain periods, we demonstrated that the improvements had become part of routine care.”

Both investigators credit frontline staff engagement as one of the central drivers of success.

“Empowering bedside nurses and providing positive feedback were essential,” Dr. Armbruster says. “When staff saw how these changes benefited patients, they became active partners in the improvement process.”

Dr. Bapat adds, “This project wasn’t just about a checklist. It was about creating a culture where everyone pauses to ensure we obtain the best possible image the first time. Those few seconds, can prevent additional radiation exposure and improve the reliability of care for our most vulnerable patients.”

Several years later, the Safety CHECK process remains in use and may serve as a model for other NICUs looking to reduce unnecessary radiation exposure while improving diagnostic quality.

Reference:

Armbruster D, Barcroft M, Stenger M, Alvarado C, Bapat R. Implementation of a Pre-X-Ray Safety CHECK in Neonates. Pediatric Quality & Safety. 2025;10(6):e860. Published 2025 Dec 23. doi:10.1097/pq9.0000000000000860

About the author

Pam Georgiana is a brand marketing professional and writer located in Bexley, Ohio. She believes that words bind us together as humans and that the best stories remind us of our humanity. She specialized in telling engaging stories for healthcare, B2B services, and nonprofits using classic storytelling techniques. Pam has earned an MBA in Marketing from Capital University in Columbus, Ohio.

You might also like