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Guideline Summary
Guideline Title
ACR Appropriateness Criteria® routine chest radiographs in ICU patients.
Bibliographic Source(s)
Amorosa JK, Bramwit MP, Mohammed TL, Reddy GP, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Jeudy J, Kirsch J, MacMahon H, Ravenel JG, Saleh AG, Shah RD, Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine chest radiographs in ICU patients. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 6 p. [20 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Amorosa JK, Bramwit MP, Khan AR, Mohammed TL, Batra PV, Dyer DS, Gurney JW, Jeudy J, Kaiser L, MacMahon H, Raoof S, Vydareny KH, Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine chest radiograph. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 5 p.

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Scope

Disease/Condition(s)

Cardiopulmonary, respiratory, or other conditions for which a routine chest radiograph is recommended

Note: This guideline concerns daily routine chest radiographs in the intensive care unit (ICU) and chest radiographs following placement of endotracheal, nasogastric (orogastric), Swan-Ganz catheter, central venous pressure catheter (CVP), and chest tube insertion.

Guideline Category
Evaluation
Clinical Specialty
Cardiology
Critical Care
Internal Medicine
Pulmonary Medicine
Radiology
Thoracic Surgery
Intended Users
Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management
Guideline Objective(s)

To evaluate the appropriateness of daily routine chest radiographs in the intensive care unit (ICU) and chest radiographs following placement of endotracheal, nasogastric (orogastric), Swan-Ganz catheter, central venous pressure catheter (CVP), and chest tube insertion

Target Population

Patients in the intensive care unit (ICU) with a cardiopulmonary, respiratory, or other condition for which a routine chest radiograph is recommended

Interventions and Practices Considered

X-ray, chest, portable

  • Routine admission and/or transfer with specified indication
  • Routine monitoring
  • Routine daily
  • Following catheter or tube insertion
  • Follow-up
  • For clinical indications only
Major Outcomes Considered

Utility of routine chest radiograph in detecting significant abnormalities affecting patient management

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search Procedure

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

  1. Articles that have abstracts available and are concerned with humans.
  2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
  3. May restrict the search to Adults only or Pediatrics only.
  4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

Number of Source Documents

The total number of source documents identified as the result of the literature search is not known.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis, and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid, but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the ACR Appropriateness Criteria® Evidence Table Development document (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Description of Methods Used to Formulate the Recommendations

Modified Delphi Technique

The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate"; 4, 5, or 6 is defined as "may be appropriate"; and 7, 8, or 9 is defined as "usually appropriate." Each panel member assigns one rating for each procedure per survey round. The surveys are collected and the results are tabulated, de-identified and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.

Consensus among the panel members must be achieved to determine the final rating for each procedure. Consensus is defined as eighty percent (80%) agreement within a rating category. The final rating is determined by the median of all the ratings once consensus has been reached. Up to three rating rounds are conducted to achieve consensus.

If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

Recommendations

Major Recommendations

ACR Appropriateness Criteria®

Clinical Condition: Routine Chest Radiograph in Intensive Care Unit (ICU) Patients

Variant 1: Monitoring stable patient.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable admission and/or transfer with specified indication 9   radioactive
X-ray chest portable clinical indications only 9 Clinical worsening only. radioactive
X-ray chest portable routine monitoring 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 2: Respiratory failure. Patient receiving mechanical ventilation.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable routine daily 3 Some subgroups may benefit from a daily chest radiograph. radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 3: Compromised respiratory function. Patient with endotracheal tubes.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable after catheter/tube insertion 9   radioactive
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable follow-up 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 4: Central venous pressure catheter (CVP) insertion.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable after catheter/tube insertion 9   radioactive
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable follow-up 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 5: Cardiopulmonary compromise. Swan-Ganz catheter insertion.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable after catheter/tube insertion 9   radioactive
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable follow-up 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 6: Potential cardiopulmonary compromise. Nasogastric (NG) feeding tube insertion.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable after catheter/tube insertion 9 If physical examination is uncertain. radioactive
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable follow-up 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 7: Potential cardiopulmonary compromise. Nasogastric (NG) suction tube (nonfeeding) insertion.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable after catheter/tube insertion 9   radioactive
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable follow-up 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Variant 8: Respiratory compromise. Chest tube insertion.

Radiologic Procedure Rating Comments RRL*
X-ray chest portable after catheter/tube insertion 9   radioactive
X-ray chest portable clinical indications only 9   radioactive
X-ray chest portable follow-up 1   radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Summary of Literature Review

Portable Chest Radiographs in the Intensive Care Unit (ICU) Setting

Portable chest radiographs can be categorized as:

  1. Daily or routine chest radiographs for patient monitoring.
  2. Chest radiographs obtained after specific procedures.
  3. Chest radiographs documenting the presence or course of disease.

This narrative concerns daily routine chest radiographs in the ICU and chest radiographs following placement of endotracheal, nasogastric (orogastric), Swan-Ganz catheter, central venous pressure catheter (CVP), and chest tube insertion.

There has been emerging controversy regarding the role of routine portable chest radiographs in critically ill patients in the ICU, especially in the mechanically ventilated patient. Traditionally, routine daily chest radiographs have been done especially on these patients. This tradition has been based on data from the 1980s which showed a high incidence of new or unexpected findings.

New data have begun to confront this solidly entrenched philosophy in ICU management of patients. A meta-analysis of eight trials was performed comprising 7,078 ICU patients, half of whom received daily chest radiographs and the other half who received chest radiographs for specific clinical indication. The study examined primary endpoints such as hospital or ICU mortality, length of mechanical ventilation, hospital stay, or adverse event rate. Eliminating routine daily chest radiographs did not affect mortality, length of stay in the hospital or ICU, or ventilator days in either group.

Another group of authors performed a large multicenter prospective trial to assess the efficiency and effectiveness of routine daily versus clinically indicated (on-demand) chest radiographs for mechanically ventilated patients in the ICU over a two-period cluster randomized design. In the first period 11 ICUs were randomly allocated to use daily chest radiographs and 10 ICUs to use an on-demand strategy based on specific clinical indications. Four hundred twenty-four patients had 4,607 routine chest radiographs, and 425 patients had 3,148 chest radiographs on demand, which represents a statistically significant 32% reduction in use of chest radiographs without a reduction in patients' quality of care or safety.

Another group of researchers concluded from a cohort observational study that the timing of portable chest radiographs needs to be included in the overall management guidelines based on clinical evaluations.

Two other studies evaluated the clinically relevant use of daily routine versus nonroutine clinically indicated (on-demand) chest radiographs. A large study prospectively evaluated the clinical value of 2,457 routine chest radiographs in a combined surgical/medical intensive care unit (SICU/MICU). In this study, 5.8% of daily routine chest radiographs showed new or unexpected findings; but only 2.2% warranted a change in therapy. No difference was found between the medical and surgical patients. A randomized control study of MICU patients prospectively divided them into those who received daily routine chest radiographs and those who only received nonroutine (clinically indicated) chest radiographs. The study found a greater percentage of radiographs with significant findings (requiring intervention) in the nonroutine group (26.5%) than in the routine group (13.3%). Significant interventions included diuresis, antibiotic administration, or invasive procedures. The nonroutine group also received significantly fewer radiographs per person than the routine group (4.4 versus 6.8). There was no significant difference in outcome between the groups in length of intubation, ICU stay, hospital stay, or mortality.

Another recent prospective observational study analyzed 1,780 routine chest radiographs in 559 hospital ICU admissions. It concluded that the diagnostic and therapeutic value of routine chest radiograph is low, and the authors recommended abandoning routine chest radiographs in the ICU.

A group of authors reported the lowest rate of significant abnormal chest radiograph findings at 3% of all chest radiographs in 18% of the MICU patients. They still recommended daily routine studies on all critically ill patients. In another study, a high yield was found in MICU patients who had acute cardiopulmonary disease, but the yield was very low in patients with stable cardiac disease (usually myocardial infarction) and in ICU patients who had extrathoracic disease only.

For cardiothoracic ICU patients, two prospective nonrandomized studies showed a low incidence of significant findings on routine radiographs (4.5% in both studies) and consequently a minimal impact on patient management. The results support the recommendation to obtain chest radiographs in cardiothoracic ICU for clinical findings but not for routine follow-up.

Recommendation

Routine daily radiographs are indicated for patients with acute cardiopulmonary problems. In stable patients admitted for cardiac monitoring, or in stable patients admitted for extrathoracic disease only, an initial ICU admission radiograph is recommended; follow-up radiographs should be obtained only for specific clinical indications.

Endotracheal Tubes

There are nine studies described in the literature since 1980 that evaluate the significance of the chest radiograph in assessing endotracheal tube placement following insertion. In five of them, between 12% and 15% of patients had malpositioned endotracheal tubes, many of which required repositioning. Two studies found 28% and 46% of tubes malpositioned upon insertion, and the single dissenting paper found 2% malpositioned. Two studies compared radiographs with physical examination. In both studies, physical examination predicted malpositioned tubes in 3% of patients, whereas the radiographs showed malpositioning in 14% of patients in one study and 28% in the other. One group of researchers found that the vast majority of malpositioned tubes were discovered in the first 3 days.

Recommendation

Very few malpositioned tubes are detected by physical examination. Radiographs immediately postintubation are indicated to insure proper positioning.

CVP Catheters

Eight studies were reviewed regarding CVP catheters. The vast majority came to the same conclusion. Approximately 10% of the chest radiographs demonstrated malpositioned catheters. Pneumothoraces were present in only a small percentage of patients. One study separated jugular and subclavian catheters. Complications were twice as common with subclavian catheters (17% versus 8%), although unsuspected complications were infrequent.

Recommendation

A chest radiograph after insertion of a CVP catheter is recommended to demonstrate proper placement and detect any complications. Beyond the initial insertion, follow-up chest radiographs have a low yield for revealing complications. Follow-up chest radiographs are suggested only when complications are suspected clinically.

Swan-Ganz Catheters

Previously mentioned studies incorporated the position and potential complications of Swan-Ganz catheter placements shown on chest radiographs obtained immediately postprocedure. The majority of complications, which occur in approximately 10% of catheter insertions, are minor and require catheter repositioning. The pneumothorax rate was approximately 2%.

Recommendation

Chest radiographs are suggested after catheter insertion. Once pneumothorax has been excluded and proper positioning has been assured, follow-up radiographs are not required except for specific clinical indications.

Nasogastric Tubes

There are no large prospective studies that consider the utility of obtaining a chest radiograph immediately after the insertion of a nasogastric suction tube or a small-bore feeding tube. Chest radiographs revealed important tube malpositioning in 1% of cases. Clearly, a patient with a functioning nasogastric tube that has already been documented to be in satisfactory position needs no imaging unless a clinical problem arises.

Recommendation

Based on limited evidence, small-bore feeding tubes may, in a small but significant number of patients, be inadvertently placed in the lungs. This error is not always detected clinically and may lead to injection of feeding material into the lung or tube penetration of the pleura, with subsequent pneumothorax. A chest radiograph is warranted after initial nasogastric tube insertion and before the first feeding. Beyond the initial chest radiograph, follow-up chest radiographs are not required for managing stable tubes.

Chest Tubes

Few studies have been performed to evaluate the efficacy of the initial chest radiograph after the insertion of a chest tube. The three available studies show that approximately 10% of tubes are malpositioned. Many of the radiographic abnormalities detected are minor and do not result in changes of tube positions.

Recommendation

After insertion of a chest tube, a chest radiograph is recommended to show the position of the tube, any success in drainage, and possible complications from insertion. Beyond this point, evaluation of tube position and function is warranted based on management of the pleural space and clinical indications.

Summary

  • Placement of endotracheal or nasogastric (orogastric) tubes, Swan-Ganz catheters, central venous pressure catheters, or any other life support item is an indication for a chest radiograph.
  • Change in the clinical condition of the patient is an indication for a chest radiograph.
  • Routine daily chest radiograph in the ICU is not indicated.

Relative Radiation Level Designations

Relative Radiation Level* Adult Effective Dose Estimate Range Pediatric Effective Dose Estimate Range
O 0 mSv 0 mSv
radioactive <0.1 mSv <0.03 mSv
radioactive radioactive 0.1-1 mSv 0.03-0.3 mSv
radioactive radioactive radioactive 1-10 mSv 0.3-3 mSv
radioactive radioactive radioactive radioactive 10-30 mSv 3-10 mSv
radioactive radioactive radioactive radioactive radioactive 30-100 mSv 10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as NS (not specified).
Clinical Algorithm(s)

Algorithms were not developed from criteria guidelines.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations are based on analysis of the current literature and expert panel consensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of routine chest radiographs for patient monitoring, evaluation after specific procedures, and documentation of the presence or course of a disease

Potential Harms

Relative Radiation Level (RRL)

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see the "Availability of Companion Documents" field).

Qualifying Statements

Qualifying Statements

The American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Amorosa JK, Bramwit MP, Mohammed TL, Reddy GP, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Jeudy J, Kirsch J, MacMahon H, Ravenel JG, Saleh AG, Shah RD, Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine chest radiographs in ICU patients. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 6 p. [20 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1995 (revised 2011)
Guideline Developer(s)
American College of Radiology - Medical Specialty Society
Source(s) of Funding

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Guideline Committee

Committee on Appropriateness Criteria, Expert Panel on Thoracic Imaging

Composition of Group That Authored the Guideline

Panel Members: Judith K. Amorosa, MD (Principal Author); Mark Paul Bramwit, MD (Research Author); Tan-Lucien H. Mohammed, MD (Panel Chair); Gautham P. Reddy, MD, MPH (Panel Vice-chair); Kathleen Brown, MD; Debra Sue Dyer, MD; Mark E. Ginsburg, MD; Darel E. Heitkamp, MD; Jean Jeudy, MD; Jacobo Kirsch, MD; Heber MacMahon, MB, BCh; James G. Ravenel, MD; Anthony G. Saleh, MD; Rakesh D. Shah, MD

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Amorosa JK, Bramwit MP, Khan AR, Mohammed TL, Batra PV, Dyer DS, Gurney JW, Jeudy J, Kaiser L, MacMahon H, Raoof S, Vydareny KH, Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine chest radiograph. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 5 p.

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site External Web Site Policy.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

Availability of Companion Documents

The following are available:

  • ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Evidence table development – diagnostic studies. Reston (VA): American College of Radiology; 2013 Nov. 3 p. Electronic copies: Available in PDF from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on May 10, 2007. This NGC summary was updated by ECRI Institute on June 1, 2010. This NGC summary was updated by ECRI Institute on February 29, 2012.

Copyright Statement

Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site External Web Site Policy.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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