How to Reduce Diagnostic Imaging in Emergency Departments

Executive Summary

Between 30-50% of the diagnostic imaging tests that are done every year are considered medically unnecessary. In the Emergency Department (ED), unnecessary testing not only exposes patients to dangerous radiation but also leads to longer wait times and higher costs. The use of clinical decision rules, computerized decision support, and point-of-care ultrasound are a few successful solutions that can be implemented.

We are interested in generating some discussion on this topic in our Fiscal Efficiency Community. Please visit this space to join the conversation.

Underlying Causes

There are many potential reasons that diagnostic imaging tests are overused. ED physicians work in a high-stress environment where clinical information is often unclear or missing. They may order tests for fear of litigation, fear of missing an important diagnosis, lack of evidence on appropriate ordering, or poor knowledge translation when good evidence exists. In a recent study, over 85% of ED physicians agreed that their patients received too much testing.

Improvement Strategies

Clinical Decision Rules

Use validated CDRs to help ED physicians make evidence-based decisions about when to order imaging tests. Some examples of well-developed and widely-used CDRs include the Canadian CT Head Rule and the Ottawa Ankle Rules. These algorithms have been shown to reduce the use of unnecessary testing, but implementation and knowledge translation remain a challenge.

Computerized Decision Support (CDS)

Influence provider decision-making at the point-of-care using computerized decision support. CDS involves using evidence-based algorithms that are integrated with a provider’s EMR to guide appropriate ordering of diagnostic tests. A large Boston-area ED was able to decrease the number of CT scans for pulmonary emboli by 20% by implementing a CDS intervention3. This intervention is most successful when healthcare providers use "Computerized Provider Order Entry" (CPOE), which has been slowly spreading across hospitals worldwide.  

Point-of-Care Ultrasound (POCUS)

Train ED physicians in POCUS and use it diagnostically at the bedside instead of ordering more expensive or time-consuming tests. Ultrasound technology is often preferred over X-Ray and CT due to the lack of radiation. More ED trainees and physicians are becoming familiar with the use of POCUS, but it is still not used everywhere. There is potential that increased training and comfort with this technology will lead to more confident bedside diagnoses, and reduce the need for more expensive or resource-intensive imaging.  

Future Directions

Although there have been some successful solutions, the number of imaging tests being done in our EDs continues to increase - from 5% of all ED visits in 2000 to 17% of all ED visits in 20104. The Society for Academic Emergency Medicine (SAEM) held a consensus conference in 2015 on optimizing diagnostic imaging in the ED, providing a framework to test and implement new solutions. 

Related Articles: