Emergency Physicians Cut More Than 3,500 Unnecessary CT Scans Without Missing a Single Injury

Every year, millions of patients arrive at emergency departments across the United States with head and neck injuries, and a large share of them undergo computed tomography scans to rule out serious damage. Many of those scans, however, are performed on patients whose clinical profiles indicate a very low probability of dangerous findings. Physician-researchers at the University of Cincinnati have now demonstrated that a sustained, systematically designed quality improvement campaign can dramatically reduce this unnecessary imaging, and their results offer one of the clearest real-world demonstrations yet that evidence-based decision rules can transform practice even under the intense pressure of a high-volume trauma center.

The study, published in the Western Journal of Emergency Medicine, was led by co-senior authors David Thompson, MD, an associate professor of clinical emergency medicine and director of quality improvement and patient safety in the UC College of Medicine’s Department of Emergency Medicine, and Anita Goel, MD, also an associate professor of clinical emergency medicine. Over a 23-month campaign spanning the emergency departments of University of Cincinnati Medical Center and West Chester Hospital, the team tracked what happened when clinicians were given the training, tools and encouragement to apply validated clinical decision rules before ordering head and cervical spine CT scans in low-risk trauma patients. The outcome was striking: an estimated 3,542 CT scans were avoided, roughly $6.2 million in patient healthcare charges were saved, and more than 14,000 hours of cumulative patient waiting time were eliminated, all with no identifiable patient harm.

The technical foundation of the campaign rested on clinical decision rules that have become core components of emergency medicine training and standards of care nationwide. These rules, which guide clinicians in determining which head or neck trauma patients genuinely need cross-sectional imaging, incorporate carefully weighted risk indicators. Patients who fall from height, are ejected from motor vehicles, experience limb weakness or numbness, present with blood in the ear, vomit after the injury or show signs of confusion are considered high risk and proceed to imaging. Patients without such red flags, including many with concussions, are classified as low risk, and in those cases the rules support withholding the CT scan and monitoring the patient instead. The rationale is grounded in both radiation biology and health economics: each head or cervical spine CT delivers a meaningful ionizing radiation dose to tissues that are inherently radiosensitive, and the diagnostic yield in truly low-risk populations is exceptionally low.

The numbers quantify just how much low-value imaging was being avoided. At an estimated cost of approximately $1,750 per scan, the 3,542 avoided CT examinations translated into $6.2 million in patient charges that were never incurred. At an average of about four hours of waiting per scan, the campaign spared patients a cumulative 14,168 hours of time spent in the emergency department. Perhaps most striking from a radiation safety perspective, the avoided scans eliminated an estimated 6,021.4 millisieverts of collective radiation dose, a figure the researchers note corresponds to roughly 2,000 years of typical natural background radiation exposure for a single person. In an era when medical imaging accounts for a substantial fraction of the population’s cumulative exposure to ionizing radiation, reductions of this magnitude carry genuine public health significance.

Crucially, the campaign’s safety review found no downside. When the team examined their data at the conclusion of the intervention period, they identified zero missed injuries, meaning every avoided scan had indeed been medically unnecessary and no patient had been sent home with an undetected serious head or spinal injury. This finding addresses the central concern that has historically slowed the adoption of imaging-reduction programs: the fear that trimming CT utilization will inevitably let dangerous pathology slip through. Thompson emphasized that the guidelines, when followed, reliably protect against missed serious injuries, and the campaign’s own outcome data provided direct, institution-level confirmation of that claim across two busy emergency departments.

The intervention itself was deliberately multifaceted, reflecting modern implementation science rather than a single blunt policy. Continuing education sessions were delivered to emergency medicine providers, reinforcing the decision rules and the research evidence behind them so that clinicians understood not just what to do but why. Simultaneously, the CT decision rules were embedded directly into the electronic health record used to order patient testing, so that the point of ordering became a structured prompt for appropriate test selection. This combination of provider education and clinical decision support embedded in the workflow is widely regarded as the most durable way to change ordering behavior, because it reduces reliance on individual memory or judgment at moments of time pressure and standardizes the application of evidence across the entire provider pool.

The campaign also extended its educational efforts to patients, recognizing that a significant fraction of unnecessary imaging is driven not by clinician uncertainty but by patient expectation. Some injured patients arrive convinced that a CT scan is required, even after a physician has determined that their risk profile does not warrant one. To address this, the team created informational handouts designed to reassure patients that declining a scan in their situation reflects careful, evidence-based medicine rather than corner-cutting. As Thompson explained, not everyone with a head or neck injury needs a CT scan; some do and some do not, and the department’s goal is to provide the right care for every patient using the tools available to make those distinctions accurately.

The setting in which these results were achieved amplifies their importance. University of Cincinnati Medical Center is the Greater Cincinnati region’s only academic medical center and its only Level I adult trauma center, functioning as a major tertiary referral hub with an 81-bed emergency department that Thompson described as almost always at capacity. West Chester Hospital adds further patient volume to the health system’s emergency care footprint. Demonstrating that imaging reduction can be achieved in such a demanding, high-acuity environment undercuts a common objection, namely that evidence-based imaging restraint works only in smaller or calmer settings. The UC experience suggests the opposite: precisely because high-volume departments face the greatest pressures of throughput, cost and radiation burden, they may have the most to gain from rigorously applied decision support.

By the end of the 23-month period, all measured outcome indicators showed reductions in the rate of head and cervical spine CT scanning at both participating hospitals, and the absence of any identified missed injuries confirmed that the avoided imaging was truly discretionary. The research team, which included co-first authors Jude C. Luke, an emergency medicine resident physician, and Rebecca N. Kubick, a medical student, alongside biostatistician Heidi J. Sucharew, Natalie E. Kreitzer, and performance improvement specialists Kayla Winkler and Mary L. Giles, framed the project as a win for both physicians and patients. Doctors retain the reassurance that validated rules protect against missed injuries, while patients receive faster care, smaller bills and less radiation. If replicated at scale, the model offers a template for how emergency departments everywhere can convert well-established clinical decision rules from guidelines on paper into measurable reductions in low-value care.

Subject of Research: A quality improvement campaign reducing head and cervical spine CT imaging in low-risk trauma patients

Article Title: University of Cincinnati emergency medicine physicians safely eliminate thousands of unnecessary CT scans

Article References: University of Cincinnati emergency medicine physicians safely eliminate thousands of unnecessary CT scans. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: emergency medicine, CT scans, quality improvement, clinical decision rules, trauma, radiation exposure, healthcare costs, University of Cincinnati, patient safety, low-value care, electronic health records, concussion