Computed tomography in the emergency department
Archived June 2020
Patients across the United States are exposed to excessive radiation levels due to multiple, and often unnecessary, medical tests. Overuse of radiation from computed tomography (CT) is projected to contribute to 29,000 future cases of cancer in the United States.
CT imaging of the head, neck, chest, abdomen and pelvis have led to significant improvements in the diagnosis of disease and injury. The value of CT scanning to diagnose injury, cancer and other health problems is undisputed. However, a national study of CT utilization in United States emergency departments (ED) demonstrates significant growth in CT use.
In 1995, 2.8 percent of ED patients received a CT scan during the course of an ED visit. In 2007, this increased to 13.9 percent. This represents an approximate six-fold increase in CT utilization with an annual growth rate of 14.2 percent (Radiology. 258(1):164-173, 2011 Jan).
Additionally, emergency department physicians are generally unaware of the risk of radiation exposure from CT scans. A 2012 study demonstrated that fewer than 30 percent of ED physicians possess accurate knowledge of the lifetime cancer risk attributable to radiation (Am J Roentgenol. 199(6):1328-36, 2012 Dec.).
In 2010, the Food and Drug Administration (FDA) announced an initiative to reduce unnecessary radiation exposure from medical imaging. Studies suggest that 30 to 50 percent of medical imaging examinations are not medically necessary (Radiology, 257(1):240-245, 2010 Oct). The FDA initiative includes a recommendation that organizations utilize multiple strategies to promote the appropriate use of medical imaging.
The American College of Emergency Department Physicians and the American College of Radiologists have both published detailed evidence-based guidelines that direct appropriate utilization of various imaging and diagnostic modalities. Awareness, education and quality improvement activities in Arkansas EDs can promote appropriate utilization of CT imaging and reduce unnecessary radiation exposure and the associated risks.
Doctors need to be aware of the radiation levels in the imaging tests they perform and of how many previous CT tests the patient has already had. Patients should keep track of their own radiation levels and keep a personal record of any CT tests or other radiation-heavy tests they have taken.
By being aware of radiation levels in medical exams and asking patients about their exam history, doctors can take the first step in protecting their patients from unnecessary radiation exposure
Remember: Radiation dose is cumulative. Significant radiation doses to children and young adults are associated with increased lifetime risk of cancer.
Strategies for success
Reducing radiation exposure during CT (children)
- Develop pediatric-specific protocols for imaging with a focus on minimal dose necessary to obtain a quality image.
- Image with radiation only when medically necessary. When ordered appropriately, the risk to benefit medical imaging is excellent. Use alternative modalities (ultrasound or MRI) when appropriate.
- Scan only the affected region. Develop protocols for follow-up examinations (e.g., follow-up of an incidental lung nodule does not require a full chest CT).
- Scan once only. Multiphase scans are rarely indicated in children.
Involve clinical staff in quality improvement initiatives relative to ordering of medical imaging studies. - Arkansas Children’s Hospital has developed pediatric-specific imaging protocols. For information about these, you may call and speak with a Pediatric CT Technologist / Radiology Technologist at 501-364-1308.
Reducing radiation exposure during CT (adults)
- Utilize guidelines-based care when making a decision to undertake a medical diagnostic examination that involves medical imaging.
- Avoid unnecessary repetition of examinations in patients who have been previously imaged, in your organization or another organization.
- Routinely question patients about other workups that they have completed at other institutions.
- Involve clinical staff in quality improvement initiatives relative to ordering of medical imaging studies.
Improve systems
- Follow Meaningful Use Stage 2
- Adhere to Joint Commission CT Imaging Standards
Educate staff
- Educate emergency department staff:
- Specific imaging protocols for pediatric/adults
- Radiation exposure awareness
- “As low as reasonably achievable” a statement by the American College of Radiology
- The patient’s rights and the five “rights” of imaging
- Routinely check medical records for previous imaging studies
- Routinely questions patients about other imaging workups
- REMEMBER: Radiation dose is cumulative. Significant radiation doses to children and young adults are associated with increased lifetime risk of cancer.
Educate patients
- Provide patient educational materials
- Utilize teach back
- Educate patients/parents/ caregivers on importance of providing imaging history
Web resources
Computed Tomography (CT) imaging of the head, neck, chest, abdomen and pelvis have led to significant improvements in the diagnosis of disease and injury. The value of CT scanning to diagnose injury, cancer and other health problems is undisputed. However, a national study of CT utilization in United States Emergency Departments (ED) demonstrates significant growth in CT use. In 1995, 2.8% of ED patients received a CT scan during the course of an ED visit. In 2007, this increased to 13.9 %. This represents an approximate 6-fold increase in CT utilization with an annual growth rate of 14.2%. (Radiology. 258(1):164-173, 2011 Jan). Additionally, Emergency department physicians are generally unaware of the risk of radiation exposure from CT scans. A 2012 study demonstrated that fewer than 30% of ED physicians possess accurate knowledge of the lifetime cancer risk attributable to radiation (Am J Roentgenol. 199(6):1328-36, 2012 Dec.).
Provider resources
FDA – U.S. Food and Drug Administration
- What are the Radiation Risks from CT?
- Pediatric X-ray Imaging
- FDA Seeks Reduction in Radiation from Medical Scans
Joint Commission
Revised requirements for diagnostic imaging services:
- jointcommission.org/assets/1/6/JCP0514_New_Hospital_Req_CMS.pdf
- jointcommission.org/assets/1/18/JCP0114_Diag_Imaging_Svcs.pdf
- jointcommission.org/prepublication_diagnostic_imaging_services_requirements/default.aspx
AAPM computed tomography radiation does education slides
American College of Radiology (ACR)
Computed tomography (CT) guidelines
ACR Practice Guidelines for Performing and Interpreting Diagnostic Computed Tomography:
- acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Performing_Interpreting.pdf
- acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Pediatric.pdf
American College of radiology computed tomography guidelines
American College of Emergency Medicine
Acute abdominal pain CT or US?
CT use in the ED soared in past decade
Imaging exposes many to worrisome doses of radiation
Alarming number of CTs ordered in some patients
Management of suspected appendicitis
US emergency physicians order too many computed tomography scans—or do they?
Emergency department computed tomography utilization in the United States and Canada
Additional articles and resources
Heavy use of CT scans raises concerns about patients’ exposure to radiation – Kaiser Health News
Most parents underestimate potential risk of CT scans
Imaging patients with acute abdominal pain
The American Association of Physicists in Medicine – 6/7/2012.
Recent issue of Scientific American examines CT scans and risk of cancer
The July 2013 issue of Scientific American examines research methodology to predict future cancer risk associated with CT scans. – 7/9/2013
PowerPoint for pediatric radiation
Resources/articles/case studies
Radiation protection and dose monitoring/ Lippincott Williams & Wilkins
Information on diagnostic imaging
Radiation risks and pediatric computed tomography (CT): A Guide for Health Care Providers
EMPRACTICE improving care through evidence (GUIDELINES SUBSCRIPTION)
Safety issues in pediatric imaging
Patient resources
Image wisely – radiation safety awareness for adults diagnostic imaging
Image gently- The Alliance for Radiation Safety in Pediatric Imaging
Study examines parental understanding of potential CT risk
A recent study in Pediatrics found that half of parents are aware of the potential increase in future cancer risk associated with pediatric CT scans. – 7/8/2013