Improving Imaging Appropriateness in the Emergency Department: Radiology Clinical Decision Support in a Quaternary Care Centre-A Retrospective Observational Study.

Abstract

Background: High volumes of low-value imaging represent a growing challenge for healthcare systems, contributing to unnecessary radiation exposure, increased costs, clinician burnout and environmental impact through CO2 emissions. Electronic Clinical Decision Support (eCDS) systems have emerged as a strategy to improve imaging appropriateness and reduce overutilisation. Method(s): This retrospective observational study with pre- and post-implementation analysis evaluated the impact of an eCDS system (MedCurrent OrderWise) implemented in the emergency department (ED) of a quaternary hospital in Australia. Data were collected from 1 July 2024 to 30 June 2025 via the hospital data warehouse and vendor software administration application. Metrics included imaging request volumes, appropriateness scores (high, medium, low), order modifications and CT utilisation rates (examinations per 100 ED presentations). Analysis was descriptive, using absolute counts, percentages and rates. Result(s): Across the 12-month period, 75.3% of imaging requests were classified as high or medium appropriateness, indicating broad adherence to guidelines. Approximately 7% of orders were modified following eCDS prompts, reflecting meaningful improvements in appropriateness within a high-volume ED setting. CT utilisation decreased by 9.1% compared with the pre-eCDS period, suggesting a shift towards more selective imaging requests without restricting clinical autonomy. Educational engagement preceding implementation likely contributed to early reductions. Applying published emission estimates, this decline equated to an approximate reduction of 4744 kg of CO2 over 12 months. Conclusion(s): Integration of eCDS into clinical workflows was associated with improved imaging appropriateness, reduced low-value CT utilisation and potential environmental benefit. Sustained impact likely depends on clinician engagement, education and broader cultural change.Copyright © 2026 The Author(s). Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.