From order to image: reducing CT order to exam start time through targeted quality improvement in the ED.

PURPOSE: Our Emergency Department (ED), like many others in the US, experiences chronic congestion, slow flow, and long wait times - all of which have notably worsened in recent years. For many of our patients, computed tomography (CT) turnaround time is a key determinant of ED flow, yet strategies to reduce preacquisition delays remain under-described. Our objective was to reduce CT order-to-exam start time by 25% through iterative quality improvement (QI) workflow interventions. METHODS: This single-center QI study was conducted in the adult ED of a metropolitan academic hospital from January 2024 through March 2026 using the Plan-Do-Study-Act (PDSA) framework. A one-year baseline preceded four PDSA cycles targeting different aspects of the process. The primary outcome was median CT order-to-exam start time. RESULTS: This study included 30,865 patients. Median CT order-to-exam start time decreased from 59 to 46 min, a 22% reduction (p < 0.001). ED arrival-to-disposition order time decreased from 335 to 315 min (p < 0.001). Median daily CT volume increased from 43 to 46 exams (p < 0.001), with no significant change in new hemodialysis diagnoses (0.0% vs. 0.1%, p = 0.30) or post-CT acute kidney injury (3.0% vs. 2.8%, p = 0.42). CONCLUSION: Four sequential, low-cost workflow interventions addressing pre-imaging laboratory practices and real-time CT readiness signaling significantly reduced CT order-to-exam start time in an academic ED. Meaningful improvements were achieved by redesigning preacquisition workflows and creating visible escalation structures. These practical strategies may help other institutions shorten the time to imaging and support timely disposition.