Breaking the bottleneck: a quality improvement initiative to reduce overnight CT turnaround times in the emergency department.

backgroundEmergency departments (EDs) across the United States are facing unprecedented patient volumes and overcrowding, amplifying the need to optimize throughput and operational efficiency. Computed tomography (CT) turnaround time (TAT) is the interval from imaging order to interpretation, and this represents a key determinant of ED flow. At our academic medical center, overnight CT TATs exceeded national benchmarks, largely due to delays between radiology resident preliminary reads and initiation of third-party attending-level teleradiology interpretations. Our objective was to reduce the interval between preliminary resident interpretation and teleradiology service request by 25% through targeted workflow redesign and implementation of iterative quality improvement (QI) interventions.

methodsThis single-center quality improvement study was conducted in the ED of a metropolitan academic quaternary care hospital from March 21, 2022, to May 1, 2025, using the Plan-Do-Study-Act (PDSA) framework. Adult ED patients undergoing overnight CT imaging requiring teleradiology interpretation were included. Four sequential PDSA cycles were implemented, each introducing a targeted intervention to enhance communication between emergency physicians, health unit clerks, and radiology residents: PDSA Cycle 1: Use of imaging order code phrases to indicate discharge intent. PDSA Cycle 2: Automated worklist-based referrals. PDSA Cycle 3: Electronic medical record (EMR)-integrated teleradiology request column on the ED track board. PDSA Cycle 4: Radiology-initiated digital "Request Nighthawk Read" button. The primary outcome was median time from preliminary read issuance to teleradiology request. Secondary outcomes included total CT order-to-result TAT, exam completion-to-result time, and ED length of stay (LOS).

resultsThe study period spanned March 21, 2022, to May 1, 2025, involving 12,126 patients. For the analysis, we compared 3,058 patients in the baseline group (March 21, 2022-March 20, 2023) with 3,698 patients in the post‑intervention group (July 22, 2024-May 1, 2025), representing timeframes preceding the first PDSA cycle and following completion of PDSA Cycle 4. The median interval from preliminary read to teleradiology request decreased from 30.5 minutes to 21.6 minutes, representing a 29.2% reduction (p <0.001). Total CT order-to-result TAT improved from 157.3 to 130.0 minutes (17.4% reduction; p <0.001), and CT exam completion-to-result time decreased from 84.2 to 72.6 minutes (13.8% reduction; p <0.001). ED arrival-to-discharge time modestly decreased from 413 to 396 minutes (4.1% reduction; p = 0.43 for medians). The EMR-integrated workflow improved transparency, communication, and user satisfaction without incurring additional costs.

conclusionAn EMR-based, radiology-initiated teleradiology request process significantly reduced delays in teleradiology imaging requests in an academic ED, improving efficiency and supporting more timely patient disposition. This intervention provides a reproducible, low-cost strategy for similar academic institutions that employ dual resident-led and teleradiology overnight workflows.