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In this single-center study, advanced imaging utilization increased significantly following the deployment of a Provider-in-Triage (PIT) model. In addition, the rate of negative CT scans in patients with abdominal pain was higher in PIT-exposed patients.
Speed is not always the answer
This was a retrospective single-center study of adult ED patients at a tertiary academic ED with an annual census of 70,000 patients. The ED launched a PIT model in July 2023 (ED attendings only), and evaluated advanced imaging utilization for an 18 month period before and after implementation. Covariates included acuity (ESI) and admission proportion, with multivariable regression analysis. A sub-cohort analysis was performed in patients with abdominal pain, comparing CT utilization after the PIT process to non-PIT exposed patients.
There were 76,731 adult ED visits in the 18 month pre-PIT period and 89,105 in the 18 month post-PIT implementation period. CT utilization increased from 0.36 studies per ED visit to 0.49 studies per ED visit, an increase of 0.135 CT scans per visit (p < 0.001). There were smaller statistically significant increases in radiology ultrasound and MRI utilization post-PIT, while POCUS use decreased. In multivariable regression analysis, PIT was independently associated with increased CT utilization in patients with abdominal pain (OR 1.27, 95%CI 1.01-1.60). The CT positivity rate in abdominal pain patients was lower in the PIT cohort (38.7% vs 46.9%; absolute risk difference of 8.2%, p=0.03).
How will this change my practice?
PIT in EM reduces left without being seen (LWBS) and door to doctor (D2D) times. These are good things, but there may be a cost to these brief, time pressured patient evaluations. If PIT curtails adequate evaluation and sound judgment, then physicians may have to lower their threshold for advanced imaging ordering in an effort to avoid missing things. Also, many patients now have to “make it past” two ED physicians without getting a CT scan ordered. Importantly, POCUS utilization was the only imaging that actually went down (though not statistically significant) in the study. If PIT inhibits POCUS and increases CT use, then any speed advantage from LWBS or D2D may be outweighed by potentially unnecessary cost, radiation, and perhaps even length of stay.
Source
Thom C, Spirek B, Mullins C, Moak J. Quantity matters: Impact of PIT deployment on advanced imaging utilization. Am J Emerg Med. 2026 Jul;105:109-114. doi: 10.1016/j.ajem.2026.04.009. Epub 2026 Apr 8. PMID: 42000674.
