PURPOSE: Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy. METHODS: Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation. RESULTS: There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1-13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6-9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway. CONCLUSIONS: The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.