Triantopoulou Ch, Tsalafoutas I, Maniatis P, Papavdis D, Raios G, Siafas I, Velonakis S, Koulentianos E
Computed Tomography Department, Konstantopoulio-Agia Olga Hospital, 3-5 Agias Olgas, Nea Ionia, 14233 Athens, Greece.
Eur J Radiol. 2005 Feb;53(2):306-11. doi: 10.1016/j.ejrad.2004.02.012.
To evaluate the adequacy of patient data and clinical information transmitted to the radiological departments by the referring clinicians in view of the justification demands concerning the radiological examinations, as those are described in the Radiation Protection Regulations of the European Union Nations.
Request forms for 1708 patients referred to radiology department and 410 referred to the CT department were evaluated concerning the proper completion of the form fields. Furthermore, for CT examinations a more detailed evaluation was carried out, to assess the rationalistic use of CT within the diagnostic algorithm.
Not properly completed request forms to both departments were observed, however, the omissions were more prominent for the referrals to the radiology department, where the age and the probable clinical diagnosis was not given in 81.5 and 46% of the forms, respectively. Furthermore, the emergency indication was less cautiously used compared to the CT requests. For the CT department 33.3% of requests were justified and the final diagnosis was included in the referring doctor's probable clinical diagnosis. U/S was the examination of choice in 51% of the cases where an examination should have been performed before CT and in 70.6% of the cases where an alternative examination was proposed.
The inadequate transmission of clinical information and the large number of not fully justified CT requests observed in this study are typical examples of the various problems that radiologists have to face in order to apply the justification directives.
鉴于欧盟国家《辐射防护条例》中所述的放射检查正当性要求,评估转诊临床医生传输至放射科的患者数据和临床信息是否充分。
对1708例转诊至放射科和410例转诊至CT科的患者的申请表进行评估,查看表格字段填写是否恰当。此外,对于CT检查进行了更详细的评估,以评估CT在诊断流程中的合理使用情况。
两个科室均存在未正确填写申请表的情况,然而,放射科转诊申请中的遗漏更为突出,分别有81.5%和46%的申请表未填写年龄和可能的临床诊断。此外,与CT检查申请相比,急诊指征的使用不够谨慎。对于CT科,33.3%的申请具有正当性,最终诊断包含在转诊医生可能的临床诊断中。在本应在CT检查前进行检查的病例中,51%的病例首选超声检查;在建议进行替代检查的病例中,70.6%的病例首选超声检查。
本研究中观察到的临床信息传输不足以及大量CT申请理由不充分的情况,是放射科医生在应用正当性指令时必须面对的各种问题的典型例子。