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超声内镜检查操作的标准报告要素:聚焦工作组的建议

Standard reporting elements for the performance of EUS: Recommendations from the FOCUS working group.

作者信息

Li Suqing, Monachese Marc, Salim Misbah, Arya Naveen, Sahai Anand V, Forbes Nauzer, Teshima Christopher, Yaghoobi Mohammad, Chen Yen-I, Lam Eric, James Paul

机构信息

Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada.

Division of Gastroenterology, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada.

出版信息

Endosc Ultrasound. 2021 Mar-Apr;10(2):84-92. doi: 10.4103/EUS-D-20-00234.

Abstract

BACKGROUND AND OBJECTIVES

Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units.

METHODS

A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting.

RESULTS

EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up.

CONCLUSIONS

Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.

摘要

背景与目的

已制定超声内镜(EUS)操作的质量指标,以监测和提高服务价值及患者预后。为支持纳入这些指标并规范EUS记录,我们为超声内镜检查医师和内镜检查科室提出标准EUS报告要素。

方法

进行全面的文献检索和综述,以确定EUS质量指标和高质量标准化EUS报告的关键组成部分。关于标准EUS报告要素的指导声明在2019年加拿大超声内镜论坛(FOCUS)年会上制定并审议。

结果

EUS报告要素可分为术前、术中和术后项目。术前组成部分包括操作类型、适应证、紧急程度以及患者临床信息和知情同意。术中组成部分包括检查的充分性和范围、相关标志、病变特征、采样方法、标本质量以及术中不良事件。术后组成部分包括相关检查结果的总结与综合以及推荐的管理和随访。

结论

规范报告要素可能有助于改善接受EUS操作患者的护理。我们的综述提供了一份实用指南以及推荐报告要素的汇编,以确保EUS持续的最佳实践和质量改进。

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本文引用的文献

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Improvement of Endoscopic Reports with Implementation of a Dictation Template.通过实施听写模板改进内镜检查报告
J Can Assoc Gastroenterol. 2019 Dec 19;4(1):21-26. doi: 10.1093/jcag/gwz033. eCollection 2021 Feb.
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How to measure quality in endoscopic ultrasound.如何在内镜超声检查中衡量质量。
Ann Transl Med. 2018 Jul;6(13):266. doi: 10.21037/atm.2018.03.36.

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