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常规使用全身创伤 CT 结构化报告有助于质量改进。

Routine Use of Structured Reporting in Whole-body Trauma CT Facilitates Quality Improvement.

机构信息

Radiology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany.

Quality and Medical Risk Management, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany.

出版信息

Rofo. 2023 Jun;195(6):521-528. doi: 10.1055/a-2031-2364. Epub 2023 Apr 5.

Abstract

PURPOSE

Structured reporting (SR) is increasingly used. So far, there is minimal experience with SR in whole-body computed tomography (WBCT). The aim of this study was to investigate the value of routine use of SR in WBCT in trauma with a focus on reporting time, reporting errors, and referrer satisfaction.

MATERIALS AND METHODS

Reporting time and reporting errors of CT reports were prospectively quantified for residents and board-certified radiologists 3 months before and for 6 months after implementation of a structured report in the clinical routine. Referrer satisfaction was prospectively quantified by means of a survey before and after the implementation period of SR using a 5-point Likert scale. Before and after results were compared to determine the effect of structured reporting on WBCT in trauma at our institution.

RESULTS

The mean reporting time was lower when using SR (65 ± 52 min. vs. 87 ± 124 min., p = .25). After 4 months, the median reporting time was significantly lower with SR (p = .02). Consequently, the rate of reports that were finished within one hour rose from 55.1 % to 68.3 %. Likewise, reporting errors decreased (12.6 % vs. 8.4 %, p = .48). Residents and board-certified radiologists reported fewer errors when using SR with 16.4 % vs. 12.6 % and 8.8 % vs. 2.7 %, respectively. General referrer satisfaction improved (1.7 ± 0.8 vs. 1.5 ± 1.1, p = .58). Referrers graded improvements for standardization of reports (2.2 ± 1.1 vs. 1.3 ± 1.1, p = .03), consistency of report structure (2.1 ± 1.1 vs. 1.4 ± 1.1, p = .09), and retrievability of relevant pathologies (2.1 ± 1.2 vs. 1.6 ± 1.1, p = .32).

CONCLUSION

SR has the potential to facilitate process improvement for WBCT in trauma in the daily routine with a reduction of reporting time and reporting mistakes while increasing referrer satisfaction.

KEY POINTS

· SR for WBCT in trauma is feasable in clinical routine.. · Reporting time in WBCT in trauma decreases by SR.. · SR for WBCT in trauma has the potential to decrease reporting mistakes.. · SR for WBCT in trauma might increase referrer satisfaction..

CITATION FORMAT

· Blum SF, Hertzschuch D, Langer E et al. Routine Use of Structured Reporting in Whole-body Trauma CT Facilitates Quality Improvement. Fortschr Röntgenstr 2023; 195: 521 - 528.

摘要

目的

结构报告(SR)的使用越来越多。到目前为止,全身计算机断层扫描(WBCT)中 SR 的经验很少。本研究旨在探讨在创伤中常规使用 SR 的价值,重点是报告时间、报告错误和转诊医生满意度。

材料与方法

在实施 SR 前后 3 个月,前瞻性地对住院医师和认证放射科医师的 CT 报告报告时间和报告错误进行了量化。在实施 SR 前后,通过使用 5 分制李克特量表前瞻性地对转诊医生的满意度进行了量化。比较前后结果,以确定结构化报告对我院创伤性 WBCT 的影响。

结果

使用 SR 时的平均报告时间较低(65±52 分钟 vs. 87±124 分钟,p=0.25)。4 个月后,SR 的中位报告时间明显较低(p=0.02)。因此,在一小时内完成报告的比例从 55.1%上升到 68.3%。同样,报告错误减少(12.6% vs. 8.4%,p=0.48)。使用 SR 时,住院医师和认证放射科医师报告的错误分别减少到 16.4%和 8.8%。一般转诊医生的满意度提高(1.7±0.8 分 vs. 1.5±1.1 分,p=0.58)。转诊医生对报告标准化(2.2±1.1 分 vs. 1.3±1.1 分,p=0.03)、报告结构一致性(2.1±1.1 分 vs. 1.4±1.1 分,p=0.09)和相关病理学可检索性(2.1±1.2 分 vs. 1.6±1.1 分,p=0.32)的改善程度进行了评分。

结论

SR 有可能通过减少报告时间和错误,同时提高转诊医生的满意度,为创伤性 WBCT 的日常工作流程带来改善。

关键点

· 在临床常规中,创伤性 WBCT 的 SR 是可行的。· 创伤性 WBCT 的 SR 可缩短报告时间。· 创伤性 WBCT 的 SR 有减少报告错误的潜力。· 创伤性 WBCT 的 SR 可能会提高转诊医生的满意度。

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