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遵守皇家放射科医师学院关于可操作报告的指南及其对患者护理的影响:对一家主要创伤中心报告实践的回顾性分析。

Compliance With the Royal College of Radiologists Guideline for Actionable Reporting and Its Impact on Patient Care: A Retrospective Analysis of Reporting Practices From a Major Trauma Center.

作者信息

Sharma Utkarsh, Gomindes Austin R, Sharma Kritika, Choudhry Jamaal, C Searle Henry K

机构信息

Major Trauma Services, Queen Elizabeth Hospital Birmingham, Birmingham, GBR.

Higher Education Academy, Advanced Higher Education - UK Professional Standards Framework, Birmingham, GBR.

出版信息

Cureus. 2023 Mar 9;15(3):e35921. doi: 10.7759/cureus.35921. eCollection 2023 Mar.

DOI:10.7759/cureus.35921
PMID:37056531
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10089639/
Abstract

Introduction Prompt diagnosis forms the mainstay of management of any patient arriving at the hospital. In developed settings, apart from clinical assessment, imaging in the form of computed tomography (CT) scan plays a vital role in arriving at the patient diagnosis. The reporting should follow pre-defined Royal College of Radiologists (RCR) standards to improve the quality of the diagnostic process. Objectives To identify the compliance of reporting as per the RCR standards for the communication of radiological reports and fail-safe alert notification. Materials and methods A retrospective review of body CT scans was done in two cycles within a span of three months. A total of 100 randomized scans were assessed in each cycle, both from the A&E (accident and emergency) and inpatients. Normal scans and outpatient scans were excluded from the study. Data were collected using the online portal (CRIS) and statistical analysis was performed. Results After the first cycle of the audit, 95 reports out of 100 met the standard RCR criteria. After the second cycle, 97 reports met the criteria of the audit. One inpatient scan and two A&E reports did not meet the specified criteria in the second cycle. Conclusion After the two cycles of the audit carried out over three months, we were able to achieve almost 97% of reporting standards as compared to 95% obtained previously through a quality improvement project and create awareness.

摘要

引言

及时准确的诊断是医院对每一位就诊患者进行治疗的关键。在发达地区,除了临床评估外,计算机断层扫描(CT)形式的影像学检查在患者诊断中起着至关重要的作用。报告应遵循皇家放射科医师学院(RCR)预先设定的标准,以提高诊断过程的质量。

目的

确定放射学报告沟通及故障安全警报通知是否符合RCR标准。

材料与方法

在三个月的时间内分两个周期对身体CT扫描进行回顾性研究。每个周期共评估100例随机扫描,包括急诊(事故与急救)患者和住院患者的扫描。正常扫描和门诊扫描被排除在研究之外。通过在线门户(CRIS)收集数据并进行统计分析。

结果

在第一轮审核后,100份报告中有95份符合RCR标准。第二轮审核后,97份报告符合审核标准。在第二轮审核中,有一份住院患者扫描报告和两份急诊报告不符合指定标准。

结论

在三个月内进行两轮审核后,我们能够达到近97%的报告标准,而之前通过质量改进项目达到的标准为95%,并提高了认识。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/c22be4af2e32/cureus-0015-00000035921-i03.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/166f50b791ae/cureus-0015-00000035921-i01.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/4914c70e58f6/cureus-0015-00000035921-i02.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/c22be4af2e32/cureus-0015-00000035921-i03.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/166f50b791ae/cureus-0015-00000035921-i01.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/4914c70e58f6/cureus-0015-00000035921-i02.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd64/10089639/c22be4af2e32/cureus-0015-00000035921-i03.jpg

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