Structured Reporting of Whole-Body Trauma CT Scans: Friend, not Foe

Structured reporting enhances the quality of radiology reports. It has arisen as a beneficial tool for both, radiologists and clinical partners [1]. The main benefits of structured reports for referrers are a faster overview of important findings, better readability, clear and understandable content according to recent guidelines as well as high objectivity [2] [3] [4]. For radiologists, fast advances in training and better communication with referrers are additional advantages [5]. As structured reporting has the potential to enhance communication with referring physicians, it provides great opportunities to promote interdisciplinary communication of imaging findings in early trauma management.

The guideline of the Royal College of Radiologists for trauma radiology in severely injured patients recommends a two-step survey [6]: The first step is a primary survey to identify life-threatening injuries while patient management is going on. The results of the primary survey are communicated to the trauma leader directly. As a second step, the secondary survey is performed as soon as all images and reformations are available. This report is comprehensive and should contain all results including random findings. Usually, one radiologist reports both surveys and the secondary survey should be finished within 1 hour.

Publication History

Article published online:
11 July 2022

• References

• 1 Nobel JM, Kok EM, Robben SGF. Redefining the structure of structured reporting in radiology. Insights Imaging 2020; 11: 10 DOI: 10.1186/s13244-019-0831-6.
• 2 Buckley BW, Daly L, Allen GN. et al. Recall of structured radiology reports is significantly superior to that of unstructured reports. Br J Radiol 2018; 91: 20170670 DOI: 10.1259/bjr.20170670.
• 3 Brown PJ, Rossington H, Taylor J. et al. Standardised reports with a template format are superior to free text reports: the case for rectal cancer reporting in clinical practice. Eur Radiol 2019; 29: 5121-5128 DOI: 10.1007/s00330-019-06028-8.
• 4 Grieve FM, Plumb AA, Khan SH. Radiology reporting: a general practitioner’s perspective. Br J Radiol 2010; 83: 17-22 DOI: 10.1259/bjr/16360063.
• 5 Schwartz LH, Panicek DM, Berk AR. et al. Improving communication of diagnostic radiology findings through structured reporting. Radiology 2011; 260: 174-181 DOI: 10.1148/radiol.11101913.
• 6 The Royal College of Radiologists. The Royal College of Radiologists. Standards of practice and guidance for trauma radiology in severely injured patients, Second edition. 2015 Im Internet: https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr155_traumaradiol.pdf
• 7 Dendl LM, Pausch AM, Hoffstetter P. et al. Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience. RöFo - Fortschritte Auf Dem Geb Röntgenstrahlen Bildgeb Verfahr 2021; DOI: 10.1055/a-1541-8265.
• 8 Andrawes P, Picon AI, Shariff MA. et al. CT scan incidental findings in trauma patients: does it impact hospital length of stay?. Trauma Surg Acute Care Open 2017; 2: e000101 DOI: 10.1136/tsaco-2017-000101.
• 9 Treskes K, Bos SA, Beenen LFM. et al. High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial. Eur Radiol 2017; 27: 2451-2462 DOI: 10.1007/s00330-016-4598-6.
• 10 Fakler JK, Özkurtul O, Josten C. Retrospective analysis of incidental non-trauma associated findings in severely injured patients identified by whole-body spiral CT scans. Patient Saf Surg 2014; 8: 36 DOI: 10.1186/s13037-014-0036-3.
• 11 Smith LM, King SA, Shealy JA. et al. Incidental Findings in the Trauma Population: Interdisciplinary Approach and Electronic Medical Record Reminder Association with Pre-Discharge Reporting and Medicolegal Risk. J Am Coll Surg 2021; 232: 380-385.e1 DOI: 10.1016/j.jamcollsurg.2020.11.028.
• 12 Wirth S, Hebebrand J, Basilico R. et al. European Society of Emergency Radiology: guideline on radiological polytrauma imaging and service (short version). Insights Imaging 2020; 11: 135 DOI: 10.1186/s13244-020-00947-7.