Key words computed tomography - reporting error - quality improvement - trauma - reporting time
- structured reporting
Introduction
Trauma is a global public health problem accounting for 9 % of deaths worldwide and
it is one of the leading causes of death among young people [1 ]. Mortality rates of severe trauma are reported between 4.6 % and 10.1 % [2 ]
[3 ]
[4 ]. Radiological imaging plays a pivotal role in the diagnostics of traumatized patients
as a relative reduction of mortality of 13 % was shown when computed tomography (CT)
is performed immediately after trauma [5 ]. Moreover, guidelines stipulate highly standardized workflows aiming to further
reduce patient mortality [6 ]
[7 ]
[8 ]
[9 ]. Especially in whole-body CT for trauma, 2.4–12.9 % of injuries are missed [10 ]
[11 ]
[12 ]. Particularly those missed injuries might endanger a good clinical outcome of trauma
patients. Accordingly, missed or delayed diagnosis aggregated to 11 % of deaths in
a large-scale review of trauma deaths by Gruen et al. [13 ]. Hence, a high diagnostic accuracy of whole-body trauma is essential for further
patient treatment and directly impacts patient outcome. Particularly in light of patient
outcome, some efforts have been made to establish a useful way to report CT examinations
of trauma patients, albeit only a few studies regarding whole-body trauma CT and the
structure of the reports. In recent years, structured reporting (SR) has been promoted
as a powerful tool to enhance the quality of radiology reports as it supports therapeutic
decisions [14 ]
[15 ]
[16 ], including surgical planning [17 ]
[18 ]
[19 ], and it improves the communication and recall of reports [20 ]
[21 ]
[22 ]. At the same time, a reduction of dictation time is reported [23 ], reporting errors decrease [24 ], and referrers’ satisfaction improves [21 ] in comparison to free-text reports (FTR). Only some studies have evaluated SR in
the setting of emergency imaging, especially whole-body trauma CT, with heterogeneous
results. To date, the value of SR in whole-body trauma CT is still unclear.
SR was recently implemented as a standard procedure for whole-body trauma CT at our
hospital. Thus, the present study aimed to investigate the influence of structured
reporting on reporting time and reporting mistakes and to measure the benefit of SR
in the secondary assessment of whole-body trauma CT for referrers by using a referrers’
survey.
Materials and Methods
This prospective study conforms to the Declaration of Helsinki and was approved by
the local ethics committee (BO-EK-27012022). Written informed consent was waived because
of the retrospective nature of the study and the risk of selection bias, with a lack
of more severely injured patients who are physically or mentally unable to give consent.
Patients
Between 9/2020 and 6/2021 every patient older than 18 years who underwent a whole-body
trauma CT examination at our institution was included in the study. Age, gender, and
injury severity score (ISS) were recorded for each patient.
CT protocol
For all patients, whole-body CT was indicated independently of the study by the trauma
team and according to the current S3 guidelines [8 ]. All trauma scans are routinely performed with a 2 × 128-slice spiral CT scanner
(Somatom Definition Edge, Siemens Healthineers, Erlangen, Germany), located directly
next to the resuscitation area. All patients are positioned supine, with their arms
on the body. Imaging and reformations follow a standardized trauma protocol ([Table 1 ]), which can be expanded for additional clinical questions. Immediately after presentation
of the initial images to the trauma team, reading of the complete data set is performed
on a workstation with two high-resolution monitors at the emergency department (Coronis
Fusion 6MP LED (MDCC-6430), Barco, Belgium) using the local picture archiving and
communication system (PACS) (IMPAX EE R20 XIX SU1; Dedalus HealthCare GmbH, Bonn,
Germany).
Table 1
Standard whole-body imaging protocol and reformations. *Protocol can be extended to
the lower extremities in the case of clinical signs of injury. Abbreviations: cCT
– cerebral CT; CTA – CT angiography.Tab. 1 Standardprotokoll beim Polytrauma und Reformationen. *Das Protokoll kann beim klinischen
Verdacht auf eine Verletzung der unteren Extremität auf diese ausgedehnt werden. Abkürzungen:
cCT – zerebrale CT; CTA – CT Angiografie.
Examination region
Acquisition
Slice thickness and plane of reconstructions (Kernel)
Head
Native angulated cCT
6.0 mm axial (Hr 40), 1.5 mm axial (Hr 40), 1.5 mm axial (Hr 68)
Aortic valve – vertex
CTA
0.75 and 1.5 mm axial (Hr 38), 1.0 mm sinuses axial and coronal (Hr 56), 2.0 mm cervical
spine coronal and sagittal (Hr 56), 2.0 mm parasagittal to aortic arch (Hr 38)
Thorax – pelvic floor*
Spiral CT
3.0 mm axial (Br 38), 1.0 mm axial (Br 59), 1.0 mm axial (Bf 37), 3.0 mm coronal (Br
59), 3.00 mm sagittal (Bf 37), 3.0 mm thorax axial (Br 59), 3.0 mm thorax coronal
(Br 59)
Reporting measures
Radiologists at our institution were not obliged to use the reporting software (Smart
Radiology, Smart Reporting GmbH, Munich. https://app.smart-radiology.com) so it was
still possible to use FTR. On this account, all reports not created with the reporting
software (before and after the implementation of SR) were defined as FTR and all reports
that were created with the reporting software were defined as SR. The template contains
a standardized text about the procedure. Its descriptive part consists of 1500 elements.
All sublevels in the findings section are a mixture of point-and-click, drop-down
menus, pick lists, and free-text to describe certain pathologies more closely, e. g.
to specify reconstruction planes and image numbers. Only pathological findings are
automatically transferred to the impression section to facilitate a quick overview
about all relevant injuries. The whole structure is given in Supplement 1 .
Reporting time
Reporting time is logged in the radiology information system (RIS) for certain actions.
For this study, the time point when the radiological technologist finished and sent
the imaging study to the PACS and the finalization of the final report by the board-certified
radiologist or the finalization of the preliminary report by the resident was documented
in minutes.
Reporting mistakes
Experienced residents with requisite qualification give a preliminary report, which
is reviewed and then signed by a board-certified radiologist as soon as possible.
Board-certified radiologists write the final reports. The final report approved by
a board-certified radiologist was defined as the standard of reference. To assess
reporting mistakes, written final reports were checked for addendums and correction
reports in the RIS for board-certified radiologists. For residents, the preliminary
report and the final report were compared. Reporting mistakes were documented separately
for residents and board-certified radiologists. The categories of reporting mistakes
were established as described by Geyer et al. as (I) no missed injury, (II) missed
injury with no clinical relevance, and (III) missed injury with clinical relevance
[11 ]. Clinical relevance was given when further specific treatment of a lesion was required
or if a lesion indicated a severe injury.
Referrer survey
An online referrer survey was carried out before the implementation of SR and after
the 6-month implementation period. 363 medical doctors who are involved in trauma
care received an email invitation for the survey consisting of 11 questions. The very
first question of the survey filtered participants who regularly take part in the
treatment of trauma patients. It was followed by 10 questions about details of the
whole-body trauma CT reports. The respondents were given a 5-point Likert scale to
indicate their consent to the given statements with 1 being “I strongly agree” and
5 meaning “I strongly disagree”. Additionally, a 3-point Likert scale was used to
indicate the importance of each statement with 1 meaning “This statement is important”,
2 meaning “undecided”, and 3 meaning “This statement is not important”.
Statistical analysis
Statistical analyses were performed with RStudio 2021.09.0 (http://www.rstudio.com/ ). For statistic evaluation of the survey, the Mann-Whitney U test was applied. The
occurrence of reporting errors and reading times were compared by the Kruskal-Wallis-Test.
The significance level was set at p < .05.
Results
A total of 408 patients with a mean age of 56.5 ± 20.3 years were included in this
prospective single-center study. Of these, 275 (67.4 %) patients were male and 133
(32.6 %) were female. Their mean injury severity score (ISS) was 13.2 (range: 0–75).
Before the implementation of SR, 187 reports were made and during the implementation
period 178 SR reports were created. Additionally, 43 FTRs were finalized during the
implementation period. Overall, 267 (65 %) CT examinations were performed during on-call
duty at night or on weekends and 141 (35 %) were performed in the daytime during work
hours. 189 reports were made by board-certified radiologists and 219 were primarily
seen by radiology residents.
Reporting time
Throughout the whole study period, the median reporting time without SR took 58 minutes,
whereas the median reporting time using SR was 48 minutes ([Table 2 ]). Overall, the difference was not statistically significant (p = .25). Residents created their reports faster when using SR (median time: 47 minutes
vs. 57 minutes; p = .31) and board-certified radiologists needed a median reporting time of 1 hour,
regardless of the reporting mode (p = .28). For residents, the difference in reporting time was seen during both on-call
duty and normal work hours (Supplement 2 ). The board-certified radiologists, however, showed a higher median reporting time
during on-call duties when using the template (61 min. vs. 50 min., p = .73) and almost constant times during normal work hours (57 min. vs. 61 min., p = .68).
Table 2
Comparison of reporting times with and without SR for all, board-certified radiologists
and residents. SD = standard deviation; SR = structured report; FTR = free-text report.
p = p-value (*p < .05 statistically significant).Tab. 2 Vergleich der Befundungsdauer mit und ohne SR für alle, Fachärzte und Weiterbildungsassistenten.
SD = Standardabweichung; SR = strukturierter Befund; FTR = freie Befundung. p = p-Wert
(*p < 0,05 statistisch signifikant).
All
Board-certified radiologists
Residents
SR
FTR
SR
FTR
SR
FTR
n
178
230
75
114
103
116
Minimum (min)
4
5
6
5
4
6
Mean±SD (min)
65 ± 52
87 ± 124
68 ± 51
120 ± 262
62 ± 52
74 ± 57
25th percentile (min)
29
32
29
26
30
36
Median (min)
48
58
59
60
47
57
75th percentile (min)
91
102
100
108
85
94
Maximum (h)
5.2
19.0
4.0
19.0
5.2
5.2
p
.25
.28
.31
Before implementation of SR, 55.1 % of whole-body trauma reports were finished within
one hour. Closer analysis of the implementation period revealed a longer interpretation
time in the first two months with the reporting template than FTR. In the following
months, that time decreased, and the proportion of reports lasting one hour or less
rose to 68.3 %. After 4 months, there was a significant decrease of the median reporting
time when using SR compared to FTR (45 min. vs. 58 min., p = .02) ([Fig. 1 ]).
Fig. 1 Boxplots for reporting time before (no SR) and during the implementation of SR. The
horizontal line indicates the one-hour reading time allowed by the ESER guideline.
P-values are displayed above the boxplots.Abb. 1 Boxplots für die Befundungsdauer vor (no SR) und während der Einführung der SR. Die
horizontale Linie markiert eine Stunde Befundungszeit, die durch die ESER-Leitlinie
vorgegeben ist. Die p-Werte sind oberhalb der Boxplots angegeben.
Reporting errors
Overall, 44 (10.7 %) reporting errors were documented. Of those, 47.7 % were relevant
findings and 52.3 % were not relevant for further diagnostic or even therapeutic steps.
Four out of the 44 affected patients died due to their injuries. However, none of
the missed injuries was the cause of death.
A large number of the clinically relevant missed findings were related to the musculoskeletal
system (n = 14, 67 %). Among the clinically relevant reporting errors, no interpretation
mistakes were found. Clinically less relevant missed findings consisted mainly of
soft tissue lesions like hematoma (n = 15, 65 %). Among the clinically less relevant
reporting errors, 2 interpretation mistakes were detected. Detailed information is
given in [Table 3 ].
Table 3
List of all missed injuries or misinterpretations. Misinterpretations are italicized.Tab. 3 Liste aller übersehener Verletzungen und Fehlinterpretationen. Fehlinterpretationen
sind kursiv hervorgehoben.
Clinical relevance
No clinical relevance
1. Sternal fracture, high-grade stenosis of internal carotid artery, hematoma
1. Small liver contusion
2. Ligamental injury cervicothoracic junction
2. Pulmonary compaction
3. Razor blades in stomach
3. Type-A ankle fracture
4. Tumor and pulmonary embolism
4. Type-A ankle fracture
5. Liver contusion
5. Avulsion fracture Proc. coronoideus
6. B-fracture of pelvis
6. Filiform M2-segment A. cerebri media
7. Teardrop fracture C 2/3
7. Suspicion of small active bleeding thigh
8. Sternal fracture
8. Joint effusion, wrong fracture classification
9. Osseous fragment in optical canal
9. Unclear liver lesion
10. Non-dislocated femoral neck fracture, liver cirrhosis
10. Small avulsion transverse process L 2
11. Dissection of A. fibularis next to fracture
11. Cervical hematoma
12. Blood in ventricles
12. Assessment compaction (tumor vs. hematoma)
13. Bilateral vertebral arch fracture C 6
13. More rib fractures with known serial rib fracture
14. Sternal fracture
14. Pulmonary nodule
15. Pulmonary embolism
15. Pulmonary infiltrations
16. Sacral fracture
16. Old myocardial infarction
17. Hemothorax
17. Abdominal wall hematoma
18. Retrosternal hematoma
18. Non-displaced radial head fracture
19. Fracture sacral body 4
19. Active bleeding axilla
20. Fractures thoracic spine
20. Metastasis
21. Fracture Th 12
21. Consolidated fracture Th 11/12
22. Unclear small liver lesion
23. Consolidated serial rib fracture
[Table 4 ] summarizes the reporting mistakes of residents and board-certified radiologists.
72.7 % of the mistakes were ascribed to residents. Generally, the percentage of mistakes
was higher when no SR was used (12.6 % vs. 8.4 %, p = .49). Both, residents and board-certified radiologists had fewer reporting mistakes
when using SR with 16.4 % vs. 12.6 % (p = .10) and 8.8 % vs. 2.7 % (p = .45), respectively. For residents, the rate of clinically relevant mistakes improved
slightly when using SR (7.8 % vs. 6.8 %, p = .79) and the rate of clinically not relevant mistakes decreased from 8.6 % to 5.8 %
(p = .43). For board-certified radiologists, the rate of clinically relevant mistakes
remained stable at a low level when using SR (2.6 % vs. 2.7 %, p = .99) and not clinically relevant mistakes decreased from 6.1 % to 0 % (p = .03). In total, significantly fewer mistakes were found in SR reports of board-certified
radiologists compared to FTRs of residents (p = .03). Altogether, the percentage of reporting mistakes was 13.6 % in reports during
on-call duties (8.30 p. m. – 7.00 a. m.) and 10.1 % in daytime reports (7.00 a. m.
– 8.30 p. m.). A closer analysis revealed an improvement of reporting errors during
the daytime when using SR (12.8 % vs. 6.8 %, p = .14). This observation pertained to both clinically relevant and not clinically
relevant findings. During on-call duties, the overall error rate increased from 11.8 %
to 16.7 % (p = .90). Interestingly, not clinically relevant mistakes also decreased from 4.0 %
to 3.4 % (p = .13) while clinically relevant errors rose from 7.8 % to 13.3 % (p = .63) (Supplement 3 ).
Table 4
Summary of reporting mistakes for residents and board-certified radiologists. Mistakes
are classified as “no mistake” (I), “no clinically relevant mistake” (II), and “clinically
relevant mistake” (III). SR = structured report; FTR = free-text report; p = p-value
for comparison of both clinically relevant and clinically not relevant mistakes with
SR vs. FTR (*p < .05 statistically significant).Tab. 4 Zusammenfassung der Befundungsfehler bei Weiterbildungsassistenten und Fachärzten.
Die Fehler sind aufgeschlüsselt in „kein Fehler“ (I), „kein klinisch relevanter Fehler“
(II) und „klinisch relevanter Fehler“ (III). SR = strukturierte Befundung; FTR = freie
Befundung; p = p-Wert für den Vergleich der Anzahl an sowohl klinisch relevanten und
nicht klinisch relevanten Befundungsfehlern mit SR vs. FTR (*p < 0,05 statistisch
signifikant).
Residents
Board-certified radiologists
All
I
II
III
p
I
II
III
p
FTR
97
10
9
.45
104
7
3
.10
230
SR
90
6
7
73
0
2
178
all
187
16
16
177
7
5
408
Referrer satisfaction
Overall, 60 participants answered the initial survey (response rate 16.5 %) and 43
of them were available for further analysis. Survey participants were equally distributed
with 12 residents, 15 board-certified radiologists, and 16 senior physicians/clinic
directors. From the follow-up survey, 36 responses (response rate 9.9 %) were obtained
with only 20 survey results for full analysis. Four of them were made by residents,
7 by board-certified radiologists, and 8 by senior physicians/clinic directors. The
remaining participant did not indicate the position. The initial referrer survey revealed
good overall satisfaction of 1.7 ± 0.8 ([Table 5 ], Supplement 4 ). However, especially in the field of report structure, potential for improvement
regarding consistency and provision of reports was identified. After the 6-month implementation
of SR, the overall satisfaction improved minimally to 1.5 ± 1.1 in the second survey.
All items that had been evaluated as very good improved further. The initial poorer
results also improved but mainly did not reach statistical significance. Thus, referrers
obviously found it easier to detect life-threatening and important pathologies in
the reports with an improvement from 2.1 ± 1.2 to 1.6 ± 1.1 (p = .32). Also, reports were rated to have a more consistent structure (2.1 ± 1.1 to
1.4 ± 1.1; p = .09) and to be significantly more standardized (2.2 ± 1.1 to 1.3 ± 1.1; p = .03). Moreover, as verified by our measurements, the referrers perceived a timelier
provision of the reports (2.8 ± 1.1 to 2.1 ± 1.3; p = .33).
Table 5
Results of the referrer survey, sorted in ascending order in regard to agreement with
the statements in the initial survey. A = agreement with the statement, I = importance
of this statement, M ± SD = mean±standard deviation. *p-value statistically significant
(p < .05).Tab. 5 Ergebnisse der Zuweiserbefragung, aufsteigend sortiert nach Zustimmungsgrad in der
Vorher-Befragung. A = Zustimmung zu der Aussage, I = Wichtigkeit der jeweiligen Aussage,
M ± SD = Mittelwert±Standardabweichung. *p-Wert statistisch signifikant (p < 0,05).
Statement
A before (M±SD)
I before (M±SD)
A after (M±SD)
I after (M±SD)
The reports are comprehensible.
1.4 ± 0.5
1.0 ± 0.2
–
–
Structured reporting makes the reports more comprehensive.
–
–
1.7 ± 1.2
1.3 ± 0.4
In trauma imaging personal discussion of the findings is crucial for me.
1.5 ± 0.9
1.1 ± 0.4
–
–
Despite structured reporting personal discussion of the findings is crucial for me.
–
–
1.0 ± 0.5
1.1 ± 0.3
In general, I am satisfied with the radiology reports.
1.7 ± 0.8
1.1 ± 0.3
1.5 ± 1.1
1.1 ± 0.4
I prefer standardized vocabulary.
1.8 ± 1.0
1.5 ± 0.7
1.5 ± 1.2
1.6 ± 0.8
The reports contain clinically relevant information and they are adequate to derive
the right therapeutic steps.
1.9 ± 0.7
1.1 ± 0.3
1.6 ± 0.9
1.3 ± 0.4
Life-threatening and important pathologies can be easily detected in the reports.
2.1 ± 1.2
1.1 ± 0.3
1.6 ± 1.1
1.1 ± 0.3
The trauma reports have a consistent structure.
2.1 ± 1.1
1.3 ± 0.5
1.4 ± 1.1
1.5 ± 0.6
The content of the trauma reports is standardized.
2.2 ± 1.1
1.3 ± 0.5
1.3 ± 1.1*
1.4 ± 0.7
The written trauma report is provided in a timely manner.
2.8 ± 1.1
1.2 ± 0.4
2.1 ± 1.3
1.3 ± 0.6
Discussion
In this study the influence of SR on reporting time and reporting errors was investigated
with routine data during an implementation project. Additionally, the benefit of SR
was evaluated by means of a referrer survey.
To achieve further standardization, a European guideline was published by the European
Society for Emergency Radiology (ESER) in December 2020 [6 ]. It is the first international guideline with a clear allowance according to communication
and reading times of whole-body trauma CT. To comply with this guideline, a three-step
approach during image reading is necessary. A primary assessment of the first available
series should be performed to identify life-threatening injuries. It is followed by
a secondary assessment of all final images within one hour. Within 24 hours, a tertiary
assessment by another radiologist is required to reduce missed injuries. Missed injuries
should be documented as an addendum. The reporting structure is not covered by the
guideline. However, it refers to the guideline of the Royal College of Radiology (RCR),
which proposes a checklist for both the primary and secondary assessment [7 ]. It clearly states that every single institution should develop a fixed protocol
or procedure for the interpretation of whole-body trauma CT to minimize the rate of
overlooked injuries as well as random findings [6 ]. Reporting time decreased during implementation of SR with 13 % more finalized reports
within one hour as prompted by the new guideline, reaching statistical significance
after 4 months. Especially residents improved their reporting times. This finding
can partially be explained by the workflow at our institution. Reports that were initially
read by a resident and immediately approved by a board-certified radiologist were
also included in the group of board-certified radiologists. However, the overall reporting
time for board-certified radiologists remained stable with SR. One obstacle to the
implementation of SR in the clinical routine is the widespread opinion that it is
more time-consuming than reporting in prose style [25 ]. Usually, the rigidity of SR for secondary findings is mentioned as one of the most
time-restricting factors [25 ]
[26 ]
[27 ]. The template used in this study was designed for a full radiology report including
a native CT scan of the brain, CT angiography of the head and neck, as well as a scan
of the thorax, abdomen, and pelvis. Hence, our findings do not confirm this assumption.
Jorg et al. investigated reporting time for SR in trauma CT in an experimental emergency
room setting [28 ]. They found similar results. Their mean reporting time was 19 min. and they only
included 14 whole-body CT examinations. Reports in our study took longer which could
be caused by the real interruptions during daily work. Only sparse data about the
reporting time for routine trauma CT scans is available. According to the national
survey of the United Kingdom the vast majority of trauma reports are finalized within
two hours [29 ]. These results correspond with the findings of this study and emphasize the challenge
to fully comply with the new European guideline.
The percentage of reporting errors decreased with SR. However, the decrease was not
statistically significant. Dendl et al. found contradictory results for board-certified
radiologists using a checklist style SR for phase 1 reporting, while the resident
in their study improved significantly [30 ]. These differences have multiple explanations. Firstly, they did not evaluate the
reporting errors under real conditions, where interruptions such as phone calls and
other examinations occur. Secondly, they only had 3 readers. Our study results stem
from one department where radiologists with different levels of experience and expertise
in emergency radiology are employed. It can, therefore, be considered as a representative
sample. Thirdly, their study aimed to take 10 min. or less for the whole checklist.
This study, however, took place during the daily routine and during implementation
of SR. All radiologists had to work with the technical possibilities, but they were
able to take time and read the CT scans at their own pace. Both our radiologists and
the study team of Dendl et al. had to master the very different workflow compared
with FTR. In contrast to Dendl et al., our study evaluated a reporting template which
includes secondary findings and covers phase 2 reading in accordance with the European
guideline. For this reason, we conclude that the implementation of SR can be undertaken
safely during the routine workflow without lessening report quality.
Jorg et al. found more detailed diagnoses in SR for whole-body trauma CT examinations
in an experimental study setting [28 ] and concluded that it adds clinical value in comparison to FTR. The quality of SR
was rated better than FTR. However, a disadvantage of their study is the evaluation
of the reports by radiologists. Value-based radiology aims to create reports that
are helpful for the referrer [31 ]. Therefore, reports should be rated by the recipients. Our referrer survey showed
an improvement of the perception of structured whole-body trauma CT reports although
the initial satisfaction was already high. Abdellatif and colleagues investigated
the needs and expectations of emergency department clinicians [32 ]. They report similar general satisfaction with radiology reports with rates greater
than 90 %. Even with high satisfaction in surveys, SR can be considered a tool for
the further improvement of radiology reports and for enhancing referrer satisfaction.
Thus, the experience from prior studies about oncological reports can be transferred
to SR of whole-body trauma CT examinations.
There are some limitations of this study. Firstly, many results are not significant.
As described above, we report real-world data, which is an important step to transfer
and verify in vitro knowledge into practical application. Thus, we interpret our results as a realistic
scale of improvement in the daily routine. Secondly, the study lacks long-term results.
Especially in light of the first limitation, long-term data need to be scrutinized
to evaluate the value and significance of SR in the daily routine.
Conclusion
In conclusion, SR for whole-body CT in trauma can be implemented safely in the clinical
routine. SR facilitates process improvement compared with FTR and results in fewer
reporting errors, decreased reporting time, and simultaneously increased referrer
satisfaction. A further validation of process improvement over the course of familiarization
with SR is warranted.
