A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey

Tertiary Trauma Survey on Emergency Department Observational Units: A Systematic Literature Review

In today's competitive world with a fast-paced lifestyle, trauma is on the rise and is globally recognized as the leading cause of mortality, morbidity, and disability. Despite the development of major trauma centers and the introduction of advanced trauma training courses and management guidelines, there remains a substantial risk of missed or delayed diagnosis of injuries with potentially life-changing physical, emotional, and financial implications. The proportion of such incidents is potentially higher in busy emergency departments and developing countries with fewer dedicated major trauma centers or where focused emergency and trauma training and skills development is still in its infancy. In the last decade, tertiary trauma surveys have been recognized as an important re-assessment protocol in reducing such missed injuries or delayed diagnoses in patients involved in major trauma. This naturally leads to the presumption that tertiary trauma surveys could also play an important role in observational medicine. This also brings into question whether a standardized tertiary trauma survey of major trauma patients on emergency observation units could reduce missed injuries, especially in low-income countries with fewer resources and trauma expertise. Thus, the purpose of this systematic literature review is to explore the potential role of tertiary trauma survey as a tool to reducing missed or delayed diagnosis in the emergency observation units and its applicability and feasibility in less-developed healthcare systems and in low- and middle-income countries. A broad-based systematic literature review was conducted to include electronic databases, grey literature, reference lists, and bibliographies using the keywords: tertiary trauma survey, major trauma, observational medicine, emergency observation units, clinical decision unit, adult, missed injuries, and delayed diagnosis. Over 19,000 citations were identified on initial search. Following a review of abstracts, application of inclusion and exclusion criteria, and review of the full article, 19 publications were finally selected for the purpose of this systematic literature review. Current evidence shows a general trend that tertiary trauma surveys performed 24 hours after admission play an important role in identifying injuries missed at the time of initial primary and secondary survey, and its implementation in observational medicine could prove beneficial, especially in resource-depleted healthcare systems.

Analysis of Missed Skeletal Injuries Detected Using Whole-Body Bone Scan Applied to Trauma Patients: A Case-Control Study

(1) Background: Skeletal injuries may be missed in patients presenting multiple traumas during initial assessment. A whole-body bone scan (WBBS) may aid the detection of missed skeletal injuries, but the current level of research in this regard is insufficient. Thus, this study aimed to investigate whether a WBBS is useful for the detection of missed skeletal injuries in patients with multiple traumas. (2) Methods: This retrospective, single-region, trauma center study was conducted at a tertiary referral center from January 2015 to May 2019. The rate of missed skeletal injuries detected via WBBSs was evaluated, and factors that could influence the outcome were analyzed and divided into missed and not-missed groups. (3) Results: A total of 1658 patients with multiple traumas who underwent WBBSs were reviewed. In the missed group, the percentage of cases with an Injury Severity Score (ISS) ≥ 16 was higher than the not-missed group (74.66% vs. 45.50%). The rate of admission route through surgery and embolization was high in the missed group. Moreover, the proportion of patients that experienced shock in the missed group was higher than that in the not-missed group (19.86% vs. 3.51%). In univariate analysis, ISS ≥ 16, admission route through surgery and embolization, orthopedic surgery involvement, and shock were related to missed skeletal injuries. ISS ≥ 16 was determined to be statistically significant in multivariate analysis. Additionally, a nomogram was constructed based on multivariable analysis. (4) Conclusions: Missed skeletal injuries were significantly associated with several statistical factors, and a WBBS can be used as a screening method to detect missed skeletal injuries in patients with multiple blunt traumas.

A Library of Logic Models to Explain How Interventions to Reduce Diagnostic Errors Work

OBJECTIVES

We aimed to create a library of logic models for interventions to reduce diagnostic error. This library can be used by those developing, implementing, or evaluating an intervention to improve patient care, to understand what needs to happen, and in what order, if the intervention is to be effective.

METHODS

To create the library, we modified an existing method for generating logic models. The following five ordered activities to include in each model were defined: preintervention; implementation of the intervention; postimplementation, but before the immediate outcome can occur; the immediate outcome (usually behavior change); and postimmediate outcome, but before a reduction in diagnostic errors can occur. We also included reasons for lack of progress through the model. Relevant information was extracted about existing evaluations of interventions to reduce diagnostic error, identified by updating a previous systematic review.

RESULTS

Data were synthesized to create logic models for four types of intervention, addressing five causes of diagnostic error in seven stages in the diagnostic pathway. In total, 46 interventions from 43 studies were included and 24 different logic models were generated.

CONCLUSIONS

We used a novel approach to create a freely available library of logic models. The models highlight the importance of attending to what needs to occur before and after intervention delivery if the intervention is to be effective. Our work provides a useful starting point for intervention developers, helps evaluators identify intermediate outcomes, and provides a method to enable others to generate libraries for interventions targeting other errors.

Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative

BACKGROUND

Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS.

METHODS

Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests.

RESULTS

Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009).

CONCLUSION

Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals.

LEVEL OF EVIDENCE

Care management, Level IV.

Trauma Tertiary Survey: Trauma Service Medical Officers and Trauma Nurses Detect Similar Rates of Missed Injuries

BACKGROUND

Trauma tertiary surveys (TTSs) can improve patient outcomes by identifying missed injuries following initial trauma reception and resuscitation. Most TTSs are conducted by medical officers despite the multidisciplinary team approach of modern trauma care.

OBJECTIVE

The study aim was to assess the accuracy of detecting missed injuries when the TTS was performed by specialist trauma nursing staff, rather than trauma service medical officers (TSMOs).

METHODS

A prospective, convenience sample of adult trauma patients admitted to a tertiary trauma center and attended by the trauma service between October 2015 and August 2018 was obtained. For this sample, a TTS was completed by both the TSMO and the trauma nurse (TN). The number of radiological investigations ordered and missed injuries identified were compared between the two clinicians. Additional injuries were graded using the Clavien-Dindo system.

RESULTS

The study sample consisted of 165 patients with a dual TTS, for which at least one team member requested 35 additional radiological investigations. There was fair agreement (κ = 0.36) between the TN and the TSMO in requesting additional radiological investigations. Ten missed injuries were identified by TN-initiated review (n = 24), and 4 missed injuries were identified by TSMO-initiated review (n = 21). Injuries identified following TTSs ranged in severity grading from 0 to 3.

CONCLUSIONS

Performance of the TN on the TTS in the identification of missed injuries is similar to that of the TSMO. Trauma nurses use an appropriate and rationalized approach to ordering additional radiological investigations and contribute a valuable addition to trauma patient care.

Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level I Trauma Center

BACKGROUND

Trauma care per Advanced Trauma Life Support addresses immediate threats to life. Occasionally, delays in injury diagnosis occur. Delayed diagnosis of injury (DDI) is a common quality indicator in trauma care, and pediatric DDI data are sparse.

OBJECTIVE

Our aim was to describe the DDI rate in a severely injured pediatric trauma population and identify any factors associated with DDI in the pediatric population.

METHODS

A prospective cohort of trauma activations in 0- to 16-year-old patients admitted to a pediatric level I trauma center over 12 months with injuries prospectively recorded were followed during admission to identify DDI.

RESULTS

A total of 170 trauma activations were enrolled. Twelve patients had type I DDI (7.1%), 15 patients had type II DDI (8.8%), and 5 patients had both type I and type II DDI (2.9%). DDI patients had twice as many injuries and higher Injury Severity Scores (ISS) as non-DDI patients. DDI patients were more likely to require intensive care unit (ICU) admission, longer hospital stay, and ventilator support. Controlling for age and ISS in multivariate analysis, the number of injuries found and requiring a ventilator were significantly associated with DDI.

CONCLUSIONS

This prospective study found a type I DDI rate of 7.1% and a type II DDI rate of 8.8% in the pediatric population. DDI patients had a greater number of injuries, higher ISS, higher rate of ICU admission, and were more likely to require mechanical ventilation. This study adds prospective data to the pediatric DDI literature, increases provider awareness of pediatric DDI, and lays the foundation for future study and quality improvement.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

The Impact of the Tertiary Survey in an Established Trauma Program

INTRODUCTION

The trauma tertiary survey (TTS) was first described in 1990 and is recognized as an essential practice in trauma care. The TTS remains effective in detecting secondary injuries in the modern era.

METHODS

Trauma patients discharged between August 1, 2016, and December 31, 2016, were identified in our trauma registry. Collected data include TTS completion rates, detection of injuries, type of provider, and timing. TTS documentation was qualitatively evaluated.

RESULTS

Out of 407 patients, 264 patients (65%) received a TTS. Injury detection rate was 1.1.%. Average time to TTS was 41 hours. TTS were completed by resident physicians (46%) and advanced practice providers (APPs; 46%). TTS documentation was more complete for APPs than for resident physicians.

CONCLUSION

TTS remains an integral component of modern trauma care. Ongoing education on the significance of TTS and the importance of thorough documentation is essential. Provision of real-time feedback to providers is also critical for improving current practices.

Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®

PURPOSE

Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®.

METHODS

In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU).

RESULTS

A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries. The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU.

CONCLUSION

In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.

Skeletal surveys lack efficacy in obtunded polytrauma patients

OBJECTIVES

To evaluate if a skeletal survey protocol initiated after 48 hours of intubation will decrease time to diagnosis and the treatment of occult fractures in the obtunded polytrauma patient.

DESIGN

Prospective cohort trial with a retrospective cohort comparison arm.

SETTING

A single level 1 trauma center.

PATIENTS

Forty-seven patients were identified prospectively for the skeletal survey protocol to screen for occult fractures. The results of the new protocol were compared to a retrospective comparison arm of 46 patients who would have met the same criteria.

INTERVENTION

A skeletal survey protocol using 2-view x-rays of the patients' extremities to evaluate for any occult injuries after 48 hours of intubation in trauma patients with altered mental status and an unreliable tertiary examination.

MAIN OUTCOME MEASURE

Time to diagnosis of delayed fractures and surgical intervention from date of admission.

RESULTS

The average time to fracture diagnosis and time to surgical intervention in days was not statistically significant between the retrospective and prospective groups [fracture diagnosis: 1.6 ± 5.1 (retrospective) versus 0.5 ± 0.9 (prospective) (P = .159); time to initial surgery: 2.7 ± 5.6 (retrospective) versus 1.1 ± 1.7 (prospective) (P = .064); time to final surgery: 5.3 ± 8.5 (retrospective) versus 2.4 ± 3.0 (prospective) (P = .029)]. In addition, only 24% (4/17) of patients with a delayed fracture diagnosis required surgical intervention making most nonoperative.

CONCLUSIONS

Given the inability to have a clinically or statistically significant impact on time to fracture diagnosis or subsequent treatment, we cannot advocate for the routine use of a skeletal survey protocol in obtunded polytrauma patients.Level of Evidence: Level III.

ICU Management of Trauma Patients

OBJECTIVES

To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.

DATA SOURCES AND STUDY SELECTION

A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.

DATA EXTRACTION AND DATA SYNTHESIS

The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.

CONCLUSIONS

The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.

Missed injuries in combat casualties: Lessons from Iraq and Afghanistan

INTRODUCTION

Once injured in the battlefield in Iraq and Afghanistan, U.S. and NATO troops receive medical treatment through tiered echelons of care with varying resources, from austere to state-of-the-art. Similar to civilian trauma systems, the aim is to provide rapid and safe patient movement toward definitive management. A consequence of the rapid transfer of patients is the possibility of missed or delayed diagnosis of injuries. With the new injury patterns seen during these conflicts, we aimed to identify and characterize which injuries are missed and what consequences do they have on our troops' road to recovery.

PATIENTS AND METHODS

A retrospective review of a PI database (established 2007) for consecutively admitted combat casualties was performed between 2007-2013. Baseline patient characteristics, injury year, admitting service, injury type, and subsequent management decisions were categorized and analyzed.

RESULTS

There were 301 missed injuries (MI) identified in 248 patients. The annual missed injury rate was 25 per 1000 admissions. Missed injuries were associated with a penetrating mechanism (82.7% vs 58.5%, p < 0.001), ICU admission (58.5% vs 27.4%, p < 0.001), higher ISS (median 14 vs 8, p < 0.001), and a longer length of stay (median 3 versus 2 days, p < 0.001). 194 (64.5%) missed injuries led to a change in management, with 68 (22.6%) requiring a surgical procedure. 1.3% of missed injuries were life threatening, 28.2% major and 65.4% minor. The most common injuries were distal extremity fractures (23.9%), followed by spine fractures (13.3%) and traumatic tympanic membrane rupture (12.6%), There were no deaths attributed to a missed injury.

DISCUSSION

Missed injuries during combat operations occur on a low but consistent basis. Most injuries are orthopedic in nature and typically occur in critically ill patients admitted to the ICU. It is rare that a missed injury results in a life-threatening condition.

CONCLUSION

As healthcare practitioners prepare for future deployments, this analysis may serve as a resource to focus on frequently missed injuries and possibly improve their detection.

Missed foot fractures in multiple trauma patients

Background

Missed or underestimated injuries are one of the central problems in trauma care. Foot injuries can easily be missed because they lay beyond the regularly screened field of a trauma computer tomography scan (CT scan). During primary and secondary survey a careful examination of the extremities often becomes of secondary interest in the severely injured patient.

Methods

Thirty-four thousand ninety-one multiple trauma patients of the TraumaRegister DGU® were evaluated from 2002 to 2014. We differentiated between patients with foot injuries, patients with missed foot injuries and patients without foot injuries. Included were ankle fractures, calcaneus fractures, talus fractures, metatarsal fractures, toe fractures, amputation, soft tissue injuries and/or ligamentous injuries.

Results

Summarized evaluation of 34,091 trauma patients showed a share of 2532 patients with foot injuries. Time of diagnosis was documented in 2199 cases. 2055 patients had early diagnosed foot injuries and 144 patients had initially missed foot injuries. Missed foot injuries were especially found in patients with car accidents or fall from ≥3 m. Patients with higher Abbreviated Injury Scale (AIS) or lower Glasgow Coma Scale (GCS) were not significantly more affected by missed foot injuries. Missing foot injuries was also not caused by injury severity or higher age.

Conclusions

Our data highlights the need of careful evaluation of the feet during primary and secondary survey particularly when a tibia or femur fracture is diagnosed. Special attention should be turned to patients after car accidents or fall from great height. Suicide victims also need major attention. Patients with early operations also need careful examination and tertiary survey is highly recommended.

Whole-Body CT in Patients with Multiple Traumas: Factors Leading to Missed Injury

Purpose To determine radiologic and clinical markers predictive of missed injuries at early whole-body CT image interpretation. Materials and Methods For this retrospective study, 2354 consecutive whole-body CT examinations were performed in patients with multiple traumas from 26 hospitals interpreted at a teleradiology center study during on-call period from February 2011 to September 2016. All whole-body CT images were interpreted by the on-call radiologist and reviewed within 12-48 hours by another radiologist to detect missed injury as the standard of reference. The first and review reports of all examinations were retrospectively reviewed. Univariable and multivariable logistic regression with a stepwise selection method were performed to identify clinical and radiologic predictors of missed injury. Results This study included 639 women (27.1%) and 1715 men (72.8%). The median age of men, women, and the entire population was 34 years (age range, 1-96 years). On a per-scan basis, there were 304 (12.9%) missed injuries and 59 (2.5%) were clinically significant. On a per-injury basis, the missed injury rate was 530 of 5979 (8.8%). More than two injured body parts (odds ratio, 1.4 [95% confidence interval: 1.1, 1.8]; P = .01), patient age older than 30 years (odds ratio, 2.8 [95% confidence interval: 2.1, 3.8]; P < .001), and an initial clinical severity class of 1 (odds ratio, 1.9 [95% confidence interval: 1.3, 2.8]; P < .001) were independent predictive factors of missed injury. Conclusion Multiple traumas with more than two injured body parts, age older than 30 years, or an initial clinical severity class of 1 were associated with missed injury at whole-body CT. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Novelline in this issue.

Maxillofacial and concomitant serious injuries: An eight-year single center experience

PURPOSE

Maxillofacial injuries are frequently associated with multiple trauma and can determine functional and aesthetic bad outcomes. The severity of maxillofacial injuries may be considerable and can divert clinicians' attention from other concomitant injuries which is less evident but potentially life-threatening. The aim of this study was to find out the concomitant injuries in patients referred to the Emergency Department (ED) of the University Hospital of Messina (North-East Sicily, Italy) for maxillofacial traumas.

METHODS

We retrospectively evaluated data of 240,833 patients admitted at the ED of the University Hospital of Messina from January 2008 to December 2015 because of maxillofacial injuries leading to hospitalization and surgical treatment. Patients who primarily received treatment care at different institutions, pediatric trauma patients and adult patients who were transferred in accordance with pre-existing agreements in case of paucity of beds were excluded. Finally we included 447 (0.2%) patients over the 8 years. Data were evaluated with emphasis on epidemiology (age, gender, mechanism of trauma), primary survey and abnormalities and pattern of trauma.

RESULTS

The most frequent cause of maxillofacial trauma was road accidents (319 patients, 71.4%), among which motorcycle ones were prevalent. The maxillofacial injured who presented major lesions were 98 patients and minor lesions occurred in 349 patients; 443 (99.1%) patients underwent maxillofacial surgery, immediate or delayed depending on the severity of concomitant injuries (χ² = 557.2, p < 0.0001). Five concomitant neglected lesions were found to be associated with severe maxillofacial traumas (χ² = 17.13, p < 0.0001 vs minor lesions). All of the neglected lesions occurred in paucisymptomatic patients who showed painless abdomen, no hemodynamic instability, no signs of hematoma of anterior and posterior abdominal wall or other suspicious clinical signs and symptoms.

CONCLUSION

Among the patients admitted firstly in other surgical wards different from the Maxillofacial Surgery Unit, diagnosis was more difficult, especially for blunt abdominal traumas, in which patients showed only vague and nonspecific symptoms concealing serious and life-threatening injuries. We recommend the routine use of whole body CT scan, when the maxillofacial injuries appear prevalent, mainly in patients affected by maxillofacial major lesions.

Missed Injuries in Polytrauma Patients after Trauma Tertiary Survey in Trauma Intensive Care Unit

BACKGROUND AND AIMS

Injuries are often missed during the primary and secondary surveys in trauma patients. Studies have suggested that a formal tertiary survey protocol lowers the number of missed injuries. Our aim was to determine the number, severity, and consequences of injuries missed by a non-formalized trauma tertiary survey, but detected within 3 months from the date of injury in trauma patients admitted to a trauma intensive care unit.

MATERIAL AND METHODS

We conducted a cohort study of trauma patients admitted to a trauma intensive care unit between 1 January and 17 October 2013. We reviewed the electronic medical records of patients admitted to the trauma intensive care unit in order to register any missed injuries, their delay, and possible consequences. We classified injuries into four types: Type 0, injury detected prior to trauma tertiary survey; Type I, injury detected by trauma tertiary survey; Type II, injury missed by trauma tertiary survey but detected prior to discharge; and Type III, injury missed by trauma tertiary survey and detected after discharge.

RESULTS

During the study period, we identified a total of 841 injuries in 115 patients. Of these injuries, 93% were Type 0 injuries, 3.9% were Type I injuries, 2.6% were Type II injuries, and 0,1% were Type III injuries. Although most of the missed injuries in trauma tertiary survey (Type II) were fractures (50%), only 2 of the 22 Type II injuries required surgical intervention. Type II injuries presumably did not cause extended length of stay in the intensive care unit or in hospital and/or morbidity.

CONCLUSION

In conclusion, the missed injury rate in trauma patients admitted to trauma intensive care unit after trauma tertiary survey was very low in our system without formal trauma tertiary survey protocol. These missed injuries did not lead to prolonged hospital or trauma intensive care unit stay and did not contribute to mortality. Most of the missed injuries received non-surgical treatment.

Tertiary survey in polytrauma patients should be an ongoing process

INTRODUCTION

Due to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients.

METHODS

In this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥ 16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI.

RESULTS

1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2-2.7), abdominal injury (OR 1.5, 95% CI 1.1-2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6-3.3) were independent risk factors for DDI.

CONCLUSION

In polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.

Meta-analysis of the effect of tertiary survey on missed injury rate in trauma patients

BACKGROUND

Missed injuries are considered as an important issue in trauma patients and can lead to significant morbidity and even mortality. It has been shown that the standard primary and secondary surveys, recommended by the Advanced Trauma Life Support (ATLS) guidelines, are associated with missed injuries. It has been suggested that tertiary survey can minimise the number and effect of missed injuries. The present paper aimed to identify comparative evidence about the effect of tertiary survey on missed injury rate in trauma patients.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies evaluating effect of tertiary survey on missed injury rate in trauma patients. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Random-effects models were applied to calculate pooled outcome data.

RESULTS

Four prospective and three retrospective cohort studies, enrolling a total of 12,581 trauma patients, were selected for analysis. Pooled odds ratio (OR) analysis of 5727 patients showed that detection of missed injuries was better in trauma patients who had tertiary survey compared to patients who did not have tertiary survey [OR=2.65, (95% CI:1.40-5.01), P=0.003]. A moderate level of heterogeneity among the studies existed (I(2)=68%, P=0.008). Also, analysis of 6,854 patients showed that fewer injuries were missed in trauma patients who had tertiary survey compared to patients who did not have tertiary survey [OR=0.63, (95% CI: 0.44-0.90), P=0.01].

CONCLUSIONS

The best available evidence demonstrates a constant trend in favour of tertiary survey in terms of missed injury reduction, and supports its use in management of trauma patients. Further studies are required to clarify the most cost-effective and systematic way of addressing missed injuries in the first 24h. We recommend use of "missed injury detection rate" and "missed injury rate" as two different outcomes in future studies in order to address the issue of heterogeneity in definition of missed injury in the current literature.

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial

Background

Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge.

Methods/Design

We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality.

Discussion

The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders.

Trial registration

ANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0733-y) contains supplementary material, which is available to authorized users.

Office hours vs after-hours. Do presentation times affect the rate of missed injuries in trauma patients?

BACKGROUND

A number of studies have investigated the effect of presentation time on the outcome of patients presenting following trauma. However, it is uncertain whether there is a difference in the incidence of missed injuries between patients presenting during 'office hours' to those presenting in the 'after-hours' period.

MATERIALS AND METHODS

We analysed all patients recorded in the Trauma Registry of Royal Perth Hospital (a Level I Trauma Centre for adults in Western Australia) between 2003 and 2013. Patients were divided into 3 groups i.e. those presenting during office hours, those presenting 'after-hours' on a weekday and those presenting on a weekend. In 2008, the State Major Trauma Unit (SMTU) at RPH was initiated following which in-hospital cover by the Trauma Fellows was extended to 11 PM on weekdays. The study was therefore divided into two time periods i.e. pre-SMTU (2003-2007) and post-SMTU (2008-2013).

RESULTS

53,030 patients were recorded in the Trauma Registry in the 10-year period (major and minor trauma). There were 2519 missed injuries in 1262 patients (2.4%). Of these, 2.2% patients presented during office hours, 2.6% 'after-hours on a weekday' and 2.5% on weekends. The odds of missing an injury were 1.2 times higher if the patient presented after-hours (p=0.048). Missed injury rates were found to have increased over the past 10 years (p=0.0179). The odds of missing an injury in 2013 were 1.34 times higher than in 2003. Most of the missed injuries were AIS 1 and 2 (19.8 and 59%) and 55% had no clinical impact on the patients. Thoracic Spine and abdominal injuries were most commonly missed. The only region to show a significant difference between the 3 groups of patients studied was the abdomen (5.3% vs 11.1% vs 6.3%; p=0.004). It was also seen that a larger number of hollow viscus abdominal injuries (5.2%) were missed when compared to solid organs (3.2%; p<0.001).

CONCLUSION

Injuries in patients sustaining trauma are more likely to be missed 'after-hours' than during 'office hours'. T-spine and abdominal injuries are more likely to be missed when compared to other anatomical regions of the body.