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Pervez T, Malik M. Tertiary Trauma Survey on Emergency Department Observational Units: A Systematic Literature Review. Cureus 2024; 16:e53187. [PMID: 38425587 PMCID: PMC10901675 DOI: 10.7759/cureus.53187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
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.
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Affiliation(s)
- Tamkeen Pervez
- Emergency Medicine, Combined Military Hospital, Rawalpindi, PAK
| | - Mehreen Malik
- Family Medicine, Heavy Industries Taxila (HIT) Hospital, Taxila, PAK
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Selçuk H, Oray N, Mert RM, Odaman H, Güleryüz H. Evaluation of Missed Radiological Diagnosis in Multiple Trauma Patients With Full-Body Computed Tomography in the Emergency Department. Cureus 2024; 16:e51621. [PMID: 38318559 PMCID: PMC10839344 DOI: 10.7759/cureus.51621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION This observational, cross-sectional, and retrospective study was conducted at the Dokuz Eylül University Emergency Department in İzmir, Turkey, after obtaining ethical consent (Dokuz Eylül University Medical Faculty Ethics Committee, approval no. 2019/15-37). In this study, we aimed to determine missed radiological diagnoses and their effects on mortality and morbidity by comparing the ED diagnoses of patients and radiology reports of these patients who presented to the emergency department (ED) with multiple traumas and scanned full-body computed tomography (CT). MATERIALS AND METHODS This observational, cross-sectional, and retrospective study was conducted at the Dokuz Eylül University Emergency Department in İzmir, Turkey. Adult patients who presented to the ED with trauma between July 1, 2016 and June 30, 2018 and who had a full-body CT were included in the study. Radiology reports of CTs and ED electronic file information were compared. Missed diagnoses were determined for all body parts. RESULTS In this study, 1,358 patients who had scanned full-body CT in the ED were evaluated. A total of 369 diagnoses were missed in 248 (18.3%) of the patients. The diagnosis-to-patient ratio was 0.27. In the process of individually evaluating pathological diagnoses in all body regions, it was low only in brain edema, pneumomediastinum, bladder injury, and mesentery injury. At least, there was one missed diagnosis in 88 (9.7%) of 907 (66.8%) discharged patients. At least, there was one missed diagnosis in 18/23 (78.3%) patients who died within the first 48 hours. Among the patients who have missed diagnosis, the rate of the discharged patients was 35.5%, patients called back from home was 1.2%, intensive care unit admission was 20.2%, hospitalization was 65.7%, and death was 8.9%. Among the patients who did not have missed diagnosis, the rates were 73.8%, 0%, 5%, 26.9%, and 0.8%, respectively. CONCLUSION Thoracic region pathologies are the most frequently missed pathologies, and orthopedics was the most frequently consulted department related to the missed diagnoses. Patients who have a missed diagnosis had lesser discharging from the ED than the other patients and had higher rates of in-hospital deaths, hospitalization, and intensive care unit admission.
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Affiliation(s)
- Hakan Selçuk
- Emergency Department, Babaeski State Hospital, Kırklareli, TUR
| | - Nese Oray
- Emergency Medicine, Dokuz Eylül University Faculty of Medicine, Izmir, TUR
| | - Recep M Mert
- Emergency Medicine, Dokuz Eylül University Hospital, Izmir, TUR
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Ulloa E, Archie J, Slevakumar S, Levy M, Elkbuli A, Plumley D. The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care. Am Surg 2023; 89:5786-5794. [PMID: 37158806 DOI: 10.1177/00031348231175111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Patients are at risk of missed or delayed injuries in the setting of multisystem trauma, which may be identified with a tertiary trauma survey (TTS). There is limited literature to support the utilization of a TTS in pediatric trauma population. We aim to assess the impact of the TTS as a quality and performance improvement tool in identifying missed or delayed injuries and improving the quality of care among pediatric trauma population. METHODS A retrospective study assessing a quality improvement/performance improvement (QI/PI) project focusing on the administration of tertiary surveys to pediatric trauma patients was conducted at our level 1 trauma center between 08-2020 and 08-2021. Patients with injury severity scores (ISS) greater than 12 and/or an anticipated hospital stay greater than 72 hours met inclusion criteria and were included. RESULTS Of the 535 trauma patients admitted to the pediatric trauma service during the study period, 85 (16%) patients met the criteria and received a TTS. Thirteen unaddressed or undertreated injuries were found in 11 patients: 5 cervical spine injuries, 1 subdural hemorrhage, 1 bowel injury, 1 adrenal hemorrhage, 1 kidney contusion, 2 hematomas, and 2 full thickness abrasions. Following TTS, 13 patients (15%) had additional imaging, which identified 6 of the 13 injuries. CONCLUSION The TTS is a valuable quality and performance improvement tool in the comprehensive care of trauma patients. Standardization and implementation of a tertiary survey have the potential to facilitate the prompt detection of injuries and improve the quality of care for pediatric trauma patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Emily Ulloa
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
| | - Jessica Archie
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
| | - Sruthi Slevakumar
- NSU NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Marc Levy
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
| | - Donald Plumley
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
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Hose BZ, Carayon P, Hoonakker PLT, Ross JC, Eithun BL, Rusy DA, Kohler JE, Brazelton TB, Dean SM, Kelly MM. Managing multiple perspectives in the collaborative design process of a team health information technology. APPLIED ERGONOMICS 2023; 106:103846. [PMID: 35985249 PMCID: PMC10024924 DOI: 10.1016/j.apergo.2022.103846] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
We need to design technologies that support the work of health care teams; designing such solutions should integrate different clinical roles. However, we know little about the actual collaboration that occurs in the design process for a team-based care solution. This study examines how multiple perspectives were managed in the design of a team health IT solution aimed at supporting clinician information needs during pediatric trauma care transitions. We focused our analysis on four co-design sessions that involved multiple clinicians caring for pediatric trauma patients. We analyzed design session transcripts using content analysis and process coding guided by Détienne's (2006) co-design framework. We expanded upon Détienne (2006) three collaborative activities to identify specific themes and processes of collaboration between care team members engaged in the design process. The themes and processes describe how team members collaborated in a team health IT design process that resulted in a highly usable technology.
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Affiliation(s)
- Bat-Zion Hose
- Department of Anesthesiology and Critical Care at the Perelman School of Medicine, University of Pennsylvania, USA.
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA; Wisconsin Institute for Health Systems Engineering, University of Wisconsin-Madison, USA
| | - Peter L T Hoonakker
- Wisconsin Institute for Health Systems Engineering, University of Wisconsin-Madison, USA
| | - Joshua C Ross
- American Family Children's Hospital, UW Health, USA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, USA
| | | | - Deborah A Rusy
- American Family Children's Hospital, UW Health, USA; Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, USA
| | | | - Thomas B Brazelton
- American Family Children's Hospital, UW Health, USA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, USA
| | | | - Michelle M Kelly
- American Family Children's Hospital, UW Health, USA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, USA
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Tougas C, Brimmo O. Common and Consequential Fractures That Should Not Be Missed in Children. Pediatr Ann 2022; 51:e357-e363. [PMID: 36098608 DOI: 10.3928/19382359-20220706-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Missed or delayed diagnosis of fractures in children is not uncommon owing to their immature skeletons, unique fracture patterns, and distinctive radiologic findings. The term occult is used to describe radiographically subtle fractures. Some of these fractures can be associated with excellent outcomes despite the pitfalls of delayed diagnosis. However, a subset of these injuries have more guarded prognoses when missed, despite their harmless radiographic appearance. A high index of suspicion should be maintained when treating pediatric extremity injuries with clinical findings disproportionate to a benign-appearing radiograph. Moreover, overreliance on radiology reports can perpetuate diagnostic error. In cases of discrepancy, timely follow-up for repeat examination or immediate advanced imaging can help avoid missed diagnoses. Most critically, the one diagnosis not to miss is nonaccidental trauma, as continued exposure to abuse puts the child at risk of further injury and death. [Pediatr Ann. 2022;51(9):e357-e363.].
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Holmstrom AL, Ott KC, Weiss HK, Ellis RJ, Hungness ES, Shapiro MB, Yang AD. Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative. J Trauma Acute Care Surg 2021; 90:1048-1053. [PMID: 34016928 DOI: 10.1097/ta.0000000000003152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Amy L Holmstrom
- From the Department of Surgery (A.L.H., K.C.O., H.K.W., R.J.E., E.S.H., M.B.S., A.D.Y.), Feinberg School of Medicine, and Surgical Outcomes and Quality Improvement Center (R.J.E., A.D.Y.), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Lowe G, Tweed J, Cooper M, Qureshi F, Huang C. Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level I Trauma Center. J Emerg Med 2021; 60:583-590. [PMID: 33487519 DOI: 10.1016/j.jemermed.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/20/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Geoffrey Lowe
- Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | | | - Michael Cooper
- Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Faisal Qureshi
- Pediatric Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Craig Huang
- Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
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Seo Y, Whang K, Pyen J, Choi J, Kim J, Oh J. Missed Skeletal Trauma Detected by Whole Body Bone Scan in Patients with Traumatic Brain Injury. J Korean Neurosurg Soc 2020; 63:649-656. [PMID: 32883059 PMCID: PMC7477155 DOI: 10.3340/jkns.2020.0171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Unclear mental state is one of the major factors contributing to diagnostic failure of occult skeletal trauma in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the overlooked co-occurring skeletal trauma through whole body bone scan (WBBS) in TBI. METHODS A retrospective study of 547 TBI patients admitted between 2015 and 2017 was performed to investigate their cooccurring skeletal injuries detected by WBBS. The patients were divided into three groups based on the timing of suspecting skeletal trauma confirmed : 1) before WBBS (pre-WBBS); 2) after the routine WBBS (post-WBBS) with good mental state and no initial musculoskeletal complaints; and 3) after the routine WBBS with poor mental state (poor MS). The skeletal trauma detected by WBBS was classified into six skeletal categories : spine, upper and lower extremities, pelvis, chest wall, and clavicles. The skeletal injuries identified by WBBS were confirmed to be simple contusion or fractures by other imaging modalities such as X-ray or computed tomography (CT) scans. Of the six categorizations of skeletal trauma detected as hot uptake lesions in WBBS, the lesions of spine, upper and lower extremities were further statistically analyzed to calculate the incidence rates of actual fractures (AF) and actual surgery (AS) cases over the total number of hot uptake lesions in WBBS. RESULTS Of 547 patients with TBI, 112 patients (20.4 %) were presented with TBI alone. Four hundred and thirty-five patients with TBI had co-occurring skeletal injuries confirmed by WBBS. The incidences were as follows : chest wall (27.4%), spine (22.9%), lower extremities (20.2%), upper extremities (13.5%), pelvis (9.4%), and clavicles (6.3%). It is notable that relatively larger number of positive hot uptakes were observed in the groups of post-WBBS and poor MS. The percentage of post-WBBS group over the total hot uptake lesions in upper and lower extremities, and spines were 51.0%, 43.8%, and 41.7%, respectively, while their percentages of AS were 2.73%, 1.1%, and 0%, respectively. The percentages of poor MS group in the upper and lower extremities, and spines were 10.4%, 17.4%, and 7.8%, respectively, while their percentages of AS were 26.7%, 14.2%, and 11.1%, respectively. There was a statistical difference in the percentage of AS between the groups of post-WBBS and poor MS (p=0.000). CONCLUSION WBBS is a potential diagnostic tool in understanding the skeletal conditions of patients with head injuries which may be undetected during the initial assessment.
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Affiliation(s)
- Yongsik Seo
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wouju, Korea
| | - Kum Whang
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wouju, Korea
| | - Jinsu Pyen
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wouju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wouju, Korea
| | - Joneyeon Kim
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wouju, Korea
| | - Jiwoong Oh
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
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Orun S, Akoz A, Duman A, Ahmet Turkdogan K, Türe M, Unlu D. Delayed injuries in the emergency department in hospitalised trauma patients. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619837845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Busy emergency departments are associated with medical errors in care and evaluation for unstable trauma patients. Our study aimed to determine the extent, causes and adverse clinical consequences of missed injuries and delayed diagnoses in patients hospitalised with trauma in a Turkish Level 3 emergency department, and provide recommendations for emergency service workers and supervisors to help them reduce the number of injury diagnoses that are delayed. Methods In our prospective study, a total of 515 emergency department patients presenting with trauma between 1 July 2014 and 1 July 2015 were examined by an emergency physician and by a consultant, if necessary. Identified injuries were recorded using case forms, and hospitalised patients were discharged when their treatment was completed. After the patients were discharged their files were reviewed again and new injuries, different from those recorded in the case forms, were investigated. Results Of the 515 patients included, it was shown that an injury diagnosis had been delayed in 21 (3.9%). Of these injuries, 65% were related to the musculoskeletal system. Insufficient clinical evaluation of 95% of the patients who had a missed injury was identified, and, in 70% of missed injuries, the radiology reports had been delayed or incorrectly completed. Conclusion We believe that the delayed injury rate can be reduced in trauma patients with the use of fast and reliable radiological support and the intervention of a multidisciplinary trauma team.
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Affiliation(s)
- Serhat Orun
- Department of Emergency Medicine, Medical Faculty, Namık Kemal University, Tekirdağ, Turkey
| | - Ayhan Akoz
- Department of Emergency Medicine, Medical Faculty, Adnan Menderes University, Aydın, Turkey
| | - Ali Duman
- Department of Emergency Medicine, Medical Faculty, Adnan Menderes University, Aydın, Turkey
| | - Kenan Ahmet Turkdogan
- Department of Emergency Medicine, Medical Faculty, Adnan Menderes University, Aydın, Turkey
| | - Mevlüt Türe
- Department of Biostatistics, Medical Faculty, Adnan Menderes University, Aydın, Turkey
| | - Derya Unlu
- Department of Emergency Medicine, Bandırma State Hospital, Bandırma, Turkey
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High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients. Eur J Trauma Emerg Surg 2019; 46:1367-1374. [PMID: 31399747 DOI: 10.1007/s00068-019-01195-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Missed injuries are reported in 1.3-65% of all admitted trauma patients. The severely injured patient that needs a higher level of care which requires an inter-hospital transfer has an increased risk for missed injuries. The aim of this study was to establish the incidence and clinical relevance of missed injuries in severely injured patients who require inter-hospital transfer to a level 1 trauma center. METHODS All patients with an Injury Severity Score (ISS) ≥ 16 transferred to the University Medical Center Groningen (UMCG) between January 2010 and July 2015 were included. Data were obtained from a prospective trauma database and supplemented with information from the patient records. A delayed diagnosis was defined as any injury detected within the first 24 h after the initial trauma, with or without a tertiary survey. Missed diagnoses were defined as any injury diagnosed after 24 h following trauma. RESULTS Two hundred and fifty-one trauma patients were included. A total of 88 patients (35%) were found to have ≥ 1 new diagnoses with 65 (26%) patients that had 1 or more delayed diagnoses and 23 (9.2%) patients had 1 or more missed diagnoses (detected > 24 h after injury) after transfer to our hospital. For 47 of the 88 patients (53%), the new diagnoses required a change of management. The Glasgow Coma Scale (GCS) was the only statistically significant risk factor for a new diagnosis upon transfer. CONCLUSIONS Inter-hospital transfer of severely injured patients increases the risk of a delayed detection of injuries. We found that 35% of all transferred patients with an ISS ≥ 16 have at least new diagnoses, with over half of these diagnoses requiring a change of management. Given these findings, clinicians should maintain a high index of suspicion when receiving a transferred severely injured trauma patient.
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Hose BZ, Hoonakker PLT, Wooldridge AR, Brazelton III TB, Dean SM, Eithun B, Fackler JC, Gurses AP, Kelly MM, Kohler JE, McGeorge NM, Ross JC, Rusy DA, Carayon P. Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care. Appl Clin Inform 2019; 10:113-122. [PMID: 30759492 PMCID: PMC6374147 DOI: 10.1055/s-0039-1677737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. METHODS We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline. RESULTS We identified five goals of the PL (to document the patient's problems, to make sense of the patient's problems, to make decisions about the care plan, to know who is involved in the patient's care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians' suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information. CONCLUSION Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patient's medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patient's electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patient's immediate problems.
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Affiliation(s)
- Bat-Zion Hose
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Peter L. T. Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Abigail R. Wooldridge
- Department of Industrial & Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois, United States
| | - Thomas B. Brazelton III
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Shannon M. Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Ben Eithun
- American Family Children’s Hospital, University of Wisconsin School of medicine and Public Health, Madison, Wisconsin, United States
| | - James C. Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States
| | - Ayse P. Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States
- Department of Anesthesiology and Critical Care Medicine, School of Medicine; Department of Health Sciences Informatics, School of Medicine; Department of Health Policy and Management, Bloomberg School of Public Health; Carey Business School; Malone Center for Engineering in Healthcare, Whiting School of Engineering; Johns Hopkins University, Baltimore, Maryland, United States
| | - Michelle M. Kelly
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, United States
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Jonathan E. Kohler
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Nicolette M. McGeorge
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Joshua C. Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Deborah A. Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, United States
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Abstract
OBJECTIVE Determine the incidence of the delayed diagnosis of orthopaedic injuries in pediatric trauma patients. DESIGN Cross-sectional retrospective analysis. SETTING Level I pediatric trauma center. PATIENTS/PARTICIPANTS All patients with an orthopaedic consultation after a trauma activation with a diagnosis of fracture, dislocation, traumatic arthrotomy, neurovascular injury, amputation, and tendon or ligament injury requiring intervention. A total of 1009 trauma codes and alerts occurred during the study period, of which 196 patients were diagnosed with an orthopaedic injury. INTERVENTION Charts were reviewed to obtain demographic information, time of presentation, Glasgow Coma Score (GCS) on presentation, injury severity score (ISS), mechanism of injury, intubation status, length of intensive care unit and hospital stay, primary and secondary survey diagnoses, discharge diagnoses, time of additional diagnoses, and reason for delayed diagnosis. MAIN OUTCOME MEASURES Incidence of delayed diagnosis of injury (DDI). RESULTS There were 196 patients with a confirmed orthopaedic injury, of which, 18 were classified as a delayed diagnosis (9.18%). The mean time to detection of injury was 77.46 hours and the mean patient age was 132.22 months. One of the 18 patients required surgical intervention while the rest were treated conservatively. The mean GCS score of patients with a DDI were significantly lower than patients without a missed injury, 12 versus 14.19 (P = 0.0009). The median ISS, 21 versus 9 (P = 0.0021), and median hospital length of stay, 4 days versus 3 days (P = 0.0369) were significantly higher for patients with a missed injury compared with those without a missed injury. The intensive care unit length of stay approached significance with a median of 2 days for patients with a missed injury versus 1 day for patients without a missed injury (P = 0.057). CONCLUSIONS In our study, factors that were associated with a DDI included lower GCS, higher ISS, and greater hospital length of stay. There was only 1 missed injury that required surgical intervention, and the remainder were treated conservatively. The initial evaluation of the trauma patient is able to detect life-threatening injuries, but the tertiary survey remains an important part of patient care to detect missed injuries. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Choi PM, Yu J, Keller MS. Missed injuries and unplanned readmissions in pediatric trauma patients. J Pediatr Surg 2017; 52:382-385. [PMID: 27839721 PMCID: PMC5409520 DOI: 10.1016/j.jpedsurg.2016.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/28/2016] [Accepted: 10/11/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. METHODS We conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014. RESULTS Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p<0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. CONCLUSIONS Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Pamela M Choi
- Division of Pediatric Surgery, St. Louis Children's Hospital, Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
| | - Jennifer Yu
- Division of Pediatric Surgery, St. Louis Children's Hospital, Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
| | - Martin S Keller
- Division of Pediatric Surgery, St. Louis Children's Hospital, Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
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Hajibandeh S, Hajibandeh S, Idehen N. Meta-analysis of the effect of tertiary survey on missed injury rate in trauma patients. Injury 2015; 46:2474-82. [PMID: 26517956 DOI: 10.1016/j.injury.2015.09.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/21/2015] [Accepted: 09/22/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Shahab Hajibandeh
- Accident and Emergency Department, Queen's Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom.
| | - Shahin Hajibandeh
- Accident and Emergency Department, Blackpool Victoria Hospital, 38 Whinney Heys Rd, Blackpool, Lancashire FY3 8NR, United Kingdom
| | - Nosakhare Idehen
- Accident and Emergency Department, Blackpool Victoria Hospital, 38 Whinney Heys Rd, Blackpool, Lancashire FY3 8NR, United Kingdom
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Keijzers GB, Del Mar C, Geeraedts LMG, Byrnes J, Beller EM. 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. Trials 2015; 16:215. [PMID: 25968303 PMCID: PMC4449594 DOI: 10.1186/s13063-015-0733-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 04/24/2015] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Gerben B Keijzers
- Emergency Physician, Staff Specialist, Emergency Department, Gold Coast Health Service District, Emergency Department, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, QLD, Australia. .,Assistant Professor, School of Medicine, Bond University, University Drive, Robina, Gold Coast, 4226, QLD, Australia. .,Associate Professor, School of Medicine, Griffith University, University Drive, Robina, Gold Coast, 4226, QLD, Australia.
| | - Chris Del Mar
- Professor of Public Health, School of Medicine, Bond University, University Drive, Robina, Gold Coast, 4226, QLD, Australia.
| | - Leo M G Geeraedts
- Trauma Surgeon, Department of Surgery, VU University Medical Centre, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Joshua Byrnes
- Griffith Health Institute, Griffith University, Gold Coast Campus, Gold Coast, 4222, QLD, Australia. .,Centre for Applied Health Economics, School of Medicine, Griffith University, Meadowbrook, 4131, QLD, Australia.
| | - Elaine M Beller
- Statistician, Associate Professor, Centre for Research in Evidence-based practice, Bond University, University Drive, Robina, Gold Coast, 4226, QLD, Australia.
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A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey. World J Surg 2014; 38:222-32. [PMID: 24081533 PMCID: PMC3889299 DOI: 10.1007/s00268-013-2226-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective This study prospectively evaluated in-hospital and postdischarge missed injury rates in admitted trauma patients, before and after the formalisation of a trauma tertiary survey (TTS) procedure.
Methods Prospective before-and-after cohort study. TTS were formalised in a single regional level II trauma hospital in November 2009. All multitrauma patients admitted between March–October 2009 (preformalisation of TTS) and December 2009–September 2010 (post-) were assessed for missed injury, classified into three types: Type I, in-hospital, (injury missed at initial assessment, detected within 24 h); Type II, in-hospital (detected in hospital after 24 h, missed at initial assessment and by TTS); Type III, postdischarge (detected after hospital discharge). Secondary outcome measures included TTS performance rates and functional outcomes at 1 and 6 months.
Results A total of 487 trauma patients were included (pre-: n = 235; post-: n = 252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8 vs. 4.8 %, P = 0.61), as were postdischarge missed injury rates (Type III) at 1 month (13.7 vs. 11.5 %, P = 0.43), and 6 months (3.8 vs. 3.3 %, P = 0.84) after discharge. TTS performance was substantially higher in the post-group (27 vs. 42 %, P < 0.001). Functional outcomes for both cohorts were similar at 1 and 6 months follow-up. Conclusions This is the first study to evaluate missed injury rates after hospital discharge and demonstrated cumulative missed injury rates >15 %. Some of these injuries were clinically relevant. Although TTS performance was significantly improved by formalising the process (from 27 to 42 %), this did not decrease missed injury rates.
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Sener MT, Kok AN, Kara C, Anci Y, Sahingoz S, Emet M. Diagnosing isolated nasal fractures in the emergency department: are they missed or overdiagnosed? Ten years experience of 535 forensic cases. Eur J Trauma Emerg Surg 2014; 40:715-9. [DOI: 10.1007/s00068-014-0373-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 01/02/2014] [Indexed: 11/24/2022]
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Pfeifer R, Pape HC. The Missed Injury: A ‘Preoperative Complication’. Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Nishijima DK, Yang Z, Clark JA, Kuppermann N, Holmes JF, Melnikow J. A cost-effectiveness analysis comparing a clinical decision rule versus usual care to risk stratify children for intraabdominal injury after blunt torso trauma. Acad Emerg Med 2013; 20:1131-8. [PMID: 24238315 DOI: 10.1111/acem.12251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 05/22/2013] [Accepted: 06/10/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Recently a clinical decision rule (CDR) to identify children at very low risk for intraabdominal injury needing acute intervention (IAI) following blunt torso trauma was developed. Potential benefits of a CDR include more appropriate abdominal computed tomography (CT) use and decreased hospital costs. The objective of this study was to compare the cost-effectiveness of implementing the CDR compared to usual care for the evaluation of children with blunt torso trauma. The hypothesis was that compared to usual care, implementation of the CDR would result in lower CT use and hospital costs. METHODS A cost-effectiveness decision analytic model was constructed comparing the costs and outcomes of implementation of the CDR to usual care in the evaluation of children with blunt torso trauma. Probabilities from a multicenter cohort study of children with blunt torso trauma were derived; estimated costs were based on those at the study coordinating site. Outcome measures included missed IAI, number of abdominal CT scans, total costs, and incremental cost-effectiveness ratios. Sensitivity analyses varying imputed probabilities, costs, and scenarios were conducted. RESULTS Using a hypothetical cohort of 1,000 children with blunt torso trauma, the base case model projected that the implementation of the CDR would result in 0.50 additional missed IAIs, a total cost savings of $54,527, and 104 fewer abdominal CT scans compared to usual care. The usual care strategy would cost $108,110 to prevent missing one additional IAI. Findings were robust under multiple sensitivity analyses. CONCLUSIONS Compared to usual care, implementation of the CDR in the evaluation of children with blunt torso trauma would reduce hospital costs and abdominal CT imaging, with a slight increase in the risk of missed intraabdominal IAI.
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Affiliation(s)
- Daniel K. Nishijima
- Department of Emergency Medicine; U.C. Davis School of Medicine; Sacramento CA
| | - Zhuo Yang
- Center for Healthcare Policy and Research; U.C. Davis School of Medicine; Sacramento CA
| | - John A. Clark
- Center for Healthcare Policy and Research; U.C. Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; U.C. Davis School of Medicine; Sacramento CA
- Department of Pediatrics; U.C. Davis School of Medicine; Sacramento CA
| | - James F. Holmes
- Department of Emergency Medicine; U.C. Davis School of Medicine; Sacramento CA
| | - Joy Melnikow
- Center for Healthcare Policy and Research; U.C. Davis School of Medicine; Sacramento CA
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Roessle TR, Freitas CD, Moscovici HF, Zamboni C, Hungria JOS, Christian RW, Mercadante MT. Tertiary assessment of trauma patients in a hospital in the city of São Paulo: a question of necessity. Rev Bras Ortop 2013; 48:357-361. [PMID: 31304133 PMCID: PMC6565909 DOI: 10.1016/j.rboe.2012.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/20/2012] [Indexed: 11/20/2022] Open
Abstract
Objective To minimize the occurrence of missed injuries, the tertiary evaluation was introduced consisting of reassessment of the patient, 24 hours after admission, with: complete history, physical examination, review of exams and diagnostic testing if necessary. Methods Observational study evaluating trauma patients admitted to a teaching hospital in São Paulo, according to a protocol for tertiary evaluation. Results Between February and May 2012, for 12 weeks, 182 patients were submitted to tertiary evaluation, 100 (55%) polytraumatized and 82 (45%) were victims of low-energy trauma. Neglected lesions were observed in 21 (11.5%) patients, who had 28 missed injuries. Of these 28 lesions, seven (25%) required surgical treatment. Conclusion Strategies including formal tertiary evaluation, the protocol applied for assessing trauma victims, seem to be beneficial in these patients, regardless of the mechanism of trauma. The method is easily applied, effective and has low cost in identifying missed injuries in the victims of trauma.
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Affiliation(s)
- Thiago Ricardo Roessle
- Trainee in Orthopedics and Traumatology at Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
- Corresponding author. Fortunato, 252, apto 62, Vila Buarque, São Paulo, SP, Brazil. CEP: 01224-030.
| | - Claudia Diniz Freitas
- Resident in Orthopedics and Traumatology at Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Herman Fabian Moscovici
- Resident in Orthopedics and Traumatology at Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Caio Zamboni
- Attending Physician in the Trauma Group, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - José Octávio Soares Hungria
- MSc; Head of Emergency Orthopedic and Traumatological Services, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Ralph Walter Christian
- PhD; Professor and Head of the Trauma Group, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Tomanik Mercadante
- PhD; Professor and Attending Physician in the Trauma Group, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
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Roessle TR, Freitas CD, Moscovici HF, Zamboni C, Hungria JOS, Christian RW, Mercadante MT. Avaliação terciária em pacientes traumatizados em hospital na cidade de São Paulo: Uma questão de necessidade. Rev Bras Ortop 2013. [DOI: 10.1016/j.rbo.2012.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Keijzers GB, Giannakopoulos GF, Del Mar C, Bakker FC, Geeraedts LMG. The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 2012. [PMID: 23190504 PMCID: PMC3546883 DOI: 10.1186/1757-7241-20-77] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes. Methods A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. ‘Missed injury’ was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale. Results Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01). Conclusions Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.
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Affiliation(s)
- Gerben B Keijzers
- Department of Emergency Medicine, Gold Coast Hospital, Gold Coast, Queensland, Australia.
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Al-Jazaeri A, Zamakhshary M, Al-Omair A, Al-Haddab Y, Al-Jarallah O, Al-Qahtani R. The role of seating position in determining the injury pattern among unrestrained children involved in motor vehicle collisions presenting to a level I trauma center. Ann Saudi Med 2012; 32:502-6. [PMID: 22871620 PMCID: PMC6081000 DOI: 10.5144/0256-4947.2012.502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Seating position in motor vehicle collisions (MVC) plays a major role in determining the injury pattern in mainly restrained children. However, compliance with child seating and restraint laws is still suboptimal. The role of seating position in predicting injury patterns among unrestrained children has not been previously studied. DESIGN AND SETTING Retrospective review based on the trauma registry of a level I trauma center in Riyadh, Saudi Arabia. Data collection was restricted to unrestrained children involved in MVC. PATIENTS AND METHODS Between July 2001 and March 2010, 274 records were identified. Detailed information about the collision, child seating position and the use of restraints was cross-verified using parental phone interviews. RESULTS Of the 274 identified records, cross-verification was possible for 89 (32.4%) unrestrained children, 64 boys and 25 girls, with a mean (SD) age of 83 (40) months. Of these children, 41 (46.1%) were front seated (FS), and 48 (53.9%) were back seated (BS). There were higher rates of rollover (52.1% vs 24.4%, P=.02), ejection (41.7% vs 22%, P=.05), and occupant death ratio (14.8 vs 4, P=.04) among BS children. However, the two groups did not differ in pediatric trauma scores, Glascow coma scale score, or age distribution. FS children were more likely to present with isolated head, neck or facial injuries (HNFI) (51.2% vs 25%, P=.01), whereas BS children were more likely to suffer long bone or pelvic fractures (LPF) (60.4% vs 36.6%, P=.025). CONCLUSION Injury pattern can vary according to seating position among unrestrained children presenting at trauma centers after MVC. While FS children are more likely to present with HNFI, BS children more often sustain LPF. BS children had similar trauma severity compared with FS children despite the higher-impact nature of their MVCs. While highlighting the value of proper restraints use and seating position, these results can be valuable in the initial assessment of traumatized children involved in MVC.
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Affiliation(s)
- Ayman Al-Jazaeri
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Rutland-Brown W, Langlois JA, Nicaj L, Thomas RG, Wilt SA, Bazarian JJ. Traumatic Brain Injuries after Mass-Casualty Incidents: Lessons from the 11 September 2001 World Trade Center Attacks. Prehosp Disaster Med 2012; 22:157-64. [PMID: 17894207 DOI: 10.1017/s1049023x00004593] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:The 11 September 2001 terrorist attacks on the World Trade Center (WTC) resulted in thousands of deaths and injuries. Research on previous bombings and explosions has shown that head injuries, including traumatic brain injuries (TBIs), are among the most common injuries.Objective:The objective of this study was to identify diagnosed and undiagnosed (undetected) TBIs among persons hospitalized in New York City following the 11 September 2001 WTC attacks.Methods:The medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the WTC attacks were abstracted for signs and symptoms of TBIs. Diagnosed TBIs were identified using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons with an undiagnosed TBI were contacted and informed of the diagnosis of potential undetected injury.Results:A total of 282 records were abstracted. Fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the abstracted records). The leading cause of TBI was being hit by falling debris (22 cases). One-third of the TBIs (13 cases) occurred among rescue workers.More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they currently were experiencing symptoms consistent with a TBI.Conclusions:Not all of the TBIs among hospitalized survivors of the WTC attacks were diagnosed at the time of acute injury care. Some persons with undiagnosed TBIs reported problems that may have resulted from these TBIs three years after the event. For hospitalized survivors of mass-casualty incidents, additional in-hospital, clinical surveys could help improve pre-discharge TBI diagnosis and provide the opportunity to link patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers deserves re-evaluation.
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Affiliation(s)
- Wesley Rutland-Brown
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Injury Response, Atlanta, Georgia 30341-3724, USA
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Willner EL, Jackson HA, Nager AL. Delayed diagnosis of injuries in pediatric trauma: the role of radiographic ordering practices. Am J Emerg Med 2012; 30:115-23. [DOI: 10.1016/j.ajem.2010.10.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022] Open
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Tertiary Survey Performance in a Regional Trauma Hospital Without a Dedicated Trauma Service. World J Surg 2011; 35:2341-7. [DOI: 10.1007/s00268-011-1231-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Chen CW, Chu CM, Yu WY, Lou YT, Lin MR. Incidence rate and risk factors of missed injuries in major trauma patients. ACCIDENT; ANALYSIS AND PREVENTION 2011; 43:823-828. [PMID: 21376872 DOI: 10.1016/j.aap.2010.11.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 09/28/2010] [Accepted: 11/01/2010] [Indexed: 05/30/2023]
Abstract
This study was designed to determine the incidence rate and risk factors of missed injuries in major trauma patients in the emergency department (ED). Hospital records of all 976 trauma patients visiting the ED and admitted to intensive care units (ICUs) of a medical center in Taiwan from 2006 to 2007 were reviewed. Missed injuries were defined as those not identified in the ED but recognized later in the ICUs. Clinically significant injuries were those with an Abbreviated Injury Scale of ≥ 2. In the 2-year period, there were 133 missed injuries in 118 patients in the ED, for a prevalence of 12.1%; 87 injuries were clinically significant in 78 patients, for a prevalence of 8.0%. The estimated incidence rate per 100 person-hours was 3.2 for missed injuries and 2.1 for clinically significant missed injuries. The most commonly involved body region of missed injuries was the head/neck, followed by the chest and extremities. Results of a Cox regression analysis showed that a younger age, more-severe injury, polytrauma, and the absence of soft-tissue injuries were significantly associated with missed injuries, while younger ages, more-severe injuries, and the presence of chest and pelvic injuries were also significantly associated with clinically significant missed injuries. In conclusion, a considerable number of injuries, particularly to the head/neck, may be undetected in the ED, while young people and patients with certain injury patterns such as severity levels, polytrauma, and the presence of a chest or pelvic injury are more likely to have missed injuries and/or clinically significant missed injuries.
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Affiliation(s)
- Chao-Wen Chen
- Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
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Emet M, Saritas A, Acemoglu H, Aslan S, Cakir Z. Predictors of missed injuries in hospitalized trauma patients in the emergency department. Eur J Trauma Emerg Surg 2010; 36:559-66. [PMID: 26816311 DOI: 10.1007/s00068-010-0018-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 12/16/2009] [Indexed: 11/24/2022]
Abstract
AIM To determine the extent of missed injuries in patients hospitalized with major trauma in a Turkish Level 1 emergency department. We also tried to identify the primary factors contributing to each missed injury and to determine their subsequent adverse short-term clinical outcomes. METHODS This is a retrospective analysis of prospectively collected data on a cohort of trauma patients. Trauma patients were divided into two groups: patients with missed injury and others. Logistic regression was used to define factors affecting "missed injury". RESULTS A total of 670 hospitalized trauma patients were included. The incidence of missed injuries in the patients and the rate of missed injury per patient were 13.3% (95% CI 6-20) and 1.64, respectively. The most frequently missed diagnosis was injuries of the musculoskeletal system (38%; 95% CI 30-46). It was "clavicle fracture and/or dislocation" (35%; 95% CI 16-53) when the rate of missed diagnosis according to the frequency of the specific injury was calculated. A multiple logistic regression analysis showed that the predictors of missed injuries were patient's age (OR 0.74, 95% CI 0.63-0.87), total number of injuries (OR 1.74, 95% CI 1.38-2.20), and ISS (OR 1.10, 95% CI 1.03-1.18). Radiological errors were prominent in almost 90% (95% CI 85-95). Missed injury caused additional hospital stay (30%; 95% CI 21-40) and additional surgery was required (15%; 95% CI 8-23). CONCLUSION The study highlights the need for a trauma team approach and the need for support of radiological report in the ED.
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Affiliation(s)
- M Emet
- Department of Emergency Medicine, Faculty of Medicine, Ataturk University, 25090, Erzurum, Turkey.
| | - A Saritas
- Department of Emergency Medicine, Faculty of Medicine, Ataturk University, 25090, Erzurum, Turkey
| | - H Acemoglu
- Department of Medical Education, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - S Aslan
- Department of Emergency Medicine, Faculty of Medicine, Ataturk University, 25090, Erzurum, Turkey
| | - Z Cakir
- Department of Emergency Medicine, Faculty of Medicine, Ataturk University, 25090, Erzurum, Turkey
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An Initiative by Midlevel Providers to Conduct Tertiary Surveys at a Level I Trauma Center. ACTA ACUST UNITED AC 2010; 68:1052-8. [DOI: 10.1097/ta.0b013e3181d87789] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient. J Pediatr Surg 2010; 45:161-5; discussion 166. [PMID: 20105598 DOI: 10.1016/j.jpedsurg.2009.10.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 10/06/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to determine whether delay in treatment had an adverse affect on patient outcome. METHODS A multi-institutional retrospective chart review using the American Pediatric Surgical Association Committee on Trauma was initiated after Institutional Review Board approval was obtained at each of the 18 institutions. All children younger than 15 years diagnosed with a BII were identified, and only those with BII noted during surgery or autopsy from January 2002 through December 2007 were included. The data form was designed and approved before chart review, and all data were combined into one database. RESULTS Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to determine the interval between injury and operation. These were divided into 4 groups (<6, 6-12, 12-24, and >24 hours) based on time from injury to intervention. Early and late complications, as well as hospital days, were compared in each group. There were 3 deaths from an abdominal source in the less-than-6-hour group and 2 in the 6-to-12-hour group. Injury Severity Score was significantly greater in the less-than-6-hour intervention group. There was no correlation between time to surgery and complication rate, nor was there a significant increase in hospital days. CONCLUSIONS These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric BII. Appropriate observation and serial examination rather than repeated computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.
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Stengel D, Frank M, Matthes G, Schmucker U, Seifert J, Mutze S, Wich M, Hanson B, Giannoudis PV, Ekkernkamp A. Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts? Injury 2009; 40 Suppl 4:S36-46. [PMID: 19895951 DOI: 10.1016/j.injury.2009.10.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.
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Affiliation(s)
- Dirk Stengel
- Dept of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin and University of Greifswald, Germany.
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Pitcher RD, Wilde JCH, Douglas TS, van As AB. The use of the Statscan digital X-ray unit in paediatric polytrauma. Pediatr Radiol 2009; 39:433-7. [PMID: 19066879 DOI: 10.1007/s00247-008-1053-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Revised: 10/02/2008] [Accepted: 10/07/2008] [Indexed: 11/27/2022]
Abstract
We present a 3-year review of clinical paediatric experience with the Statscan (Lodox Systems, Johannesburg, South Africa), a low-dose, digital, whole-body, slit-scanning X-ray machine. While focusing on the role of the unit in paediatric polytrauma, insight into its applications in other paediatric settings is provided.
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Affiliation(s)
- Richard D Pitcher
- Division of Paediatric Radiology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Rondebosch, Cape Town, South Africa.
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Holland AJA, Soundappan SVS, Cass DT. Comment on: "Missed injury and the tertiary trauma survey" [Injury 2008; 39:107-114]. Injury 2009; 40:110. [PMID: 19100543 DOI: 10.1016/j.injury.2008.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 05/22/2008] [Accepted: 05/22/2008] [Indexed: 02/02/2023]
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Pfeifer R, Pape HC. Missed injuries in trauma patients: A literature review. Patient Saf Surg 2008; 2:20. [PMID: 18721480 PMCID: PMC2553050 DOI: 10.1186/1754-9493-2-20] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 08/23/2008] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Overlooked injuries and delayed diagnoses are still common problems in the treatment of polytrauma patients. Therefore, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care. This review summarizes the available literature on missed injuries, focusing on overlooked muscoloskeletal injuries. METHODS Manuscripts dealing with missed injuries after trauma were reviewed. The following search modules were selected in PubMed: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuires. Three time periods were differentiated: (n = 2, 1980-1990), (n = 6, 1990-2000), and (n = 9, 2000-Present). RESULTS We found a wide spread distribution of missed injuries and delayed diagnoses incidence rates (1.3% to 39%). Approximately 15 to 22.3% of patients with missed injuries had clinically significant missed injuries. Furthermore, we observed a decrease of missed pelvic and hip injuries within the last decade. CONCLUSION The lack of standardized studies using comparable definitions for missed injuries and clinically significant missed injuries call for further investigations, which are necessary to produce more reliable data. Furthermore, improvements in diagnostic techniques (e.g. the use of multi-slice CT) may lead to a decreased incidence of missed pelvic injuries. Finally, the standardized tertiary trauma survey is vitally important in the detection of clinically significant missed injuries and should be included in trauma care.
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Affiliation(s)
- Roman Pfeifer
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Hans-Christoph Pape
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
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Montmany S, Navarro S, Rebasa P, Hermoso J, Manuel Hidalgo J, Cánovas G. Estudio prospectivo de la incidencia de las lesiones inadvertidas en el paciente politraumatizado. Cir Esp 2008; 84:32-6. [DOI: 10.1016/s0009-739x(08)70601-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
OBJECTIVE To improve identification of traumatic brain injury (TBI) in survivors of nonmilitary bomb blasts during the acute care phase. METHODS The Centers for Disease Control and Prevention convened a meeting of experts in TBI, emergency medicine, and disaster response to review the recent literature and make recommendations. RESULTS Seven key recommendations were proposed: (1) increase TBI awareness among medical professionals; (2) encourage use of standard definitions and consistent terminology; (3) improve screening methods for TBI in the acute care setting; (4) clarify the distinction between TBI and acute stress disorder; (5) encourage routine screening of hospitalized trauma patients for TBI; (6) improve identification of nonhospitalized TBI patients; and (7) integrate the appropriate level of TBI identification into all-hazards mass casualty preparedness. CONCLUSIONS By adopting these recommendations, the United States could be better prepared to identify and respond to TBI following future bombing events.
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Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury 2008; 39:107-14. [PMID: 18164007 DOI: 10.1016/j.injury.2007.07.030] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 07/25/2007] [Accepted: 07/26/2007] [Indexed: 02/02/2023]
Abstract
Missed injury in the context of major trauma remains a persistent problem, both from a clinical and medico-legal point-of-view. Estimates of the incidence vary widely, dependent on the precise parameters of the studied population, the definition of missed injury and the extent of follow-up, but may be as high as 38%. The tertiary survey, in which formal repeated examination of the patient is undertaken after initial resuscitation and treatment have taken place, has been suggested as a way of identifying injuries not found at presentation. This paper appraises the concept of the tertiary survey, and also reviews the literature on missed injury in order to identify the risk factors, the types of injury and the reasons for error.
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Affiliation(s)
- Charles B Thomson
- Academic Department of Emergency Medicine, University of Teesside, James Cook University Hospital, Marton Road, Middlesbrough, United Kingdom.
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A pilot study evaluating the “STATSCAN” digital X-ray machine in paediatric polytrauma. Emerg Radiol 2007; 15:35-42. [DOI: 10.1007/s10140-007-0668-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 08/14/2007] [Indexed: 11/26/2022]
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Okello CR, Ezati IA, Gakwaya AM. Missed injuries: a Ugandan experience. Injury 2007; 38:112-7. [PMID: 17055508 DOI: 10.1016/j.injury.2006.07.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 07/09/2006] [Accepted: 07/09/2006] [Indexed: 02/02/2023]
Abstract
BACKGROUND Missed injuries (MIs) have been noted worldwide in all trauma centres that have studied them, and they are a significant cause of patient morbidity and mortality. OBJECTIVE To establish the prevalence, contributing factors and short-term outcome of missed injuries in cases of multiple and major trauma. METHOD Longitudinal prospective study involving 403 patients over 5 months. RESULTS Missed injuries were discovered in 78 cases (prevalence 19.4%). Contributing factors included incomplete assessment (52.5%), radiological errors, surgical failures and patient's arrival time. The most affected body regions were the head and neck, extremities and pelvic girdle and contents; in the abdomen, 49.1% of injuries were missed. Among the 28 deaths in the study, 21 occurred in cases with missed injuries, and 13 (62%) of these deaths were directly attributable to missed injuries (R2=12.5, p=0.0001, 95% CI 5.5-28.35). CONCLUSION There is need for improvement in patient assessment and monitoring, in efficiency of the trauma team, and for staff redistribution to address the increase in night arrivals.
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Howard J, Sundararajan R, Thomas SG, Walsh M, Sundararajan M. Reducing Missed Injuries at a Level II Trauma Center. J Trauma Nurs 2006; 13:89-95. [PMID: 17052086 DOI: 10.1097/00043860-200607000-00003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The phenomenon of missed injury in trauma patients has been recognized for some time. Tertiary examination has been proposed as one strategy to decrease the incidence of missed injuries. The tertiary examination is a comprehensive reevaluation that includes a repeated head-to-toe examination and review of all laboratory and radiologic studies, completed within 24 hours of admission. The purpose of this study was to assess the statistical significance of missed injuries discovered through tertiary examinations at a level II trauma center. Over a period of 6 months, a tertiary examination was completed before discharge of admitted patients who met activation criteria. Of the 90 patients, 13 had a missed injury (incidence of 14%), which was significant. The 16 missed injuries represented only 2.7% of the total 589 injuries, which was not significant. The most commonly missed injuries were fractures of the extremities. We propose that tertiary examinations be adopted as a standard of care for patients admitted to level II trauma centers.
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Affiliation(s)
- Janet Howard
- Memorial Leighton Trauma Center, 615 North Michigan Street, South Bend, IN 46601, USA.
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Senthil Kumar R, Gul A, Sen RK, Nagi ON. A missed injury in multiple trauma patient-is it avoidable? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2006; 16:181-184. [PMID: 28755107 DOI: 10.1007/s00590-005-0028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Accepted: 07/25/2005] [Indexed: 06/07/2023]
Abstract
We report a case of a 24-year-old male with fractures at multiple levels of both femur and tibia. The patient was operated upon and a satisfactory clinical outcome was achieved. In spite of a thorough secondary survey, a displaced ankle fracture had been missed. The case is reported for the unusual combination of fractures and to highlight the importance of undetected injuries. We recommend that a tertiary survey should be carried out routinely in all polytrauma patients to prevent missed injuries.
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Affiliation(s)
| | - Arif Gul
- Department of Orthopaedics, Princess of Wales Hospital, 41 Tremains Court, Brackla, Bridgend, Wales, UK, CF31 2SR.
| | - Ramesh K Sen
- Department of Orthopaedics, PGIMER, Chandigarh, India
| | - O N Nagi
- Department of Orthopaedics, PGIMER, Chandigarh, India
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Unal VS, Gulcek M, Unveren Z, Karakuyu A, Ucaner A. Blood Loss Evaluation in Children Under the Age of 11 with Femoral Shaft Fractures Patients with Isolated Versus Multiple Injuries. ACTA ACUST UNITED AC 2006; 60:224-6; discussion 226. [PMID: 16456460 DOI: 10.1097/01.ta.0000196374.40891.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Blood loss from non-cavitary hemorrhages is a significant source of hypovolemic shock in trauma patients. It has been reported that pediatric femoral fractures do not cause excess blood loss if there is no additional injury or trauma. The purpose of this study was to define the magnitude of blood loss resulting from pediatric femoral fractures and the factors influencing the loss. METHODS Twenty children under the age of 11 with femoral shaft fractures were included in this study. The patients' data were collected prospectively for 2 years. Hemoglobin concentrations, hematocrit levels, emergency room records, and clinical findings were evaluated and additional injuries were considered. RESULTS AND CONCLUSION The patients with additional trauma showed significant decreases in both hemoglobin concentrations and hematocrit levels, comparison with the patients who had only isolated femoral fractures. If there is an obvious decrease in hematocrit and/or hemoglobin concentration in a child with a femoral fracture, the possibility of additional injuries should be investigated.
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Affiliation(s)
- Vuslat Sema Unal
- Ankara Numune Education and Research Hospital, Ankara Opera 06100, Turkey.
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Abstract
Trauma remains the most common cause of death in childhood after the first year of life. It accounts for considerable morbidity that may extend into adult life at great cost to the community. Despite the scale of the disease, paediatric trauma and injury prevention research attract little funding. International data indicate that children in Australia and New Zealand would benefit from improved injury prevention strategies and the introduction of a more formalized paediatric trauma system. Such a system would need to take account of Australasian geographical and population distribution characteristics, which mandate local provision of expert and immediate care in rural areas. There would appear to be economic and clinical arguments for the introduction of an ambulance trauma bypass system for stable but severely injured children in metropolitan areas with a paediatric trauma centre.
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Affiliation(s)
- A J A Holland
- Department of Academic Surgery, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia.
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Abstract
BACKGROUND Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC). METHODS A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred. RESULTS A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury. CONCLUSIONS The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.
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Affiliation(s)
- Andrew J A Holland
- Department of Paediatric Surgery, Royal North Shore Hospital, The University of Sydney, St Leonards, New South Wales, Australia.
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