The effect of tertiary surveys on missed injuries in trauma: a systematic review

Surgical and critical care management of earthquake musculoskeletal injuries and crush syndrome: A collective review

Earthquakes are unpredictable natural disasters causing massive injuries. We aim to review the surgical management of earthquake musculoskeletal injuries and the critical care of crush syndrome. We searched the English literature in PubMed without time restriction to select relevant papers. Retrieved articles were critically appraised and summarized. Open wounds should be cleaned, debrided, receive antibiotics, receive tetanus toxoid unless vaccinated in the last 5 years, and re-debrided as needed. The lower limb affected 48.5% (21.9%-81.4%) of body regions/patients. Fractures occurred in 31.1% (11.3%-78%) of body regions/patients. The most common surgery was open reduction and internal fixation done in 21% (0%-76.6%), followed by plaster of Paris in 18.2% (2.3%-48.8%), and external fixation in 6.6% (1%-13%) of operations/patients. Open fractures should be treated with external fixation. Internal fixation should not be done until the wound becomes clean and the fractured bones are properly covered with skin, skin graft, or flap. Fasciotomies were done in 15% (2.8%-27.2%), while amputations were done in 3.7% (0.4%-11.5%) of body regions/patients. Principles of treating crush syndrome include: (1) administering proper intravenous fluids to maintain adequate urine output, (2) monitoring and managing hyperkalemia, and (3) considering renal replacement therapy in case of volume overload, severe hyperkalemia, severe acidemia, or severe uremia. Low-quality studies addressed indications for fasciotomy, amputation, and hyperbaric oxygen therapy. Prospective data collection on future medical management of earthquake injuries should be part of future disaster preparedness. We hope that this review will carry the essential knowledge needed for properly managing earthquake musculoskeletal injuries and crush syndrome in hospitalized patients.

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

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

The Incidence of Carpal Tunnel Syndrome Diagnosis Increases after Arthroscopic Shoulder Surgery

Purpose

Arthroscopic shoulder surgery has been identified as a potential risk factor for carpal tunnel syndrome (CTS). The purposes of this study were as follows: to (1) examine the percentage of patients who underwent arthroscopic shoulder procedures and later developed ipsilateral CTS within 1 year of the procedure, (2) determine the percentage of those patients with CTS who subsequently underwent an injection or release, and (3) examine comorbidities associated with developing CTS after surgery.

Methods

Patients who underwent arthroscopic rotator cuff repair (RCR), labral repair, or biceps tenodesis were retrospectively identified in a national database. Within 1 year, we compared the rates of ipsilateral CTS diagnoses versus the contralateral side. The rates of comorbidities between those who did and did not develop CTS were also compared.

Results

Within 1 year, arthroscopic RCR patients (1.47% vs 1.00%; odds ratio [OR], 1.48; P < .001) and arthroscopic labral repair patients (0.76% vs 0.52%; OR, 1.47; P < .001) had a significantly higher rate of ipsilateral carpal tunnel diagnosis versus contralateral side diagnosis. Arthroscopic RCR patients were also significantly more likely to have ipsilateral carpal tunnel injection (0.16% vs 0.11%; OR, 1.45; P < .001) and release (0.46% vs 0.37%; OR, 1.24; P < .001). Patients who had an ipsilateral carpal tunnel diagnosis following arthroscopic RCR and labral repair were both significantly older (both P < .001), a higher percentage of women (both P<.001), and more likely to have had a preoperative nerve block (both P < .05). Both cohorts had significantly higher mean Elixhauser comorbidity Index (P < .001) and more comorbidities.

Conclusions

This study demonstrated a significantly higher incidence of operative side CTS within 1 year following arthroscopic RCR and labral repairs. Arthroscopic RCR was also demonstrated to result in significantly higher rates of injections and carpal tunnel release. The cohort that developed ipsilateral CTS was older, had higher percentage of women, and had more comorbidities.

Type of study/level of evidence

Prognostic III.

Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients

Background

Although an intensive care unit (ICU) admission is a risk factor for missed injury, there has been some disagreement on whether missed injuries in trauma ICU patients have a longer length of stay (LOS). With this in mind, these patients' frequency of missed injuries and related factors were investigated.

Materials and methods

This was a prospective cohort study on multiple trauma injury patients in a tertiary referral trauma center's trauma intensive care unit (TICU) from March 2020 to March 2021. A tertiary survey was conducted in the TICU by attending physicians to find the types I and II missed injuries (any injury discovered after primary and secondary surveys during the hospital stay). A logistic regression model was designed for predictors of missed injuries in ICU-admitted multiple trauma patients.

Results

Out of 290 study participants, 1,430 injuries were found, and of those injuries, 74 cases (25.5%) had missed injuries. In other words, there were 103 missed injuries, resulting in a missed injury detection rate of 7.2%. The most frequently missed injuries (43.4%) were concluded as extremities fractures. The regression model showed that the patients with missed injuries are prone to longer TICU LOS [odds ratio (OR) = 1.15; p = 0.033], and cases who underwent a computed tomography (CT) scan are less likely to have missed injuries (OR = 0.04; p < 0.001). The abbreviated injury scale (AIS) range was 1-3 in missed injuries.

Conclusion

Our research underlines the importance of finding missed injuries and the necessity of CT scan to decrease them. In teaching centers, life-threatening injuries decrease with increasing visits and examination times. Although these missed injuries do not increase mortality, they cause longer TICU LOS and costs.

How to cite this article

Bahramian M, Shahbazi P, Hemmati N, Mohebzadeh P, Najafi A. Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients. Indian J Crit Care Med 2023;27(3):201-204.

Social admissions in older trauma patients, not just a one night stay

PURPOSE

Older trauma patients (65 years or older), who suffer minor or moderate injury for which immediate hospitalization is not strictly indicated, are often admitted to the hospital due to a self-sufficiency problem. Although hospitalization is expensive and associated with risks, little is known about the course of such a social admission. Therefore, the aim of this study was to clarify the course and outcome of social admissions.

METHODS

A single centre retrospective cohort study was performed in a level II trauma centre. All hospitalized trauma patients aged 65 or older between 2015 and 2021 with an Abbreviated Injury Scale (AIS) code of 1 or 2 were included. The primary outcome was defined as the number of complications during admission (e.g. pneumonia, urinary tract infection, delirium, decubitus and, in-hospital mortality). Secondary outcomes were missed injury, length of stay, discharge location (home, with homecare or a skilled nursing facility), 30-day hospital return and 1-year mortality.

RESULTS

Out of 2900 older hospitalized trauma patients, 563 (19.4%) were included. Complications occurred in 99 patients (17.6%), eight patients (1.4%) died during admission, and in 17 patients (3.0%) a previously missed injury was found during the admission. The median length of stay was 5 days [IQR 2.00-9.00] and of all independent living patients, 49.1% could be discharged to their homes. After discharge, 4.4% of the patients returned within 30 days and, a total of 17.6% of all patients died within one year after discharge.

CONCLUSIONS

One out of five older trauma patients presenting at the emergency department were admitted because of social reasons. Social admissions are lengthy and are accompanied by a considerable amount of complications.

Subcoracoid acromioclavicular joint dislocation (Rockwood type VI) sustained in motorcycle crash: A case report

We present the case of a young male who sustained a rare acromioclavicular joint (ACJ) injury during a road traffic accident. A left-sided ACJ injury was identified on plain radiographs fourteen days following a motorcycling accident during which significant distracting injuries were sustained. Owing to persistent shoulder pain during awake tertiary surveillance, repeat shoulder plain radiographs were obtained, along with re-examination of the patient's index computed tomography (CT) shoulder imaging, indicating a grade VI left-sided acromioclavicular subluxation. The patient underwent operative management of the above injury at three weeks, with initial examination under anesthetic revealing a stiff shoulder joint significantly limited external rotation requiring extensive release of fibrosis. The left ACJ was reduced under anesthesia, being temporarily secured with Kirschner wire insertion. A Synthes locking distal tibial "L" plate was contoured and applied across the AC joint, and secured with locking screws. Intensive post-operative physiotherapy resulted in an significantly improved post-operative range of motion in the patient's left shoulder. Acromioclavicular joint injuries, commonly shortened to ACJ injuries, are most regularly traumatic in etiology, ranging in severity from mild sprain to complete joint disruption. ACJ injuries are classified according to the position of the clavicle with respect to the acromion and coracoid. The above case highlights the requirement for comprehensive tertiary surveillance of trauma patients both pre and postextubation, in order to identify such injuries that may require prompt surgical management in order to restore range of motion and function in affected joints.

Perspective: the top 11 priorities to improve trauma outcomes, from system to patient level

BACKGROUND

The Haemorrhage, Airway, Breathing, Circulation, Disability, Exposure/Environmental control approach to individual patient management in trauma is well established and embedded in numerous training courses worldwide. Further improvements in trauma outcomes are likely to result from a combination of system-level interventions in prevention and quality improvement, and from a sophisticated approach to clinical innovation.

TOP ELEVEN TRAUMA PRIORITIES

Based on a narrative review of remaining preventable mortality and morbidity in trauma, the top eleven priorities for those working throughout the spectrum of trauma care, from policy-makers to clinicians, should be: (1) investment in effective trauma prevention (likely to be the most cost-effective intervention); (2) prioritisation of resources, quality improvement and innovation in prehospital care (where the most preventable mortality remains); (3) building a high-performance trauma team; (4) applying evidence-based clinical interventions that stop bleeding, open & protect the airway, and optimise breathing most effectively; (5) maintaining enough circulating blood volume and ensuring adequate cardiac function; (6) recognising the role of the intensive care unit in modern damage control surgery; (7) prioritising good intensive care unit intercurrent care, especially prophylaxis for thromboembolic disease; (8) conducting a thorough tertiary survey, noting that on average the intensive care unit is where approximately 15% of injuries are detected; (9) facilitating early extubation; (10) investing in formal quantitative and qualitative quality assurance and improvement; and (11) improving clinical trial design.

CONCLUSION

Dramatic reductions in population trauma mortality and injury case fatality rate over recent decades have demonstrated the value of a comprehensive approach to trauma quality and process improvement. Continued attention to these principles, targeting areas with highest remaining preventable mortality while also prioritising functional outcomes, should remain the focus of both clinician and policy-makers.

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center

BACKGROUND

To investigate the incidence of osseous wrist and hand injuries on whole-body computed tomographies (WBCT) at an urban maximum-care trauma center, to report the number of missed cases in primary radiology reports, and to develop an algorithm for improved detection of these injuries.

METHODS

Retrospective analysis reviewing all WBCT for a period of 8 months for osseous wrist and hand injuries. (1) Reconstruction of hands/wrists in three planes (thickness 1-2 mm) and analysis by a blinded musculoskeletal radiologist. (2) Scanning of primary radiology reports and comparison to the re-evaluation. (3) Calculation of the diagnostic accuracy of WBCT during primary reporting. (4) Search for factors potentially influencing the incidence (trauma mechanism, associated injuries, Glasgow Coma Scale, artifacts). (5) Development of an algorithm to improve the detection rate.

RESULTS

Five hundred six WBCT were included between 01/2020 and 08/2020. 59 (11.7%) WBCT showed 92 osseous wrist or hand injuries. Distal intra-articular radius fractures occurred most frequently (n = 24, 26.1%); 22 patients (37.3%) showed multiple injuries. The sensitivity of WBCT in the detection of wrist and hand fractures during primary evaluation was low with 4 positive cases identified correctly (6.8%; 95% CI 1.9 to 16.5), while the specificity was 100% (95% CI 99.2 to 100.0). Forty-three cases (72.9%) were detected on additional imaging after clinical reassessment. Twelve injuries remained undetected (20.3%). Motorcycle accidents were more common in positive cases (22.0% vs. 10.1%, p = 0.006). 98% of positive cases showed additional fractures of the upper and/or lower extremities, whereas 37% of the patients without osseous wrist and hand injuries suffered such fractures (p < 0.001). The remaining investigated factors did not seem to influence the occurrence.

CONCLUSION

Osseous wrist and hand injuries are present in 11.7% on WBCT after polytrauma. 93.2% of injuries were missed primarily, resulting in a very low sensitivity of WBCT during primary reporting. Motorcycle accidents might predispose for these injuries, and they often cause additional fractures of the extremities. Clinical re-evaluation of patients and secondary re-evaluation of WBCT with preparation of dedicated multiplanar reformations are essential in polytrauma cases to detect osseous injuries of wrist and hand reliably.

TRIAL REGISTRATION

The study was registered prospectively on November 17th, 2020, at the German register for clinical trials (DRKS-ID: DRKS00023589 ).

Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk

Purpose

Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries.

Methods

In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed.

Results

In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053).

Conclusion

Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey.

Level of evidence

Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).

Challenges associated with recovery from blunt thoracic injuries from hospital admission to six-months after discharge: A qualitative interview study

BACKGROUND

Recovery for patients presenting to trauma services globally with blunt thoracic injury (BTI) remains challenging with substantial levels of physical, psychological socio-economic burden. The aim of this study is to examine the challenges experienced by patients with BTI from hospital admission to 6-months after hospital discharge.

METHODS

Participants were recruited from trauma patients admitted with BTI and were recruited from 7 sites across England and Wales between March and June 2019. Semi-structured interviews were conducted at six-months after discharge from hospital, and in total 11 interviews were undertaken. Interviews were recorded, transcribed, and analysed with reflexive thematic analysis.

RESULTS

Two themes were identified within the data: (i) Challenges within the acute hospital admission where pain and analgesic management and the processes of investigation and treatment were the sources of most challenges to recovery. (ii) Challenges within the post-discharge recovery journey, where managing pain at home, unidentified injuries, and mental well-being impacted most on recovery.

CONCLUSIONS

This study adds to the body of qualitative evidence surrounding recovery from major trauma and the patient experience within the recovery journey after BTI and It is important that clinicians consider the whole recovery journey as a continuous process rather than two isolated processes.

The association of hand and wrist injuries with other injuries in multiple trauma patients. A retrospective study in a UK Major Trauma Centre

BACKGROUND

Approximately 20,000 major trauma cases occur in England every year. However, the association with concomitant upper limb injuries is unknown. This study aims to determine the incidence, injury pattern and association of hand and wrist injuries with other body injuries and the Injury Severity Score (ISS) in multiply injured trauma patients.

METHODS

Single centre retrospective study was performed at a level-one UK Major Trauma Centre (MTC). Trauma Audit and Research Network (TARN) eligible multiply injured trauma patients that were admitted to the hospital between January 2014 and December 2018 were analysed. TARN is the national trauma registry. Eligible patients were: a trauma patient of any age who was admitted for 72 h or more, or was admitted to intensive care, or died at the hospital, was transferred into the hospital for specialist care, was transferred to another hospital for specialist care or for an intensive care bed and whose isolated injuries met a set of criteria. Data extracted included: age, gender, mode of arrival, location of injuries including: hand and/or wrist and mechanism of injury. We performed a logistic regression analysis to assess the association between hand/wrist injury to ISS score of 15 points or above/below and to the presentation of other injuries.

RESULTS

107 patients were analysed. Hand and wrist injuries were the second most common injury (26.2%), after thoracic injuries. Distal radial injuries were found in 5.6%, carpal/carpometacarpal in 6.5%, concurrent distal radius and carpometacarpal in 0.9%, phalangeal injuries in 4.7%, tendon injuries in 0.9% and concurrent hand and wrist injuries in 7.5% cases. There was a significant association between hand or wrist injuries and lower limb injuries (Odds Ratio (OR): 3.84; 95% confidence intervals (CI): 1.09 to 13.50; p = 0.04) and pelvic injuries (OR: 4.78; 95% CI: 1.31 to 17.44; p = 0.02). There was no statistical association between hand and wrist injuries and ISS score (OR: 0.80; 95% CI: 0.11 to 5.79; p = 0.82).

CONCLUSIONS

Hand and wrist injuries are prevalent in trauma patients admitted to MTCs. They should not be under-estimated but routinely screened for in multiply injured patients particularly those with a pelvic or lower limb injury.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

The yield of tertiary survey in patients admitted for observation after trauma

PURPOSE

Existing literature on trauma tertiary survey (TTS) focusses on multitrauma patients. This study examines the yield of the TTS in trauma patients with minor (AIS 1) or moderate (AIS 2) injury for which immediate hospitalization is not strictly indicated.

METHOD

A single center retrospective cohort study was performed in a level II trauma center. All hospitalized trauma patients with an abbreviate injury score (AIS) of one or two at the primary and secondary survey were included. The primary outcome was defined as any missed injury found during TTS (Type 1). Secondary outcomes were defined as any missed injury found after TTS but during admission (Type 2); overall missed injury rate; mortality and hospital length of stay.

RESULTS

Out of 388 included patients, 12 patients (3.1%) had a type 1 missed injury. ISS and alcohol consumption were associated with an increased risk for type 1 missed injuries (resp. OR = 1.4, OR = 5.49). A type 2 missed injury was only found in one patient. This concerned the only case of trauma related mortality. Approximately one out of five patients were admitted for more than 2 days. These patients were significantly older (66 vs. 41 years, p < 0.001), had a higher ISS (4 vs. 3, p = 0.007) and ASA score, 3-4 vs. 1-2 (42.5% vs. 12.6%, p < 0.001).

CONCLUSION

TTS showed a low rate of missed injuries in trauma patients with minor or moderate injury. TTS helped to prevent serious damage in two out of 388 patients (0.5%). ISS and alcohol consumption were associated with finding missed injury during TTS.

Delayed injuries in the emergency department in hospitalised trauma patients

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.

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients

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.

Missed injuries in combat casualties: Lessons from Iraq and Afghanistan

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Epidemiology of distal radius fractures in polytrauma patients and the influence of high traumatic energy transfer

INTRODUCTION

For several extremity fractures differences in morphology, incidence rate and functional outcome were found when polytrauma patients were compared to patients with an isolated injury. This is not proven for distal radius fractures (DRF). Therefore, this study aimed to analyse fracture morphology in relation to energy transfer in both poly- and mono-trauma patients with a DRF.

METHODS

This was a retrospective cohort study. All patients aged 16 years and older with a DRF were included. Patients with an Injury Severity Score of 16 or higher were classified as polytrauma patients. Injuries were defined as high or low energy. All DRFs were classified using the AO/OTA fracture classification system.

RESULTS

A total of 830 patients with a DRF were included, 12% were polytrauma. The incidence rate of DRF in polytrauma patients was 3.5%. Ipsilateral upper extremity injury was found in >30% of polytrauma and high-energy monotrauma patients, compared to 5% in low-energy monotrauma patients. More type C DRF were found in polytrauma and high-energy monotrauma patients versus low-energy monotrauma patients. Operative intervention rates for all types of DRF were similar for polytrauma and high-energy monotrauma patients. Non-union rates were higher in polytrauma patients.

CONCLUSION

Higher energy mechanisms of injury, in polytrauma and high-energy monotrauma patients, were associated with more severe complex articular distal radius fractures and more ipsilateral upper extremity injuries. Polytrauma and high-energy monotrauma patient have a similar fracture morphology. However, polytrauma patients have in addition to more injured body regions also more non-union related interventions than high-energy monotrauma patients.

Incidence of Delayed Diagnosis of Orthopaedic Injury in Pediatric Trauma Patients

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.

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

BACKGROUND AND AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Tertiary survey in polytrauma patients should be an ongoing process

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Severity and treatment of "occult" intra-abdominal injuries in blunt trauma victims

BACKGROUND

to assess the severity and treatment of "occult" intra-abdominal injuries in blunt trauma victims.

METHOD

Retrospective analysis of charts and trauma register data of adult blunt trauma victims, admitted without abdominal pain or alterations in the abdominal physical examination, but were subsequently diagnosed with intra-abdominal injuries, in a period of 2 years. The severity was stratified according to RTS, AIS, OIS and ISS. The specific treatment for abdominal injuries and the complications related to them were assessed.

RESULTS

Intra-abdominal injuries were diagnosed in 220 (3.8%) out of the 5785 blunt trauma victims and 76 (34.5%) met the inclusion criteria. The RTS and ISS median (lower quartile, upper quartile) were 7.84 (6.05, 7.84) and 25 (16, 34). Sixty seven percent had a GCS≥13 on admission. Injuries were identified in the spleen (34), liver (33), kidneys (9), intestines (4), diaphragm (3), bladder (3) and iliac vessels (1). Abdominal injuries scored AIS≥3 in 67% of patients. Twenty-one patients (28%) underwent laparotomy, 5 of which were nontherapeutic. The surgical procedures performed were splenectomy (8), suturing of the diaphragm (3), intestines (3), bladder (2), kidneys (1), enterectomy/anastomosis (1), ligation of the common iliac vein (1), and revascularization of the common iliac artery (1). Angiography and embolization of liver and/or spleen injuries were performed in 3 cases. Three patients developed abdominal complications, all of which were operatively treated. There were no deaths directly related to the abdominal injuries.

CONCLUSION

Severe "occult" intra-abdominal injuries, requiring specific treatment, may be present in adult blunt trauma patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Omitted spinal X-ray examination after a fall from a height of 3 m]

A 59-year-old patient with right-sided chest pains after a fall from a height of 3 m was referred to hospital by an emergency physician. The chest x-rays showed fractures of the third and seventh ribs on the right side. Inpatient analgesic therapy was initiated and after 3 days the patient was discharged from hospital for further outpatient treatment. As the pain persisted the patient consulted a surgeon 5 weeks later and the first X-ray examination of the spine was carried out which revealed the formation of several wedge-shaped thoracolumbar vertebral bodies. Further magnetic resonance imaging (MRI) diagnostics also revealed alterations to T10, T12, L1 and L3 as well as radiological signs of Scheuermann's disease; however, a definite statement differentiating these findings from older spinal fractures as a result of the accident was no longer possible. The patient claimed that the hospital failed to perform spinal X-ray investigations leading to prolonged pain and limitations in the quality of life. An external expert stated that the distracting injury of the ribs and the pain medication might have veiled the additional vertebral fractures. Thus, an earlier diagnosis of the apparently stable vertebral fractures would not have changed the conservative therapy approach. The decision of the arbitration board differed from the expert opinion as additional imaging techniques of the spine should have been initially performed due to the mechanism of injury. Although no irreversible damage to health resulted an earlier targeted treatment could have reduced the overall length of therapy.

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

Background

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

Methods/Design

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

Discussion

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

Trial registration

ANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013

Electronic supplementary material

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Tertiary survey in trauma patients: avoiding neglected injuries

INTRODUCTION

Medical personnel in trauma centres in several countries have realised that undiagnosed injuries are common and are now focussing their attention on reducing the incidence of these injuries. Tertiary survey is a simple and easy approach to address the issue of undiagnosed injuries in trauma patients. Tertiary survey consists of reevaluating patients 24 hours after admission by means of an anamnesis protocol, physical examination, review of complementary tests and request for new tests when necessary.

OBJECTIVE

To show the importance of tertiary survey in trauma patients for diagnosing injuries undetected at the time of initial survey.

METHODS

A standardised protocol was used to perform a prospective observational study with patients admitted through the emergency department, Department of Orthopaedics and Trauma, Santa Casa de São Paulo. The patients were reevaluated 24 hours after admission or after recovering consciousness. New physical examinations were performed, tests performed on admission were reassessed and new tests were requested, when necessary.

RESULTS

Between February 2012 and February 2013, 526 patients were evaluated, 81 (15.4%) were polytraumatised, and 445 (84.6%) had low-energy trauma. A total of 57 new injuries were diagnosed in 40 patients, 61.4% of which affected the lower limb. Diagnosis of 11 new injuries (19.3%) resulted in changes in procedure.

CONCLUSION

The application of the protocol for tertiary survey proved to be easy, inexpensive and beneficial to patients (particularly polytraumatised patients) because it enabled identification of important injuries that were not detected on admission in a large group of patients.

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

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.

System-related factors contributing to diagnostic errors

Several studies in primary care, internal medicine, and emergency departments show that rates of errors in test requests and result interpretations are unacceptably high and translate into missed, delayed, or erroneous diagnoses. Ineffective follow-up of diagnostic test results could lead to patient harm if appropriate therapeutic interventions are not delivered in a timely manner. The frequency of system-related factors that contribute directly to diagnostic errors depends on the types and sources of errors involved. Recent studies reveal that the errors and patient harm in the diagnostic testing loop have occurred mainly at the pre- and post-analytic phases, which are directed primarily by clinicians who may have limited expertise in the rapidly expanding field of clinical pathology. These errors may include inappropriate test requests, failure/delay in receiving results, and erroneous interpretation and application of test results to patient care. Efforts to address system-related factors often focus on technical errors in laboratory testing or failures in delivery of intended treatment. System-improvement strategies related to diagnostic errors tend to focus on technical aspects of laboratory medicine or delivery of treatment after completion of the diagnostic process. System failures and cognitive errors, more often than not, coexist and together contribute to the incidents of errors in diagnostic process and in laboratory testing. The use of highly structured hand-off procedures and pre-planned follow-up for any diagnostic test could improve efficiency and reliability of the follow-up process. Many feedback pathways should be established so that providers can learn if or when a diagnosis is changed. Patients can participate in the effort to reduce diagnostic errors. Providers should educate their patients about diagnostic probabilities and uncertainties. The patient-safety strategies focusing on the interface between diagnostic system and therapeutic intervention are strategies that involve both processes to facilitate appropriate follow-up and structural changes, such as the use of electronic tracking systems and patient navigation programs.