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

Abstract

BackgroundMissed 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/DesignWe 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.DiscussionThe 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 registrationANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0733-y) contains supplementary material, which is available to authorized users.

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

“…Missed injuries can be minor, requiring only conservative treatment, or can be clinically significant, requiring a prompt recognition. Few studies have defined “clinically significant” post hoc , 34 with most studies not providing any definition. Even if the incidence of clinically significant missed injuries is unknown, they are more likely to lead to prolonged morbidity or mortality.…”

The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care

“…21,22 The secondary outcomes further support the notion that TTS may serve as a key quality improvement tool within the pediatric trauma service. 8,15,23,24 TTS allows for additional time for communication and multidisciplinary care coordination. At our institution, the TTS was routinely performed following morning rounds during which the providers were able to dedicate more time towards the survey, the patient, and the family.…”

“…The ISS, mechanism of injury, presence of multisystem trauma, and Glasgow Coma Scale are potential data components that may benefit such criteria. 1,4,8,9,24 The clinical judgement of the trauma care team and a careful assessment of the benefits vs costs for both the patient and the institution would also be required to determine the necessity of TTS. Future multi-center studies assessing the impact of the TTS in a larger pediatric trauma population may provide further insight regarding this matter and may assist in further optimization of the TTS process.…”

“…7 An increasing number of institutions have employed an additional tertiary trauma survey (TTS) 24 to 72 hours following admission with the goals of capturing comorbidities, identifying missed or delayed injuries, and risk-stratifying trauma patients. 4,[8][9][10][11][12][13] TTS has been demonstrated as an integral quality improvement measure and a component of trauma care in the adult trauma population. [11][12][13][14][15][16] However, the application of TTS in the pediatric trauma center has yet to be standardized and is not well-defined in pediatric trauma literature.…”

“…[8][9][10] The impact of the TTS is additionally dependent on multidisciplinary collaboration between the trauma team and subspecialists, as well as ancillary services including rehabilitation, care coordination, social work, and nursing staff. [8][9][10] A review of existing literature has demonstrated the potential benefits of the TTS in reduction of readmissions, prevention of missed injuries, and improvement in the discharge process for trauma patients. 1,3,8,10,17 However, there is currently a paucity of literature that discusses the impact of the TTS as a clinical tool in the setting of pediatric trauma patients.…”