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Implementation of a Tertiary Trauma Survey Decreases Missed Injuries

Biffl, Walter L. MD; Harrington, David T. MD; Cioffi, William G. MD

Journal of Trauma and Acute Care Surgery: January 2003 - Volume 54 - Issue 1 - p 38-44
Annual Meeting Articles

Background  Missed injuries (MIs) adversely affect patient outcome and damage physician/institutional credibility. The primary and secondary surveys are designed to identify all of a patient’s injuries and prioritize their management; however, MIs are prevalent in severely injured and multisystem trauma patients, especially when the patient’s condition precludes completion of the secondary survey. We hypothesized that implementation of a routine tertiary trauma survey (TS) would reduce the incidence of MIs in a Level I trauma center.

Methods  In mid 1999, a TS form was created and TS documentation was mandated on all trauma intensive care unit (TICU) patients within 24 hours of admission. Patient data, including TS documentation and injury patterns, were concurrently recorded in an institutional trauma registry. Data were compared for patients admitted in 1997 to 1998 (PRE period) and 2000 to 2001 (POST period) using χ2 or Student’s t test.

Results  MIs decreased from 2.4% to 1.5% overall, and from 5.7% to 3.4% in TICU patients, after TS implementation. Patients with MIs were slightly older (49 vs. 45 years;p > 0.05) and had higher Injury Severity Scores (21 vs. 10;p < 0.05) than patients without MIs. Sixty percent of MI patients had brain injuries, 56% were admitted to the TICU, and 26% went directly from the emergency department to the operating room. The large majority of MIs in the POST period were detected in patients not undergoing timely TS.

Conclusion  ICU patients—particularly brain injury victims and those undergoing emergent surgical procedures—appear to be at highest risk for MI. Implementation of a standardized TS decreased MIs by 36% in our Level I trauma center, and more timely TS would likely have further reduced MIs. A TS should be routine in trauma centers.

From the Division of Trauma and Surgical Critical Care, Rhode Island Hospital/Brown Medical School, Providence, Rhode Island.

Submitted for publication September 30, 2002.

Accepted for publication October 10, 2002.

Presented at the 61st Annual Meeting of the American Association for the Surgery of Trauma, September 26–28, 2002, Orlando, Florida.

Address for reprints: Walter L. Biffl, MD, Division of Trauma and Surgical Critical Care, Rhode Island Hospital, 593 Eddy Street, APC 110, Providence, RI 02903; email:

© 2003 Lippincott Williams & Wilkins, Inc.