Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients

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It aims to identify missed injuries. This research aims to study the benefits of tertiary surveys in severely traumatized patients. Methods This prospective with historical control, case-matched cohort was conducted on critically-ill trauma patients who were admitted to the surgical intensive care unit (SICU) of Thammasat University Hospital. The study compared the period before and after the implementation of the tertiary survey. Tertiary survey record form was used in all severely traumatized patients with Injury Severity Score (ISS) > 15 within the first 24 hours and before discharge from SICU between August 2022 and February 2023. The comparison data were retrieved from electronic medical records of patients admitted to SICU with ISS > 15 between April 2020 and July 2022. Results We identified 55 type II missed injuries in 39 of 100 cases prior to implementation and 1 type II missed injury after implementation. Type II missed injury decreased from 31% to 4%, and the missed injury detection rate was 56% after implementing the tertiary survey. However, there is no statistically significant difference in morbidity and mortality rates from missed injuries before and after implementation. Conclusions Using tertiary surveys can reduce missed injury rates and increase missed injury detection rates. This research highlights the importance of implementing tertiary surveys as a routine part of trauma evaluation to improve patient care. However, there is no effect on the outcomes, which may require more sample size. Clinical Trials Registry (reference number TCTR20230625001). 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F1000Research 2024, 13 :321 ( https://doi.org/10.12688/f1000research.148012.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients [version 1; peer review: awaiting peer review] Amonpon Kanlerd 1 , Tanudchaporn Porntewabuncha 1 , Chompoonut Achavanuntakul 1 , Piyapong Boonyasatid 1 , Karikarn Auksornchart 1 Amonpon Kanlerd 1 , Tanudchaporn Porntewabuncha 1 , [...] Chompoonut Achavanuntakul 1 , Piyapong Boonyasatid 1 , Karikarn Auksornchart 1 PUBLISHED 23 Apr 2024 Author details Author details 1 Department of Surgery, Thammasat University, Bangkok, Bangkok, 12120, Thailand Amonpon Kanlerd Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Tanudchaporn Porntewabuncha Roles: Data Curation, Formal Analysis, Investigation, Methodology, Software, Writing – Original Draft Preparation Chompoonut Achavanuntakul Roles: Conceptualization, Investigation, Supervision, Validation Piyapong Boonyasatid Roles: Conceptualization, Investigation, Methodology, Resources, Supervision, Validation Karikarn Auksornchart Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Resources, Supervision, Validation OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Faculty of Medicine – Thammasat University collection. Abstract Background The tertiary survey is an evaluation process conducted after the primary and secondary surveys. It aims to identify missed injuries. This research aims to study the benefits of tertiary surveys in severely traumatized patients. Methods This prospective with historical control, case-matched cohort was conducted on critically-ill trauma patients who were admitted to the surgical intensive care unit (SICU) of Thammasat University Hospital. The study compared the period before and after the implementation of the tertiary survey. Tertiary survey record form was used in all severely traumatized patients with Injury Severity Score (ISS) > 15 within the first 24 hours and before discharge from SICU between August 2022 and February 2023. The comparison data were retrieved from electronic medical records of patients admitted to SICU with ISS > 15 between April 2020 and July 2022. Results We identified 55 type II missed injuries in 39 of 100 cases prior to implementation and 1 type II missed injury after implementation. Type II missed injury decreased from 31% to 4%, and the missed injury detection rate was 56% after implementing the tertiary survey. However, there is no statistically significant difference in morbidity and mortality rates from missed injuries before and after implementation. Conclusions Using tertiary surveys can reduce missed injury rates and increase missed injury detection rates. This research highlights the importance of implementing tertiary surveys as a routine part of trauma evaluation to improve patient care. However, there is no effect on the outcomes, which may require more sample size. Clinical Trials Registry (reference number TCTR20230625001). READ ALL READ LESS Keywords Tertiary survey, Missed injury, Missed injury detection, Severe traumatized patient, Critically-ill trauma Corresponding Author(s) Amonpon Kanlerd ( [email protected] ) Close Corresponding author: Amonpon Kanlerd Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Kanlerd A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Kanlerd A, Porntewabuncha T, Achavanuntakul C et al. Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients [version 1; peer review: awaiting peer review] . F1000Research 2024, 13 :321 ( https://doi.org/10.12688/f1000research.148012.1 ) First published: 23 Apr 2024, 13 :321 ( https://doi.org/10.12688/f1000research.148012.1 ) Latest published: 23 Apr 2024, 13 :321 ( https://doi.org/10.12688/f1000research.148012.1 ) Introduction The rationale for worldwide trauma care usually follows the Advanced Trauma Life Support (ATLS ® ) of the American College of Surgeons. These guidelines emphasize problems prioritizing and managing life-threatening conditions using systematic approaches consistent with primary and secondary surveys. The primary survey aimed to identify immediate life-threatening injuries and to provide appropriate resuscitation. By contrast, the secondary survey focused on diagnosing and detailing the injury to lead to a specific treatment. The secondary survey includes important history taking (AMPLE), head-to-toe examination, and diagnostic adjunct. 1 However, there is still a risk of missed injury even if the secondary survey is complete, especially in patients with severe injury (Injury Severity Score [ISS] > 15), altered mental status, life-threatening injuries, requiring an emergent operation, or mechanical ventilation. 2 – 4 The missed injury rate after the initial evaluation was 1.3 – 39%. 5 Missed injuries could lead to morbidity and mortality, increase the length of hospital stays, and increase total care costs. The tertiary survey was developed in 1990 to reduce missed injuries, consisting of repeated head-to-toe examinations, reviewing previously conducted laboratory and radiology test results, and considering additional testing. 3 The previous studies showed that the tertiary survey significantly reduced missed injuries. 3 – 7 However, a study in 2014 showed no significant difference in missed injury rates before and after implementing the tertiary survey. 8 Missed injuries can be classified into two types: type I represents missed injuries that occurred after primary and secondary surveys and can be detected by a tertiary survey. Type II missed injury is an injury that cannot be detected by a tertiary survey and is presented late after discharge. 7 Most studies measured missed injury detection rates that were not equal to missed injury rates. The tertiary survey was effective in increasing the missed injury detection rate. 6 While it significantly decreased the missed injury rate. 3 – 7 This study aimed to compare the missed injury rate before and after implementing the tertiary survey in critically ill trauma patients and declare the benefits of the tertiary survey in morbidity and mortality. Methods This case-matched cohort study was conducted on critically ill trauma patients treated at Thammasat University Hospital (TUH). TUH is a tertiary medical school hospital in the central region of Thailand, mimicking a Level-1 trauma center in the US. The study compared two periods of time: before the implementation of the tertiary survey between April 2020 and July 2022, and after implementation between August 2022 and February 2023. The inclusion criteria were adult trauma patients (age at least 18 years), initial ISS >15, and admission to the Surgical Intensive Care Unit (SICU). The exclusion criteria were referred cases with time to be admitted >24 h after the injury. The tertiary survey record form was created and validated before implementation, including demographic data, primary and secondary survey results, initial interventions, repeated head-to-toe examinations, review of previously conducted laboratory and radiology tests, injury diagnosis, and treatment module results. Our tertiary survey record form is available in the supplementary data. The attending physicians or investigators of the SICU were trained to use the record form before implementing the tertiary survey. Two tertiary surveys were conducted in all adults critically ill trauma patients with ISS > 15 admitted to the SICU. The first survey was performed within 24 h of admission, and the second was performed before SICU discharge. The missed injury detected with the first survey was defined as missed injury type I, which was detected with the second refers to missed injury type II. The comparison data before the implementation period were retrieved from the electronic medical records of TUH. Missed injuries in the pre-implementation era were mainly detected in the outpatient department after patient discharge and were defined as missed injury type II. We matched the comparison data before and after implementing the tertiary survey with the maximum regional Abbreviated Injury Scale (AIS) at a 4:1 ratio. After matching, the data were compared in terms of missed injury detection rate, missed injury type I, missed injury type II, interventions for missed injuries, and missed injury-related morbidity and mortality. The Human Research Ethics Committee of Thammasat University (Medicine) approved this study (certificate project number MTU-EC-SU-1-080/65) and approved on August 4, 2022. This study was registered with the Thai Clinical Trials Registry (reference number TCTR20230625001). All baseline characteristics and demographic data were assessed during the pre- and post-implementation periods. Percentages, means, and standard deviations (SD) were calculated from the numerical data of both groups. Dichotomous variables were analyzed using the χ 2 or Fisher’s exact test. Continuous variables were calculated using the paired t-test. Statistical analysis was performed using STATA/SE 16.0 for Macs (Stata Corp LP, Tx, USA, available at https://www.stata.com ), and p-values <0.05 were regarded as indicating statistically significant. The flow diagram of the cohort study is shown in Figure 1 . Figure 1. Study flow. Results A total of 25 patients in the post-implementation period were included in this study, and the comparison data of 100 patients in the pre-implementation era were retrieved from the electronic medical records. The demographic data between the pre- and post-implementation groups showed no statistically significant differences, except for sex (96% and 81%; p = 0.004 ). AIS However, both groups were predominantly male. The maximum AIS in the two groups was 40% in the head and neck region, followed by the abdomen (28%), extremities (16%), chest (12%), and face (4%). Population characteristics are presented in Table 1 . Table 1. Characteristics of the study population. Pre-implementing group (n = 100) Post-implementing group (n = 25) p-value Male (n, %) 81 (81) 24 (96) 0.004 Age (mean years ± SD) 38.33 ± 2.81 36.24 ± 4.54 0.089 SBP ≤ 90 mmHg (n, %) 15 (15) 6 (24) 0.094 GCS ≤ 8 (n, %) 47 (47) 13 (52) 0.434 Intubation (n, %) 60 (60) 16 (64) 0.514 Emergency operation (n, %) 30 (30) 10 (40) 0.280 ISS (mean ± SD) 21.96 ± 0.99 22.04 ± 2.51 0.082 Overall mortality (n, %) 17 (17) 2 (8) 0.075 Maximum AIS Head and neck (n) 5 8 2 0.568 4 16 4 3 16 4 Face (n) 5 0 0 4 0 0 3 4 1 Chest (n) 5 0 0 4 12 3 3 0 0 Abdomen (n) 5 0 0 4 20 5 3 8 2 Extremity (n) 5 0 0 4 12 3 3 4 1 We identified 55 type II missed injuries in 39 of 100 cases before implementation, 20 type I missed injuries in 14 patients, and 1 type II missed injury in 1 of 25 patients after implementation of the tertiary survey. The pre-implementation group had the highest number of missed injuries in the extremities (29.09%), followed by the chest (27.27%), abdomen (20%), head and neck (14.54%), face (9.09%), and external regions (1.81%). After implementation, we discovered that 25% of missed injury type I was located in the external regions and extremities, including the pelvis; 20% on the chest; and 10% on the head and neck, face, and abdomen. An additional 1 case of missed type II injuries was found in the extremities, including the pelvis. Details of the missed injuries in both the groups are presented in Table 2 . Table 2. Missed injuries in different body regions in two groups. Pre-implementing group Post-implementing group No. of missed injury type II No. of missed injury type I No. of missed injury type II Head and neck 8 (14.54%) 2 (10.00%) 0 (0%) Intracerebral artery dissection 1 # 0 0 Skull fracture 3 0 0 Subarachnoid hemorrhage 2 0 0 Tympanic membrane perforation 1 0 0 Hyoid bone fracture 1 0 0 Cervical fracture 0 1 0 Base of skull fracture 0 1 0 Face 5 (9.09%) 2 (10.00%) 0 (0%) Facial bone fracture 1 0 0 Traumatic optic neuropathy 2 * 1 * 0 Facial nerve palsy 1 0 0 Submandibular gland injury 1 0 0 Tongue laceration 0 1 # 0 Chest 15 (27.27%) 4 (20.00%) 0 (0%) Rib fracture 4 3 0 Pneumothorax/Hemothorax 6 1 0 Pulmonary contusion 4 0 0 Diaphragmatic injury 1 0 0 Abdomen 11 (20.00%) 2 (10.00%) 0 (0%) Adrenal injury 7 0 0 Splenic injury 1 1 0 Kidney injury 1 1 0 Liver injury 2 0 0 Extremity include pelvis 16 (29.09%) 5 (25.00%) 1 (100%) Brachial plexus injury 1 * 0 0 Ulnar fracture 7 0 1 # Scapular fracture 2 2 0 Clavicle fracture 0 1 0 Acetabulum fracture 1 1 0 Pelvic fracture 3 0 0 Femur fracture 1 # 0 0 Patella fracture 1 # 0 0 Ankle fracture 1 0 0 Thoracic and lumbar fracture 5 1 0 External 1 (1.81%) 5 (25.00%) 0 (0%) Superficial wound 1 5 0 Total 39 patients (55 missed injuries) 14 patients (20 missed injuries) 1 patient (1 missed injury) * Morbidity cases related to missed injury. # Required operative intervention. Three missed injuries required surgical intervention in the pre-implementation group, such as an intracerebral artery dissection, which was treated with cerebral angiography with balloon angioplasty; a femur fracture that was treated with open reduction internal fixation with a reconstruction locking plate and headless screw; and a patellar fracture that required open reduction and internal fixation with a locking compression plate. After implementing the tertiary survey, one patient with missed injury type I (tongue laceration) underwent suturing under general anesthesia. Additionally, there was one missed type II injury, specifically an ulnar fracture that required open reduction and internal fixation with a locking plate. Three morbidities were related to missed injury type II in the preimplementation group. Two individuals exhibited visual impairment from traumatic optic neuropathy, while the other had upper-extremity weakness related to brachial plexus injury. Conversely, in the post-implementation group, only one patient had visual impairment resulting from traumatic optic neuropathy, which was the missed injury type I. Fortunately, there was no mortality related to missed injury in either group. However, both groups showed no statistically significant differences in morbidity and mortality rates owing to missed injuries. After conducting a tertiary survey, the missed injury type II rate declined from 31% to 4% (OR, 0.36; 95%CI 0.15-0.86). Additionally, the missed injury detection rate was 56%. The differences between the missed injury rates and missed injury detection rates in both groups are shown in Table 3 . Table 3. Comparison of results between two groups. Pre-implementing group Post-implementing group OR (95%CI) Missed injury type I rate - 0.56 Missed injury type II rate 0.31 0.04 0.36 (0.15-0.86) Missed injury detection rate - 0.56 Morbidity rate 0.02 0.08 0.28 (0.04-1.79) Mortality rate 0 0 Discussion Previous studies have demonstrated that altered levels of consciousness, 2 , 3 , 9 , 10 other life-threatening injuries, 2 the requirement for immediate operative intervention, 3 , 4 and intubated patients 2 have a high likelihood of missed injuries. The two groups of population baseline characteristics showed no statistically significant differences. We cannot conclude which factors may be related to the development of missed injuries. In 2004, Walter and colleagues 4 discovered that implementing a tertiary survey reduced missed injuries from 2.4% to 1.5% in the overall population and from 5.7% to 3.4% in trauma intensive care unit patients. Additionally, a meta-analysis conducted by Shahab 5 in 2015 demonstrated fewer missed injuries and higher missed injury detection rates following the implementation of a tertiary survey. Corresponding to our results, the missed injury type II rate significantly decreased from 31% to 4% after the implementation of the tertiary survey, with a missed injury detection rate of up to 56%. However, only one patient underwent operative intervention, while two patients experienced morbidity and no deaths resulted from missed injuries in our population. Traumatic optic neuropathy (TON) is the most common morbidity related to missed injuries. TON is likely to be a missed diagnosis because symptoms are difficult to recognize and may cause permanent disability, such as blindness. 11 Early detection may lead to better outcomes. Our tertiary survey record form focuses on this condition and may be beneficial in the early recognition of TON. This study has some limitations. First, this study was conducted within a single institution, which may restrict the generalizability of the findings. Second, the small number of participants in the study may limit the statistical significance of any observed differences between the pre- and post-implementation groups. Third, the medical record review was partially limited because of the incompleteness of some portions of medical documentation. Conclusion Based on our research, implementing tertiary surveys in patients experiencing severe trauma can effectively decrease the missed injury rates from 31% to 4%. Additionally, tertiary surveys can result in missed injury detection rates of as high as 56%. Tertiary surveys are recommended as a routine aspect of severely traumatized patient care. Nonetheless, it is still unclear whether implementing this practice results in improved outcomes, such as decreased morbidity and mortality rates, as further studies with larger sample sizes are required to determine this effect. Ethical approval and consent to participants The Human Research Ethics Committee of Thammasat University (Medicine) approved the study with the certificate project number MTU-EC-SU-1-080/65 and approved on August 4, 2022. Written Informed consent was obtained from all enrolled patients who were asked by investigators or research assistants. Investigators will ask for reconsent if the research participant regains consent capability if the investigator asks for consent from a legally authorized representative. The investigator will ask the impartial witness to witness the consent process of an illiterate participant. Data availability Underlying data Zenodo: Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients. https://doi.org/10.5281/zenodo.10612453 . 12 This project contains the following underlying data: - Case record raw data anonymous.xlsx (raw data of this study) - TU tertiary survey.pdf (tertiary survey module of Thammasat University Hospital) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Extended data Zenodo: STROBE checklist for “prospective with historical control, case-match cohort study of the tertiary survey beneficial in critically severe trauma patients.”. https://zenodo.org/doi/10.5281/zenodo.10612453 . Acknowledgements This work was supported by the Research Group in Surgery, Faculty of Medicine, Thammasat University. References 1. American College of S, Committee on T: Advanced Trauma Life Support (ATLS ® ): student course manual.2018. 2. Houshian S, Larsen MS, Holm C: Missed injuries in a level I trauma center. J. Trauma. 2002; 52 (4): 715–719. PubMed Abstract 3. Enderson BL, Reath DB, Meadors J, et al. : The tertiary trauma survey: a prospective study of missed injury. J. Trauma. 1990; 30 (6): 666–670. discussion 9-70. Publisher Full Text 4. Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary trauma survey decreases missed injuries. J. Trauma. 2003; 54 (1): 38–44. discussion -4. PubMed Abstract | Publisher Full Text 5. Hajibandeh S, Hajibandeh S, Idehen N: Meta-analysis of the effect of tertiary survey on missed injury rate in trauma patients. Injury. 2015; 46 (12): 2474–2482. PubMed Abstract | Publisher Full Text 6. Keijzers GB, Giannakopoulos GF, Del Mar C, et al. : The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand. J. Trauma Resusc. Emerg. Med. 2012; 20 : 77. PubMed Abstract | Publisher Full Text | Free Full Text 7. Keijzers GB, Campbell D, Hooper J, et al. : A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey. World J. Surg. 2014; 38 (1): 222–232. PubMed Abstract | Publisher Full Text | Free Full Text 8. Pfeifer R, Pape HC: Missed injuries in trauma patients: A literature review. Patient Saf. Surg. 2008; 2 : 20. PubMed Abstract | Publisher Full Text | Free Full Text 9. Thomson CB, Greaves I: Missed injury and the tertiary trauma survey. Injury. 2008; 39 (1): 107–114. Publisher Full Text 10. Vles WJ, Veen EJ, Roukema JA, et al. : Consequences of delayed diagnoses in trauma patients: a prospective study. J. Am. Coll. Surg. 2003; 197 (4): 596–602. Publisher Full Text 11. Chalela JA: Traumatic Optic Neuropathy: The Forgotten Concussion. Mil. Med. 2023; 188 (1-2): 398–400. PubMed Abstract | Publisher Full Text 12. Kanlerd A, Porntewabuncha T, Achavanuntakul C, et al. : Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients. Zenodo. 2024. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 Apr 2024 ADD YOUR COMMENT Comment Author details Author details 1 Department of Surgery, Thammasat University, Bangkok, Bangkok, 12120, Thailand Amonpon Kanlerd Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Tanudchaporn Porntewabuncha Roles: Data Curation, Formal Analysis, Investigation, Methodology, Software, Writing – Original Draft Preparation Chompoonut Achavanuntakul Roles: Conceptualization, Investigation, Supervision, Validation Piyapong Boonyasatid Roles: Conceptualization, Investigation, Methodology, Resources, Supervision, Validation Karikarn Auksornchart Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Resources, Supervision, Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 23 Apr 2024, 13:321 https://doi.org/10.12688/f1000research.148012.1 Copyright © 2024 Kanlerd A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Kanlerd A, Porntewabuncha T, Achavanuntakul C et al. Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients [version 1; peer review: awaiting peer review] . 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });