A. L. Holmstrom1, H. K. Weiss2, K. C. Ott1, R. J. Ellis1,3, M. B. Shapiro1, A. D. Yang1,3 1Northwestern University,Department Of Surgery,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA
Introduction: The tertiary survey is an important component of trauma patient evaluation and has been shown to reduce the rate of missed injuries, particularly in polytrauma and critically ill patients. More complicated injury patterns and hospital stays in these patients may make formal evaluation for missed injuries challenging. Despite their importance, no contemporary studies have evaluated rates of tertiary survey completion at trauma centers. The objectives of this study were (1) to determine the frequency of trauma tertiary survey performance at a Level 1 academic trauma center, and (2) to identify patient and encounter characteristics associated with failure to receive the trauma tertiary survey.
Methods: Retrospective cohort study performed at a single Level 1 academic trauma center. Trauma encounters from July 2016 through June 2017 were included in the analysis. A random 20% sample from each month was audited for performance and documentation of the trauma tertiary survey. The primary outcome was documentation of the trauma tertiary survey, with secondary outcomes of interest being the ordering of additional studies and detection of additional injuries based on tertiary evaluation. Associations between outcomes and categorical patient/encounter characteristics were assessed using chi-square tests.
Results: Among 297 trauma encounters, a complete tertiary survey was documented in 91 (30.6%), a partial tertiary survey was documented in 114 (38.4%), and no tertiary survey was documented in 92 (31.0%). Among patients with a completed tertiary survey, 10.2% underwent additional evaluation and 3.9% were diagnosed with additional injuries. A tertiary survey was significantly less likely to be documented earlier in the academic year (56.5% in the first academic quarter vs 86.1% in the last academic quarter, p<0.001). Documentation of a tertiary survey was also less likely to occur in patients following penetrating trauma (51.9% vs. 72.0% for blunt, p=0.004), more severe injuries (56.3% in high acuity trauma activations vs. 76.2% in low acuity trauma activations, p=0.003), and in those patients requiring intensive care (48.3% vs. 73.2%, p<0.001). There was no difference in tertiary exam performance based on age, sex, time of day, or in operative traumas.
Conclusion: Performance and documentation of a trauma tertiary survey at a Level 1 academic trauma center was inconsistent, with higher acuity and sicker patients being less likely to receive a thorough tertiary assessment. Significant improvement in performance during the academic year suggests that some variation may be driven by the resident learning curve, and thus improvement in tertiary survey performance may be achieved through focused quality improvement efforts. Design and implementation of rigorous, standardized mechanisms to ensure tertiary survey documentation may improve tertiary survey performance and reduce the rate of missed traumatic injuries.