Background
Aims
Methods
Study eligibility
Search strategy and information sources
Selection of studies
Data extraction and management
Assessment of risk of bias
Results
Author, year, origin | Population (number and description) | Population characteristics (Age, Gender, Mechanism, ISS) | Intervention | Outcome measure | Study design |
---|---|---|---|---|---|
Enderson, 1990, Tennessee, USA | 399 admitted trauma patients | Age>15 yrs: 86% | TTS as part of trauma admission form, conducted within 24–48 hours after patient stabilization | Missed injuries – defined as detected as a result of TTS. (Type I) | Prospective cohort study – comparing with historical summary data |
Gender: N/A | |||||
Mechanism: 89% | |||||
Blunt Mean ISS: 21 | |||||
Biffl, 2003 | All admitted trauma patients. | Mean Age: 45.3 vs. 44.5 yrs | Implementation of formal TTS, using standardized form and TTS policy. TS within 24 hours and after ICU discharge | Missed injury rate – defined as injuries detected after 24 hours admission or injuries missed by TTS. (Type II) | Cohort study with before-and-after design |
Rhode Island, USA | Before: 3,412 | Gender: 63% vs. 64% Male | |||
After: 3,442 | Mechanism: N/A | ||||
Mean ISS: 10.7 vs. 10.7 | |||||
Vles, 2003 | All (3,879) admitted trauma patients | Age: N/A | Use of standard trauma forms, TTS and review of radiology within 24 hours | Missed injury rate – Any injury missed on primary and secondary survey. (Type I) | Prospective cohort study |
The Netherlands | Gender: N/A | ||||
Mechanism: N/A | |||||
ISS>16: 1.2% | |||||
Hoff, 2004 | 432 admitted trauma patients | Age: N/A | Formal radiology rounds as part of TTS | Missed injury or ‘new diagnosis’ as result of radiology rounds with trauma surgeons. (Type I) | Prospective cohort study |
Pennsylvania, USA | Gender: N/A | ||||
Mechanism: N/A | |||||
ISS: N/A | |||||
Soundappan, 2004 | 76 children admitted with ISS>9 | Mean Age: 8.5 yrs | TTS performed using standardized from by trauma fellow on day after admission and after extubation | Missed injury rate – Any injury missed on primary and secondary survey. (Type I) | Prospective cohort study |
Sydney, Australia | Gender: 66% Male | ||||
Mechanism: 100% Blunt | |||||
Mean ISS: 15 | |||||
Howard, 2006 | 90 admitted trauma patients | Age: N/A | TTS performed using standardized from by single clinician within 24 hours | Missed injury rate – Any injury detected on the TTS. (Type I) | Prospective cohort study |
Indianapolis, USA | Gender: 74% Male | ||||
Mechanism: N/A | |||||
ISS: N/A | |||||
Okello, 2007 | 403 admitted trauma patients | Mean Age: 29 yrs | Daily physical examination up to 30 days, including TTS in first 24 hours | Missed Injury – unclear definition – implied as injury detected after primary and secondary survey. (Type I) | Prospective cohort study |
Uganda | Gender: 82% Male | ||||
Mechanism: 91% Blunt | |||||
ISS: N/A | |||||
Janjua, 2008 | 206 admitted trauma patients | Mean Age: 35 yrs | TTS performed by trauma fellow within 24 hours and after regaining consciousness | Missed injury rate – Any injury missed on primary and secondary survey and operating room. (Type I) | Prospective cohort study |
Sydney, Australia | Gender: 75% Male | ||||
Mechanism: 91-100% Blunt | |||||
ISS: N/A | |||||
Ursic, 2009 | All admitted trauma patients. | Mean Age: 43.4 vs. 44.4 yrs Gender: 69.4% vs 68.9% Male Mechanism:94.3 vs. 94.4% Blunt ISS>15: 26% vs 31% | Implementation of a dedicated trauma service, which included a formalised TTS | Mortality and Length of Hospital stay. Missed injury – not in article -data retrieved via author communication - any injury missed at primary and secondary survey. (Type I) | Cohort study with before-and-after design |
Sydney, Australia | Before: 981 | ||||
After: 1,006 | |||||
Huynh, 2010 | 5,143 admitted trauma patients | Mean Age: 36.2 yrs | Mid level providers performed TTS using a form within 48 hours. This was reviewed by trauma surgeon | Missed injury – defined as detected at TTS. (Type I) | Prospective cohort study |
North Carolina, USA | Gender: 71% Male | ||||
Mechanism: 85% Blunt | |||||
Mean ISS: 14.2 |
Missed injury rate – in patients receiving TTS
Type I missed injury rate – in patients receiving TTS
PRE TTS implementation | POST TTS implementation | |||||
---|---|---|---|---|---|---|
Missed injuries
|
Study population (N)
|
Missed injury rate (%)
|
Patients with Missed injuries (N)
|
Study population (N)
|
Missed injury rate (%)
| |
Enderson, 1990 | N/A | 2.0 | 37 | 399 | 9.27 | |
Vles, 2003 | 49 | 3,879 | 1.26 | |||
Hoff, 2004 | 42 | 432 | 9.72 | |||
Soundappan, 2004 | 12 | 76 | 15.8 | |||
Howard, 2006 | 12 | 90 | 13.3 | |||
Okello, 2007 | 78 | 403 | 19.4 | |||
Janjua, 2008 | 134 | 206 | 65.0 | |||
Ursic, 2009 | 35 | 981 | 3.57 | 62 | 1,006 | 6.16 |
Huynh, 2010 | 80 | 5,143 | 1.56 | |||
Overall
|
35
|
981
|
3.57
|
506
|
11,634
|
4.35
|
Type II missed injury rate – in patients receiving TTS
PRE Tertiary survey implementation | POST Tertiary survey implementation | |||||
---|---|---|---|---|---|---|
Missed injuries
|
Study population (N)
|
Missed injury rate (%)
|
Missed injuries
|
Study population (N)
|
Missed injury rate (%)
| |
Biffl, 2003 | 81 | 3,412 | 2.37 | 52 | 3,442 | 1.51 |
Overall
|
81
|
3,412
|
2.37
|
52
|
3,442
|
1.51
|
Type I and II missed injury rate – before and after introduction of TTS
Clinical relevance of missed injuries
Author, year, origin, N | (N)with MI | Area involved | % | (N)with clinically significant MI | Description of change in management | Mortality and morbidity |
---|---|---|---|---|---|---|
Enderson, 1990, Tennessee, USA N=399 |
36
| MSK | 51 |
7
| OT, N= 7 | Nil deaths |
Spinal | 12 | (MSK N=3, Facial N=1, Abdomen N=3) | Stroke, N=1 | |||
Facial | 5 | |||||
Thoracic | 12 | |||||
Abdominal | 15 | |||||
Vascular | 5 | |||||
Biffl, 2003, |
81 vs. 52
| MSK | 32 vs. 46 |
Not reported
| Not reported | Not reported |
Rhode Island, USA | Spinal | 29 vs. 24 | ||||
Pre TTS: N= 3412 vs. Post TTS: 3442 | Abdominal | 17 vs. 18 | ||||
Brain | 10 vs. 6 | |||||
Pelvic | 5 vs. 0 | |||||
Vascular | 3 vs. 2 | |||||
Diaphragm | 3 vs. 0 | |||||
Vles, 2003, |
49
| Chest | 33 |
22
| OT, N=12 | Morbidity unspecified, N=3 |
The Netherlands N=3879 | MSK | 27 | (Chest N=1, MSK N=4, Facial N=5, Other N=2) | |||
Skull | 7 | ICC, N=2 | ||||
Facial | 13 | Cast, N=6 | ||||
C-Spine | 7 | |||||
Other | 10 | Halo/brace, N=2 | ||||
Hoff, 2004 |
42
| Extremities | 45 |
19
| OT, N=4 (not specified) | Not reported |
Pennsylvania, USA | Spine | 21 | Cast, N=7 | |||
N=432 | Chest | 15 | Transfer, N=1 | |||
Pelvis/proximal skeleton | 19 | Change in advice, N=6, Home equipment, N=1 | ||||
Soundappan, 2004 |
12
| Head/face | 33 |
1
| OT, N=1 (not specified) | Nil deaths |
Sydney, Australia | Spine | 17 | Prolonged LOS, N=4 | |||
N=76 | Extremities | 50 | Delay in mobilisation, N=4 | |||
Howard, 2006, |
13
| Extremities | 70 |
Not reported
| Not reported | Not reported |
Indianapolis, USA | Face | 12 | ||||
N=90 | Spine | 12 | ||||
Chest | 6 | |||||
Okello, 2007, |
76
| Head and neck | 24 |
Not reported
| Not reported | Not reported |
Uganda | Face | 8 | Mulivariate regression shows higher morbidity and longer LOS in patients with MI compared to patients without MI. This may not reflect causality. | |||
N=403 | Thorax | 11 | ||||
Abdomen/pelvis | 20 | |||||
Extremities | 26 | |||||
Janjua, 2008 |
134
| MSK | 40 |
30
| OT, N=11 (Orthopedic n=3, Laparatomy N=7, | Death 1.5% (N=2: C1 fracture; epidural hematoma) |
Sydney, Australia | STI | 36 | Thoracotomy N=1) | Complications 8% (peritonitis N=4 after missed hollow viscus injury) | ||
Abdomen | 6 | Laceration repair, N=2 | ||||
N=206 | Nerve injury | 9 | Embolisation, N=1 | |||
(Hemo-) Pneumothorax | 5 | Not specified, N=17 | ||||
Ursic, 2009 |
35 vs 62
| Not reported |
Not reported
| Not reported | Mortality | |
Sydney, Australia | Pre 3.5% vs. post 2.5% | |||||
Pre TTS: N=981 vs. Post TTS= 1006 | ||||||
Huynh, 2010 |
80
| Orthopedic | 60 |
31
| OT, N=7 (Orthopedic N=4, Facial N=2, Spinal N=1) | Not reported |
North Carolina, USA | Facial/plastics/dental | 21 | Cast, N=24 | |||
N=5143 | Neurosurgical | 16 | ||||
Ophthalmology | 3 |
Subgroup analyses
Long-term health outcomes
Completeness of data
Discussion
Limitations
Missed injury type | Description |
---|---|
Type I
|
Before TTS or as result of TTS:
|
Injury missed at initial assessment (primary and secondary survey and emergency intervention), but detected within 24 hours, before or through formal TTS (i.e. delayed diagnosis at 24 hours) | |
(Injury missed at initial assessment) | |
Type II
|
After TTS, during hospital stay:
|
Injury missed by TTS, detected in hospital after 24 hours. | |
(Injury missed at initial assessment and TTS) | |
Type III
|
After TTS, after hospital discharge:
|
Injury missed during hospital stay including TTS, detected after hospital discharge. | |
(Injury missed at initial assessment and TTS and hospital stay) |
Author | Description |
---|---|
Hoff et al. | Level 1 - Missed injury would likely lead to morbidity/mortality |
Level 2- Missed injury alters care in hospital (including additional imaging) | |
Vles et al. | Any missed injury that leads to change in treatment resulting from the detection of the missed injury |
Huynh et al. | Clinically significant missed injuries are injuries that are judged as such by the trauma attending and required intervention |