Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative

Amy L. Holmstrom, Katherine C. Ott, Hannah K. Weiss, Ryan J. Ellis, Eric S. Hungness, Michael B. Shapiro, Anthony D. Yang*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


BACKGROUND: Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS. METHODS: Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcomewas documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using ?2 tests. RESULTS: Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009). CONCLUSION: Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTSwas also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals.

Original languageEnglish (US)
Pages (from-to)1048-1053
Number of pages6
JournalJournal of Trauma and Acute Care Surgery
Issue number6
StatePublished - 2021


  • Missed injury
  • Quality improvement
  • Resident education
  • Trauma tertiary survey

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine


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