title: Process improvement in trauma: traumatic bladder injuries and compliance with recommended imaging evaluation.
abstract: BACKGROUND
  We hypothesized that our compliance was low with recommended imaging for evaluation of traumatic bladder injury, which includes either a computed tomographic (CT) cystogram or plain cystogram. We sought to determine if poor compliance impacted diagnosis, management, and outcome of patients with bladder injury.
  
  
  METHODS
  Patients with bladder injury were identified from all Level 1 hospital trauma registries in Utah from 1996 to 2010. Details including presentation, management, and outcome of bladder injury were described using descriptive statistics and bivariate and logistic regression analysis.
  
  
  RESULTS
  A total of 124 patients were identified from the trauma registries with bladder injury and adequate records for review. The mean age was 35 years. Blunt trauma occurred in 110 patients (88%). Mean Injury Severity Score was 26.3. The leading concomitant injury was pelvic fracture in 98 patients (79%). Bladder injury was extraperitoneal in 75 patients (60%), intraperitoneal in 39 (31%), and both or undetermined in 10 (8%). A higher risk of death was seen in intraperitoneal with or without concomitant extraperitoneal injury compared with extraperitoneal injury only (odds ratio, 12.4; 95% confidence interval, 2.37-99.2). Management was operative in 68 (55%) patients (95% intraperitoneal, 31% extraperitoneal). Of the 124 injuries, 100 were detected with imaging: standard CT scan in 70 (56%) and cystogram or CT cystogram in 30 (24%). The remaining injuries were discovered operatively or were undocumented (n = 24, 19%). Initial imaging missed or incorrectly diagnosed bladder injury in 13 (13%) patients (nine from standard CT scan and four from CT or plain cystogram). In five cases diagnosed by standard CT scan, extraperitoneal injuries were misdiagnosed as intraperitoneal and operatively explored.
  
  
  CONCLUSIONS
  There was poor compliance with imaging recommendations for evaluation of suspected bladder injury by either CT cystogram or plain cystogram at Level 1 trauma centers in Utah. We have implemented a genitourinary trauma imaging algorithm designed to minimize errors in bladder injury diagnosis.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: Department of Surgery, Division of Urology and the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City, Utah 84132, USA. jeremy.myers@hsc.utah.edu
authors.forename: Jeremy B
authors.initials: JB
authors.lastname: Myers
authors.forename: Michael B
authors.initials: MB
authors.lastname: Taylor
authors.forename: William O
authors.initials: WO
authors.lastname: Brant
authors.forename: William
authors.initials: W
authors.lastname: Lowrance
authors.forename: M Chad
authors.initials: MC
authors.lastname: Wallis
authors.forename: Angela P
authors.initials: AP
authors.lastname: Presson
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Morris
authors.forename: Raminder
authors.initials: R
authors.lastname: Nirula
authors.forename: Mark H
authors.initials: MH
authors.lastname: Stevens
mesh_terms: D000328:Adult; D002648:Child; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D001743:Urinary Bladder / Q000000981:diagnostic imaging* / Q000293:injuries*; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging