title: The effect of tertiary surveys on missed injuries in trauma: a systematic review.
abstract: BACKGROUND
  Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes.
  
  
  METHODS
  A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. 'Missed injury' was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale.
  
  
  RESULTS
  Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01).
  
  
  CONCLUSIONS
  Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.
authors.affiliation: Department of Emergency Medicine, Gold Coast Hospital, Gold Coast, Queensland, Australia. gerben_keijzers@health.qld.gov.au
authors.forename: Gerben B
authors.initials: GB
authors.lastname: Keijzers
authors.forename: Georgios F
authors.initials: GF
authors.lastname: Giannakopoulos
authors.forename: Chris
authors.initials: C
authors.lastname: Del Mar
authors.forename: Fred C
authors.initials: FC
authors.lastname: Bakker
authors.forename: Leo M G
authors.initials: LM
authors.lastname: Geeraedts
mesh_terms: D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D004632:Emergency Medical Services / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards; D006801:Humans; D009104:Multiple Trauma / Q000175:diagnosis*; D010808:Physical Examination; D019984:Quality Indicators, Health Care; D018570:Risk Assessment