title: Meta-analysis of the effect of tertiary survey on missed injury rate in trauma patients.
abstract: BACKGROUND
  Missed injuries are considered as an important issue in trauma patients and can lead to significant morbidity and even mortality. It has been shown that the standard primary and secondary surveys, recommended by the Advanced Trauma Life Support (ATLS) guidelines, are associated with missed injuries. It has been suggested that tertiary survey can minimise the number and effect of missed injuries. The present paper aimed to identify comparative evidence about the effect of tertiary survey on missed injury rate in trauma patients.
  
  
  METHODS
  In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies evaluating effect of tertiary survey on missed injury rate in trauma patients. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Random-effects models were applied to calculate pooled outcome data.
  
  
  RESULTS
  Four prospective and three retrospective cohort studies, enrolling a total of 12,581 trauma patients, were selected for analysis. Pooled odds ratio (OR) analysis of 5727 patients showed that detection of missed injuries was better in trauma patients who had tertiary survey compared to patients who did not have tertiary survey [OR=2.65, (95% CI:1.40-5.01), P=0.003]. A moderate level of heterogeneity among the studies existed (I(2)=68%, P=0.008). Also, analysis of 6,854 patients showed that fewer injuries were missed in trauma patients who had tertiary survey compared to patients who did not have tertiary survey [OR=0.63, (95% CI: 0.44-0.90), P=0.01].
  
  
  CONCLUSIONS
  The best available evidence demonstrates a constant trend in favour of tertiary survey in terms of missed injury reduction, and supports its use in management of trauma patients. Further studies are required to clarify the most cost-effective and systematic way of addressing missed injuries in the first 24h. We recommend use of "missed injury detection rate" and "missed injury rate" as two different outcomes in future studies in order to address the issue of heterogeneity in definition of missed injury in the current literature.
authors.affiliation: Accident and Emergency Department, Queen's Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom. Electronic address: shahab_hajibandeh@yahoo.com.
authors.forename: Shahab
authors.initials: S
authors.lastname: Hajibandeh
authors.affiliation: Accident and Emergency Department, Blackpool Victoria Hospital, 38 Whinney Heys Rd, Blackpool, Lancashire FY3 8NR, United Kingdom.
authors.forename: Shahin
authors.initials: S
authors.lastname: Hajibandeh
authors.affiliation: Accident and Emergency Department, Blackpool Victoria Hospital, 38 Whinney Heys Rd, Blackpool, Lancashire FY3 8NR, United Kingdom.
authors.forename: Nosakhare
authors.initials: N
authors.lastname: Idehen
mesh_terms: D003951:Diagnostic Errors; D004632:Emergency Medical Services; D019538:Health Care Surveys; D006801:Humans; D009104:Multiple Trauma / Q000175:diagnosis*; D011446:Prospective Studies; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*
keywords: Missed injury; Tertiary survey; Trauma