Prospective evaluation of tertiary survey for identification of missed musculoskeletal injuries in trauma patients.

Trauma survey include a rapid primary survey to immediately identify and manage life-threatening injuries followed by a head to toe secondary survey supplemented with diagnostic testing is the standard of care in trauma management. Tertiary survey had been introduced to identify injuries missed during the primary and secondary surveys performed in the resuscitation room, and includes a repeated head-to-toe examination and review of all laboratory and radiology studies, usually completed within 24 hours of admission. Once trauma call is activated, cardiothoracic surgery and emergency physiotherapists’ pagers are alerted Senior cardiothoracic and senior emergency physiotherapists (Coordinators) screen patients and provide tertiary survey forms to allocated physiotherapists (assessors) in respective wards. (For trauma admissions occurring overnight during the week and over the weekend, a senior physiotherapist will coordinate and screen any eligible trauma patients) Within 24 hours, the assessors will inform the coordinators when ready to assess the patient. Blinding: If trauma team has already completed the tertiary survey, one of the coordinators will cover trauma team’s tertiary survey with an opaque paper before assessor conducts tertiary survey on the patient. The patient will also be encouraged by the coordinator prior to the assessor’s tertiary survey, not to disclose what trauma team may have informed the patient after their tertiary survey. Similarly, if the trauma team has not completed tertiary survey, the coordinator will inform the patient not to disclose assessor’s tertiary findings to the trauma team. Once the assessors complete the tertiary survey assessment form, the forms will return to the coordinators Coordinators then will document when the treating team has completed the tertiary survey form/photocopy treating team trauma survey Physiotherapists and medical/trauma team who are conducting the tertiary survey will be blinded from each other’s tertiary survey as described above. However, pre tertiary survey information (results of initial work up, physical examination and radiologic studies that have been performed as part of primary/secondary surveys) will be available to both physiotherapists who are completing the tertiary survey and the medical/trauma team. This would be considered the norm for any patients having a tertiary survey. Currently, when a treating physiotherapist identifies a missed injury, the physiotherapist would inform the treating team of such finding. Therefore, when an assessor prior to the trauma team has identified a missed injury, the coordinator will inform the trauma team of the findings. For the purpose of this study, missed injury is defined as any injuries missed after primary and secondary surveys conducted within 24 hours of admission. This is the definitive assessment