The effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients, protocol for a cluster-randomised controlled trial.

The intervention will consist of: 1) The implementation of a formalised Trauma Tertiary Survey (TTS) form. This form prompts documentation for relevant features of history (such as mechanism of injury) and physical examination of relevant body regions. Furthermore the form prompts for review and documentation of relevant pathology and imaging results. The final part of the form includes a (new) injury list. 2) All medical and nursing staff on trauma admitting wards will attend two education sessions on the rationale and use of the TTS form, provided by a chief or associate researcher in small-group work-shop format. The duration of education will be 2 separate sessions of approximately 45 min each 3) Key stake holder engagement (Hospital executives, Directors of trauma admitting units; Emergency Department, General Surgery, Orthopaedic Surgery, Neurosurgery, Intensive Care Unit) with a clear directive to all levels of medical and nursing staff for compliance with training and education sessions and mandatory TTS form completion as part of routine care within 24 hours of admission. The intervention (Form, Education, Executive directive) will be conducted over several wards, and is expected to take up to 4 weeks for each hospital. Participating hospitals (clusters) will be 1:1 randomised to either immediate (Group 1) or delayed (Group 2) introduction of TTS, using computer generated random number function. Group 1 will implement formalised TTS in the first 12 months, with continuation of formalised TTS in the second 12 months. Group 2 hospitals will continue routine trauma care in the first 12 months followed by implementation of formalised TTS in the second 12 months. After cluster (hospital) randomisation occurs - the hospital coordinator will be informed of the allocation. If the hospital is allocated to the TTS - the 4 week introduction/education will start, where the hospitals (clusters) randomised to the routine care, start data collection. After 12 months of data collection - the hospitals providing routine care change to the introduce TTS. The 4 week TTS /introduction and education will occur and afterwards another 12 month data collection periods will occur Time Schedule of enrolment The intervention will be introduced over a 1-month period via formalised TTS and education on trauma admitting wards via key stakeholder engagement. In the Group 1 hospitals this will occur at the start of the trial. For the Group 2 hospitals, this introduction period will occur after the 12-month data collection period for routine care (Group 1: TTS implementation --> TTS maintenance, Group 2: standard care --> TTS implementation). Overall recruitment is expected to take approximately 24-25 months, with another 12 months for complete follow up. Optimising patient enrolment and outcomes: The study will require initial education on TTS performance on introduction and ongoing education while maintaining this intervention. Although the clinical workload for participating hospitals will not increase, there will be additional education and research resources required. Ongoing education for all staff working on trauma admitting wards (rationale and logistics of TTS performance) is essential. Telephone follow-up compliance despite consent is often sub-optimal, hence the research assistants will be trained to prime and prepare participants for this, as to not include patient who are unwilling or unable to be followed up. We will ask for alternative phone numbers and ask for consent to contact GPs at 1, 6 and 12 months.