3.14 Tertiary Survey

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Description of Indicator

Relationship to Quality Medical care should be safe and effective
Type of Indicator Hospital process, Hospital level
Proposed Data Source Trauma Registry
Definition Tertiary survey completed within 24 hours of hospital admission
Numerator All patients age 18 years and older admitted to hospital with an injury diagnosis AND a tertiary survey documented in the medical record within 24 hours of hospital admission
Denominator All patients age 18 years and older admitted to hospital with an injury diagnosis
Benchmark All patients age 18 years and older admitted to hospital with an injury diagnosis
Risk Adjustment Not applicable


This indicator is intended to monitor the use of tertiary surveys to identify injuries not diagnosed upon patient admission.

Panel Review
The indicator was derived from another indicator that was designed to evaluate the occurrence of missed injuries. However, panelists had concerns that identifying missed injuries was challenging and suggested that focusing on a key process to minimize the risk of missed injuries, such as the tertiary survey, may be more effective.
There was debate among panelists as to what time frame would be most appropriate for this indicator. It was suggested that a time frame of 24 hours would be reasonable, but other panelists argued that the time frame should be extended to 36 to 48 hours to accommodate the practicalities of coordinating other patient investigations and interventions as well as patient handoffs post call. Panelists highlighted the importance of establishing who is responsible for conducting the survey (e.g. trauma service versus ICU service).

Trauma Center Review
Trauma centers noted the importance of this indicator and suggested that it may be beneficial to document the number of injuries identified by tertiary surveys. As in the panel review, there were discordant responses from trauma centers as to what time frame is most appropriate with the majority of centers suggesting 24 hours as a reasonable time frame. In addition, trauma centers questioned what documentation would be required for evaluation of the indicator.

Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated a 36% overall reduction in missed injuries with the completion of a tertiary survey within 24 hours of admission in a Level 1 trauma center70. One study demonstrated that implementation of a tertiary survey within 24 hours of admission in a Level 2 trauma center identified 14% of patients that had a missed injury71.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: No data identified.
Enderson et al.72 proposed the implementation of a tertiary survey after completing a prospective study looking into injuries missed in the primary and secondary evaluations of patients72. The tertiary survey should include a structured and comprehensive evaluation of the patient including review of diagnostic studies by both a physician familiar with and a physician unfamiliar (fresh set of eyes) with the patient73. Guidelines for completion of the tertiary survey vary in the literature73 with the majority of articles suggesting within 24 hours of admission70,71,74.


The indicator was developed from the American College of Surgeons Committee on Trauma audit filters, Missed Injuries and Injuries Diagnosed >24 hours Post Presentation2.


2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
70. Biffl WL, Harrington DT, Cioffi WG, Enderson BL, Mackersie RC, Tinkoff G. Implementation of a tertiary trauma survey decreases missed injuries. J Trauma. 2003;54(1):38-44.
71. Howard J, Sundararajan R, Thomas SG, Walsh M, Sundararajan M. Reducing missed injuries at a level II trauma center. J Trauma Nurs. 2006;13(3):89-95.
72. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990;30(6):666-669; discussion 669-670.
73. Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury. 2008;39(1):107-114.
74. Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury. 2004;35(4):407-410.