Results and analysis
Each reviewer assessed the MTC documents against a total of 68 features and a total of 1428 data points. Full review of all features is out of the scope of this short report; however, highlights are included below.
Respiratory and abdominal assessment sections were the most frequently identified (present in 90.4% of the TTS pro formas; n=19). Neck, limbs and neurological assessment were included within 85.7% of the TTS pro formas (n=18).
Spine assessment was seen in 10 MTCs and back assessment was contained in nine MTCs. Back or spinal assessment was seen in 16 MTCs. Spine and back assessment was seen in three MTC pro formas. This may reflect differing terminology between hospitals; however, arguably these two standards reflect different aspects of patient assessment and could be interpreted differently between clinicians.
Specific neck assessment was seen in 18 of the MTC pro formas. Immobilization plan or spine clearance comment has an important role inpatient management, comfort and physiotherapy which ultimately aids rehabilitation. Neck immobilization comment was seen in nine MTC pro formas and spine cleared comment was seen in eight MTC pro formas. Neck immobilization or spine cleared comment was seen in 13 MTC pro formas.
New features identified in Round 1 and assessed in Round 2 included items that could be considered more focused and specific features to a TTS; for example, pregnancy test and DNACPR discussions were found in 1 MTC TTS each (4%).
One investigator was removed from Likert analysis due to skew on their Likert scoring. After discussion, this was revealed to be due to the individual not following the proposed methodological Likert scale. Likert analysis interassessor agreement with the remaining three investigators was ‘poor’6 with an average interclass correlation Score of 0.49.
Missed injuries
The literature search attempted to identify potential ‘missed injuries triggers’ was performed and revealed that for polytrauma patients who received some form of CT scan as part of their initial work-up. The compiled research identified trauma registry interrogation and meta-analysis which showed upper and lower limb extremity fractures were by far the most commonly missed at initial presentation,7–9 in particular, fractures of the hand and wrist, ankle, foot and shoulder.10
A single-center study11 showed injuries covered anatomically by CT but still missed on the scan report included:
Bowel/mesentery
Thoracic/lumbar spine
Pelvis.
Another single-center study12 showed that injuries most likely to be completely missed (ie, patient discharged home without ever being diagnosed) were:
Few eye and ear injuries were missed, and these were found to be rarely commented on. In patients who do not receive a CT scan, missed injuries are commonly chest, ribs and upper extremities,13 and spines and heads were the most commonly missed injuries.14
From this work, we identified that within our ‘model’ TTS document, we should include:
A consultant review of CT images to ensure adequate anatomic coverage.
Inspection, palpation and range of motion assessment of the bones of the arm, hand, leg, ankle and foot for fractures.
Formal re-examination of the abdomen for delayed presentation of abdominal injuries.
Assessment of active range of movement of the shoulder for rotator cuff tears.
Assessment of the knee—straight leg raise, inspection, palpation, range of movement. If there is knee swelling or tenderness X-ray should be recommended. Although drawer signs and ligamentous testing could be done in intensive care unit, it is often too painful in the severely injured patient. Where there are concerns about significant soft tissue knee injury, the patient should be reviewed by the orthopedic team.