|Year : 2014 | Volume
| Issue : 1 | Page : 48-52
Evaluation of injury severity score of missed injuries in pediatric trauma patients at institutional adult level II trauma center: Do we need a revised National Trauma policy for pediatric trauma?
Ajai Singh, Sabir Ali, Rajeshwar Nath Srivastava
Department of Orthopaedics, K. G. Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||6-Jun-2014|
Department of Orthopaedics, K. G. Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aims: The aim of the following study is to establish the incidence contributing factors and impact of the missed injuries in pediatric trauma patients at adult trauma center on the prognosis and overall outcome of these children. Settings and Design: Longitudinal prospective cohort study involving 603 patients in over 06 months. Materials and Methods: The relevant data (as defined) of all included patients were recorded. These patients were then followed to document the total length of hospital stay and the injury list defined at the discharge or on the 7 th day of admission; whichever came first. The injury severity score (ISS) at admission was compared with final ISS (multivariate regression analysis). Results: Total 115 (19.1%) missed injuries (adult + pediatric both) were discovered, out of which 71 (61.7%) were pediatric trauma missed injuries. The pediatric trauma missed injuries were 32.2% of all pediatric trauma patients and 11.8% of all trauma patients. Main contributing factors were incomplete assessment (52.5%) and patients' arrival time. None of the missed injuries led to any mortality, morbidity or increased length of hospitalization. Final ISS did not correlate with missed injury. Conclusions: Missed injuries are a significant problem in trauma patients especially the pediatric trauma patients. Though the majority of children with trauma were treated efficiently in the anaplastic thyroid carcinoma, but there is a need for improvement in patient assessment and monitoring, that is, extended tertiary survey; with special exposure to the attending residents at casualty about pediatric trauma and its pathophysiology.
Keywords: Injury severity score of missed injuries, missed injuries, pediatric trauma, pediatric trauma center, trauma center
|How to cite this article:|
Singh A, Ali S, Srivastava RN. Evaluation of injury severity score of missed injuries in pediatric trauma patients at institutional adult level II trauma center: Do we need a revised National Trauma policy for pediatric trauma?. J Orthop Traumatol Rehabil 2014;7:48-52
|How to cite this URL:|
Singh A, Ali S, Srivastava RN. Evaluation of injury severity score of missed injuries in pediatric trauma patients at institutional adult level II trauma center: Do we need a revised National Trauma policy for pediatric trauma?. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 26];7:48-52. Available from: http://www.jotr.in/text.asp?2014/7/1/48/134014
| Introduction|| |
The trauma cases have reached at epidemic proportion. Modernization has resulted into high speed trauma, involving multiple systems. The incidence of such trauma cases has reached at an alarming position. It is a well-known fact that in India, trauma centers are being established with the basic concept of the needs of a trauma patient. In these trauma centers, the pediatric trauma patients are being managed by the same staff and same concepts and principles of adult trauma management are being applied to reporting pediatric population also. In India, mostly interns with limited exposure and non-specialized knowledge, participate in primary emergency services. Our training system fails to recognize this fact, thus these interns/residents fail to appreciate the fact of different pediatric pathophysiology and their response to trauma. We define a missed injury as any injury identified as occurring as a direct result of the patient's primary injury (not acquired in the hospital) that was not identified in patient's diagnosis at admission. The missed injuries in trauma patients may result in increased morbidity/mortality and prolonged length of hospitalization. The morbidity and mortality can be decreased significantly with better and timely detection of lesions/complications, prompt intervention and accordingly reorganization of medical emergency care services. The review of western adult trauma literature reveals the incidence between 10% and 23%, respectively. ,,,,, Unfortunately, we do not have any Indian data to review. Available literature shows that the retrospective studies may have a selective memory component or incomplete information, with an attitude of reluctance to expose our mistake, resulting into difficulty in determining the real incidence of missed injuries. Enderson and Maull  observed that instead of missed injuries being disregarded as freak incidents or mishaps that happen only to the inexperienced health personnel, missed injuries should be looked in an open and analytical manner so that means can be devised to avoid them. A retrospective study on trauma showed that injuries were missed in about 2% of the trauma patients (mostly adults) during the primary and secondary survey. The same performed a prospective study and found a higher rate of missed injuries, approximately 10%. This led to a recommendation for a tertiary survey to be performed within 24 h for all trauma patients. A tertiary examination is a thorough re-examination performed outside of the trauma resuscitation, after primary and secondary surveys, actively looking for additional injuries. Beaty et al.  performed a retrospective study evaluating pediatric trauma patients and found a 20% missed injuries rate. The same group conducted a prospective study on pediatric trauma patients and noted 18.4% patients with missed injuries. We plan this study to establish the incidence contributing factors and impact of the missed injuries in pediatric trauma patients at our institutional adult trauma center on the prognosis and overall outcome of these children.
| Materials and methods|| |
- Study site: Trauma center level II, K. G. Medical University, Lucknow, Uttar Pradesh. This 243 bedded trauma center was a part of 3300 bedded medical university associated hospital.
- Type of study: Longitudinal prospective cohort study.
- Study period: 06 months.
- Sample size: All trauma patients.
- Inclusion criteria: All trauma patients of both sexes and all ages.
- Exclusion criteria:
- Trauma patient died within first 24 h of injury.
- Patients reporting late (after first 24 h of injury).
- Institutional ethical clearance: Obtained.
In our set up, only interns and post-graduate trainee (JR-I) are being posted in casualty room, attending these trauma patients. These patients are first attended by these interns/PG residents, and then later post-graduate resident doctor (SR-I) comes into the picture. All trauma (adults, as well as children) patients, following the inclusion and exclusion criteria were enrolled in this study. The informed consent was taken up. The relevant data including age, sex, duration of injury, mechanism of injury, first aid taken if any, the type of person involved in first aid (before reaching us), injuries noted at the time of admission and the designation/specialty of the medical person noting these injuries was recorded. The investigator then followed the patients to document the total length of hospital stay and the injury list defined at the discharge or at 7 th day of admission; whichever came first. It was also be noted that who (designation and the specialty of the medical person) defined these final injuries. The final injury list was compared with the injury list at admission. A final survey was conducted by the investigator, who is a qualified orthopedic surgeon with special training in pediatric orthopedic surgery. The injury severity score (ISS) at admission was compared with final ISS. We used the revised ISS for this purpose. We also planned to look for any seasonal variation, any specific period of a year (e.g., when the new trainee casualty medical officers join casualty) having different missed injury rate, any variation of missed injuries related to age or sex of the trauma patient, the nature and rate of missed injuries in relation to the designation/specialty of the injury - noting person and any type of injury related missed injuries. The pattern of missed injuries in adult trauma patients was compared with that of pediatric trauma patients and the statistical analysis was done by the institutional statician. We tried to assess the (prognostic) impact of these injuries in relation to changes in the total hospital stay, type of additional investigation if required, type/nature of any of the additional procedure performed and the effect of these injuries on the final result. There was no legal implication, as all the primary surveys by different doctors were done on the same or by next day.
| Results|| |
This longitudinal prospective study was conducted over 06 months in a 243 bedded level II trauma center of our teaching and tertiary referral hospital. Total 603 trauma patients were included in this study as per above inclusion and exclusion criterion. Out of these, 219 (36.3%) were pediatric trauma patients. Total missed injuries found in these 603 patients were 115 (19.1%). Out of these missed injuries, 71 (61.7%) were pediatric missed injuries. These pediatric traumas missed injuries were 32.2% of pediatric trauma patients and 11.8% of all trauma patients. The comparison with missed injury and non-missed injury group is shown in [Table 1] and [Table 2] is showing location, nature, and number of missed injuries in our study population. Multiple factors contributed to the occurrence of missed injuries, the most frequent being an incomplete assessment of abbreviated injury score body areas (52.5%) of missed injuries. There was failure to assign significance to an apparent superficial injury overlying. The occurrence of missed injuries was significantly influenced by patients' arrival time and seniority of the attending doctor. We observed that 75 (65.2%) patients with missed injuries were admitted in night and rest 40 (34.8%) during the day. The mean waiting time between arrival and first assessment of the patient was 37 min during the night against 09 during day hours. Out of 44 adult missed injuries, 31 (70.5%) were first attended by post-graduate trainee and rest 13 (29.5%) were first attended by post-graduate medical officer and post-graduate resident doctor, out of 71 pediatric missed injuries, 39 (54.9%) were first attended by JRs and rest 32 (45.1%) were by post-graduate medical officers and post-graduate resident doctor. Out of total 115 missed injuries, only 33 (28.7%) were diagnosed by post-graduate resident doctor and rest (71.3%) were by the consultant (investigator). Radiological errors occurred in 25 (21.7%) patient and included views taken, limitation of the technique chosen and interpretation of radiographs. All these radiological missed injuries were detected by the consultant (investigator) only. There was a significant association between the incidence of missed injuries and mechanism of injuries [Table 3]. The overall ISS without missed injuries was 8.55, whereas the mean ISS of patients with a missed injury was 12.94 (P = 0.003). ISS for pediatric missed injuries committed by JRs was 12.38 and by post-graduate resident doctor and medical officers were 10.78. Higher the missed injury ISS means higher the numbers of missed injuries. Mean delay in diagnosis of missed injuries was 21 h. However, the observations of our present study failed to establish any significant association of pediatric missed injuries with mortality, morbidity and prolonged hospital stay.
|Table 1: Comparison of patients' (n = 603) characteristics in two groups|
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A multivariate regression analysis showed that the severity of the injuries, patients' time of arrival and seniority of the attending officer had significant modifying effects on each other and on the occurrence of a missed injury (P = 0.001).
| Discussion|| |
Trauma remains a leading cause of death in the first four decades of life. Before the first advanced trauma life support (ATLS) course was field tested in 1978, there was no standard protocol for trauma patients' management. The course changed the approach to trauma patients and the classic "examine, diagnose and treat the patients" was obsolete. The new paradigm was to identify and treat all life threatening problems first, with indefinite deferment of additional diagnostic and therapeutic for non-threatening problems. With this new step and paradigm, missed injuries were a natural result. Curriculum in India however has failed to emphasize and to project to the learners the difference in the pathophysiology of adult and pediatric trauma, the missed injury in children appears more than in adult trauma patients in the same trauma center facilities. 
The missed injuries in adults have led to increased morbidity and mortality in the adult population. However, the observations of our present study failed to establish any significant association of pediatric missed injuries with mortality, morbidity, and prolonged hospital stay. The same observations were made by various retrospective and prospective studies in literature. 
Our study shows that when the post-graduate trainee (JRs) alone evaluated the adult patients, the missed injuries were higher than that of the missed injuries by the more experienced post-graduate resident doctors (SRs). But when it came to the pediatric missed injuries, both post-graduate trainee and post-graduate resident doctors missed injuries significantly, which was then diagnosed by a consultant (investigator). Although none of the missed injuries resulted in serious morbidity or mortality in these children, it does seem that the presence of a trained (in pediatric trauma) surgeon will be beneficial in the initial evaluation of pediatric trauma patients. In India, there are very few trained trauma surgeons, that too pediatric trauma surgeons are still rarer. It seems that an ATLS like program with special emphasis on pediatric trauma must be included in the curriculum to train such surgeons. It should be made mandatory by the MCI to attend these courses preferably during their 1 st year of residency. These certificates should be made mandatory before appearing for the diploma/degree final examination for both medical and surgical specialties.
The next question is, whether the higher pediatric trauma missed injuries in adult trauma centers (as per our observations) justify the need of exclusive pediatric trauma center in India or not? We are of the opinion that as these injuries have failed to establish any significant association of pediatric missed injuries with mortality, morbidity and prolonged hospital stay for such children, we can draw the inference that the adult trauma centers are not finding any unpreventable deaths of pediatric trauma patients and the morbidity/complication rates in these children in adult trauma centers are comparable with that of adult trauma patients. Even the same observation was made in a retrospective study  conducted in the USA, in which 53,113 pediatric trauma cases from 22 pediatric trauma centers (PTCs) and 31 anaplastic thyroid carcinoma (ATCs) included in a national pediatric trauma registry were reviewed. It concluded that although PTCs had higher overall survival rates than ATCs, this difference disappeared when the analysis controls for ISS, pediatric trauma score, age, sex, and mechanism.
| Conclusion|| |
In the adult trauma center, having a person with special pediatric trauma training, present during initial resuscitation and an extended detailed tertiary survey will probably decrease these missed injuries in pediatric trauma patients. This is an important point to observe that in our community, as we are not having any specialized pediatric trauma centers. MCI must look into the fact and evolve a curriculum with special emphasis on pediatric trauma to the young learners. Close attention must be paid to the patients involved in motor vehicle crashes and superficial abrasions must be given its due importance in these high velocity trauma.
As these contributory factors were clearly defined, a conscious effort can be made by the national policy makers to identify those changes to be made in the overall approach to these trauma patients, which may help to decrease/avoid the overall incidence of missed injuries and thus making our services more cost effective and making our medical education more effective, result oriented and comprehensive. A revised National Trauma Policy is the need of the hour, which may incorporate this deficit exclusively by exposing the trainee to the pediatric trauma patients specifically. The undergraduate and post-graduate curriculum should also be revised in such a manner that pediatric trauma and its pathophysiology may be taught to these students specifically.
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[Table 1], [Table 2], [Table 3]