Abstract
Millions of people obtain trauma-related medical care on a yearly basis. Due to the critical nature of traumas some injuries are not detected during the initial primary and secondary evaluation, thus morbidity and mortality rates are high. Literature has shown that implementation of a tertiary survey reduces the rate of missed or delayed injuries in trauma patients and can improve patient outcomes. The tertiary survey is a full head-to-toe examination completed 24 hours after admission. All diagnostics are reviewed at this time and if there is any suspicion or new findings on exam, further diagnostic studies are obtained, and appropriate consultations made. The purpose of this quality improvement project was to implement a standard tertiary trauma survey template in the electronic medical record that was utilized by all attending physicians, residents, and mid-level providers as required documentation for all patients admitted to the Trauma and Critical Care Surgery service at an academic Level 1 Trauma Center in Omaha, Nebraska. The expected outcomes of this project included implementation of the tertiary trauma survey template; increased education and understanding of how to perform, utilize and appropriately document the tertiary trauma survey; increased compliance by all providers with performing a tertiary survey on patients admitted to the trauma service; and decreased missed injuries with the utilization of the tertiary trauma survey.