The selection of the right manner at the right time is fundamental in managing trauma patients. Approach, skills trauma programs, reliable, bedside, and rapidly accomplished routine investigations can be pivotal. These skills trauma programs should be differentiated between patients with life-threatening conditions and others with hidden injuries who are better with additional diagnostic workup, patients in whom additional diagnostic workup is unnecessary, and patients requiring surgical intervention, without risking the patient’s clinical outcome.
Skills trauma programs include those such as the STEPs course, which was created through a collaborative effort of physicians in the United States and Egypt. One of the aims of this course was to create high-quality, modular, and sustainable trauma skills care course that can be adopted by lower- or middle-income countries (10).
Missed injuries in trauma patients remain a worldwide problem, especially in trauma centers. Thus, the implementation of trauma courses (e.g., STEPs, ATLS, and European Trauma Course) should be mandatory for all ED physicians to minimize the occurrence and incidence of missed injuries. This would serve to help decrease morbidity and mortality among trauma patients. And still paucity of knowledge and information regarding missed injuries in Egypt (12).
This interventional training study conducted in the SCUH ED was intended to improve the management process for polytrauma patients by evaluating and decreasing the incidence of missed injuries after the implementation of the STEPs course. This study revealed that, of the 458 polytrauma patients, 64.6% were between the ages of 18 and 60 years old and 87.5% were men. In addition, according to the mechanism of trauma, 229 (50%) of the patients were injured in MCAs.
Our results agree with those in a study performed by Kozaci et al., which was conducted at the Antalya Education and Research Hospital in Turkey between June 2015 and March 2018, in which the mean age of the study population was 38 ± 20 years (13).
Road traffic crashes are among the world’s most preventable public health problems. According to the World Health Organization, there were 1.25 million road traffic deaths in 2013, a number that has remained fairly constant since 2007 despite the increase in global motorization and population and the predicted rise in deaths (14). In our study, MCA was responsible for 52.8% of injuries in the pre-STEPs group and 50% in the post-STEPs group, followed by assault (pre-STEPs, 31.2%; post-STEPs, 14.4%) and falling from heights (pre-STEPs, 25.5%; post-STEPs, 23.1%). These results agree with another study conducted by Mahmood et al., which was published in January 2016, in which road traffic accidents, assault, and fall from heights were the most common mechanisms of injury among 993 Egyptian patients (16).
Our study showed that, based on vital data records that were missing, there was a significant difference between the pre- and post-STEPs groups in respiratory rate, heart rate, and systolic blood pressure but that there was no significance difference in Glasgow coma scale between the groups.
All polytrauma patients entered the resuscitation trauma room once they arrived at the ED. We followed the STEPs course principles and treated life-threatening conditions if found. Patients were then subjected to full history and secondary survey, as well as progressive notes for the detection of missed injuries according to the clinical picture of the patients. Our study included 458 polytrauma cases, of which 15 (12%) had missed injuries in the pre-STEPs group and 30 (9%) had missed injuries in the post-STEPs group. However, there were 413 polytrauma patients without missed injuries.
Our study showed that the site of polytrauma was the head and facial injuries in 59 (47.2%) cases and the extremities in 52 (41.6%) cases in the pre-STEPs group. However, in the post-STEPs group, the site of polytrauma was the head and neck in 171 (51.3%) cases and the extremities in 129 (38.7%) cases. This agrees with a study by Elbaih et al., who reported on 300 multiple trauma patients. Injuries of the extremities and pelvis were the most common in trauma patients (43%), and the head and neck (62%) was the only injury showing a significant association with mortality (P < 0.05) in contrast with other injuries (P > 0.05).
In our study, there were 15 (12%) missed injuries in the pre-STEPs group and 30 (9%) in the post-STEPs group. According to the type of missed injuries in both groups, the reduction of missed injuries (3.0%) was not statistically significant in relation to demographic and trauma findings but was an essential clinically significant finding to decrease the number of missed injuries in post-STEPs cases. This agrees with a study by Elbaih et al., who reported that the incidence of missed injuries in the study was 9.0% after the ATLS guidelines were applied and all life-threatening conditions were treated, if present, with a short follow-up outcome of 28 days, which is still high, compared with many trauma centers (5).
Our study showed that most of the missed injuries in both groups were mild (pre-STEPs, 53.3%; post-STEPs, 76.7%), but there was one case (6.7%) of missed life-threatening injuries in the pre-STEPs group. This agrees with a study by Elbaih et al., which reported that injuries in the head and neck were frequently missed (32.2%), followed by injuries of the extremities (28.6%), chest injuries (17.9%), abdomen and pelvis injuries (14.2%), and spine injuries (7.1%) (5).
Our study showed that there was one case (6.7%) of life-threatening missed injuries in the pre-STEPs course group but no cases (0%) in the post-STEPs group. This indicates that training programs, such as the STEPs course, for physicians should be mandatory and can affect the outcome of polytrauma patients by decreasing the incidence of life-threatening missed injuries. This agrees with a study by Pfeifer et al., who reported that, to reduce the rate of missed injuries, we must focus on unconscious and intubated patients with severe trauma (increased ISS) and brain injuries (decreased Glasgow coma scale) during the primary and secondary surveys by applying repeated training programs (11).
These results also match those of Chalya et al., who found that mortality in patients with missed injuries was 19.8% compared with 8.7% in patients without missed injuries (P < 0.001). Among deaths in patients with missed injuries, 57.9% were directly attributable to missed injuries, indicating that missed injuries should be detected early (12).
Our study showed that there was statistically significant difference between the contributing factors of missed injuries in the pre- and post-STEPs groups, respectively: three (20%) and nine (30%) were caused by inadequate diagnostic workup, six (40%) and nine (30%) by deficiency in physical examination, zero and three (10%) by incomplete assessment owing to patient instability, and six (40%) and nine (30%) by incorrect interpretation of imaging in traumatic patients. This corresponds with the findings of Elbaih et al., who reported that clinical error was the most frequent cause of missed injuries (42.9% in our study). Deficiency in physical examination was the second cause (35.7%), followed by incomplete assessment owing to patient instability (10.7%) and incorrect interpretation of imaging in (10.7%) (5, 18, 19).
Thus, repeated completion of the trauma STEPs course or other advanced trauma courses are essential for physicians to decease contributing factors that increase the incidence of missed injuries. Our study showed that most of the missed injuries in both groups had delayed time of final diagnosis within 6 hours (pre-STEPs, 93.3%; post-STEPs, 76.7%). However, most of the patients (pre-STEPs, 9 [60.0%]; post-STEPs, 20 [66.7%]) had missed injuries after arriving at the hospital at night. This also matches the findings of Elbaih et al., who noted high rates of missed injuries (59.2%) in patients arriving during the night compared with 40.8% among patients arriving during the day (5). The high rates of missed injuries among night arrivals can be explained by the fact that well-trained ED physicians and senior surgical team members, which we found to be vital in the diagnosis of missed injuries, were unlikely to be present during night hours, unless called for difficult cases. In our resource-limited setting, in which staff shortage is a challenging problem, redistribution of the few available staff should be conducted to address this problem.
This research shows that all patients with missed injuries in the pre-STEPs group underwent X-ray and ultrasound, and 40% underwent full examination for the final detection and diagnosis of missed injuries. Among the patients with missed injuries in the post-STEPs group, all underwent X-ray, ultrasound, and full examination for the determination and detection of missed injuries. No significant difference was noted between missed injury cases in the pre- and post-STEPs groups regarding missing characteristics.
This agrees with another study by Elbaih et al., which reported a lack of admission X-rays of the specific area of injury (46.3–53.8%) and misinterpreted X-rays (15–34.9%) as main radiological factors contributing to missed diagnosis. Further factors noted were clinical inexperience (26.5%) and assessment errors (33.8–60.5%). Other investigations have found additional contributing factors such as technical errors, inadequate X-rays, interrupted diagnosis, and neighboring injuries. The authors found that, in 50% of cases, more than q1 factor was responsible. (5, 17)
This research showed 15 (12%) missed injuries in the pre-STEPs group and 30 (9%) in the post-STEPs group. Most of the missed injuries in both groups were classified as mild (pre-STEPs, 53.3%; post-STEPs, 76.7%), but there was one patient (6.7%) with missed life-threatening injuries in the pre-STEPs group. After the STEPs program implementation and the resulting increase in skills through training, the rate of missed injuries decreased and no life-threatening missed injuries were found. Elbaih et al. reported that the incidence of missed injuries in their study was 9.0% after the ATLS guidelines were applied and all the life-threatening conditions were treated, if present (5).
In our study, the incidence of missed injuries from the first to fourth week before the course was four cases per week. However, the number of missed injuries increased from the first to the sixth month after the course (two and seven cases, respectively), mostly owing to the increase skills after the STEPs course for ED physicians, which initially resulted in a decreased the rate of missed injuries but began to elevate again with time after the implementation. The loss of scientific knowledge and skills then affects the outcome of polytrauma patients through increased incidence of missed injuries. Therefore, refresher or repeated courses for physicians should be mandatory for to prevent missed injuries. The validation of the STEPs course certificate should not last more than 2 years.
The STEPs principles deal with all polytrauma or major trauma patients, defined by an ISS greater than 16 for all age groups and sexes seen in the ED. For the purpose of this study, early detection of missed injuries was defined as injury detected and exactly diagnosed 6 or 12 hours after the traumatic event.
The STEPs course was developed in 2006 at the University of Maryland, based in part on the World Health Organization’s emergency and surgical care materials, and designed to introduce course participants to basic concepts of injury management. After the award of the National Institutes of Health, Egyptian officials and Ain Shams University requested that the University of Maryland faculty provide the American College of Surgeons ATLS course. However, this was impossible at the time owing to the lack of in-country infrastructure required by the international ATLS process, implementation costs, and difficulty in adapting the course to limited-resource settings. The STEPs course was designed to improve services in EDs by training residents and physicians with good materials in a 4-day course. Materials include a combination of lectures, interactive sessions (e.g., radiology review, splinting workshop, and airway workshop), and a half-day veterinary procedure laboratory. So in our study depending on STEPs course guidelines (10).
The ATLS course by the American College of Surgeons introduced primary and secondary surveys in the management of multiple traumatized patients to allow for the prioritization of the most life-threatening injuries and to address all other injuries, respectively. Despite such detailed and standardized treatment principles, some injuries still escape detection during these two phases. However, most studies of missed injuries report an incidence of 0.6–65%, depending on how a missed injury was defined and the type of injury considered (11, 15).
After the implementation of the STEPs course in our study, the incidence of missed injuries decreased from 12% in pre-STEPs to 9% in post-STEPs, corresponding with the study of Elbaih et al., who reported that the incidence of missed injuries was 9.0% after ATLS guideline application. Therefore, the STEPs course may be considered at the same level of ATLS training skills programs in dealing with trauma for decreasing the missed injury cases.
First, there may be untrained senior ED physicians who newly joined the ED and have not attended the STEPs course, which may result in an increased incidence of missed injuries. Second, for the elimination of bias owing to differences in personal skills and years of experience, the redistribution of the few staff available needs to be designed to address the problem. In particular, all residents and assistant lecturers should attend the STEPs course. Third, the STEPs course needs attendance for 4 days by all residents and assistant lecturers. Trauma patients should be transferred to other trauma centers to allow all ED physicians the chance to attend the STEPs course, with the end result being a standardized approach for trauma. Finally, in our resource-limited setting, in which staff shortage is a challenging problem, the redistribution of the few available staff should be designed to address the problem for decreased incidence of missed injuries.