Process improvement in trauma: Compliance with recommended imaging evaluation in the diagnosis of high-grade renal injuries

BACKGROUND: Appropriate imaging in renal trauma can avoid delayed recognition of collecting system injuries, allowing for prompt intervention and less morbidity. Current recommendations include obtaining abdominal and pelvic computed tomographic scans with intravenous contrast, followed by excretory images for high-grade injury or perinephric fluid. The purpose of this study was to evaluate compliance with this recommendation among adult Level I trauma centers in Utah. METHODS: A retrospective review was performed on all renal trauma patients evaluated at adult Level I trauma centers in Utah from January 2005 to January 2011. For all American Association for Surgery of Trauma grade 3 to 5 renal injuries, injury characteristics and outcomes were reviewed. We defined compliance as obtaining delayed images for grade 3 injuries with perinephric fluid or any grade 4 to 5 injuries. Descriptive statistics and univariate comparisons were calculated using statistical software. RESULTS: A total of 147 patients were identified with injuries of grade 3 or higher, but only 126 had available images for review at the time of the study. Of the 102 patients with a perinephric fluid collection or grade 4 to 5 injuries, delayed images were obtained in 74 (73%). In these patients, 14 (19%) had a collecting system injury. In the 28 patients without delayed images, 7 (25%) were later identified to have a collecting system injury. Of the 21 collecting system injuries, 7 (33%) had a delay in diagnosis because of lack of excretory images obtained on initial evaluation. CONCLUSION: Our findings support obtaining excretory images in patients with grade 4 to 5 injuries or those with a perinephric fluid collection. Poor compliance led to delayed diagnosis, with several patients requiring intervention for persistent urinary leak. We have implemented trauma imaging guidelines within Utah Level I trauma hospitals, which seek to minimize these diagnostic problems. (J Trauma Acute Care Surg. 2013;74: 558-562. Copyright (C) 2013 by Lippincott Williams & Wilkins)