Polytraumatic Injuries in Motor Vehicle Crash Victims:

(1)

Polytraumatic Injuries

in Motor Vehicle Crash

Victims:

On the Advantages of

Trauma Registry

versus

Hospital Administrative Billing Data

for Polytraumatic Injury Assessment

Sylvia Hobbs

Massachusetts

Office of Emergency

Medical Services

(2)

Definitions

•

Hospital Administrative Billing Data

– Case specific, diagnostic data that describes

patient socio-demographic characteristics, medical reason for admission, procedures

performed and duration and status of the patient's stay in the hospital. Data are a slightly

modified version of the current uniform billing data set negotiated by the National Uniform

Billing Committee used by major third party payers and most hospitals, hospital-based

skilled nursing facilities and home health agencies. data set and includes the data

elements specified by State Regulatory Agencies. The data are submitted to:

– Agency for Healthcare Quality Research

– Centers for Disease Control & Prevention

– State Agencies

•

Trauma Registry

– Specific physiologic, anatomic, diagnostic, functional impairment,

demographic, and procedure data on patients who receive hospital care for certain types

of injuries. The collection of trauma data is required for verification as a trauma center by

the American College of Surgeons. The data are primarily designed to ensure quality

trauma care and outcomes in individual institutions and trauma systems, but have the

secondary purpose of providing useful data for the surveillance of injury morbidity and

mortality. The data are submitted to:

– National Trauma Databank

– State Agencies

•

Polytrauma

– Severe multiple injuries to the body’s anatomical systems, one of them

endanger life, Injury Severity Score > 16 (Different Definitions for Polytrauma)

(3)

•

Hannover

– three severe injury, one of them endanger

life

• Uppsala – multiple injury of soft tissues, bones,

parenchymatic organs combined with shock

• Basilei – severe injury of at least one body cavity and

one long bone fracture, or two body cavitis or three

fractures of long bones

•

Paris

- two or more complex injuries with respiratory or

circulatory failure

• Dallas – multiple injury of 1-2 body cavities and at least

2 fractures ordutin, or more then 3 fractures of long

bones

Different Definitions for

Polytrauma

(4)

Trauma Registry

Severity Metrics

(5)

0

10

20

30

40

50

60

70

80

90

Ar

kansas

Ar

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Ca

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Co

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Fl

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Ill

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Indi

ana

Iowa

K

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as

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Loui

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Ma

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and

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ing

FY2009 Number of Inpatient Hospital

Diagnoses Collected by State

Variations in Commonly Used Data for Motor Vehicle Crash

Injury Analysis

Mystery Box Number Two (Categorical Data)

Mystery Box Number One (Numeric Injury Data)

(6)

0

10

20

30

40

50

60

70

80

90

Ar

kansas

Ar

izona

Ca

lifo

rni

a

Co

lor

ado

C

onnec

ti

cut

Fl

or

ida

G

eor

gi

a

H

awa

ii

Ill

inoi

s

Indi

ana

Iowa

K

ans

as

K

ent

ucky

Loui

si

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Ma

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M

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and

M

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Number of Inpatient Hospital Diagnoses

Collected by State

Variation in the Number of Inpatient Hospital Diagnoses

Collected by States used to Compare Injury Severity

(7)

(8)

(9)

Number of Inpatient Diagnoses States Collect through Hospital Administrative Data (AHRQ HCUP Data

Source)

State

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Arkansas

n/a

9

18

Arizona

11

9

25

California

30

25

Colorado

15

Connecticut

30

Florida

10

31

Georgia

10

30

Hawaii

11

15

20

Illinois

9

25

Indiana

n/a

15

18

Iowa

11

9

60

66

62

Kansas

30

25

30

Kentucky

n/a

10

11

9

25

Louisiana

n/a

9

Maine

n/a

10

n/a

10

Maryland

16

15

30

Massachusetts

10

16

15

Michigan

n/a

30

Minnesota

n/a

10

9

25

28

Missouri

30

Montana

n/a

25

Nebraska

n/a

10

9

State by State Variation in Number of Inpatient Diagnoses

Collected in Administrative Data (FY 1998 – 2009)

(10)

Number of Inpatient Diagnoses States Collect through Hospital Administrative Data (AHRQ HCUP Data Source)

State

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Nevada

n/a

15

14

15

33

New Hampshire

n/a

10

New Jersey

10

9

25

24

New York

17

15

North Carolina

n/a

15

17

18

17

24

New Mexico

n/a

18

Ohio

n/a

15

Oklahoma

n/a

16

Oregon

11

9

25

Pennsylvania

10

9

n/a

9

Rhode Island

n/a

12

11

25

South Carolina

10

12

10

15

South Dakota

n/a

11

9

79

61

77

Tennessee

10

9

18

Texas

n/a

10

9

25

Utah

10

9

Vermont

n/a

21

20

Virginia

n/a

10

9

n/a

9

18

Washington

10

11

9

25

West Virginia

n/a

10

9

18

Wisconsin

10

9

30

Wyoming

n/a

30

State by State Variation in Number of Inpatient Diagnoses

Collected in Administrative Data (FY 1998 – 2009)

Continued

(11)

Blood

Increase in Motor Vehicle Crash Victims

who are transported to Hospital by

Private Transport and polytraumatic

patients risk delayed care due to transfer

to appropriate facility

Major Resource and Staffing Differences

in Trauma Centers versus Non-Trauma

Centers

The Obvious One: Trauma Centers Bank

More Blood

(12)

Blood

(unfrozen) FFP

Platelets

Cryoprecipitate

The Use of Revenue Codes in Crash Analysis

with Trauma Registry Bring into focus the

volume of Blood needed for Polytraumatic

Patients

(13)

The Use of Revenue Codes in Crash Analysis Brings into

view the problem of redundant CT Scans

(14)

Severely Injured Crash Victim’s Transported to

Hospital by Friends or Family lose the Gain in

Survival Probability through EMS Scene to

Hospital Management of Hemodynamic Stability

Patterns of Hemodynamic

Deterioration

Description

Cardiogenic Shock

Myocardium damaged:

⇓

pumping

Hypovolemic Shock

⇓

Blood volume

(15)

Six Health Care Databases

linkable for Motor Vehicle

(16)

Drug Use Screening by

Trauma Center Level

40%

13%

2%

12%

32%

0% 5% 10% 15% 20% 25% 30% 35% 40% No (not suspected, not tested) No (confirmed by test) Yes (confirmed by test [prescription drug]) Yes (confirmed by test [illegal use drug]) No Response

40%

10%

3%

7%

40%

0% 5% 10% 15% 20% 25% 30% 35% 40% No (not suspected, not tested) No (confirmed by test) Yes (confirmed by test [prescription drug]) Yes (confirmed by test [illegal use drug]) No Response

55%

4%

1%

4%

36%

0% 10% 20% 30% 40% 50% 60% No (not suspected, not tested) No (confirmed by test) Yes (confirmed by test [prescription drug]) Yes (confirmed by test [illegal use drug]) No Response

Note: Drug Toxicology Data is

only required from Trauma

Centers

Level I Trauma

Centers

Level II Trauma

Centers

Level III Trauma

Centers

(17)

Alcohol Use Screening

by Trauma Center Level

9%

19%

3%

10%

58%

0% 10% 20% 30% 40% 50% 60% No (not suspected) No (confirmed by test) Yes (confirmed by test [trace levels]) Yes (confirmed by test [beyond legal limit]) No Response

31%

23%

2%

11%

33%

0% 5% 10% 15% 20% 25% 30% 35% No (not suspected) No (confirmed by test) Yes (confirmed by test [trace levels]) Yes (confirmed by test [beyond legal limit]) No Response

25%

11%

2%

7%

56%

0% 10% 20% 30% 40% 50% 60% No (not suspected) No (confirmed by test) Yes (confirmed by test [trace levels]) Yes (confirmed by test [beyond legal limit]) No Response

Note: Alcohol Toxicology Data is

only required from Trauma Centers

Level I Trauma Centers

Level II Trauma

Centers

Level III Trauma

Centers

(18)

Trauma Registry Geocoded Fields

City

State

ZIP

Latitude

Longitude

GeocodeQualityType

MatchType Block

Tract

CountyFIPS StateFIPS

WEST WARREN

MA

xxxxxxxxx

ZCTACentroid

Exact

4011 7611.00 027

25

BROOKFIELD

MA

xxxxxxxxx

AddressRangeInterpolation

Exact

2019 7601.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

2041 7591.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

2041 7591.00 027

25

WEST BROOKFIELD MA

xxxxxxxxx

Relaxed

1050 7591.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

1035 7591.00 027

25

WEST WARREN

MA

xxxxxxxxx

ZCTACentroid

Exact

2009 7611.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

1032 7591.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

1032 7591.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

1032 7591.00 027

25

EAST BROOKFIELD MA

xxxxxxxxx

Exact

1012 7591.00 027

25

STURBRIDGE

MA

xxxxxxxxx

Exact

6027 7581.00 027

25

STURBRIDGE

MA

xxxxxxxxx

Soundex

6027 7581.00 027

25

The trauma registry is now

Geocoded to provide more

Exact injury rate calculations

By either census tract or

Block.

(19)

Pre-existing Comorbitites (% of Total Cases)

Level I

Level II

Level III

Alcoholism

6.47%

6.19%

4.41%

Ascites within 30 days

0.03%

0.00%

0.02%

Bleeding disorder

3.50%

8.25%

6.47%

Chemotherapy for cancer within 30 days

0.14%

0.22%

0.17%

Congenital Anomalies

0.58%

1.11%

0.04%

Congestive heart failure

4.99%

5.33%

4.84%

Current smoker

0.58%

1.76%

1.17%

Currently requiring or on dialysis

0.43%

1.83%

1.17%

CVA/residual neurological deficit

2.80%

6.64%

3.45%

Diabetes mellitus

4.81%

6.89%

8.37%

Disseminated cancer

0.31%

3.69%

1.19%

Do not resuscitate (DNR) status

0.04%

0.07%

1.06%

Esophageal varices

0.31%

1.84%

0.04%

Functionally dependant health status

0.08%

0.00%

0.69%

History of angina with past 1 month

0.07%

0.13%

0.06%

History of myocardial infarction within past 6 months

1.13%

3.54%

0.56%

History of revascularization / amputation for PVD

0.07%

0.00%

0.29%

Hypertension requiring medication

16.48%

33.74%

32.34%

Impaired sensorium

2.76%

8.87%

4.80%

No NTDS co-morbidities are present

25.01%

18.75%

73.42%

Obesity

1.90%

1.49%

1.69%

Prematurity

0.01%

0.23%

0.02%

Respiratory Disease

1.53%

4.31%

2.30%

Steroid Use

0.43%

0.05%

0.54%

(20)

0

1

2

3

4

5

6

<5

5-14

15-24

25-44

45-64

65-84

85 and up

Trauma Centers

Non Trauma Centers

Trauma Patient Average Length of Inpatient Stay

(in Days) by Age and Trauma Center Designation Status

3.39

5.27

7.4

9.56

9.59

3

4.98

7.13

9.67

9.93

2.61

4.36

7.21

9.94

10.75

2.27

3.94

6.85

9.13

9.74

0

2

4

6

8

10

12

<16

16 to 44

45 to 64

65 to 84

85 and up

Non-Trauma Centers

Level III

Level II

Level I

Non-Trauma Centers

2.27

3.94

6.85

9.13

9.74

Level III

2.61

4.36

7.21

9.94

10.75

Level II

3

4.98

7.13

9.67

9.93

Level I

3.39

5.27

7.4

9.56

9.59

<16

16 to 44

45 to 64

65 to 84

85 and up

Average Number of Diagnoses

per Trauma Patient by Age &

Hospital Trauma Designation

(21)

Level I

Level II

Level III

Non-Trauma

Center

Total Trauma Cases

14983

5963

4789

28705

Age in Years (SD)

43.68(+ 26.85)

56.13 (+ 26.54)

57.6 (+ 28.25)

53.4 (+ 28.35)

Age > 65 years (%)

3859/14983 (26%)

2631/5963 (44%)

2334/4789 (49%)

11941/28705

(42%)

Gender (% Male)

63.7%

53.4%

49.0%

47.1%

Glasgow Coma Score (SD)

13.95 (+3.1)

14.54 (+1.93)

14.61 (+1.74)

14.7 (+1.28)

Revised Trauma Score (SD)

7.55 (+1.01)

7.71 (+0.68)

7.66 (+0.88)

7.55 (+0.94)

TMPM-ICD-9-CM Mortality Risk

3.49%

2.46%

0.15%

Trauma Registry Patient Demographics by Trauma Center Triage Level

FY2008

(22)

(23)

AIS = Abbreviated injury scale

• 0- without injury

• 1- minor injury (chest contusion)

• 2- moderate (humerus fracture)

• 3- serious-non life threatening (skull fracture

without licvorhea)

• 4- severe -life threatening(3rd grade burns of

30% body surface)

• 5- critical -survival uncertain(C5 fracture with

tetraplegia)

(24)

ISS = Injury severity score

-American College of Surgeon’s standard medical

score to assess trauma severity

-is based upon AIS

-ISS = A² + B ² + C ²;

-A, B, C being the AIS score of the three most injured

of the following body regions: A = head/ neck and

face; B = thorax and abdomen; C = extremities (incl.

pelvis), external.

-the ISS takes scores from 0 to 75 (i.e. AIS scores of 5

for each category).

-if any of the three scores is a 6, the score is

automatically set at 75.

(25)

The Problem of Focusing on Three Separate

Body Regions when a Polytraumatic Patient’s

Most Severe Injuries are in One Region

The Problem of Using

Administrative

diagnostic data to

severity adjust when a

the number of injuries

exceed the diagnoses

fields

(26)

Severity scores

Definition

Characteristics

Required resources

Abbreviated injury scale (AIS)

An injury categorization with severity scores assigned to each injury category. Injuries are rated from 1 (minor) to 6 (fatal).

– Not designed for survival prediction. – Determined based on expert consensus.

– Duplicate coding or computer software (ICDMAP) to obtain AIS severity scores from ICD codes.

Injury severity score (ISS)

Indicates overall severity for a patient with multiple injuries. ISS is a sum of the square of the highest AIS severity scores of the three most severely injured body regions (from a choice of six body regions).

ISS = AIS12+ AIS

22+AIS32

– Does not consider physiological parameters.

– Equal weighting given to each body region.

– Does not account for multiple

injuries in the same body region. – AIS severity score

Revised trauma score (RTS)

Consists of physiological parameters independent of anatomical injury scores.

RTS = 0.9364×GCS + 0.7326×SBP + 0.2908×RRb

– Physiological parameters are time-sensitive.

– Patient data and statistical software to calculate country-specific coefficients.

Trauma and injury severity score (TRISS)

A combination of an anatomical measure (ISS), physiological measure (RTS) and patient ability to withstand injury severity (age) by type of injury (blunt/penetrating). Probability of survival (Ps) is determined using a logistic regression model. Logit (Ps) =β₀+ β₁×RTS + β₂×ISS + β₃×ageb

– Widely used in outcome studies because of its good predictive ability.

– Availability of AIS severity score. – Patient data and statistical software to calculate country-specific coefficients. – Computer software to calculate the score because of its mathematical complexity.

ICD-based injury severity score (ICISS)

A multiplicative prediction model with an assumption that all injuries contribute to the overall severity. The SRR for each code is empirically derived from the patient data. To obtain ICISS, SRRs of all injuries are multiplied.

ICISS = SRR_inj1×SRR_inj2×SRR_inj3×SRR_injn

– Directly derived from ICD or ICD-CM codes. – Predictive ability is equal to, or better than, that of the TRISS.

– Large patient data set.

– Computer software might be required to calculate each patient’s score due to large number of codes

Matrix-based method

In a body-region by injury-nature matrix (such as the Barell matrix), the proportions of survival and

approximated AIS score are calculated based on data for each cell. These values are used in the same way as ICISS and AIS-based indices.

– Relatively easy to handle due to diminished number of categories compared with other methods.

– Patient data set (not necessarily a large one) and statistical software to calculate country-specific values.

– AIS severity score if approximated severity scores are determined.

Methods for scoring severity of injuries

a

Notes: GCS, Glasgow Coma Score; ICD, International Classification of Diseases; ICD-CM, International Classification of

Diseases-Clinical Modification; RR, respiratory rate; SBP, systolic blood pressure; SRR, survival risk ratio.

a This is not a comprehensive list of injury scores, but rather shows typical and popular indices to indicate their relationships

with the ICD codes and required resources.

(27)

Da Vinci, Le Corbusier, Durer and

other artists have identified

the appearance of the Fibonaacci

Series in the relationships between

the bone lengths however 3D

CT Scans have proven some anatomic

geometries wrong

Human Anatomy and

the Fibonacci Series

(28)

TMPM-ICD-9-CM

Trauma Mortality Prediction Model ICD-9-CM is an empirically derived

severity metric that uses a mapping algorithm to group ICD-9-CM

injury codes & construct weighted average predicted probability of

death coefficients based on 2 different probit regressions models

known as modeled average regression coefficients (MARC) values.

The predicted probability of death is given by:

Where P(death) is the mortality predicted by the TMPM &

Φ

is the

standard normal cumulative distribution function (available in

statistical software packages & Excel), & I

₁

,...,I

₅

are the ICD-9-CM

based MARC values for the 5 worst injuries, ordered with the highest

MARC value (worst injury) first, the second highest MARC value

second, & the lowest MARC value last. is an indicator variable equal

to if the worst & second worst injuries are in the same body region, &

I

₁

I

₂

represents the product of the MARC values for the most severe

injuries.

- TMPM-ICD9 is a new

validated metric that

out-performs ICISS &

the single worst injury

model. The creator of

this tool is an

investigator on this

study. He has provided

EXCEL spreadsheets &

STATA program for

readily calculating

TMPM using the

ICD-9-CM lexicon.

Coefficients are

calculated using

ICD-9-CM injury

codes & MARC

values

TMPM-AIS

For P(death ) ,

Φ

, & I1,...,I5 (see above) & S is an indicator variable

set to 0 if the worst 2 injuries occur in different body regions & set to

one if they occur in the same. The terms C0…C7 are the AIS-based

MARC values & the term C7 X I1 X I2 represents the interaction of

the worst & second worst injuries that a patient has sustained.

- TMPM-AIS is a new

validated metric that

out-performs ICISS &

the single worst injury

model. The creator of

this tool is an

investigator on this

study. He has provided

EXCEL spreadsheets &

STATA program for

readily calculating

TMPM using the AIS

lexicon

Coefficients are

calculated using

AIS (see above)

& MARC values

(29)

Trauma Registry Crash Victims by Predicted Mortality using

5 worst Diagnoses and Interaction for Some Region Injuries

Trauma Center

Motor

Vehicle

Crash

Victims

Gender

Average AIS

Predicted

Mortality

Standard

Deviation

Average

ICD-9-CM

Predicted

Mortality

Standard

Deviation

Level 1

1337

F

5.20%

12.50%

4.70%

9.64%

Level 1

2586

M

6.09%

13.63%

6.41%

11.72%

Level 2

284

F

3.65%

10.26%

3.30%

6.31%

Level 2

509

M

3.63%

11.13%

4.69%

12.08%

Level 3

199

F

1.95%

3.47%

4.04%

8.06%

Level 3

356

M

4.10%

10.79%

4.82%

8.99%

Non Trauma Centers

707

F

1.15%

0.89%

1.63%

2.85%