TEMR THE ISRAELI CENTER FOR Limor Aharonson-Daniel, Israel Megan Davies, USA The Center for Trauma...

TEMRTHE ISRAELI CENTER FOR

Limor Aharonson-Daniel, IsraelMegan Davies, USA

The Center for Trauma and Emergency Medicine Research,Gertner Institute for Epidemiology and Health Policy Research, IsraelNational Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA

The Barell Matrix, Updates;

The Composition of TBI Rows

Multiple Injury Analysis Using Matrix

The Matrix is a tool for classifying

injury ICD-9-CM codes by body

region and nature of injury.

It is useful for standardized

retrieval of injury cases for

epidemiological, clinical and

management oriented analyses

What is the Matrix?

Matrix Reminder

To characterize the patterns of injury

Matrix objectives

To serve as a standard for casemix comparison

To simplify the process of classifying

injuries To provide a standard format for

reports

Matrix Reminder

Motivation for building the matrix

Sorted by nature of injury

Detecting injuries by body

region

requires collating codes across

chapters

ICD 9-CM CODES 800-995

Matrix Reminder

ICD 9-CM CODES 800-995

Motivation for building the matrix

nature of injury

body region

Matrix Reminder

The Matrix structure

Nature of injuryB

od

y

Reg

ion

ICD-9-CM in

jury co

des

Matrix Reminder

Anatomic subgroups

High Incidence

Variability in Outcome

Difference in health care utilization

Body Region (Rows) are based on :

Matrix Reminder

Nature of injury (Columns) are based onSequence of codes in ICD-9-CM codebook

Dissemination

The Matrix was posted on the net by

Lois in October 2001.

A paper describing matrix construction

will be published in the June 2002 issue

of Injury Prevention.

“Five digit ICD-9-CM codes will be used where necessary”.

“Priority codes will not be used, an “other and unspecified” by body region row will be added in order to minimize loss of information”.

April 3, 2001: ICE meeting, Washington DC

General Agreements Reached

“Instructions on how to collapse rows will be available to ensure a standard collapsed table”.

“Spine will be divided to Spinal Cord injury (SCI) and to Vertebral Column injury (VCI) each group will be divided into Cervical, Dorsal, Lumbar, Sacrum and Coccyx”.

Cervical SCI9

Thoracic/ Dorsal 10 SCI

Lumbar SCI 806(.4-.5), 952.211

Sacrum Coccyx 806(.6-.7), 952(.3-.4)12 SCI

Spine+ Back 806(.8-.9), 952(.8-.9)41 13 unspecified SCI

Cervical VCI 805(.0-.1), 839(.0-.1), 847.014

Thoracic /Dorsal 805(.2-.3), 839(.21,.31), 847.115 VCI

Lumbar VCI 805(.4-.5), 839(.20,.30), 847.216

Sacrum Coccyx 805(.6-.7), 839(.41-.42), 839(.51-.52), 847.3-.417 VCI

Spine+ Back 805(.8-.9), 839(.40,.49), 839(.50,.59)43 42 18 unspecified VCI

sp

ine

an

d b

ack

Sp

ina

l Co

rd (

SC

I)

806(.0-.1), 952.0

806(.2-.3), 952.1

Ve

rte

bra

l Co

lum

n (

VC

I)

ICE meeting, Washington DC, 2001Specific Agreements,

“A detailed extremity module needs to be added”.24 shoulder &

upper arm

25 forarm & elbow

26 wrist, hand

& fingers

27 other & unspecified

45

28 hip

29 upper leg & thigh

30 knee

31 lower leg & ankle

32 foot & toes

33 other &

47 46 unspecified

813, 832, 841, 881(.x0-.x1), 887(.0-.1), 923.1, 927.1, 943(.x1-.x2)

Ext

rem

itie

s

810-812, 831, 840, 880, 887(.2-.3), 912,923.0, 927.0, 943(.x3-.x6) ,959.2

818, 884, 887(.4-.7), 903, 913, 923(.8-.9), 927(.8-.9),

Up

per

Lo

wer

820, 835, 843, 924.01, 928.01

943(.x0,.x9), 953.4, 955, 959.3

814-817, 833-834, 842,881.x2, 882, 883, 885-886, 914-915,

821, 897(.2-.3), 924.00, 928.00, 945.x6

923(.2-.3) ,927(.2-.3), 944 ,959(.4-.5)

827,844(.8-.9), 890-891, 894, 897(.4-.7), 904(.0-.8), 916, 924(.4-.5),

928(.8-.9), 945(.x0,.x9), 959.6-.7

822, 836, 844.0-.3, 924.11, 928.11, 945.x5

823-824, 837, 845.0, 897(.0-.1), 924(.10,.21), 928(.10,.21), 945(.x3-.x4)

825-826, 838, 845.1, 892-893, 895-896, 917, 924(.3,.20),

928 (.3,.20), 945 (.x1-.x2)

ICE meeting, Washington DC, 2001Specific Agreements,

“Amputations will be separated from open wound.” F G H I

AMPUTATIONS BLOOD CONTUSION / CRUSH

885-887, VESSELS SUPERFICIAL

895-897 900-904 910-924 925-929

/ / / /

/ / / /

/ / / /

/ / 918, 921 /

/ / / 925.2

/ 900 910, 920 925.1

/

874

872, 873.2-.7

870-871

873.0-.1,.8-.9

870-884, 890-894

/

E

OPEN WOUND

ICE meeting, Washington DC, 2001Specific Agreements,

“Superficial injuries and contusions will be joined”. F G H I

AMPUTATIONS BLOOD CONTUSION / CRUSH

885-887, VESSELS SUPERFICIAL

895-897 900-904 910-924 925-929

/ / / /

/ / / /

/ / / /

/ / / /

/ / 918, 921 /

/ / / 925.2

/ 900 910, 920 925.1

874

/

872, 873.2-.7

870-871

/

873.0-.1,.8-.9

OPEN WOUND

870-884, 890-894

/

E

ICE meeting, Washington DC, 2001Specific Agreements,

ICE meeting, Washington DC, 2001Specific Agreements,

“The matrix has a row for “system wide

conditions” enabling use for non traumatic

injuries”.34 other/ multiple

35 unspecified

48 site

36 system-wide &

late effects

819, 828, 902(.87,.89), 947(.1-.2), 953.8, 956

829, 839(.8-.9), 848(.8-.9), 869, 879(.8,.9), 902.9, 904.9, 919, 924(.8,.9), 929,

946, 947(.8,.9), 948, 949, 953.9, 957(.1,.8,.9), 959(.8,.9)

syst

em

wid

e 905-908, 909 (.0,.1,.2,.4,.9), 930-939,958, 960-994,

995.5, 995(.80-.85)

Un

clas

sifi

able

by

site

oth

er &

un

spec

ifie

d

“The presence of Traumatic Brain Injury (TBI) is important. The matrix will have three rows identifying Definite TBI, possible TBI and other head injuries”.

ICE meeting, Washington DC, 2001Specific Agreements,

Definite TBI(#)1

Possible TBI(#)2

Other Head3

Face 4

Eye5

Neck 6

Head, Face and7 Neck Unspecified

Hea

d a

nd

Nec

k

36

Hea

d a

nd

Nec

k

The split of TBI

conventional

definition into two

rows in the matrix

brought about

discussions with CDC

NCIPC, the American

Academy of Neurology

and others on TBI

definition and

separation into

several levels of TBI.

Original Original TBI definitionTBI definitioninjury to the head that is documented in a

medical record, with one or more of the

following conditions attributed to head

injury: observed or self-reported

decreased level of consciousness,

amnesia, skull fracture, objective

neurological or neuropsychological

abnormality, or diagnosed intracranial

lesion; Thurman DJ, Sniezek JE, Johnson D, Greenspan A, Smith SM. Guidelines for Surveillance of Central Nervous System Injury. Atlanta: Centers for Disease Control and Prevention, 1995.

Definite TBI

Injuries with no mention of intracranial injury or with loss of consciousness of less than one hour.

injuries with a specific mention of intracranial injury or loss of consciousness of more than one hour

Original Two-row TBI definition(created by Vita Barell)

A derivation from CDC definitions: concussions with no or short loss of consciousness were classified as ‘possible TBI’.

Possible TBI

An addition to the definition: injuries indicating damage to the optic nerve pathways:

•optic chiasm (950.1) •optic pathway (950.2) and •visual cortex (950.3)

CDC concerns regarding TBI separation

959.01 Concussions with no or short LOC TBI with LOC of unspecified duration TBI with unspecified level of consciousness Shaken baby syndrome

Three-row TBI definition

Definite TBIType 1

Injuries with no mention of intracranial injury or with no loss of consciousness

Injuries with a recorded evidence of an intracranial injury or a moderate or prolonged loss of consciousness (loc).

Possible TBI

Three-row TBI definition

Definite TBIType 2

Injuries with no recorded evidence of intracranial injury and loc of less than one hour; loc of unknown duration or unspecified level of consciousness.Concussions.

Definite TBIType 1

Injuries with no mention of intracranial injury or with no loss of consciousness

Injuries with a recorded evidence of an intracranial injury or a moderate or prolonged loss of consciousness (loc).

Possible TBI

Three-row TBI definition

Definite TBIType 2

Injuries with no recorded evidence of intracranial injury and loc of less than one hour; loc of unknown duration or unspecified level of consciousness.Concussions.

959.01 854 Concussions with no or short LOC Shaken baby syndrome (995.55) LOC of unspecified duration Unspecified level of consciousness

Possible Possible TBITBIProbable TBI

Plausible TBI

Definite TBI type 1 (grade 1)

Definite TBI type 2 (grade 2)

Definite severe/moderate Definite severe/moderate TBITBI

Definite mild Definite mild TBITBI

Definite TBI 800,801,803,804(.1-.4,.6-.9), (.03-.05,.53-.55)

1 Type 1 850(.2-.4), 851-854, 950(.1-.3), 995.55

Definite TBI 800,801,803,804(.00,.02,.06,.09) (.50,.52,.56,.59) , 850(.0,.1,.5,.9)37 Type 2

Possible TBI 38 3

Other Head 873(.0-.1,.8-.9), 941.x6, 951, 959.014

Face 5

Eye6

Neck 7

Head, Face and 900, 910, 920, 925.1, 941.x0, .x9, 947.0, 957.0, 959.09

PT

BI # 800,801,803,804(.01, .51)

Oth

er h

ead

, fac

e a

nd

ne

ck

802, 830, 848.0-.1, 872, 873.2-.7, 941(.x1,.x3-.x5,.x7)

870-871, 918, 921, 940, 941.x2, 950(.0,.9)

807.5-.6, 848.2, 874, 925.2, 941.x8, 953.0, 954.0

Hea

d a

nd

Nec

k

Tra

um

atic

Bra

in In

jury

DT

BI

#

2

Three-row TBI

1997-2000 ITR data

Traumatic Brain Injury

Traumatic Brain I njury Definite Definite Possible

Type 1 Type 2

Total number 4787 9493 672

I SS 25+ 30.4 % 1.3 % 1.2 %

I npatient death 13.3 % 0.3 % 0.2 %

Median (iqr) Median (iqr) Median (iqr)

Duration of stay (days) 5 (2-10) 1 (1-2) 2 (1-3)

I ntensive care stay (days) 4 (1-10) 2 (1-4) 1 (1-3)

Age (years) 25 (9-57) 10 (3-26) 3 (1-7.5)

iqr - interquartile range

Megan

Multiple injuryAnd the construction of injury profiles

The Center for Trauma and Emergency Medicine Research,Gertner Institute for Epidemiology and Health Policy Research, Israel

•Multiple injury requires timely care by a

number of specialists simultaneously.

•Multiple injury is often associated with

greater severity and mortality.

• ISS takes into account the contribution

of multiple injuries to severity, but does

not profile the injury.

Summarizing multiple injuries Motivation

To create a method for presenting aggregated data on injury patterns in populations.

To standardize this method to enable the conduct of comparable studies across populations, time, place etc.

Summarizing multiple injuries

AIMS

Adam

JoFractured ankle

Skull fracture, with an intracranial injury

Flail chest

multiple diagnoses

Single diagnosis

Single diagnosis

Summary report

Total %

Head& Neck 16865 36.0

Spine& back 1284 2.7

Torso 6296 13.5

Extremities 21499 45.9

Other & Unspecifi ed 854 1.8Total 46798 100.0

I sraeli Trauma Registry data, 97- 99

Summarizing multiple injury diagnostic data

Select one diagnosis

first listed/major

multiple diagnosespatients

single diagnosispatients

Difficulty in assigning the principal diagnosis

Limitation of using a Single diagnosisFor summarizing multiple injuries

Adam

Distorts the description of the actual injury

Skull fracture, with an intracranial injury

Flail chest

0

2000

4000

6000

8000

10000

Head and

Neck

Spinal Cord Vertebral

Column

Torso Extremities

multiple

single

`

Population: ITR Road Traffic Accidents, 1997-2000, total of 17459 patients

Distribution of injuries by body regionSingle or Multiple?

• Enable counting all cases with a specific injury

• Reflect the actual injury pattern in the individual

• Often associated with greater severity

• Identification of common profiles of multiple injuries

Reasons for using multiple diagnosesFor multiple injury patients

Multiple diagnoses injury profiles

Select one diagnosisfirst listed/major

Create injury profile

multiple diagnosespatients

Summarizing multiple injury diagnostic data

Creating injury profiles

Divide body regions into groups

•Head and Neck H•Spine and Back S•Torso T•Extremities E•Other O

Legend•Head and Neck H•Spine and Back S•Torso T•Extremities E•Other multiple O

Frequency distribution of groups

Diagnostic group Distribution

combinations N %

H 4346 24.9

S 417 2.4

T 2010 11.5

E 3760 21.5

H T 1319 7.6

H E 1935 11.1

T E 922 5.3

H T E 1121 6.4

X X X X O 1629 9.3

Total 17459 100

Characterizing diagnostic groups

•ISS

•Inpatient death

•Duration of inpatient stay

•External cause of injury

etc.

Duration of Inpatient stay by diagnostic group combinations

Legend•Head and Neck H•Spine and Back S•Torso T•Extremities E•Other Multiple O

Multiple injuries

Single injuries

0

2

4

6

8

10

12

14

16

18

H TE H T TE H E T H S E

days

75%

25%

Median

Inpatient death by diagnostic group combinations

4346

1935

2010

922

1319

1121

417

3760

n

Mult

iple

in

juri

es

Sin

gle

in

juri

es

0 2 4 6 8 10 12 14

H TE

H T

TE

H E

T

H

S

E

%

Inpatient death

H 4346 24.9 953 21.3 186 10.2 1242 25.4S 417 2.4 168 3.8 35 1.9 35 0.7

T 2010 11.5 766 17.1 147 8 252 5.2E 3760 21.5 501 11.2 863 47.2 1276 26.1

H T 1319 7.6 477 10.7 53 2.9 347 7.1H E 1935 11.1 434 9.7 160 8.7 726 14.9

T E 922 5.3 296 6.6 132 7.2 241 4.9H T E 1121 6.4 378 8.5 80 4.4 360 7.4x x x x O 1629 9.3 498 11.1 174 9.5 402 8.2

17459 100 4471 100 1830 100 4881 100

H= Head & Neck, S= Spine & Back, T= Torso, E= Extremities, O=Other, including combinations of 3,4 or 5 body regions with frequencies < 1% of total

N %Pedestrians

 Total

diagnostic

combinationsgroup

external cause of injury

N %MotorcyclesN %

AllN %

Drivers

Summary to date A technique for analyzing multiple injuries was presented using the Barell diagnostic matrix

The importance of using multiple injury in The importance of using multiple injury in describing the injured has been demonstrated.describing the injured has been demonstrated.

Injury profiles enable standardized Injury profiles enable standardized comparisons of casemix and outcome between comparisons of casemix and outcome between external cause of injury, hospitals and external cause of injury, hospitals and countries. countries.

Profiles could also serve for efficient staffing of Profiles could also serve for efficient staffing of specialists in multidisciplinary trauma teams.specialists in multidisciplinary trauma teams.

Problems, Limitations and Unresolved issues

Definition of multiple

Number of combinations

Severity measures

Thanks for your attentionThanks for your attention