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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