Measuring Trauma Outcomes - TARN - Home. Measure Trauma ou… · Brain stem: laceration, crush,...

Measuring Trauma OutcomesInjury Severity Score (ISS)

Probability of Survival (Ps19)Hospital Survival rate (Ws)

Major Trauma PROMs

The Trauma Audit & Research Network (TARN)

TARN

Injury coding performed centrally at TARN

Ensuring coding uniformity

Coders check injury descriptions & imaging reports

Abbreviated Injury Scale dictionary (AIS2005) currently used

Every submission assigned an Injury Severity Score (ISS)

85,000+ submissions per year coded

Injury Coding

TARN

Abbreviated Injury Scale: AIS

THE Internationally recognised system for injury scoring

Produced by AAAM (Association for the Advancement of Automotive Medicine) in U.S.A

Introduced in 1970, originally for Vehicle Crash investigators

AIS2005 version >2000 injury descriptors

Anatomically based system, ranking injuries according to severity on a 6 point ordinal scale

TARN

AIS: 6 point severity scale AIS

(Severity) Grade Injury example

1 Minor Bruise to abdomen

2 Moderate Small Liver laceration

3 Serious Liver laceration with >1 litre of blood loss

4 Severe Ruptured liver

5 Critical Liver laceration involving hepatic vessels

6 Maximum Avulsed liver

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AIS Severity indicates

The relative risk of “threat to life”in an average person

who sustains the coded injury as his or her only injury

It’s not a disability scale

TARN

AIS code structure: 7 digits

Code Injury Numerical identifier

Severity Score

853271.3 Comminuted Femoral Shaft # 853271 .3

140656.5 Large Subdural haemorrhage 140656 .5

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Abbreviated Injury Scale: Sections

Skin DeglovingPenetrating HypothermiaCrush Asphyxia: Hanging/StrangulationTraumatic Amputation DrowningNerve FrostbiteVessel BurnsJoint InhalationSkeletal Electrocution

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AIS: Spinal Injuries

Cervical Spine (C1-C7) Thoracic Spine (T1-T12) Lumbar spine (L1-L5)

Severity can be affected by location of spinal injury

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AIS: Confirmed injuries only

Suspected injuries

Possible injuries

Probable injuries

Ruled out injuries

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AIS: Not Coded

Infections Pneumonia Death BlindnessMiscarriage Epilepsy following head injury Pulmonary embolism following skeletal injury

Don’t affect Severity score

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NFS: Not Further Specified

This appears throughout the AIS dictionary & allows the coding of injuries when detailed

information is lacking

Example:Injury description = Liver laceration

Coded as: 541820.2 (Liver laceration NFS)

TARN

Most used NFS codeswhich affect data accreditation

Most used NFS codes Information needed

Cerebrum/cerebellum contusionDiameter of the contusion or a description of the size e.g.

tiny, small, large, extensive.

Cerebrum/cerebellum subdural/extradural The depth of the haematoma or a description of the size e.g. tiny, small, large, extensive confirmed in imaging

Cerebrum/cerebellum intracerebral haematomaDiameter of the ICH or a description of the size e.g. tiny,

small, large, extensive.

Brain swellingSeverity of the swelling e.g mild; sulcal effacement,

moderate; compressed or partially effaced ventricles, major; effaced ventricles

Multiple rib fractures Number of ribs fractured and which side the fracture are on

Long bone fractures e,g clavicle, femur & fibular Location of the fracture e.g. proximal, shaft, distal.

Facial fractures e.g. zygoma, orbit Location of the fracture

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AIS 6: Maximum score

AIS 6 not used just because a patient dies!

Has to be documented medical evidence of an AIS 6 injury

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AIS 6: Maximum score Head or Neck

Brain stem: laceration, crush, penetrating or transectionC3 or higher complete cord transection or contusionSigmoid or Transverse sinus or Internal carotid artery: Bilateral lacerations

Thorax Heart: rupture, multiple lacerations or avulsion Total chest crush Aortic rupture + haemorrhage not confined to mediastinum Bilateral pulmonary artery or vein transection Severe inhalation

Abdominal & Pelvic contents Liver avulsion

External 2nd or 3rd degree burns > 90% Total Body SurfaceMassive Whole body Explosion type injury

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AIS: Localisers2 additional localiser codes, allow coding of:

Localiser 1 Side or aspect of an injury e.g. Right, left, Upper, Temporal, Frontal

Localiser 2 Actual Site of an injury e.g. 5th rib, 12th Thoracic vertebrae, 2nd toe

• Don’t affect ISS• Used mainly in Research

TARN

AIS dictionary

Available only from: www.aaam.org

• Latest Version: AIS 2015 recently released • $225 each + shipping• TARN will be moving to AIS2015• All existing codes will be mapped over • All Trusts notified well in advance

TARN

http://www.aaam.org/

Injury Coding exerciseTARN

Spiral Shaft of Femur 147

Open complete articular fracture to distal Radius 127

Open book fracture to pelvis with blood loss >20% 159

3 ribs fractured on left 82

Extensive bilateral cerebral contusion 44

Skull vault fracture 49

Grade III (OIS grade) Spleen laceration 96

853251.3

752372.3

856164.5

450203.3

140626.5

150400.2

544224.3

EXAMPLE SUBMISSION 1: INJURIES Page AIS code

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Calculating the ISSInjury Severity Score

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Calculating the ISS: Step 1

Determine the scores of the individual injuries using the

Abbreviated Injury Scale

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Identify the highest severity score in each body areaTARN

Injury Severity Score: 6 body areas

1. Head & Neck & Cervical spine

2. Face

3. Chest & Thoracic spine

4. Abdomen & pelvic contents & Lumbar spine

5. Extremities & bony pelvis

6. External (incl. Skin injuries and Burns)

TARN

Head Extensive bilateral cerebral contusion 140626.5

Skull vault fracture 150400.2

Thorax 3 ribs fractured on left 450203.3

Abdomen Grade III Spleen laceration 544224.3

Extremities Open complete articular fracture to distal Radius 752372.3

Open book fracture to pelvis with blood loss >20% 856164.5

Spiral Shaft of Femur 853251.3

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Square the highest score in each body area

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Open book fracture to pelvis with blood loss >20%856164.5


5² =25

3² =9

3² =9

5² = 25

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Code individual injuries

Identify the highest score in each body area

Square the highest score in each body area

Add together the highest AIS2 from 3 different body areas

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Open book fracture to pelvis with blood loss >20%856164.5


5² =25

3² =9

3² =9

5² = 25

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Injury Severity Score(ISS) = 59

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ISS = 8

Injury Severity Score (ISS)Body area Injury AIS code

Head Closed vault fracture 150402.2

Thorax 5+6 ribs fractured on left 450202.2

2² = 4

2² = 4TARN

ISS = 9

Injury Severity Score (ISS)Body area Injury AIS code

Head Closed vault fracture 150402.2

Thorax 5+6 ribs fractured on left 450202.2

External Lower limb – skin laceration 810600.1

2² = 4

2² = 4

1² = 1TARN

Injury Severity Score (ISS)

Ranges from 1 to 75

Maximum 75 achieved in 2 ways:

1. Severity 5 in 3 different body areas52 + 52 + 52 = 75

2. ISS convention:AIS = 6 in any body area, ISS = 75

TARN

Importance of Injury Detail Length, depth or Grade of lacerations (especially to internal organs)

Depth, size and location of haemorrhages and contusions (especially in the brain)

Open or Closed fracturesStability & site of Fractures (e.g. Comminuted/Displaced Shaft/Proximal/Distal fracture)

Articular (joint) involvement (e.g. Intra-articular, extra-articular)

Blood loss Vessel damageLocation & number of rib fractures Compression or effacement of ventricles/brain stem cisternsNeurology associated with spinal cord injuries Grade, Instability, Blood loss or Vascular damage associated with Pelvic Fractures Cardiac arrest associated with asphyxia or drowning

Ensure all injuries are documentedInclude imaging reports or Post Mortems for every submission.

Jan 17: Grade now requested for pelvic ring fixations

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Probability of SurvivalOnce ISS is assigned

Probability of Survival (Ps) calculated eachsubmission

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Why calculate PS?

• Need to assign weight to deaths and survivors.

• Some deaths more statistically significant than others.

• Case mix adjustment.

• Performances measurement: hospital and networks.

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Ps history

TARN developed first Ps model in 2004

Remodelled in 2007, 2009, 2012, 2014, 2017 and 2019

Components used in Ps since 2014 (best predictors of outcome): ISS Age Gender GCS Pre-Existing Medical Conditions (PMC)

Charlson comorbidity index adds ‘weighting’ PMC

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Ps19 (launched July 19)

Age Gender ISS GCS/intubation PMC

Ps19 calculation

Patient PS: 63%

*

*Charlson index (1984, revised).

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What is Ps?

PS% is retrospective measure of pts with same profile on TARN database.TARN database: past 4 years (Approx 300,000 cases)

Ps = 63%, then 63 out of every 100 patients with that profile have previously survived.

37 out of every 100 patients have previously died.

TARN

Ps is calculated using:

GCS taken on arrival in ED at first receiving hospital where unavailable

Pre Hospital GCS where unavailable

Presence of Intubation/ventilationwhere unavailable

Impute a “probable” GCS (equivalent weighting)

Probability of Survival

TARN

Ps19 Weighting groups Pre-Existing Medical Conditions

0 Bone conditionsConnective tissue disorderGU/GI diseaseNeurological disorders

No PMCOtherParaplegiaPulmonary disease

1-5 Alcohol abuseBlood conditionsCancerCVADementiaDiabetes

Heart failureHIVMental healthMIRenal diseaseVascular disease

6-10 Haematological malignancyLiver disease

Metastatic cancer

Weight PMC group

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Ps19 Weightings for Age, GCS, Gender & PMC

Age: 25 Gender: Male ISS: 25 GCS: 15 PMC:Nil

Ps19 calculation

Ps: 99.2%

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Age: 25 Gender: Male ISS: 25 GCS: 15 PMC:Alcohol abuse

Ps19 calculation

Ps: 98.6%

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Age: 25 Gender: Male ISS: 25 GCS: 15PMC:

Alcohol AbuseLiver Disease

Ps19 calculation

Ps: 95.7%

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Ps19 calculation

Ps: 21.6%

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Ps19 calculation

Ps: 4.7%

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Age: 65 Gender:Female ISS: 25 GCS: 3

PMC:Alcohol AbuseLiver Disease

Ps19 calculation

Ps: 5.09%

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Ps19 Importance of accurate injury detail

Full injury detail Code


Open complete articular fracture to distal Radius 752372.3

Open book fracture to pelvis with blood loss >20% 856164.5

3 ribs fractured on left 450203.3

Extensive bilateral cerebral contusion 140626.5


Grade III (OIS grade) Spleen laceration 544224.3

Incomplete injury detail Code


Fracture to distal Radius 752371.2

Fracture to pelvis 856151.2

Multiple ribs fractured on left 450210.2

Cerebral contusion 140604.3


Spleen laceration 544220.2

Accurate ISS Accurate Ps

59 58%

Incomplete ISS

22

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Ps19 Importance of accurate injury detail

Age: 40 Gender: Male ISS: 22 GCS: 5 PMC:Nil

Ps19 calculation

Ps: 86%

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PS breakdown: shown on website & clinical reports (more later)

• Ps Bandings• No. of patients in each band • Observed/Actual survivors• Expected survivors (compared to TARN database)

• Difference = Observed – Expected x 100No. in group

• Ws = Difference x fraction of patients on database in each band

Hospital Survival Rate= 0.67 additional survivors per 100 patients

95% Confidence interval Ws lies between this line

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Individual Hospital Survival Rate shown on website: English & Welsh sites only

+1.2 SurvivorsStatistically significant outcome

(+0.39 to +1.97)

+1.2 SurvivorsNot Statistically significant

(-1.83 to +4.2)

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Comparative Survival rate (Ws) shown in Clinical report: Trauma Units

95% confidence intervals

All hospitals

Your hospital

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Funnel plots: Major Trauma Centres only

Hospitals shown by Precision (no. of cases)Ws must always be viewed in conjunction with Case ascertainment

Lower Precision: Fewer cases (not as reliable)

Greater Precision: More cases (more reliable)

Normal range

All hospitals

Potential outlier (positive)

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Negative Ps Bands: more deaths than expected

Produce a Performance Review Indicators report (PRI) & review data in negative Ps bands: Particularly the deaths using the Data Quality Report >>>>

Highlighting patients for Ws review

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Example patients to review: Ps:45-65%

With large SDH & Liver disease: ISS= 25, Ps= 28%

With GCS 3 & Dementia: Ps= 3%

On review both these patients move out of the 45-65 Ps band, and into lower Ps bands, where we expect more patients to die.

Ps Age

Sex ISS GCS Int Outcome PMC Mechanism

Injuries Submission ID

46.2% 46 Male 16 3 Yes Death N/K Fall >2m Skull Vault # SDH NFS (AIS4)Brain swelling

999900004552

Ps Age

Sex ISS GCS Int Outcome PMC Mechanism

Injuries Submission ID

57.7% 94 Female 38 14 No Death N/K Fall <2m T cord transection (AIS5)BOS # (AIS3)Pelvic # (AIS2)

999900004517

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Moving Ps BandsThe deaths we have reviewed have moved out of the 45-65 Ps band:

Ps Band Number in band

ObservedSurvivors

Expected Survivors Difference TARN

fraction Ws

45-65 79 45 44.24 0.76 0.03 0.02

Total Ws 0.72

TARN

The Performance Review Indicators reportTARN

Performance Review IndicatorsIncludes Approved cases only

Highlights Key Performance Measures that underpin TARN reports

Submission IDNHS number

AgeGender

Injury MechanismISS & ISS band

GCSIntubation

Probability of SurvivalOutcome at 30 daysIncident date/timeArrival date/time

Discharge date LOS

ICU LOSTransfer from/toMode of arrival

PROMS AvailableTrauma Team

Senior Dr in ED Date/TimeFirst Dr in ED Date/Time

No of OperationsDate/time 1st Operation

Time to 1st OperationDate/Time 1st CT

Time to 1st CTIncident & Home postcodes

Triage Tool

Pre AlertPRF

Wards visited (first 2)Visited ED

NICE criteriaShocked Patient (SBP<110)

Rehab PrescriptionGOS

Case for ReviewMost severely injured body

region Maximum AIS

All Injuries

TARN

Analysing your own data using PRI Report

Create a PRI report

List specific patients e.g.

Ps bands: To review

AIS3+ Head injuries CT within 1 hour

ISS 16+ who saw a Consultant

Produce a breakdown

Link to submissions

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Major Trauma PROMs Patient reported outcome measures

TARN

Background

TARN collects patient outcome data at discharge or 30 days.

Previously, little understanding of long term impact of Major Trauma on return to

work or education.

12 month DOH funded MT PROMS feasibility launched : Autumn 2014

19 MTCs involved initially

Children’s MT PROMs launched January 2015

Study continued: Now all MTCs, CMTCs, 1 Welsh site & 1 TU involved

Trusts asked to include ISS >15 patients, but can include all TARN eligible.

TARN

The PROMs process PROMs are short questionnaires completed by patients or carers.

Measure the patients’ perception of their health status at a single point in time.

PROMs questionnaire (Q1) is given to patients in hospital when stable.

Follow-up Q2 questionnaire (Q2) sent to patients via post at 6 months post discharge. TARN

Processing the data NHS-E Accredited PROMS supplier: Quality Health process PROMs data.

PROMs and TARN data linkage then performed.

Reports produced by TARN every quarter. Uploaded to website Identify pts reporting serious to extreme problems at 6 months. Trusts can then follow these patients up. PROMS guidance document on website

Data download also available from TARN website every month>>>>>

TARN

PROMS: Data download

Uploaded on TARN site after 25th of every month Secure log in required 2 nominated PROMS contacts per Trust TARN submission IDs included in Excel file TARN

34%

26%

19%

16%

3% 2%

Patients that were working, looking after family or studying before incident Same work

Unable to work or work in shelteredworkshop

Same work but some problems

Work at a reduced level

Not recorded

Ability to work changed but not due to injury

PROMs figures: Change in ability to work at 6 months

61% change in ability to work

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Change in patient’s ability to look after themselves at 6 months

59%20%

11%7%

2% 1%

I do not need

I need some help in the home, but not every day

I could look after myself for at least 8 hours ifnecessaryI could not look after myself for 8 hours during thedayI need help in the home, but not because of theinjuryNot stated

38% of patients = change to their independence

TARN

Measuring Trauma Outcomes - TARN - Home. Measure Trauma ou… · Brain stem: laceration, crush,...

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