1. Measuring Injury Severity A brief introduction Thomas Songer, PhD University of Pittsburgh tjs@pitt.edu

2. Degrees of Injury Severity Households Emergency Dept. Hospitalization Injury Deaths Physician Visit

3. Injury Police Hospital Self-Treat Robertson, 1992 doctor EMS Rehab Center Trauma Center Morgue Emergency Dept.

4. Major Areas of Application on Injury Severity Indices  Triage  Prognostic Evaluation  Research and Evaluation

5. Is there potential for improvement in the care of injured patients?

6. Improvements in outcomes related to injury may be achieved by: Enhancing pre-hospital care Adopting ATLS principles Integrating trauma care within and between hospitals Investing in rehabilitation services

7. Measuring the Burden of Injuries Fatal –Counts and rates –Years of Potential Life Lost Non-fatal –Short term Health care use –Hospitalization rates Functional limitations Severity –AIS –RTS, etc Pathology Segui-Gomez

8. Injury Severity Scales

9. Impact of the Injury will depend on...  Extent of tissue damage  Physiological response to the injury  Host factors that mediate the response

10. Aspects of Injury Severity Anatomical Injury Physiological Measurements Age Blunt/Penetrating Probability of survival of individual patients Comparisons between groups

11. INJURY SEVERITY INJURY SEVERITY Alphabet Soup

12. Abbreviated Injury Scale (AIS)  Anatomical measure that addresses the extent of tissue damage  ICD-based classifications

13. AIS Severity Component MINORMODERATESERIOUSSEVERECRITICAL MAXIMUM INJURY, VIRTUALLY UNSURVIVABLE 1 2 3 4 5 6

14. Severity scores are subjective assessments assigned by experts Implicitly based on four criteria:  Threat to life  Permanent Impairment  Treatment Period  Energy Dissipation

15. Addressing Multiple Injuries for predicting survival  Injury Severity Score (ISS)  The New Injury Severity Score (NISS)  The Anatomic Profile (AP)

16. The Injury Severity Score (ISS)  Sum of squares of the highest AIS in each of 3 most severely injured body regions  ISS Body Regions: –Head or neck - Face –Abdominal - Chest –Extremities - External

17. INJURY SEVERITY SCORE Example AIS Score Small subdural haematoma4 Parietal lobe swelling3 Major liver laceration4 Upper tibial fracture (displaced)3 ISS = 4 2 + 4 2 + 3 2 = 41

18. Criticisms of the ISS  Does not take into account multiple injuries within a body system  Equal weights across body regions; underscores severe head injuries

19. The New Injury Severity Score (NISS) Sums of squares of the 3 highest AIS scores regardless of body region

20. ISS vs. NISS - an Example Multiple abrasions Deep laceration tongue Subarachnoid hemorrhage Major kidney laceration Major liver laceration 1234412344 External Face Head/Neck Abdomen ISS = (4) 2 + (3) 2 + (2) 2 = 29 NISS = (4) 2 + (4) 2 + (3) 2 = 41 AIS Score Region

21. Anatomic Profile

22. Anatomic Profile Definition of Components AIS Region AIS Severity AIS Severity ABCD Head/Brain Spinal cord Thorax Front of Neck All other body regions All others 3-63-63-63-63-61-2 The square root of the sum of squares of AIS scores is used to summarize a component’s injuries Component

23. ICD to AIS Conversion (ICDMAP)  Converts ICD-9CM coded discharge diagnoses into AIS scores and computes ISS, NISS, APS  Conservative measure of injury severity - refer to as ICD/AIS scores

24. Injury Severity Scales In Use

25. Evaluating System Performance  Using hospital discharge data, classify patients according to where they should have been treated (based on AIS severity)  Compare where they should have been treated to where they actually were treated

26. Percent of ISS > = 16 Patients Getting to Trauma Centers: Metro Area A55% Metro Area B59% Metro Area C66% Metro Area D68% Metro Area E73% Metro Area F78% Metro Area G85%

27. Physiologic Response  Glasgow Coma Score  Revised Trauma Score

28. Glasgow Coma Scale Head injuries vary as to severity ranging from mild, moderate, to severe The Glasgow Coma Scale is a measure of this severity The GCS is assessed immediately following the injury and during the initial recovery

29. Glasgow Coma Scale ParameterResponseScore Nil1 To pain2 To speech3 Eye opening Spontaneously4 Nil1 Extensor2 Flexor3 Withdrawal4 Localising5 Motor response Obeys command6 Nil1 Groans2 Words3 Confused4 Verbal response Orientated5

30. Revised Trauma Score - a physiological measurement - based on data at arrival to hospital considers: Respiratory rate Systolic blood pressure Glasgow Coma Scale

31. Revised Trauma Score Clinical Parameter CategoryScore x weight 10-294 >293 6-92 1-51 Respiratory rate (Breaths per minute) 00 0.2908 >894 76-893 50-752 1-491 Systolic blood Pressure 00 0.7326 13-154 9-123 6-82 4-51 Glasgow Coma Scale 30 0.9368

32. Assessing RTS may be problematic Accurate GCS and RR difficult when the patient is intubated, chemically paralyzed or under the influence of drugs or alcohol

33. Host Factors  Age  Pre-existing conditions  Other

34. Combining information on … Tissue damage Physiologic response Host factors

35. Probability of Survival Models  TRISS  ASCOT

36. Further Improvements

37. Refining the State of the Art 1. Further refine the AIS and RTS 2. Revisit Probability of Survival Models -- especially for population based data 3. Better delineate role of host factors

38. AIS BASED MEASURES of IMPAIRMENT  Injury Impairment Scale (IIS)  Functional Capacity Score (FCI)