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Hospital-Based Injury Surveillance: Tools, Resources and Concepts. Holly Hedegaard, MD, MSPH. National Center for Health Statistics Office of Analysis and Epidemiology Safe Kids Worldwide Childhood Injury Prevention Conference June 21, 2013. National Center for Health Statistics.

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Holly Hedegaard, MD, MSPH

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Holly hedegaard md msph

Hospital-Based Injury Surveillance:Tools, Resources and Concepts

Holly Hedegaard, MD, MSPH

National Center for Health Statistics

Office of Analysis and Epidemiology

Safe Kids Worldwide Childhood Injury Prevention Conference

June 21, 2013

National Center for Health Statistics

Office of Analysis and Epidemiology



  • Resources and partners

  • Local data on injury hospitalizations

    • Data from hospital billing departments

    • Trauma registry data

  • National data on injury hospitalizations

    • Web-based Injury and Statistics Query and Reporting System (WISQARS)

    • Healthcare Cost and Utilization Project (HCUP)

Resources and partners

Resources and Partners

  • The Injury Prevention Program at your state or local public health department

  • Trauma registrars at hospitals

  • Universities or schools of public health; Injury Control Research Centers

  • National organizations

    • Safe States Alliance

    • CDC, National Center for Injury Prevention and Control

Useful tools

Useful Tools

Consensus Recommendations for Using Hospital Discharge Data for Injury Surveillance


Holly hedegaard md msph

Local Data on Injury Hospitalizations

Data from hospital billing departments

Data from Hospital Billing Departments

  • Based on the 2004 Universal Billing form (UB-04)

  • May be available for both ED visits and hospital discharges

  • Includes basic information on:

    • Patient demographics (e.g., age, sex)

    • Diagnoses

    • Cause of injury

    • Procedures

    • Hospital charges

Data from hospital billing departments1

Data from Hospital Billing Departments

  • Diagnoses, causes of injury and procedures are coded using the ICD-9-CM

    • Change to ICD-10-CM in October 2014

  • Tools for creating standard groups

    • Barell Matrix, for injury diagnoses


    • ICD-9-CM External Cause Matrix, for causes of injury


Hospitalizations for children ages 4 8 injured as an occupant in a motor vehicle crash colorado

Hospitalizations for Children Ages 4-8 Injured as an Occupant in a Motor Vehicle Crash, Colorado

Relevant Colorado Child Passenger Safety Laws for 4-8 Year Olds

A. 1995 Children under age 16 required to use seatbelts/car seats in front and back seats, primary enforcement.

B. 1999 Children must be in a seating position with a seatbelt/car seat available.

C. 2003 Children 4- or 5-years-old, unless > 55 inches tall, must ride in a booster seat, secondary enforcement.

D. 2010 Children ages 6-7 must ride in a booster seat.





Trauma registry data

Trauma Registry Data

  • Collected by trauma nurses and registrars

  • Often based on the National Trauma Data Standards


  • Additional information collected

    • Clinical data

    • Use of protective devices

Holly hedegaard md msph

Selected Mechanisms of Injury, by AgeData from the National Trauma Data Bank Pediatric Annual Report 2010

Holly hedegaard md msph

National Data on Injury Hospitalizations

Holly hedegaard md msph

Web-based Injury and Statistics Query and Reporting System (WISQARS)Centers for Disease Control and Prevention

  • Data are obtained from a sample of hospital emergency departments and analyzed to provide national estimates

  • Includes ED visits and hospitalizations that result from ED visits

  • On-line query system www.cdc.gov/injury/wisqars/index.html

Holly hedegaard md msph

5 Leading Causes of Non-fatal Injuryfor Children Treated and Released from the EDBy Age Group, US, 2011

*Accidentally struck by or struck against a person or object, including in sports

+Bite or sting, not including dog bites

Healthcare cost and utilization project hcup agency for healthcare research and quality

Healthcare Cost and Utilization Project (HCUP)Agency for Healthcare Research and Quality

  • Hospital discharge data from 44 states

  • Can provide national estimates on injury hospitalizations and ED visits

  • Several on-line query systems, one specific to kids

    • Pediatric age groups are pre-set

    • Need to have an understanding about ICD codes

    • hcupnet.ahrq.gov

Percent of children ages 17 with traumatic brain injury tbi admitted to the hospital from the ed

Percent of Children Ages < 17 with Traumatic Brain Injury (TBI) admitted to the hospital from the ED

ICD-9-CM codes for TBI: 800-804, 850-854, 950.1-950.3, 995.55, 959.01

From the National Emergency Department Sample (NEDS), HCUPnetat http://hcupnet.ahrq.gov/

Suggestions for getting started

Suggestions for Getting Started

  • Identify people who can help

  • Learn a little bit about the International Classification of Diseases (ICD) codes for injury

  • On-line tools for national estimates



Holly Hedegaard, MD, MSPH

Office of Analysis and Epidemiology

National Center for Health Statistics

3311 Toledo Rd.

Hyattsville, MD 20782

Phone: 301-458-4460


Injury surveillance in connecticut

Injury Surveillance In Connecticut

Data in connecticut

Data in Connecticut

  • What we have

  • How we share it

  • What we can do with it

Our set up

Our set up

  • Safe Kids Connecticut is a program of the Injury Prevention Center (IPC)

  • IPC has 10 hour per week GIS Research Assistant (RA) to run geo-spatial analysis (including making maps) and run data

  • Money for RA and to purchase data comes out of IPC money

Our statewide resources

Our statewide resources

  • Dept of Public Health (DPH)

    • No longer has Injury Prevention section

      • Lost funding 2011

      • Previously had injury data and ran CODES project

  • Dept of Transportation (DOT)

    • Has some data, but MV only

  • Poison Control Center

    • Has some data, but Poison only

Statewide resources cont d

Statewide Resources (cont’d)

  • Office of the Child Advocate

    • Runs Connecticut Child Fatality Review Panel which reviews all unexpected and unexplained child deaths

    • Runs special analysis upon request

    • Detailed information on topics like safe sleep

    • We do not have access to the data but do to the detailed analysis

Data we have purchased

Data we have – Purchased

  • Connecticut Hospital Association (CHA)

    • Emergency Department visits

    • Hospitalizations

    • Deaths (that occur in a hospital or are processed through a hospital)

  • DPH - Vital Records

    • CT Death Certificate Files

    • $10/year

Data we have free

Data we have - Free

  • DOT Crash file

    • Requires extensive formatting and processing of the data

  • Medical Examiner Data

    • Must request yearly

    • Specific Causes (Firearm and Drowning)

Data limitations

Data Limitations

  • Data Cleaning

    • Almost all data we receive (including CHA) requires extensive data formatting processing

  • Time Lag

    • We generally have a 2 to 3 year data lag

      • Example: Just now requesting 2011 and 2012 data

  • Hard to compare long periods of time

    • Ex) CT Death cert data 1990-2010, but change in ICD9 to ICD10 makes long term analysis difficult

Data limitations1

Data Limitations

  • E-Codes make certain information hard to get

    • Motor vehicle crash info? Yes!

    • Bike crash info? No… (only if they crashed into MV)

  • Based on cause of injury, rather than consumer product

    • Bikes

    • Batteries

    • Crib bumpers

Sharing data

Sharing data

  • Due to our agreements, we share the analysis of the data, not the raw data

  • We share data via:

    • ED Injury books for our local Safe Kids

    • Reports (Drowning, violent death)

    • Requests

Ed data books

ED data books

  • Updated when we get new data from CHA

  • Data books started 1995 and ends 2010

  • We give all unintentional injury data for kids 19 and under by 5 year age groups

  • Data broken down by county (8) and then total for the state

  • We collapse and expand categories as needed

  • Given to each local Safe Kids organization

Safe kids in ct are not county based

Safe Kids in CT are not county based

Example from data book

Example from Data Book

How we use our data

How we use our data

  • Media

    • Lots of requests for local data

      • Especially with national reports

      • Stories we pitch to them

    • Posts for our Facebook page

    • Social media for our lead organization

How we use our data1

How we use our data

  • Grants

    • Statewide data

    • Local data for local foundations

    • Mapped data

    • Safe Kids Worldwide

Educational material

Educational material



Karen Brock Gallo, MPH

Safe Kids Connecticut



Using e coded data in the pediatric emergency department

Using E-Coded Data in the Pediatric Emergency Department

Rennie Ferguson, MHS, CPH

Safe Kids Worldwide



  • Purpose of E-coding

  • Why it isn’t used more often

  • Hospital-based injury surveillance

  • Components of a successful injury surveillance system

Pediatric emergency care july 2013

Pediatric Emergency Care, July 2013

Injury surveillance s ystems

Injury surveillance systems

  • Provide information on populations susceptible to injury, types of injuries, and factors that put people at increased risk

  • How well interventions are working

  • Successful systems require:

    • Simplicity

    • Flexibility

    • Acceptability

    • Reliability

    • Utility

    • Sustainability

    • Timeliness

What is e coding

What is E-coding?

  • International Classification of Diseases external causes of injury and poisoning codes

  • Provide information about mechanism, location and intentionality of the injury

Design of literature review

Design of literature review

  • 2 sets of search criteria:

    • E-coding in the PED

    • Injury surveillance by the PED

  • PubMed, PubMed Central, Google Scholar

    • CINAHL, EMBASE, Academic Search Elite

  • Exclusion criteria



  • 111 sources identified

  • E-coding in the PED: 2 reports met criteria

  • Non-E-coding PED injury surveillance: 5 reports met criteria

E coding in ped

E-coding in PED

Injury surveillance in ped

Injury surveillance in PED

Injury surveillance in ped1

Injury surveillance in PED

Common challenges

Common challenges

  • Insufficient chart information (n=4)

  • Incompleteness of questionnaires by physicians (n=2)

  • Bias toward more severe cases (n=1)

Reduce the burden

Reduce the burden

  • Earlier systems: “flagging” injury cases, questionnaires, assigning clinical staff to enter data

    • Economic and resource burden

  • Electronic charting



  • Usefulness in tracking health outcome of interest

    • Falls (n=2)

    • Relevant by tailoring questions

  • Ease of use for hospital trauma education coordinators and others

Ensuring data quality

Ensuring data quality

  • Little published research on quantifying the accuracy of E-codes

    • Outside of PED—ranged from 64-85% (McKenzie 2009)

  • Need for more research on feasibility, quality, and utility of individual hospital PED injury surveillance systems

  • Role of triage nurses, parents in improved E-coding



Preparation of this research was supported by Cooperative Agreement 5R49CE001507 from the Centers for Disease Control and Prevention.

The contents of this presentation are solely the responsibility of the authors and do not represent the official views of the Centers for Disease Control and Prevention.

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