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The Barell Matrix , Updates; The Composition of TBI Rows Multiple Injury Analysis Using Matrix. Limor Aharonson-Daniel, Israel Megan Davies, USA. The Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Israel

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  1. The Barell Matrix, Updates; The Composition of TBI Rows Multiple Injury Analysis Using Matrix Limor Aharonson-Daniel, Israel Megan Davies, USA The Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Israel National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA THE ISRAELI CENTER FOR TEMR

  2. Matrix Reminder What is the 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

  3. Matrix Reminder Matrix objectives • To simplify the process of classifying injuries • To provide a standard format for reports • To serve as a standard for casemix comparison • To characterize the patterns of injury

  4. Matrix Reminder Motivation for building the matrix ICD 9-CM CODES 800-995 Sorted bynature of injury Detecting injuries bybody region requires collating codes across chapters

  5. Matrix Reminder Motivation for building the matrix ICD 9-CM CODES 800-995 nature of injury body region

  6. Matrix Reminder The Matrix structure Nature of injury Body Region ICD-9-CM injury codes

  7. Matrix Reminder Nature of injury (Columns) are based on Sequenceof codes in ICD-9-CM codebook Body Region (Rows) are based on : Anatomic subgroups High Incidence Variability in Outcome Difference in health care utilization

  8. 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.

  9. General Agreements Reached April 3, 2001: ICE meeting, Washington DC “Instructions on how to collapse rows will be available to ensure a standard collapsed table”. “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”.

  10. Specific Agreements, ICE meeting, Washington DC, 2001 “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”.

  11. Specific Agreements, ICE meeting, Washington DC, 2001 “A detailed extremity module needs to be added”.

  12. Specific Agreements, ICE meeting, Washington DC, 2001 “Amputations will be separated from open wound”.

  13. Specific Agreements, ICE meeting, Washington DC, 2001 “Superficial injuries and contusions will be joined”.

  14. Specific Agreements, ICE meeting, Washington DC, 2001 “The matrix has a row for “system wide conditions” enabling use for non traumatic injuries”.

  15. Specific Agreements, ICE meeting, Washington DC, 2001 “The presence of Traumatic Brain Injury (TBI) is important. The matrix will have three rows identifying Definite TBI, possible TBI and other head injuries”. 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.

  16. Original TBI definition injury 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.

  17. Original Two-row TBI definition (created by Vita Barell) Definite TBI PossibleTBI injuries with a specific mention of intracranial injury or loss of consciousness of more than one hour Injuries with no mention of intracranial injury or with loss of consciousness of less than one hour. A derivation from CDC definitions: concussions with no or short loss of consciousness were classified as ‘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)

  18. 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

  19. Three-row TBI definition Definite TBI Type 1 Definite TBI Type 2 Possible TBI Injuries with a recorded evidence of an intracranial injury or a moderate or prolonged loss of consciousness (loc). Injuries with no mention of intracranial injury or with no loss of consciousness 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.

  20. 959.01 854 • Concussions with no or short LOC • Shaken baby syndrome (995.55) • LOC of unspecified duration • Unspecified level of consciousness Three-row TBI definition Definite TBI Type 1 Definite TBI Type 2 Possible TBI Injuries with a recorded evidence of an intracranial injury or a moderate or prolonged loss of consciousness (loc). Injuries with no mention of intracranial injury or with no loss of consciousness 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.

  21. Definite severe/moderate TBI Definite TBI type 1 (grade 1) Definite mild TBI Definite TBI type 2 (grade 2) Probable TBI Possible TBI Plausible TBI

  22. Three-row TBI

  23. Traumatic Brain Injury 1997-2000 ITR data

  24. Megan

  25. Multiple injury And the construction of injury profiles The Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Israel

  26. Summarizing multiple injuriesMotivation • 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.

  27. Summarizing multiple injuries AIMS 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.

  28. Adam multiple diagnoses Skull fracture, with an intracranial injury Flail chest Jo Fractured ankle Single diagnosis

  29. Single diagnosis

  30. Summary report

  31. Summarizing multiple injury diagnostic data multiple diagnoses patients single diagnosis patients Select one diagnosis first listed/major

  32. Limitation of using a Single diagnosis For summarizing multiple injuries Difficulty in assigning the principal diagnosis Distorts the description of the actual injury Skull fracture, with an intracranial injury Flail chest Adam

  33. Distribution of injuries by body region Single or Multiple? Population: ITR Road Traffic Accidents, 1997-2000, total of 17459 patients

  34. Reasons for using multiple diagnoses For multiple injury patients Multiple diagnoses injury profiles • 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

  35. Summarizing multiple injury diagnostic data multiple diagnoses patients Select one diagnosis first listed/major Create injury profile

  36. Creating injury profiles Divide body regions into groups • Head and Neck H • Spine and Back S • Torso T • Extremities E • Other O

  37. Frequency distribution of groups • Legend • Head and Neck H • Spine and Back S • Torso T • Extremities E • Other multiple O

  38. Characterizing diagnostic groups • ISS • Inpatient death • Duration of inpatient stay • External cause of injury • etc.

  39. Duration of Inpatient stay by diagnostic group combinations • Legend • Head and Neck H • Spine and Back S • Torso T • Extremities E • Other Multiple O 75% Median 25% Multiple injuries Single injuries

  40. Inpatient death by diagnostic group combinations n 3760 Single injuries 417 4346 2010 1935 Multiple injuries 922 1319 1121 Inpatient death

  41. A technique for analyzing multiple injuries was presented using the Barell diagnostic matrixThe importance of using multiple injury in describing the injured has been demonstrated.Injury profiles enable standardized comparisons of casemix and outcome between external cause of injury, hospitals and countries. Profiles could also serve for efficient staffing of specialists in multidisciplinary trauma teams. Summary to date

  42. Problems, Limitations and Unresolved issues Definition of multiple Number of combinations Severity measures

  43. Thanks for your attention

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