Injury coding in a national trauma registry: a one-year validation audit in a level 1 trauma centre
Abstract
BACKGROUND: Hospitals must improve patient safety and quality continuously. Clinical quality registries can drive such improvement. Trauma registries code injuries according to the Abbreviated Injury Scale (AIS) and benchmark outcomes based on the Injury Severity Score (ISS) and New ISS (NISS). The primary aim of this study was to validate the injury codes and severities registered in a national trauma registry. Secondarily, we aimed to examine causes for missing and discordant codes, to guide improvement of registry data quality.
METHODS: We conducted an audit and established an expert coder group injury reference standard for patients met with trauma team activation in 2015 in a Level 1 trauma centre. Injuries were coded according to the AIS. The audit included review of all data in the electronic health records (EHR), and new interpretation of all images in the picture archiving system. Validated injury codes were compared with the codes registered in the registry. The expert coder group's interpretations of reasons for discrepancies were categorised and registered. Inter-rater agreement between registry data and the reference standard was tested with Bland-Altman analysis.
RESULTS: We validated injury data from 144 patients (male sex 79.2%) with median age 31 (inter quartile range 19-49) years. The total number of registered AIS codes was 582 in the registry and 766 in the reference standard. All injuries were concordantly coded in 62 (43.1%) patients. Most…
Read the paper
Related studies
- Regulation of nucleolus assembly by non-coding RNA polymerase II transcripts
- For a Healthy Histone Code, a Little SUMO in the Tail Keeps the Acetyl Away
- Discovering a binary CTCF code with a little help from BORIS
- Article Commentary: Stabilizing the Code–-Methods to Preserve RNA Prove Their Worth
- Foreword to the Special Issue for the RINTC (The Implicit Seismic Risk of Code-Conforming Structures) Project
- Commentary: Promoting Health and Well-being in Pediatric Primary Care Settings: Using Health and Behavior Codes at Routine Well-child Visits
Go deeper in Evidence Hub
Evidence Hub adds a study data sheet (design, sample size, evidence level, key numbers), an AI summary and a chat grounded in the paper's text.