Scoring & AssigningTARN an ISS

The Trauma Audit & Research Network (TARN) Injury Coding

 Injury coding performed centrally at TARN

 Ensuring coding uniformity

 Coders check injuryTARN descriptions & imaging reports

dictionary (AIS2005) currently used

 Every submission assigned an (ISS)

 85,000+ submissions approved per year 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,TARN originally for Vehicle Crash investigators

 AIS2005 version >2000 injury descriptors

 Anatomically based system, ranking according to severity on a 6 point ordinal scale AIS: 6 point severity scale

AIS Grade Injury example (Severity) 1 Minor Bruise to abdomen 2 ModerateTARNSmall 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 AIS Severity indicates

The relative risk of “threat to life” inTARN an average person who sustains the coded injury as his or her only injury

It’s not a disability scale AIS code structure: 7 digits

Code Injury Numerical Severity identifier Score 853271.3 ComminutedTARNFemoral Shaft # 853271 .3 140656.5 Large Subdural haemorrhage 140656 .5 Abbreviated Injury Scale: Sections

Skin Penetrating Hypothermia Crush TARNAsphyxia: Hanging/Strangulation Traumatic Amputation Drowning Nerve Frostbite Vessel Joint Inhalation Skeletal AIS: Spinal Injuries

 Cervical Spine (C1-C7)  Thoracic Spine (T1-T12)  Lumbar spine (L1TARN-L5)

Severity can be affected by location of spinal injury AIS: Confirmed injuries only

Suspected injuries  PossibleTARN injuries  Probable injuries  Ruled out injuries  AIS: Not Coded

 Infections  Pneumonia  Death  Blindness TARN  Miscarriage  Epilepsy following  Pulmonary following skeletal injury

Don’t affect Severity score NFS: Not Further Specified This appears throughout the AIS dictionary & allows the coding of injuries when detailed TARNinformation is lacking

Example: Injury description = Liver laceration Coded as: 541820.2 (Liver laceration NFS) Most used NFS codes which affect data accreditation

Most used NFS codes Information needed

Diameter of the contusion or a description of the size e.g. Cerebrum/cerebellum contusion tiny, small, large, extensive.

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

Diameter of the ICH or a description of the size e.g. tiny, Cerebrum/cerebellum intracerebral haematoma small, large, extensive.

Severity of the swelling e.g mild; sulcal effacement, Brain swelling 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 AIS 6: Maximum score

AIS 6 not usedTARN just because a patient dies! Has to be documented medical evidence of an AIS 6 injury AIS 6: Maximum score Head or Neck Brain stem: laceration, crush, penetrating or transection C3 or higher complete cord transection or contusion Sigmoid or Transverse sinus or Internal carotid artery: Bilateral lacerations  Heart: rupture, multiple lacerations or avulsion  Total chest crushTARN  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 Surface  Massive Whole body Explosion type injury AIS: Localisers 2 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. 5thTARNrib, 12th Thoracic vertebrae, 2nd toe Numerical identifier Severity Localiser 1 Localiser 2

• Don’t affect ISS • Used mainly in Research AIS dictionary

TARN

Available only from: www.aaam.org

• Latest Version: AIS 2015 recently released • $225 each + shipping • TARN currently using AIS2005, but will move to AIS2015 • All existing codes will be mapped over • All Trusts notified well in advance InjuryTARN Coding exercise EXAMPLE SUBMISSION 1: INJURIES Page AIS code Spiral fracture Shaft of Femur 147 853251.3 Open complete articular fracture to distal Radius 127 752372.3 Open book fracture to pelvisTARN with blood loss >20% 159 856164.5

3 ribs fractured on left 82 450203.3

Extensive bilateral cerebral contusion 44 140626.5

Skull vault fracture 49 150400.2

Grade III (OIS grade) Spleen laceration 96 544224.3 CalculatingTARN the ISS Injury Severity Score Calculating the ISS: Step 1

DetermineTARN the scores of the individual injuries using the Abbreviated Injury Scale Calculating the ISS: Step 2

Identify the highest severity score inTARN each body area Injury Severity Score: 6 body areas 1. Head & Neck & Cervical spine

2. Face

3. Chest & ThoracicTARN spine

4. Abdomen & pelvic contents & Lumbar spine

5. Extremities & bony pelvis

6. External (incl. Skin injuries and Burns) Head Extensive bilateral cerebral contusion 140626.5

Skull vault fracture 150400.2 Thorax 3 ribs fracturedTARN 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 Calculating the ISS: Step 3

Square the highest score in each TARNbody area Head Extensive bilateral cerebral contusion 5² =25 140626.5

Skull vault fracture 150400.2 Thorax 3 ribs fracturedTARN on left 3² =9 450203.3 Grade III Spleen laceration Abdomen 3² =9 544224.3 Extremities Open complete articular fracture to distal Radius 752372.3

Open book fracture to pelvis with blood loss >20% 5² = 25 856164.5 Spiral Shaft of Femur 853251.3 Calculating the ISS: Step 4

 Code individual injuries

 Identify the highestTARN score in each body area

 Square the highest score in each body area

Add together the highest AIS2 from 3 different body areas Head Extensive bilateral cerebral contusion 5² =25 140626.5

Skull vault fracture 150400.2 Thorax 3 ribs fracturedTARN on left 3² =9 450203.3 Grade III Spleen laceration Abdomen 3² =9 544224.3 Extremities Open complete articular fracture to distal Radius 752372.3

Open book fracture to pelvis with blood loss >20% 5² = 25 856164.5 Spiral Shaft of Femur 853251.3 InjuryTARN Severity Score (ISS) = 59 Injury Severity Score (ISS)

Body area Injury AIS code Head Closed vault fracture 150402.2 2² = 4 Thorax 5+6 ribs fracturedTARN on left 450202.2 2² = 4

ISS = 8 Injury Severity Score (ISS)

Body area Injury AIS code

Head Closed vault fracture 150402.2 2² = 4

Thorax 5+6 ribs fractured on left 450202.2 2² = 4

External Lower limb TARN– skin laceration 810600.1 1² = 1

ISS = 9 Injury Severity Score (ISS)

Ranges from 1 to 75 Maximum 75 achievedTARN in 2 ways: 1. Severity 5 in 3 different body areas 52 + 52 + 52 = 75

2. ISS convention: AIS = 6 in any body area, ISS = 75 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 fractures Stability & site of Fractures (e.g. Comminuted/Displaced Shaft/Proximal/Distal fracture) Articular (joint) involvement (e.g. Intra-articular, extra-articular) Blood loss TARN Vessel damage Location & number of rib fractures Compression or effacement of ventricles/brain stem cisterns Neurology 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 documented Include imaging reports or Post Mortems for every submission.

Jan 17: Grade now requested for pelvic ring fixations Probability of Survival Once ISS is assigned TARN Probability of Survival (Ps) calculated each submission Ps19 Importance of accurate injury detail

Age: 40 Gender: Male ISS: 59 GCS: 5 PMC: Nil  TARN  

Ps19 calculation 

Ps: 58% Ps19 Importance of accurate injury detail

Full injury detail Code Accurate ISS Accurate Ps Spiral Shaft of Femur 853251.3 Open complete articular fracture to distal Radius 752372.3 59 58% Open book fracture to pelvis with blood loss >20% 856164.5 3 ribs fractured on left TARN450203.3 Extensive bilateral cerebral contusion 140626.5 Skull vault fracture 150400.2 Grade III (OIS grade) Spleen laceration 544224.3

Incomplete injury detail Code Incomplete ISS Spiral Shaft of Femur 853251.3 22 Fracture to distal Radius 752371.2 Fracture to pelvis 856151.2 Multiple ribs fractured on left 450210.2 Cerebral contusion 140604.3 Skull vault fracture 150400.2 Spleen laceration 544220.2 Ps19 Importance of accurate injury detail

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

Ps19 calculation 

Ps: 86% Inaccurate Ps Summary

 Inclusion Criteria  Identifying Cases  Data Entry TARN  System Features  Quality Assurance: Case ascertainment & Data Accreditation  Injury scoring & calculating the ISS