Review
The injury scale – a valuable tool for forensic documentation of trauma

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Abstract

An accurate method for quantitatively summarizing injury severity has many potential applications. The ability to predict outcome from trauma (i.e., mortality) is perhaps the most fundamental use of injury severity scoring, a use that arises from the patient’s and the family’s desires to know the prognosis. Field trauma scoring also is used to facilitate rational pre-hospital triage decisions, thereby minimizing the time from injury occurrence to definitive management. Another use of trauma scoring is for quality assurance by allowing evaluation of trauma care both within and between trauma centers, a contentious and controversial area that is likely to only increase in importance. However, the most important role for injury severity scoring is in trauma care research. Scientific study of the epidemiology of trauma and trauma outcomes would not be possible otherwise. Injury severity scoring is indispensable in stratifying patients into comparable groups for prospective clinical trials. Similarly, this technique can be used retrospectively to identify and control for differences in baseline injury severity between patient populations. More recently, physicians suggested that injury severity scoring could provide objective information for end-of-life decision-making and resource allocation. Unfortunately, trauma mortality prediction in the individual patient is limited and fraught with uncertainty. In fact, decisions for individual patients should never be based solely on a statistically derived injury severity score.

Introduction

Trauma has only relatively recently been recognized as a discrete entity by the medical community. The National Academy of Sciences, exploring the state of trauma research, has recommended continuous systemic data collection using common coding schemes in hospitals and trauma centers.1 Characterization and documentation of injury severity are requirements not only for the evaluation of trauma systems and development of initiative in injury control but also for assessment of short-term survival period among the trauma victims for the following reasons: (a) to plan issues related to death such as ‘will’, (b) to optimally utilize the scarce ICU and other critical care medical facilities, (c) to make the relatives mentally prepared to the ultimate eventuality and (d) To assess the quality of care provided by an institution.

Interpretation of trauma deaths by autopsy remains profoundly important to trauma research and particularly to continuous quality improvement. ‘Quality of care’ audits using autopsy and clinical data have indicated that in many US communities, up to 35% of the trauma deaths were preventable.2 Similar studies in England found that 30% of deaths were preventable.3 The results of these studies lead to the implementation of trauma care systems and trauma centers. Follow-up studies using clinical evaluations and autopsy findings have reported up to a 50% reduction in preventable deaths.4 Such studies demonstrate the vital role of autopsy as a tool in the continuing efforts to improve the quality of trauma treatment. The regular use of trauma scores in forensic medicine may provide a standardized database of autopsy findings, which would be a tremendous contribution to the quality of trauma treatment and the assessment of preventable death.

The development of valid and useful quality-improvement methods, comparisons of therapeutic modalities with the outcomes of trauma patients, collection of basic epidemiological trauma data and effective use of pre-hospital and inter-hospital triage are major needs in the trauma care system. A prerequisite to meeting these needs is the uniform application of severity scales to the trauma patients. Current, commonly used scales are grouped according to the type of patient information on which they are based, such as physiologic measures, measures of anatomic damage and biochemical measures.

This include vital signs such as pulse, blood pressure, respiratory rate and level of consciousness and are useful for early evaluation of trauma victim. They are not relevant in postmortem evaluation for obvious reasons.

The Glasgow Coma Scale (GCS) is widely used for the assessment of a patient’s level of consciousness and has been incorporated into the Revised Trauma Scale (RTS), which provides a more accurate estimation of severity for patients with serious head injuries and enables reliable predictions of out come.5 The Glasgow Coma Scale is scored between 3 and 15, 3 being the worst and 15 the best. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury. Despite its being an indicator of severity, GCS is occasionally compromised in non-head injured patients due to hypoxia, hypovoluaemia, hypothermia, drugs and alcohol intoxication. It is composed of the patient’s best response and takes into consideration three parameters as tabulated below:

The Circulation, Respiration, Abdominal/Thoracic, Motor, Speech (CRAMS) Scale resulted from an attempt to simplify the original trauma score (Glasgow Coma Scale, Cardiovascular Status, Respiratory Status) for triage in the field. Each of the five categories in the CRAMS Scale was graded from Zero (severe physiologic or neurologic deficit or overt abdominal or thoracic injury) to 2 (no deficit or injury). A total score of 8 or less indicated major trauma, while a score of 9 or above suggested minor trauma. However, neither inter- nor intra-rater reliability has been demonstrated for the abdominal or thoracic field assessments.

The RTS is a physiological scoring system, with high inter-rater reliability and demonstrated accuracy in predicting death. It is scored from the first set of data obtained on the patient, and consists of Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate. The RTS has 2 forms depending on its use. When used for field triage, the RTS is determined by adding each of the coded values together. Thus, the RTS ranges from 0 to 12 and is calculated very easily. An RTS of less than 11 is used to indicate the need for transport to a designated trauma center. The coded form of the RTS is used more frequently for quality assurance and outcome prediction. The coded RTS is calculated as follows, in which Systolic Blood Pressure (SBPc), Respiratory Rate (RRc), and Glasgow Coma Scale (GCSc) represent the coded values of each variable: RTSc = 0.7326 SBPc + 0.2908 RRc + 0.9368 GCSc.

Obviously, this value is more complicated to compute, which limits its usefulness in the field. The main advantage of the coded RTS is that the weighting of the individual components emphasizes the significant impact of traumatic brain injury on outcome.

The RTS has several limitations that affect its usefulness. Most of these limitations are related to the GCS. As originally described, the GCS was intended to measure the functional status of the central nervous system. Because of the importance of head injury in determining trauma outcome, the GCS also is used by many as a component of trauma severity scoring. Problems inherent to the GCS (and RTS) include the inability to accurately score patients who are intubated and mechanically ventilated. Determining the verbal component of the GCS and the respiratory rate are difficult in these patients. Moreover, patients who are pharmacologically paralyzed or under the influence of alcohol or illicit drugs also are difficult to score. Alternative approaches in this setting include using the best motor response and the eye-opening response to calculate or predict the verbal response. Research has shown that substitution of the best motor response for the GCS results in no loss of predictive capability. More recently, it has been reported that the best motor response predicts trauma mortality as well as or better than other trauma severity scores.[6], [7]

The Acute Physiology and Chronic Health Evaluation (APACHE), introduced in 1981, is used widely for the assessment of illness severity in intensive care units (ICUs).8 This system has two components, (1) the chronic health evaluation, which incorporates the influence of co-morbid conditions (e.g., diabetes mellitus, cirrhosis) and (2) the Acute Physiology Score (APS).

The APS consists of weighed variables representing the major physiologic systems, including neurologic, cardiovascular, respiratory, renal, gastrointestinal, metabolic, and hematologic variables. Researchers use data that are the most abnormal during the first 24 h. In 1985, the APACHE system was revised to APACHE II by reducing the number of APS variables from 34 to 12, restricting the co-morbid conditions and deriving coefficients for specific diseases.9 APACHE II though most widely applied APACHE system, has several potential limitations.

  • The GCS, which forms a powerful predictive component of the APS, was not intended to reflect extracranial injuries. Being a relatively younger population, co-morbidity is unusual in these patients and the potential exists for lead-time bias. By using only ICU data and not accounting for prior treatment, APACHE II underestimates mortality in patients who are transferred to the ICU after relative stabilization. Patients with trauma frequently are resuscitated in the emergency department or operating room prior to admission to the ICU.

  • Patients with trauma comprise only 8% of the population used to develop APACHE II, with only a 9% case-fatality rate. Moreover, 85% of trauma fatalities were related to traumatic brain injury.

  • Researchers have contested that APACHE II is inferior to the TRISS in predicting mortality in injured patients. Poor performance was related largely to the absence of an anatomic component in the APACHE system.[10], [11]

The most recent version, APACHE III, was published in 1991 and was designed to address many of these issues.12 The most important modifications were including 17 variables; limiting co-morbid conditions to those affecting immune function; disease-specific equations, including multiple trauma; distinguishing between head and non-head trauma; and accounting for potential lead-time bias. However, the practitioners do not widely accept APACHE III, partially because it is proprietary and expensive. In addition, its accuracy needs to be convincingly validated in patients with trauma.

The first attempt to classify injuries on the basis of severity was perhaps, made by DeHaven in early 1950s, when he created a scale to study light plane crash injuries.[13], [14] Development of the Abbreviated Injury Scale (AIS) began in 1969 with an emphasis on blunt trauma associated with motor vehicle accidents.15 The AIS has been revised at least six times since the original 1971 version to introduce the severity value of different injuries. The 1985 version (AIS – 85), introduced severity values for penetrating injuries and clinical terminology to describe thoracic, abdominal and vascular injuries and these severity values have been assigned to ICD-9-CM injury rubrics.16 According to the incarnation of the AIS score is the 1990 revision (AIS – 90), injuries are ranked on a scale of 1–6, with 1 being minor, 5 severe and 6 an Unsurvivable injury. This represents the ‘threat to life’ associated with an injury and is not meant to represent a comprehensive measure of severity. The AIS is not an injury scale, in that the difference between AIS1 and AIS2 is not the same as that between AIS4 and AIS5. There are many similarities between the AIS scale and the HYPERLINK “ois.html” Organ Injury Scales of the American Association for the Surgery of Trauma.17 AIS Score Injury as: 1 Minor, 2 Moderate, 3 Serious, 4 Severe, 5 Critical and 6 Unsurvivable. According to the Organ Injury Scaling[18], [19], [20] some of the organs are scaled as listed below:

Cardiac (Grade Injury Description AIS-90)

  • Blunt cardiac injury with minor ECG abnormality (nonspecific ST or T wave changes, premature atrial or ventricular contraction or persistent sinus tachycardia) 3 Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade or cardiac herniation 3.

  • Blunt cardiac injury with heart block or ischaemic changes without cardiac failure 3 Penetrating tangential cardiac wound up to but not extending through endocardium, with tamponade 3–4.

  • Blunt cardiac injury with sustained or multifocal ventricular contractions 3–4. Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, pap muscle dysfunction or distal coronary artery occlusion without cardiac failure 3–4. Blunt pericardial laceration with cardiac herniation 3–4. Blunt cardiac injury with cardiac failure Penetrating tangential myocardial wound up to but not through endocardium, with tamponade 3.

  • Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetent papillary muscle dysfunction or distal coronary artery occlusion producing cardiac failure. Blunt or penetrating cardiac injury with aortic or mitral incompetence 3. Blunt or penetrating cardiac injury of the right ventricle, right or left atrium 5.

  • Blunt or penetrating cardiac injury with proximal coronary artery occlusion 5. Blunt or penetrating left ventricular perforation 5. Stellate injuries <50% tissue loss of the right ventricle, right or left atrium 5.

  • Penetrating would producing >50% tissue loss of a chamber 6. (Advance one grade multiple penetrating wounds to a single chamber or multiple chamber involvement.)

Chest Wall (Grade Injury Description AIS-90)

  • Contusion any size 1, Laceration skin and subcutaneous 1, Fracture <3 ribs, closed 1–2 and non-displaced fracture of clavicle, closed 2.

  • Laceration skin, subcutaneous and muscle 1, Fracture >3 adjacent ribs, closed 2–3, Open displaced clavicle 2, Non-displaced sternum, closed 2 and Scapular body 2.

  • Laceration Full thickness including pleura 2, Fracture Open, displaced or flail sternum 2, Unilateral flail segment <3 ribs 3–4.

  • Laceration Avulsion of chest wall tissues with underlying rib fractures 4, Fracture Unilateral flail chest >3 ribs 3–4.

  • Fracture bilateral flail chest 5.

    (Advance one grade for bilateral injuries).

Diaphragm (Grade Injury Description AIS-90)

  • Contusion 2.

  • Laceration <2 cm 3.

  • Laceration 2–10 cm 3.

  • Laceration >10 cm with tissue loss < 25 sq cm 3.

  • Laceration with tissue loss >25 sq cm 3.

    (Advance one grade for bilateral injuries).

Spleen (Grade Injury Description AIS-90)

  • Haematoma Subcapsular, <10% surface area 2, Laceration capsular tear, <1 cm parenchymal depth 2.

  • Haematoma Subcapsular, 10–50% surface area, Intraparenchymal, <5 cm diameter 2 a Laceration 1–3 cm parenchymal depth not involving a parenchymal vessel 2.

  • Haematoma Subcapsular, >50% surface area or expanding ruptured Subcapsular or parenchymal haematoma, Intraparencymal haematoma >5 cm 3, Laceration >3 cm parenchymal depth or involving trabecular vessels 3.

  • Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen) 4.

  • Laceration/Completely shattered spleen 5, Hilar vascular injury which devascularized spleen 5.

    (Advance one grade for multiple injuries to same organ up to Grade III).

Liver (Grade Injury Description AIS-90)

  • Haematoma Subcapsular, <10% surface area 2, Laceration/Capsular tear, <1 cm parenchymal depth 2.

  • Haematoma Subcapsular, 10–50% surface area 2, Intraparenchymal, <10 cm diameter Laceration 1–3 cm parenchymal depth, <10 cm length 2.

  • Haematoma Subcapsular, >50% surface area or expanding. Ruptured Subcapsular or parenchymal haematoma 3, Intraparencymal haematoma >10 cm or expanding 3, Laceration >3 cm parenchymal depth 3.

  • Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Coinaud’s segments in a single lobe 4.

  • Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Coinaud’s segments within a single lobe 5, Juxtahepatic venous injuries i.e. retrohepatic vena cava/central major hepatic veins 5.

  • Vascular Hepatic Avulsion 6.

    (Advance one grade for multiple injuries to same organ up to Grade III).

Kidney (Grade Injury Description AIS-90)

  • Contusion Microscopic or gross haematuria, urological studies normal 2, Haematoma Subcapsular, none-expanding without parenchymal laceration 2.

  • Haematoma None-expanding peri-renal haematoma confined to renal retroperitoneum Laceration <1 cm parenchymal depth of renal cortex without urinary extravasation 2.

  • Laceration >1 cm depth of renal cortex, without collecting system rupture or urinary extravasation 3.

  • Parenchymal laceration extending through the renal cortex, medulla and collecting sys 4, Main renal artery or vein injury with contained haemorrhage 5.

  • Laceration/Completely shattered kidney 5, Vascular Avulsion of renal hilum which devascularizes kidney 5.

    (Advance one grade for multiple injuries to same organ).

Ureter (Grade Injury Description AIS-90)

  • Haematoma Contusion or haematoma without devascularization 2.

  • Laceration <50% transection 2.

  • Laceration >50% transection 3.

  • Laceration Complete transection with 2 cm devascularization 3.

  • Laceration Complete transection with >2 cm devascularization 3.

Bladder (Grade Injury Description AIS-90)

  • Haematoma Contusion, intramural haematoma 2, Laceration Partial thickness 3.

  • Extraperitoneal bladder wall laceration <2 cm 4.

  • Extraperitoneal (>2 cm) or intra-peritoneal (<2 cm) bladder wall lacerations 4.

  • Intraperitoneal bladder wall laceration >2 cm 4.

  • Laceration extending into bladder neck or ureteral orifice (trigone) 4.

Urethra (Grade Injury Description AIS-90).

  • Contusion/Blood at urethral meatus, urethrography normal 2.

  • Stretch injury/Elongation of urethra without extravasation on urethrography 2.

  • Partial disruption/Extravasation of contrast at injury site with contrast visualized in bladder 2.

  • Complete disruption/Extravasation of contrast at injury site without visualization of the bladder. <2 cm urethral separation 3.

  • Complete disruption/Complete transection with >2 cm urethral separation, or extensio into the prostate or vagina 4.

Moore and colleagues facilitated identification of the patient at high risk of postoperative complications when they developed the Penetrating Abdominal Trauma Index (PATI) scoring system for patients whose only source of injury was penetrating abdominal trauma.21 A complication risk factor was assigned to each organ system involved, and then multiplied by a severity of injury estimate. Each factor was given a value ranging from 1 to 5. The complication risk designation for each organ was based on the reported incidence of post-operative morbidity associated with the respective injury.

The severity of injury was estimated by a simple modification to the Abbreviated Injury Scale, where 1 = minimal injury to 5 = maximal injury. The sum of the individual organ score times risk factor comprised the final PATI. If the PATI is 25 or less, the risk of complications is reduced (and where it was 10 or less, there were no complications), where if it is greater than 25, the risks are much higher. In a group of 114 patients with gunshot wounds to the abdomen a study reported that a PATI score >25 dramatically increased the risk of postoperative complications (46% of patients with a PATI score of >25 developed serious postoperative complications compared to 7% of patients with a PATI of <25). Further studies have validated the PATI scoring system.22

The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an AIS score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities and Pelvis. Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score. The ISS score takes values from 0 to 75. If an injury is assigned AIS of 6 (Unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity.

The ISS has several limitations. The most obvious limitation is its inability to account for multiple injuries to the same body region.23 Similarly, it limits the total number of contributing injuries to only 3. This seriously impairs the usefulness of the ISS in penetrating injuries, in which multiple injuries are common. The high velocity gunshot wounds are especially associated with problematic coding, since the effect of the shock wave and temporary cavitation in the tissue resulting from the dissipation of energy by the bullet are not expressed by this scoring system.24 The ISS weights injuries to each body region equally, ignoring the importance of head injuries in mortality from trauma. Furthermore, mortality is not strictly an increasing function of the ISS. The mortality rate for an ISS of 16, therefore, is higher than the mortality rate for an ISS of 17 because of the different combinations of AIS scores that comprise each. It has been documented that any error in AIS scoring increases the ISS error, many different injury patterns can yield the same ISS score and injuries to different body regions are not weighted. Also, as a full description of patient injuries is not known prior to full investigation & operation, the ISS (along with other anatomical scoring systems) is not useful as a triage tool.25 Another idiosyncrasy of the ISS is that many ISS values cannot occur, while other ISS values can result from multiple different combinations of AIS scores. Obviously, this makes the ISS a heterogeneous score and reduces its predictive ability.

Although the classic use of the ISS is to predict mortality from trauma, the ISS also has been noted to be a consistent risk factor predictor for post-injury multiple-organ failure (MOF). In developing predictive models for MOF, researchers categorized risk factors as related to tissue injury severity, cellular shock severity, the magnitude of the systemic inflammatory response to the injury, and host factors (e.g., age, sex, co-morbidity). Tissue injury severity is a major component of these predictive models, and it is readily quantifiable using the NISS.

Recently, Osler et al reported a modified ISS (new ISS or NISS) based on the 3 most severe injuries regardless of body region.26 This simple but significant modification of the ISS avoids many of its previously acknowledged limitations. By preserving the AIS as the framework for injury severity scoring, the NISS remains familiar and user-friendly. Preliminary studies suggest that the NISS is a more accurate predictor of trauma mortality than the ISS, particularly in penetrating trauma. Other researchers demonstrated that the NISS is superior to the ISS as a measure of tissue injury in predictive models of post-injury MOF.27 Osler et al. recommended that the NISS replace the ISS as the standard anatomic measure of injury severity. A study28 in Canada evaluated ISS and NISS among patients with blunt trauma and concluded that NISS provides a more accurate prediction of short-term mortality.

In response to the limitations of the ISS, researchers developed the Anatomic Profile (AP) Unlike the ISS, the AP includes all serious injuries in a body region. Moreover, the AP appropriately weights head and torso injuries more heavily than other body regions. This index summarizes all serious injuries (AIS greater >3) into 3 categories. Category A includes the head and spinal cord. Category B encompasses the thorax and anterior neck. Category C includes all remaining serious injuries. A fourth category, category D, summarizes all non-serious injuries.

Practitioners calculate each component as the square root of the sum of squares of the AIS scores of all serious injuries within each region. A region with no injury receives a score of zero. Using logistic regression, these AP component values are used to calculate a probability of survival. The AP performs better than the ISS in discriminating survivors from non-survivors and may provide a more rational basis for comparing injury severity between patients. However, the AP failed to garner much interest or support, probably due to its mathematical complexity and only modest improvement in predictive performance.

Another, more recent approach to anatomic injury scoring is based on the International Classification of Disease, Ninth Edition (ICD-9) codes. This method is termed ICD-9 Injury Severity Score (ICISS) and uses survival risk ratios (SRRs) calculated for each ICD-9 discharge diagnosis. SRRs are derived by dividing the number of survivors in each ICD-9 code by the total number of patients with the same ICD-9 code. ICISS is calculated as the simple product of the SRRs for each of the patient’s injuries.[29], [30]

ICISS has some advantages over the ISS. First, it represents a true continuous variable that takes on values between 0 and 1. Second, it includes all injuries. Third, ICD-9 codes are readily available and do not require special training or expertise to determine. Finally, ICD-9 has better predictive power when compared to the ISS. Moreover, ICISS has the potential to better account for the effects of co-morbidity on outcome by including the SRR for each co-morbidity present. Recently, researchers have shown that the ICISS outperforms the ISS in predicting other outcomes of interest (e.g., hospital length of stay, hospital charges).[31], [32] Despite the apparent advantage of the ICISS, it has not yet replaced other methods of outcome analysis. Further validation is needed before it can be used widely.

The predictive capability of any model usually is improved with the inclusion of additional relevant information. Champion and colleagues exemplified this concept with the development of the Trauma and Injury Severity Score (TRISS). This test combines both anatomic and physiologic measures of injury severity (ISS and RTS, respectively) and patient age in order to predict survival from trauma.33 TRISS could be used to estimate probabilities of survival for trauma patients from a retrospective data-base, using a logistic model: Ps = 1/(1 + eb), where ‘Ps’ is the probability of survival and ‘e = 2.7183 (base of Napierian logarithms) and b = b0 + b1 (RTS) + b2 (ISS) + b3 (A), where b0, b1, b2 and b3 are weights derived from study data; RTS is the Revised Trauma Score on admission and ISS is the Injury Severity Score; and A = 1 if patient’s age is over 54 years and A = 0 if patient age is less than 54 years. Recognizing the difference between blunt and penetrating injury, researchers developed separate models for each mechanism.

TRISS quickly became the standard methodology for outcome assessment. It appears to be valid for both adult and pediatric patients but has been criticized because (1) it is only moderately accurate for predicting survival; (2) problems already are noted with the ISS (e.g., inhomogeneity, inability to account for multiple injuries to the same body region); (3) no information is incorporated related to preexisting conditions (e.g., cardiac disease, chronic obstructive pulmonary disease, cirrhosis); (4) similar to the RTS, it cannot include intubated patients because respiratory rate and verbal responses are not obtainable; and (5) it does not incorporate an accounting for patient mix (making comparisons between trauma centers difficult).[34], [35]

In an attempt to address these shortcomings, Champion et al introduced A Severity Characterization of Trauma (ASCOT) in 1990 as an improvement over TRISS.36 ASCOT uses the AP in place of the ISS and categorizes age into deciles. In addition, changes include the individual components of the coded RTS that were included as independent predictors in the final logistic regression model. Despite these modifications, the predictive performance of ASCOT is only marginally better than the ISS. This, coupled with the complex nature of the AP component, has discouraged widespread acceptance of ASCOT.

The measurement and documentation of injury severity are prerequisites for the development, evaluation and improvement of trauma care systems, as well as for the advancement of public policy for control of injuries. The relationship between injury severity and survival, expressed through trauma scoring, is integral to every phase of the spectrum of trauma care. The scarcity of injury data on the estimated 50% of fatally injured persons who die at the scene of accident or in transit continues to represent a real information gap. Demographics and injury information on these victims, if it exists, is found only in autopsy reports. Lack of uniform system of death investigation sometimes renders this data incomplete and not easily accessible.37

Every trauma service should review the process and outcome of patient care on monthly basis as recommended by the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) mandated reviews of quality improvement and utilization.38 Indices of severity and audit criteria are of value in identifying aberrant outcomes or potential problems in patient care, and in prompting remedial action. Strategies for quality improvement in trauma care should involve the policy or process of managing the major trauma victim, including:

  • 1.

    Re-emphasis on certain basic tenets or doctrines of trauma-patient care.

  • 2.

    Introduction to or emphasis on the advanced trauma life support course.

  • 3.

    Emphasis on triage in pre-hospital treatment protocols.

  • 4.

    Introduction of inter-hospital triage guidelines.

  • 5.

    Introduction of guidelines for rehabilitative care.

  • 6.

    Introduction of guidelines for massive blood transfusion.

  • 7.

    Introduction of institutional policy guidelines for discontinuing resuscitation.

  • 8.

    Regional trauma care systems should perform at least annual reviews of all pre-hospital and in-hospital, trauma center, and non-trauma-center care and of the autopsy results on all trauma-related deaths.

Many hospitals have found that a trauma registry is an efficient method for storing and analyzing data on trauma patients. Basic data elements in the registry should include demographics (patient’s age, sex, injury cause and injury type), information on pre-hospital care, data on the process of acute care (treatment, major surgical procedures, identification of the attending service, response time), clinical items (sequential measurements of RTS and blood alcohol level), final anatomic diagnosis (from examination, X-rays/CT, surgery or autopsy), and outcome data (discharge status, hospital and ICU length of stay, complications and functional disability at discharge).39 Trauma registries must be founded on complete, accurate data that includes explicit and accurate descriptions of physiologic derangement and injuries as well as accurate injury coding based on ICD-9-CM codes, by the clinicians in medical record.40

Section snippets

Conclusion

Fundamentally, trauma outcome prediction is a multivariate problem. Researchers use multiple independent variables (e.g., age, injury severity) to predict the dependent variable (or outcome). Most physicians are familiar with the simplest form of regression analysis – simple linear regression, which describes the linear relationship between 2 variables. Multiple regression is an extension of this technique, in which more than one independent variable is used to describe a single, continuous

References (40)

  • H.R. Champion et al.

    A revision of the Trauma score

    J Trauma

    (1989)
  • H.R. Champion et al.

    A new characterization of injury severity

    J Trauma

    (1990)
  • W.A. Knaus et al.

    APACHE – Acute physiology and chronic health evaluation: a physiologically based classification system

    Crit Care Med

    (1981)
  • W.A. Knaus et al.

    APACHE – II: a severity of disease classification system

    Crit Care Med

    (1985)
  • O.J. McAnena et al.

    Invalidation of the APACHE II scoring system for patients with acute trauma

    J Trauma

    (1992)
  • DeHaven H. The site, frequency and dangerousness of injury sustained by 800 survivors of light plane accidents. New...
  • Ryan GA, Gassett JW. A quantitative scale of impact injury. Publication CAL No. VT-1823-R34. Buffalo: Cornell...
  • The Abbreviated Injury Scale –1985 Revision. Des Plaines, II, Association for the Advancement of Automotive...
  • E.J. MacKenzie et al.

    Classifying trauma severity based on hospital discharge diagnosis. Validation of an ICD-9-CM to AIS-85 conversion table

    Med Care

    (1989)
  • W.S. Copes et al.

    Progress in characterizing anatomic injury

    J Trauma

    (1990)
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