TEMR

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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 National Center
for Injury Prevention and Control, Centers for
Disease Control and Prevention, Atlanta, GA USA
THE ISRAELI CENTER FOR
TEMR
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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
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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

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Matrix Reminder
Motivation for building the matrix
ICD 9-CM CODES 800-995
Sorted by nature of injury
Detecting injuries by body region requires
collating codes across chapters
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Matrix Reminder
Motivation for building the matrix
ICD 9-CM CODES 800-995
nature of injury
body region
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Matrix Reminder
The Matrix structure
Nature of injury
Body Region
ICD-9-CM injury codes

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Matrix Reminder
Nature of injury (Columns) are based on Sequence
of codes in ICD-9-CM codebook
Body Region (Rows) are based on
Anatomic subgroups High Incidence Variability in
Outcome Difference in health care utilization
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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.
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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.
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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.
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Specific Agreements,
ICE meeting, Washington DC, 2001
A detailed extremity module needs to be added.
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Specific Agreements,
ICE meeting, Washington DC, 2001
Amputations will be separated from open wound.
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Specific Agreements,
ICE meeting, Washington DC, 2001
Superficial injuries and contusions will be
joined.
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Specific Agreements,
ICE meeting, Washington DC, 2001
The matrix has a row for system wide
conditions enabling use for non traumatic
injuries.
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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.
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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.
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Original Two-row TBI definition
(created by Vita Barell)
Definite TBI
Possible TBI
Injuries with no mention of intracranial injury
or with loss of consciousness of less than one
hour.
injuries with a specific mention of intracranial
injury or loss of consciousness of more 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)

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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
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Three-row TBI definition
Definite TBI Type 1
Possible TBI
Definite TBI Type 2
Injuries with no mention of intracranial injury
or with no loss of consciousness
Injuries with a recorded evidence of an
intracranial injury or a moderate or prolonged
loss of consciousness (loc).
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.
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• 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
Possible TBI
Definite TBI Type 2
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.
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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
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Three-row TBI
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Traumatic Brain Injury
1997-2000 ITR data
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Megan
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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
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Summarizing multiple injuries Motivation

• 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.

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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.
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Adam
multiple diagnoses
Skull fracture, with an intracranial injury Flail
chest
Jo
Fractured ankle
Single diagnosis
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Single diagnosis
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Summary report
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Summarizing multiple injury diagnostic data
multiple diagnoses patients
single diagnosis patients
Select one diagnosis
first listed/major
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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
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Distribution of injuries by body region
Single or Multiple?
Population ITR Road Traffic Accidents,
1997-2000, total of 17459 patients
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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

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Summarizing multiple injury diagnostic data
multiple diagnoses patients
Select one diagnosis
first listed/major
Create injury profile
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Creating injury profiles
Divide body regions into groups

• Head and Neck H
• Spine and Back S
• Torso T
• Extremities E
• Other O

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Frequency distribution of groups

• Legend
• Head and Neck H
• Spine and Back S
• Torso T
• Extremities E
• Other multiple O

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Characterizing diagnostic groups

• ISS
• Inpatient death
• Duration of inpatient stay
• External cause of injury
• etc.

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Duration of Inpatient stay by diagnostic group
combinations

• Legend
• Head and Neck H
• Spine and Back S
• Torso T
• Extremities E
• Other Multiple O

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Median
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Multiple injuries
Single injuries
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Inpatient death by diagnostic group combinations
n
3760
Single injuries
417
4346
2010
1935
Multiple injuries
922
1319
1121
Inpatient death
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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
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Problems, Limitations and Unresolved issues
Definition of multiple
Number of combinations
Severity measures
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Thanks for your attention