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This study explores the issues related to selecting a main injury from multiple causes of death, specifically focusing on head and chest injuries. It suggests the use of the Multiple Injury Profile concept to determine the main injury and recommends the creation of new codes for specific injury combinations.
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Selecting a main injury frommultiple causes of death“ISSUES” ICE on Injury Statistics, Sept 2006 Limor Aharonson-Daniel , PhD Israel National Center for Trauma and Emergency Medicine Research Gertner Institute for Epidemiology and Health Policy Research for ICE on Injury Statistics working group
Head & Chest injury chest Head Head Chest 3. Select from among remaining injuries using severity ranking (e.g. Precedence list). Is “Head” = (“Head & Chest”)? Is “Chest” = (“Head & Chest”)? yes no Select “head & chest” Good
For these cases, we should consider applying Multiple Injury Profile Concepts • The population of patient injuries: • Patients with - • One injury only • Multiple where one injury has clear precedence in causing death • Multiple where no ‘one injury’ has precedence 4.6% of patients in the ‘TBI row only’ died 6.5% of patients in the ‘chest row only’ died 14.7% of patients in both rows died
The study simulated selection by precedence and showed what proportion of each body region was: Isolated, Selected by precedence list, would be additional if multiple injuries were used rather than primary injury. • Differences were mostly in external and face => minor • In Head, Chest and Abdomen the proportion of diagnoses ranked “in” by precedence list is larger than their proportion by isolated injuries. • Based on this data, I thought we should consider a multiple code: • A code for Head & chest • A code for Head & Abdomen • Elimination of trivial injuries and superficial injuries should prevail as suggested in current MRG guidelines
Arguments against using a new multiple code • Would be an exception to the guideline/principles of the ICD • combination code would be less specific and if available it might be chosen over the individual codes in the data collection phase
Arguments against selecting a main injury by precedence • We lose information • Sometimes precedence just can’t be forced: • Certain combinations are “killers” while their components are not - • Selecting in these cases creates a false presentation • SRRs are affected by additional injuries*
Possible solution: Create an indicator / flag as an optional addition to ICD codes. A tick mark that could be the equivalent of “the first two authors contributed equally to this manuscript” meaning “this case is not suitable for selection of a primary cause use alternative methods”. Arguments for this approach: It would enable applying multiple injury approach where needed It would not change current coding guidelines It can serve as a “warning” where this is all you will get
Method for eliminating unspecified injuries Example: S26.9 Injury of heart, unspecified Injuries occurring simultaneously (i.e. sequential order is not inherent) Consideration of external cause in determining main injury if indicates something about nature Example: External cause: car crash Main injury: poisoning? ICE working group concerns with current recommendations ☺ MIP Example: Car crash with multiple specified injuries on each line of death certificate ☺ poisonings, drowning, suffocation and fire/flames.