Coding traumatic brain injury with the abbreviated injury scale following a standardised radiologic template will improve classification of trauma populations.

INTRODUCTION

Injury coding with the Abbreviated Injury Scale (AIS) is an important element for benchmarking, trauma registries and research.

OBJECTIVE

To compare the severity of traumatic brain injury (TBI) coding derived from the AIS with or without the use of a standardised radiologic template.

METHODS

A retrospective two-centre cohort study including patients aged ≥ 18 years with isolated TBI admitted to an intensive care between 2011 and 2016 was conducted. TBI was re-coded to conform the AIS by coders, and CT-brain imaging was reassessed by a neuro-radiologist following a standardised radiologic template from which AIS codes were derived.

RESULTS

A total of 560 patients were included (median age 57, 37% female). The percentage of MAIS ≥ 4 and major trauma was higher when AIS coding for TBI was derived from a standardised radiologic template vs. coding without (n = 456 (81.4%) and n = 374 (66.8%), p < 0.001; n = 441 (78.8%) and n = 352 (62.9%), p < 0.001, respectively). There was an inter-centre difference in the proportion of MAIS ≥ 4 re-coded without a standardised radiologic template (n = 212 (68.2%) and n = 140 (56.2%), p = 0.004), and no difference when re-coded with the template (n = 251 (80.7%) and n = 190 (76.3%), p = 0.206).

CONCLUSION

Coding TBI with AIS based on a standardised radiologic template results in fewer missed AIS head codes, more detailed AIS head codes, and more patients classified as 'major trauma'.

KEY POINTS: Question Radiologic reports are an important source for injury coding with the abbreviated injury scale (AIS) and are often not sufficiently specific. Findings An AIS-based standardised radiologic template for reporting resulted in more detailed AIS head codes and more patients classified as major trauma. Clinical relevance Injury coding with the AIS based on a standardised radiologic template will improve exchanging medical information in the acute health care setting and classification of trauma populations.