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

IF 4.7 2区医学 Q1 RADIOLOGY, NUCLEAR MEDICINE & MEDICAL IMAGING

European Radiology Pub Date : 2025-08-01 Epub Date: 2025-01-31 DOI:10.1007/s00330-025-11384-9

Jan C van Ditshuizen, Menco J S Niemeyer, Esther M M Van Lieshout, Dennis Den Hartog, Jan-Jaap Visser, Karlijn J P van Wessem, Michiel H J Verhofstad

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引用次数: 0

Abstract

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.

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根据标准化的放射学模板，用简略的损伤量表对创伤性脑损伤进行编码，将改善创伤人群的分类。

简介：损伤编码与简略伤害量表（AIS）是基准，创伤登记和研究的重要元素。目的：比较使用或不使用标准化放射学模板的AIS编码的创伤性脑损伤（TBI）严重程度。方法：回顾性双中心队列研究，纳入2011年至2016年间入住重症监护的年龄≥18岁的孤立性TBI患者。编码人员对TBI进行重新编码以符合AIS，神经放射科医生根据AIS编码的标准化放射学模板对ct -脑成像进行重新评估。结果：共纳入560例患者（中位年龄57岁，37%为女性）。与未编码相比，使用标准化放射模板编码TBI的AIS患者MAIS≥4的比例更高（n = 456（81.4%）和n = 374(66.8%)）。p结论：使用基于标准化放射模板的AIS编码TBI的AIS头部代码丢失较少，AIS头部代码更详细，并且更多的患者被归类为“严重创伤”。放射学报告是使用简易损伤量表（AIS）进行损伤编码的重要来源，但往往不够具体。基于AIS的标准化放射学报告模板导致更详细的AIS头部代码和更多的患者被归类为重大创伤。基于标准化放射学模板的AIS损伤编码将改善急性卫生保健环境中医疗信息的交换和创伤人群的分类。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

European Radiology 医学-核医学

CiteScore

11.60

自引率

8.50%

发文量

874

审稿时长

2-4 weeks

期刊介绍： European Radiology (ER) continuously updates scientific knowledge in radiology by publication of strong original articles and state-of-the-art reviews written by leading radiologists. A well balanced combination of review articles, original papers, short communications from European radiological congresses and information on society matters makes ER an indispensable source for current information in this field. This is the Journal of the European Society of Radiology, and the official journal of a number of societies. From 2004-2008 supplements to European Radiology were published under its companion, European Radiology Supplements, ISSN 1613-3749.