|CDC's Short Version of the ICECI - International Classification of External Causes of Injury - A Pilot Test (Centers for Disease Control and Prevention, 2000, 30 p.)|
This pilot study suggests that CDCs short ICECI can be a useful surveillance tool for capturing external-cause-of-injury data on hospital emergency department visits through the use of medical records. The current version needs to be revised and refined to improve its utility and efficiency. However, this pilot study did demonstrate that with the use of this coding system in the United States, valid and reliable data can be captured in a timely manner. Further development of CDCs short ICECI as an ED surveillance tool will need to consider compatibility with the full ICECI, ICD-10, and ICD-10-CM coding systems. CDCs short ICECI has code sets for each of the fundamental components of these systems, including work-relatedness, locale of the injury incident, activity at the time of injury, intent of injury, and mechanism of injury. It also has components to capture data on safety equipment use, consumer products involved, and provides a narrative description of the injury circumstances. Information in the narrative could be used for more detailed coding that uses the full ICECI and the ICD coding systems.
Based on data from a 1997 pilot study on expanding NEISS to capture all injuries, we estimate that for every injury death in the United States, approximately 190 injured persons are treated and released from hospital emergency departments.7 Interest in having a surveillance tool for timely capture of external-cause-of-injury data from hospital ED records to establish state and local injury morbidity data systems is increasing. CDCs short ICECI could be a useful tool for obtaining population-based data on injury-related ED visits in state and local jurisdictions.
This pilot study of CDCs short ICECI brought to light a number of aspects that are relevant to future development and implementation of the full ICECI and various short versions of the ICECI for use in injury morbidity data systems. Below is a discussion of each of these aspects based on our findings:
1. Protocols and instruction manuals for orientation and training of coders and for ongoing quality assurance activities are essential to ensuring valid and complete coding of external-cause-of-injury data.
Kappa statistics for the Massachusetts ED-SCIP substudy were consistently higher than those for the NEISS substudy. This difference in kappas could be attributed to a number of factors: coders in the Massachusetts ED-SCIP substudy had the training material in advance, took part in a substantially enhanced training session, and were subject to an ongoing quality assurance effort. A concerted effort was made to provide extensive up-front training and orientation and ongoing feedback to coders in the Massachusetts ED-SCIP substudy. This effort, including an 8-hour training session, a prepilot test at two hospitals, ongoing com-munication by conference call, and a site visit by CDC coinvesti-gators, resulted in excellent agreement for code sets among coders and between the gold standard and each coder for the case scenarios and hospital ED cases.
A detailed training module with practice case scenarios was used to instruct coders to properly apply coding rules and definitions. After the pilot study, coders commented that the training module would have been more effective if it had included practice exercises using actual ED records followed by immediate feedback from coinvestigators. Prepilot visits by coders to two Massachusetts ED-SCIP hospitals helped to reveal ambiguities in the coding guidelines. Follow-up discussions between CDC coinvestigators and the MA coders helped to clarify coding rules and definitions before proceeding to other study hospitals.
2. A detailed, user-friendly coding manual is needed to provide the case definition, coding rules and definitions, and guiding principles for coding.
A reference manual with clear definitions and detailed examples of inclusions and exclusions for each data element and associated response categories is essential for coders. This set of standard coding guidelines should be readily available to each coder to ensure consistency and uniformity in how codes are assigned. In addition, coders must refer to these documents often; otherwise, coders could have a tendency to base their coding decisions on their own intuitions, opinions, or preconceived notions.
In the pilot study, coders were given a detailed manual with coding rules and definitions, inclusions, and exclusions for use as a reference during the study. Whenever coders questioned how to code a case, they were instructed to refer to the manual. Then, if the manual was unclear, the CDC coinvestigators would clarify and interpret the coding rules and definitions. To maintain consistency in coding, coders were then notified about these coding decisions. Changes to the coding rules and definitions were then noted in the manual.
3. The data collection instrument should facilitate efficiency in the collection and processing of ICECI data from medical records; electronic versions are needed.
The check-box type format of the short ICECI data collection form worked well in recording and coding external-cause-of-injury data using medical records. The average time to code all short ICECI data elements from a medical record was about 3 to 4 minutes. However, coders sometimes failed to code fields or to follow skip patterns. These problems could be avoided by developing a computer data entry screen with drop-down windows revealing code choices. Selections could then easily be made by the click of a computer mouse. Automatic skip patterns and range checks could be programmed into this system to minimize recording errors. The data could be handled entirely electronically to perform additional checks for completeness and consistency. These electronic data could then be passed to a data base for further quality assurance analysis and feedback to the coders. Final edited data could be prepared for timely analysis and reporting.
CDC is currently working with CPSC to expand NEISS to capture all types and causes of injuries treated in hospital EDs. The new system is called the NEISS All Injury Program. CPSC is developing such an automated system for capturing data on an expected 600,000 injury-related ED cases annually from a nationally representative sample of 100 U.S. hospital EDs. NEISS is capturing data on intent of injury and mechanism of injury in addition to the routine injury-related data elements historically collected in NEISS (i.e., age, sex, race/ethnicity, diagnosis, primary body part affected, locale of injury incident, work-relatedness, consumer products, disposition at ED discharge, and a narrative description of the diagnosis and circumstances of the injury incident). Intent of injury and mechanism of injury were derived as modified data elements from CDCs short ICECI.
4. Coding the mechanism of injury should be limited to two mechanisms: the precipitating cause (i.e., the cause that initiated the chain of events leading to the injury) and the immediate cause of injury (i.e., the direct cause of the most severe injury being treated).
Coding practices of NEISS and MA coders varied substantially in the number of ED cases that were assigned more than one mechanism of injury. NEISS coders were much more likely to use more than one mechanism. The data collection form was set up to capture as many mechanisms as applicable. Sometimes coders assigned several mechanism codes to account for multiple injuries noted in the hospital ED record, making it difficult to interpret the data. This problem could be eliminated by specifying the following rules:
Code the intent and mechanism of injury for the most severe injury being treated. This is usually the injury indicated as the principal diagnosis by the attending physician or other health care provider.
Code only two mechanisms of injury: the precipitating cause (i.e., the mechanism that initiated the chain of events that led to the injury) and the immediate cause (i.e., the mechanism directly responsible for the most severe injury being treated).
We plan to modify the short ICECI data collection form to accommodate these rules. The NEISS All Injury Program is using these rules to code intent and mechanism of injury.
5. A narrative description of the injury incident should be included as an essential ICECI data element. Narratives can be very helpful in quality assurance reviews of the assigned codes and for capturing further details about injury-related circumstances.
A narrative description of the injury incident should be an essential component of the full version and all short versions of the ICECI. We found that these brief descriptions of the injury circumstances were invaluable in reviewing how coding rules and definitions were applied by coders and allowed us to provide timely feedback to the coders. The narratives can also be useful to researchers who need more specific details about the causes and circumstances of the injury incident.
6. Training and orientation of hospital medical staff is imperative to improve information on intent of injury, mechanism of injury and other injury-related circumstances provided in the medical record.
To maintain objectivity in coding for the pilot study, coders were instructed to record information only if it was provided in the medical record. Therefore, coders were often not able to capture data on locale of the injury incident, activity at the time of injury, and other circumstances because the information was not provided in the medical record. Also, infor-mation provided in EMS reports, nurses notes, and doctors notes were sometimes in disagreement. Research needs to be conducted on methods to improve these data sources. EMS technicians, nurses, and doctors need to be educated about their important role in obtaining high-quality external-cause-of-injury data.
7. Proposed short ICECI data elements and code sets should be cross-walked to the full ICECI, ICD-10, and ICD-10-CM code sets as a measure of compatibility and cross-reference. The full ICECI should serve as a standard coding system for all proposed short ICECIs.
All proposed short ICECI coding systems must map to the full ICECI data elements and code sets. In this way, the full ICECI can serve as the standard coding system for all short ICECIs. A process is underway for further development of the ICECI for use in the ICD coding framework. Therefore, proposed short ICECIs also need to consider compatibility with ICD-10. CDCs short ICECI has been cross-walked to the current version of the full ICECI and to the ICD-10. We also plan to cross-walk the short ICECI to ICD-10-CM once this classification system has been finalized in the United States.