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PEDIATRICS Vol. 103 No. 2 February 1999, pp. 524-526
AMERICAN ACADEMY OF PEDIATRICS:
The Hospital Record of the Injured Child and the Need for
External Cause-of-Injury Codes
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ABSTRACT |
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Recommendation
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Proper record-keeping of emergency department visits and hospitalizations of injured children is vital for appropriate patient management. Determination and documentation of the circumstances surrounding the injury event are essential. This information not only is the basis for preventive counseling, but also provides clues about how similar injuries in other youth can be avoided. The hospital records have an important secondary purpose; namely, if sufficient information about the cause and mechanism of injury is documented, it can be subsequently coded, electronically compiled, and retrieved later to provide an epidemiologic profile of the injury, the first step in prevention at the population level. To be of greatest use, hospital records should indicate the "who, what, when, where, why, and how" of the injury occurrence and whether protective equipment (eg, a seat belt) was used. The pediatrician has two important roles in this area: to document fully the injury event and to advocate the use of standardized external cause-of-injury codes, which allow such data to be compiled and analyzed.
In 1996, injuries accounted for 64% of deaths in children
and teenagers 1 to 19 years of age.1 The National Center for Health Statistics estimates that for every injury death occurring in the United States, about 18 hospitalizations and 250 emergency department visits occur for people of all ages.2
Information about the external cause of injury fatalities, in general,
is more accurate and precise than is information about the external cause of nonfatal injuries.
Several problems exist with nonfatal injury data. First, national
morbidity estimates are based on a representative statistical sample of
the US population. The data cannot be disaggregated to the state or
local level. Second, national estimates of morbidity data are not
always reported in a timely manner. Third, not all states have
statewide hospital discharge data systems that actively gather
information concerning the specific external cause of injury. In
communities without ready access to local cause-specific injury data
that are coded, hospital administrators, public health officials, and
safety advocates are impeded in their attempts to prioritize and plan
appropriate services for their communities, such as emergency medical
services, acute and rehabilitative inpatient and outpatient services,
and primary prevention activities. Lack of local data makes it
difficult to identify high-risk groups and environmental hazards that
are specific to a given community. This in turn impedes efforts to
develop and implement targeted, population-specific prevention
programs.
The first logical step for local injury programs should be a review of
local morbidity data. Ideally these data should be available in a
readily accessible and electronic form. Data must be of high quality,
with ascertainment of all cases or a statistically representative
sample of all cases.
Three types of ongoing injury surveillance systems are 1) the
national vital statistics registry, 2) hospital discharge data systems,
and 3) local emergency department data systems. The national mortality
reporting system (vital statistics) serves as a model because data
collection, coding, compilation, and reporting have been in use longer
and are more refined than are morbidity-based systems. Vital records
are collected by each county and state health department by compiling
data from death certificates. The underlying and contributing causes of
death, as certified by the physician, are coded (as of January 1, 1999)
using the International Classification of Diseases, 10th
revision (ICD-10).3 Under this system (and its
predecessor, ICD-9),4 fatal injuries can
receive two types of codes: an external cause-of-injury code and one or
more diagnosis codes. The external cause-of-injury code specifies both
the mechanism (eg, motor vehicle, fire, fall) and the intent
(unintentional, suicide, homicide, or undetermined). The diagnosis code
specifies the anatomic site and nature of the injury; for example, a
skull fracture or an open wound of the chest.
In ICD-9 (effective 1979-1998), the codes for external
causes of injury are referred to as E-codes. The nature of injury codes were often referred to as "N-codes." With ICD-10,
however, the use of the term "E-code" should be replaced with
"external cause-of-injury" code because the referent chapters now
are prefaced with the letters "V," "W," "X," and "Y"
and the codes range from V01 to Y89. Similarly in
ICD-10, the nature of injury codes are prefaced with the
letters "S" and "T" and codes range from S00 to T98.
A comparable classification system exists for coding nonfatal injuries,
known as the Clinical Modification of the ICD (ICD CM).5 Currently, the 9th revision is in effect.
ICD-10 CM will most likely become effective after
October 1, 2001. ICD-10 CM will likely have twice
the number of external cause-of-injury codes as the ICD-9
CM, allowing for more precise and specific codes.
The combined use of diagnosis and external cause-of-injury codes is a
highly specific way to classify injuries. For example, a facial
fracture resulting from a bicycle injury can be distinguished from a
similar fracture resulting from a fight. Information about the
diagnosis, cause, and place of occurrence is needed to plan effective
injury-prevention programs.
Two major problems exist with current morbidity-reporting systems.
First, documentation of the injury event in the hospital record often
is incomplete or even absent. For example, physicians and nurses
treating a patient in the emergency department or hospital may note
that a playground injury occurred but neglect to define the particular
circumstances of the injury, eg, whether the injury was sustained
because the child fell from a height, the distance of the fall, the
type of equipment involved, the surface on to which the child fell,
whether anyone else was present or involved in the occurrence, and
whether the playground was in a schoolyard, at a private residence, or
in a public recreation area. The record does not indicate the "who,
what, when, where, why, and how" of the injury occurrence, probably
because the caregivers focus their efforts on the immediate treatment
of the injury. The hospital record should document key patient
identification data such as the child's name, date of birth, sex,
race, ethnicity, address, and telephone number. To maximize the use of
hospital records, physicians, nurses, and other health care
professionals should record the time, place, nature, and mechanism of
injury; whether the injury was inflicted intentionally; contributing
risk factors (eg, the use of alcohol or other drugs); whether
protective equipment was used; whether any other persons were injured
in the event; and whether the injury was work-related. If the primary
(intake) record does not include such information, reconstructing the
event later is difficult, even by direct interview.
The second problem is that medical records department personnel may not
assign the hospital record an external cause-of-injury code. As of
October 1997, 42 states had statewide hospital discharge data systems,
but only 23 had mandatory external cause-of-injury code reporting for
injury-related hospital discharges.6 Based on a 1996 national survey of emergency department visits by patients of all ages,
it is estimated that >34 million injury-related visits were made that
year.7 However, only nine states currently have mandates
that require the reporting of external cause-of-injury codes for
injury-related emergency department visits.6 Voluntary
reporting by external cause-of-injury code is incomplete and possibly
biased by the number of diagnostic codes assigned; patient
characteristics (eg, age, sex, or race); the nature and severity of the
injury; and the type of hospital (eg, size, location).8 As
a result, compilations based on voluntary external cause-of-injury
coding may not reflect all injuries accurately. Mandatory reporting of
external cause-of-injury codes would improve the quality of the
estimates of external causes of injury morbidity in the United States.
Administrators of hospitals and managed care organizations
can expect to gain several direct benefits from universal reporting of
injuries by external cause-of-injury code. The improvement in
population-based case ascertainment and accuracy if reporting is
implemented by all hospitals would allow for planning,
implementation, and evaluation of acute care and rehabilitation
services (eg, bed, staffing, and emergency department needs) and would
provide data needed to assess the financial effect of different types of injuries. Public health officials would have the necessary data to
identify risk factors and high-risk populations to target primary
prevention programs and to provide improved prehospital care.
Pediatricians and other advocates would learn which injury issues
warrant the most attention in their community. For example, the Indian
Health Service, which has included external cause-of-injury codes in
its hospital discharge data for >20 years, combined such information
with police reports to identify a narrow stretch of roadway in
Cherokee, NC, where motor vehicle-pedestrian collisions were occurring
at a high rate. The roadway was modified, thereby virtually eliminating
the problem.9 Improved external cause-of-injury code data
would help state and federal injury experts track national and state
objectives for injury prevention according to goals established by
Healthy People 2000.10 Policy-makers could
study more readily the effects of local and state injury-prevention
legislation, such as laws mandating the installation of residential
smoke detectors, use of safety belts and motorcycle helmets, and the
recision of the 55-mph speed limit. Mandatory reporting of external
cause-of-injury codes for hospital discharge data has been endorsed by
the Council of State and Territorial Epidemiologists, the American
Public Health Association, the American College of Emergency Medicine,
the National Center for Health Statistics, the National Center for
Injury Prevention and Control of the Centers for Disease Control and
Prevention,11 and the American Academy of
Pediatrics,12 as well as many state and local health
departments.
The administrative costs associated with the external cause-of-injury
coding of inpatient hospital records are relatively small.13 It takes Proper coding of injuries is critical for establishing priorities
for child and adolescent injury-prevention programs. Pediatricians can
serve their patients and communities well by documenting the injury
event thoroughly in the hospital record and by encouraging the expanded
reporting of external cause-of-injury codes. The American Academy
of Pediatrics recommends the following specific steps:
OVERVIEW
INJURY SURVEILLANCE SYSTEMS
PROBLEMS WITH CURRENT MORBIDITY-REPORTING SYSTEMS
BENEFITS TO BE GAINED
3 minutes to assign an external
cause-of-injury code to each injury record and, because only 9% of
hospital discharges are injury-related,14 most inpatient
records would not require external cause-of-injury coding. Also,
because many large hospitals already assign external cause-of-injury
codes (by mandate or voluntarily) to the hospital admission records,
the additional cost of external cause-of-injury coding all hospital
discharge records may not be excessive.
RECOMMENDATIONS
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Abstract
Recommendation
References
COMMITTEE ON INJURY AND POISON PREVENTION, 1998-1999
Murray L. Katcher, MD, PhD, Chairperson
Phyllis Agran, MD, MPH
Danielle Laraque, MD
Susan H. Pollack, MD
Gary A. Smith, MD, DrPH
Howard R. Spivak, MD
Milton Tenenbein, MD
Susan B. Tully, MD
LIAISON REPRESENTATIVES
Ruth A. Brenner, MD, MPH
National Institute of Child Health and Human Development
Stephanie Bryn, MPH
Maternal and Child Health Bureau
Cheryl Neverman
United States Department of Transportation
Richard A. Schieber, MD, MPH
Centers for Disease Control and Prevention
Richard Stanwick, MD
Canadian Pediatric Society
Deborah Tinsworth
United States Consumer Product Safety Commission
William P. Tully, MD
Pediatric Orthopaedic Society of North America
SECTION LIAISONS
Marilyn Bull, MD
Section on Injury and Poison Prevention
Victor Garcia, MD
Section on Surgery
CONSULTANTS
J. Lee Annest, PhD
Robert Brewer, MD, MPH
Joseph Sniezek, MD, MPH
National Center for Injury Prevention and Control, Centers for
Disease Control and Prevention
Lois Fingerhut, MA
Donna Pickett, RRA, MPH
National Center for Health Statistics, Centers for Disease
Control and Prevention
Susan S. Gallagher, MPH
Education Development Center
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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REFERENCES |
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- National Center for Health Statistics. Public use data tapes 1996. Compressed Mortality File. Hyattsville, MD: US Dept of Health and Human Services; 1998
- Fingerhut LA, Warner M. Injury Chart Book. Health, United States, 1996-97. Hyattsville, MD: National Center for Health Statistics; 1997
- World Health Organization. World Health Classification. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 9th Rev. Geneva, Switzerland: World Health Organization; 1977
- World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th Rev. Geneva, Switzerland: World Health Organization; 1992
- US Dept of Health and Human Services. International Classification of Diseases. 9th Rev. Clinical Modifications. 6th Ed. Washington, DC: US Dept of Health and Human Services. Public Health Service, Health Care Financing Administration, DHHS Publication No (PHS) 97-120; 1997
- American Public Health Association, Data Committee of the Injury Control and Emergency Health Services Section. How States Are Collecting and Using Cause of Injury Data. San Francisco, CA: American Public Health Association; 1998
- McCaig LF, Stussman BJ. National hospital ambulatory medical care survey: 1996 emergency department summary. In: Advance Data from Vital and Health Statistics. Hyattsville, MD: Centers for Disease Control and Prevention, US Public Health Service, US Dept of Health and Human Services; No. 293; 1997
- MacKenzie EJ. Techniques of injury surveillance: use of uniform hospital-discharge data. In: Haller JA Jr, ed. Emergency Medical Services for Children. Report of the 97th Ross Conference on Pediatric Research. Columbus, OH: Ross Laboratories; 1989
- National Committee on Vital and Health Statistics Subcommittee on Ambulatory and Hospital Care Statistics. Report on the Need to Collect External Cause-of-Injury Codes in Hospital Discharge Data. Hyattsville, MD: US Dept of Health and Human Services, Public Health Service; National Center for Health Statistics Working Paper Series; No. 38; 1991
- Healthy People 2000: Midcourse Review and 1995 Revisions. Hyattsville, MD: US Dept of Health and Human Services, Public Health Service; 1995
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Sniezek JE,
Finklea JF,
Graitcer PL
Injury coding and hospital discharge data.
JAMA.
1989;
262:2270-2272
[Abstract/Free Full Text] - American Academy of Pediatrics, Committee on Injury and Poison Prevention. Hospital discharge data on injury: the need for E codes. AAP News. March 1992; p 17
- The Friedrich Group. Estimated Costs for State-wide E-code Reporting Using the Commission Hospital Abstract Reporting System. Olympia, WA: Dept of Social and Health Services, Disease Prevention and Control; 1988
- Hall MJ, Owings MF. Hospitalizations for injury and poisoning in the United States, 1991. In: Advance Data From Vital and Health Statistics. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, US Public Health Service, Dept of Health and Human Services. No. 252; 1994
Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
Statements of reaffirmation:
- AAP Publications Retired and Reaffirmed
- American Academy of Pediatrics
Pediatrics 2005 116: 796.[Extract] [Full Text] [PDF]
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AAP Publications Retired and Reaffirmed
Pediatrics 2009 123: 188.[Extract] [Full Text] [PDF]
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