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Creating an Injury Surveillance System for Indian Country

Designing and Implementing Surveillance Systems in Indian Country

Introduction

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Welcome to Designing and Implementing Injury Surveillance Systems in Indian Country. In this course you will explore the steps to creating an injury surveillance system. Throughout the course, you should feel free to ask questions, share your experiences and offer examples that help illustrate the concepts or points being made.

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Introductions

Who are you?

Where are you from?

What do you do?

Do you have any experience in injury surveillance?

Introduction

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Instructor and participants will introduce themselves.

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Introduction

Course Learning Objectives

Review the concepts and framework of injury prevention

Learn to assess injury data sources and use data to describe the injury problem

Learn how to build partnerships or a coalition to support the injury surveillance system

Introduction

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These are the learning objectives that will be covered in this course. Each objectives corresponds to one of 7 steps to developing an injury surveillance system. The first three steps, shown here, are primarily a review of information and concepts covered in IHS Level 2 Intermediate Injury Prevention Training.

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Course Learning Objectives

Learn how to determine the appropriate methodology for the surveillance system

Learn how to define and develop an analysis plan for the surveillance data

Learn to use injury surveillance data to inform injury prevention

Learn how to define an evaluation plan for the surveillance system and monitor prevention activities

Introduction

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Introduction

About the Course Manual

Pre-test on Page 3

Post-test Page 107

Larger versions of charts in Appendix 6

Introduction

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Introduction

What is an Injury

Surveillance System?

Introduction

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Note for Instructor: Ask the class to answer this question in their own words. A definition is offered on the next slide.

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Introduction

What is an Injury Surveillance System?

Ongoing systematic collection, analysis and interpretation of injury data for use in planning, implementing and evaluating prevention activities

Injury prevention programs use the data to assess the need for new policies or programs and to evaluate the effectiveness of those that already exist

Introduction

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The definition on the slide is from The Safe States Working Group

If you can, share an example of a successful injury surveillance system you know of or have been involved in. What was the goal of the system? What made it successful?

For examples of other successful injury surveillance systems in Indian Country see Appendix 1 or check out the IHS Primary Care Provider Injury Special Issues on Injury Prevention, July 2007 (http://www.ihs.gov/injuryprevention/Documents/PROV0707.pdf) and September 2007 (http://www.ihs.gov/provider/documents/2000_2009/PROV0907.pdf)

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Introduction

Questions for Class

Why do you want to develop an injury surveillance system?

What do you plan to do with the data you collect?

Introduction

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Introduction

Create a surveillance system

Goal to show how each step or concept could be applied

Choose a scenario

Work in groups

Complete worksheet after each section or at the end of the course

Share with group

About the Course Exercise

Introduction

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NOTE TO INSTRUCTOR: Distribute Handout 1. Poll the class to determine their preference on whether the exercise should be completed as they learn the concepts or at the end of the course after all the concepts have been covered. Divide the class into groups based on the number of students in the class. There are two unintentional injury scenarios and two intentional injury scenarios on the handout; be sure at least one of each is being covered in this exercise. Assign each group a scenario. If this exercise is going to be completed as the concepts are taught, the groups should remain together to consult at the end of each section. Allow time at the end of Sections 1, 2, 3, and 4, for students to complete worksheet. At the end of the course, allow students to share their decisions with the entire class.

This exercise, which will be completed throughout the course or at the end of the course, is designed to help you see how each step or concept is applied. You are creating the broad outline for a surveillance system to collect and disseminate data that relates to the scenario you have chosen from the worksheet your instructor has handed out. You will be asked to share the decisions you have made about your system with the class.

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Introduction

Step 1: Understand the Concepts and Framework of Injury Prevention

Section 1

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NOTE TO INSTRUCTOR: Most of this section is a review of concepts covered in the IHS Level 2 Intermediate Injury Prevention Training. Most of the material in this section should be covered quickly. The Ecological Model may be new to some participants and may require more time.

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Objectives for Section 1

Review the concepts, definitions and classification of injuries

Review the burden and the cost of injury

Understand the conceptual models for understanding and preventing injuries

Introduce the steps to developing an injury surveillance system

Understand the ethical considerations associated with injury surveillance

Section 1

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Injury Problem in the United States

Unintentional & Intentional Injuries in 2010

3rd leading cause of death all ages

Leading cause of death in ages 15-34

Cost an estimated $403 billion annually in medical expenses and lost productivity

Section 1

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Nationwide, injuries were the 3rd leading cause of death for all ages and the leading cause of death for ages 15-34. According the Centers for Disease Control, injuries cost the United States an estimated $403 billion annually in medical expenses and lost productivity.

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Injury Problem in Indian Country

Unintentional & Intentional Injuries in 2010

3rd Leading Cause of Death all ages

Leading cause of death in ages 15-34

Section 1

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In 2010, unintentional and intentional injuries were the third leading cause of death for all ages (behind cancer and heart disease) in Indian Country. For ages 15-34, injuries were the leading cause of death.

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Injury Definition

Damage to the body caused by:

Exposure to an outside force or

Lack of something essential or

Uncontrolled release of mechanical energy

Section 1

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An injury is caused by exposure to an outside force, such as mechanical energy, electricity, heat or chemicals. In some cases, injury can be caused by a lack of something essential, such as air, as in drowning, or by exposure to something, such as extreme cold, as in frostbite. About three-fourths of all injuries are caused by the uncontrolled release of mechanical energy.

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Introduction

Injury Definition

Injuries

Disease

Are Not the Same As

Section 1

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The distinction between injury and disease is an important issue to consider when conducting injury surveillance.

Some experts think that an injury is defined by immediate damage to the body from an external force. Other experts believe that the interval between the exposure and the damage can be relatively long, such as in poisoning from carbon monoxide, alcohol abuse or lead poisoning.

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Injury DefinitionInjury vs. Disease

Injury: Broken toe caused by a jackhammer

Disease: Tendonitis of the elbow caused by years of exposure to the vibration of a jackhammer

Section 1

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Both conditions in this example were caused by exposure to a jackhammer. The first condition, the broken toe, is an injury because the condition was produced immediately by the jackhammer. The second condition, tendonitis of the elbow, is considered a disease, because the condition took years to develop. Acuteness is a factor. The shorter the time from the exposure to a hazard to the impact on the body, the more likely it is to be classified as an injury rather than a disease.

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Introduction

Injury DefinitionInjury vs. Disease

InjuryDiseaseA child is bitten by a dog and requires ten stitches to his legA child contracts rabies after a dog biteA firefighter suffers smoke inhalation while fighting a wildfireA former uranium miner contracts lung cancer from years of exposure to uranium dust

Section 1

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Here are two more examples. In each of the examples here, you would say the first victim suffered from an injury, while the second victim suffered from a disease because the impact of the exposure to the harmful element was not felt immediately.

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Introduction

Injury Definition

Injuries

Accidents

Are Not

Section 1

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Injuries are not the result of accidents. For many people, accidents are something unpredictable or something that happens by chance. But events that injure people have identifiable risk factors that can be modified. Many experts believe that the use of the word accident when referring to injury events creates confusion and inhibits prevention efforts.

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Introduction

Injury Classification

Unintentional

Fall

Car Crash

Dog Bites

Burns

Drowning

Intentional

Suicide

Stabbing

Gun Shot

Section 1

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Injuries can be broadly classified into two groups unintentional injuries or intentional injuries (also called violence-related injuries). Unintentional injuries relate to traffic crashes, events in the home or the workplace, in public places or as the result of natural disasters. Intentional injuries are related to interpersonal, collective or self-directed violence.

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Injury ClassificationUnintentional Injury

Occur without the intent of anyone involved

5th leading cause of death in US -- all ages

In Indian Country

3rd leading cause of death all ages

Leading cause of death under age 44

Section 1

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Unintentional injuries such as falls, car crashes, burns or drowning -- occur without the intent of anyone involved. According to information obtained from the Centers for Disease Control WISQARS site, in 2010 unintentional injuries were the fifth leading cause of death for all ages in the United States. In Indian Country, unintentional injuries were the third leading cause of death for all ages and the leading cause of death for people under the age of 44.

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Introduction

Physical damage to the body

Caused by

Excessive force or

Exposure to external agents, such as poison or

Deprivation of an essential elements, such as air or warmth

Damage is not done deliberately


Section 1

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An unintentional injury can be described as follows:

Physical damage to the body

Damage that results from excessive force to the body; exposure to external agents, such as poison; or deprivation of an essential element such as air or warmth

The damage is not done deliberately

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Introduction

Can be inflicted by a number of mechanisms, including:

Mechanical

Radiant

Thermal

Electrical

Chemical


Section 1

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Unintentional injuries can be inflicted by a number of mechanisms, including:

Mechanical (impact with a moving or stationary object)

Radiant (ultraviolet radiation)

Thermal (air or water that is too hot or too cold)

Electrical (lightning strike, electrical shock)

Chemical (Poison or drug overdose)

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Introduction

Injury ClassificationIntentional Injury

Deliberate harm to oneself or another

Includes

Domestic violence

Child or elder abuse

Suicide attempts

Section 1

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Intentional or violence-related injuries occur because of a persons deliberate intent to harm another or oneself. Intentional injuries can be the result of a number of things, including domestic violence, child or elder abuse or suicide attempts.

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Introduction

In US (2010)

10th Leading Cause of Death all ages

Leading Cause of Death ages 15-34

In Indian Country (2010)

6th leading cause of death all ages

Leading cause of death ages 15-34

Account for 28% of all injury deaths


Section 1

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According to statistics from the Centers for Disease Control and Prevention, in 2010:

Intentional injuries homicides and suicides are the 10th leading cause of death in the US for all ages and the leading cause of death for ages 15-34.

Homicide and Suicide were the 6th leading cause of death in Indian Country for all ages

The leading cause of death for ages 15-34

28 percent of all injuries in Indian Country were the result of violence.

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Introduction

World Health Organization divides intentional injuries in three categories

Self-directed

Interpersonal

Collective


Section 1

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The World Health Organization divides violence-related injuries into three broad categories:

Self-directed, which includes suicidal behavior and self-abuse

Interpersonal, which includes violence between family members and intimate partners, and community violence between individuals who are unrelated

Collective, which includes violence inflicted by large groups such as the government, mobs or terrorists.

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Introduction

Nature of Intentional Injuries

Physical violence

Sexual violence

Psychological violence

Deprivation or neglect


Section 1

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Intentional injuries can also be classified by the nature of the act that inflicts the injury. The four categories are:

Physical violence

Sexual violence

Psychological violence

Violence involving deprivation or neglect

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Introduction

US 2010

Burden of Injury Injury Severity Pyramid

Section 1

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In 2010, nationwide, there were 180,811 deaths attributed to injuries. But injury deaths are just the tip of the iceberg as the pyramid illustrates (Note: this depicts data for the general U.S. population, as hospitalization and ambulatory care data are not available for Indian Country). The majority of injuries do not result in death, but they may require costly treatment or result in permanent disability.

*Includes care administered for adverse effects of medical treatment.

Death

180,811

Hospitalization*

2.4 million

Ambulatory Care*

Visits to physicians offices, outpatient care and emergency department

80.2 million

The Burden of Injury in Indian Country

2,523 deaths in 2010

66,612 years of potential life lost in 2010

Cost an Estimated $2.1 billion

Medical care

Rehabilitation cost

Lost wages and productivity

Section 1

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In 2010, 2,523 deaths in Indian Country were attributed to injuries; 66,612 years of potential life were lost. According to some estimates, injuries cost Indian Country more than $2.1 billion a year in medical care and rehabilitation costs, lost wages and productivity.

Injuries take their heaviest toll on youth. Unintentional injuries are the leading cause of death for American Indians/Alaska Natives ages 1-44. In some cases, deaths from injuries among this group are two to three times higher than that of the general population. In addition to the years of life lost, there are the unmeasured years of productivity lost due to injuries that are debilitating but not fatal.

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Burden of InjuryLifetime Cost of AI/AN Injuries

Medical CostsProductivity LossAdministrativeCostsTotal Costs($ Millions)All Injuries$489$1,477$211$2,176Motor Vehicle 285 610 83 978Suicide 19 156 20 194Falls 30 89 16 135Homicides 16 94 19 129Fires 19 30 7 56

Section 1

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The economic burden of injuries is particularly acute in Indian Country because health care funding and money for economic development are severely limited. According to one study, the lifetime costs from injuries to AI/AN is over $2.1 billion. This means that each year, over $2.1 billion is withdrawn from health care and economic development resources that would have been available if the injuries had not occurred. The data in the table illustrate the lifetime impact of fatal and non-fatal injuries occurring in 2000 based on medical and administrative costs, as well as productivity lost, but it does not include all the relevant direct and indirect costs, such as dental care, long-term care, funeral costs, law enforcement costs, and the pain and suffering of victims and loved ones. NOTE: A larger version of this slide is in Appendix 6

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Introduction

Interventions that Save Money in Indian Country

DUI Laws

Personal Flotation Devices

Smoke Detectors

Bike Helmets

Primary Seat Belt Laws

Livestock Control

Child Car Seat Program

Financial Benefits of Injury Prevention

Section 1

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Injury prevention can save lives and spare people needless suffering. It can also save money not just for individuals but for the community. Even if injury prevention efforts do not reduce all injuries, they can reduce the severity of injuries resulting in lower overall treatment costs. Fewer injuries or less severe injuries result in less money being spent on emergency medical treatment and more money available for other activities, such as economic development. In areas where medical facilities and doctors are in short supply, lowering the need for emergency treatment means that resources are available for elective and preventative health care.

These are some injury prevention programs that have achieved results in Indian Country. They began with surveillance efforts. Do you have examples of injury prevention programs that have worked in your community? Share them with the class.

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Financial Benefits of Injury PreventionCost Outcome Analysis

InterventionCost per UnitCostSavingsSobriety Checkpoints$12,000 per checkpoint$82,000 per checkpointBattery-Operated Smoke Alarms$44 per alarm$770 per alarmBicycle Helmets for ages 3-14$12 per helmet$580 per helmetChild Safety Seat Distribution, Ages 0-4$52 per seat$2,200 per seat

Section 1

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Cost Outcome Analysis: Another way to judge the value of injury prevention efforts is to compare the cost of the intervention with the savings that result for the community because the number of injuries is reduced. Most tribal government officials will want to know that a program is producing the desired results and that it is cost effective. The table here shows the average cost and the average cost savings in medical and other expenses realized by some common injury prevention programs that have been implemented in the United States. Note: A larger version of this slide is in Appendix 6

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Conceptual Models for Understanding and Preventing InjuryPublic Health Approach

Section 1

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Public Health Approach: The public health model for injury prevention is concerned with the public in general as well as the health of the individuals that make up the community. The public health approach is a repeating four-step process and so the Indian Health Service depicts it with a Medicine Wheel as shown on the slide.

In the public health model you:

Define the problem through surveillance

Identify the risk factors who and /or what

Find out what works to prevent the problem

Implement and evaluate prevention programs

Note: A larger version of this slide in Appendix 6.

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Host

Agent

Environment

Conceptual Models for Understanding and Preventing InjuryEPI Triad

Section 1

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The Epi Triad: Epidemiology considers the interaction of three factors in the development of disease: the host, the agent and the environment. Dr. William Haddon, former director of the National Highway Safety Administration, maintained that the same concept could be applied when examining the cause of injuries. Haddon applied the epidemiological principal to unintentional injuries, and particularly to injuries from motor vehicle crashes.

Conceptual Models for Understanding and Preventing InjuryEPI Triad

Offers three opportunities for intervention

Host: Injured Person

Agent: Mechanism that inflicted the injury

Environment: Physical and social environment in which the injury occurred

Section 1

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The Epi Model is a useful way of approaching injury prevention, because it gives the injury prevention specialist three different opportunities for intervention. In the Epi Model of injury prevention, the host is the injured person, the agent is the mechanism that inflicted the injury and the environment refers to the characteristics of the physical and social environment in which the injury occurred

Conceptual Models for Understanding and Preventing InjuryHaddon Matrix

HostAgentPhysical & Social EnvironmentFactors in a motor vehicle crashPhasePre EventAlcohol consumption, fatigue, experience Brakes, tires, steeringDUI laws (social), road conditions (physical), speed limit (social)EventSeat belt use, age, sexSpeed at impact, automatic restraintsMedian barriers, roadside embankments (both physical)Post EventPhysical condition, disabilitiesIntegrity of fuel systemEmergency communications (social), transport systems (social), distance to medical service (physical)

Section 1

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The Haddon Matrix: Haddon went even further and added a time element to the model, developing the Haddon Matrix. Haddon maintained that this model could be used when examining the cause of injuries. Haddon applied it to unintentional injuries, and particularly to injuries from motor vehicle crashes. The Haddon Matrix, examines each of the three factors considered in the Epi Triad at three different intervals of an injury event pre-event, event and post-event. The Haddon Matrix helps chart the course of an injury and allows the injury prevention specialist to plan interventions at each interval. The slide shows the Haddon Matrix as it could apply to a motor vehicle crash. For each phase of the event, the matrix shows the elements or circumstances that could have impacted each factor involved in the event the host or injured person, the mechanism or car and the physical and social conditions that exist where the crash occurred. Note: A large version of this slide is available in Appendix 6.

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Societal

Community

Relationship

Individual

Section 1

Conceptual Models for Understanding and Preventing InjuryEcological Model for Understanding Violence

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Just as the Haddon Matrix assists in the understanding of unintentional injuries, the Ecological Model (shown on the slide) is helpful in understanding the cause and prevention of intentional or violence-related injuries. The ecological model looks at violence on four levels. This model considers the complex interplay between individual, relationship, community, and societal factors. It allows you to address the factors that put people at risk for experiencing or perpetrating violence. This model was first introduced in the 1970s and was initially applied to child abuse. Subsequently it was applied to youth violence and, most recently, researchers have used it to understand intimate partner violence and abuse of the elderly

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Interaction of biology, behavior and environment

Changes over the course of life

Violence prevention a continuum of activities

Section 1


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The Ecological Model proposes that health and well-being are affected by dynamic interaction of biology, behavior and the environment and that this interaction changes over the life course. Prevention strategies should consist of a continuum of activities that address multiple levels of the model. These activities should be developmentally appropriate and conducted across the lifespan. This approach is more likely to sustain prevention efforts over time than any single intervention.

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Introduction

Looks at factors on four levels

Individual

Relationship

Community

Societal

Section 1


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Four Levels of Ecological Model: The ecological model considers factors on four levels that increase the probability that someone will be the victim or perpetrator of violence. The levels are: the individual; relationships; community and societal. Each of these levels is explained in more detail on the following four slides.

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Introduction

Individual Level

Biological and personal factors, such as age, education, income, substance abuse, history of abuse

Prevention strategies would promote attitudes, behaviors or beliefs to prevent violence


Section 1

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Individual: The first level identifies biological and personal history factors that increase the likelihood of becoming a victim or perpetrator of violence. Some of these factors are age, education, income, substance use, or history of abuse. Prevention strategies at this level are often designed to promote attitudes, beliefs, and behaviors that ultimately prevent violence. Specific approaches may include education and life skills training.

Relationship

Presentation - 39

Introduction

Relationship Level

Includes peers, partners and family members

Prevention strategies would promote healthy relationships

Section 1


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Relationship: The second level examines close relationships that may increase the risk of experiencing violence as a victim or perpetrator. A person's closest social circle-peers, partners and family members-influences their behavior and contributes to their range of experience. Prevention strategies at this level may include mentoring and peer programs designed to reduce conflict, foster problem solving skills, and promote healthy relationships.

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Introduction

Community Level

Includes settings, such as schools, workplace and neighborhood

Prevention strategies designed to impact system could include marketing campaigns to promote healthy relationships

Section 1


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Community: The third level explores the settings, such as schools, workplaces, and neighborhoods, in which social relationships occur and seeks to identify the characteristics of these settings that are associated with becoming victims or perpetrators of violence. Prevention strategies at this level are typically designed to impact the climate, processes, and policies in a given system. Social norm and social marketing campaigns are often used to foster community climates that promote healthy relationships.

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Introduction

Societal Level

Include societal or cultural norms, policies that maintain economic or social inequalities

Prevention strategies aimed at policy

Section 1


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Societal: The fourth level looks at the broad societal factors that help create a climate in which violence is encouraged or inhibited. These factors include social and cultural norms. Other large societal factors include the health, economic, educational and social policies that help to maintain economic or social inequalities between groups in society.

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Introduction

Energy damage and the 10 countermeasures strategies by Dr. William Haddon, Jr.

The Social Ecological Model: A Framework for Prevention Centers for Disease Control and Prevention

The Ecological Model and Risk Protection Factors Centers for Disease Control and Prevention

Section 1

Conceptual Models for Understanding and Preventing InjuryFor More Information

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Energy damage and the 10 countermeasures strategies -- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1067540/?page=1

The Social Ecological Model: A Framework for Prevention -- http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

The Ecological Model and Risk Protection Factors -- http://www.ctfalliance.org/images/initiatives/CDC_Ecological_Model.pdf

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Introduction

1. Review the concepts and framework of injury prevention

2. Assess injury data sources and define the injury problem

3. Build a partnership or coalition to support the injury surveillance system and prevention activities

4. Determine the appropriate methodology for the surveillance system

5. Define and develop an analysis plan for the surveillance data

6. Use injury surveillance data to inform injury prevention

7. Define an evaluation plan for the surveillance system and monitor prevention activities

Steps to Developing an Injury Surveillance System

Section 1

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Steps to Developing an Injury Surveillance System: These steps incorporate and in some cases expand on the 10 steps that were discussed in the IHS Level 2 Intermediate Injury Prevention training. Each of these steps will be discussed in more detail throughout the course. You are about to complete Step 1 Review the concepts and framework of injury prevention. Note: A larger version of this slide is in Appendix 6.

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Steps to Developing a Surveillance SystemImportant Things to Remember

These steps are a guide

Not every step will be achievable or feasible

Implement as much as you can

Modify steps as need be

Seek the help of experts

Section 1

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Remember, these steps are a guide to creating an injury surveillance system. Not every step will be achievable or feasible for everyones situation.

For example, it may not be possible to form a coalition, or obtain all the data they would want.

Implement each step or as much of each step you can.

Modify steps as need be to fit your situation and seek help from an expert when needed.

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Introduction

Steps to Developing a Surveillance SystemEthical and Cultural Considerations

Privacy

Confidentiality

Privacy Act of 1974

HIPAA

Section 1

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A successful surveillance system depends on a trusting relationship between the people who gather data and the community. Every consideration must be given to protecting peoples privacy, to following the law and to respecting the cultural concerns of the people of tribal government you are working with when collecting data and publicizing the results.

Privacy refers to the right of an individual to withhold or control the use of information about her or himself. Confidentiality refers to the obligation one has to protect information about someone. Small communities, such as many Alaska villages or Indian reservations make it difficult to ensure confidentiality. Its sometimes possible to identify people even when precautions have been taken. Its important to have clear policies in place to ensure confidentiality and privacy considerations are met.

The Privacy Act of 1974, a precursor to HIPAA, addresses how government agencies handle and maintain records about individuals. HIPAA requires HHS to address the security and privacy of health information, especially individually identifiable health information in all forms.

For training or more information on HIPAA you can check these sites:

HC Pro Healthcare Marketplace

www.hcmarketplace.com

Indian Health Service

http://www.ihs.gov/hipaa/Appendix

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Steps to Developing a Surveillance SystemEthical and Cultural Considerations

Institutional Review Boards

Cultural Concerns

Section 1

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In addition to federal laws, the IHS and some tribes have Institutional Review Boards (IRB). An IRB reviews and approves or disapproves research activities that use medical facilities, data, staff or, for the IHS, funding. The IRB will examine the informed consent process between the researcher and the volunteers, and the negotiations between the researcher and the Tribal community to verify that the research is safe, of benefit and respectful to participants.

Its important to be aware of the community standards for your activities. The process of collecting data and the procedure for using data from tribes may be different from other governments or organizations. And the process may differ from Tribe to Tribe. In addition, each Tribe in your area has a unique culture, which may impact your ability to collect data and publicize your results. Its important to be aware of and respect Tribal cultural concerns.

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Summary of Section 1

Questions?

What did you already know?

What did you learn that was new?

Complete Question 1 on Final Exercise

Section 1

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Step 2: Assess Injury Data Sources and Describe Injury Problem

Section 2

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Data for an injury surveillance system can come from many sources, including the health sector, law enforcement, and the Tribal government. No data source is perfect. In Indian Country, data collection can be complicated by racial misclassifications, incomplete or missing patient charts, missing or incorrect codes for injuries, limited access to data on the Tribal level and the decentralized nature of the Indian Health Service data system, which is facility based. Its important to know the strengths and weaknesses of your data source so you can determine how it may impact your objective. This section reviews some common data sources and shows how data can be used to identify the scope of the injury problem.

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Objectives for Section 2

Identify injury data sources and the strengths and weaknesses of each

Identify available data sources that can provide information to your surveillance system

Use data to describe the size of the injury problem

Section 2

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Overview of Common Data Sources

Death Certificates

Pros

Inexpensive

Readily accessible

Cons

May not contain enough information

Not all tribal or IHS facilities report to state

Not a good guide to determining overall problem or medical consequences

Section 2

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Death certificates are an important and inexpensive source of information for fatal injuries. Information from death certificates is readily accessible from state and central databases. In some cases, however, death certificates may not contain enough information about the circumstances surrounding an injury, the victim or, in the event of violence, the perpetrator. Not all Tribal or IHS healthcare facilities report to the states, so state data may not reflect the complete number of deaths. Death certificates are not a good guide to determining the overall injury problem or the medical consequences, such as long term-disability.

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Hospitalization Records

Pros

Combined with mortality data, can provide a better picture of injury problem

Cons

Access more difficult

Coding inconsistent

Difficult to determine ethnicity of victim

May require manual review of records

Section 2


#

When combined with mortality data, hospitalization records can provide a much better picture of the injury problem and assist in describing the disability and healthcare costs associated with injuries. However, access to such data is more difficult because of privacy issues; the coding of causation is not consistent; it may be difficult or impossible to determine the ethnicity of the victim and it may require a manual review of records which can consume a great deal of time.

Presentation - 52

Introduction

Outpatient Visits Records

Pros

Good source of supplementary information on specific injuries

Cons

Injuries that require hospitalization may be treated at non-IHS/non-tribal facilities

May need to combine with contract health care records for a better picture

Access may be difficult

Section 2


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For those who already have access to hospital or emergency department data, outpatient records may provide some good supplemental information on specific injuries such as sports injuries or eye injuries. However, many tribes have only an outpatient clinic for care and injuries requiring hospitalization are treated at non-tribal and non-IHS facilities and later billed back to the IHS through contract health. In this case, combined outpatient visits with contract health records can provide a better picture of the injury problem. Access to outpatient records may prove difficult as practitioners are highly protective of their records. In addition, AI/AN patients may receive hospitalized care at non-tribal or non-IHS facilities without services paid by the IHS.

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Introduction

CDC WISQARS

Interactive

Online database

Fatal and nonfatal injuries

Information from

variety of trusted sources

Section 2


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CDCs WISQARS (Web-based Injury Statistics Query and Reporting System) is an interactive, online database that provides fatal and nonfatal injury, violent death, and cost of injury data from a variety of trusted sources. Researchers, the media, public health professionals, and the public can use WISQARS data to learn more about the public health and economic burden associated with unintentional and violence-related injury in the United States.

Presentation - 54

Introduction

WISQARS

Pros

Search, sort, and view injury data

Create reports, charts and maps based on mechanism, body region, nature of injury, geographic location, sex, race/ethnicity, age

Con

Morbidity data not available for AI/AN population

Section 2


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At the WISQARS site, users can search, sort, and view the injury data and create reports, charts, and maps based on the following:

Intent of injury (unintentional injury, violence-related, homicide/assault, legal intervention, suicide/intentional self-harm)

Mechanism (cause) of injury (e.g., fall, fire, firearm, motor vehicle crash, poisoning, suffocation)

Body region (e.g., traumatic brain injury, spinal cord, torso, upper and lower extremities)

Nature (type) of injury (e.g., fracture, dislocation, internal injury, open wound, amputation, and burn)

Geographic location (national, regional, state) where the injury occurred

Sex, race/ethnicity, and age of the injured person

Morbidity data is limited to the state and U.S. level and is not available for the AI/AN population.

Presentation - 55

Introduction

Police Reports

Records of Occupational Injuries

State Data Sources

National Data Sources

Local Newspaper Accounts

See Appendix 2 for Matrix of Data Sources

Section 2

Other Common Data Sources

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Police Reports

Police reports can also be an important source of information about injuries, particularly road traffic or violence related injuries. Police records can be very useful for determining the details surrounding an injury event, including, road conditions or the condition of the driver in the event of a crash or the condition of the perpetrator in the event of violence.

Records of Occupational Injuries

Information on injuries that occur in an occupational setting is sometimes available from the Department of Labor or organizations that monitor the industry.

State Data Sources

Some states keep registries of injury data, particularly traffic injury data, which can be accessed.

National Data Sources

The National Highway Traffic Safety Administration, Occupational Safety and Health Administration the Fatal Accident Reporting System and other agencies within the federal government maintain a number of databases that might prove useful in your injury surveillance.

Local or Tribal Newspaper Accounts

Newspaper accounts can sometimes offer a great deal of information about the victims of injury, including the age of the victim, the circumstances surrounding the injury event and the address of the victim.

Note: You will find a matrix of common data sources in Appendix 2

Presentation - 56

Introduction

Section 2

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NOTE TO INSTRUCTOR: Review the slide then ask class to share their experience using these data sources.

This slide shows some common data sources that could be used when investigating an injury in Indian Country. Share your experience using these data sources. Were records accessible, timely, accurate, complete etc.?

Did you find that race/ethnicity information was available and if so, was it accurate? If youve used more than one of the data sources on the slide, how did they differ? What was similar about them?

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Common Data Sources for Investigating an Injury in Indian Country

Forensic Medicine/Coroner may conduct autopsy,but autopsies are not always done

Local EMS

District Attorney attends all cases of injury deaths and collects information on victims, suspects and circumstances

State Data Sources

Law Enforcement:

BIA Police, Tribal Police, Country or State Police

Transportation Office collects information related to victims, vehicles and circumstances

Its usefulness for injury surveillance, research and practices.

Estimates of its accuracy, completeness and representativeness

Timeliness of the data

Resource requirements. (How long will it take you to collect the data? How much will it cost?)

Simplicity

Determining the Strength and Weaknesses of Each Data Source

Section 2

#

Each institution collects data for different purposes based on its mission. Health institutions, for example, may focus more on the injury and less on the circumstances under which the injury occurred. Police may have a different view of what constitutes an injury and that may impact their traffic injury data. There is no perfect data source that will serve all the needs of your surveillance system. That is why it is important to judge the strengths and weaknesses of your potential data sources in determining which ones will best suit your needs.

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Determining the Strengths and Weaknesses of Each Data Source

Jurisdiction

Who collected the data and why?

Section 2

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When considering which data sources to include in your surveillance system, its important to understand the mission of each entity collecting data and the method they use to collect the data.

In a road traffic fatality for example, police may or may not gather information about the victim if he or she died at the scene. However police records may have more details about the circumstances surrounding the crash. At the hospital, where the major concern is treating the victim, there may not be any information about the circumstances of the injury event, but a great deal of information about the injury itself. Also each may report different information about the injury event depending on its point of intervention. Each data source may record a different time for the occurrence of the event. At the hospital, there may be a discrepancy between the initial and final diagnosis. If a victim dies at the scene of a crash and doesnt make it to the hospital, the death will not be registered by the hospital at all.

Note to Instructor: Ask the class to consider how many potential data sources would be involved in a road traffic fatality on tribal land. EMS, tribal police, hospital, coroner. Ask them what types of information each source would collect. Each would be collecting information, but for different reasons Each would have a different focus that would impact the information they collect.

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Determining the Strengths and Weaknesses of Each Data Source

Method and Flow

How was the data collected?

Where does it go?

Section 2

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Data collection methods vary with institutions because each uses its own forms to collect information. This information is entered into databases and analyzed to produce reports. Police produce reports based on the information they collect at the scene of an injury event. Forensic medicine and public health officials prepare reports of cases they treat. Data collection and data flow can vary also among institutions depending on the technology available in each place.

For instance, when a death occurs, the funeral director obtains information from the family about the deceased persons education, occupation, birthplace, racial identity, etc. The local Coroner/Medical Examiner supplies cause-of-death information and basic information about the context of the death. The certificate is then filed with the local or state health department. In most states, the health department assigns the ICD cause of death code, usually with software assistance.

Vital statistics offices collect information from the death certificates. If the death certificates are incomplete or inaccurate the data will be unreliable.

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Information Taken at the Scene

Preliminary Reports, Certificates, Etc.

Database

Data Assessment Exercise

Time: 30-45 minutes

Purpose: What specific things would you want to see in a database.

You have been offered access to a locally run database on youth activity

What specific questions would you ask to determine the strengths and weaknesses of this data source?

Keep previously discussed considerations in mind

Section 2

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Data Assessment Exercise

You have been offered access to a locally run database on youth activity.

What specific questions would you ask to determine the strengths and weaknesses of this data source?

Keep the previously discussed considerations in mind

Instructor will write your questions on a flip chart. Compare your questions to those that are on the handout. Were there any additional questions on the handout that would be useful to you in assess the database?

Note to Instructor: Write the questions on a flip chart. When class has finished providing questions, distribute Handout 1, Data Assessment Questions.

There are no right or wrong questions to ask. The purpose of this exercise is to get you thinking about what specific things you would want to see in a database and what could make it more or less useful for your needs and the resources you have available. Is there anything about a data source that would eliminate it from consideration?

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Identify Data Sources to Include in the System

Consider the injury youre tracking

Consider the goal of your surveillance system

Quality of the data

Existing sources

Section 2

#

The goal of your system and the injury events your tracking will determine which data sources are necessary to provide information to the system. The availability of quality data is important when selecting data sources. Take advantage of existing data sources. There may be some limitations depending on the intent of the data collection, but almost all data sources have some limitations. Using existing data sources will save you time.

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Identify Data Sources to Include in the SystemPreliminary Data Analysis

Develop a strategy to ensure cases are not counted more than once

Start with the analysis of a broad category, such as interpersonal violence

Then go more in depth if possible

Section 2

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Develop a strategy or a method to ensure cases are not counted more than once. The goal is to eliminate duplicate cases to ensure the data is accurate.

To understand the nuances of a data source and gauge its completeness and adequacy it is important to conduct preliminary data analysis. Start with the analysis of a broad category, such as interpersonal violence. Then go more in depth if possible, for example, domestic violence against women. Epidemiologists can be useful in this step. Seek them out from such places as state health departments, epidemiology centers, academic institutions and among graduate students. You will find a list of Tribal Epidemiology Centers (TECs) at this web site: http://www.ihs.gov/epi/index.cfm?module=epi_tec_tecs

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Identify Data Sources to Include in the SystemCompare Frequency with Data from Different Sources

You may find discrepancies

Identify the mission/goal of the institution collecting the data

Compare it with the goal of the surveillance system

Section 2

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Injury data are commonly collected for different reasons depending on the mission of the institution collecting the data, therefore numbers may vary. Identifying the mission and operation of the institution where the data is located will help you understand why there is a discrepancy in numbers from one institution to another and allow you to determine what steps to take based on the goal of your surveillance system. In Indian Country, for example, there may be a high proportion of patients who are transported from tribal or IHS facilities to other facilities for treatment. Therefore, you may find that IHS facilities records show no traffic fatalities, but tribal police or local EMS logs show many. On the other hand, police or EMS records may not provide any information on the number of less severe injuries from motor vehicle crashes. If you were gathering data only from IHS medical records, you would not have a complete picture of the severity of the problem in your region and if you were gathering data only from police or EMS records, you might not get a clear idea of the scope or cost of the problem. Be aware that data collected by institutions outside Indian Country may contain racial misclassifications, which will skew the numbers.

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Identify Data Sources to Include in the SystemLinkage with Other Data Sources

Advantages

Supplemental data

More comprehensive descriptions

Highlights the completeness

Improved data quality

Disadvantages

Personal identifiers

Interagency politics

Different storage media

Worse data quality

Duplications

Section 2

#

A single database may not provide all the information you need for your surveillance system. You might consider using data from more than one source either by combining data from different sources, such as supplementing police crash data with state crash data, or by electronically linking data sets.

It would be ideal to be able to compare data sources, but for most of Indian Country it is not practical. Some of the advantages and disadvantages of data linkage are noted here. It is good to weigh both when youre considering this strategy.

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Who is being injured

How they are being injured

Cause of injury

Severity of injury

Section 2

Using Data to Define the Injury Problem

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The collection of data is vital to defining the injury problem and identifying a solution. Data will allow you to identify who is being injured and how, and better identify the cause and severity of injury. This will be discussed in more detail in Section 4. In this section we will talk about how to use mortality data, such as the frequency of the 20 leading cause of death and the leading causes of injury death, to define the injury problem. If morbidity data are available, such as hospital discharge data, they can be used to broaden the understanding of the problem and add more detail.

Presentation - 66

Introduction

Using Data to Define the Injury Problem

Determining the frequency of the leading causes of death

Determine the frequency of injury deaths

Section 2

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Deaths are commonly used to describe and compare public health problems, in part, because deaths are well defined and detailed mortality data is often available. Data on fatalities and on motor vehicle and other unintentional injuries can provide an indication of the extent of an injury problem in a community or state.

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10 Leading Causes of Death - 2010

General US PopulationAmerican Indian/Alaska NativeRankCause of DeathNumberRankCause of DeathNumber1Heart Disease597,6891Malignant Neoplasms2,9622Malignant Neoplasms574,7432Heart Disease2,7933Chronic Low. Respiratory Disease138,0803Unintentional Injury1,7014Cerebrovascular129,4764Diabetes Mellitus8575Unintentional Injury120,8595Liver Disease7876Alzheimer's Disease83,4946Chronic Low. Respiratory Disease7027Diabetes Mellitus69,0717Cerebrovascular5598Nephritis50,4768Suicide4699Influenza & Pneumonia50,0979Nephritis33910Suicide38,36410Influenza & Pneumonia326

Section 2

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This chart shows the 10 leading causes of death in the United States and among the AI/AN population. As you can see, unintentional injuries ranks fifth in the United State overall, but third among the AI/AN population.

(Note a large version of this slide is available in Appendix 6)

Presentation - 68

Introduction

10 Leading Causes of AI/AN Injury Deaths 2010RankCause of DeathNumber1Unintentional MV Traffic6102Unintentional Poisoning5213Suicide Suffocation2064Suicide Firearm1785Unintentional Fall1616Homicide Firearm1137Unintentional Suffocation698Unintentional Drowning689Suicide Poisoning6410Unintentional Natural/ Environment62

Section 2

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Once the leading causes of death are known, the next step is to determine the leading causes of injury deaths. On this chart, you can see that the leading cause of injury death in Indian Country in 2010 is unintentional motor vehicle crashes and poisoning. (Note a large version of this slide is available in Appendix 6)

Presentation - 69

Introduction

Why Determine the Leading Cause of Injury Deaths

Monitor trends

Identify high risk groups or communities

Make comparison among groups.

Motivate stakeholders to support injury prevention

Help in building a coalition

Section 2

#

Leading cause of injury death data can be useful for monitoring changes in injury rates over time, identifying high risk groups or communities and making comparison among groups. These data are also useful for motivating stakeholders to support injury prevention and in building a partnership or coalition.

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Section 2

Questions?



Questions 2 and 3 of course exercise.

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Step 3: Build Partnerships or Coalition to Support the Injury Surveillance System, Data Collection and Prevention Activities

Section 3

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INSTRUCTOR NOTE: Ask the class if they are familiar with or have worked with a coalition or community group on a common purpose or project. If so, what was their experience? What did they like about it? What did they dislike about it?

In this section we will discuss the feasibility of forming a coalition of groups to support your surveillance efforts, data collection activity and prevention activities. A coalition is an alliance of organizations working together for a common purpose.

Presentation - 72

Introduction

Section 3 Objectives

Identify partners to include in the system

Identify local, regional and national organizations working on injury prevention in your area

Define the existing social, legal and political framework in which an injury surveillance system and prevention activities may be established.

Section 3

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Considerations for Coalition/Partnerships

Commitment of lead agency

Effective core planning group

Planned recruitment of coalition members/partners

Structure of coalition or partnership

Roles

Mission and goals

Leadership

Section 3

#

Ideally an injury surveillance system would include a coalition of people from many different sectors in the community with different skill sets and expertise to lend to the effort. However, this may not be a practical approach in Indian Country. In most circumstances the work of surveillance will fall to one or two people. It might make more sense to identify a few people you can call on for advice or assistance from time to time. Here are some considerations for a coalition or partnership.

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Identify Partners/Coalition Members

Who would contribute to success of system?

Who has access to data sources you need?

What is the quality of their data?

What other support do you need?

Whose objectives overlap with yours?

Can you share or link data?

What expertise do you need?

Section 3

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Whether you form a coalition or a partnership with a few people, here are some considerations when choosing people or organizations to assist you.

Include people with different expertise from you or who have information that would be useful to you. For example, is there someone at a health center that can provide information on HIPAA guidelines for that center.

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Identify State and Local Organizations Working in Injury Prevention

Health care providers

Police departments

Fire departments

Schools

Social service agencies

Government agencies

Local IP coalition

State death review team

Section 3

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Injury prevention is a goal for many institutions within and outside the health sector. Some of these institutions can be sources of financial or technical assistance.

Since injury prevention is best done at the local level where problems can be addressed, there is an opportunity to form a local coalition of institutions that share a concern about an injury problem and in doing so, strengthen the response and probability of having an impact.

At the national level, a variety of government institutions not just the Indian Health Service, but the Bureau of Indian Affairs, the Department of Education, the National Parks Service might be working on preventing injuries, such as violence- or traffic-related injuries. Similar agencies exist at the state and local level, such as Education Departments or the Parks Department. Locally and across the nation, church and non-profit organizations have formed to address a number of injury issues, such as violence prevention. The slide shows some organizations that might have an interest in injury prevention.

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Determine the Existing Social, Legal, and Political Framework

Section 3

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Its important to be aware of the social, political and legal implications that injury surveillance or prevention programs might have in your community. For example, does the tribal council have an interest in doing something to address the possible cause of injuries, such as domestic violence or driving under the influence of alcohol? Is there money for surveillance or prevention efforts? Would community members be apprehensive about privacy issues? Are there socially or culturally acceptable practices that might come under scrutiny as the result of surveillance?

If your surveillance efforts are successful, the data you gather and present will drive policy at the local level and maybe even at the national or state level. Depending on your focus, you may experience resistance for any of a number of reasons, including those mentioned above.

NOTE TO INSTRUCTOR: Ask the class to share their experiences in dealing with government or community resistance to surveillance or injury prevention efforts. Why was there resistance? Were they successful in overcoming it? How?

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Section 3

Questions?



Questions 3, 4 and 5 of course exercise.

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Step 4: Determine the Appropriate Methodology for Your Surveillance System

Section 4

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When selecting a methodology for your injury surveillance system, several factors must be taken into consideration, including data needs and existing resources. In this section we will discuss the key elements that must be addressed.

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Section 4 Objectives

Define the injury events and data elements to include in the system

Develop the data collection instrument and determine data collection frequency

Plan for systemization, maintenance and data security

Define the functions and skill sets for key positions in your surveillance system

Section 4

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Considerations When Developing Methodology

Potential for intervention

What do you want the system to do?

The size and type of the injury problem

Available data sources

Access to information

Political priorities

Sustainability

Section 4

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When determining a methodology for your surveillance system, consider these questions:

Potential for intervention. The primary goal of an injury surveillance system is to identify appropriate interventions. You should not waste time and resources on collected data and data analysis if it wont result in prevention activity.

What do you and other stakeholders want the system to do? Should it be comprehensive, gathering data on all types of injuries? Or should it focus on a particular injury?

The size and the type of the injury problem. The magnitude of an injury problem in your area may impact which injury events you decide to monitor.

Availability of data sources. You must identify the sources of information for the system. In Section 2 we talked about identifying appropriate data sources and how to determine their strengths and weaknesses.

Access to information. How easy or difficult will it be to get the information you need from the institutions that have it?

Political priorities. Involving stakeholders and elected officials in the development of your system will keep them informed and will help you understand their priorities. They can also help you gain access to information that you might otherwise not be able to get.

Sustainability. Make sure the system you design will be able to be sustained by the resources you have available, both staff an financial resources.

Source: Holder Y, Peden M, Krug E, Luna J, Gururaj G, Kobusingye O, eds. Injury Surveillance Guidelines. Geneva: World Health Organization; 2001.

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Keep the data collection plan in mind

Identify your topic

Narrow your focus

Identify a specific question

Anticipate data needs

Develop and pre-test your data collection instrument

Considerations When Developing Methodology

Section 4

#

Keep the data collection plan from the IHS Level II Intermediate Injury Prevention Training in mind.

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Defining Injury EventsWhat are Your Objectives

Identifying emerging hazards

Describing injury patterns to justify the need for intervention

Assessing the impact of a prevention program

Determining the health care costs associated with injury

Describe the magnitude of the injury problem

Section 4

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The first task in creating a surveillance system is determining the objectives and then deciding the injury events you will track.

This slide shows some possible objectives for a surveillance system. What others are there?

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Defining Injury EventsCase Definition

Needs to be clearly stated and easily understood

Use comparable definitions as those used elsewhere

Contain a clear statement of the following

Person

Place

Time

Intentionality: intentional/unintentional

Age grouping

Severity

Optional: Injury Code

Section 4

#

Being aware of the objectives of your system will help you develop a case definition. The injury definition and case definition are inter-related. A case definition will determine which injuries you track in when you are gathering data.

The case definition should:

Be clearly stated and easily understood

Use comparable definitions as those used elsewhere for example, the national definition for elderly is 65 or older; yours should be the same

Contain a clear statement of the following

Person: race, tribe, age, gender

Place: state, reservation, roadway

Time: year, time of day, day of week, specific dates (4th of July), weekends

Intentionality: intentional/unintentional/undetermined intention, legal intervention

Age grouping

Severity: non-fatal, fatal, disability

Optional: Injury Code

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Defining an Injury EventA Closer Look at Injury Severity

Important to determine severity for case definition

Severity is based on the level of medical intervention required

Deaths

Hospitalization

Emergency Department (ED) visits

Outpatient visits

Advantages and disadvantages for each

Section 4

#

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Defining Injury EventsInjury Severity - Death

Advantages

Data is readily accessible

Cause of death is consistently reported

Race or ethnicity information is usually available

Disadvantages

Rare event

Not a good guide to ascertaining overall injury problem or medical consequences

Influenced by small numbers

Potential for racial misclassification

Section 4

#

Note: The Injury Severity Pyramid, which was introduced in Section 1, shows U.S. data for all races.

This slide shows the advantages and disadvantages to tracking injury deaths.

Advantages

Data is readily accessible from death certificates which are tracked by the state and kept in a central database

Cause of death is consistently reported on death certificates

Race or ethnicity information is usually available

Disadvantages

Rare event. Injury deaths represent less than 1% of injury events

Not a good guide to ascertaining overall injury problem or medical consequences, such as long term disability

Influenced by small numbers, especially in small populations or over a short period of time

There is the potential for racial misclassification

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Death

180,811

Hospitalization

2.4 million

Ambulatory Care

Visits to physicians offices, out-patient care and emergency department

80.2 million

Defining Injury EventsInjury Severity - Hospitalization

Advantages

Combined with mortality data, offers a better picture of overall problem

Disability and healthcare costs can be better described

Staff can collect data

Patients and family can be interviewed

Disadvantages

Access to data is more difficult

Privacy is more of a consideration

Records may be manual

Inconsistent, incomplete or incorrect coding

Race or ethnicity information is sometimes not available

May not be representative of problem

Section 4

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This slide shows the advantages and disadvantages of tracking injuries that result in hospitalizations.

Advantages

When combined with mortality data it offers a better picture of the overall problem

Disability and healthcare costs can be better described

Data can be collected by staff

Patients are captive audience that can be interviewed at the hospital, along with their relatives

Disadvantages

Access to data is more difficult

Privacy is more of a consideration


Inconsistent, incomplete or incorrect coding of injury causation

Race or ethnicity information is sometimes not available

May not be representative of the problem as only most severe injuries require hospitalization

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Death

180,811

Hospitalization

2.4 million

Ambulatory Care


80.2 million

Defining Injury EventsInjury Severity ED Visits

Advantages

Combined with other data, helps provide the big picture

Casts the net wider

Useful for specialized studies

Staff can collect data

Patients and family can be interviewed

Disadvantages

Large number of cases may be difficult to handle

Access to data may be difficult


Inconsistent, incomplete or incorrect coding

Race or ethnicity information not readily available from non-local sources

Section 4

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Note: ED and Out Patient Visits are included under Ambulatory Care on the Pyramid

Advantages

When combined with death and hospitalization data, helps provide the big picture

If youre dealing with a small population and have limited injury and mortality information you may benefit from casting the net wider

Can be useful for specialized studies

Data can be collected by staff

Patients are captive audience that can be interviewed at the hospital, along with their relatives

Disadvantages

Large number of cases may be difficult to handle

Access to data may be difficult


Inconsistent, incomplete or incorrect coding of injury causation

Race or ethnicity information is not readily available from non-local sources

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Death

180,811

Hospitalization

2.4 million

Ambulatory Care


80.2 million

Defining Injury EventsInjury Severity Out-patient Visits

Advantages

May be a primary source of injury data if there is no hospital

May be good for specialized injuries, such as sports related injuries or eye injuries

Might be good supplemental information

Might be the only source of data for some

Disadvantages

Difficult access

Privacy issues

Race or ethnicity information is not readily available

Section 4

#

Advantages

Clinics might be a primary source of information if there is no hospital

May be good for specialized injuries, such as sports related injuries or eye injuries

Might be good supplemental information

Maybe the only source of data in some places

Disadvantages

Difficult access

Privacy issues (data is highly protected by practitioners)

Race or ethnicity information is not readily available

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Death

180,811

Hospitalization

2.4 million

Ambulatory Care


80.2 million

Defining Injury EventsA Closer Look at Injury Codes

What is an injury code?

Part of standardized codes used by the health sector to classify diseases and health conditions

Used worldwide, including IHS and tribal health care

ICD-9 CM = International Classification of Disease , Version 9, Clinical Modification

Supplemental Classification of External Causes of Injury and Poisoning (E-Codes)

ICD-10/CM = International Classification of Disease, version 10, Clinical Modification

Section 4

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Injury codes are part of a standardized set of codes used by the health sector to classify diseases and health conditions on health care claims. These codes are used worldwide, including in IHS facilities and tribal healthcare settings. Currently, there are two sets of codes used in the US. The ICD-9 CM is the International Classification of Disease , Version 9, Clinical Modification. The ICD9-CM has a supplemental section with codes called E-Codes that describe external causes of injuries and poisonings. The ICD-10/CM is the International Classification of Disease, Version 10, Clinical Modification.

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Defining Injury EventsMore about ICD Codes

Used for health data management and to improve healthcare

Updated periodically for new conditions and system changes

Sometimes easier to query data system using specific codes

Section 4

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ICD codes are used worldwide for health data management and to improve health care. ICD codes are updated periodically to adjust for new and emerging illnesses/diseases and for system changes such as improving specificity. If a health care facility has a high percentage of coded injuries, the data can be mined or queried using specific codes.

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ICD-9 CM

Used to code non-fatal events (doctors visits and hospitalizations)

Diagnosis codes (injury or illness - fractures, diabetes, etc.)

External cause codes = E-codes (used for what caused injury - fall, car crash, etc.)

Used US-wide from 1999-2014

Primary user = those who assign codes

Training required

Secondary user = those who utilize coded data

Section 4

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The ICD-9 CM is used to code non-fatal events such as those requiring only doctors visits or hospitalizations. There are two broad categories of codes: diagnosis codes that describe injury or illness type such as fractures or diabetes, and external cause codes, otherwise known as E-Codes, that describe the cause for the injury. The ICD-9 CM has been used in the US from 1999 to 2014. There will be a national switch to ICD-10 codes in 2014. Those who assign codes are primary users. Training is required for primary users. (Slide100 has training links). Those who utilize coded data are secondary users.

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Anatomy of an E-Code

X X X . Y

E

Injury Category

Specificity

Section 4

E = External cause

#

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An E-code is a 4 (sometimes just 3) digit number preceded by the letter E.

The first 3 digits indicate the type of injury group.

The fourth digit, which follows the decimal point, provides additional descriptive information or specificity of the injury event.

ICD-9 Code Example

Example:

804.12 (injury)

E813.1 (cause of injury)

813.1

E

Motor vehicle traffic accident

involving collision with other vehicle

Passenger

E = External cause

Section 4

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In a data report or medical record you might see code(s) for the injury or injuries and a code for external cause of injury. In this example the first code tells us the patient suffered closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness (804.12). Multiple injuries will have multiple codes. The cause of the skull fracture is a motor vehicle colliding with another vehicle (E813). The .1 denotes the injured person was the passenger.

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ICD-10 CM

October 1, 2014, the ICD-9 code sets will be replaced by ICD-10 code sets

More codes for more specificity

Used in the US for coding fatal illness and injury

Primary user = those who assign codes

Training required

Secondary user=those who utilize coded data

ICD-9 codes valid through 10/2014

Section 4

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On October 1, 2014, the ICD-9 code sets used to report diagnoses and inpatient procedures will be replaced by ICD-10 code sets. The ICD-10 CM has more codes for more specificity. Since 1999 the US has used ICD-10 to code deaths but after October 2014 ICD-10 will be used to code all non-fatal and fatal illnesses, diseases and injuries. As with ICD-9 those who assign codes are primary users. Training is required for primary users. (Slide 100 has training links). Those who utilize coded data are secondary users. ICD-9 codes are valid up to October 2014. Users should be familiar with ICD-9 codes as they may still be in use for data collected prior to October 2014.

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X X X . XXX X

Encounter

Specificity: Cause, Anatomic Site, Severity

Injury Category

Anatomy of an ICD-10 Code

Section 4

#

This slide illustrates the additional detail that can be provided with ICD 10. An ICD-10 Code consists of three to seven characters. The first digit is a letter.

Second digit is a number and third digit can be a number or a letter. The fourth, fifth, sixth, and seventh digits can be alpha or numeric. The decimal placed after the first three characters. As is illustrated in the diagram the first three digits are a category of injury, the next three digits are for the cause, anatomical site or severity of injury and the final digit is an extension used to indicate whether the visit was an initial encounter or subsequent encounter or because of a chronic condition resulting from the original injury.

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ICD-10 Code Example

S02.91X A

S06.332 A

V54

Section 4

Skull Fracture

Initial Encounter

Laceration, Loss of Consciousness

Initial Encounter

Occupant of a pick-up truck or van injured in collision with a heavy transport vehicle or bus

#

In this example the first code tells us the patient suffered unspecified fracture of skull, initial encounter for closed fracture (S02.91XA) and the second denotes contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter (S06.332A). Multiple injuries will have multiple codes. The cause of the skull fracture was an occupant of a pick-up truck or van injured in collision with a heavy transport vehicle or bus (V54).

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Defining an Injury EventUsing ICD-Codes

Advantages

Ability to identify trends

Ability to describe the specific causes and contributing factors

Standardization of descriptions that can aid in sharing data or linking databases

As of October 1, 2014 all Indian Health Service/Tribal/Urban programs must use ICD-10 codes on all HIPAA electronic record transactions.

Disadvantages

Not all records may be coded

Records can be miscoded or inconsistently coded

Poor chart information results in non-specific code

Dont always provide the desired specificity

You must stay apprised of updates

Previously not required for billing, so seen by some coders as unnecessary

Section 4

#

There are advantages and disadvantages to using codes as noted on the slide. You should keep in mind that other data sources in your system, such as law enforcement, use different definitions for incidents, such as assault or neglect.

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Defining an Injury EventDetermining if Injury Codes Should be Included in Case Definition

Does your data source (clinic, hospital, trauma registry, etc.) use ICD codes?

Are you looking for specific types of injuries?

Does your data source assign a code to most injuries?

Are you confident in the completeness, accuracy, and specificity of the coded data?

Yes? Consider including codes in the case definition.

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If you answer yes to any of the questions on this slide, you could use ICD codes in the case definition.

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For More Information on ICD-9 or ICD-10 Codes

Contact your Area Office for training options.

Check these references:

American Academy of Professional Coders

http://www.aapc.com/

World Health Organization

http://www.who.int/classifications/icd/en/

CDC National Center for Health Statistics

http://www.cdc.gov/nchs/icd.htm

CDC article on improving E-coding

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5701a1.htm

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Case Definition Exercise

Purpose: Practice developing a case definition

Time for exercise: 30 minutes

Develop case definition to include the following:

Person, injury type(s), place, time, intent, severity

Report back to the group. Include how/why decisions were made for each.

Example:

All confirmed fractures (outpatient and inpatient) resulting from a fall from a horse during a rodeo, including all genders and ages, from 2010-2013, with treatment paid for by tribal health.

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Note for Instructor:

Ask the class to identify injury concerns in their community and agree on one for which a case definition will be developed. Or if you are completing the final exercise as the concepts are taught instruct the class to answer question 5 and develop a case definition for their groups chosen scenario.

Read the example and then ask to write a case definition.

Review: Is it clear? Does it clearly state level of severity? Location for where injuries occur? Is there anything that should be clarified?

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Its not necessary to be all encompassing

Start small; track the most severe injuries

Expand or phase in other levels when you can

You can initiate prevention without knowing everything about every injury in your community

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Defining Injury EventsImportant Things to Remember

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Its not necessary to be all-encompassing at the outset. Start small, tracking deaths and the most severe injuries. Plan to expand or phase in other levels of severity as your resources permit. You can initiate prevention efforts without knowing everything about every injury in your community.

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Introduction

Determine the Variables in Your System

Variables = Data for each injury event

Determines the data collected

Determines data collection form

Keep injury prevention goal in mind

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Data elements are the variables needed for each injury event, such as the demographic information, information on the time of the event, information on where the event took place or where the victim died and the circumstances surrounding the event. The case definitions and codes are included in the data elements as well.

The variables you define will determine the data you collect and the data collection form you develop. When determining the variables, keep the goal of surveillance in mind. The goal is prevention activity.

Theres value in collecting as much information as possible, but the more information you try to collect, the less likely your form will be filled out accurately or at all. A simple form will be more likely to yield information, even if its not all the information you would like. Some IHS areas have used a two-phased approach. A Phase 1 form is used to collect basic information about an injury. A Phase 2 form is used to collect more detailed information about specific injuries.

The variables you choose to include will depend on many things, including your locality, culture and the availability of data sources. Be realistic about what you include based on your circumstances and location. The next three slides shows some variables that are commonly collected.

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Name or other identifier

Age and sex

Marital Status

Education Level

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Name/Identifier -- The name of the injured person is often not available. For surveillance purposes it is not used or not collected because of privacy issues. Use hospital case number or DOB in lieu of name. Its important to use some kind of unique identifier in place of a name to avoid a duplication of cases, particularly when you are using data from two or more sources.

Age and sex

Marital Status

Education Level Consider whether this information is needed. Will knowing the education level of the victim impact your intervention activities?

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Introduction

Employment Level

BAC - Nice to have, but rarely available

Occupant Protection for Transportation

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Employment Level Same consideration as Education Level. Will it impact intervention? In some circumstances it could help you determine work-related injuries.

BAC This is an important variable, but its not always available. You may have to settle for Alcohol-involved or Alcohol-related designations. If you are using alcohol-involved or alcohol-related you will have to check with the local government or law enforcement to determine how these designations are defined.

Occupant Protection for Transportation Transportation includes all modes, such as horses, skateboards, bicycles as well as motorized vehicles, such as snow mobiles, boats. Protection includes seat belts, helmets, life jackets, etc.

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Introduction

Time

Place

Circumstances surrounding the injury event

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Time This is the date and time of an injury event. Ideally its the time the injury occurred, but most of the time you will only know the time of medical treatment. Choose one variant and go with it, even if its not the most accurate indication of when the injury occurred. A drawback to choosing the time of treatment is that in some cases people dont seek medical treatment until much later.

Place This could be the place where the injury occurred and/or the residence of the injured person. Injuries often occur when people travel to places for activities hunting, fishing, drinking ideally you collect both. Sometimes the information is very general such as the nearest village. Specifics are great, but if you cant get them you work with what you have.

Circumstances surrounding the injury event This could include information about the following.

Relationship of victim to aggressor

Mechanism

Context

Criminal history of victim and/or aggressor

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Introduction

Data Collection Instrument and Data Collection FrequencyDesigning a Form

Define what you want in your system first

Keep it simple

Only include the data you need

Make sure it is well-designed and easy to read

Decide whether or not to pre-code the form

PRE-TEST YOUR FORM!

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Data Collection Instrument and Data Collection Frequency

Deciding on the variables in a system will lead to the creation of a form. There is no right or wrong way to design a form. The shows some basic considerations when designing a form.

The simpler the form, the greater its usefulness over a long period of time

Gather only the data that is needed, you can use analysis to answer case definition questions later

A well-designed form is easy to fill out.

Pre-coding means providing a pre-coded list of possible answers, rather than filling the answers in. If you do pre-code, use numbers if possible. N