Improving National Trauma Data Bank® coding data reliability for traumatic injury using a prospective systems approach

• Published in: Health informatics journal Vol. 22; no. 4; pp. 1076 - 1082
• Main Authors: Ewing, Michael, Funk, Geoffrey A, Warren, Ann Marie, Rapier, Nakia, Reynolds, Megan, Bennett, Monica, Mastropieri, Cyndi, Foreman, Michael L
• Format: Journal Article
• Language: English
• Published: London, England SAGE Publications 01.12.2016; SAGE PUBLICATIONS, INC
• Subjects: Data Accuracy; Databases, Factual - standards; Epidemiology; Feature extraction; Humans; Prospective Studies; Quality Improvement - trends; Reproducibility of Results; Retrospective Studies; Systems Analysis; Trauma centers; Trauma Centers - organization & administration; Trauma Centers - trends; Wounds and Injuries; decision-support systems; electronic health records; health-care service innovation and IT; databases and data mining; quality control; information and knowledge management
• DOI: 10.1177/1460458215610896
• ISSN: 1460-4582

Trauma centers manage an active Trauma Registry from which research, quality improvement, and epidemiologic information are extracted to ensure optimal care of the trauma patient. We evaluated coding procedures using the Relational Trauma Scoring System™ to determine the relative accuracy of the Relational Trauma Scoring System for coding diagnoses in comparison to the standard retrospective chart-based format. Charts from 150 patients admitted to a level I trauma service were abstracted using standard methods. These charts were then randomized and abstracted by trauma nurse clinicians with coding software aide. For charts scored pre-training, percent correct for the trauma nurse clinicians ranged from 52 to 64 percent, while the registrars scored 51 percent correct. After training, percentage correct for the trauma nurse clinicians increased to a range of 80–86 percent. Our research has demonstrated implementable changes that can significantly increase the accuracy of data from trauma centers.