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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2016

Open Access 01-12-2016 | Original research

Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study

Authors: Ting Hway Wong, Gita Krishnaswamy, Nivedita Vikas Nadkarni, Hai V. Nguyen, Gek Hsiang Lim, Dianne Carrol Tan Bautista, Ming Terk Chiu, Khuan Yew Chow, Marcus Eng Hock Ong

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2016

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Abstract

Background

Anatomy-based injury severity scores are commonly used with physiological scores for reporting severity of injury in a standardized manner. However, there is lack of consensus on choice of scoring system, with the commonly used injury severity score (ISS) performing poorly for certain sub-groups, eg head-injured patients. We hypothesized that adding a dichotomous variable for polytrauma (yes/no for Abbreviated Injury Scale (AIS) scores of 3 or more in at least two body regions) to the New Injury Severity Score (NISS) would improve the prediction of in-hospital mortality in injured patients, including head-injured patients—a subgroup that has a disproportionately high mortality. Our secondary hypothesis was that the ISS over-estimates the risk of death in polytrauma patients, while the NISS under-estimates it.

Methods

Univariate and multivariable analysis was performed on retrospective cohort data of blunt injured patients aged 18 and over with an ISS over 9 from the Singapore National Trauma Registry from 2011–2013. Model diagnostics were tested using discrimination (c-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit statistic). All models included age, gender, and comorbidities.

Results

Our results showed that the polytrauma and NISS model outperformed the other models (polytrauma and ISS, NISS alone or ISS alone) in predicting 30-day and in-hospital mortality. The NISS underestimated the risk of death for patients with polytrauma, while the ISS overestimated the risk of death for these patients.
When used together with the NISS and polytrauma, categorical variables for deranged physiology (systolic blood pressure of 90 mmHg or less, GCS of 8 or less) outperformed the traditional ‘ISS and RTS (Revised Trauma Score)’ model, with a c-statistic of greater than 0.90. This could be useful in cases when the RTS cannot be scored due to missing respiratory rate.

Discussion

The NISS and polytrauma model is superior to current scores for prediction of 30-day and in-hospital mortality. We propose that this score replace the ISS or NISS in institutions using AIS-based scores.

Conclusions

Adding polytrauma to the NISS or ISS improves prediction of 30-day mortality. The superiority of the NISS or ISS depends on the proportion of polytrauma and head-injured patients in the study population.
Appendix
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Literature
1.
Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, et al. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg. 2012;214(5):756–68.CrossRefPubMedPubMedCentral
2.
Milzman DP, Boulanger BR, Rodriguez A, Soderstrom CA, Mitchell KA, Magnant CM. Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score. J Trauma. 1992;32(2):236–43. discussion 43.CrossRefPubMed
3.
4.
Baker SP, O'Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96.CrossRefPubMed
5.
Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43(6):922–5.CrossRefPubMed
6.
Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. Systematic review of predictive performance of injury severity scoring tools. Scand J Trauma Resusc Emerg Med. 2012;20:63.CrossRefPubMedPubMedCentral
7.
Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The new injury severity score: a more accurate predictor of in-hospital mortality than the injury severity score. J Trauma. 2004;56(6):1312–20.CrossRefPubMed
8.
9.
Hannan EL, Waller CH, Farrell LS, Cayten CG. A comparison among the abilities of various injury severity measures to predict mortality with and without accompanying physiologic information. J Trauma. 2005;58(2):244–51.CrossRefPubMed
10.
Meredith JW, Evans G, Kilgo PD, MacKenzie E, Osler T, McGwin G, et al. A comparison of the abilities of nine scoring algorithms in predicting mortality. J Trauma. 2002;53(4):621–8. discussion 8.CrossRefPubMed
11.
Harwood PJ, Giannoudis PV, Probst C, Van Griensven M, Krettek C, Pape H-C, et al. Which AIS based scoring system is the best predictor of outcome in orthopaedic blunt trauma patients? J Trauma. 2006;60(2):334–40.CrossRefPubMed
12.
Stephenson SCR, Langley JD, Civil ID. Comparing measures of injury severity for use with large databases. J Trauma. 2002;53(2):326–32.CrossRefPubMed
13.
Dillon B, Wang W, Bouamra O. A comparison study of the injury score models. Eur J Trauma. 2006;32(6):538–47.CrossRef
14.
Cooke RS, McNicholl BP, Byrnes DP. Use of the injury severity score in head injury. Injury. 1995;26(6):399–400.CrossRefPubMed
15.
Balogh ZJ, Varga E, Tomka J, Süveges G, Tóth L, Simonka JA. The new injury severity score is a better predictor of extended hospitalization and intensive care unit admission than the injury severity score in patients with multiple orthopaedic injuries. J Orthop Trauma. 2003;17(7):508–12.CrossRefPubMed
16.
Moore L, Lavoie A, Le S, Liberman M, Bergeron E. Two worst injuries in different body regions are associated with higher mortality than two worst injuries in the same body region. J Trauma. 2006;60(4):802–5.CrossRefPubMed
17.
Pape HC, Lefering R, Butcher N, Peitzman A, Leenen L, Marzi I, et al. The definition of polytrauma revisited: an international consensus process and proposal of the new 'Berlin definition'. J Trauma Acute Care Surg. 2014;77(5):780–6.CrossRefPubMed
18.
19.
20.
Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. The injury severity score revisited. J Trauma. 1988;28(1):69–77.CrossRefPubMed
21.
Ringdal KG, Coats TJ, Lefering R, Di Bartolomeo S, Steen PA, Roise O, et al. The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG. Scand J Trauma Resusc Emerg Med. 2008;16:7. doi:10.​1186/​1757-7241-16-7.CrossRefPubMedPubMedCentral
22.
Wong TH, Lumsdaine W, Hardy BM, Lee K, Balogh ZJ. The impact of specialist trauma service on major trauma mortality. J Trauma Acute Care Surg. 2013;74(3):780–4.CrossRefPubMed
23.
MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–78.CrossRefPubMed
24.
Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, et al. Relationship between trauma center volume and outcomes. JAMA. 2001;285(9):1164–71.CrossRefPubMed
25.
Groven S, Eken T, Skaga NO, Roise O, Naess PA, Gaarder C. Long-lasting performance improvement after formalization of a dedicated trauma service. J Trauma. 2011;70(3):569–74.CrossRefPubMed
26.
Paffrath T, Lefering R, Flohé S. How to define severely injured patients?-An Injury Severity Score (ISS) based approach alone is not sufficient. Injury. 2014;3:S64–9.CrossRef
27.
Ho AF, Chew D, Wong TH, Ng YY, Pek PP, Lim SH et al. Prehospital Trauma Care in Singapore. Prehosp Emerg Care. 2015;19(3):409–15.CrossRefPubMed
28.
(MOH) MoH. Population And Vital Statistics,Ministry of Health (MOH) Singapore. Ministry of Health, Singapore, Singapore. 2014. Accessed 20/07/2015 2015.
29.
Lim J. Myth Or Magic - The Singapore Healthcare System (Select Books: The Asian Book Specialist - Bookseller, Publisher and Distributor). Singapore: Select Books; 2013.
30.
National Registry of Diseases Office (NRDO) HPB, Singapore. Singapore National Trauma Registry Annual Registry Report 2012–2013. National Registry of Diseases Office (NRDO), Health Promotion Board, Singapore, Singapore. 2014. Accessed 20/07/2015 2015.
31.
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the trauma score. J Trauma. 1989;29(5):623–9.CrossRefPubMed
32.
33.
34.
Champion HR, Copes WS, Sacco WJ, Frey CF, Holcroft JW, Hoyt DB, et al. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation. J Trauma. 1996;40(1):42–8. discussion 8–9.CrossRefPubMed
35.
36.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.CrossRefPubMed
37.
38.
39.
Lefering R, Huber-Wagner S, Nienaber U, Maegele M, Bouillon B. Update of the trauma risk adjustment model of the TraumaRegister DGU™: the Revised Injury Severity Classification, version II. Crit Care. 2014;18(5):476.CrossRefPubMedPubMedCentral
40.
Copes WS, Champion HR, Sacco WJ, Lawnick MM, Gann DS, Gennarelli T, et al. Progress in characterizing anatomic injury. J Trauma. 1990;30(10):1200–7.CrossRefPubMed
41.
Gabbe BJ, Cameron PA, Finch CF. Is the revised trauma score still useful? ANZ J Surg. 2003;73(11):944–8.CrossRefPubMed
42.
Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5(8):10.CrossRef
43.
Collaborators MCT, Perel P, Arango M, Clayton T, Edwards P, Komolafe E, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336(7641):425–9.CrossRef
44.
Roozenbeek B, Lingsma HF, Lecky FE, Lu J, Weir J, Butcher I, et al. Prediction of outcome after moderate and severe traumatic brain injury: external validation of the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models. Crit Care Med. 2012;40(5):1609–17.CrossRefPubMedPubMedCentral
45.
Whitaker IY, Gennari TD, Whitaker AL. The difference between ISS and NISS in a series of trauma patients in Brazil. Ann Proc Assoc Adv Automot Med. 2003;47:301–9.
46.
Samin OA, Civil ID. The new injury severity score versus the injury severity score in predicting patient outcome: a comparative evaluation on trauma service patients of the Auckland Hospital. Annu Proc Assoc Adv Automot Med. 1999;43:1–15.PubMedCentral
47.
Raj R, Brinck T, Skrifvars MB, Kivisaari R, Siironen J, Lefering R, et al. Validation of the revised injury severity classification score in patients with moderate-to-severe traumatic brain injury. Injury. 2015;46(1):86–93.CrossRefPubMed
48.
Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5(8):e165. discussion e.CrossRefPubMedPubMedCentral
49.
Jones JM, Skaga NO, Søvik S, Lossius HM, Eken T. Norwegian survival prediction model in trauma: modelling effects of anatomic injury, acute physiology, age, and co-morbidity. Acta Anaesthesiol Scand. 2014;58(3):303–15.CrossRefPubMedPubMedCentral
Metadata
Title
Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study
Authors
Ting Hway Wong
Gita Krishnaswamy
Nivedita Vikas Nadkarni
Hai V. Nguyen
Gek Hsiang Lim
Dianne Carrol Tan Bautista
Ming Terk Chiu
Khuan Yew Chow
Marcus Eng Hock Ong
Publication date
01-12-2016
Publisher
BioMed Central
DOI
https://doi.org/10.1186/s13049-016-0215-6

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