van Ditshuizen Jan C, Niemeyer Menco J S, Van Lieshout Esther M M, Den Hartog Dennis, Visser Jan-Jaap, van Wessem Karlijn J P, Verhofstad Michiel H J
Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Trauma Centre Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Eur Radiol. 2025 Jan 31. doi: 10.1007/s00330-025-11384-9.
Injury coding with the Abbreviated Injury Scale (AIS) is an important element for benchmarking, trauma registries and research.
To compare the severity of traumatic brain injury (TBI) coding derived from the AIS with or without the use of a standardised radiologic template.
A retrospective two-centre cohort study including patients aged ≥ 18 years with isolated TBI admitted to an intensive care between 2011 and 2016 was conducted. TBI was re-coded to conform the AIS by coders, and CT-brain imaging was reassessed by a neuro-radiologist following a standardised radiologic template from which AIS codes were derived.
A total of 560 patients were included (median age 57, 37% female). The percentage of MAIS ≥ 4 and major trauma was higher when AIS coding for TBI was derived from a standardised radiologic template vs. coding without (n = 456 (81.4%) and n = 374 (66.8%), p < 0.001; n = 441 (78.8%) and n = 352 (62.9%), p < 0.001, respectively). There was an inter-centre difference in the proportion of MAIS ≥ 4 re-coded without a standardised radiologic template (n = 212 (68.2%) and n = 140 (56.2%), p = 0.004), and no difference when re-coded with the template (n = 251 (80.7%) and n = 190 (76.3%), p = 0.206).
Coding TBI with AIS based on a standardised radiologic template results in fewer missed AIS head codes, more detailed AIS head codes, and more patients classified as 'major trauma'.
Question Radiologic reports are an important source for injury coding with the abbreviated injury scale (AIS) and are often not sufficiently specific. Findings An AIS-based standardised radiologic template for reporting resulted in more detailed AIS head codes and more patients classified as major trauma. Clinical relevance Injury coding with the AIS based on a standardised radiologic template will improve exchanging medical information in the acute health care setting and classification of trauma populations.
使用简明损伤定级（AIS）进行损伤编码是基准评估、创伤登记和研究的重要组成部分。
比较使用或不使用标准化放射学模板得出的AIS创伤性脑损伤（TBI）编码的严重程度。
开展一项回顾性双中心队列研究，纳入2011年至2016年间入住重症监护病房、年龄≥18岁的孤立性TBI患者。编码人员对TBI重新编码以符合AIS，神经放射科医生按照标准化放射学模板重新评估脑部CT影像，并从中得出AIS编码。
共纳入560例患者（中位年龄57岁，女性占37%）。当TBI的AIS编码源自标准化放射学模板时，严重AIS（MAIS）≥4及重伤的比例高于未使用模板时（分别为n = 456例（81.4%）和n = 374例（66.8%），p < 0.001；n = 441例（78.8%）和n = 352例（62.9%），p < 0.001）。在未使用标准化放射学模板重新编码的情况下，MAIS≥4的比例存在中心间差异（n = 212例（68.2%）和n = 140例（56.2%），p = 0.004），而使用模板重新编码时则无差异（n = 251例（80.7%）和n = 190例（76.3%），p = 0.206）。
基于标准化放射学模板使用AIS对TBI进行编码，可减少AIS头部编码遗漏、使AIS头部编码更详细，并使更多患者被归类为“重伤”。
问题 放射学报告是使用简明损伤定级（AIS）进行损伤编码的重要来源，但往往不够具体。 发现 基于AIS的标准化放射学报告模板可使AIS头部编码更详细，且更多患者被归类为重伤。 临床意义 基于标准化放射学模板使用AIS进行损伤编码将改善急性医疗环境中的医疗信息交换以及创伤人群的分类。
