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Injury surveillance systems: strengths, weaknesses, and issues workshop

Article · January 1985

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 Association of Schools of Public Health

Injury Surveillance Systems: Strengths, Weaknesses, and Issues Workshop

Author(s): Roy T. Ing, Susan P. Baker, J. B. Eller Jr., Ralph R. Frankowski, Bernard Guyer,
William H. Hollinshead, Jeff Pine and Ian R. H. Rockett
Source: Public Health Reports (1974-), Vol. 100, No. 6 (Nov. - Dec., 1985), pp. 582-586
Published by: Association of Schools of Public Health
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I also in age-specific patterns. Native Americans i income areas, and drivers who run red lights or
have the highest rates at all ages. Whites have the follow other cars too closely. There has been very
second highest rates among teenagers and the el little emphasis on protecting high-risk groups from
derly. Unlike rates for other races, those for blacks injuries by using measures that require only a mini
do not peak between ages 15 and 24, and they in mum of effort, although in other public health areas
crease after age 25. these types of measures (for example, pasteuriza
For most categories of unintentional injuries, death tion) have proved most effective.
rates are higher in low-income areas than in high 2. There is a tragic discrepancy between our
income areas and higher in rural than in urban knowledge about the etiology of injury and the ap
areas. There is pronounced geographic variation plication of that knowledge. For example, (a) cer
among unintentional injury deaths. These dramatic tain lifesaving features of car and aircraft design
variations illustrate the importance of the environ have been known and proved effective, often for
ment as a determinant of injury death rates. decades, but have not been incorporated into vehi
Almost all causes of death from unintentional in cle manufacture, (b) most roads do not provide
jury have weekend peaks, generally coinciding with state-of-the-art protection against even the most
increased social and recreational activity and foreseeable crashes into roadside hazards, and (c)
greater alcohol use. The patterns of injury deaths by residences are not required to have automatic
month are different for most causes of injury. sprinkler systems. The effective control of many
Issues that must be addressed by the participants causes of injury is within our grasp, provided we
at this conference include the following: give them the same priority that we give other major
environmental problems and that we address them
with the same basic scientific approaches.
1. Members of population groups at especially high
risk of being injured are often least apt to change
Reference
their behavior regarding protection against injury.
The use of seatbelts, for example, is least common 1. S. P., O'Neill, and Karpf, R. S.: The fact
Baker, B., injury
among persons at greatest risk of being in a crash: book. Lexington Books, D.C. Heath and Company,

teenagers, intoxicated drivers, people in low- | Lexington, MA, 1984.

Injury Surveillance Systems? Value of Existing Data Sources

Strengths, Weaknesses,
Before data are collected, we should understand
and Issues Workshop
fully what questions need to be answered and how
Roy T. Ing,MD, MPH (Group Leader); Susan the data will help answer them. Since the costs
P. Baker, MPH; J. B. Eller, Jr.; Ralph R. associated with collecting data may be very high, it
Frankowski, PhD; Bernard Guyer, MD, MPH; is not surprising that some recurring questions are
William H. Hollinshead, MD, MPH; Jeff Pine, (a) how important is it to have the question an

MSPH, MS; and Ian R. H. Rockett, PhD swered? (b) what costs are associated with collect
ing the data? (c) can less costly alternatives satisfy
The motivation for convening this workshop the need? (d) are the answers to the questions
was to recommend model injury surveillance sys worth the costs involved in collecting the data?
tems at the national, State, and local levels; estab Because of the potentially high costs associated
lishing specific details of a model are difficult, how with starting and maintaining any surveillance sys
ever, especially when data collection methods are tem, we should take advantage of existing data
changing rapidly because of changes in health care sources as much as possible. Although such data may
delivery and computer technology. For this reason, be obtained easily, they are usually collected for other
we present a framework for viewing data needs and purposes?such as death certification or workmen's
I data collection under various circumstances, rather compensation?and may lack information deemed
than describing a model surveillance system that essential for injury surveillance or studies. Never
I soon would be outmoded. theless, all existing sources of information should

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be examined carefully for their potential usefulness questions, but also they may present new concerns
in injury prevention. to be investigated and new hypotheses to be
Existing data collection systems can be used tested. As information needs change, collection sys
more widely and more effectively. For example, tems are frequently unable to satisfy the needs be
injury mortality for a particular State or county can cause of the way they are structured. Even minor
be produced easily and regularly by the State's vital changes in items of data may require legislation
statistics department. (such as changes in death certificates) or wide
spread cooperation (such as from staff of a large
Recommendations : number of hospitals and physicians when changes in
1. Examine, improve, and make full use of the medical records are proposed). Another concern is
existing sources of information for injury surveil the confidentiality of records, especially when data
lance and studies. Examples of the diversity of have been obtained from multiple sources and
sources are emergency medical services, fire mar merged.
shals reports, and fiscal data, such as Medicare and Incompleteness, errors, and bias can affect data
Medicaid payment records. For a more complete at any or all of the multiple steps in collection and
listingof potential sources, contact Injury Epi analysis. Clearly, data must be collected and pro
demiology and Control, Center for Environmental cessed before they can be interpreted. Data on in
Health, Centers for Disease Control, Atlanta, GA jured persons treated in hospital emergency rooms,
30333. for example, must first be written in the patient's
2. Since sources of information vary substantially medical chart by the attending physician or medical
among geographic areas, develop a comprehensive personnel before they can be coded by the medical
inventory of sources. The inventory should give the records personnel. The coded data then must be
source, form (such as computer tapes and reports), entered into a computer system and merged with
specific items included, and data quality, documen data from other hospitals. Finally, the data are tabu
tation, coverage, and availability. The purpose of lated, analyzed, and disseminated. Because of re
the inventory is to provide a catalog of injury infor source limitations, only preselected items are coded,
mation that is useful at all levels of surveillance. and these data will be readily available for analysis
3. State vital statistics departments and other agen only if they are coded and entered into a computer
cies collecting injury-related data should analyze system. Data items must be in agreement and cod
and disseminate the information in a timely manner. ing schemes must be uniform if data are to be aggre
4. Data sources should be encouraged to report gated and compared.
incidence and mortality rates by age groups. Age Not only must we specify which items are to be
grouping for children and adolescents should be as coded, but we must also specify the ones that need
follows: less than 1 year, 1-4 years, 5-9 years, and to be recorded systematically but not coded (for
10-14 years. example, clinical variables used in assessing the
severity of the injuries). Such information is impor
Data Needs in Injury Prevention tant for researchers who require more detailed in
formation.

Data required for injury prevention are varied, There are four different methods of collecting
depending on the intended uses of the data. Data are injury-related information: routine active surveil
needed for planning and evaluating prevention pro lance, monitoring sentinel injuries, specialized sur
grams, for a better understanding of the factors veillance and registries, and epidemiologic studies.
associated with injuries, and for identifying emerg
such as injuries related to changes in Routine
ing problems active surveillance. The primary goal of sur
lifestyle, technology, and consumer products. The veillance is the continuous of rates of
monitoring
myriad data needed require a combination of meth injury morbidity and mortality in defined popula
ods of collecting data from a number of sources, tions. Although all injuries need not be identified, a
including agencies outside the health care system, good surveillance system must enable researchers
such as police and fire departments. to estimate accurately at least the age-specific inci
Usually, information-gathering systems cannot dence and mortality rates for the selected injuries
keep pace with the information desired. Data needs over time. Great care must be exercised in selecting
are continuously changing as more is learned about the injuries and the data to be collected; otherwise,
the nature of injuries and the factors associated with the burden and costs of data gathering will cause the
them. Often, the data collected may answer some rapid demise of the system.

November-December 1985, Vol. 100, No. 6 583

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 Some significant issues related to surveillance fol I areas over time. In such situations, reporting cases I
low: to centralized registries may be a good method for
data collection. Examples of injuries that may be
1. Which injuries should be included? candidates for registries are severe burns, severe
2. What items of data should be included? head trauma, and spinal cord injuries.
3. What geographic areas or populations should be
included? Recommendation: Identify injuries that are candi
4. Is demographic information available on the dates for registries and determine what items and
population so that rates can be calculated? schemes are for the different
coding appropriate
5. How should the data be collected, that is, ob types of injuries.
tained through routine certificates, reporting, ab
stracting records, and so forth? studies. In contrast to surveillance, in
Epidemiologic
6. How soon must the data be available to those which the major objective is to show variations in
needing them? incidence rates over time, place, and personal
characteristics, an epidemiologic study may try to
Recommendations : establish causative and risk factors in the occur
1. Before starting an injury surveillance system, be rence and severity of injuries through intensive ex
sure that itwill enable researchers to estimate accu amination of data on the injury or injuries in ques
rately the incidence of selected injuries and injury tion and, where appropriate, of data on noninjured
related deaths in a defined population over a period comparison groups. An epidemiologic study may
of time. establish incidence rates, but such a study is not a
2. Identify important injuries, data items, data col surveillance system unless it is repeated period
lection methods, and costs and make recom ically so that trends in incidence can be determined.
mendations on injury surveillance systems that are This distiction between epidemiologic studies and
feasible now and in the future. surveillance needs to be kept in mind, since in a
surveillance system the amount of data collected
Monitoring sentinel injuries. The concept of monitor must be limited (to assure the feasibility of collec
ing sentinel injuries or injury-producing events can tion over time), but in an epidemiologic study the
be useful in identifying emerging problems or chang amount of information collected may be very large
ing patterns of injury rates. Persons may be injured (to control for possible confounding factors). Im
in new ways as they change their recreational ac portant risk factors identified through studies may
tivities of daily living. Reports of injuries in the be incorporated into surveillance, especially when
news media may prompt further investigation and interventions related to these factors may be part of
monitoring of these injuries. Certain types of in an injury prevention program in the community.
juries may serve as sentinels, that is, they may alert
us to a much larger problem. For example, changing Statistical Sampling
patterns (time, place, and demographic characteris
tics of the injured) of severe head and neck injuries
Because the cost of collecting and compiling de
may reflect changes in sport or motorcycle ac
sired injury data can be very high, an alternative
tivities. Increases in rates should prompt inves
strategy is to obtain information only on a statistical
tigators to examine the causes of these and other
sample of injuries. The size of the sample and the
injuries that may be produced by similar events. to select the study population
way chosen depend
on many factors, such as the incidence and geo
Recommendation: Determine which injuries or in graphic distributions of the injuries. Sampling is
jury-producing events can act as sentinels for spe especially useful when the incidence of the injuries
cial monitoring. in question is high and the distributions are some
what predictable?such as with motor vehicle in

Specialized surveillance and registries. In many types juries, falls, and burns.
of severe injuries, we would like to have more de With less common injuries or injuries that occur
tailed information on the injury-producing event, sporadically, an extremely large sample may be
the nature of the injuries, the patient's survival and needed to obtain reliable estimates, and other
disabilities, and outcomes of treatment. If the injury methods?such as reporting?may be preferable to
is uncommon, we need to compile information on sampling for certain uncommon but severe injuries.
similarly injured persons from different geographic I Sampling can be applied to one or more hospitals |

584 Public Health Reports

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or emergency rooms as well as to selected types of that are used routinely in coding underlying causes
injuries within the hospitals or emergency rooms. of death in death certificates. However, other
sources of injury data?such as hospital discharge
Severity of Injury summaries?often use the nature of disease (N
codes) format of the ICD codes. Since the corre
Not only do researchers need information on var spondence between the N codes and the E codes is
ious types of injuries and their frequency of occur not one to one, it is difficult to compare data from
rence, but also they need to know the extent and different sources if injuries are coded by different
severity of injuries. Scoring systems for severe schemes.
trauma have been established, and these scores, if
routinely included in medical records, would be Recommendations :
very valuable to researchers. 1. Hospitals should code hospital discharge diag
noses by both E and N codes instead of by N codes
Recommendations : current practice. The E codes should also
only?the
1. Hospitals should be strongly encouraged to be used for future coding of injuries of ambulatory
adopt and use the severity of injury scores (Trauma patients.
Score and Abbreviated Injury Scale or Injury Sever 2. State health departments should establish a
ity Score), in addition to coding the nature of in model for reporting injury mortality.
juries in the medical records for trauma patients. 3. Physicians and health care workers should care
2. Hospitals should be strongly to in the hospital
encouraged fully record discharge record the
adopt and use standard scores, such as the Glasgow cause and the outcome, in addition to the nature of
Coma Scale in head injuries, and similar scoring the injury.
for the severity of particular 4. The Centers for Disease
systems injury pathol Control (CDC), in col
ogies. laboration with the National Center for Health
3. Hospitals should record outcome scores to show Statistics should assist State health de
(NCHS),
the course of recovery and need for rehabilitative partments in promoting the use of uniform and
care.
comparable reports on injury mortality.

for Surveillance
Coding of Injuries Funding

Ongoing funding for injury surveillance is re

A major source of data is the hospital record. The
quired if injury rates are to be monitored over time.
type of injury is usually recorded and reported for a
The most efficient methods need to be used so that
hospital discharge, but often the event or cause of
costs can be kept to a minimum, yet the needs will
the injury is not. For example, the hospital dis
be met.
charge may mention the diagnosis of hip fracture,
but the fact that the fracture resulted from a fall is
Recommendation: Funding for developing and im
not routinely reported. Frequently, the physician
plementing injury surveillance should be increased.
who writes the note in the hospital chart may not
Funding of pilot projects should be encouraged,
have inquired whether the "fall" resulted from the
since new and existing systems need to be evaluated
patient's being pushed or knocked down. When an
in terms of costs and effectiveness. Funding for
injury is known to have been intentional, such in
surveillance also must match the need for reducing
formation is even less likely to be in the hospital
chart. A researcher interested in studying fall injury rates.
related injuries, for example, would have to search Control Programs
through records of many different types of injuries,
such as head injuries, lacerations, and fractures. The ultimate goal of injury surveillance is using
Furthermore, these injuries may have been caused the information to prevent injuries. Since surveil
by events other than falls. lance often requires considerable expenditure of ef
For the purpose of monitoring and studying in fort and time, it should be undertaken only if there
juries, the diagnoses have to be assigned diagnostic is a commitment to injury prevention programs.
codes. The most widely used coding scheme is
the International Classification of Diseases (ICD) Recommendation: Injury prevention programs must
codes. For injuries and other "external" causes of have clearly defined objectives for injury surveil
death, the ICD provides the separate set of E codes lance.

November-December 1985, Vol. 100, No. 6 585

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 Death Certificates 2. Encourage the National Association of Medical
Examiners to adopt guidelines for uniformity in data
Death certificates provide valuable data that con items and coding schemes in the Medical Examiner
tribute to the epidemiologic profile of an injured Record.

person. The value of death certificates may be en 3. Conduct routine standardized testing for blood
hanced by implementing proposed recommenda alcohol content in all injury-related deaths if the
tions. death occurred within 6 hours of injury.
4. Study the feasibility of having medical examiners
Recommendations : submit a supplemental form along with death cer
1. Use ICD N codes in addition to E codes for tificates for selected cases. Identify candidate in
injury-related deaths. juries and data items for this supplement.
2. Include the location of the injury classified ac
cording to (a) at home, (b) in transportation (not
Emergency Room Records
work related), (c) in transportation (work related),
and (d) at work (not transportation related).
3. Include the person's occupation at the time of For many State and community-based injury con
death; NCHS should code the occupation for all trol programs, emergency room (ER) records are an
deaths receiving an E code. integral part of their surveillance system. The fol
4. Include in the death certificate, and in NCHS lowing recommendations are aimed at increasing
mortality tapes, whether the injury occurred at the overall effectiveness of these records.
work.

Recommendations :
Medical Examiners' Records 1. Hospitals should computerize their ER log
books.

The value of medical examiners' records may be 2. A CDC-organized interagency committee should
enhanced by adoption of the following recommen study and recommend a minimum uniform set of
dations. data to be included in all ER logs.
3. The Joint Commission on Accreditation of Hos
Recommendations : pitals should require hospitals to keep minimum
1. Encourage the sharing of medical examiners' rec statistical records on characteristics of patients and
ords for injury prevention purposes. injuries treated at the ERs.

Surveillance in Injury Prevention I Surveillance can be used to define the epidemiol

ogy of injuries and to facilitate control programs.
Surveillance data can be used in epidemiology to
Roy T. Ing, MD, MPH, Medical
Epidemiologist, Special Studies Branch, Document the magnitude of injury problems,
Chronic Diseases Division, Center for Characterize at risk for injuries by
populations
Environmental Health, Centers for Disease using demographic, geographic, and environmental
Control, Atlanta, G A 30333 data,

Identify emerging or recurrent problems in injury

Epidemiologic surveillance is the continuous prevention and control, and
of diseases, their consequences, and Generate hypotheses of injury risk factors.
monitoring
their causative and associated factors in defined
populations. of
In the prevention injuries, surveil Before can decide how to prevent
we injuries in a
lance includes the monitoring not only of injury-re community, we need to know what persons and
lated deaths, morbidity, and disability but also of groups are at high risk of injuries; what types of
agents, events, and situations that produce human injuries occur; and when, where, and under what
injuries or that predispose persons to injuries. One circumstances injuries occur. By comparing such
of the primary aims of surveillance is to identify data over time and for different populations, we can
populations at high risk for injuries. I observe changing patterns of injuries and perhaps I

586 Public Health Reports

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