# Presentation: 142966

## Updating Recommendations for Injury Surveillance in State Health Departments

**Report from the Injury Surveillance Workgroup**

**Notes:**
Good afternoon, I will be updating you on the progress of an Injury Surveillance Workgroup that has been working
On recommendations for injury surveillance at State health departments   

## Collaborative Effort of STIPDACSTENCIPCNCHSSAVIR

**Notes:**
State and Territorial Injury Prevention Directors Association
Council of state and territorial epidemiologists
National Center for Injury Prevention and Control
National Center for Health Statistics
Society for  Advancement of Violence and Injury Research

## Injury Surveillance Workgroup Members

**Lee Annest**
**Lois Fingerhut**
**Holly Hedegaard **
**Renee Johnson**
**Mark Kinde**
**Mel Kohn**
**Sue Mallonee**
**Hank Weiss**

## Consensus Recommendations for Injury Surveillance in State Health Departments-1st Edition (ISW1)

**Notes:**
In 1999 the first consensus recommendations report was produced to try to establish some capacities for state health departments for injury surveillance

## Table. Core Injuries, Injury Risk Factors, and Data Sets for State Injury Surveillance

** **

**(Indicates supplemental)**

**Notes:**
NOTES
1.        Abbreviation: VR=vital records, HDD=hospital discharge, FARS=Fatality Analysis Reporting System data, BRFSS=Behavioral Risk Factor Surveillance System data, YRBSS=Youth Risk Behavior Surveillance System data, ED=emergency department data, ME=medical examiner and coroner data, CDR=child death review team data, OPU=National Occupant Protection Use Survey data, UCR=Uniform Crime Reporting System data, EMS=emergency medical services data.
2.        Parentheses indicated data sets that are considered supplementary. All other data sets are considered essential.
3.        Asterisks(*) indicate three conditions -- traumatic spinal cord injuries (TSCI), fall injuries and poisoning -- for which the Working Group did come to closure on specific recommendations for surveillance.TCSI - Vital records systems have very low sensitivity in the detection of TSCI.Surveillance systems for TSCI that have been developed in several states have depended on medical record abstraction of hospitalized cases for reliable data collection. Developments of a less costly and less labor-intensive approach would put TSCI surveillance more realistically within reach for all state health departments.Fall Injuries and Poisoning - For these conditions, the Working Group has not yet developed surveillance case definitions to be recommended for routine use in all states. 

NOTES
1.        Abbreviation: VR=vital records, HDD=hospital discharge, FARS=Fatality Analysis Reporting System data, BRFSS=Behavioral Risk Factor Surveillance System data, YRBSS=Youth Risk Behavior Surveillance System data, ED=emergency department data, ME=medical examiner and coroner data, CDR=child death review team data, OPU=National Occupant Protection Use Survey data, UCR=Uniform Crime Reporting System data, EMS=emergency medical services data.
2.        Parentheses indicated data sets that are considered supplementary. All other data sets are considered essential.
3.        Asterisks(*) indicate three conditions -- traumatic spinal cord injuries (TSCI), fall injuries and poisoning -- for which the Working Group did come to closure on specific recommendations for surveillance.TCSI - Vital records systems have very low sensitivity in the detection of TSCI.Surveillance systems for TSCI that have been developed in several states have depended on medical record abstraction of hospitalized cases for reliable data collection. Developments of a less costly and less labor-intensive approach would put TSCI surveillance more realistically within reach for all state health departments.Fall Injuries and Poisoning - For these conditions, the Working Group has not yet developed surveillance case definitions to be recommended for routine use in all states. 
This is perhaps one of the most substantial parts of the green document where the workgroup recommended 14 injuries and risk factors and 11 data sets as core surveillance for state injury programs

## Injury Surveillance Workgroup (ISW5) Challenge

**Update Green Book**
**Readership-Novice and Experienced State Injury Personnel**
**Move Injury Surveillance Field Forward**
**Challenge the Field Toward the Future**

**Notes:**
This workgroup which was the 5th such ad hoc workgroup established was challenged to update the green initial report. Other interesting challenges are that the readership includes both novice personnel and personnel with vast years of experience so to make it interesting to all levels and innovative to move the injury surveillance field forward  was challenging. We wanted to look forward to what needs to be done next-
We wanted to challenge the field to keep looking toward the future

## Background

**Define uses of surveillance at the state and local level**
**Document many efforts at improving state injury surveillance since 1999**
**CSTE Position Statements**
**State Injury Indicators**
**Matrices**
**STAT Guidelines**
**Other Consensus Documents**

**Notes:**
We actually start with a background section that defines uses of surveillance at the state and local level
Then we documents 10 some odd efforts that have occurred since 1999 that have kept the field moving, such as the CSTE position statements that put standardized definitions to the 14 injuries and risk factors listed in the green book and then the subsequent collection of these State injury indicators by NCIPC and several state health departments.
The injury frameworks that have been developed to standardize organizing and presenting injury breakdowns.
There have been other consensus documents produced and the State Technical assessment team program has a comprehensive review of what a state injury surveillance program should be doing. Finally  

##  Injury Surveillance Principles

**Classification and Coding of Fatal Injuries**
**Underlying and Multiple Cause Coding**
**Matrices**
**Comparability of Mortality Data: ICD9-ICD10**
**Coding of Nonfatal Injury Data **
**External Cause Coding **
**Injury Severity**
**AIS**
**ICDMAP**
**ICISS  **

## Injury Surveillance PrinciplesRecommendations

**S****tate injury prevention programs should: **
**Regularly evaluate the completeness and specificity of external cause coding in their statewide hospital discharge and emergency department databases.**
**Provide information on the uses and adequacy of external cause coding back to those who produce the data as a way to improve data quality. **
**Explore the possibility of using statutory tools, rule-making or other policy actions to enhance the completeness and specificity of external cause coding. **

## Injury Surveillance PrinciplesRecommendations

**S****tate injury prevention programs should:**** **
**Support efforts at the national level to improve external cause coding.**
**Explore opportunities to provide training for health care providers and hospital coders regarding the importance of injury cause documentation. **

## State Injury Surveillance Capacity

**Access to Data**
**Need for Statutes/Regulations**
**HIPAA**
**National Sources of Data**
**Confidentiality **
**Human Subjects Issues **

**Notes:**
The State Injury Surveillance Capacities section describes the need for access to HDD, VS, ED, and BRFSS data for state injury surveillance systems. There is also a need to have explicit authority for injury surveillance in unusual circumstances-disasters, grant-related opportunities, and legislative mandates.
OK statute
HIPAA and exemption of public health for surveillance
List a broad source of national data sources for comparison to state data
The importance of confidentiality issues cannot be underappreciated and we make recommendations regarding formalizing confidentiality procedures at the sate level.
We describe some tools that help in the differences between research and surveillance activiies at the state level 

## State Injury Surveillance Capacity

**Core Injuries and Injury Risk Factors for State Injury Surveillance**
**Motor Vehicle Injuries ****	****	****•   ****Fire/Burn Injuries**
**Alcohol in MV Deaths****	****	****•   ****Smoke Alarm Use**
**Self-Reported Seat Belt Use ****	****•   Submersion Injuries**
**Homicide****	****	****	****	****•   Fall Injuries**
**Suicide/Suicide Attempts****	****	****•   Poisoning**
**Firearm Injuries****	****	****	****•   Spinal Cord Injuries**
**Traumatic Brain Injuries **

**Notes:**
The workgroup recommends the 14 injuries and injury risk factors and 1 data sets continue to be the core data for state heath depts.

## State Injury Surveillance Capacity

**Data Quality**
**Data Linkage**
**Dissemination of Data**
**Staffing and Training **
**Partnerships**

**Notes:**
Data quality is recommended to follow the updated guidelines for evaluating public health surveillance systems as a guideline for evaluating surveillance systems
Data linkage is a huge issue in injury surveillance today: CODES / NVDRS

## Recommendations for State Injury Surveillance Capacity

**State injury programs should:**
**Utilizing the STIPDA STAT guidelines, conduct a self-review of surveillance capacities.**
**Have injury morbidity, mortality, and risk behavior data available via web-based query systems.**
**Make it a priority to invest in training staff in injury surveillance and epidemiology.**
**Work with other organizations and agencies to implement statewide hospital discharge or emergency department data if no such data systems exists in the state.**

## New Challenges in Injury Surveillance

**Injury Surveillance in Statewide Emergency Department Datasets**
**Disaster Surveillance**

## Case Definition for Injury Hospitalization in Discharge Data

**Principal reason for admission (I.e., first listed code) is injury using nature of injury codes**
**800-994; 995.5**
**Excludes adverse effects & complications of care**
**External cause codes not included**

## Injury Surveillance in Statewide Emergency Department (ED) Datasets

**25 states have access to ED data**
**No definition of Injury ED visits to be counted has been recommended**
**State-to-state or state-to-national comparisons of ED visits requires standardization of definitions**

## Trends in Number of Injury Visits to Emergency Departments based on Five Alternative Definitions: United States, 1995-2004

## NCHS Recommendation for Injury Surveillance in ED Datasets

**First listed injury diagnosis **
**	****	****	****	****OR**
**Any mention of an external cause of injury code**
**Initial visits only**
**Excludes adverse effects and complications of care**

## New Challenges in Injury Surveillance Recommendations

**State injury programs should:**
**Use the expanded injury case definition in analysis of the state’s Emergency Department data  if they have the requisite data elements.**
**Each state should establish and maintain expertise in disaster epidemiology and collaborate with the state all-hazards preparedness programs.**
**State injury programs should support efforts at the national level to establish standardized reporting methods and data collection instruments for disaster surveillance.**

## Future Challenges

**Determining Incidence: De-duplicating Injury Morbidity Data**
**Capturing Complete Data from Hospitalized Injuries**
**Emergency Medical Service (EMS) Data**

## Future Challenges in Injury Surveillance Recommendations

**States should understand the importance of de-duplication of statewide hospital discharge and emergency department data systems **
**States should consider participation in efforts to develop standardized guideline for the de-duplication of statewide injury morbidity data.**
**There should be efforts to continue analyses of the effect of expanding the case definition to include external causes.**

## Report Finalization and Distribution

**Recommendations and report to be finalized by July 31, 2007.**
**Printing and distribution to all states, collaborating agencies, and other interested partners by October 2007.**