Hospitals must improve patient safety and quality continuously. Clinical quality registries can drive such improvement. Trauma registries code injuries according to the Abbreviated Injury Scale (AIS) and benchmark outcomes based on the Injury Severity Score (ISS) and New ISS (NISS). The primary aim of this study was to validate the injury codes and severities registered in a national trauma registry. Secondarily, we aimed to examine causes for missing and discordant codes, to guide improvement of registry data quality. We conducted an audit and established an expert coder group injury reference standard for patients met with trauma team activation in 2015 in a Level 1 trauma centre. Injuries were coded according to the AIS. The audit included review of all data in the electronic health records (EHR), and new interpretation of all images in the picture archiving system. Validated injury codes were compared with the codes registered in the registry. The expert coder group’s interpretations of reasons for discrepancies were categorised and registered. Inter-rater agreement between registry data and the reference standard was tested with Bland–Altman analysis. We validated injury data from 144 patients (male sex 79.2%) with median age 31 (inter quartile range 19–49) years. The total number of registered AIS codes was 582 in the registry and 766 in the reference standard. All injuries were concordantly coded in 62 (43.1%) patients. Most non-registered codes (n = 166 in 71 (49.3%) patients) were AIS 1, and information in the EHR overlooked by registrars was the dominating cause. Discordant coding of head injuries and extremity fractures were the most common causes for 157 discordant AIS codes in 74 (51.4%) patients. Median ISS (9) and NISS (12) for the total population did not differ between the registry and the reference standard. Concordance between the codes registered in the trauma registry and the reference standard was moderate, influencing individual patients’ injury codes validity and ISS/NISS reliability. Nevertheless, aggregated median group ISS/NISS reliability was acceptable.

中文翻译：

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国家创伤登记中的伤害编码：在1级创伤中心进行的为期一年的验证审核

医院必须不断提高患者的安全性和质量。临床质量注册机构可以推动这种改善。创伤登记处根据缩写伤害量表（AIS）和基于伤害严重度评分（ISS）和新ISS（NISS）的基准结果对伤害进行编码。这项研究的主要目的是验证在国家创伤登记处记录的伤害代码和严重程度。其次，我们旨在检查代码丢失和不一致的原因，以指导提高注册表数据质量。我们进行了审核，并为2015年在1级创伤中心遭受创伤团队​​激活的患者建立了专家编码组伤害参考标准。根据AIS对伤害进行编码。审核包括审查电子健康记录（EHR）中的所有数据，以及图片存档系统中所有图像的新解释。将经过验证的伤害代码与注册表中注册的代码进行比较。专家编码小组对差异原因的解释已分类并注册。注册表数据与参考标准之间的评分者之间的一致性已通过Bland-Altman分析进行了测试。我们验证了144位中位年龄为31岁（四分位间距19-49岁）的患者（男性79.2％）的损伤数据。在注册表中，已注册的AIS代码总数为582，在参考标准中为766。62位患者（43.1％）的所有伤害均一致编码。大多数未注册的代码（71位患者中的166位患者（49.3％））为AIS 1，而由注册服务商忽略的EHR中的信息是主要原因。头部受伤和四肢骨折的编码不一致是74位（51.4％）患者中157条不一致的AIS编码的最常见原因。登记册和参考标准之间总人口的中位数ISS（9）和NISS（12）没有差异。在创伤登记处注册的代码与参考标准之间的一致性适中，从而影响了各个患者的伤害代码有效性和ISS / NISS可靠性。尽管如此，ISS / NISS汇总中位数的信度还是可以接受的。影响个别患者的伤害代码有效性和ISS / NISS可靠性。尽管如此，ISS / NISS汇总中位数的信度还是可以接受的。影响个别患者的伤害代码有效性和ISS / NISS可靠性。尽管如此，ISS / NISS的总体中位数可靠性还是可以接受的。