The Journal of TRAUMA Injury, Infection, and Critical Care

Validation of a Relative Head Injury Severity Scale for

Pediatric Trauma
Sara Cuff, RN, Stephen DiRusso, MD, PhD, Thomas Sullivan, BS, Donald Risucci, PhD, Peter Nealon, BA,
Adil Haider, MD, MPH, and Michel Slim, MD
Background: Brain injury is the most
important independent predictor of mortality and morbidity in pediatric trauma.
The Glasgow Coma Score (GCS) is the
commonly used clinical instrument to assess brain injury. However, the GCS or
one of its components is often not applicable in children under a certain age or cannot be computed reliably because of the
patients condition or the circumstances
surrounding resuscitation efforts. This
limits its usefulness in statistical models
of trauma outcomes, which rely on complete data collection and entry into
trauma registries. This study provides evidence validating use of a relative head
injury severity scale (RHISS) derived
from available International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes to stratify degree of head
injury.

Methods: The patient population was

derived from the National Pediatric
Trauma Registry (NPTR;1994 2001).
Survival Risk Ratios (SRRs) were computed for each head injury ICD-9 code.
ICD-9 diagnosis codes related to head
injury were then assigned to a RHISS category based on duration of loss of consciousness, location of skull fracture, or
both: 0 none; 1 mild; 2 moderate,
or 3 severe head injury. Analysis of
variance compared mean SRRs across
RHISS categories. Each patient was then
assigned to a RHISS category based on
their single worst ICD-9 head injury code.
Logistic regression analysis was used to
predict mortality based on New Injury Severity Score (NISS), whether the patient
had been intubated, RHISS, and the Abbreviated Injury Score (AIS) for head and
neck injuries.

Results: GCS score was missing for

96% of nonsurvivors in the NPTR. Mean
SRRs differed significantly ( p < 0.001)
among ICD-9 codes assigned to each
RHISS category, as follows (Mean SD):
RHISS (0) 0.93 0.16; RHISS (1)
0.89 0.22; RHISS (2) 0.85 0.26;
RHISS (3) 0.55 0.35. Logistic regression identified RHISS as an independent
significant predictor ( p < 0.01) of mortality.
Conclusion: RHISS is a valid index
of degree of head injury in the pediatric
trauma population. Unlike GCS, RHISS is
more likely to be available in trauma registries, and can be computed from administrative data. RHISS provides a feasible
and valid method for quantifying the degree of brain injury in statistical models of
pediatric trauma outcome.
Key Words: Trauma, Head injury,
Pediatrics, Outcome.
J Trauma. 2007;63:172178.

losed head injury is the dominant outcome factor in traumatic injury in children, accounting for as much as 80% of
pediatric trauma-related deaths.1 The Glasgow Coma
Score (GCS) has been the standard for assessment of neurologic
status among patients with traumatic closed head injuries. GCS
is a strong predictor of mortality25 and complications in
children,6 and of functional outcome among survivors.7,8
There are however, major difficulties in using the GCS
as an outcome prediction tool or as a variable in more complex outcome prediction models.

Submitted for publication January 21, 2006.

Accepted for publication February 1, 2007.
Copyright 2007 by Lippincott Williams & Wilkins, Inc.
From the NY Medical College Department of Surgery (S.C., T.S., D.R.,
P.N., M.S.), Valhalla, New York; Department of Surgery, St. Barnabas Hospital
Bronx and Weill Medical College of Cornell University (S.D.), New York, New
York; and Johns Hopkins School of Medicine/Public Health (A.H.), Baltimore,
Maryland.
Supported in part by an unrestricted grant from the Institute of Trauma
and Emergency Medicine, NY Medical College, Valhalla, NY.
Presented at the 18th Annual Meeting of the Eastern Association for the
Surgery of Trauma, January 1215, 2005, Ft. Lauderdale, Florida.
Address for reprints: Stephen M. DiRusso, MD, PhD, Director Surgical
Services, St. Barnabas Hospital, Third Avenue and 183rd Street Bronx, New
York 10457; email: stephen_dirusso@stbarnabas-ny.org.
DOI: 10.1097/TA.0b013e31805c14b1

172

The GCS is often missing in a large percentage of patients in large database cohorts. In addition, the calculation of
the GCS in intubated patients is still controversial and a
source of variability. The use of the GCS may be even more
difficult in the pediatric population, especially assessing the
verbal component of the score. The use of only the motor and
eye components has been proposed.9 Hannan et al.10 have
proposed a prediction model for pediatric blunt trauma patients where only the motor response of the GCS is used. The
GCS is often unavailable in administrative data sets. Therefore, an alternate indicator of severity of head injury must be
constructed if these data sets are to be analyzed for outcomes
related to traumatic closed head injury.
We propose an alternate indicator of the degree of closed
head injury in the pediatric trauma patient that is based on ICD-9
diagnosis codes that correlate with the degree of head injury and
with fractures of the skull. These codes are categorized to form
a scale describing the degree of head injury: 1 mild, 2
moderate, and 3 severe. This article describes initial steps to
validate this scale in the pediatric trauma population.

METHODS
Patient Population
The patient population was composed of patients entered
in the last phase of the National Pediatric Trauma Registry
July 2007

Validation of a Relative Head Injury Severity Scale

(NPTR) with hospital admission dates from April 1996
through September 2001. The NPTR is a national pediatric
trauma registry started in 1985 and is designed to provide
data for studying outcomes and management of the acutely
injured pediatric trauma patient.11 More than 90 pediatric
hospitals or trauma centers were contributors to this database,
which includes all trauma patients less than 20 years of age
admitted with a primary diagnosis of injury. At most hospitals, trauma nurse coordinators collected data, which included
demographics, mechanism of injury, injury diagnoses, prehospital care, hospital care and procedures, and outcomes at
discharge.11 Burns, drowning, near drowning, and poisoning
are excluded from the data set.

compare mean SRRs of the ICD-9 Dx codes assigned to the

four RHISS categories.
Next, each patient was assigned to a RHISS category,
based on the RHISS category of his or her most severe ICD-9
head injury Dx code (range: 0 no closed head injury (CHI);
to 3 severe CHI). A logistic regression model was then
developed to predict mortality using the following variables:
intubated in the field or not intubated in the field, New Injury
Severity Score (NISS),12 Abbreviated Injury Score (AIS) for
the head and neck region (AIS-HN),13 and RHISS category.
These variables were chosen based on past research on prediction models for pediatric and adult trauma.14,15 Performance of the model was assessed by calculating the area
under the receiver operating characteristic curve (ROC-Az).

The Relative Head Injury Severity Scale (RHISS)

A relative head injury severity scale (RHISS) was constructed on the basis of groups of International Classification
of Diseases, 9th Revision (ICD-9) diagnosis (Dx) codes.
First, all ICD-9 Dx codes for fractures of the skull vault or
skull base, or for brain injury were identified. These included
codes for fractures of the skull (800 804, excluding 802:
fracture of facial bones), and intracranial injury without skull
fractures (850 854).
These ICD-9 Dx codes were then mapped to a scale of
mild (1), moderate (2), or severe (3). A value of zero was
assigned to all other ICD-9 Dx codes. The criteria for assigning a diagnosis code to each of these groups was determined
on the basis of the presence or absence of brain injury,
location of skull fracture, and duration of loss of consciousness. Each individual ICD-9 code was assigned a grade on the
basis of these criteria. When a single ICD-9 Dx code covered
multiple injuries or a wide range of duration of loss of
consciousness, the lesser injury was assigned that code. The
set of rules of assignment is shown in Table 1.

Statistical Analysis
Survival Risk Ratios (SRRs) were computed for each
brain injury or skull fracture ICD-9 diagnosis code. This was
done as follows: for the entire NPTR, all patients with a
particular ICD-9 Dx code were identified,2 the SRR was then
calculated to be the number of survivors with that ICD-9 Dx
code divided by the total number of patients with that ICD-9
Dx code. Analysis of variance (ANOVA) was then used to

RESULTS
There were a total of 50,199 patients and the overall
mortality in the entire cohort was 2.9%. Table 2 shows the
general demographics for this cohort. Forty two percent of
the patients had some degree of traumatic closed head injury.
Figure 1 shows the number of patients in each of the RHISS
categories. Twenty-three percent (11,507 patients) had no
recorded GCS. Figure 2 shows the distribution of missing
GCS values stratified by the RHISS categories. Importantly,
close to 90% of patients with an RHISS of 3 (severe head
injury) had missing GCS values.

SRR Differences Across RHISS Categories

The first step in validating the RHISS was to verify that
SRRs were higher for the less severe RHISS categories and
decreased for the more severe RHISS categories. ANOVA com-

Table 2 General Demographics of the Patient Cohort

Total number of patients
Average age (years)
% Male
Average NISS
% with closed head injury
Mortality

50,199
8.15 5.2
64%
10.33 11.0
41.60%
2.90%

Table 1 Rules of Assignment of RHISS Value

Any head injury with loss of consciousness for 24 hours
severe (RHISS 3)
No other diagnosis yields an assignment of severe
Any brain injury (contusion) at least moderate (RHISS 2)
ICD-9 codes with unspecified nature of injury mild
(RHISS 1)
Skull base fracture at least moderate (RHISS 2)
Vault of skull fracture at least mild (RHISS 1)
loss of consciousness for 124 hours increases RHISS to
moderate (RHISS 2)

Volume 63 Number 1

Fig. 1. Percentage distribution of patients stratified by RHISS.

173

The Journal of TRAUMA Injury, Infection, and Critical Care

significantly lower than those in RHISS categories 0, 1, and 2.
The mean SRR for injury codes in RHISS category 2 was
significantly lower than that of RHISS category 0.

Application of the RHISS to the NPTR

Patient Population

Fig. 2. Frequency of each RHISS category for patients with and

without a GCS in the registry. The majority of patients with missing
GCS have higher RHISS values.

Table 3 Mean Survival (as mean SD) of the ICD-9

Head Injury Diagnosis Codes in Each of the RHISS
Categories (Significant p < 0.001)
RHISS
RHISS
RHISS
RHISS

0
1
2
3

Mean Survival (%)

95% Confidence Interval

0.93 0.16
0.89 0.22
0.85 0.26
0.55 0.35

0.9280.946
0.8160.973
0.8170.885
0.4720.618

The next step in validating the RHISS involved assigning

each patient to the RHISS category corresponding to his or
her most severe head injury code and examining differences
in mortality, GCS, and AIS-HN. Figure 3 shows the percentage of all deaths that occurred among patients assigned to
each RHISS category. Eighty six percent of the deaths had
some degree of closed head injury. Approximately 45% of
deaths occurred among patients assigned to RHISS category
3. Approximately 80% of all deaths occurred among patients
assigned to RHISS categories 2 and 3 combined.
Figure 4 shows the correlation between GCS and RHISS.
For low RHISS values, the predominant GCS values tend
toward a GCS of 15. As RHISS increases, the distribution of
GCS values trends toward lower scores. Importantly, a GCS
score was not recorded for 1,392 of the 1,492 deaths. Further,
for patients assigned to RHISS category 3, GCS was missing
approximately 90% of the time (Fig. 3). For those patients
with a GCS available, Figure 5 shows the frequency of
patients in each of the RHISS categories at different GCS
states; high GCS (9), mid GCS (6 and 9), and low GCS
(5). For the high GCS scores the RHISS tends toward none
or mild categories and as the GCS decreases the RHISS shift
toward the more severe RHISS categories.
RHISS and the scores for the head and neck body region
from the AIS system were also compared. Figure 6 shows the
distribution of the severity of the AIS-HN stratified by
RHISS. Patients for whom RHISS 0 represent nonhead
injury patients in the AIS-HN Group. The severity of the
AIS-HN shifts toward more severe categories as the RHISS
increases.

Fig. 3. Percent mortality in each RHISS category. RHISS 0 199

deaths (total 29,293 patients); RHISS 1 108 deaths (total 10,116
patients); RHISS 2 526 deaths (total of 9,613 patients); RHISS
3 616 deaths (total of 1,177 patients).

paring mean SRRs of diagnosis codes categorized according to

RHISS was used to validate the assignment of codes to RHISS
categories (see Table 3). Scheffe posthoc comparisons showed
that the mean SRR for injury codes in RHISS category 3 was
174

Fig. 4. Percentage of cases in each GCS category stratified by

RHISS. For each group of RHISS, the higher GCSs are on the right
(GCS 15), lower values on the left (GCS 3).

July 2007

Validation of a Relative Head Injury Severity Scale

Fig. 6. Distribution of AIS head and neck body region stratified by

RHISS. Distribution of severity of the AIS head and neck body
region for each of the RHISS groups. Those cases for RHISS 0
represent nonhead injury patients in the AIS-HN Group. The severity of the AIS-HN shift toward more severe injury (AIS 6) as the
RHISS increases.

AIS-HN. The LR model demonstrated excellent performance

(ROC-Az 0.96). The RHISS was an independently significant predictor of mortality. When the interaction term between intubation in the field and RHISS was included in the
model, RHISS 1 was not a significant predictor of mortality, but RHISS 2 (OR 1.974) and RHISS 3 (OR
101.715) were significant predictors.

DISCUSSION

Fig. 5. Frequency of patients in each RHISS category stratified by

GCS. (A) Patients with GCS 9; (B) patients with GCS 9 and 5;
(C) patients with GCS 5.

Logistic regression (LR) was used to identify significant

predictors of mortality. Variables used in the LR model
included NISS, intubation in the field (binary), RHISS, and
Volume 63 Number 1

Closed head injury is the major determinant of outcome

in pediatric trauma. In this data set, from the NPTR, 86% of
the deaths were associated with some form of traumatic
closed head injury. Therefore, it becomes imperative to have
a tool that allows stratification of the severity of closed head
injuries in this population. The GCS has served as the standard for the assessment of neurologic status in both adult and
pediatric trauma patients, and has performed exceptionally
well in the prospective prediction of outcomes for pediatric
trauma patients with respect to mortality,2 complications,6
and functional outcome among survivors with traumatic
closed head injury.8 There are, however, difficulties with
using the GCS. The most important, with respect to outcome
research, is that it can be missing in a large number of patients
in any given cohort. In this study, using the final collection
from the NPTR, the GCS was missing in 23% of the patients.
Even more important, the GCS was missing in 96% of the
deaths. The reasons for the missing GCS values are many9
and center on the difficulty of obtaining verbal and eye scores
in patients, especially those that are intubated. Further, interrater reliability of the GCS has been shown to be poor.16,17
The elimination of the verbal score or the use of only the
motor score has been advocated,10 yet the motor response
175

The Journal of TRAUMA Injury, Infection, and Critical Care

may be the part of the GCS subject to the greatest
inaccuracy.16 This difficulty becomes evident if one looks at
the distribution of GCSs in the NPTR. Almost all the GCSs
are 15. There are almost no intermediate scores, suggesting
that data collectors may be comfortable with scoring patients
with a GCS of 15 but not so comfortable with intermediate
values. With GCS missing in 96% of the deaths, the usefulness of the GCS in mortality prediction based on the NPTR
is very suspect.
This article presents an alternative method, the RHISS,
for retrospective assessment of the degree of head injury in
pediatric patients based on discharge ICD-9 Dx codes and
provides evidence supporting its validity. The codes for skull
fractures and head injury and loss of consciousness were
grouped into three categories, stratifying the degree of head
injury into mild, moderate, and severe and these groups
formed the RHISS. Survival rates were shown to be lowest
for ICD-9 Dx codes assigned to RHISS categories associated
with the most severe head injuries. Results of logistic regression analyses demonstrated that RHISS was a significant
independent predictor of outcome. Mean Survival Risk Ratios grouped by RHISS decreased for increasing RHISS (Table 3), and the mortality rate increased as the severity of
RHISS increased. Further, RHISS correlated significantly
with GCS (Fig. 4): patients with low RHISS values tended to
have high GCSs and vice versa.
The GCS is not assigned by data collectors but is
graded by medical personnel at the time of presentation.
The RHISS is scored by data collectors at a later time in
the patients course, either at discharge or after all injuries
have been identified. The GCS still has use in acute management of patients. The RHISS does not have this property. However, the most obvious shortcoming of the GCS
with respect to its use in outcome prediction modeling is that
is it missing in a large percentage of patients and most
importantly in almost all the deaths. The RHISS does not
suffer from this deficiency because it is based on ICD-9
discharge diagnosis codes, which are available retrospectively for all patients.
The RHISS values in this cohort also correlated with the
AIS values for the head and neck body region, further supporting the validity of RHISS as a measure of head injury. As
the RHISS values increase the AIS-values also increase (Fig.
6). Importantly, the RHISS value reflects only the degree of
traumatic closed head injury. In contrast the AIS score reflects neck as well as head injury (Fig. 6: RHISS 0).
Therefore, using the AIS scale for analysis of closed head
injuries in a given cohort would yield an impure result with
respect to head injury.
Clearly, RHISS is not meant to replace the GCS. The
Glasgow Coma Scale is a clinical scale and is important in the
assessment of individual patients. The RHISS is a population
based tool, and is only available at patient discharge. However, as a population tool, for the assessment of degree of
176

closed head injury, it has excellent characteristics and stratifies patients with traumatic closed head injury. It can be used
as a risk indicator in closed head injury and can be applied to
administrative data-sets that have no GCSs. This use of the
RHISS has already been undertaken. The RHISS had been
used in adult trauma patients with traumatic closed head
injury,18 and in a large state trauma registry assessing head
injury.19 We will now extend its use to the pediatric population, especially for analysis of large state-wide and national
hospital discharge data-sets.

REFERENCES
1.

2.

3.

4.
5.

6.

7.

8.

9.

10.

11.
12.

13.

14.

15.

16.

VanRooyen MJ, Sloan EP, Barrett JA, Smith RF, Reyes HM.
Outcome in an urban pediatric trauma system with unified
prehospital emergency medical services care. Prehospital Disaster
Med. 1995;10:19 23.
Chiaretti A, Pisaatra M, Pulitano S, et al. Prognostic factors and
outcome of children with severe head injury: an 8-year experience.
Childs Nerv Syst. 2002;18:129 136.
Cantais E, Paut O, Giorgi R, Viard L, Camboulives J. Evaluating the
prognosis of multiple, severely traumatized children in the intensive
care unit. Intensive Care Med. 2001;27:15111517.
White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely
head-injured children. Crit Care Med. 2001;29:534 540.
Orliaguet GA, Myer PG, Blanot S, et al. Predictive factors of
outcome in severely traumatized children. Anesth Analg. 1998;
87:537542.
Hedequist D, Starr AJ, Wilson P, Walker J. Early versus delayed
stabilization of pediatric femur fractures: analysis of 387 patients.
J Orthop Trauma. 1999;13:490 493.
Jaimovich DG, Blostein PA, Rose WW, et al. Functional outcome of
pediatric trauma patients identified as non salvageable survivors.
J Trauma. 1991;31:196 199.
Campbell CG, Kuehn SM, Richards PM, Ventureyra E, Hutchison
JS. Medical and cognitive outcome in children with traumatic brain
injury. Can J Neurol Sci. 2004;31:213219.
Hannam Edward L, Farrell LS, Bessey PQ, et al. Accounting for
intubation status in predicting mortality for victims of motor vehicle
crashes. J Trauma. 2000;48:76 81.
Hannan EL, Farrell LS, Meaker PS, et al. Predicting inpatient
mortality for pediatric trauma patients with blunt injuries: a better
alternative. J Pediatr Surg, 2000;35:155159.
Teppas JJ III, Ramenofsky ML, Barlow B, et al. National Pediatric
Trauma Registry. J Pediatr Surg. 1989;24:156 158.
Sullivan T, Haider A, DiRusso S, et at. Prediction of mortality in
pediatric trauma patients: New Injury Severity Score outperforms
Injury Severity Score in the severely injured. J. Trauma. 2003;
55:10831088.
Demetriades D, Kuncir E, Murry J, Velmahos GC, Rhee P, Chan L.
Mortality prediction of Head Abbreviated Injury Score and Glasgow
Coma Scale: analysis of 7,764 head injuries. J Am Coll Surg. 2004;
199:216 22.
DiRusso S, Chahine AA, Sullivan T, et. al. Development of a model
for prediction of survival in pediatric trauma patients: comparison of
artificial neural networks and logistic regression. J Ped Surgery.
2002;37:1098 1104.
DiRusso S, Sullivan T, Holy C, et al. An artificial neural network as
a model for prediction of survival in trauma patients: validation for a
regional trauma area. J Trauma. 49:212221.
Heron R, Davie A, Gillies R, Courtney M. Interrater reliability of
the Glasgow Comma Scale scoring among nurses in sub-specialties
of critical care. Aust Crit Care. 2002;14:100 105.

July 2007

Validation of a Relative Head Injury Severity Scale

17.

Gill M, Reiley D, Green S. Interrater reliability of Glasgow Coma

Scale Scores in the emergency department. Ann Emerg Med. 2004;
43:215223.
18. Susman M, DiRusso S, Sullivan T, et al. Traumatic brain injury in
the elderly: Increased mortality and worse functional outcome at
discharge despite lower injury severity. J Trauma. 2002;53:219 224.
19. Harris C, DiRusso S, Sullivan T, Benzil D. Mortality risk after head
injury increases at 30 years. J Am Coll Surg. 2003;197:711716.

DISCUSSION
Dr. Oscar D. Guillamondegui (Nashville, Tennessee):
Utilizing a tool previously developed and described in the
adult population, the relative head injury severity score, or
RHISS, was compared with the admitting GCSs culled from
the National Pediatric Trauma Registry. The RHISS is proposed as an alternate tool to assess the degree of closed head
injury in the pediatric population, a group notorious for poor
GC scoring because of the nature of the said population, and
pointed that out in the article.
After defining ICD-9 codes and stratifying to mild, moderate, and severe with given values, the RHISS score was
validated with survival risk ratios in a nova statistical analysis. Not surprisingly, the risk performed well when applied to
the National Pediatric Trauma Registry. The authors note the
limitations of the GCS are approximately one-quarter of all
values, and 90 percent of the trauma deaths are missing
scores. Further work by logistic regression analysis defines
RHISS as an independent predictor of mortality. I have three
questions for the authors.
Number one, is the comparison to GCS necessary to
validate the RHISS score as an outcome tool in the pediatric
population, given the database deficiency? Number two, what
guidelines were instituted to stratify these RHISS scores for
each group? For example, is an open two table frontal sinus
fracture without brain injury better or worse than bilateral
occipital condyle fractures? Number three, if RHISS is ultimately based upon discharge diagnosis codes, what role can
the relative head injury severity score have in the daily
assessment of pediatric head injured patients or the trauma
patient in general?
Dr. Joseph J. Tepas (Jacksonville, Florida): Its very
exciting to sit and listen to people who are still massaging the
National Pediatric Trauma Registry dataset. There are
103,000 children in that dataset and its closed. Its getting
stale and using it for things of this variety, I think, are critical
and important, and anybody that is interested in accessing
that data can contact me by email, because its now been
completely translated into an access database.
I have a number of comments and questions, and my first
comment is that the reason that that particular segment of the
NPTR has such a paucity of complete Glasgow Coma Scales
was a design flaw. When we developed the NPTR, we designed it to record the specific components of each of the
scales, whether it was the trauma score, the pediatric trauma
Volume 63 Number 1

score, or the Glasgow Coma Scale, not anticipating that with

the evolution of improved prehospital care that more and
more children would arrive intubated.
Quite simply, the computer cant calculate a t because
its a numeric calculation; thus, those fields all have 99 in
them. My first question involves the issue of Glasgow Coma
Scale motor score. This is emerging as (1) a reliable predictor
and indicator of severity of central nervous system function;
(2) it is extremely difficult to fudge. You either are decorticate,
discerebrate, responsive, or not responsive; and (3) Dr. Meredith
and his colleagues recently have demonstrated to us that, potentially, a methodology for evaluating outcomes is this TRISS for
everyone, which actually uses that as a component.
Now obviously, thats not in hospital discharge diagnosis
datasets, so thats problematic, I understand, but in validating
this particular permutation of that, have you looked at GCSM
as a specific comparison?
The second question is regarding the fact that youve
calculated survival risk ratios for these children. Did you do
that from just NPTR Phase III or did you do it with both
phases? We actually have calculated survival risk ratios for
both the entire registry and individual phases. Do these survival risk ratios differ in any way from NTDB survival risk
ratios, because that too is an area that were beginning to
demonstrate that these survival risk ratios in the pediatric
population are different in certain diagnoses than they are in
adults?
Some of the adults fare worse and in some of them, the
children fare worse. Finally, the assignment of the RHISS
categories seems to me to be a bit subjective, and thats a little
worrisome to me, because as an uncontrolled observational
multi-institutional study, the NPTR essentially depended upon
the compliance, commitment, and effect of all of the different
participating institutions who came and went at whim.
The codes, in many cases, came from registrars. We
know, in comparing our Florida diagnosis dataset, in which
the discharge diagnosis codes come from the coding room
and are probably the result of a 3M statistical software product, that they vary significantly from the codes that are
calculated by our trauma nurse registrars and coordinators
and entered into our trauma registries. So my question to you
is how reliable is this going to be if the source of the
coding for the state discharge data sets is not well known
and well understood, because there appears to be significant inaccuracy there, especially with the fourth and fifth
digits?
Dr. Barbara A. Gaines (Pittsburgh, Pennsylvania): A
quick question. One of the groups that falls out in TRISS
analysis in children are infants with anoxic brain injuries, the
so-called shaken baby. They can often have relatively low
scores, but a very high mortality, and I wonder if you looked
specifically at this group and whether they fell out in your
RHISS scoring and whether you were able to capture the high
mortality in this particular group?
177

The Journal of TRAUMA Injury, Infection, and Critical Care

Dr. Stephen DiRusso (Valhalla, New York): Of the first
comments, that was a very good question about whether comparing it with the GCS and the RHISS is a valid comparison, and
in some ways, it really wasnt because many of the GCS values
were missing. However, we thought that this would, at least for
the cases that were present, add some validity to the RHISS,
remembering that we showed, and as was stated, that 90% of the
deaths were missing the GCS values.
This is related a little to both questions and Dr. Tepas
question about how the codes were assigned. I would like to
say that they were scientifically assigned, but in actuality, Sarah
Cuff, who is probably one of the most amazing people Ive ever
met as far as understanding of trauma coding and the clinical
implications of those codes, actually took all the ICD-9 codes
and using her skill, mapped them into these categories.
What we have done since then though, both in the adult
and the pediatric population, using the New York State
Trauma Registry, weve actually looked at the individual
SRRs for each of those diagnosis codes and how they mapped
into the RHISS, and except for a few very minor differences,
the mapping seemed to be incredibly accurate.
As far as using the RHISS for a daily assessment, the
RHISS uses the discharge diagnosis codes, which theoretically could be obtained for computed tomography scans obtained early in the patients course. However, I dont think
that we intend this tool to be a clinical tool thats used in the
daily assessment of the patient.
Whether it could be used at admission if the diagnosis codes
for the head injury could be ascertained to kind of predict
outcome and maybe tailor care a little bit more aggressively,
thats an interesting question, and we may look into that.
We were very sorry when the NPTR funding was eliminated and the data was no longer being collected. It is an
incredible collection of data and probably one of the best
national trauma data sets. The data was extremely accurate
and very well collected.
As far as the question related to intubated and the t
values, yes, thats true. We did look at the motor scores. The
motor scores were missing, and there are several articles that
show now that probably really only the motor scores should
be used in predictive cases. However, we did look at it in the
NPTR, and it was still missing in a fair amount of the cases,
especially the deaths.

178

Ill handle Dr. Gaines question about the shaken baby

syndrome. We did not actually look at that, but we certainly
will when we go back.

EDITORIAL COMMENT
Any trauma score is in a sense a model, an attempt to
characterize or predict some aspect of trauma, in this case,
pediatric head trauma. The problem with the use of most
trauma scores is their original focused purpose is often forgotten and a useful score is then misapplied to tasks for which
it was never designed with consequent less than useful results. The GCS is often victim of this kind of misuse.
In this article, Cuff et al. are to be commended for
defining exactly what their score is designed to do and what
it should not be used to do. Their goal is to provide an
alternative to the GCS as a quantitative measure of head
injury severity in the statistical analysis of head injury outcome data. They point out that the GCS is ill suited for this
task because the GCS is often missing from the data set. This
is because it is often not recorded in fatalities and is disproportionately applied to the least severely injured.
They do not overstate their case, however. They appropriately point out that the scale cannot be used during the
initial treatment of the patient. The reasons for this are that it
was not designed for this and it would not be easy to calculate
early in the course of care.
The RHISS does work well for the purpose for which it
was designed, the modeling of head injury in posthoc analysis. The authors have statistically validated their model and
have shown good correlation between their score and the risk
of mortality. They compare their score to other measures of
head injury severity and it compares well.
To arrive at this score, the authors had to make some
assumptions and estimates about the severity of the various
ICD-9 codes. This introduced some subjectivity into the score,
but the estimates appear to be reasonable since the correlation
between the score and the mortality risk appear to be good.
The authors have succeeded in showing that the RHISS is
a useful tool in the posthoc analysis of head injury. The RHISS
is nothing more than that, but it is certainly nothing less. For this
accomplishment, the authors are to be congratulated.
Peter B. Letarte, MD
Hines VA Hospital

July 2007