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Clinical applications of the Injury Severity Scoring system (ISS): The clinical,
radiological, educational, research and economic implications on reporting in
trauma. Results from...

Poster · April 2015

DOI: 10.1594/ecr2015/C-1860

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Clinical applications of the Injury Severity Scoring system
(ISS): The clinical, radiological, educational, research and
economic implications on reporting in trauma. Results from
a tertiary trauma centre in UK.

Poster No.: C-1860

Congress: ECR 2015
Type: Scientific Exhibit
Authors: J. Kumaraguru, A. Isaac, N. Kandasamy, L. M. Meacock, L. Strom,
S. Luck, D. A. Elias, D. Lewis; London/UK
Keywords: Trauma, Education and training, Treatment effects, Medico-legal
issues, Education, CT, Professional issues, Emergency
DOI: 10.1594/ecr2015/C-1860

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Page 1 of 18
Aims and objectives

Injury Severity Scores (ISS) are an essential tool for calculating the severity of trauma and
to record the injuries with precision and detail. At present in UK, the Trauma and Research
network (TARN) calculates the trauma score for each trauma patient presenting to a
Major Trauma Centre. The ISS score is used for assessing the predicted survival score,
a tool used for evaluating the performance of major trauma centres and is also used for
funding assessment.

Injury severity score is calculated based on the Abbreviated Injury Scale (AIS) 2005
revision, update 2008[1] based on the radiology reports (CT), clinical findings and/or
postmortem findings in the event of death.

(AIS) is an anatamical score dividing the body into 6 areas:

• Head and neck

• Face
• Chest
• Abdomen
• Pelvis and extremities
• Skin

Each injury on the AIS gets a score of 0-5, 0-uninjured, and then1 trivial/minor to 5-
extremely severe. ISS is calculated by adding the square of the three highest-scoring
injuries from three highest-scoring body regions (only one injury per body region is
2
included). Thus, the ISS may range from 0 to a maximum of 75 (3 x 5 ).

Example: A patient presenting with H/o fall with the following injuries:

Scalp contusion (=1), Nose fracture closed (=1), Cervical spine- lamina fracture (=2). The
2 2 2
ISS score would therefore be 6. (1 + 1 + 2 = 6).

ISS of 16 or more is classified as "major trauma" and an ISS >40 as "massive trauma".

Financial implications:

The Major Trauma Best Practice Tariff (BPT) launched by the Department of Health, and
provides funding to major trauma centres to enhance the trauma system and to improve

Page 2 of 18
patients' care. The BPT uses ISS to assign one of two levels of tariff based on whether
the ISS is more than 8 or more than 15[3].

ISS 9-15 qualifies for level-1 payment and ISS >15 for higher level-2 payment which
is 50 % more than level-1 payment. This is paid by TARN to major trauma centres for
admitting and treating the trauma patient in addition to the usual costs (like length of
stay, surgery, imaging costs)- provided certain criteria are met, e.g. Head CT performed
within an hour of arrival and the patient seen by Consultant within 5 minutes of arrival.
The level-1 payment is 25 times the amount paid for a routine CT and level-2 payment
is approximately 50 times.

Research implications:

• The ISS scores for each patient forms the data record in TARN which is
used to calculate Predicted Survival Score (PSS)
• The Predicted survival scores assess whether individual hospitals have
more or fewer trauma survivors than expected and is used to compare the
"performance in major trauma care" of one hospital against another.
• There are emerging evidence that new trauma and Injury severity scoring is
better than original TRISS[4].

Underscoring of the trauma gives the impression that patients have died from injuries
that on their PSS suggests "should" have survived.

Images for this section:

Page 3 of 18
Fig. 8: Splenic injury- AIS score 3 , more than 50% surface area is involved.

Page 4 of 18
Fig. 7: Fractures of left 5th - 8th ribs. It is important to mention the number of ribs involved
and if unilateral or bilateral AIS score of 3 as 4 ribs involved on one side.

Page 5 of 18
Methods and materials

The number of patients who were triaged or presented to our institution with trauma in
2014 was 968, out of which 526 were classified as major trauma based on the injury
severity score of more than 15. This includes patients with both blunt and penetrating
trauma.

We performed a retrospective pilot audit on patients with ISS score of less than15 on 40
Direct Admissions with a CT performed and ISS # 15, since January 2013. The list of
patients was randomly chosen by TARN out of the 442 patients who presented to our
Major Trauma centre and were classified as non major trauma or ISS less than 15.

We re-calculated the ISS scores based on imaging with a knowledge of the AIS manual
scoring, and compared these with the ISS Scores calculated by TARN at the time of re-
imbursment.

The AIS is the only approved reference system specifically designed as a system to define
the severity of injuries throughout the body[3]. The AIS scoring manual, AIS 2005, update
2008 is a 167 page document and we have chosen few injuries and descriptors and
corresponding scores, and presented them as tables ( Fig. 2-6). The potential caveats in
reporting which can lead to underscoring are followed by asteriks (***).

Images for this section:

Page 6 of 18
Fig. 9: AIS Score of 5- Cord laceration with fracture ( Major injury , qualifies for level 2
payment)

Page 7 of 18
Fig. 6: Intracranial bleed- the importance of quantifying the bleed

Fig. 5: Renal injuries AIS scoring

Page 8 of 18
Fig. 2: Importance of mentioning the number of rib fractures and identifying radiological
flail

Fig. 4: Splenic injuries AIS scoring

Page 9 of 18
Fig. 3: AIS scoring of pulmonary contusions and lacerations

Page 10 of 18
Results

• 34/40 (85%) patients had no discrepancy between the original reported ISS
score and recalculated score.
• 1/40 was reclassified as major injury (reported score of 9 to recalculated
score of 16) (with subsequent loss of level-2 payment).
• 1/40 showed an increase from 5 to 10 (also incurred loss of level-1 payment)
• 1/40 showed an increase from 12 to 13 (with no effects of payments).
• 2/40 had external injuries not seen on imaging ( eg blood loss and skin
injuries).
• 1/40 had lower calculated ISS score; that is decrease from the reported
score of 13 to 9. (with no implications on billing).

Reported ISS Recalculated ISS Reason for

discrepancy
1. 9 16 Reported as small
lower pole
laceration with
and moderate
renal injury in
the conclusion.
However, on review
there was evidence
of main renal
vessel injury with a
contained
haematoma, which
gives AIS of 4
instead of 3.
2. 2
5 (1 +2 )
2 2 2
10 (1 +3 ) Reported as
multiple rib fractures
on CXR (AIS 2), on
review there were 3
rib fractures on the
right (AIS 3).
3. 12 13 Lumbar vertebral
body compression
4. 13 9 No cervical fracture
on CT, reported on
plain film as a
fracture.

Page 11 of 18
5. 10 9 External scalp
laceration. Other
injuries remianed
the same.
6. 5 4 External scalp
contusion

Images for this section:

Fig. 10

Page 12 of 18
Conclusion

The AIS/ISS is a valuable tool for systematic analysis of trauma.

The use of ISS has clinical implications ensuring adequate description of complex
traumas,. It also provides a good educational tool for trauma reporting.

Accurate analysis of injuries with detailed documentation according to ISS scoring system
is required. This ensures accurate funding for hospitals, which ensures financial viability
of the national trauma services.

The coding used in the AIS manual is very useful for research purposes. The collated
information is intergated into trauma databases for identifying cases with similar injuries,
and further evaluating the patient care pathways and outcomes in different hospitals.

Our department is in the process of developing a proforma/ reporting template based on

ISS, to ensure standardised reporting across our service.

Images for this section:

Page 13 of 18
Fig. 10

Page 14 of 18
Fig. 11: Main renal vessel injury - AIS score 4 KIDNEY INJURIES AIS 2005 scoring Less
than 1cm parenchymal depth/ minor/ laceration - score 2 More than 1cm parenchymal
depth / moderate - score 3 Major/ extending through renal cortex, medulla and collecting
system, main renal vessel injury with contained haemorrhage- score 4 Hilar avulsion- 5
Rupture- when no detailed descriptors available- score 4

Page 15 of 18
Fig. 12: This case demonstrates the importance of explaining the percentage loss of
body height : More than 20% of body height - AIS score 3 (ISS-9 Loss of level 1 payment
due to underreporting) Compression fracture - less than 20% of body height - AIS score 2

Page 16 of 18
Personal information

• Dr. Janani Kumaraguru MBBS BA FRCR, Specialty Registrar in Radiology

(Musculoskeletal & Trauma), Kings College Hospital, London UK E-mail:
jan@doctor.com
• Dr Amanda Isaac MBBS MRCS FRCR, Consultant Musculoskeletal &
Trauma Radiologist, Kings College Hospital, London UK
• Dr Nagachandar Kandasamy MBBS DMRD FRCR, Consultant
Neurovascular Radiologist, Kings College Hospital, London UK
• Dr Lisa Meacock MBBS MRCS FRCR, Consultant Musculoskeletal &
Trauma Radiologist, Kings College Hospital, London UK
• Ms Louise Strom BAppSci (MRS)DI, Radiographer, Kings College Hospital,
London UK
• Mr Simon Luck, Systems and Trauma analyst, Kings College Hospital,
London UK
• Dr David Elias MBBS MRCP FRCR, Consultant Musculoskeletal & Trauma
Radiologist, Kings College Hospital, London UK
• Dr Dylan Lewis MBBCh(Hons) FRCR, Consultant Trauma & Intervention
Radiologist

References

1. Association for the advancement of Automotive medicine. The abbreviated

Injury Scale(AIS). Illinois:Des Plaines 2005.
2. Domingues Cde A1, de Sousa RM, Nogueira Lde S, Poggetti RS, Fontes B,
Muñoz D.The role of the New Trauma and Injury Severity Score (NTRISS)
for survival prediction. Rev Esc Enferm USP. 2011 Dec;45(6):1353-8.
3. The trauma and research network procedures manual. Salford England:
TARN. 2014 Oct; 70-77.
4. AIS 2005: a contemporary injury scale.Gennarelli TA1, Wodzin E. Injury.
2006 Dec;37(12):1083-91.
5. Measuring trauma severity using the 1998 and 2005 revisions of the
abbreviated injury scale. Lopes MC, Whitaker IY..Rev Esc Enferm USP.
2014 Aug;48(4):640-7. Portuguese.
6. Application of abbreviated injury scale and injury severity score in fatal
cases with abdominopelvic injuries. Subedi N, Yadav B, Jha S. Am J
Forensic Med Pathol. 2014 Dec;35(4):275-7.
7. Using Abbreviated Injury Scale (AIS) codes to classify Computed
Tomography (CT) features in the Marshall System.BMC Med Res Methodol.
2010 Aug 6;10:72. Lesko MM, Woodford M, White L, O'Brien SJ, Childs C,
Lecky FE.

Page 17 of 18
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8. The abbreviated injury scale as a predictor of outcome of severe head

injury. Walder AD, Yeoman PM, Turnbull A. Intensive Care Med. 1995
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