Trauma data requirements in NSW

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Mandate for trauma data in NSW

The mandate for the collection of trauma data in NSW derives from the NSW Trauma Services Plan.1

The NSW Trauma Services Plan requires ITIM to:

  • monitor and report on the performance of individual trauma services
  • ensure that performance is consistent with the standard of care
  • manage a statewide clinical injury data collection process.

The plan also positions ITIM to develop partnerships with injury stakeholders in order to build an improved critical mass for research and education across the spectrum of trauma prevention care and rehabilitation. The collection of trauma data is an important aspect of these activities.

Scope of trauma data collection in NSW

The NSW Trauma Registry contains de-identified patient records submitted by trauma registries in NSW. The NSW Trauma Registry does not hold data for every injured person admitted to hospital in NSW. Data is only included for patients with the greatest needs – the most seriously injured – who are treated at a designated hospital in NSW which contributes to the NSW Trauma Registry. This data is known as the NSW Trauma Minimum Dataset (MDS), and forms the basis of data analysis and reporting activities at ITIM.

As the scope of the current data collection is restricted to these designated hospitals, there may be some data for trauma admissions to other hospitals which is not included in the NSW Trauma Registry. However, these numbers are estimated to be small.

Criteria for inclusion in the NSW Trauma Minimum Dataset

All patients of any age, who were admitted to a designated NSW Trauma Service within seven days of sustaining an injury, and:

  • had an Injury Severity Score (ISS) >12 (moderate to critically injured), or
  • were admitted to an intensive care unit (irrespective of ISS) following injury, or
  • died in hospital (irrespective of ISS) following injury, except those with an isolated fractured neck of femur injury sustained from a fall from a standing height (<1 metre) and those aged 65 years or older who die with minor soft tissue injury only.

About the inclusion criteria

The key criterion for including a patient record in the NSW Trauma Registry is a classification of injuries as moderate to critical. This classification relies on the Abbreviated Injury Scale (AIS) and the ISS. The AIS and ISS are used by accredited staff at each hospital trauma service to score individual patient injuries and their severity. They provide common tools for comparing and selecting patient records for inclusion in the NSW Trauma Registry.

    Patients with injuries classified as moderate are identified for the NSW Trauma Registry when they have an ISS of 13 or 14.

    Patients with injuries classified as serious to critical are identified for the NSW Trauma Registry when they have an ISS of greater than 15.

    As a result of the inclusion criteria, patient records in the NSW Trauma Registry do not represent:

    • all injuries in NSW. For example patients with minor injuries with an ISS <13 are generally not included in the NSW Trauma Registry unless the patient is deceased or admitted to and intensive care unit.
    • the full work or case-load of trauma teams in hospitals
    • the full set of data recorded in hospital trauma registries.

    The data is, however, a very complete and accurate record of the moderate to critically injured group of patients. Data submitted for inclusion in the NSW Trauma Registry is subject to rigorous checking and validation prior to inclusion in the registry. Missing or invalid data is flagged and returned to individual trauma services for completion. Missing data however is rare and the NSW Trauma Registry has an extremely low incidence of incomplete records.

    The NSW Trauma Minimum Dataset

    The NSW Trauma MDS consists of several data elements. The data elements conform to state and national standards, including the AIS system and Independent Health and Aged Care Pricing Authority ICD-10-AM/ACHI/ACS sixth edition.12

    The data elements are described in the Data dictionary (PDF 1.5 MB)

    Data elements

      Demographic
      • Demographic – Recording Trauma Facility
      • Demographic – Trauma Record Number
      • Demographic – Facility Arrival Date / Time
      • Demographic – Record Complete
      • Demographic – System Access
      • Demographic – Home Postcode
      • Demographic – Age
      • Demographic – Gender
      Injury
      • Injury – Injury Date / Time
      • Injury – Primary Injury Cause
      • Injury – Primary Injury Type
      • Injury – Place of Injury
      • Injury – Activity when Injured
      • Injury – Height of Fall
      • Injury – Injury Location (Postcode)
      Pre-hospital
      • PreHosp – Scene/Transport Providers – Agency
      • PreHosp – Scene/Transport Providers – Mode
      • PreHosp – Scene/Transport Providers – Run Number
      • PreHosp – Scene/Transport Providers – Call Received Date / Time
      • PreHosp – Scene/Transport Providers – At Patient Date / Time
      • PreHosp – Scene/Transport Providers – Left Location Date / Time
      • PreHosp – Scene/Transport Providers – Was Patient Extracted
      • PreHosp – Scene/Transport Providers – Time Required (for Patient Extraction)
      Referring facility
      • Ref Facility – Referring Facility Name (1 and 2)
      • Ref Facility – Referring Facility 1 – Arrival Date and Time
      • Ref Facility – Referring Facility 2 – Arrival Date and Time
      • Ref Facility – Transfer Rationale (1 and 2)
      • Ref Facility – Referring Facility Procedures – Procedure (1 and 2)
      • Ref Facility – Inter-Facility Transport – Agency (1 and 2)
      • Ref Facility – Inter-Facility Transport Agency (1) – Call Received Date / Time
      • Ref Facility – Inter-Facility Transport Agency (2) – Call Received Date / Time
      • Ref Facility – Inter-Facility Transport Agency (1) –  Arrived at Patient Date / Time
      • Ref Facility – Inter-Facility Transport Agency (2) –  Arrived at Patient Date / Time
      • Ref Facility – Inter-Facility Transport Mode (1 and 2)
      Patient tracking
      • Pt Tracking – Location Tracking - Location
      • Pt Tracking – Location Tracking – Arrival and Departure Date / Time
      • Pt Tracking – Ventilator Tracking – Start and Stop Date / Time
      Emergency department (ED)
      • ED – ED Arrival Date / Time
      • ED – ED Departure Date / Time
      • ED – Trauma Response
      • ED – Post ED Disposition
      • Initial ED Vital Date / Time - Recorded
      • Initial ED Vitals – Temperature
      • Initial ED Vitals – Temperature Units
      • Initial ED Vitals – Route for Temperature
      • Initial ED Vitals – Intubated
      • Initial ED Vitals – Intubation Method
      • Initial ED Vitals – Paralytic Agents
      • Initial ED Vitals – Sedated
      • Initial ED Vitals – Respiration Assisted
      • Initial ED Vitals – Respiration Type
      • Initial ED Vitals – SaO2
      • Initial ED Vitals – Pulse Rate
      • Initial ED Vitals – Respiration Rate
      • Initial ED Vitals – SBP/DBP
      • Initial ED Vitals – GCS Eye
      • Initial ED Vitals – GCS Verbal
      • Initial ED Vitals – GCS Motor
      • Initial ED Vitals – GCS Total
      • Initial ED Vitals – RTS
      Procedures
      • Procedures – Procedure Name
      • Procedures – Start Date/Time
      Diagnosis
      • Diagnosis – AIS Code/Description
      • Diagnosis – AIS Body Region
      • Diagnosis – Injury Severity Score (ISS)
      • Diagnosis – TRISS
      • Diagnosis – Pregnancy Status
      Outcome
      • Outcome – Discharge Status
      • Outcome – Discharge or Death Date/Time
      • Outcome – Total ICU Days
      • Outcome – Total Ventilator Days
      • Outcome – Total Hospital Days
      • Outcome – Discharged To
      • Outcome – If Transferred, Facility and If Other, Facility Name
      • Outcome – Transfer Rationale
      • Outcome – Location of Death
      Quality assurance
      • QA – QA Filter Code
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