Description | Specific Indicators | Ontario Public Health Standards (OPHS) | Corresponding Indicator(s) from Statistics Canada and CIHI | Corresponding Health Indicator(s) from Other Sources | Data Sources | Alternative Data Sources | ICD Codes | Analysis Check List | Method of Calculation | Basic Categories | Indicator Comments | Definitions | Cross-References to Other Sections | Cited References | Other References | Changes Made | Acknowledgements

• Crude emergency department (ED) visits rate - the total number of emergency department visits (not scheduled) for selected causes of injury relative to the total population during a given year (fiscal or calendar) (usually expressed per 100,000).
• Age-specific emergency department visits rates - the total number of number of emergency department visits for selected causes of injury in a given age group per population in that age group during a given year (fiscal or calendar) (usually expressed per 100,000).
• Age-standardized emergency department visits rate (SRATE) - the number of emergency department visits for injury per 100,000 population that would occur in the population if it had the same age distribution as the 1991 Canadian population.
• Standardized morbidity ratio (SMR) -  the ratio of observed emergency department visits for injury to the number expected if the population had the same age-specific emergency department visit rates as Ontario.

• Crude emergency department visits rate
• Age-specific emergency department visits rate
• Age-standardized emergency department visits rate (SRATE)
• Standardized morbidity ratio (SMR) for specific unintentional injury (e.g., emergency department visits for injury due to all causes, burns, falls, poisoning etc.)
  • For suggestions on how to categorize injury data, refer to Recommended ICD-10-CA Codes for Injury Core Indicators.
• Injury-specific Standardized Morbidity Ratio (SMR) for intentional injury due to:
• Self-harm
• Assault

• Board of Health Outcome (Prevention of Injury and Substance Misuse): The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the prevention of injury and substance misuse.
• Board of Health Outcome (Foundational Standard): The public, community partners and health care providers are aware of relevant and current population health information.

• The board of health shall conduct epidemiological analysis of surveillance data in the areas of injury and substance misuse outcomes.

• Age-Standardized Injury Hospitalization Rate (per 100 000)

• None

• Ontario Trauma Registry

• Please refer to the Recommended ICD10-CA codes for Injury Core Indicators document and Recommended ICD-10 groupings for injury Core Indicators Stata syntax file.

• The IntelliHEALTH licensing agreement does not require suppression of small cells, but caution should be used when reporting at a level that could identify individuals, (e.g. reporting at the postal code level by age and sex). Please note that privacy policies may vary by organization. Prior to releasing data, ensure adherence to the privacy policy of your organization.
• Aggregation (e.g. combining years, age groups, categories) should also be considered when small numbers result in unstable rates.
• IntelliHEALTH Ontario is developing a complete set of pre-defined reports for injury-related Core Indicators, (i.e., templates that permit standardized queries by local public health agencies). Registered IntelliHEALTH users can find a predefined report called 'ED visits - Ext Cause of Injury - PHU indicator list' in the APHEO Public Health Indicator folder in the Standard Reports section. 
• An 'Ambulatory Visits User Guide' is available within IntelliHEALTH.
• The Report Inventory and Webinar Materials tab contains information on external causes of injury from a webinar titled ‘Ambulatory Visits:  Emergency Visits - External Causes of Injury - PHU' in October, 2011.  The webinar material provides guidance on how to extract external cause hospitalization and mortality data.  A Tips & Tricks webinar on Dec. 16, 2011, also provides some useful information on hospitalizations and emergency room visits. 
• It is important to note that an individual can have more than one external cause diagnosis for each ED visit. Unlike with other ICD-10-CA diagnostic codes, no ‘most responsible diagnosis' exists for external cause diagnosis.
• For emergency department visit tabulations through IntelliHEALTH, use Ambulatory Emergency External Cause (Chapter 20) source from the '04 Ambulatory visits' folder.  Please note that this source differs from the Ambulatory All Visits Main Table in that it includes only unscheduled ED visits.  If you use the Ambulatory All Visits Main Table, you must use a filter, AM Case Type = EMG, to get only unscheduled ED visits.
• For unintentional injuries:
• For all unintentional injury ED visits, filter for ‘ICD10 Block All Dx' and select blocks V01-09 through X58-X59, and Y85-Y89.
• Add in a filter on ‘ICD10-CA Problem (3 char) All Dx' to filter not equal to for 'Y87', 'Y88' and 'Y89', as these codes are not part of unintentional injuries.
• The ‘ICD10 Block All Dx' and ‘ICD10-CA Problem (3 char) All Dx' MUST be hidden under the Assign Data option, in order to avoid double counting.  For example, a person who has both a V03 code and W10, will only be counted once. 
• Select # Visits (D) measure.
• For intentional injuries:
• For all intentional hospitalizations, filter for ‘ICD10 Block All Dx' and select blocks X60-X84 and X85-Y09 (Filter A).
• Add in a filter on ‘ICD10-CA Problem (4 char) All Dx' to filter equal to for 'Y870', and 'Y871' (Filter B). (Please note: decimal points normally found in these ICD10-CA codes (e.g. ‘Y87.1') have been removed as four character ICD-10-CA codes must be entered into IntelliHEALTH without decimal points)
• In the ‘Combine filter', cases must consist of Filter A OR Filter B. If using other custom filters (eg. Filter C), brackets must be used around this request. Eg. (Filter A or Filter B) AND Filter C.
• The ‘ICD10 Block All Dx' and ‘ICD10-CA Problem (4 char) All Dx' MUST be hidden under the Assign Data option, in order to avoid potential double counting.
• Select # Visits (D) measure.
• For all injury ED visits by ICD10 block, include the ‘ICD10 Block All Dx‘ variable (not hidden) in your report.  For example, a person who has both a V03 code and W10, will be counted twice, once in the V01-V09 block and once in the W00-W19 block. 
• Distinct counts - a patient can have more than one diagnosis code for one visit (eg. cardiovascular disease). In such cases, one code is deemed ‘the most responsible diagnosis code' or main problem Dx (or MRDx is some data sources).  Diagnoses that are identified as due to external causes (eg. fractured elbow) also have a companion "external cause" ICD-10-CA code.  A person can have more than one external cause diagnosis for one visit.  However, unlike the diagnoses codes mentioned above, external cause diagnoses do not have a main problem diagnosis in emergency (or other hospital) data.  Thus, the external cause diagnoses are only included in the multi-record per visit data sources such as the Ambulatory Emergency External Cause (Chapter 20) source.  Because the source has multiple records per visit, only distinct counts (# Visits (D)) can be used in order tally number of visits.  IntelliHEALTH can now create crosstab tables and sum across distinct counts for external causes (Note: because the column total is a distinct count, it may be smaller than the sum of the cells within the column).   For more information, please see the Report Inventory and Webinar Materials and Training sections within IntelliHEALTH.
• Use the pre-defined filter to select the appropriate geography (e.g. public health unit, LHIN) before running the report. Hospital information (hospital name, PHU or LHIN) can also be selected in the report.
• Note that ambulatory care data (and in-patient data) are reported by fiscal year (April 1 - March 31). Any changes in the source data occur on a fiscal year basis (e.g., ICD10 reporting began on April 1, 2002) and will affect reporting by calendar year.
• 'Place of occurrence' may also be used for codes W00-Y34 to identify place of external cause. Please note that there may be a large number of cases where place of occurrence is missing or not specfied.
• NOTE**Intellihealth has made a change and will now expose both historical data and current fiscal year data in the NACRS maps - folder 04. In practice, you will need to pay close attention to year filtering when creating reports using maps in folder 04 - as the most recent year may not have a complete year of data.

• Suggested Age Groups:
• <1-19 yr, 20-44, 45-64, 65-74, 75+. (IntelliHEALTH Chronic Disease age groups -Age Group (CD)) or
• <1, 1-4, then 5 yr groups to 90+. (IntelliHEALTH Infant + 5-yr age groups - (inf,5yr))
  *Note: Health units may choose to merge age categories due to small numbers, or change age categories depending on the specific analysis questions. Examples of other potential age categories include:
• '<1, 1-4 could be changed to "0-4"
• ‘Youth' could be analyzed as '15-24', a common category for analyzing self-harm data
• ‘Seniors/Older adults' could be analyzed as ages "65+"
• Sex: male, female and total
• Geographic areas of residence: Ontario, public health unit, municipality, and smaller areas of geography based on aggregated postal code.

• According to the Institute for Clinical Evaluative Sciences (ICES), in 2002-2003 someone visits an emergency department approximately every 30 seconds and someone is hospitalized about every 10 minutes in Ontario due to an injury (1).
• In 2009-2010, there were 1,277,121 visits made to EDs for trauma, accounting for almost one-quarter (22.2%) of all visits. Of these, 30.7% were due to unintentional falls (391,839 visits), while 8.8% were due to motor vehicle collisions (111,928 visits). The highest proportion of fall-related ED visits were observed in females age 65 and older (17.3%) and males younger than 20 (18.3%) (2).
• ICD-10-CA has a greater level of specificity and different code titles than ICD-9. CIHI does not endorse forward conversions because of differences in the classification systems. Refer to Resources: ICD-10-CA for more information. 
• The grouping of unintentional injury ED visit codes excludes codes for "misadventures to patients during surgical and medical care" (Y40-Y84). This coding matches that used for the National Indicators (3, 4).
• Emergency department visit data will not capture those who did not seek treatment in hospital, those treated in doctors' offices or clinics, or those who did not seek treatment in hospital for an injury and therefore will underestimate burden of injury.
• To best understand mortality or disease trends in a population, it is important to determine crude rates, age-specific rates and age-standardized rates (SRATES) and/or ratios (SMRs, SIRs). Although the crude death (or disease) rate depicts the "true" picture of death/disease in a community, it is greatly influenced by the age structure of the population: an older population would likely have a higher crude death rate. Age-specific rates can best describe the "true" death/disease pattern within particular age groups of a community, and allow for comparison of age groups across populations that have different age structures.
• Since many age-specific rates are cumbersome to present, age standardized rates have the advantage of providing a single summary number that allows different populations to be compared; however, they present an "artificial" picture of the death /disease pattern in a community. For more information about standardization, refer to the Resources section: Standardization of Rates.

• Emergency department visit - An ED visit occurs when a person presents the emergency department, or a hospital-based urgent care centre, either by their own means or by ambulance, and without a prior scheduled appointment. (Urgent care centres provide diagnosis and treatment for most injuries and illnesses through emergency trained doctors and other health care professionals and are a health care option for  urgent, but non life-threatening illness or injury like sprains or strains. Urgent care centre visits are captured in NACRS).
• Injuries can be categorized as unintentional (i.e. accidental) and intentional (i.e. deliberate) (5) and assigned with the Recommended ICD-10-CA codes for injury indicators.

• Fall-Related Injury Emergency Department Visits (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Self-Reported Injury (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Population Estimates (Section 1: Population)

1. Ministry of Health and Long-term Care [homepage on the Internet]. Toronto: Queen's Printer for Ontario; 2011 Oct 21 [2012 Jun 27]. Quick facts: emergency department visits for injury. Available from: http://www.mhp.gov.on.ca/en/prevention/injury-prevention/facts.asp.
2. Canadian Institute for Health Information. Highlights of 2009-2010 Inpatient Hospitalizations and Emergency Department Visits. Ottawa: Canadian Institute for Health Information; 2011 [cited 2012 Jun 27]. Available from: https://secure.cihi.ca/free_products/quickstats_dad_nacrs_2009_10_highlight_en.pdf.
3. Public Health Agency of Canada [homepage in the Internet]. Ottawa: Public Health Agency of Canada; 2010 Feb 1 [2012 Jul 10]. Injury Surveillance On-line. Available from: http://dsol-smed.phac-aspc.gc.ca/dsol-smed/is-sb/index-eng.php.
4. Centers for Disease Control and Prevention [homepage on the Internet]. Atlanta: Centers for Disease Control and Prevention; 2009 Nov 25 [cited 2012 Jul 10].  ICD 10 injury matrices. Available from: http://www.cdc.gov/nchs/injury/injury_matrices.htm  Matrix File: http://www.cdc.gov/nchs/data/ice/icd10_transcode.pdf  User friendly Matrix file: http://www4.state.nj.us/dhss-shad/query/InjuryMatrix.html.
5. Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O, editors. Injury surveillance guidelines. Geneva: World Health Organization; 2001 [cited 2012 Jun 27]. Available from: http://whqlibdoc.who.int/publications/2001/9241591331.pdf.

1. Canadian Institute for Health Information [homepage on the Internet]. Ottawa: Canadian Institute for Health Information; 1996-2012 [cited 2012 Jun 29]. Trauma and injuries. Available from: http://www.cihi.ca/CIHI-ext-portal/internet/EN/TabbedContent/types+of+care/specialized+services/trauma+and+injuries/cihi010639. 
2. Canadian Institute for Health Information. Ontario Trauma Registry 2011 report: major injury in Ontario, 2009 - 2010 data. Ottawa: Canadian Institute for Health Information; 2011 [cited 2012 Jun 27]. Available from: https://secure.cihi.ca/free_products/OTR_CDS_2009_2010_Annual_Report.pdf.
3. Canadian Institute for Health Information. Analysis in Brief. Emergency departments and children in Ontario. 2008. Ottawa: Canadian Institute for Health Information; 2008 [cited 2012 Jun 27]. Available from: https://secure.cihi.ca/free_products/aib_apr24_08_en.pdf.
4. Macpherson AK, Schull MJ, Manuel D, Cernat C, Redelmeier DA, Laupacis A. Injuries in Ontario: ICES Atlas. Toronto, ON: Institute for Clinical Evaluative Sciences; 2005 [cited 2012 Jul 9]. Chapter 1, General Description of Injuries in Ontario. 2002-2003; p. 1-22. Available from: http://www.ices.on.ca/file/injuries_chp1_final.pdf.
5. SMARTRISK. The economic burden of injury in Canada. Toronto: SMARTRISK; 2009 [cited 2012 Jun 27]. Availalbe from: http://www.smartrisk.ca/downloads/burden/Canada2009/EBI-Eng-Final.pdf.
6. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Fazlur Rahman AKM et al, editors. World report on child injury and prevention. Geneva: World Health Organization, 2008 [cited 2012 Jun 29]. Available from: http://whqlibdoc.who.int/publications/2008/9789241563574_eng.pdf.