• Crude hospitalization rate - the number of hospital admissions from neurotrauma relative to the total population during a given year (fiscal or calendar) (usually expressed per 100,000)
• Age-specific hospitalization rates - the total number of hospital admissions from neurotrauma 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 hospitalization rate (SRATE) - the number of hospitalizations from neurotrauma 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 hospitalizations from neurotrauma to the number expected if the population had the same age-specific hospitalization rates as Ontario.

• Hospitalization rate for Neurotrauma Injuries (Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI))
• Hospitalization rate for Traumatic Brain Injuries (TBI)
• Hospitalization rate Spinal Cord Injuries (SCI)

• 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.

• None

• None

Numerator: Emergency Visits
Original source: National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI)
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes): Ambulatory All Visits Main Table [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].


Denominator: Population Estimates
Original source: Statistics Canada
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes):  Population Estimates [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

• Ontario Trauma Registry
• Discharge Abstract Database (DAD) (Hospitalization) Note: for those interested in using hospitalization data from DAD, to avoid double counting of those patients that were admitted to one hospital and then transferred to another (e.g. to a regional trauma hospital), please use the ‘Inpatient Discharges All Tables' and add in the following filter when extracting hospital discharge data:
• 'Transfer from Institution Type' not equal to #1 - which is 'acute care facilities'
• Please refer to Indicator Comments for rationale for choice of data source.

Traumatic Brain injury ICD-10-CA Codes 

• Postconcussional syndrome (F07.2)
• Fracture of skull (S02.0, S02.1)
• Fracture of orbital floor (S02.3)
• Multiple fractures involving skull and facial bones (S02.7)
• Fracture of other skull and facial bones (S02.8)
• Fracture of skull and facial bones, part unspecified (S02.9)
• Intracranial Injury (S06 (all codes))
• Crushing injury of skull (S07.1)
• Sequelae of fracture of skull and facial bones (T90.2)
• Sequelae of intracranial injury (T90.5)

Spinal Cord Injury ICD-10-CA Codes 

• Injury of cervical spinal cord (S14.0, S14.1)
• Injury of thoracic spinal cord (S24.0, S24.1)
• Injury of lumbar spinal cord  (S34.0, S34.1)
• Injury of cauda equine (S34.3)
• Injuries of brain and cranial nerves with injuries of nerves and spinal cord at neck level (T06.0, T06.1)

• 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 'Hospitalization - Neuromtrauma - Ext Cause of Injury - PHU indicator list' inthe APHEO Public Health Indicators folder in the Standard Reports section.
• For in-patient hospitalization in IntelliHEALTH: In the Ambulatory All Visits Main Table, the filter "AM Case Type = EMG" must be used to extract only unscheduled ED visits.
• Add in a filter on ‘ICD10_CA_MPDX_code'' to filter equal to the ICD-10-CA codes listed above eg. F072, S020, S020, S023...etc. (Please note: decimal points normally found in these ICD-10-CA codes (e.g. ‘F07.2') have been removed as four character ICD-10-CA codes must be entered into IntelliHEALTH without decimal points)
• Filter for Admit Entry Type not equal to ‘N' and ‘S' - to exclude healthy newborns and stillbirths from your counts, as ICES and CIHI do for their publications.
• Filter for Hospital Type = AT (Acute Treatment) or AP (Acute Psychiatric) - to include only acute care hospitals.
• To select clients admitted as inpatients, use the 'Disposition Status' variables = '6' - (i.e.'Client admitted as inpatient to critical care unit/operating room in reporting facility direct from amb care visit functional center') OR = '7' ('Client admitted as inpatient to other units in reporting facility direct from amb. care visit functional') OR = '8' (Transferred to another acute care facility directly from an ambulatory care visit functional centre).
• Select # Visits (D) measure.
• Please note: the main problem diagnosis code is being used for this indicator instead of all diagnoses. 
• 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.
• 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

• The World Health Organization (WHO) has recognized the importance of surveillance systems for neurotrauma to inform prevention programs, as well as to inform the population of the significance of brain and spinal cord injuries (2).
• Traumatic brain injury is a leading cause of death and disability among children and young adults in North America. A study in Canada analyzed data between 1992 and 2002 and found that the age-sex standardized incidence rate of TBI hospitalizations decreased from 83.1 per 100,000 population per year to 50.4 per 100,000 population per year during this time frame, still contributing significantly to disabilities in Canada (3).
• The incidence rate of SCI in Ontario has been estimated at 24.2 per million population in 2003 and 23.1 per million population in 2006. Although SCI does not have a large incidence rate, these injuries are typically very serious, leading to long-term disability, poor quality of life, and mortality, with high social and economic costs to the individual and the community (4).
• It is essential to use a definition that is precise and accurate for the surveillance of traumatic brain injuries (TBI) and spinal cord injuries (SCI) (5).
• 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.
• To examine sports-acquired concussion, ICD-10-CA S06 (all codes) may be analyzed by place of occurrence.
• A person may be hospitalized for more than one occurrence of the same injury classification or discharged from more than one hospital for the same injury event in a given time period. Therefore, hospitalization data cannot be used to measure the incidence of a specific injury.
• Hospitalization data include multiple admissions for a single individual. Multiple admissions likely occur more frequently for chronic diseases.
• Hospitalization data are influenced by the availability of services and the practice patterns of providers.
• 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.

Choice of Data Source:

• NACRS, and not DAD, captures admissions to acute care psychiatric beds. For this reason, NACRS is used to derive the Intentional Self-Harm-Related Hospitalization Core Indicator. For consistency, NACRS is also the recommended data source for all other injury-related hospitalization indicators (i.e. Injury-Related Hospitalization, Fall-Related Hospitalization and Neurotrauma-Related Hospitalization).
• More timely information is provided through NACRS as injury data are based on admission to an inpatient bed from the emergency department. Discharge information following injury-related hospitalization obtained from the DAD may not be captured in the same year in which the injury occurred for some patients (especially those hospitalized for a prolonged period of time).
• All non-elective hospital admissions (i.e. including all hospital admissions for injury) must first be admitted to the emergency department and thus, will be captured in NACRS. Sometimes a patient seen in one ED can be transferred to another acute care facility. Ideally, a person that is transferred to another acute care facility will enter through the ED and receive a NACRS record with the new facility, however, this does not always occur. Thus, we recommend the inclusion of disposition status code '8', even though this may result in some over-counting of visits. Over-counting varied between 7% and 10% over the past several years in Ontario.
• Note that injury events found in DAD will not be identical to those found in NACRS:
• DAD also captures injury events that occur in acute care (e.g. a fracture from a fall in hospital will not be captured in NACRS). However, in-care injury events reflect patient safety within hospitals rather community safety, which is of greater public health concern.
• ICD-10-CA codes assigned based on emergency department presentation may differ from those assigned on discharge after hospitalization.

• Traumatic brain injury (2)  - an occurrence of injury to the head with at least one of the following:
• Observed or self-reported alteration of consciousness or amnesia due to head trauma
• Neurologic or neuropsychological changes or diagnoses of skull fracture or intracranial lesions that can be attributed to the head trauma
• Or an occurrence of death resulting from trauma with head injury or traumatic brain injury listed in the sequence of conditions that resulted in death

• Spinal Cord Injury (2) - an occurrence of an acute traumatic lesion of neural elements in the spinal canal, resulting in temporary or permanent sensory deficit, motor deficit, or autonomic dysfunction

• Hospitalization - in this indicator, a hospitalization occurs when a patient is admitted as an inpatient after being seen in the emergency department for an unscheduled visit.

• All-cause Hospitalization (Section 3: Mortality, Morbidity and Health-Related Quality of Life)
• Injury-Related Hospitalization (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Fall-Related Hospitalization (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Child and Adolescent Hospitalization (Section 6C: Child and Adolescent Health)
• Population Estimates (Section 1: Population)

1. Ontario Neurotrauma Foundation. Improving neurotrauma prevention through surveillance proceedings Final Draft (Email Communication with JoAnn Heale, MOHLTC, November 15^th, 2011)
2. Thurman DJ, Kraus JF, Romer CJ, editors. Standards for surveillance of neurotrauma. Geneva: World Health Organization; 1995.
3. Colantonio A, Croxford R, Farooq S, Laporte A, Coyte PC. Trends in hospitalization associated with traumatic brain injury in a publicly insured population, 1992-2002. J Trauma. 2009;66(1):179-183.
4. Couris CM, Guilcher SJ, Munce SE, Fung K, Craven BC, Verrier M, Jaglal SB. Characteristics of adults with incident traumatic spinal cord injury in Ontario, Canada. Spinal Cord. 2010;48(1):39-44.
5. Chen AY, Colantonio A.  Defining neurotrauma in administrative data using the International Classification of Diseases Tenth Revision. Emerg Themes Epidemiol. 2011 [cited 2012 Mar 15];8(4):1-13. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121731/pdf/1742-7622-8-4.pdf.