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Combat injury coding: A review and reconfiguration

Lawnick, Mary M. BSN; Champion, Howard R. FRCS; Gennarelli, Thomas MD; Galarneau, Michael R. MS; D’Souza, Edwin MS; Vickers, Ross R. PhD; Wing, Vern MS; Eastridge, Brian J. MD; Young, Lee Ann MS; Dye, Judy MSN; Spott, Mary Ann MPA, MBA; Jenkins, Donald H. MD; Holcomb, John MD; Blackbourne, Lorne H. MD; Ficke, James R. MD; Kalin, Ellen J. MA; Flaherty, Stephen MD

Journal of Trauma and Acute Care Surgery: October 2013 - Volume 75 - Issue 4 - p 573–581
doi: 10.1097/TA.0b013e3182a53bc6
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BACKGROUND The current civilian Abbreviated Injury Scale (AIS), designed for automobile crash injuries, yields important information about civilian injuries. It has been recognized for some time, however, that both the AIS and AIS-based scores such as the Injury Severity Score (ISS) are inadequate for describing penetrating injuries, especially those sustained in combat. Existing injury coding systems do not adequately describe (they actually exclude) combat injuries such as the devastating multi-mechanistic injuries resulting from attacks with improvised explosive devices (IEDs).

METHODS After quantifying the inapplicability of current coding systems, the Military Combat Injury Scale (MCIS), which includes injury descriptors that accurately characterize combat anatomic injury, and the Military Functional Incapacity Scale (MFIS), which indicates immediate tactical functional impairment, were developed by a large tri-service military and civilian group of combat trauma subject-matter experts. Assignment of MCIS severity levels was based on urgency, level of care needed, and risk of death from each individual injury. The MFIS was developed based on the casualty’s ability to shoot, move, and communicate, and comprises four levels ranging from “Able to continue mission” to “Lost to military.” Separate functional impairments were identified for injuries aboard ship. Preliminary evaluation of MCIS discrimination, calibration, and casualty disposition was performed on 992 combat-injured patients using two modeling processes.

RESULTS Based on combat casualty data, the MCIS is a new, simpler, comprehensive severity scale with 269 codes (vs. 1999 in AIS) that specifically characterize and distinguish the many unique injuries encountered in combat. The MCIS integrates with the MFIS, which associates immediate combat functional impairment with minor and moderate-severity injuries. Predictive validation on combat datasets shows improved performance over AIS-based tools in addition to improved face, construct, and content validity and coding inter-rater reliability. Thus, the MCIS has greater relevance, accuracy, and precision for many military-specific applications.

CONCLUSION Over a period of several years, the Military Combat Injury Scale and Military Functional Incapacity Scale were developed, tested and validated by teams of civilian and tri-service military expertise. MCIS shows significant promise in documenting the nature, severity and complexity of modern combat injury.

Supplemental digital content is available in the text.

From Department of Surgery, SimQuest Solutions Inc. (M.M.L., H.R.C., E.J.K.), Annapolis; and Uniformed Services University of the Health Sciences (H.R.C.), Bestheda, Maryland; Medical College of Wisconsin (T.G.), Milwaukee, Wisconsin; Naval Health Research Center (M.R.G., E.D., R.R.V., V.W., J.D.), San Diego, California; University of Texas (B.J.E.); US Army Institute of Surgical Research (M.A.S., L.H.B.); University of Texas Health Science Center (J.H.); and Brooke Army Medical Center (J.R.F.), Fort Sam Houston, San Antonio, Texas; Applied Research Associates (L.A.Y.), Albuquerque, New Mexico; Mayo Clinic (D.H.J.), Rochester, Minnesota; and Walter Reed Army Medical Center, Washington, DC (S.F.).

Submitted: March 28, 2013, Revised: June 5 2013, Accepted: June 6 2013.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Howard R. Champion, FRCS, 954 Melvin Rd, Annapolis, MD; email: hrchampion@aol.com.

© 2013 Lippincott Williams & Wilkins, Inc.