Appendix VII. Charlson Comorbidity Index (Reference

Pan-Asian Trauma Outcomes Study Clinical Research Network

65

Appendix VII. Charlson Comorbidity Index (Reference: Charlson, M.E. 1994)


66


67


68


69

Appendix VIII. Structured interview for Glasgow Outcome Scale (GOS) (Reference: Wilson, J.T. et al., 1998)


70


71

Appendix IX. Modified Rankin Scale (Reference: Bruno, A., et al. 2010)


72

Appendix X. Structured interview for Glasgow Outcome Scale - Extended (GOSE) (Refrence: Wilson, J.T. et al., 1998)


73


74


75

Appendix XI. Structured interview for EQ5D (Refrence: EuroQol Research Foundation)


76


77

PATOS CASE REPORT

core **; comprehensive *

A. DEMOGRAPHIC

1 Research institute

**

2 Site ID ** □□□ 3 Country ** □□□

4 EMS district or

city **

□□□ 5 Case ID ** □□□□□□

(PATOS use only)

6 Date of birth ** □□ □□ □□□□

Mo. Day Year

7 Age **

□□□

(only if DOB is missing)

8 Gender ** □ 1 Male

□ 2 Female

9 Residential postal

code *

10 Citizenship * □ 1 Citizenship □ 2 No citizenship □ 99 Unknown

B. INJURY EPIDEMIOLOGY

11 Date/time of

injury **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

12 Weather

(check all that apply)

□ 1 Wet

□ 2 Dry

□ 3 Snow

□ 4 Ice

□ 5 Dark

□ 6 Light

□ 7 Fog

□ 99 Unknown

13 Incident site

address *

(Province, city, district) 14 Incident site

postal code *

15 Intent **

□ 1 Unintentional (accidental)

□ 2 Intentional self-harm (suicide, attempted

suicide)

□ 3 Assault (interpersonal violence)

□ 4 Undetermined (awaiting results of

investigation)

(check one)

□ 5 Legal interventions

□ 6 Operations of war and civil insurrection

□ 99 Unknown

16 Mechanism of

injury **

□ 1 Traffic injury

□ 2 Sexual assault

□ 3 Fall

□ 4 Struck/hit by person or object

□ 5 Stab or cut

□ 6 Gun shot

□ 7 Fire, flames or heat

□ 8 Choking or hanging

□ 9 Drowning or near-drowning

(check one)

8X Other

□ 80 Physical over-exertion

□ 81 Cooling

□ 82 Exposure to (effect of) weather, natural

disaster or other force of nature

□ 83 Complications of health care

□ 84 Corrosion by chemical or other

substance

□ 88 Other mechanism of injury


78

□ 10 Poisoning □ 99 Unknown

17 Location of

injury **

□ 1 Head

□ 2 Face

□ 3 Neck

□ 4 Thorax

□ 5 Abdomen and pelvic contents


□ 6 Spine

□ 7 Upper extremity

□ 8 Lower extremity (including bony pelvis)

□ 9 External (skin)

□ 88 Other (non-anatomical inury)

18 Type (Nature) of

injury **

□ 1 Fracture

□ 2 Sprain, strain or dislocation

□ 3 Cuts, bites or open wound

□ 4 Bruise or superficial injury

□ 5 Burns


□ 6 Concussion

□ 7 Organ system injury

□ 88 Other

□ 99 Unknown

19 Place of injury **

□ 1 Home, including garden and out buildings

□ 2 School, including kindergarten and

schoolyard

□ 3 Street/highway

□ 4 Residential institution

□ 5 Sports and athletics area

□ 6 Other transport area

□ 7 Industrial/construction

□ 8 Farm, excluding home

(check one)

□ 9 Commercial

□ 10 Countryside, water, sea

8X Other

□ 80 Medical service area

□ 81 Recreational and cultural area and

public building

□ 88 Other place of occurrence

□ 99 Unknown

20 Work-related

injury *

□ 1 Yes □ 0 No □ 99 Unknown

21 Activity **

□ 1 Work, including travel for work (e.g. truck

driving)

□ 2 Education, including school sports

□ 3 Sports

□ 4 Leisure/play

□ 5 Traveling not elsewhere classified

(check one)

8X Other

□ 80 Unpaid activities

□ 81 Activities of daily living

□ 82 During treatment

□ 88 Other activities, not elsewhere

classified

□ 99 Unknown

22 Alcohol use **

□ 1 Suspected (by report or observation)

□ 2 Confirmed by biological evidence

□ 3 No use – by report or observation or

biological evidence

(check one)

□ 99 No information available

23 Alcohol use of

others who were

directly involved




biological evidence

(check one)

□ 88 Not applicable


24 Psychoactive (check one)


79

drug/substance use

**




biological evidence


25 Psychoactive

drug/substance use

of others who were

directly involved




biological evidence

(check one)

□ 88 Not applicable


26 Arrival type ** □ 1 Prehospital ambulance transport

□ 2 Interhospital ambulance transport

□ 3 Prehospital transport using other vehicles

(non-EMS)

□ 4 Interhospital transport using other

vehicles (non-EMS)

(If 1 or 3, complete section C: Prehospital Care)

(If 2 or 4, complete section D: Interhospital Transfer)

27 Prehospital care

provider **

□ 1 Non-EMT (includes volunteer)

□ 2 EMT(basic, intermediate, advanced,

paramedic)


□ 3 Doctors

□ 4 Nurses

□ 99 Unknown

C. PREHOSPITAL CARE

28 Incident no. * 29 Ambulance no. *

30 Mode of arrival

**

□ 1 Road ambulance

□ 2 Helicopter

□ 3 Ship

(check one)

□ 88 Other

□ 99 Unknown

31 Date/time call

received **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

32 Date/time call

ambulance

departed from **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

33 Date/time

ambulance arrived

at accident site **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

34 Date/time

ambulance left

accident site **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

35 Date/time

ambulance arrived

at hospital **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

36 Prehospital CPR

**

□ 1 Yes

□ 0 No

□ 99 Unknown

37 Prehospital BP –

systolic **

□□□ Prehospital BP –

diastolic

□□□

38 Prehospital HR

**

□□□ per minute 39 Prehospital RR

**

□□□ per minute

40 Prehospital □□□ %


80

O2Sat **

41 Prehospital

mental status **

□ 2 Glasgow Coma Scale □ 3 AVPU □ 1 Not measured

□ 99 Unknown Eye

□ 1 No eye opening

□ 2 Eyes open only with painful

stimuli

□ 3 Eyes open to verbal command

□ 4 Eyes open spontaneously

Verbal

□ 1 No verbal response

□ 2 Incomprehensible sounds

□ 3 Inappropriate words

□ 4 Disoriented

□ 5 Oriented

□ 6 Intubated

Motor

□ 1 No motor response

□ 2 Extension (decerebrate)

□ 3 Flexion (decorticate)

□ 4 Withdraws from pain

□ 5 Localizes pain

□ 6 Obeys verbal commands

□ 1 A

□ 2 V

□ 3 P

□ 4 U

42 Prehospital

airway *

□ 20 Oropharyngeal airway

3X Supraglottic Airway

□ 31 Combitube

□ 32 Laryngeal tube

□ 33 Laryngeal mask airway

□ 34 Other types


□ 40 Endotracheal tube

□ 88 Other

□ 10 None

□ 99 Unknown

43 Prehospital

oxygen *

□ 2 Nasal

□ 3 Venturi mask

□ 4 Facial mask (breathing or non-

rebreathing)


□ 5 BVM

□ 6 Mechanical ventilator

□ 88 Other

□ 1 None

□ 99 unknown

Amount

□□.□ litres per minute

44 Prehospital

immobilization *

□ 2 Backboard

□ 3 Scoop

□ 4 Femur traction splint

□ 5 Other extremity splint


□ 6 Bandaging

□ 7 Pelvic binder

□ 8 C-spine

□ 88 Other

□ 1 None

□ 99 Unknown

45 Prehospital fluid (check all that apply) □ 1 None


81

access * □ 2 IV

□ 3 IO

□ 99 Unknown

Type (check all that apply)

□ 1 NS

□ 2 5DW

□ 3 10DW

□ 4 50DW

□ 5 HS

□ 6 Hypertonic saline

□ 88 Other

□ 99 Unknown

Amount

□□□.□ mL

46 Pain control

during prehospital

phase

□ 2 Entonox (medical nitrous oxide

and oxygen mixture)

□ 3 IM/IV NSAIDs

□ 4 IM/IV Opioids

□ 5 Penthorox (Penthrox inhaler for

self-administration of

methoxyflurane for analgesia)


□ 6 IM/IV Ketamine

□ 7 PO Paracetamol

□ 88 Other

□ 1 None

□ 99 Unknown

47 Medications

given during

prehospital phase *

Medication 1: ___________________________________

Medication 2 ___________________________________

Medication 3 ___________________________________

Medication 4 ___________________________________

Medication 5 ___________________________________

Medication 6 ___________________________________

Medication 7 ___________________________________

Medication 8 ___________________________________

Medication 9 ___________________________________

Medication 10 __________________________________

48 Prehospital

procedure for

thoracic cavity

□ 1 None

□ 2 Thoracentesis

□ 3 Thoracotomy


□ 4 Pericardiocentesis

□ 99 Unknown

49 Prehospital

diagnosis

□ 1 Superficial injuries

□ 2 Musculoskeletal injuries

□ 3 Burn and corrosion injuries

□ 4 Internal organ injuries - chest

□ 5 Internal organ injuries – abdomen

□ 6 Crushing injuries

□ 7 Open wound injuries

□ 8 Blood vessel injuries


□ 9 Nerves and spinal cord injuries

□ 10 Other and unspecified injuries

□ 11 Skull and facial bone fracture injuries

□ 12 Intracranial injuries

□ 13 Head crushing injuries

□ 14 Neck injuries

□ 15 Other multiple body injuries

□ 99 Unknown

50 Decontamination

□ 1 Yes. Dry decontamination was done.

□ 2 Yes. Wet decontamination was done.

□ 3 No. Decontamination was indicated but

not conducted.

(check one)

□ 4 No. Decontamination was not indicated.

□ 99 Unknown

D. INTERHOSPITAL TRANSFER

51 Level of (check one) 52 Name of


82

referring hospital ** □ 1 Level I trauma center

□ 2 Level II trauma center

□ 3 Level III trauma center or

below

□ 99 Unknown

referring hospital

53 Date/time of

arrival at referring

hospital

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

54 Date/time of

departure from

referring hospital

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

55 Mode of

interhospital

transfer *

□ 1 Road ambulance

□ 2 Helicopter

□ 3 Ship

(check one)

□ 88 Other

□ 99 Unknown

56 Reason for

transfer *

□ 10 Insufficient availability of wards

□ 20 Insufficient availability of ICUs

□ 30 Unable to provide emergency

operations/procedure

4X Transfer for professional emergency care

□ 41 Burns

□ 42 Neurology/neurosurgery

□ 43 Cardiothoracic surgery

□ 44 Pediatrics/pediatric trauma

□ 45 Hand surgery

□ 46 Other

(check one)

□ 50 Transfer to a lower level hospital for mild

illness

□ 60 Transfer to a long-term care facility

□ 70 Personal reasons

□ 88 Other

□ 99 Unknown

57 Transfer from

where *

□ 1 ED

□ 2 ICU

(check one)

□ 3 Ward (other than ICU)

□ 99 Unknown

58 Intervention

before transfer

□ 1 ED resuscitation

□ 2 Surgery

□ 3 ICU care


□ 4 Non-specific intervention

□ 5 No intervention

□ 99 Unknown

59 GCS at referring

hospital before

transfer *

□ 1 Measured □ 0 Not all GCS

measured

□ 99 Unknown

Eye

□ 0 Not measured


□ 2 Eyes open only with painful stimuli



Verbal

□ 0 Not measured




83


□ 4 Disoriented

□ 5 Oriented

□ 6 Intubated

Motor

□ 0 Not measured







E. ED AND HOSPITAL CARE

60 BP at triage -

systolic **

□□□

BP at triage –

diastolic

□□□

61 HR at triage ** □□□ per minute 62 RR at triage ** □□□ per minute

63 Temperature at

triage **

□□.□ ℃ 64 O2Sat at triage

**

□□□ %

65 Mental status at

triage (GCS) **

□ 1 Measured □ 0 Not all GCS

measured

□ 99 Unknown

Eye

□ 0 Not measured


□ 2 Eyes open only with painful stimuli



Verbal

□ 0 Not measured




□ 4 Disoriented

□ 5 Oriented

□ 6 Intubated

Motor

□ 0 Not measured






84



66 DOA ** □ 1 Yes □ 0 No

67 Date/time of

arrival at ED **

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

68 Date/time of

disposition from ED

**

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

69 ED disposition ** (check one)

□ 1 Treated and

discharged

□ 2 Transfer to

another hospital

□ 4 Dead

□ 88 Other

□ 99 Unknown

□ 3 Admitted to hospital

70 Hospital

Discharge

disposition **

(check one)

□ 10 Treated and discharge

□ 20 Hopeless discharge

□ 30 Discharge against advice [1]

4X Transfer

□ 41 Transferred to another hospital for acute

care treatment

□ 42 Transferred to a rehabilitation center

□ 43 Transferred to a nursing home

□ 50 Dead

□ 88 Other

□ 99 Unknown

71 Date/time of

hospital discharge

**

□□ □□ □□□□ □□:□□

Mo. Day Year Time

72 Total length of

stay in ICU **

□□□ days

73 Airway

management **

□ 20 Oropharyngeal airway

3X Supraglottic Airway

□ 31 Combitube

□ 32 Laryngeal tube

□ 33 Laryngeal mask airway

□ 34 Other types


□ 40 Endotracheal tube

□ 88 Other

□ 10 None

□ 99 Unknown

74 Fluid

□ 1 Yes □ 0 No

□ 99 unknown Amount

□□□.□ mL

75 Transfusion * □ 1 Yes □ 0 No

□ 99 unknown Amount

Whole blood: □□□ cc

Packed cells: □□□ cc

FFP: □□□ cc

Platelets: □□□ cc

Platelets (apheresis): □□□ cc


85

Cryoprecipitate: □□□ cc

76 Surgical airway * □ 1 Yes □ 0 No □ 99 Unknown

77 Tension

pneumothorax

decompression *


78 Non-surgical

external bleeding

control *


79 Cardiocentesis * □ 1 Yes □ 0 No □ 99 Unknown

80 Thoracostomy or

thoracotomy *


81 Positive

ventilation *


82 Non-surgical

immobilization *


83 CPR * □ 1 Yes □ 0 No □ 99 Unknown

84 Operation *

85 Operation –

date/time *

□ 1 None

□ 2 Head

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 3 Face

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 4 Neck

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 5 Thorax

□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year


□ 7 Spine

□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 10 Unspecified

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 99 Unknown


86

□□:□□

Time

86 First

angiography scan *

87 First

angiography scan –

date/time *

□ 1 None

□ 2 Head

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 3 Face

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 4 Neck

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 5 Thorax

□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□ 7 Spine

□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 10 Unspecified

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 99 Unknown

88 Embolization *

89 Embolization

date/time *

□ 1 None

□ 2 Head

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 3 Face

□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□ 7 Spine

□□ □□ □□□□

Mo. Day Year

□□:□□

Time


□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 9 Lower extremity + bony pelvis


87

□ 4 Neck

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 5 Thorax

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 6 Abdomen

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 10 Unspecified

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

□ 99 Unknown

90 Pre-existing

comorbidity *

□ 1 Yes □ 0 No

□ 99 Unknown


□ 1 Myocardial infarction

□ 2 Congestive heart failure

□ 3 Peripheral vascular disease

□ 4 Cerebrovascular disease

□ 5 Hemiplegia

□ 6 Pulmonary disease

□ 7 Diabetes

□ 1) End-organ damage

□ 2) No end-organ damage

□ 8 Moderate to severe renal disease

□ 9 Chronic liver disease

□ 1) Moderate to severe liver disease

□ 2) Mild liver disease

□ 10 Peptic ulcer disease

□ 11 Cancer

□ 1) Lymphoma

□ 2) Leukemia

□ 3) Solid tumor

□ 4) Metastatic tumor

□ 1) Breast

□ 2) Colon

□ 3) Prostate

□ 4) Lung

□ 5) Melanoma

□ 6) Other


88

□ 12 Dementia

□ 13 Rheumatologic disease

□ 14 HIV/AIDS

91 Pre-existing

disability (GOS) **

(check one)

□ 1 Vegetative state: unable to move on a bed

□ 2 Severe disability: Independent activities of daily living are not possible

□ 3 Moderate disability: Independent activities of daily living are possible, but cannot resume

work/school life

□ 4 Mild or no disability; no disability reported

□ 99 Unknown

92 Modified Rankin

Scale at discharge

**

□ 0 No symptoms at all

□ 1 No significant disability despite symptoms;

able to carry out all usual duties and

activities

□ 2 Slight disability; unable to carry out all

previous activities, but able to look after

own affairs without assistance

□ 3 Moderate disability; requiring some help,

but able to walk without assistance

(check one)

□ 4 Moderately severe disability; unable to

walk without assistance and unable to

attend to own bodily needs without

assistance

□ 5 Severe disability; bedridden, incontinent

and requiring constant nursing care and

attention

□ 6 Dead

□ 99 Unknown

93 Pediatric * □ 1 Yes □ 0 No

94 Weight * □□□ kg

95 Airway * (check one)

□ 1 Normal airway

□ 2 Maintained airway

□ 3 Unmaintainable (invasive) airway (i.e.

intubated)

□ 99 Unknown

96 Level of

consciousness *

(check one)

□ 1 Awake

□ 2 Obtunded or any loss of consciousness

(responsive)

□ 3 Unresponsive

□ 99 Unknown

97 Fracture * (check one)

□ 1 None

□ 2 Single and closed or suspected

□ 3 Multiple closed or open

□ 99 Unknown

98 – Wound * (check one)

□ 1 None

□ 2 Minor; contusion, abrasion, laceration

<7 cm not through fascia

□ 3 Major, penetrating, or burns >10%


89

□ 99 Unknown

99 – Child abuse (check one)


100 – Sport-related

injury

(check one)


F. INJURY SEVERITY AND OUTCOME

Injury code 101 ICD-10 Diagnosis ** 102 Abbreviated injury scale **

(check one)

□ 1 ICD-10

□ 2 ICD-9

1 □□□.□ □□□□□□.□

2 □□□.□ □□□□□□.□

3 □□□.□ □□□□□□.□

4 □□□.□ □□□□□□.□

5 □□□.□ □□□□□□.□

6 □□□.□ □□□□□□.□

7 □□□.□ □□□□□□.□

8 □□□.□ □□□□□□.□

9 □□□.□ □□□□□□.□

10 □□□.□ □□□□□□.□

103 GOS at

discharge **

(check one)

□ 1 Dead

□ 2 Vegetative state: unable to move on a bed

□ 3 Severe disability: Independent activities of daily living are not possible

□ 4 Moderate disability: Independent activities of daily living are possible, but cannot resume

work/school life

□ 5 Recovering state: Mild or no disability; can resume work/school life

□ 99 Unknown

G. REHABILITATION

104 Date for first

rehabilitation

evaluation during

hospital stay *

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

105 Date for first

psychiatric

evaluation during

hospital stay *

□□ □□ □□□□

Mo. Day Year

□□:□□

Time

H. OUTCOME AT 6 MONTH

106 Current

residence at 6

month

□ 1 Home: no additional treatment and

assistance required

□ 2 Home: additional treatment and assistance

required

□ 3 General hospital

(check one)

□ 5 Nursing home

□ 6 Hospice

□ 7 Dead

□ 88 Other

□ 99 Unknown


90

□ 4 Rehabilitation hospital

107 Occupational

status at 6 month

□ 1 Patient returned to the same workplace

(school) he/she was attending prior to

injury; patient is currently at the same

level(grade) as before.

□ 2 Patient returned to the same workplace

(school) he/she was attending prior to

injury; patient is currently at a different

level(grade) as before.

□ 3 Patient returned to the same

workplace(school) he/she was attending

prior to injury; patient does not know the

level(grade) he/she is in.

□ 4 Patient returned to a different

workplace(school) than the one he/she was

attending prior to injury; patient is currently

at the same level(grade) as before.

(check one)



attending prior to injury; patient is currently

at a different level(grade) as before.



attending prior to injury; patient does not

know the level(grade) he/she is in.

□ 7 Patient never worked or attended school

prior to injury.

□ 99 Unknown

108 Extended

Glasgow Outcome

Scales (GOSE)

Interview at

6 month *

□ 1 Dead

□ 2 Vegetative State

□ 3 Lower Severe Disability

□ 4 Upper Severe Disability

(check one)

□ 5 Lower Moderate Disability

□ 6 Upper Moderate Disability

□ 7 Lower Good Recovery

□ 8 Upper Good Recovery

109 EQ5D at 6

month *

Mobility

□

□ 2 I have slight problems walking about

□ 3 I have moderate problems walking about

Self-care

□ 1 I have no problems washing or dressing

myself

□ 2 I have slight problems washing or dressing

myself

□ 3 I have moderate problems washing or

dressing myself

Usual activities

□ 1 I have no problems doing my usual

activities

□ 2 I have slight problems doing my usual

activities

□ 3 I have moderate problems doing my usual

activities

(check one)

□ 4 I have severe problems walking about

□ 5 I am unable to walking about

(check one)

□ 4 I have severe problems washing or

dressing myself

□ 5 I am unable to wash or dress myself

(check one)

□ 4 I have severe problems doing my usual

activities

□ 5 I am unable to do my usual activities


91

Pain/discomfort

□ 1 I have no pain or discomfort

□ 2 I have slight pain or discomfort

□ 3 I have moderate pain or discomfort

Anxiety/depression

□ 1 I am not anxious or depressed

□ 2 I am slightly anxious or depressed

□ 3 I am moderately anxious or depressed

VAS □□□

(check one)

□ 4 I have severe pain or discomfort

□ 5 I have extreme pain or discomfort

(check one)

□ 4 I am severely anxious or depressed

□ 5 I am extremely anxious or depressed

I. OUTCOME AT 12 MONTH

110 Extended

Glasgow Outcome

Scales (GOSE)

Interview at

12 month *

□ 1 Dead

□ 2 Vegetative State

□ 3 Lower Severe Disability

□ 4 Upper Severe Disability

(check one)

□ 5 Lower Moderate Disability

□ 6 Upper Moderate Disability

□ 7 Lower Good Recovery

□ 8 Upper Good Recovery

111 EQ5D at 12

month *

Mobility

□

□ 2 I have slight problems walking about

□ 3 I have moderate problems walking about

Self-care

□ 1 I have no problems washing or dressing

myself

□ 2 I have slight problems washing or dressing

myself

□ 3 I have moderate problems washing or

dressing myself

Usual activities

□ 1 I have no problems doing my usual

activities

□ 2 I have slight problems doing my usual

activities

□ 3 I have moderate problems doing my usual

activities

Pain/discomfort

□ 1 I have no pain or discomfort

□ 2 I have slight pain or discomfort

□ 3 I have moderate pain or discomfort

(check one)

□ 4 I have severe problems walking about

□ 5 I am unable to walking about

(check one)

□ 4 I have severe problems washing or

dressing myself

□ 5 I am unable to wash or dress myself

(check one)

□ 4 I have severe problems doing my usual

activities

□ 5 I am unable to do my usual activities

(check one)

□ 4 I have severe pain or discomfort

□ 5 I have extreme pain or discomfort


92

Anxiety/depression

□ 1 I am not anxious or depressed

□ 2 I am slightly anxious or depressed

□ 3 I am moderately anxious or depressed

VAS □□□

(check one)

□ 4 I am severely anxious or depressed

□ 5 I am extremely anxious or depressed

J. DEATH CERTIFICATE

112 Date/time of

death **

□□ □□ □□□□ □□:□□

Mo. Day Year Time

113 Primary cause

of death **

□ 1 Unknown diagnosis due to DOA / DNR

□ 2 Shock bleeding / hypervolemia

□ 3 Severe traumatic brain injury

□ 4 Major chest or abdominal organ injury

□ 5 Septic shock / multi-organ failure

(check one)

□ 6 Complicated medical condition (MI, Stroke,

infection etc.)

□ 88 Other

□ 99 Unknown


93

Reference

1. ICECI Coordination and Maintenance Group (2004). International Classification of External Causes of Injuries (ICECI) version 1.2. Consumer Safety Institute, Amsterdam and AIHW National Injury Surveillance Unit, Adelaide.

2. Concise Medical Dictionary (8 ed.). 2010, Oxford University Press. 3. Committee on Trauma America College of Surgeons, Resources for Optimal Care of the Injured

Patient 2014 M.F. Rotondo, C. Cribari, and R.S. Smith, Editors. 2014.

4. American College of Surgeons, ACS NTDB National Trauma Data Standard: Data Dictionary. 2015.

5. Wilson, J.T., L.E. Pettigrew, and G.M. Teasdale, Structured interviews for the Glasgow Outcome

Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma, 1998. 15(8): p. 573-85.

6. Charlson, M.E., Charlson Comorbidity Index: Chart review version 1994. 7. Bruno, A., et al., Improving modified Rankin Scale assessment with a simplified questionnaire.

Stroke, 2010. 41(5): p. 1048-50.

8. EuroQol Research Foundation, EQ-5D-5L. Sample UK English EQ-5D-SL. 2015.

Documents

Appendix VII. Charlson Comorbidity Index (Reference