The new injury severity score underestimates true injury severity in a
resource-constrained setting
Dublin Core
Title
The new injury severity score underestimates true injury severity in a
resource-constrained setting
resource-constrained setting
Subject
Injury severity score
Trauma
Global health
Abbreviated injury scale
South Africa
Trauma
Global health
Abbreviated injury scale
South Africa
Description
Background: The new injury severity score (NISS) is widely used within trauma outcomes research. NISS is a
composite anatomic severity score derived from the Abbreviated Injury Scale (AIS) protocol. It has been
postulated that NISS underestimates trauma severity in resource-constrained settings, which may contribute to
erroneous research conclusions. We formally compare NISS to an expert panel’s assessment of injury severity in
South Africa.
Methods: This was a retrospective chart review of adult trauma patients seen in a tertiary trauma center.
Randomly selected medical records were reviewed by an AIS-certified rater who assigned an AIS severity score
for each anatomic injury. A panel of five South African trauma experts independently reviewed the same charts
and assigned consensus severity scores using a similar scale for comparability. NISS was calculated as the sum of
the squares of the three highest assigned severity scores per patient. The difference in average NISS between rater
and expert panel was assessed using a multivariable linear mixed effects regression adjusted for patient demographics, injury mechanism and type.
Results: Of 49 patients with 190 anatomic injuries, the majority were male (n = 38), the average age was 36
(range 18–80), with either a penetrating (n = 23) or blunt (n = 26) injury, resulting in 4 deaths. Mean NISS was
16 (SD 15) for the AIS rater compared to 28 (SD 20) for the expert panel. Adjusted for potential confounders, AIS
rater NISS was on average 11 points (95 % CI: 7, 15) lower than the expert panel NISS (p < 0.001). Injury type
was an effect modifier, with the difference between the AIS rater and expert panel being greater in penetrating
versus blunt injury (16 vs. 7; p = 0.04). Crush injury was not well-captured by AIS protocol.
Conclusion: NISS may under-estimate the ‘true’ injury severity in a middle-income country trauma hospital,
particularly for patients with penetrating injury.
composite anatomic severity score derived from the Abbreviated Injury Scale (AIS) protocol. It has been
postulated that NISS underestimates trauma severity in resource-constrained settings, which may contribute to
erroneous research conclusions. We formally compare NISS to an expert panel’s assessment of injury severity in
South Africa.
Methods: This was a retrospective chart review of adult trauma patients seen in a tertiary trauma center.
Randomly selected medical records were reviewed by an AIS-certified rater who assigned an AIS severity score
for each anatomic injury. A panel of five South African trauma experts independently reviewed the same charts
and assigned consensus severity scores using a similar scale for comparability. NISS was calculated as the sum of
the squares of the three highest assigned severity scores per patient. The difference in average NISS between rater
and expert panel was assessed using a multivariable linear mixed effects regression adjusted for patient demographics, injury mechanism and type.
Results: Of 49 patients with 190 anatomic injuries, the majority were male (n = 38), the average age was 36
(range 18–80), with either a penetrating (n = 23) or blunt (n = 26) injury, resulting in 4 deaths. Mean NISS was
16 (SD 15) for the AIS rater compared to 28 (SD 20) for the expert panel. Adjusted for potential confounders, AIS
rater NISS was on average 11 points (95 % CI: 7, 15) lower than the expert panel NISS (p < 0.001). Injury type
was an effect modifier, with the difference between the AIS rater and expert panel being greater in penetrating
versus blunt injury (16 vs. 7; p = 0.04). Crush injury was not well-captured by AIS protocol.
Conclusion: NISS may under-estimate the ‘true’ injury severity in a middle-income country trauma hospital,
particularly for patients with penetrating injury.
Creator
Smitha Bhaumik a
, Krithika Suresh b
, Hendrick Lategan c
, Elmin Steyn c
,
Nee-Kofi Mould-Mil
, Krithika Suresh b
, Hendrick Lategan c
, Elmin Steyn c
,
Nee-Kofi Mould-Mil
Source
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Publisher
a Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CO, USA b Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA c Department of Surgery, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
Date
4 desember 2023
Contributor
Fajar Bagus W
Format
PDF
Language
English
Type
Text
Files
Citation
Smitha Bhaumik a
, Krithika Suresh b
, Hendrick Lategan c
, Elmin Steyn c
,
Nee-Kofi Mould-Mil, “The new injury severity score underestimates true injury severity in a
resource-constrained setting,” Repository Horizon University Indonesia, accessed June 20, 2025, https://repository.horizon.ac.id/items/show/9550.
resource-constrained setting,” Repository Horizon University Indonesia, accessed June 20, 2025, https://repository.horizon.ac.id/items/show/9550.