2  Severity

2.1 Post Traumatic Amnesia (PTA)

Date Added : 1989-10-01

2.1.0.1 Definition

Date of emergence from Post-traumatic Amnesia (PTA).

Where possible, PTA emergence should be measured (tracked) prospectively by direct testing. With prospective tracking, emergence from PTA is defined as:

  1. two consecutive GOAT scores of 76 or greater with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday)
  2. two consecutive scores of 11 or greater on the Revised GOAT with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday)
  3. two consecutive scores of 25 or greater on the Orientation-Log with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday)
  4. two consecutive scores of 8 or greater on the Non-Verbal version of the Orientation-Log with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday), or
  5. in the judgment of a qualified clinician (i.e., speech-language pathologist, physician, neuropsychologist), the person has cleared PTA but administration of an orientation test is not possible due to language functioning.

The day of clearance of PTA is the first day the person gets the first of 2 consecutive scores of 76 or greater on the GOAT, the first of 2 consecutive scores of 11 or greater on the Revised GOAT, the first of 2 consecutive scores of 25 or greater on the Orientation-Log, or the first of 2 consecutive scores of 8 or greater on the Non-Verbal version of the Orientation-Log.

If within a 7-day period, there are multiple scores exceeding the PTA cut-off, but the first two are separated by more than two full calendar days (e.g. Assessment 1 = Friday, Assessment 2 = Tuesday; this would be 3 full calendar days apart), then it is acceptable to use the midpoint between the first and second dates the PTA assessment was administered.

It is the choice of the Project Director as to whether to use the GOAT, Revised GOAT (Bode, Heinemann, & Semik, 2000 – see SOURCES) or the Orientation-Log (Jackson, Novack, & Dowler, 1998; Novack, Dowler, Bush, Glen, & Schneider, 2000 – see SOURCES) to establish the duration of PTA. Alternating use of the scales in an individual patient is not acceptable, however. Preferably, copies of the test protocols documenting PTA tracking should be kept in the research record. If the PTA data is elsewhere (e.g., in the rehabilitation chart), the location should be noted in the research record.

The Non-Verbal version of the Orientation-Log is the preferred assessment of orientation for persons with traumatically induced expressive language disorder with significant difficulty generating comprehensible verbal output. Common causes for this problem include expressive aphasia and severe dysarthria accompanied by an inability to write responses. Non-verbal responses are scored according to the following criteria: 1 = correct upon multiple choice / 0 = incorrect or no response. This scoring adjustment is intended to be used only for non-verbal individuals with significant difficulty generating comprehensible verbal or written output. Careful clinical judgment will be required in each case to determine that the person’s expressive problems are clearly due to neurological disorder, and the person is unable to respond in writing.

Determining Date of PTA Emergence During Acute Care
For those patients who are already oriented at rehabilitation admission (as defined by the first two GOAT scores after rehabilitation admission >75), prospective tracking of the date of emergence from PTA is not possible, because the date falls within the acute care stay. In these cases, PTA emergence can be determined via chart review of the acute care records only. (NOTE: Rehabilitation hospital charts may NOT be used for this purpose). The following procedure can be used to determine the length of PTA based on acute care hospital records. This procedure should be followed only for those patients who are oriented at rehabilitation admission.

  1. Obtain all available physician, nursing and therapy notes from the acute hospitalization. In most hospital medical records, physician, nursing and therapy notes are filed in different sections. You may have to specifically request therapy and nursing notes, if you routinely only receive the physician progress notes.

  2. Review all notes to determine the first DATE on which all notes referencing orientation indicate that the patient is fully oriented, oriented X 3 (or 4), or GCS Verbal Score = 5 (oriented). This is Orientation Day 1.

  3. Review notes from the next calendar day to determine if all relevant notes again indicate that the patient is fully oriented.

  4. If yes, the second day is Orientation Day 2, and Orientation Day 1 is the resolution date of PTA. If there are missing notes or no comments about orientation on the second day, keep looking for the second day that the notes consistently document full orientation. As long as Orientation Day 2 is no more than 2 full calendar days from Orientation Day 1, and if no notes from intervening days indicate less than full orientation, record Orientation Day 1 as the resolution date of PTA.

  5. If any note from calendar days intervening between Orientation Days 1 and 2 indicate less than full orientation, use Day 2 as the new starting point (i.e., new Day 1) and repeat procedure from Step 3 above.

  6. If there is no Orientation Day 2 (i.e., if the patient is never fully oriented on more than one day; or if more than 2 full calendar days elapse after Orientation Day 1 with no further notation about orientation), code date of PTA resolution as unknown. An exception would be if on the day before or the day of transfer to rehabilitation, the patient is specifically noted not to be oriented. If the patient then produces GOATs >75 on the first two examinations after rehabilitation admission, code the date of PTA resolution in the usual manner.

2.1.0.2 Form

[X] Form 1
[ ] Form 2

2.1.0.3 Source

Form 1 - Abstraction (acute record only) or measured by direct O-Log or GOAT testing (rehab record)

2.1.0.4 Details

Administer the test every 1 to 3 calendar days until patient emerges from PTA.

There is no code for “unknown” for method of PTA determination because this should never be unknowable. Please contact the TBINDC if you are in a situation in which this variable is truly unknown (and unknowable).

Code date of admission to ER if person was never in PTA.

If PTA lasts less than 24 hours, code day 2 as the date of emergence from PTA, since this would be the first day that they were fully oriented.

If participant was not out of PTA at Rehab discharge score is coded as “888. Person Still in PTA at time of Rehab Discharge”.
If a person was never in PTA the days = 0.

For cases who do not emerge from PTA by rehab discharge, code the method used to decide if the patient is still in PTA.

The same instrument must be used for all scores to capture the date emerged from PTA during rehabilitation. GOAT and O-Log scores may not be mixed and matched.

Record review can not be used to determine Date Emerged from PTA during rehab. If PTA was not tracked with GOAT or O-Log during rehab and patient did not emerge during the acute stay, Date Emerged from PTA should be coded as “09/09/9999 (Unknown)”, and Method of Determination should be coded as “88. (N/A PTA Not Tracked)”.

Patients who don’t have any documented GOAT or O-Log scores possibly due to other cognitive deficits (e.g. “confused due to dementia’‘) and formal testing may not have been possible should be’‘09/09/999 - Unknown’’ rather than ‘’08/08/8888 - Never Emerged.’’ The method of PTA determination should be coded as ‘88. PTA has not been tracked.’. Record review cannot be used to determine emergence from PTA during rehab.

If an acute record states “patient is A&O x3 with choices”, and the patient has aphasia or some other expressive language disorder, then testing with choices would be appropriate to asses orientation and would count as being oriented.

Computer calculates duration of post-traumatic amnesia by subtracting the date of injury from this date.

Duration of PTA is calculated only for those cases which emerge from PTA prior to discharge from inpatient rehabilitation.

Duration of PTA is not to be calculated from date of emergence from coma [FLLW], per decision of the neuropsychology databusters group.

Two consecutive GCS Verbal scores of “5-Oriented” may be used to determine length of PTA when there is no other source of documentation using acute chart review.

For cases who never had PTA, code “Method of PTA Determination” as “1-Acute Chart Review”.

2.1.0.6 Reference

GOAT: Levin, HS, O’Donnell, VM, & Grossman, RG. (1979). The Galveston Orientation and Amnesia Test: A practical scale to assess cognition after head injury. Journal of Nervous and Mental Diseases, 167, 675-684. See External Links

Revised GOAT: Bode RK, Heinemann AW, Semik P. Measurement properties of the Galveston Orientation and Amnesia Test (GOAT) and improvement patterns during inpatient rehabilitation. J Head Trauma Rehabil. 2000 Feb;15(1):637-55. See External Links

Orientation-Log (and Non-Verbal version of the Orientation-Log): Jackson WT, Novack TA, Dowler RN. Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log. Arch Phys Med Rehabil. 1998 Jun;79(6):718-20. Link to PubMed: See External Links

Novack, TA, Dowler, RN, Bush, BA, Glen, T, Schneider, JJ. Validity of the Orientation Log, Relative to the Galveston Orientation and Amnesia Test. J Head Trauma Rehabil, 2000, 15(3), 957-961. See External Links

2.1.0.7 Characteristics

A few participants have a very long time in PTA. These have been checked and found to be correct.

A modified GOAT can be used to assist with this decision. The examiner presents three alternatives, in written form and orally, including the correct choice for each question. The patient is to indicate a choice in some manner, such as nodding or pointing. This procedure can be used for all questions except numbers 4 and 5. The three response alternatives for each question should be arranged vertically in large print on an index card. Error points are assigned and subtracted from 80 (the maximum score with items 4 and 5 removed). A score of 61 or higher is reflective of orientation. PTA is considered resolved when a score of 61 or greater is achieved on two consecutive occasions with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday). Scores from the modified GOAT are for determination of PTA duration only.

Note

There are 3880 in PTA at the time of discharge.

Days From Injury to Date Out of PTA
Characteristic N = 21,526
Days From Injury to Date Out of PTA
    N Non-missing 16,789
    Mean (SD) 22 (22)
    Median (Q1, Q3) 17 (5, 32)
    Min, Max 0, 361
    Unknown 4,737

78% of the abstracted people have valid data

2.2 Time to Follow Commands (TFC)

Date Added : 1989-10-01

2.2.0.1 Definition

Date that the individual with brain injury is able to follow simple motor commands. The individual has the ability to follow simple motor commands if:

  1. follows simple motor commands accurately at least two out of two times within a 24-hour period, or
  2. GCS motor component = 6 (follows simple motor commands), two out of two times within a 24-hour period.

The purpose of this variable is to establish the duration of unconsciousness.

2.2.0.2 Form

[X] Form 1
[ ] Form 2

2.2.0.3 Source

Form 1 - Abstraction (acute or rehab record)

2.2.0.4 Details

A patient with severe motor or sensory impairment (i.e. spinal cord injury, locked in syndrome) must demonstrate some ability to follow eye commands such as close your eyes, look to the right or left, blink eyes.

If patient is able to follow commands, then following surgery he/she can not follow commands for a period of time, use the first date the patient was able to follow commands.

If the two assessments of ability to follow simple motor commands within a 24-hour period fall across two dates, use the second date.

If patient was always able to follow simple motor commands, code date of admission to emergency room.

Notes such as ‘’following commands at times’’ or ‘’follows some commands’’ may be used, as long as the ability to follow commands is documented 2 times consecutively.

Notes of “inconsistently following commands” should be counted as following.

Other scenarios that indicate following commands include “ability to answer questions appropriately” or “2 consecutive GSC total scores of 15”.

Scenarios that indicate NOT following commands include “localizing”, “flexing”, “withdraws from pain” or “posturing”.

In unusual cases where two or more motor scores of 6 occur within a very short time frame of each other but have motor scores preceding and following that are below 6, data collectors should consult with their Project Director or Medical Director.

If patient was always able to follow simple motor commands, code date of admission to emergency room.

Note

There are 372 who were never able to follow simple motor commands.

Days From Injury to Follow Commands
Characteristic N = 21,526
Days From Injury to Follow Commands
    N Non-missing 20,708
    Mean (SD) 8 (14)
    Median (Q1, Q3) 2 (1, 9)
    Min, Max 0, 290
    Unknown 818

96% of the abstracted people have valid data

2.3 Glasgow Coma Scale (GCS)

Date Added : 1989-10-01

2.3.0.1 Definition

Glasgow Coma Scale scores on admission to emergency department.

2.3.0.2 Form

[X] Form 1
[ ] Form 2

2.3.0.3 Source

Form 1 - Abstraction (acute record)

2.3.0.4 Details

If patient was admitted to a model systems acute facility within the first 24 hours of injury, use model systems ER data. However, if the patient was not admitted to a model systems acute facility within the first 24 hours of injury, use the first ER to obtain GCS data regardless of whether it was a model systems ER or not.

If only 1 GCS is recorded, use that score for an assessment.

If the patient is chemically paralyzed with neuromuscular blocking agents or barbiturates, or is sedated with anesthetics, code the GCS as ‘Chemically Paralyzed or Sedated’ even if GCS scores are present in the record. The paralysis or sedation must be induced by medical personnel, and not by the patient.

If however, a GCS score of 15 is present in the record, and there is evidence that the patient was given sedatives, do not code as sedated, and use the Verbal score and Total score provided in the record.

Applicable medications commonly used in emergency care for sedation include…

  • Neuromuscular blocking agents: atracurium (TRACRIUM), pancuronium (PAVULON), rocuronium (ZEMURON), succinylcholine (ANECTINE, QUELICIN), vecuronium (NORCURON) and ketamine (KETALAR).

  • Barbiturates: pentobarbital (NEMBUTAL), and sodium thiopental (SODIUM PENTOTHAL or THIOPENTAL).

  • Anesthetics: fentanyl (ABSTRAL, ACTIQ, DUROGESIC, FENTORA, IONSYS, LAZANDA, ONSOLIS, SUBLIMAZE, SUBSYS), lorazepam (ATIVAN), midazolam (VERSED), and propofol (DIPRIVAN).

If chemical paralysis or sedation at time of arrival is unclear, data collectors should seek the advice of their project director or physician at their hospital.

If patient is intubated at the time of assessment, record the verbal score as 8 and the total score as 88. For the purposes of analysis, these cases will not be included unless specified for recoding during analysis.

If patient is intubated and in chemically-induced coma or paralysis, code 8 for verbal response and 7’s for eye opening, motor response and 77 for total GCS.

If patient is only nasally intubated, the patient can provide a verbal GCS score (do not code as intubated).
If patient is only bagged, the patient can provide a verbal GCS score (do not code as intubated). Medical records may show this as “BVM” (bag-valve-mask ventilated).

If patient is intubated using RSI (rapid sequence intubation), code as intubated and sedated.

2.3.0.6 Reference

Teasdale G, Jennett B (1976) Assessment and Prognosis of Coma After Head Injury, Acta Neurochir 34, 45-55.

2.3.0.7 Characteristics

In the days that 3 GCSs were collected (highest, lowest, admit), there was the option of using 1 GCS for the other 2 GCSs if they were missing. A cursory check suggests that this was not done consistently.

Note

77 - Patient Chemically Paralyzed or in Chemically-Induced Coma for Treatment Purposes: Sedated; 88 - Intubated

Characteristic N = 21,526
GCS, n (%)
    3 2,870 (13)
    4 429 (2.0)
    5 462 (2.2)
    6 1,093 (5.1)
    7 1,161 (5.5)
    8 786 (3.7)
    9 577 (2.7)
    10 641 (3.0)
    11 669 (3.1)
    12 571 (2.7)
    13 1,052 (4.9)
    14 2,364 (11)
    15 3,811 (18)
    77 4,740 (22)
    88 61 (0.3)
    Unknown 239

99% of the abstracted people have valid data

GCS
Characteristic N = 21,526
GCS Category, n (%)
    Severe 6,801 (41)
    Moderate 2,458 (15)
    Mild 7,227 (44)
    Missing 5,040

2.4 Spinal Cord Injury

Date Added : 1989-10-01

2.4.0.1 Definition

Any injury to neural elements within the spinal canal.

2.4.0.2 Form

[X] Form 1
[ ] Form 2

2.4.0.3 Source

Abstraction (acute record)

2.4.0.4 Details

Includes complete and incomplete injuries.

Includes conus medullaris and cauda equina syndromes, but does not include brachial or lumbar plexus injuries occurring outside the spinal canal.

Only spinal cord injuries occurring at the same time as the brain injury should be reported.

2.4.0.5 Reference

ASIA

Spinal cord Injury
Characteristic N = 21,526
Spinal cord injury:, n (%)
    No 20,298 (95)
    Yes 1,173 (5.5)
    Missing 55

100% of the abstracted people have valid data

2.5 CT

Caution

There is a known issue for the CT Status variable where the response is unknown yet there is evidence of data stored in the CT form. We are working through a process to get this better alligned and will be fixed in susbequent runs of the report

Date Added : 1989-10-01

2.5.0.1 Definition

CT diagnoses based on a combination of reports taken from radio-graphic CT scan results within 7 days of injury.

“CT Data” form: See SOP 0. Current Forms

Code CTStatus as 99-unknown if CT scans/reports done, but unavailable

2.5.0.2 Form

[X] Form 1
[ ] Form 2

2.5.0.3 Source

To be coded by a CT certified individual from all CT reports of the head and/or neck dated within 7 days of injury.

2.5.0.4 Details

A properly trained person at the facility who has been certified following TBIMS procedures may code this variable.

Do not use MRI findings to code this variable.

If CT reports are not available from a system acute hospital, CT reports from non-system hospitals may be used if available.

CTA (CT angiography) reports should not be included.

Findings, including old infarcts and midline shift, should be coded as ‘present’ regardless of cause.

2.5.0.5 Characteristics

All CT variables were removed from data collection on 6/30/2025.

2.5.0.6 Training

Testing and certification of collectors of this variable is required. It is available from the National Data and Statistical Center.

A score of 80% or greater is required for certification.

CT status
Total
CT Not Done CT Done Unknown
1. Intracranial hemorrhage and/or contusions, extra-axial collections, n



    No Visible Pathology 0 1,613 0 1,613
    Yes, Pathology Exists 0 18,475 1 18,476
    Unknown 142 46 1,249 1,437
Total, n 142 20,134 1,250 21,526

CT Not Done CT Done 142 20134

CT
Characteristic N = 21,526
CT status, n (%)
    CT Not Done 142 (0.7)
    CT Done 20,134 (99)
    Missing 1,250
Extent of compression, n (%)
    No Visible Intracranial Compression 11,988 (60)
    Cisterns Are Present But Midline Shift is Noted of 1-5 mm. 2,116 (11)
    Cisterns Compressed or Absent With Midline Shift of 0-5 mm. Compression 1,818 (9.1)
    Midline Shift of Greater Than 5 mm. 2,941 (15)
    Extent Not Specified 1,128 (5.6)
    Missing 1,535
1. Intracranial hemorrhage and/or contusions, extra-axial collections, n (%)
    No Visible Pathology 1,613 (8.0)
    Yes, Pathology Exists 18,476 (92)
    Missing 1,437
2. Punctate/petechial hemorrhages, n (%)
    No 15,753 (78)
    Yes 4,329 (22)
    Missing 1,444
3. Subarachnoid hemorrhage, n (%)
    No 6,880 (34)
    Yes 13,204 (66)
    Missing 1,442
4. Intraventricular hemorrhage, n (%)
    No 14,851 (74)
    Yes 5,235 (26)
    Missing 1,440

94% of the abstracted people have valid data

2.6 Craniotomy

Date Added : 1989-10-01

2.6.0.1 Definition

Craniotomy and/or craniectomy performed (separate procedures).
- Craniotomy means “cranium opened, something removed, cranium closed.”
- Craniectomy means “cranium opened and left open.”

2.6.0.2 Form

[X] Form 1
[ ] Form 2

2.6.0.3 Source

Abstraction (acute record)

2.6.0.4 Details

Craniectomy is coded yes when bone flap is removed and not replaced during initial surgery.

The guidelines below should be followed when considering burr holes:

When a burr hole is drilled, the patient is left with a 1 cm diameter hole. Removing a small disc of bone is not equivalent to removing the cranium or any part of the cranium. A burr hole to put in an ICP monitor is neither a craniotomy nor craniectomy, simply placement of a monitor.

Situations where a chronic subdural is drained or washed out through a burr hole should be counted as a craniotomy. It is the removal of the chronic subdural that is the key part, because the goal is to remove something (the liquefied old blood).

An EVD (External Ventricular Drain) should not be counted as a craniotomy.

Craniotomy
Characteristic N = 21,526
Craniotomy/Craniectomy:, n (%)
    Neither Craniotomy Nor Craniectomy 13,157 (74)
    Craniotomy 2,409 (13)
    Craniectomy 1,771 (9.9)
    Both: Separate Procedures 545 (3.0)
    Missing 3,644

83% of the abstracted people have valid data