brain injury rehabilitation directorate minimum dataset ... traumatic brain injury a traumatic brain

NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset

Brain Injury Rehabilitation

Minimum Dataset Data Dictionary

NSW Brain Injury Rehabilitation Directorate

NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset i

AGENCY FOR CLINICAL INNOVATION

Level 4, 67 Albert Avenue

Chatswood NSW 2067

PO Box 699 Chatswood NSW 2057

T +61 2 9464 4666 | F +61 2 9464 4728

E aci-info@nsw.gov.au | www.aci.health.nsw.gov.au

SHPN (ACI) 190386, ISBN 978-1-76081-214-0.

Produced by: Brain Injury Rehabilitation Directorate, Agency for Clinical Innovation.

Further copies of this publication can be obtained from

the Agency for Clinical Innovation website at www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be

reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source.

It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above,

requires written permission from the Agency for Clinical Innovation.

Version: 3.0 Trim: ACI/D19/3082

Date Amended: July 2019

© Agency for Clinical Innovation 2019

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and

promote better healthcare for NSW. It does this by:

 service redesign and evaluation – applying redesign methodology to assist healthcare providers and

consumers to review and improve the quality, effectiveness and efficiency

of services

 specialist advice on healthcare innovation – advising on the development, evaluation and adoption of

healthcare innovations from optimal use through to disinvestment

 initiatives including guidelines and models of care – developing a range of evidence-based healthcare

improvement initiatives to benefit the NSW health system

 implementation support – working with ACI Networks, consumers and healthcare providers to assist

delivery of healthcare innovations into practice across metropolitan and rural NSW

 knowledge sharing – partnering with healthcare providers to support collaboration, learning capability

and knowledge sharing on healthcare innovation and improvement

 continuous capability building – working with healthcare providers to build capability

in redesign, project management and change management through the Centre for Healthcare

Redesign.

ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across

clinical specialties and regional and service boundaries to develop successful healthcare innovations.

A priority for the ACI is identifying unwarranted variation in clinical practice and working in partnership

with healthcare providers to develop mechanisms to improve clinical practice

and patient care.

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NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset ii

Acknowledgements

The NSW Brain Injury Rehabilitation Directorate (BIRD) wishes to acknowledge the members of

the NSW BIRD Data and Information Management Committee for their contribution to the

development of the BIRD Minimum Dataset (MDS) Data Dictionary V3.0, and for guiding and

supporting the data management processes and practises of the BIRD network.

Further thanks are extended to previous BIRD data and information managers and committee

members for their valued work and contribution to previous versions of the BIRD MDS Data

Dictionary.

Finally, thanks are given to the dedicated staff of the NSW Brain Injury Rehabilitation Programs

(BIRPs) for their continued commitment to the implementation and collection of the BIRD MDS.

NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset iii

Abbreviations

ABI Acquired brain injury

ACI Agency for Clinical Innovation

ABS Australian Bureau of Statistics

BIRD Brain Injury Rehabilitation Directorate

BIRP Brain Injury Rehabilitation Program

BIRS Brain Injury Rehabilitation Service

BIRT Brain Injury Rehabilitation Team

BIRU Brain Injury Rehabilitation Unit

BIS Brain Injury Service

CDS Clinical dataset

EOC Episode of care

FIM Functional independence measure

GCS Glasgow coma scale

NDIA National Disability Insurance Agency

NDIS National Disability Insurance Scheme

NEC Not elsewhere classified

MDS Minimum dataset

MPAI-4 Mayo-Portland Adaptability Inventory - 4

MVA Motor vehicle accident

Non-TBI Non-traumatic brain injury

PROMIS-29 Patient Reported Outcomes Measurement Information System - 29

PTA Posttraumatic amnesia

SCHN Sydney Children’s Hospital Network

SOC Setting of care

TBI Traumatic brain injury

TLP Transitional living program

TLU Transitional living unit

NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset iv

Glossary

Acquired brain injury Acquired brain injury is an injury to the brain, which results in

deterioration in cognitive, physical, emotional and/or independent

functioning. Acquired brain injury can occur as a result of trauma,

hypoxia, infection, substance abuse, degenerative neurological

diseases or stroke.

Admission The process whereby a BIRS accepts responsibility for the patient's care and/or treatment. Admission follows a clinical decision based upon specified criteria in line with the BIRS service’s intake criteria.

Active or current client Clients within a BIRP service who have an episode of care (EOC) which hasn’t ended.

Client A client is a person for whom a healthcare provider accepts

responsibility for assessment and/or treatment. Used

interchangeably with ‘consumer’, ‘person’ and ‘patient’ throughout

this document.

Episode of care An EOC is a period of contact between a client and the BIRP service that occurs in one setting of care and in which there is no major change in the goal of intervention

Glasgow Coma Scale The Glasgow Coma Scale is a widely used method for assessing

the level of consciousness and initial injury severity of a brain injury.

New client An individual presenting him/herself to a BIRP service unit for any form of intervention. These would be ‘new admission’ clients with no previous records of an EOC at that particular BIRP.

Non-traumatic brain injury Non-traumatic brain injury is caused by internal events such as a

stroke, lack of oxygen to the brain resulting from ruptured or blocked

blood vessels in the brain, brain tumours, poisoning or infections.

Post-traumatic Amnesia Post-traumatic amnesia) is the state of confusion experienced post

traumatic brain injury which can result in temporary amnesia and

disorientation. Duration of post-traumatic amnesia is widely

acknowledged to be the best predictor of outcome and is used to

measure injury severity in the NSW BIRPs.

Referral Recommendation for transfer of client from a referring agency to a BIRP service, regardless of whether or not they meet the intake criteria and are accepted into the service.

Setting of care The different care settings determining the type of rehabilitation services the client will receive once admitted to the BIRP. The settings of care for the BIRP are: adult inpatient, adult community (including non-inpatient, outreach and rehabilitation), adult transitional living program or unit, paediatric inpatient and paediatric outpatient (community including non-inpatient and outreach).

Transfer The movement of a client from one setting of care to another within a BIRP service.

Traumatic brain injury A traumatic brain injury is an acquired brain injury occurring as a

result of external force to the brain that occurs after birth, impacting

on brain function and development.

NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset v

Contents

Acknowledgements ...................................................................................................................... ii

Abbreviations ............................................................................................................................... iii

Glossary ....................................................................................................................................... iv

Contents ........................................................................................................................................ v

Background ................................................................................................................................... 1

Introduction ................................................................................