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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 [email protected] | 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

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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:

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consumers to review and improve the quality, effectiveness and efficiency

of services

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

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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 ................................................................................................................................... 2

The Brain Injury Rehabilitation Program ................................................................................. 2

Table 1. Brain Injury Rehabilitation Programs and their settings of care ....................... 2

Brain Injury Rehabilitation Directorate .................................................................................... 3

BIRD minimum dataset .......................................................................................................... 3

Inclusion and exclusion criteria .............................................................................................. 4

REDCap ................................................................................................................................ 4

Overview of data dictionary .................................................................................................... 4

NSW BIRD minimum data set ....................................................................................................... 6

Section 1: Demographics ....................................................................................................... 8

Section 2: Injury details ........................................................................................................ 21

Section 3: Pre-injury education or employment .................................................................... 40

Section 4: Compensation details .......................................................................................... 47

Section 5: Pre-injury accommodation and support ............................................................... 50

Section 6: Referral details .................................................................................................... 54

Section 7: Episode of care details ........................................................................................ 61

Section 8: Discharge details ................................................................................................. 76

Section 9: Discharge education or employment ................................................................... 82

Section 10: Outcome measures ........................................................................................... 88

Appendices ................................................................................................................................. 91

Appendix 1.1: Full list of codes for data element: language_spoken3 ................................... 91

Appendix 1.2: Full list of codes for data element: cob4 ....................................................... 103

Appendix 1.3: Full list of codes for data element: ref_unit_hosp ......................................... 110

References ................................................................................................................................ 120

NSW Brain Injury Rehabilitation Directorate Brain Injury Rehabilitation Minimum Dataset 1

Background

The NSW Brain Injury Rehabilitation Directorate (BIRD) data systems are designed to assist in

understanding the Brain Injury Rehabilitation Program (BIRP), contribute to service planning and to

maximise the recovery of persons who have experienced a traumatic brain injury (TBI). This is

achieved through:

identifying relevant clinical data complying with both NSW health data standards and the

requirements of the BIRP network

providing efficient data collection systems and procedures for the BIRP network

monitoring data collection systems to ensure data accuracy and integrity

providing regular reporting at an individual service level

providing regular reporting at a statewide level.

The BIRD Data and Information Management Committee oversees the data systems in place. The

committee comprises of clinical and administrative representatives from the BIRP network as well

as the BIRD Network Manager, Outcomes Manager and Data and Information Manager. The

committee meets regularly to discuss issues and topics related to the design, collection and

dissemination of the BIRP network’s data.

The BIRD undertook major changes to its data systems in the years 2017-18. Historically, the

database implemented by the BIRD for data collection at a statewide level was known as the CDS

– clinical data set. Originally designed as a stand-alone system for the collection of the BIRD

minimum data set (MDS) in 2004, the CDS expanded and developed to provide clinical information

about clients admitted to the BIRP network. Changes in the collection and reporting of local health

district (LHD) and NSW health data, that occurred in recent years, impacted on the collection,

analysis and reporting of clinical data from the CDS. As such, the CDS was gradually

decommissioned in 2018 and an updated data collection initiative implemented using a new

custom-designed system on REDCap.

Coinciding with the trial of a new data collection system, an opportunity to extensively review the

network’s data practices and processes presented itself. The BIRD Minimum Dataset Data

Dictionary was previously in its 2nd version as implemented on the CDS and was last reviewed

extensively in 2010. An extensive review of the MDS was thus undertaken by the BIRD Data and

Information Management Committee over the period July 2018 to October 2018.


Introduction

The Brain Injury Rehabilitation Program

The BIRP was established in 1990 as a clinical network as part of a joint initiative between NSW

Health and the NSW Motor Accidents Authority. The BIRP provides specialist rehabilitation

interventions to children, young people and adults of working age who have sustained primarily a

Traumatic (Acquired) Brain Injury. The NSW BIRP currently consists of 15 adult and/or paediatric

centres distributed across the state (see Table 1).

Table 1. Brain Injury Rehabilitation Programs and their settings of care

Using

REDCap Adult inpatient

Adult community

Adult TLP

Paediatric inpatient

Paediatric community

Dubbo BIRP - - - -

Hunter Brain Injury Service (HBIS)

- - -

Illawarra Brain Injury Service (IBIS)

- - -

Liverpool BIRU (LBIRU)*

- -

Mid North Coast BIRS (MNC BIRS)†

- - -

New England BIRS (NEBIRS)

- -

Mid-West BIRP (MWBIRP)

- -

Northern BIRS (NBIRS)

- - - -

Paediatric BIRT – Newcastle (PBIRT)‡

- - -

Royal Rehab BIRS‡ - - -

Southern Area BIS (SABIS)

- -

Sydney Children’s Hospital Network – Randwick‡

- - -

Sydney Children’s Hospital Network – Westmead*

- - -

South West BIRS (SWBIRS)

- -

Westmead BIRS (WBIRS)

- - -

* Use of own database † Consisting of Coffs Harbour and Port Macquarie branches ‡ No database


The BIRPs operate within defined settings of care: inpatient management, Transition Living

Programs (TLPs), and community or outreach rehabilitation services.

Inpatient management is generally provided for people who have attained the more severe

TBIs and have experienced more pronounced physical, cognitive and/or behavioural problems.

There are three adult and three paediatric inpatient programs across the network.

Transitional living programs or units are primarily available for people over 18 years, to

assist in the transition from acute or hospital based rehabilitation to home based rehabilitation.

There are currently seven TLPs across the network.

Community or outreach rehabilitation provides specialist rehabilitation to the person with

TBI once they have returned to the community. The services are aimed at increasing

independence and social participation. Community rehabilitation is provided at all BIRP

services across the network.

Brain Injury Rehabilitation Directorate

The BIRD is one of the clinical networks which make up the NSW Agency for Clinical Innovation.

The BIRD aims to actively assist the Brain Injury Rehabilitation Services (BIRS) of NSW in

engaging consumers, staff, clinicians and managers to deliver best practise rehabilitation services.

The BIRD takes into consideration both the need of the consumers and the need to operate

efficiently with the available resources. The BIRD recognises the contribution and importance of

data collection, analysis and research in achieving its aims.

BIRD minimum dataset

The MDS attempts to capture data of relevance and importance to the NSW BIRP network, while

maintaining compliance with national and state level data standards. The data collected traces

individual clients from their initial acceptance to a BIRP service until the point of their discharge

from that BIRP service, encompassing in many cases more than one episode of care (EOC) in

multiple settings of care (SOC). No follow up data collection is conducted after discharge unless

the client is readmitted to the service. Client’s may not only have multiple referrals within the same

BIRP service, but may also be admitted to multiple different BIRPs throughout the course of their

rehabilitation and thus may appear multiple times in the BIRD database. The MDS is divided into

ten sections.

1. Demographics

2. Injury

3. Pre-injury education and employment

4. Compensation

5. Pre-injury accommodation and support

6. Referral

7. Episode of care

8. Discharge

9. Discharge education and employment

10. Outcome measures.


It is recognised that various demographic details (e.g. marital status, residential address) and

compensability status of a client may change during the course of their rehabilitation, however it is

recommended that this data element reflect the status of the client at time of referral to the BIRP

service and is therefore not expected to be regularly updated.

Inclusion and exclusion criteria

All client referrals accepted to one of the 15 BIRPs are entered in to the database. The majority of

clients will have sustained a severe to very severe TBI in accordance with the BIRP inclusion

criteria, however a small percentage may include mild, moderate, and non-TBI injuries admitted at

the discretion of the individual BIRPs. Paediatric services primarily include children up to the age of

16, after which they are gradually transitioned to one of the adult service. The adult services

primarily include adults of working age (16-65) but again may include those outside of these limits.

REDCap

REDCap (Research Electronic Data Capture) is a secure web-based portal designed specifically

for the electronic recording of data. REDCap has built-in data collection tools and real-time

reporting functions allowing for immediate feedback to users. The REDCap portal is hosted in a

government domain adhering to the privacy and confidentiality policies of NSW Health. All data

entered into REDCap is stored in a secure location on the NSW Health server. The BIRD Data

Manager is able to access all statewide data in REDCap, while end users are able to access only

their site-specific data.

BIRD started the transfer from CDS to REDCap in March 2018. At the time of writing this

document, 10 of the 15 BIRP sites were using REDCap as their primary data collection system.

Two others were using their own custom designed internal databases for data collection. These

sites are able to obtain their data and deliver it to the BIRD Data Manager for statewide reporting

purposes. The remaining three sites were not putting data systematically into REDCap or any other

database (see Table 1).

Users at each BIRP site (primarily administrative staff, clinicians and managers) input data for their

caseloads regularly. Each client entered is automatically assigned a system-generated client

identification number, devoid of any identifying information which can be used for internal searches

and identification processes. Each site is also assigned an automatic BIRP identification, a unique

4-digit number, which is then applied to all clients entered for that site as identified by the unique

user logins. The REDCap data system is actively monitored by both the end-users and the BIRD

Data & Information Manager to ensure data integrity and high completion rates.

Overview of data dictionary

This document describes and defines the BIRD MDS as implemented primarily on REDCap.

Unless otherwise specified, all data elements listed in the document are mandatory collection at a

statewide level. The data elements are grouped into their appropriate MDS section with each data

element displayed on a separate page. Specific REDCap database information is also included

which may only be useful for persons entering data. The information contained for each data

element is outlined below.

Data element title

Definition and intended use

Name of REDCap ‘instrument’ (or form) within which the data element is contained

data element name, or the variable name, which will be used in any data extract or data file


REDCap specific field label, or the prompt displayed on the users screen when inputting data into the system

Data element type or format

Whether or not the data element is an identifier, a field containing identifying information

Any special conditions for the data element’s use and functionality on REDCap

Data element options or categories and codes where applicable.

Note this document does not contain instructions on how to input data into REDCap, as that information is contained in the ‘BIRD REDCap user guide’ (internal document).


NSW BIRD minimum data set

Section 1: Demographics

1.1 BIRP ID 1.2 Patient ID

1.3 First name 1.4 Surname

1.5 MRN 1.6 Medicare

1.7 Date of birth 1.8 Age

1.9 Street address 1.10 Suburb

1.11 Postcode 1.12 State

1.13 Sex 1.14 Indigenous status

1.15 Marital status 1.16 Language spoken

1.17 Country of birth 1.18 NDIA

Section 2: Injury details

2.1 Date of injury 2.2 Time since injury

2.3 Age at injury 2.4 Type of injury

2.5 Injury circumstance (TBI) 2.6 Injury circumstance (TBI: MVA)

2.7 Injury circumstance (TBI: non-MVA) 2.8 Injury Circumstance (non-TBI)

2.9 Injury circumstance (non-TBI: hypoxia)* 2.10 GCS (at scene)

2.11 GCS (at admission) 2.12 PTA (yes/no)

2.13 PTA (status) 2.14 PTA (range)

2.15 PTA (days) 2.16 PTA (unknown)

2.17 Paeds severity rating 2.18 Paeds Injury Significance

2.19 Previous brain injury

Section 3: Pre-injury education and employment

3.1 Pre-injury highest education 3.2 Pre-injury employment status

3.3 Pre-injury employment mode 3.4 Pre-injury job title

3.5 Pre-injury unemployment status 3.6 Pre-injury study status

3.7 Pre-injury study type

Section 4: Compensation details

4.1 Claim type 4.2 Other chargeable

4.3 Claim status

Section 5: Pre-injury accommodation and support

5.1 Pre-injury accommodation 5.2 Pre-injury living situation

5.3 Pre-injury support level 5.4 Pre-injury support hours

Section 6: Referral details

6.1 Referral date 6.2 Referral source

6.3 Referral hospital 6.4 Referral BIRP unit

6.5 Referral setting of care 6.6 Referral outcome

6.7 Referral non acceptance reason§

§ Indicates non-mandatory fields


Section 7: Episode of care details

7.1 EOC setting of care 7.2 EOC start date

7.3 EOC admission type 7.4 EOC accommodation (start)

7.5 EOC living situation (start) 7.6 EOC support level (start)

7.7 EOC support hours (start) 7.8 EOC end date

7.9 Length of EOC 7.10 EOC end reason

7.11 EOC transfer setting of care 7.12 EOC accommodation (end)

7.13 EOC living situation (end) 7.14 EOC support level (end)

7.15 EOC support hours (end)

Section 8: Discharge details

8.1 Discharge reason 8.2 Discharge incomplete reason

8.3 Cause of death 8.4 Discharge additional services required

8.5 Discharge additional services specific 8.6 Discharge BIRP unit

Section 9: Discharge education and employment

9.1 Discharge employment status 9.2 Discharge employment mode

9.3 Discharge job title 9.4 Discharge unemployment status

9.5 Discharge study status 9.6 Discharge study type

Section 10: Outcome measures

10.1 FIM** 10.2 MPAI-4

10.3 PROMIS-29

** Inpatient clients only


BIRP ID

Definition

The identifying number of the BIRP unit providing the client services. BIRP ID is automatically assigned to clients based on the BIRP associated with the data entry user upon login.

Data element specifics

Redcap instrument name Demographics

Redcap data element name redcap_data_access_group

Redcap field label N/A

Data element type System generated 4 digit number

Identifier No

Condition Nil

Data element options REDCap code

Dubbo BIRP 1138

HBIS 1135

IBIS 1139

MNC BIRS – Coffs Harbour 1186

MNC BIRS – Port Macquarie 1185

MW BIRP 1193

NBIRS 1172

NEBIRS 1053

SABIS 1074

SWBIRS 1173

WBIRS 1184

Section 1: Demographics


Patient ID

Definition

The Patient ID is automatically assigned to a client on a consecutive numbering basis per site, prefixed by the specific BIRP ID.


REDCap instrument name Demographics

REDCap data element name patient_id

REDCap field label Patient ID

Data element type system generated ≥1 digit number

Identifier No

Condition Nil


N/A N/A

First name

Definition

Person’s given name(s)



REDCap data element name first_name

REDCap field label First Name

Data element type text/string

Identifier Yes

Condition Nil


N/A N/A


Surname

Definition

Person’s family name



REDCap data element name last_name

REDCap field label Surname

Data element type text/string

Identifier Yes

Condition Nil

Data element options REDCap cde

N/A N/A

MRN

Definition

Medical record number (MRN) is a person identifier (up to 8 digit number) unique to each hospital or facility in NSW


REDCap instrument name demographics

REDCap data element name mrn

REDCap field label MRN

Data element type Up to 8 digit number

Identifier Yes

Condition Nil


N/A N/A


Medicare

Definition

The 11 digit number found on an individual’s Medicare card used as a unique identifier and for data linkage purposes



REDCap data element name medicare

REDCap field label Medicare #

Data element type 11 digit number

Identifier Yes

Condition Nil


N/A N/A

Date of birth

Definition

The date of birth of the person



REDCap data element name dob

REDCap field label Date of birth

Data element type Date (yyyy-mm-dd)

Identifier Yes

Condition Nil


N/A N/A


Age

Definition

The person’s current age, expressed in years. The field is derived from the ‘Date of birth’ field and calculated to the current (today’s) date. This field is updated each time the form is accessed.



REDCap data element name age

REDCap field label Age

Data element type System generated number > 0

Identifier No

Condition Nil


N/A N/A

Street address

Definition

Street address of usual residence of the person, entered at time of referral to the service.



REDCap data element name address

REDCap field label Street address

Data element type Text/string

Identifier Yes

Condition Nil


N/A N/A


Suburb

Definition

Suburb or town of usual residence of the person, entered at time of referral to the service.



REDCap data element name suburb

REDCap field label Suburb


Identifier Yes

Condition Nil


N/A N/A

Postcode

Definition

Postcode of usual residence of the person, entered at time of referral to the service.



REDCap data element name postcode

REDCap field label Postcode

Data element type 4 digit number

Identifier Yes

Condition Nil


N/A N/A


State

Definition

State of usual residence of the person, entered at time of referral to the service



REDCap data element name state

REDCap field label State

Data element type Multiple choice

Identifier No

Condition Nil


ACT 0

NSW 1

QLD 2

SA 3

VIC 4

WA 5

NT 6

TAS 7


Sex

Definition

The identification of the person as male, female or other, with other encompassing any person not exclusively identifying as male or female (including but not limited to indeterminate, intersex, transgender).

REDCap specifics


REDCap data element name sex

REDCap field label Sex


Identifier no

Condition nil


Male 1

Female 2

Other 3

Not stated or inadequately described 9999


Indigenous status

Definition

An Aboriginal or Torres Strait Islander is a person of Aboriginal and/or Torres Strait Islander descent who identifies as an Aboriginal and/or Torres Strait Islander and is accepted as such by the community in which he or she lives. Codes for the Indigenous status element were taken from Admitted Patient Data Collection1

REDCap specifics


REDCap data element name indigenous_status

REDCap field label Indigenous status


Identifier Yes

Condition Nil


Aboriginal 1

Torres Strait Islander 2

Both Aboriginal and Torres Strait Islander origin

3

Neither Aboriginal nor Torres Strait Islander origin

4

Indigenous – not further specified 5

Declined to respond 8

Not stated or unknown 9999


Marital status

Definition

Marital status of person entered at time of referral to BIRP service. Field options and codes were taken from the Australian Bureau of Statistics (ABS) Census of Population and Housing classifications2

REDCap specifics


REDCap data element name marital_status

REDCap field label Marital status


Identifier No

Condition Nil


Single (never married) 1

Widowed 2

Divorced 3

Separated 4

Married or de facto 5



Language spoken

Definition

The language (including sign language) most preferred by the person for communication. This may be a language other than English even where the person can speak fluent English. Languages and codes were taken from the ABS Standard Australian Classification of Languages.3

REDCap specifics


REDCap data element name language_spoken

REDCap field label Main language spoken at home


Identifier No

Condition Nil


See Appendix 1.1 See Appendix 1.1

Note: Includes a free-text ‘other’ option (data element name: language_other) to specify language if selected ‘other’ option.


Country of birth

Definition

The country in which the person was born. Countries and codes were taken from the ABS Standard Australian Classification of Countries4

REDCap specifics


REDCap data element name cob

REDCap field label Country of birth


Identifier No

Condition Nil



Note: Includes a free-text ‘other’ option (data element name: cob_other) to specify country if selected ‘other’ option.


NDIA

Definition

Whether or not the person has been accepted into the National Disability Insurance Scheme (NDIS), regardless of whether they have an NDIS plan approved or not.

REDCap specifics


REDCap data element name ndia

REDCap field label Has client been accepted as an NDIS participant”


Identifier no

Condition nil


No 0

Yes 1


Date of injury

Definition

Date the person’s brain injury occurred. If the exact date is not known, an approximation is entered as the first of the month (e.g. yyyy-01-01), where yyyy is the approximate year of injury.

REDCap specifics

REDCap instrument name injury_details

REDCap data element name doi

REDCap field label Date of injury


Identifier No

Condition Nil


N/A N/A

Section 2: Injury details


Time since injury

Definition

The time elapsed, in months, since the person’s injury. The field is automatically derived from the ‘Date of injury’ entered and calculated to the current (today’s) date. This field is automatically updated each time the form is accessed.

REDCap specifics


REDCap data element name timesinceinj

REDCap field label Time since injury

Data element type System generated/ number > 0

Identifier No

Condition Nil


N/A N/A


Age at injury

Definition

The person’s age, expressed in years, at the time they had their injury. The field is automatically derived from the ‘Date of injury’ and ‘Date of birth’ fields and is updated each time the form is accessed.

REDCap specifics


REDCap data element name Ageatinj

REDCap field label Age at injury

Data element type System generated number > 0

Identifier No

Condition Nil


N/A N/A


Type of injury

Definition

The classification of the injury into either TBI or non-TBI. A TBI 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. TBIs include those caused by motor vehicle accidents (MVA), assaults and falls. A non-TBI 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, near drowning, brain tumours, poisoning or infections.

REDCap specifics


REDCap data element name injury_type

REDCap field label Type of injury


Identifier No

Condition Nil


Non-TBI 0

TBI 1


Injury circumstance (TBI)

Definition

If the type of injury was a TBI, whether the injury was caused from a MVA or not

REDCap specifics


REDCap data element name injury_circ_tbitype

REDCap field label If TBI, was the injury a result of a motor

vehicle accident?


Identifier No

Condition If injury_type = TBI(1)


MVA 0

Non - MVA 1


Injury Circumstance (TBI - MVA)

Definition

Description of the circumstances under which the injury occurred, when the injury type is a TBI and due to a motor vehicle accident

REDCap specifics


REDCap data element name injury_circ_tbi_mva

REDCap field label If TBI was due to a motor vehicle accident,

specify the injury circumstance


Identifier No

Condition If injury_type = TBI(1) AND injury_circ_tbimva = MVA(0)


MVA driver 1

MVA passenger 2

MVA Motorcycle rider or pillon passenger 3

MVA vs pedestrian 4

MVA vs skateboard, rollerblade, scooter or wheelchair

5

MVA vs pedal cyclist or pushbike 7

MVA unspecified 9

Other MVA 16



Injury circumstance (TBI – non-MVA)

Definition

Description of the circumstances under which the injury occurred, when the injury type is a TBI and due to something other than a motor vehicle accident

REDCap specifics


REDCap data element name injury_circ_tbi_nonmva

REDCap field label If TBI was not from a motor vehicle accident,

specify the injury circumstance


Identifier No

Condition If injury_type = TBI(1) AND injury_circ_tbimva = non-MVA(1)


Non-MVA skateboard, rollerblade, scooter or wheelchair

6

Non-MVA pedal cyclist or pushbike 8

Gunshot 10

Assault or non-accidental injury 11

Fall or dive on same level or from one level to another

12

Fall from horse 13

Sport related 14

Other TBI (specify) 15


Note: Includes a free-text ‘other’ option (data element name: injury_circ_tbi_nonmva_other) to specify injury circumstance if selected ’other’ option.


Injury circumstance (non-TBI)

Definition

Circumstances under which injury occurred, when the injury type is non-TBI.

REDCap specifics


REDCap data element name injury_circ_abi

REDCap field label If non-TBI, Injury Circumstance


Identifier No

Condition If injury_type = Non-TBI(0)


Hypoxia 16

Stroke 17

Infections 18

Other non-TBI (specify) 19


Note: Includes a free-text ‘other’ option (data element name: injury_circ_abi_other) to specify injury circumstance if selected ‘other’ option.


Injury circumstance (non-TBI: hypoxia)

Definition

Detailed description of the circumstance/cause when the non-TBI was due to hypoxia (e.g. near drowning, hanging, cardiac arrest, or asthma). It is NOT mandatory to enter information for this field.

REDCap specifics


REDCap data element name injury_circ_hypox

REDCap field label If hypoxia, specify cause


Identifier No

Condition If injury_type = Non-TBI(0) AND injury_circ_abi = Hypoxia(16)


Cardiac arrest or asthma 0

Hanging 1

Water related or near drowning 2

Other (specify) 3


Note: Includes a free-text ‘other’ option (data element name: injury_circ_hypox_other) to specify hypoxic injury if selected ‘other’ option


Glasgow Coma Scale (at scene)

Definition

Glasgow Coma Scale – available score at scene of injury

REDCap specifics


data element nameREDCap data element name

gcs_scene

REDCap field label GCS at scene

Data element type Number, range 3-15

Identifier No

Condition Nil


N/A N/A


Glasgow Coma Scale (at admission)

Definition

Glasgow Coma Scale – available score at admission to acute hospital following injury

REDCap specifics



gcs_adm

REDCap field label GCS at admission (to acute hospital)

Data element type Number, range 3-15

Identifier No

Condition Nil


N/A N/A


PTA (yes/no)

Definition

When the injury is of a TBI nature, whether or not the client experienced PTA, regardless if the exact length of PTA is known or was measured. In situations where PTA is unknown, an informed decision needs to be made as to whether PTA was experienced or not.

REDCap specifics



pta_yn

REDCap field label Did the client experience PTA?


Identifier No

Condition If injury_type = TBI(1)


No 0

Yes 1


PTA (status)

Definition

The status of PTA, if it was experienced. When selecting ‘Still in PTA’ (i.e. PTA testing is still underway at the time of data entry), this field is required to be updated at the time of client’s discharge from the service to reflect the completion or cessation of PTA testing. If PTA ≥ 184 days (i.e. 6 months), this is coded as first ‘Emerged from PTA and number of date or range is known’, and option ‘184 days chronic amnesic state’ selected in the next data element, under PTA (range). If client is under 8 years of age at the time of their injury, no PTA testing is undertaken and the option ‘Not applicable – injury in child < 8yrs’ is selected For all other reasons for not having a recorded PTA, option ‘Unable to be estimated or duration unknown’ is selected.

REDCap specifics



pta_status

REDCap field label If yes, specify PTA status


Identifier No

Condition If injury_type = TBI(1) AND pta_yn = Yes(1)


Emerged from PTA and number of days or range is known

0

Not applicable - injury in child < 8yrs 3

Still in PTA†† 4

Unable to be estimated or duration unknown 5

†† Request to update provided at time of discharge


PTA (range)

Definition

Length of PTA severity ranges. Descriptors of severity ranges were derived through consultation of the available literature on injury severity and through clinical consensus for the purposes of analysis and reporting.5 Clinically derived estimates of the PTA range may be entered here as well.

REDCap specifics



pta_range

REDCap field label Length of PTA (range)


Identifier No

Condition If injury_type = TBI(1) AND pta_yn = Yes(1) AND pta_status = Emerged from PTA and number of days or range is known (0)


< 24hours (mild) 0

1-7 days (moderate) 1

8-28 days (severe) 2

29-90 days (very severe) 3

91-183 days (very severe) 4

>=184 days (chronic amnesic state) 5


PTA (days)

Definition

Number of days that client was in PTA. Clinically derived estimates of the PTA length are also accepted and entered.

REDCap specifics


REDCap data element name pta_days

REDCap field label No. of PTA days

Data element type Number ≥ 0

Identifier No

Condition

If injury_type = TBI(1) AND pta_yn = Yes(1) AND pta_status = Emerged from PTA and number of days or range is known (0) AND (pta_range =


PTA (unknown)

Definition

When PTA is known to have been experienced by the client, but was not tested, is unknown, was not estimated, or is missing, the reason why is specified.

REDCap specifics


REDCap data element name pta_unableest

REDCap field label If PTA is unknown or unable to be estimated,

specify why


Identifier No

Condition If injury_type = TBI(1) AND pta_yn = Yes(1) AND pta_status = Unable to be estimated or duration unknown (5)


Not tested 0

Severe language impairment 1

Severe behavioural impairment 2

Other 3

Note: Includes a free-text ‘other’ option (data element name: pta_unableest_other) to specify reasons if selected ‘other’ option.


Paeds severity rating

Definition

PTA cannot be measured correctly in young children so where PTA is unavailable due to age at injury being less than 8 years, clinicians determine a severity rating using their clinical judgement, cerebral imaging and/or neuropsychological report to rate the child’s injury as mild, moderate, or severe.

REDCap specifics


REDCap data element name paeds_severity

REDCap field label Severity rating for paeds


Identifier No

Condition if injury_type = TBI(1) AND pta_status = Not applicable-injury in child


Paeds injury significance

Definition

When unable to determine the severity of a paediatric injury, a significance rating is provided instead.

REDCap specifics


REDCap data element name paeds_sig

REDCap field label For injuries where severity cannot be

determined, was the injury significant?


Identifier No

Condition If injury_type = TBI(1) AND pta_status = Not applicable-injury in child


Previous brain injury

Definition

Any known brain injury prior to the current injury that required hospitalisation.

REDCap specifics


REDCap data element name previousinj

REDCap field label Has client had a previous brain injury

(requiring hospitalisation)?


Identifier No

Condition Nil


No 0

Yes 1


Pre-injury highest education

Definition

The highest level of education that the person had completed at the time of their injury.

REDCap specifics


REDCap data element name preinj_highestedu

REDCap field label Highest education attained at time of injury


Identifier No

Condition Nil


No formal education 0

Primary school 1

High school incomplete 2

High school yr 10 cert 3

High school yr 12 4

TAFE or college (Cert, Diploma, Adv Dip) 5

University (Bachelor, Masters, PhD) 6

Unknown 9999

Section 3: Pre-injury education

or employment


Pre-injury employment status

Definition

The person’s employment status in binary format at the time of their injury, with employment defined as being in paid work. If the client is on official paid or unpaid leave (e.g. annual, sick), this is entered as being currently employed. This does not include verbal or unofficial agreement regarding potential future employment.

REDCap specifics


REDCap data element name preinj_emp_yn

REDCap field label Was client working at time of injury?


Identifier No

Condition Nil


No 0

Yes 1

Unknown 9999


Pre-injury employment mode

Definition

If the person was working at the time of their injury, whether that was in a full or part time capacity. Full time is defined as working 35 or more hours in a week, with part time defined as working less than 35 hours per week as per ABS Labour Statistics classifications6

REDCap specifics


REDCap data element name preinj_emp_status

REDCap field label If working, was it full or part time


Identifier No

Condition If preinj_emp_yn = Yes(1)


Employed full time (>=35 hours/wk) 0

Employed part time (< 35 hours/wk) 1

Unknown 9999


Pre-injury job title

Definition

The person’s job title if employed at the time of injury, entered as free text. Job titles are then used to classify jobs into occupation categories in the data pre-processing stage according to the Australian and New Zealand Standard Classification of Occupations for reporting purposes.7

REDCap specifics


REDCap data element name preinj_jobtitle

REDCap field label If working, what was their job title


Identifier No

Condition If preinj_emp_yn = Yes(1)


N/A N/A


Pre-injury unemployment status

Definition

The person’s main activity status if they were not in paid employment. Activity status includes but is not limited to categories such as ‘volunteer’, ‘student’, ‘job-seeking or ‘in-between jobs’, ‘retired’, ‘homemaker’, ‘unpaid family carer’, and so on.

REDCap specifics


REDCap data element name preinj_emp_status_2

REDCap field label If not working, what was their activity status


Identifier No

Condition if preinj_emp_yn = No(0)


N/A N/A


Pre-injury study status

Definition

Whether the person was studying or not at the time of their injury. Studying includes but is not limited to primary and high school, TAFE, college, or university.

REDCap specifics


REDCap data element name preinj_edu_status

REDCap field label Was client studying at time of injury?


Identifier No

Condition Nil


No 0

Yes 1

Unknown 9999


Pre-injury study type

Definition

The specific type of study the person was engaging in at the time of their injury.

REDCap specifics


REDCap data element name preinj_edu_type

REDCap field label Study type at time of injury


Identifier No

Condition If preinj_edu_status = Yes(1)


School student 0

TAFE or college (includes apprenticeship) 1

University 2

Other 5

Unknown 9999

Note: Includes a free-text ‘other’ option (data element name: preinj_edu_type_other) to specify study type if selected ‘other’ option.


Note: REDCap allows the user to add up to three claims per injury (i.e. repeating the data elements ‘Claim type’, ‘Other chargeable’, and ‘Claim status’).

Claim type

Definition

The potential or actual source of compensation should this be pursued by the client.

REDCap specifics


REDCap data element name claim_type

REDCap field label Claim type/ Financial status


Identifier No

Condition Nil


Non-chargeable 0

NSW CTP 1

icare LTC 2

Workers comp or workers insurance 3

Interstate motor vehicle compensation 4

Other chargeable 5


Section 4: Compensation details


Other chargeable

Definition

If compensation source is something other than that listed in the claim_type field, a free text option to specify the source is presented. This includes but is not limited to victims of crime, armed forces, health fund, and department of veterans’ affair, and so on.

REDCap specifics


REDCap data element name claim_type_other

REDCap field label If other chargeable, specify


Identifier No

Condition If claim_type = Other chargeable(5)


N/A N/A


Claim status

Definition

The status of each applicable claim, as recorded at the time of referral into the BIRP service or initial data entry. Any person who is entitled to the payment of, or who has been paid compensation for, damages or other benefits (including a payment in settlement of a claim for compensation, damages or other benefits) in respect of the injury, illness or disease for which he or she is receiving care and treatment, is classified as a compensable patient. Claim status is to be recorded on the person’s time of referral or initial data entry. It is recognised that the compensable status of a client may change during the course of their rehabilitation, and it is therefore recommended that this data element reflect the status of the client at time of referral to the BIRP service.

REDCap specifics


REDCap data element name comp_status

REDCap field label Status of claim


Identifier No

Condition

If claim_type = NSW CTP(1) OR icare LTC(2) OR Workers comp or workers insurance(3) OR Interstate motor vehicle compensation(4) OR Other chargeable(5)


Claim not yet lodged 0

Pending – payment without prejudice 1

Pending – Payment under paediatric less than $20000 scheme

2

Pending – liability not determined or in dispute 3

Compensable – liability accepted 4

Compensable- claim settled and paying 5

Compensable – claim settled and public 6

Compensable – LTC interim participant 7

Compensable – LTC lifetime participant 8

Non-compensable – liability denied 9



Pre-injury accommodation

Definition

The usual residential accommodation type prior to injury, or where the client slept the night before they had their injury. These fields are modified slightly from the National Health Data Dictionary.8

REDCap specifics


REDCap data element name accominj

REDCap field label The client’s usual residential accommodation type prior to injury


Identifier No

Condition Nil


Private residence (e.g. house, flat, bedsitter, caravan, boat, independent unit in retirement village), including privately and publicly rented homes

0

Psychiatric hospital 1

Residential aged care service 2

Specialised alcohol or other drug treatment residence 3

Specialised mental health community-based residential support service

4

Domestic-scale supported living facility (e.g. group home for people with disability)

5

Boarding, rooming house, hostel or hostel type accommodation, not including aged person’s hostel

6

Homeless (e.g. homeless person’s shelter, public place) 7

Shelter or refuge (not including homeless person’s shelter) 8

Other supported accommodation 9

Prison, remand centre or youth training centre 10

Other accommodation, not elsewhere classified 11

Acute hospital 12

Unknown or unable to determine 9999

Section 5: Pre-injury accommodation

and support


Pre-injury living situation

Definition

The living situation of the person at the time they had their injury, or who they were living with the night before they had their injury. Multiple entries are allowed in this field. These fields are modified slightly from the National Stroke Data Dictionary and TBI-impact guidelines for common data elements.9,10

REDCap specifics


REDCap data element name livingsitinj

REDCap field label Living situation prior to injury


Identifier No

Condition

If accominj = Private residence(0) OR if accominj = Residential aged care services(2) OR if accominj = Domestic-scale supported living facility(5) OR if accominj = Boarding/rooming house/hostel(6)


Lives alone 0

Lives with spouse/partner 1

Lives with parents 2

Lives with other family 3

Foster care (in care) 5

Child services (out of home care) 6

Lives with other (specify) 7

Inadequately described or unknown 9999

Note: Includes a free-text ‘other’ option (data element name: livingsitinj_other) to specify living situation if selected ‘other’ option.


Pre-injury support level

Definition

The support level received by the person prior to having their injury.

REDCap specifics


REDCap data element name supportinj

REDCap field label What was the client’s level of support at the time of their injury?


Identifier No

Condition Nil


Independent 0

Independent with aids 1

Dependent (1 person) 2

Dependent (2 people) 3

Dependent (3 or more people) 4



Pre-injury support hours

Definition

If dependent on other people, the number of hours or days per week of support provided to the client is specified. The field options are derived from the Manual for the Care and Needs Scale.11

REDCap specifics


REDCap data element name supporthrsinj

REDCap field label If dependent on others, specify the total support provided by the support persons at the time of their injury


Identifier No

Condition If supportinj = Dependent (1 person)(2) OR Dependent (2 people)(3) OR Dependent (3 or more people)(4)


Intermittent, less than weekly support or client can live alone

1

Support provided at least once per week or

client can be left alone for almost all week 2

Support provided a few days per week or client can be left alone for a few days a week

3

Support provided up to 11 hours per day or client can be left alone for part of the day and overnight

4

Support provided 12-19 hours per day or client can be left alone for part of the day but not overnight

5

Support provided 20-23 hours per day or client can be left alone for a few hours

6

Support provided 24 hours per day or cannot leave client alone

7



Referral date

Definition

Date referral to BIRP service was made by the referring agency, irrespective of client readiness for rehabilitation. The first referral of a client to the BIRP unit is the main referral for REDCap data collection and reporting purposes.

REDCap specifics

REDCap instrument name referral_admission_discharge_details

REDCap data element name ref_date

REDCap field label Referral date


Identifier No

Condition Nil


N/A N/A

Section 6: Referral details


Referral source

Definition

The source of referral to the BIRP service

REDCap specifics


REDCap data element name ref_source

REDCap field label Referral source


Identifier No

Condition Nil


Own BIRP unit 0

Other BIRP unit 1

Hospital 2

Family or self-referral 3

GP or specialist 4

School or work place 5

Non-BIRP brain injury clinic 6

Brain injury support group 7

Community agency 8

Other rehab facility 9

Nursing home 10

Other 11


Note: Includes a free-text ‘other’ option (data element name: ref_source_other) to specify referral source if selected ‘other’ option.


Referral hospital

Definition

If the referral source was a hospital, the specific hospital that made the referral.

REDCap specifics


REDCap data element name ref_unit_hosp

REDCap field label Referral hospital


Identifier No

Condition If ref_source = Hospital(2)



Note: Includes a free-text ‘other’ option (data element name: ref_unit_hosp_other) to specify hospital if selected ‘other’ option.


Referral BIRP unit

Definition

If the referral source was from another BIRP unit, the specific BIRP that made the referral.

REDCap specifics


REDCap data element name ref_unit_otherbirp

REDCap field label Referral BIRP unit


Identifier No

Condition If ref_source = Other BIRP unit(1)


Liverpool BIRU 1

Royal Rehab BIRS 2

Westmead BIRS 3

HBIS 4

IBIS 5

Dubbo BIRP 6

MWBIRP 7

NEBIRS 8

Northern BIRS 9

Port Macquarie – MNC BIRS 10

Coffs Harbour – MNC BIRS 11

SABIS 12

SWBIRS 13

SCHN – Randwick 14

SCHN – Westmead 15

PBIRT – Newcastle 16

Unknown 9999


Referral setting of care

Definition

If the referral source was from another BIRP unit, the setting of care the client is being referred from at that BIRP unit.

REDCap specifics


REDCap data element name ref_soc

REDCap field label Referral setting of care


Identifier No

Condition If ref_source = Other BIRP unit(1)


Adult – inpatient 0

Adult – community (including non-inpatient, outreach or rehab)

1

Adult – transitional living unit 2

Paediatric – inpatient 3

Paediatric – outpatient (community including non-inpatient or outreach)

4


Referral outcome

Definition

The decision reached by the BIRP service after the client referral was reviewed for intake. Only accepted clients are reported on in BIRD statewide reports, however the field options ‘pending’, ‘not-accepted’ and ‘consult or review’ are included for reporting on an individual BIRP unit level. It is NOT mandatory to enter clients who are ‘pending’, ‘not accepted’ or ‘consult orreview’ into REDCap. Notes Acceptance of referrals is decided by the individuals unit’s intake criteria. Consults or reviews are one-off provisions of service, in which the intervention does not result in an episode of care e.g. phone consultations.

REDCap specifics


REDCap data element name ref_outcome

REDCap field label Referral outcome


Identifier No

Condition Nil


Pending 0

Accepted 1

Not accepted 2

Consult or review 3


Referral non acceptance reason

Definition

Reason for client not being accepted. This is a non-mandatory item and is only used for those BIRP services wishing to enter in clients that are not accepted.

REDCap specifics


REDCap data element name ref_notaccept

REDCap field label Reason for non-acceptance


Identifier No

Condition If ref_outcome = Accepted(2)


No rehab goals 0

Out of area 1

Not TBI 2

TBI – symptoms resolved 3

Doesn’t meet age criteria 4

No capacity to engage in rehab process 5

Mild TBI – GP managed 6

Client declined service 7

Other (specify) 8

Note: Includes a free-text ‘other’ option (data element name: ref_notaccept_other) to specify reason if selected ‘other’ option.


EOC setting of care

Definition

The type of service the client will receive once admitted to the BIRP. Note A setting of care can have many episodes of care within it. The first episode of care is a New admission and subsequent episodes of care are Readmission within that setting of care.

REDCap specifics


REDCap data element name eoc_soc

REDCap field label Setting of Care


Identifier No

Condition Nil


Adult – inpatient 0

Adult – community (including non-inpatient, outreach or rehab)

1

Adult – transitional living unit 2

Paediatric – inpatient 3

Paediatric – outpatient (community including non-inpatient or outreach

4

Section 7: Episode of care details


EOC start date

Definition

Date on which a client starts an EOC. ‘Episode start’ begins when the client starts active rehabilitation with the service. Inpatient and TLP settings have distinct EOC start (and end) dates which correspond to the first occasion of service, or the day of admission to a designated inpatient or TLP bed. Community EOC start dates correspond to the BIRP service’s first contact with the client in the designated SOC after the client referral is accepted.

REDCap specifics


REDCap data element name eoc_startdate

REDCap field label EOC start date


Identifier No

Condition Nil


N/A N/A


EOC admission type

Definition

Admission type classifies client’s as either new or readmission within a specific setting of care for an individual BIRP service. The first episode of care is a ‘New admission’ and subsequent episodes of care are ‘Readmission’ within that setting of care.

REDCap specifics


REDCap data element name eoc_admtype

REDCap field label EOC type of admission


Identifier No

Condition Nil


New admission 0

Readmission 1


EOC Accommodation (Start)

Definition

The usual residential accommodation captured at the start of an EOC, or where the client slept the night before they started the EOC. These fields are modified slightly from the National Health Data Dictionary.8

REDCap specifics


REDCap data element name eoc_preaccom

REDCap field label The client’s usual residential accommodation type prior to starting EOC


Identifier No

Condition Nil


Private residence (e.g. house, flat, bedsitter, caravan, boat, independent unit in retirement village), including privately and publicly rented homes

0

Psychiatric hospital 1

Residential aged care service 2

Specialised alcohol or other drug treatment residence 3

Specialised mental health community-based residential support service 4

Domestic-scale supported living facility (e.g. group home for people with disability)

5

Boarding, rooming house, hostel or hostel type accommodation, not including aged person’s hostel

6

Homeless (e.g. homeless person’s shelter, public place) 7

Shelter or refuge (not including homeless person’s shelter) 8

Other supported accommodation 9

Prison, remand centre or youth training centre 10

Other accommodation, not elsewhere classified 11

Acute hospital 12

BIRP transitional living unit 13

BIRP inpatient ward 14

Other inpatient rehab 15

Unknown or unable to determine 9999

Note: Includes a free-text ‘other’ option (data element name: eoc_preaccom_other) to specify accommodation if selected ‘other’ option.


EOC living situation (start)

Definition

The living situation of the person at the start of the EOC, or who they were living with the night before they started the EOC. Multiple entries are allowed in this field. These fields are modified slightly from the National Stroke Data Dictionary and TBI-impact guidelines.9,10

REDCap specifics


REDCap data element name eoc_ prelivingsit

REDCap field label Living situation prior to starting EOC


Identifier No

Condition

If eoc_preaccom = Private residence(0) OR if eoc_preaccom = Residential aged care services(2) OR if eoc_preaccom = Domestic-scale supported living facility(5) OR if eoc_preaccom = Boarding, rooming house or hostel(6)


Lives alone 0

Lives with spouse or partner 1

Lives with parents 2

Lives with other family 3

Foster care (in care) 5

Child services (out of home care) 6

Lives with other (specify) 7


Note: Includes a free-text ‘other’ option (data element name: eoc_prelivingsit_other) to specify support level if selected ‘other’ option.


EOC Support Level (Start)

Definition

The support level received by the person prior to commencing EOC.

REDCap specifics


REDCap data element name eoc_presupport

REDCap field label What is the client’s level of support prior to commencing EOC?


Identifier no

Condition nil


Independent 0

Independent with aids 1

Dependent (1 person) 2

Dependent (2 people) 3

Dependent (3 or more people) 4



EOC support hours (start)

Definition

If the client was dependent on other people at the start of the EOC, the number of hours or days per week of support provided to the client is specified. The field options are derived from the Manual for the Care and Needs Scale.11

REDCap specifics


REDCap data element name eoc_ presupporthrs

REDCap field label If dependent on others, specify the total support provided by the support persons at the start of the EOC


Identifier No

Condition

If eoc_presupport = Dependent (1 person)(2) OR eoc_presupport = Dependent (2 people)(3) OR eoc_presupport = Dependent (3 or more people)(4)


Intermittent, less than weekly support or client can live alone

1

Support provided at least once per week or

client can be left alone for almost all week 2

Support provided a few days per week or client can be left alone for a few days a week

3

Support provided up to 11 hours per day or client can be left alone for part of the day and overnight

4

Support provided 12-19 hours per day or client can be left alone for part of the day but not overnight

5

Support provided 20-23 hours per day or client can be left alone for a few hours

6

Support provided 24 hours per day or cannot leave client alone

7



EOC end date

Definition

Date on which a patient completes an episode of care. Episode end is the process by which a BIRP unit records the completion of an episode of care. The end of episode of care may or may not indicate the discharge of the client from the service. A client can end an episode of care in any BIRP setting of care and require further or more intensive rehabilitation in other settings of care. In such circumstances, clients ending an episode of care are not discharged from the service but are transferred to a separate setting of care, e.g. from community to TLP.

REDCap specifics


REDCap data element name eoc_enddate

REDCap field label EOC end date

Data element type Date (dddd-mm-yy)

Identifier No

Condition Nil


N/A N/A


Length of EOC

Definition

The length of time in days the client was present in a specific EOC, automatically calculated from the EOC start and end dates entered. Note There are no overlaps within the BIRP settings of care or the episodes of care.

For clients in the inpatient setting, length of EOC is calculated with the inclusion of any leave

and interruption days for reporting purposes. This includes weekend leave, transfers to acute

hospitals for procedures, and so on.

REDCap specifics


REDCap data element name eoc_endlength

REDCap field label Total length of EOC (in days)

Data element type System generated number ≥0

Identifier No

Condition Nil


N/A N/A


EOC end reason

Definition

The reason for the client’s episode of care end. Either: i) client is transferred to another setting of care within the same BIRP service (e.g.

from inpatient to community, community to TLU, and so forth), or

ii) client is discharged from all settings of care within the BIRP service.

The movements (transfers) of clients within a service should not be confused with incoming referrals to the service as a whole. Transfers refer to clients who are transferred between various teams in the same BIRP service. Note Clients in the inpatient setting of care are not considered to be discharged from the BIRP service when their rehabilitation is suspended for a short period of time (for example, to go on weekend leave, or if they are transferred to acute hospital for a procedure), when the intention is for the client to return to the inpatient rehabilitation setting. For extended periods of leave (i.e. >28 days), it is at the clinician’s discretion to decide if the period of absence constitutes a discharge and subsequent readmission. The decision is based on the time spent away from the inpatient ward, any changes to the patient’s functional status and any changes to the goals and objectives of the client’s rehabilitation plan.

REDCap specifics


REDCap data element name eoc_dc

REDCap field label Reason for EOC completion


Identifier No

Condition Nil


Transferred to other BIRP setting within this service

0

Discharged from this BIRP service 1


EOC transfer setting of care

Definition

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

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