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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

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Chatswood NSW 2067

PO Box 699 Chatswood NSW 2057

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E [email protected] | www.aci.health.nsw.gov.au

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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

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and patient care.

www.aci.health.nsw.gov.au

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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 = <24 hours(0) OR pta_range = 1-7 days(1) OR pta_range = 8-28 days(2) OR pta_range = 29-90 days(3) OR pta_range = 91-183 days(4))


N/A N/A


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 <8yrs(2)


Mild 0

Moderate 1

Severe 2

Unable to estimate 9999


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 <8yrs(2)


No 0

Yes 1


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




1



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



0




Specialised mental health community-based residential support service 4


5


6






Acute hospital 12

BIRP transitional living unit 13

BIRP inpatient ward 14

Other inpatient rehab 15


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







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







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)



1




3


4


5


6


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

If the client is being transferred to another setting of care within the same BIRP service, the setting of care where they will start their next EOC is specified.

REDCap specifics


REDCap data element name eoc_transferto

REDCap field label Setting of care client is being transferred to


Identifier No

Condition If eoc_dc = Transferred to other BIRP setting within this service(0)




1



Paediatric – outpatient (community including non-inpatient or outreach

4


EOC accommodation (end)

Definition

The usual residential accommodation captured at the end of an EOC, or where the client will sleep the night after they finish the EOC. These fields are modified slightly from the National Health Data Dictionary.9

REDCap specifics


REDCap data element name eoc_postaccom

REDCap field label The client’s usual residential accommodation type at the end of the EOC


Identifier No

Condition Nil



0




Specialised mental health community-based residential support service 4


5


6






Acute hospital 12

BIRP transitional living unit 13

BIRP inpatient ward 14



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


EOC living situation (end)

Definition

The living situation of the person at the end of the EOC, or who they will live with when they complete the EOC. Multiple entries are allowed in this field.

REDCap specifics


REDCap data element name eoc_ postlivingsit

REDCap field label Living situation at the end of the EOC


Identifier No

Condition

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


Lives alone 0

Lives with spouse or partner 1







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


EOC support level (end)

Definition

The support level received by the person at the end of the EOC.

REDCap specifics


REDCap data element name eoc_postsupport

REDCap field label What is the client’s level of support at the end of the EOC?


Identifier No

Condition Nil


Independent 0







EOC support hours (end)

Definition

If the client was dependent on others at the end 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 Scale11

REDCap specifics


REDCap data element name eoc_ postsupporthrs

REDCap field label Specify the support level each support person provides to the client, at the end of the EOC


Identifier No

Condition

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



1




3


4


5


6


7



Discharge reason

Definition

When all EOCs have been completed, the reason for discharge is specified in terms of whether the treatment program was completed or not. Incomplete treatment programs refer to those that were ceased prior to the planned discharge date or before rehabilitation plans were completed/goals of rehabilitation achieved.

REDCap specifics


REDCap data element name dc_reason

REDCap field label Reason for discharge from BIRP service


Identifier No

Condition Nil


Treatment program completed 0

Treatment program incomplete 1

Section 8: Discharge details


Discharge incomplete reason

Definition

The reason why the treatment program was incomplete.

REDCap specifics


REDCap data element name dc_incomplete

REDCap field label Reasons for incomplete program


Identifier No

Condition If dc_reason = Treatment program incomplete(1)


Absconded or failed to attend 0

Client declined services 1

Died 2

Mental health issues 3

Drug and alcohol issues 4

Moved location 5

Other 6

Unknown 9999

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


Cause of death

Definition

If the reason for an incomplete program was due to client mortality, the cause of death is specified in free text format.

REDCap specifics

REDCap instrument name mortality_details

REDCap data element name deceased_cause

REDCap field label Cause of death


Identifier No

Condition If dc_reason = Treatment program incomplete(1) AND dc_incomplete = Died(2)


N/A N/A


Discharge additional services required

Definition

Whether or not the client was referred to any services post discharge. This includes community based services, other BIRP units, private or public services.

REDCap specifics


REDCap data element name dc_servicesyn

REDCap field label Was client referred to any services for follow-up post discharge?

Data element type Multiple choice (multiple responses)

Identifier No

Condition Nil


No 0

Yes 1


Discharge additional services specific

Definition

The specific services that the client was referred on to, regardless of whether it is known the client followed up with the referrals or not. Multiple options can be selected for this field.

REDCap specifics


REDCap data element name dc_services

REDCap field label What services was the client referred to?


Identifier No

Condition If dc_servicesyn = Yes(1)


Referred to other BIRP unit 0

BIRP medical clinic 1


Private rehab services 6

Mental health services 3

Drug and alcohol services 4

Legal services 5

Education assistance (incl. teacher aide, tutor) 7

Child support services 8

Private case management services 9

NDIS funded services 10

Other 11

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


Discharge BIRP unit

Definition

If client was referred on to another BIRP service, that BIRP service is specified.

REDCap specifics


REDCap data element name dc_services_birp

REDCap field label Which BIRP service was client referred too?


Identifier No

Condition If dc_servicesyn = Yes(1) AND dc_services = Referred to other BIRP unit(0)


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


Discharge employment status

Definition

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

REDCap specifics


REDCap data element name dc_emp_yn

REDCap field label Was client working at time of discharge from the service?


Identifier No

Condition Nil


No 0

Yes 1

Unknown 9999

Section 9: Discharge education

or employment


Discharge employment mode

Definition

If the person was working at the time of discharge from the service, 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 classifications.6

REDCap specifics


REDCap data element name dc_emp_status

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


Identifier No

Condition If dc_emp_yn = Yes(1)


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

Employed part time (< 35 hours/wk) 1

Unknown 9999


Discharge job title

Definition

The person’s job title if employed at the time of discharge from the BIRP service, entered as free text. This is then used to classify jobs into occupation categories for reporting purposes.

REDCap specifics


REDCap data element name dc_jobtitle

REDCap field label If working, what was their job title


Identifier No

Condition If dc_emp_yn = Yes(1)


N/A N/A


Discharge unemployment status

Definition

The person’s main activity status at time of discharge 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 dc_emp_status_2

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


Identifier No

Condition If dc_emp_yn = No(0)


N/A N/A


Discharge 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 or college, or university.

REDCap specifics


REDCap data element name dc_edu_status

REDCap field label Was client studying at time of discharge


Identifier No

Condition Nil


No 0

Yes 1

Unknown 9999


Discharge study type

Definition

The specific type of study the person was engaging in at the time of discharge from the service.

REDCap specifics


REDCap data element name dc_edu_type

REDCap field label Study type at time of discharge


Identifier No

Condition If dc_edu_status = Yes(1)


School student 0

TAFE or college (includes apprenticeship) 1

University 2

Other 3

Unknown 9999

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


FIM

Definition

The Functional Independence Measure (FIM) instrument is an internationally used clinician rated outcome measure used in assessing the severity of disability and to track changes in functional ability.12 The FIM is completed for clients in the inpatient setting as part of Australian Rehabilitation Outcomes Center requirements, at admission and discharge (and if not yet discharged, at 12 monthly intervals).

Instrument specifics

No. of items 18

Item level scoring 7 point ordinal scale

Autoscore Yes, system generated

Subscales Motor (13 items) Cognition (7 items) Total

Section 10: Outcome measures


MPAI-4

Definition

The Mayo-Portland Adaptability Inventory (MPAI-4) is an ABI specific clinician rated outcome measure of sequelae following an ABI.13 It encompasses assessments of physical, cognitive, behavioural, emotional and social problems as well as social reintegration. The MPAI-4 is completed for clients in the community and TLU settings, at admission and discharge (and if not yet discharged, at 12 monthly intervals).


No. of items 35



Subscales

Ability index (12 items) Adjustment index (12 items) Participation index (8 items) Total score


PROMIS-29

Definition

The Patient Reported Outcomes Measurement Information System v2 (PROMIS-29 Profile v2.1) is a client (or carer, as proxy) rated instrument used to capture their perspective about their physical, mental, emotional health and wellbeing.14 The PROMIS-29 was selected to align with The NSW ACI Patient Reported Measures Program. The PROMIS-29 is completed for clients in the community and TLU settings, at admission and discharge (and if not yet discharged, at 12 monthly intervals). These time periods align with the completion of the clinician rated measure MPAI-4.


No. of items 29



Subscales

Depression (4 items) Anxiety (4 items) Physical function (4 items) Pain interference (4 items) Pain severity (1 item) Fatigue (4 items) Sleep disturbance (4 items) Ability to participate in social roles and activities (4 items)


Appendices

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


Gaelic (Scotland) 1101

Irish 1102

Welsh 1103

Celtic, nec‡‡ 1199

English 1201

German 1301

Letzeburgish 1302

Yiddish 1303

Dutch 1401

Frisian 1402

Afrikaans 1403

Danish 1501

Icelandic 1502

Norwegian 1503

Swedish 1504

Scandinavian, nec 1599

Estonian 1601

Finnish 1602

Finnish and Related Languages, nec 1699

French 2101

Greek 2201

Catalan 2301

Portuguese 2302

Spanish 2303

Iberian Romance, nec 2399

Italian 2401

Maltese 2501

Basque 2901

Latin 2902

Other Southern European Languages, nec 2999

Latvian 3101

Lithuanian 3102

‡‡ Not elsewhere classified


Hungarian 3301

Belorussian 3401

Russian 3402

Ukrainian 3403

Bosnian 3501

Bulgarian 3502

Croatian 3503

Macedonian 3504

Serbian 3505

Slovene 3506

Serbo-Croatian/Yugoslavian, so described 3507

Czech 3601

Polish 3602

Slovak 3603

Czechoslovakian, so described 3604

Albanian 3901

Aromunian (Macedo-Romanian) 3903

Romanian 3904

Romany 3905

Other Eastern European Languages, nec 3999

Kurdish 4101

Pashto 4102

Balochi 4104

Dari 4105

Persian (excluding Dari) 4106

Hazaraghi 4107

Iranic, nec 4199

Arabic 4202

Hebrew 4204

Assyrian Neo-Aramaic 4206

Chaldean Neo-Aramaic 4207

Mandaean (Mandaic) 4208

Middle Eastern Semitic Languages, nec 4299

Turkish 4301

Azeri 4302

Tatar 4303

Turkmen 4304


Uygur 4305

Uzbek 4306

Turkic, nec 4399

Armenian 4901

Georgian 4902

Other Southwest and Central Asian Languages, nec 4999

Kannada 5101

Malayalam 5102

Tamil 5103

Telugu 5104

Tulu 5105

Dravidian, nec 5199

Bengali 5201

Gujarati 5202

Hindi 5203

Konkani 5204

Marathi 5205

Nepali 5206

Punjabi 5207

Sindhi 5208

Sinhalese 5211

Urdu 5212

Assamese 5213

Dhivehi 5214

Kashmiri 5215

Oriya 5216

Fijian Hindustani 5217

Indo-Aryan, nec 5299

Other Southern Asian Languages 5999

Burmese 6101

Chin Haka 6102

Karen 6103

Rohingya 6104

Zomi 6105

Burmese and Related Languages, nec 6199

Hmong 6201

Hmong-Mien, nec 6299


Khmer 6301

Vietnamese 6302

Mon 6303

Mon-Khmer, nec 6399

Lao 6401

Thai 6402

Tai, nec 6499

Bisaya 6501

Cebuano 6502

IIokano 6503

Indonesian 6504

Malay 6505

Tetum 6507

Timorese 6508

Tagalog 6511

Filipino 6512

Acehnese 6513

Balinese 6514

Bikol 6515

Iban 6516

Ilonggo (Hiligaynon) 6517

Javanese 6518

Pampangan 6521

Southeast Asian Austronesian Languages, nec 6599

Other Southeast Asian Languages 6999

Cantonese 7101

Hakka 7102

Mandarin 7104

Wu 7106

Min Nan 7107

Chinese, nec 7199

Japanese 7201

Korean 7301

Tibetan 7901

Mongolian 7902

Other Eastern Asian Languages, nec 7999

Anindilyakwa 8101


Maung 8111

Ngan'gikurunggurr 8113

Nunggubuyu 8114

Rembarrnga 8115

Tiwi 8117

Alawa 8121

Dalabon 8122

Gudanji 8123

Iwaidja 8127

Jaminjung 8128

Jawoyn 8131

Jingulu 8132

Kunbarlang 8133

Larrakiya 8136

Malak Malak 8137

Mangarrayi 8138

Maringarr 8141

Marra 8142

Marrithiyel 8143

Matngala 8144

Murrinh Patha 8146

Na-kara 8147

Ndjebbana (Gunavidji) 8148

Ngalakgan 8151

Ngaliwurru 8152

Nungali 8153

Wambaya 8154

Wardaman 8155

Amurdak 8156

Garrwa 8157

Kuwema 8158

Marramaninyshi 8161

Ngandi 8162

Waanyi 8163

Wagiman 8164

Yanyuwa 8165

Marridan (Maridan) 8166


Gundjeihmi 8171

Kune 8172

Kuninjku 8173

Kunwinjku 8174

Mayali 8175

Kunwinjkuan, nec 8179

Burarra 8181

Gun-nartpa 8182

Gurr-goni 8183

Burarran, nec 8189

Arnhem Land and Daly River Region Languages, nec 8199

Galpu 8211

Golumala 8212

Wangurri 8213

Dhangu, nec 8219

Dhalwangu 8221

Djarrwark 8222

Dhay'yi, nec 8229

Djambarrpuyngu 8231

Djapu 8232

Daatiwuy 8233

Marrangu 8234

Liyagalawumirr 8235

Liyagawumirr 8236

Dhuwal, nec 8239

Gumatj 8242

Gupapuyngu 8243

Guyamirrilili 8244

Manggalili 8246

Wubulkarra 8247

Dhuwala, nec 8249

Wurlaki 8251

Djinang, nec 8259

Ganalbingu 8261

Djinba 8262

Manyjalpingu 8263

Djinba, nec 8269


Ritharrngu 8271

Wagilak 8272

Yakuy, nec 8279

Nhangu 8281

Yan-nhangu 8282

Nhangu, nec 8289

Dhuwaya 8291

Djangu 8292

Madarrpa 8293

Warramiri 8294

Rirratjingu 8295

Other Yolngu Matha, nec 8299

Kuku Yalanji 8301

Guugu Yimidhirr 8302

Kuuku-Ya'u 8303

Wik Mungkan 8304

Djabugay 8305

Dyirbal 8306

Girramay 8307

Koko-Bera 8308

Kuuk Thayorre 8311

Lamalama 8312

Yidiny 8313

Wik Ngathan 8314

Alngith 8315

Kugu Muminh 8316

Morrobalama 8317

Thaynakwith 8318

Yupangathi 8321

Tjungundji 8322

Cape York Peninsula Languages, nec 8399

Kalaw Kawaw Ya/Kalaw Lagaw Ya 8401

Meriam Mir 8402

Yumplatok (Torres Strait Creole) 8403

Bilinarra 8504

Gurindji 8505

Gurindji Kriol 8506


Jaru 8507

Light Warlpiri 8508

Malngin 8511

Mudburra 8512

Ngardi 8514

Ngarinyman 8515

Walmajarri 8516

Wanyjirra 8517

Warlmanpa 8518

Warlpiri 8521

Warumungu 8522

Northern Desert Fringe Area Languages, nec 8599

Alyawarr 8603

Kaytetye 8606

Antekerrepenh 8607

Central Anmatyerr 8611

Eastern Anmatyerr 8612

Anmatyerr, nec 8619

Eastern Arrernte 8621

Western Arrarnta 8622

Arrernte, nec 8629

Arandic, nec 8699

Antikarinya 8703

Kartujarra 8704

Kukatha 8705

Kukatja 8706

Luritja 8707

Manyjilyjarra 8708

Martu Wangka 8711

Ngaanyatjarra 8712

Pintupi 8713

Pitjantjatjara 8714

Wangkajunga 8715

Wangkatha 8716

Warnman 8717

Yankunytjatjara 8718

Yulparija 8721


Tjupany 8722

Western Desert Languages, nec 8799

Bardi 8801

Bunuba 8802

Gooniyandi 8803

Miriwoong 8804

Ngarinyin 8805

Nyikina 8806

Worla 8807

Worrorra 8808

Wunambal 8811

Yawuru 8812

Gambera 8813

Jawi 8814

Kija 8815

Kimberley Area Languages, nec 8899

Adnymathanha 8901

Arabana 8902

Bandjalang 8903

Banyjima 8904

Batjala 8905

Bidjara 8906

Dhanggatti 8907

Diyari 8908

Gamilaraay 8911

Garuwali 8913

Githabul 8914

Gumbaynggir 8915

Kanai 8916

Karajarri 8917

Kariyarra 8918

Kaurna 8921

Kayardild 8922

Kriol 8924

Lardil 8925

Mangala 8926

Muruwari 8927


Narungga 8928

Ngarluma 8931

Ngarrindjeri 8932

Nyamal 8933

Nyangumarta 8934

Nyungar 8935

Paakantyi 8936

Palyku/Nyiyaparli 8937

Wajarri 8938

Wiradjuri 8941

Yindjibarndi 8943

Yinhawangka 8944

Yorta Yorta 8945

Baanbay 8946

Badimaya 8947

Barababaraba 8948

Dadi Dadi 8951

Dharawal 8952

Djabwurrung 8953

Gudjal 8954

Keerray-Woorroong 8955

Ladji Ladji 8956

Mirning 8957

Ngatjumaya 8958

Waluwarra 8961

Wangkangurru 8962

Wargamay 8963

Wergaia 8964

Yugambeh 8965

Aboriginal English, so described 8998

Other Australian Indigenous Languages, nec 8999

American Languages 9101

Acholi 9201

Akan 9203

Mauritian Creole 9205

Oromo 9206

Shona 9207


Somali 9208

Swahili 9211

Yoruba 9212

Zulu 9213

Amharic 9214

Bemba 9215

Dinka 9216

Ewe 9217

Ga 9218

Harari 9221

Hausa 9222

Igbo 9223

Kikuyu 9224

Krio 9225

Luganda 9226

Luo 9227

Ndebele 9228

Nuer 9231

Nyanja (Chichewa) 9232

Shilluk 9233

Tigre 9234

Tigrinya 9235

Tswana 9236

Xhosa 9237

Seychelles Creole 9238

Anuak 9241

Bari 9242

Bassa 9243

Dan (Gio-Dan) 9244

Fulfulde 9245

Kinyarwanda (Rwanda) 9246

Kirundi (Rundi) 9247

Kpelle 9248

Krahn 9251

Liberian (Liberian English) 9252

Loma (Lorma) 9253

Lumun (Kuku Lumun) 9254


Madi 9255

Mandinka 9256

Mann 9257

Moro (Nuba Moro) 9258

Themne 9261

Lingala 9262

African Languages, nec 9299

Fijian 9301

Gilbertese 9302

Maori (Cook Island) 9303

Maori (New Zealand) 9304

Nauruan 9306

Niue 9307

Samoan 9308

Tongan 9311

Rotuman 9312

Tokelauan 9313

Tuvaluan 9314

Yapese 9315

Pacific Austronesian Languages, nec 9399

Bislama 9402

Hawaiian English 9403

Norf'k-Pitcairn 9404

Solomon Islands Pijin 9405

Oceanian Pidgins and Creoles, nec 9499

Kiwai 9502

Motu (HiriMotu) 9503

Tok Pisin (Neomelanesian) 9504

Papua New Guinea Languages, nec 9599

Invented Languages 9601

Auslan 9701

Key Word Sign Australia 9702

Sign Languages, nec 9799


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


Australia 1101

Norfolk Island 1102

Australian External Territories, nec 1199

New Zealand 1201

New Caledonia 1301

Papua New Guinea 1302

Solomon Islands 1303

Vanuatu 1304

Guam 1401

Kiribati 1402

Marshall Islands 1403

Micronesia, Federated States of 1404

Nauru 1405

Northern Mariana Islands 1406

Palau 1407

Cook Islands 1501

Fiji 1502

French Polynesia 1503

Niue 1504

Samoa 1505

Samoa, American 1506

Tokelau 1507

Tonga 1508

Tuvalu 1511

Wallis and Futuna 1512

Pitcairn Islands 1513

Polynesia (excludes Hawaii), nec 1599

Adelie Land (France) 1601

Argentinian Antarctic Territory 1602

Australian Antarctic Territory 1603

British Antarctic Territory 1604

Chilean Antarctic Territory 1605

Queen Maud Land (Norway) 1606

Ross Dependency (New Zealand) 1607

England 2102


Isle of Man 2103

Northern Ireland 2104

Scotland 2105

Wales 2106

Guernsey 2107

Jersey 2108

Ireland 2201

Austria 2301

Belgium 2302

France 2303

Germany 2304

Liechtenstein 2305

Luxembourg 2306

Monaco 2307

Netherlands 2308

Switzerland 2311

Denmark 2401

Faroe Islands 2402

Finland 2403

Greenland 2404

Iceland 2405

Norway 2406

Sweden 2407

Aland Islands 2408

Andorra 3101

Gibraltar 3102

Holy See 3103

Italy 3104

Malta 3105

Portugal 3106

San Marino 3107

Spain 3108

Albania 3201

Bosnia and Herzegovina 3202

Bulgaria 3203

Croatia 3204

Cyprus 3205


The former Yugoslav Republic of Macedonia 3206

Greece 3207

Moldova 3208

Romania 3211

Slovenia 3212

Montenegro 3214

Serbia 3215

Kosovo 3216

Belarus 3301

Czechia 3302

Estonia 3303

Hungary 3304

Latvia 3305

Lithuania 3306

Poland 3307

Russian Federation 3308

Slovakia 3311

Ukraine 3312

Algeria 4101

Egypt 4102

Libya 4103

Morocco 4104

Sudan 4105

Tunisia 4106

Western Sahara 4107

Spanish North Africa 4108

South Sudan 4111

Bahrain 4201

Gaza Strip and West Bank 4202

Iran 4203

Iraq 4204

Israel 4205

Jordan 4206

Kuwait 4207

Lebanon 4208

Oman 4211

Qatar 4212


Saudi Arabia 4213

Syria 4214

Turkey 4215

United Arab Emirates 4216

Yemen 4217

Myanmar 5101

Cambodia 5102

Laos 5103

Thailand 5104

Vietnam 5105

Brunei Darussalam 5201

Indonesia 5202

Malaysia 5203

Philippines 5204

Singapore 5205

Timor-Leste 5206

China (excludes SARs and Taiwan) 6101

Hong Kong (SAR of China) 6102

Macau (SAR of China) 6103

Mongolia 6104

Taiwan 6105

Japan 6201

Korea, Democratic People's Republic of (North) 6202

Korea, Republic of (South) 6203

Bangladesh 7101

Bhutan 7102

India 7103

Maldives 7104

Nepal 7105

Pakistan 7106

Sri Lanka 7107

Afghanistan 7201

Armenia 7202

Azerbaijan 7203

Georgia 7204

Kazakhstan 7205

Kyrgyzstan 7206


Tajikistan 7207

Turkmenistan 7208

Uzbekistan 7211

Bermuda 8101

Canada 8102

St Pierre and Miquelon 8103

United States of America 8104

Argentina 8201

Bolivia 8202

Brazil 8203

Chile 8204

Colombia 8205

Ecuador 8206

Falkland Islands 8207

French Guiana 8208

Guyana 8211

Paraguay 8212

Peru 8213

Suriname 8214

Uruguay 8215

Venezuela 8216

South America, nec 8299

Belize 8301

Costa Rica 8302

El Salvador 8303

Guatemala 8304

Honduras 8305

Mexico 8306

Nicaragua 8307

Panama 8308

Anguilla 8401

Antigua and Barbuda 8402

Aruba 8403

Bahamas 8404

Barbados 8405

Cayman Islands 8406

Cuba 8407


Dominica 8408

Dominican Republic 8411

Grenada 8412

Guadeloupe 8413

Haiti 8414

Jamaica 8415

Martinique 8416

Montserrat 8417

Puerto Rico 8421

St Kitts and Nevis 8422

St Lucia 8423

St Vincent and the Grenadines 8424

Trinidad and Tobago 8425

Turks and Caicos Islands 8426

Virgin Islands, British 8427

Virgin Islands, United States 8428

St Barthelemy 8431

St Martin (French part) 8432

Bonaire, Sint Eustatius and Saba 8433

Curacao 8434

Sint Maarten (Dutch part) 8435

Benin 9101

Burkina Faso 9102

Cameroon 9103

Cabo Verde 9104

Central African Republic 9105

Chad 9106

Congo, Republic of 9107

Congo, Democratic Republic of 9108

Cote d'Ivoire 9111

Equatorial Guinea 9112

Gabon 9113

Gambia 9114

Ghana 9115

Guinea 9116

Guinea-Bissau 9117

Liberia 9118


Mali 9121

Mauritania 9122

Niger 9123

Nigeria 9124

Sao Tome and Principe 9125

Senegal 9126

Sierra Leone 9127

Togo 9128

Angola 9201

Botswana 9202

Burundi 9203

Comoros 9204

Djibouti 9205

Eritrea 9206

Ethiopia 9207

Kenya 9208

Lesotho 9211

Madagascar 9212

Malawi 9213

Mauritius 9214

Mayotte 9215

Mozambique 9216

Namibia 9217

Reunion 9218

Rwanda 9221

St Helena 9222

Seychelles 9223

Somalia 9224

South Africa 9225

Eswatini 9226

Tanzania 9227

Uganda 9228

Zambia 9231

Zimbabwe 9232

Southern and East Africa, nec 9299


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


Aesthetic Day Surgery 0

Albury Wodonga Health [Albury Campus] 1

Albury Wodonga Private Hospital 2

Allowah Presbyterian Children's Hospital 3

Armidale Hospital 4

Armidale Private Hospital 5

Auburn Hospital 6

Ballina Day Surgery 7

Ballina Hospital 8

Balmain Hospital 9

Balranald Multi Purpose Service 10

Bankstown Lidcombe Hospital 11

Baradine Multi Purpose Service 12

Barham Hospital 13

Baringa Private Hospital 14

Barraba Multi Purpose Service 15

Batemans Bay Hospital 16

Bathurst Health Service 17

Bathurst Private Hospital 18

Batlow/Adelong Multi Purpose Service 19

Bega Valley Private Hospital 20

Bellinger River District Hospital 21

Belmont Hospital 22

Berkeley Vale Private Hospital 23

Berrigan Multi Purpose Service 24

Bingara Multi Purpose Service 25

Blacktown Hospital 26

Blayney Multi Purpose Service 27

Blue Mountains Hospital 28

Boggabri Multi Purpose Service 29

Bombala Multi Purpose Service 30

Bonalbo Hospital 31

Boorowa Multi Purpose Service 32


Bourke Multi Purpose Service 33

Bourke Street Health Service 34

Bowral Hospital 35

Braeside Hospital 36

Braidwood Multi Purpose Service 37

Brewarrina Multi Purpose Service 38

Brisbane Waters Private Hospital 39

Broken Hill Hospital 40

Bulahdelah Hospital 41

Bulli Hospital 42

Byron Central Hospital 43

Calvary Health Care Riverina 44

Calvary Hospital 45

Calvary Mater Newcastle Hospital 46

Camden Hospital 47

Campbelltown Hospital 48

Campbelltown Private Hospital 49

Canowindra Hospital 50

Canterbury Hospital 51

Casino Hospital 52

Castle Hill Day Surgery 53

Castlecrag Private Hospital 54

Central Coast Day Hospital 55

Centre for Digestive Diseases 56

Cessnock Hospital 57

Chatswood Private Hospital 58

Cobar Health Service 59

Coffs Day Hospital 60

Coffs Harbour Hospital 61

Coledale Hospital 62

Collarenebri Multi Purpose Service 63

Concord Hospital 64

Condobolin Health Service 65

Coolah Multi Purpose Service 66

Coolamon Multi Purpose Service 67


Coolenberg Day Surgery 68

Cooma Hospital 69

Coonabarabran Health Service 70

Coonamble Multi Purpose Service 71

Cootamundra Hospital 72

Coraki Hospital 73

Coral Tree Family Centre 74

Corowa Hospital 75

Cowra Health Service 76

Crookwell Hospital 77

Crows Nest Day Surgery 78

Cudal Health Service 79

Culcairn Multi Purpose Service 80

Cumberland Hospital 81

Dalcross Adventist Hospital 82

David Berry Hospital 83

Dee Why Endoscopy Unit 84

Delegate Multi Purpose Service 85

Deniliquin Hospital 86

Denman Multi Purpose Service 87

Diagnostic Endoscopy Centre 88

Dorrigo Multi Purpose Service 89

Dubbo Hospital 90

Dudley-Orange Private Hospital 91

Dunedoo Multi Purpose Service 92

Dungog Hospital 93

Eastern Heart Clinic 94

Epping Surgery Centre 95

Eugowra Multipurpose Service 96

Fairfield Hospital 97

Figtree Private Hospital 98

Finley Hospital 99

Forster Private Hospital 100

Gilgandra Multi Purpose Service 101

Glen Innes Hospital 102


Gloucester Hospital 103

Goodooga Health Service 104

Gosford Hospital 105

Goulburn Hospital 106

Gower Wilson Multi Purpose Service 107

Grafton Base Hospital 108

Greenwich Hospital 109

Grenfell Multi Purpose Service 110

Griffith Base Hospital 111

Gulargambone Multi Purpose Service 112

Gulgong Multi Purpose Service 113

Gundagai Hospital 114

Gunnedah Hospital 115

Guyra Multi Purpose Service 116

Hawkesbury Hospital 117

Hay Hospital 118

Henty Multi Purpose Service 119

Hillston Hospital 120

Holbrook Hospital 121

Hornsby Ku-ring-gai Hospital 122

Hunter New England Mater Mental Health Service 123

Hunter Valley Private Hospital 124

Hunters Hill Private Hospital 125

Hurstville Private 126

Illawarra Mental Health Services 127

Inverell Hospital 128

Ivanhoe Hospital 129

Jerilderie Multi Purpose Service 130

John Hunter Hospital 131

Junee Multi Purpose Service 132

Justice Health Services 133

Kareena Private Hospital 134

Karitane Mothercraft Society 135

Kempsey Hospital 136

Kenmore Hospital 137


Kiama Hospital 138

Kingsway Day Surgery 139

Kurri Kurri Hospital 140

Kyogle Multi Purpose Service 141

Lachlan Health Service - Forbes 142

Lachlan Health Service - Parkes 143

Lady Davidson Private Hospital 144

Lake Cargelligo Multi Purpose Service 145

Lake Macquarie Private Hospital 146

Lawrence Hargrave Private Hospital 147

Leeton Hospital 148

Lightning Ridge Multi Purpose Service 149

Lismore Hospital 150

Lithgow Hospital 151

Liverpool Day Surgery 152

Liverpool Eye Surgery 153

Liverpool Hospital 154

Lockhart Hospital 155

Long Jetty Health Care Centre 156

Lourdes Hospital Dubbo 157

Macksville Hospital 158

Maclean Hospital 159

Macquarie Hospital 160

Macquarie University Hospital 161

Maitland Hospital 162

Manilla Hospital 163

Manly Hospital 164

Manning Hospital 165

Mater Hospital Sydney 166

Menindee Health Service 167

Mercy Care Hospital - Albury 168

Mercy Care Hospital - Young 169

Merriwa Multi Purpose Service 170

MetroRehab Hospital 171

Metwest Surgical 172


Milton Ulladulla Hospital 173

Miranda Eye Surgical Centre 174

Mogo Day Surgery 175

Molong Health Service 176

Mona Vale Hospital 177

Moree Hospital 178

Morisset Hospital 179

Moruya Hospital 180

Mosman Private Hospital 181

Mount Druitt Hospital 182

Mount Wilga Private Hospital 183

Mudgee Health Service 184

Murrumburrah-Harden Hospital 185

Murwillumbah Hospital 186

Muswellbrook Hospital 187

Narrabri Hospital 188

Narrandera Hospital 189

Narromine Health Service 190

Nepean Hospital 191

Nepean Private Hospital 192

Neringah Hospital 193

Newcastle Private Hospital 194

Nimbin Multi Purpose Service 195

North Shore Private Hospital 196

Northside Clinic 197

Northside Cremorne Clinic 198

Northside Macarthur Clinic 199

Northside West Clinic 200

Norwest Private Hospital 201

Nowra Private Hospital 202

Nyngan Multi Purpose Service 203

Oberon Multi Purpose Service 204

Orange Day Surgery Centre 205

Orange Health Service 206

Pambula Hospital 207


Peak Hill Multipurpose Service 208

Pennant Hills Day Endoscopy Centre 209

Perfect Vision Day Surgery 210

Port Kembla Hospital 211

Port Macquarie Hospital 212

Port Macquarie Private Hospital 213

Portland Hospital 214

Prince of Wales Hospital 215

Prince of Wales Private Hospital 216

Queanbeyan Hospital 217

Quirindi Hospital 218

Radiation Oncology Institute - Gosford 219

Radiation Oncology Institute - The Sydney Adventist Hospital Wahroonga 220

Riverina Day Surgery 221

Riverlands Drug and Alcohol Centre 222

Royal Hospital for Women 223

Royal North Shore Hospital 224

Royal Prince Alfred Hospital 225

Royal Prince Alfred Institute of Rheumatology & Orthopaedics 226

Royal Rehabilitation Hospital 227

Ryde Hospital 228

Rylstone Multi Purpose Service 229

Sacred Heart Hospice 230

San Day Surgery Hornsby 231

Scone Hospital 232

Shellharbour Hospital 233

Shoalhaven Hospital 234

Singleton Hospital 235

South East Regional Hospital 236

South Pacific Private 237

Southern Highlands Private Hospital 238

Springwood Hospital 239

St George Hospital NSW 240

St George Private Hospital 241

St John of God Burwood Hospital 242


St John of God Richmond Hospital 243

St Joseph's Hospital 244

St Luke's Hospital 245

St Vincents Hospital 246

St Vincents Private Hospital [Lismore] 247

St Vincent's Private Sydney 248

Strathfield Private Hospital 249

Sutherland Heart Clinic 250

Sutherland Hospital 251

Sydney Adventist Hospital 252

Sydney Children's Hospital 253

Sydney Day Surgery - Prince Alfred 254

Sydney Dental Hospital 255

Sydney Hospital / Sydney Eye Hospital 256

Sydney Southwest Private Hospital 257

Tamara Private Hospital 258

Tamworth Hospital 259

Temora Hospital 260

Tenterfield Hospital 261

The Border Cancer Hospital 262

The Children's Hospital at Westmead 263

The Hills Clinic Kellyville 264

The Hills Private Hospital 265

The Skin & Cancer Foundation Australia 266

The Sydney Clinic 267

The Sydney Private Hospital Incorporating the NSW Eye Centre 268

The Tweed Hospital 269

Thomas Walker Hospital 270

Tibooburra Hospital 271

Tingha Multi Purpose Service 272

Tocumwal Hospital 273

Tomaree Hospital 274

Tottenham Multipurpose Service 275

Trangie Multi Purpose Service 276

Tresillian Family Care Centre, Canterbury 277


Tresillian Family Care Centre, Kingswood 278

Trundle Multi Purpose Health Service 279

Tullamore Multi Purpose Health Service 280

Tumbarumba Multi Purpose Service 281

Tumut Hospital 282

Tweed Day Surgery 283

Ulladulla Endoscopy and Medical Centre 284

Urana Multi Purpose Service 285

Urbenville Multi Purpose Service 286

Vegetable Creek Multi Purpose Service Emmaville 287

Vision Day Surgery Chatswood 288

Vision Day Surgery Hurstville 289

Wagga Endoscopy Centre 290

Wagga Wagga Rural Referral Hospital 291

Walcha Multi Purpose Service 292

Walgett Multipurpose Service 293

War Memorial Hospital 294

Waratah Private Hospital 295

Warialda Multi Purpose Service 296

Warners Bay Private Hospital 297

Warren Multi Purpose Service 298

Wauchope Hospital 299

Wee Waa Hospital 300

Wellington Health Service 301

Wentworth Hospital 302

Wentworth Psychiatric Services 303

Werris Creek Hospital 304

Wesley Hospital Ashfield 305

Wesley Hospital Kogarah 306

Western Sydney Oncology & Infusion Centre 307

Westmead Hospital 308

Westmead Private Hospital 309

Westmead Rehabilitation Hospital 310

Wilcannia Multi Purpose Service 311

Wilson Memorial Community Hospital, Murrurundi 312


Wingham Hospital 313

Wollongong Day Surgery 314

Wollongong Hospital 315

Wollongong Private Hospital 316

Wolper Jewish Hospital 317

Woy Woy Hospital 318

Wyalong Hospital 319

Wyong Hospital 320

Yass Hospital 321

Young Hospital 322

Canberra Hospital 323

Alfred Health Acquired Brain Injury Rehabilitation Centre 324

Royal Talbot Rehabilitation 325

Royal Melbourne Hospital 326

Victorian Paediatric Rehabilitation Service 327

Albury Wodonga Health / Wodonga Campus 328

Wangaratta Hospital 329

Epworth Hospital 330

Alfred Hospital 331

Royal Children's Hospital 332

Monash Medical Centre 333

Other 334

Princess Alexandra Hospital 335

Princess Alexandra Brain Injury Rehabilitation Unit (BIRU) 336

Gold Coast University Hospital 337

John Hunter Children's Hospital 338

Unknown 9999


References

1 NSW Ministry of Health. Admitted Patient Data Collection. Sydney, Australia: NSW Ministry of

Health. 2016.Retrieved from http://www.cherel.org.au/data-dictionaries#section1

2 Australian Bureau of Statistics. Census of Population and Housing Cat no. 2901.0. Canberra,

Australia: Commonwealth of Australia, ABS; 2016.

3 Australian Bureau of Statistics. Standard Australian Classification of Languages (SACL) Cat

no. 1267.0. Canberra, Australia: Commonwealth of Australia, ABS; 2016.

4 Australian Bureau of Statistics. Standard Australian Classification of Countries (SACC) Cat no.

1269.0. Canberra, Australia: Commonwealth of Australia, ABS; 2016.

5 Khan F, Baguley IJ, Cameron ID. 4: Rehabilitation after traumatic brain injury. Medical Journal

of Australia. 2003;178(6):290-97.

6 Australian Bureau of Statistics. Labour Statistics: Concepts, Sources and Methods cat no.

6102.0.55.001. Canberra: Australia: Commonwealth of Australia, ABS; 2013.

7 Australian Bureau of Statistics. ANZSCO - Australian and New Zealand Standard

Classification of Occupations cat no.1220.0.30.001 v1.2. Canberra, Australia: Commonwealth

of Australia, ABS; 2013.

8 Australian Institute of Health and Welfare. National Health Data Dictionary. Version 16 Cat.

no. HWI 119. Canberra: AIHW; 2012.

9 Stroke Foundation. AuSDAT National Stroke Data Dictionary. Melbourne, Australia; 2019

10 American Brain Injury Consortium. TBI-impact guidelines Common Data Elements. USA; 2011

11 Tate RL. Manual for the Care and Needs Scale (CANS). Unpublished manuscript. John

Walsh Centre for Rehabilitation Research, University of Sydney; 2017. Updated version 2.

12 Wright J. The FIM(TM). The Center for Outcome Measurement in Brain Injury.

Available from:http://www.tbims.org/combi/FIM

13 Malec J.. The Mayo Portland Adaptability Inventory. The Center for Outcome Measurement in

Brain Injury. 2005. Available from: http://www.tbims.org/combi/mpai

14 Cella D, Riley W, Stone A, et al. The Patient-Reported Outcomes Measurement Information

System (PROMIS) developed and tested its first wave of adult self-reported health outcome

item banks: 2005-2008. J Clin Epidemiol. 2010;63(11):1179–1194.

doi:10.1016/j.jclinepi.2010.04.011

http://www.cherel.org.au/data-dictionaries#section1

Download - Brain Injury Rehabilitation Directorate Minimum Dataset...Traumatic brain injury A traumatic brain injury is an acquired brain injury occurring as a result of external force to the

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