Implementation of a pediatric in situ, train-the-trainer simulation program in general emergency departments.

Background: Most children receive emergency care in general emergency departments (EDs). Pediatric resuscitations require specific equipment and weight-based dosing that may be less familiar to general ED healthcare professionals. In situ simulation (ISS) improves teamwork and problem solving, and it may identify latent safety threats. This innovative program brought academic faculty to participating hospitals and taught simulation principles in a small-group environment. This format removed many of the barriers to implementing simulations for general EDs and was intended to teach principles for utilizing simulation to meet unique departmental needs. Methods: Using the Consolidated Framework for Implementation Research (CFIR) framework, ED teams at eight hospitals participated in a train-the-trainer program from 2016 to 2020 intended to help them implement their own ISSs. Training covered benefits of ISS, use of simulation for identifying latent safety threats, debriefing principles, and potential safety risks of ISS. Faculty also provided on-site mentoring during the implementation phase. We identified factors and barriers that contributed to the successful adoption of an ISS program. Results: Most hospitals continued their ISS program after the study ended. Several themes emerged as pearls and pitfalls to implementing a train-the-trainer program. Successful teams had strong nursing and physician leadership participation, and team members had positive working relationships with early positive feedback which encouraged future ISS implementation. Barriers to simulation included high staff turnover of nurses and physicians as well as social distancing protocols related to infection control. Conclusions: Academic EDs can partner with general EDs to implement a train-the-trainer simulation program. We describe facilitators and barriers to implementing a train-the-trainer ISS program in general EDs to improve emergency care for high-risk, low-frequency events.

Characteristics of Pediatric Patient Transfers From General Emergency Departments in California From 2005 to 2018.

OBJECTIVE: Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time. METHODS: This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005-2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission. RESULTS: Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87-16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46-3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90-63.20), poisoning (OR, 11.78; 95% CI, 11.30-12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84-6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46-4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45-3.79) had increased odds of transfer. CONCLUSION: Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.

Clinicians' perceptions of the health status of formerly detained immigrants.

BACKGROUND: In the past decade, the U.S. immigration detention system regularly detained more than 30,000 people per day; in 2019 prior to the pandemic, the daily detention population exceeded 52,000 people. Inhumane detention conditions have been documented by internal government watchdogs, and news media and human rights groups who have observed over-crowding, poor hygiene and sanitation and poor and delayed medical care, as well as verbal, physical and sexual abuse. METHODS: This study surveyed health professionals across the United States who had provided care for immigrants who were recently released from immigration detention to assess clinician perceptions about the adverse health impact of immigration detention on migrant populations based on real-life clinical encounters. There were 150 survey responses, of which 85 clinicians observed medical conditions attributed to detention. RESULTS: These 85 clinicians reported seeing a combined estimate of 1300 patients with a medical issue related to their time in detention, including patients with delayed access to medical care or medicine in detention, patients with new or acute health conditions such as infection and injury attributed to detention, and patients with worsened chronic or special needs conditions. Clinicians also provided details regarding sentinel cases, categorized into the following themes: Pregnant women, Children, Mentally Ill, COVID-19, and Other serious health issue. CONCLUSIONS: This is the first survey, to our knowledge, of health care professionals treating individuals upon release from detention. Due to the lack of transparency by federal entities and limited access to detainees, this survey serves as a source of credible information about conditions experienced within immigration detention facilities and is a means of corroborating immigrant testimonials and media reports. These findings can help inform policy discussions regarding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.

California Children Presenting to an Emergency Department for Mental Health Emergencies: Trajectories of Care.

OBJECTIVES: Pediatric emergency department (ED) mental health visits are increasing in the United States. At the same time, child/adolescent psychiatric services are limited. This study examines the trajectory of pediatric patients presenting with mental health emergencies to better understand availability of specialty care resources in regional networks. METHODS: This retrospective cohort study used a California Office of Statewide Health Planning and Development linked ED and Inpatient Discharge Dataset (2005-2015) to study pediatric patients (5-17 years) who presented to an ED with a primary mental health diagnosis. Outcomes were disposition: discharge, admission, or transfer.Patients transferred were further analyzed for disposition. Regression models to identify characteristics associated with disposition were created. RESULTS: There were 384,339 pediatric patients presented for a primary mental health emergency from 2005 to 2015; 287,997 were discharged, 17,564 were admitted, and 78,725 were transferred. Among those not discharged, patients with public (odds ratio [OR], 1.28; P < 0.01) or self-pay insurance (OR, 5.64; P < 0.01), Black (OR, 2.15; P < 0.01), or Native American race (OR, 2.32; P < 0.01), and who presented to rural EDs (OR, 3.10; P < 0.01), nonteaching hospitals (OR, 3.06; P < 0.01), or hospitals in counties without dedicated child/adolescent psychiatric beds (OR, 5.59; P < 0.01) had higher odds of transfer.Among those not discharged from the second hospital, Black patients (OR, 2.47; P < 0.03) and those who were transferred to a teaching hospital (OR, 1.9; P < 0.01) had higher odds of second transfer. CONCLUSIONS: Pediatric patients with mental health emergencies experience different trajectories of care. Transfer protocols and regionalized networks may help streamline services and decrease inefficiencies in care.

Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income.

INTRODUCTION: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. METHODS: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. RESULTS: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. CONCLUSION: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Regionalization Patterns for Children with Serious Trauma in California (2005-2015): A Retrospective Cohort Study.

OBJECTIVE: Trauma centers provide coordinated specialty care and have been demonstrated to save lives. Many states do not have a comprehensive statewide trauma system. Variable geography, resources, and population distributions present significant challenges to establishing an effective uniform system for pediatric trauma care. We aimed to identify patterns of primary (field) triage and transfer of serious pediatric trauma throughout California. We hypothesized that pediatric primary triage to trauma center care would be positively associated with younger age, increased injury severity, and local emergency medical service (EMS) regions with increased resources. We hypothesized that pediatric trauma transfer would be associated with younger age, increased injury severity, and rural regions with decreased resources. Methods: We conducted a retrospective cohort study of the California Office of Statewide Health Planning and Development emergency department and inpatient discharge data (2005-2015). All patients with serious injury, defined as Injury Severity Score (ISS) >9 were included. Demographic, injury, hospital, and regional characteristics such as distances between patient residence and destination hospitals were tabulated. Univariate and multinomial logit analyses were conducted to analyze individual, hospital, and regional characteristics associated with the outcomes of location of primary triage and transfer. Estimates were converted into predicted probabilities for ease of data interpretation. Results: Primary triage to was to either a pediatric trauma center (37.8%), adult level I/II trauma center (35.0%), adult level III/IV trauma center (1.9%), pediatric non-trauma hospital (3.4%), or an adult non-trauma hospital (21.9%).Younger age, private non-HMO insurance, motor vehicle mechanism, and rural areas were the major factors influencing primary triage to any trauma hospital. Younger age, private non-HMO insurance, higher ISS, fall mechanism, <200 bed hospital, and rural areas were the major factors influencing transfer from a non-trauma hospital to any trauma center. Conclusions: We demonstrate statewide primary triage and transfer patterns for pediatric trauma in a large and varied state. Specifically we identified previously unrecognized individual, hospital, and EMS system associations with pediatric trauma regionalization. Knowledge of these de facto trauma care access patterns has policy and process implications that could improve care for all injured children in need.

Using In Situ Simulations to Improve Pediatric Patient Safety in Emergency Departments.

PROBLEM: Given the complex interaction among patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care. APPROACH: Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, nonacademic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients. OUTCOMES: Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-its ability to provide emergency care for children-was evaluated at baseline and 12 months. NEXT STEPS: The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes.

Patient Age, Race and Emergency Department Treatment Area Associated with "Topbox" Press Ganey Scores.

INTRODUCTION: Hospitals commonly use Press Ganey (PG) patient satisfaction surveys for benchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest, which is known as the "topbox" score. Our objective was to identify patient and physician factors associated with topbox PG scores in the emergency department (ED). METHODS: We looked at PG surveys from January 2015-December 2017 at an academic, urban hospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions: "Likelihood of your recommending our ED to others"; and "Courtesy of the doctor." We analyzed topbox scores using generalized estimating equation models clustered by physician and adjusted for patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED area where patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical (urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physician factors included age, gender, race, ethnicity, and number of years at current institution. RESULTS: We analyzed a total of 3,038 surveys. For "Likelihood of your recommending our ED to others," topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12); less likely among female compared to male patients (OR 0.81; 95% CI, 0.70-0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60-0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54-0.93) and vertical areas (OR 0.71; 95% CI 0.53-0.95) compared to fast track. For "Courtesy of the doctor," topbox scores were more likely with increasing patient age (OR 1.1; CI, 1.06-1.14); less likely among Asian (OR 0.70; 95% CI, 0.58-0.84), Black (OR 0.66; 95% CI, 0.45-0.96), and Hispanic patients (OR 0.68; 95% CI, 0.55-0.83) compared to White patients; and less likely in urgent area (OR 0.69; 95% CI, 0.50-0.95) compared to fast track. CONCLUSION: Increasing patient age was associated with increased likelihood of topbox scores, while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. We encourage hospitals that use PG topbox scores as financial incentives to understand the contribution of non-service factors to these scores.

Correction to: Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan.

An amendment to this paper has been published and can be accessed via the original article.

Undergraduate Premedical Student Perceptions of an Emergency Department-Based Social Needs Screening Program.

BACKGROUND: Medical school admission requirements increasingly encompass competencies beyond the traditional premedical curriculum, such as service orientation and knowledge of "social determinants of health." ACTIVITY: The Stanford Help Desk is an undergraduate service-learning program that provides didactic and experiential exposure to the social determinants of health through screening for social and legal needs of emergency department (ED) patients. We assessed student perceptions of program impact through student applications, course evaluations, and an online program survey. RESULTS AND DISCUSSION: This course strengthened students' understanding of their career aspirations in medicine. Students were resolved to incorporate consideration of social determinants of health in future practice.

Variations in access to specialty care for children with severe burns.

BACKGROUND: Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access. METHODS: Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not. RESULTS: Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692). CONCLUSION: The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005-2015): a retrospective cohort study.

BACKGROUND/OBJECTIVE: Trauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is not well understood. METHODS: Retrospective observational study of all children (0-17 years) hospitalized for severe trauma in California (2005-2015). We used the California Office of Statewide Health Planning and Development linked Emergency Department and Inpatient Discharge data sets. Logistic regression models were created to analyze characteristics associated with undertriage. The model was clustered on differential distance between distance from residence to primary triage hospital and distance from residence to nearest trauma center. We controlled for body part injured, injury type, intent and year. The a priori hypothesis was that uninsured and publicly insured children and hospitals and regions with limited resources would be associated with undertriage. RESULTS: Twelve percent (1866/15 656) of children with severe injury experienced undertriage. Children aged >14 years compared with 0-13 years had more than 2.5 times the odds of undertriage (OR 2.58; 95% CI 2.1 to 3.16). Children with private Health Maintenance Organization (HMO) insurance compared with public insurance had 13 times the odds of undertriage (OR 12.62; 95% CI 8.95 to 17.79). Hospitals with >400 compared with <200 beds had more than three times the odds of undertriage (OR 3.64; 95% CI 2.6 to 5.11). Urban versus suburban residence had 1.3 times increased odds of undertriage (OR 1.31; 95% CI 1.02 to 1.67) Undertriage volume was largest in urban areas. CONCLUSION: Undertriage is associated with private HMO insurance, primary triage to large hospitals and urban residence. Understanding the characteristics associated with undertriage can help improve trauma systems. LEVEL OF EVIDENCE: Level III (non-experimental retrospective observational study).

Continuum of Care for Hepatitis C Virus Among Patients Diagnosed in the Emergency Department Setting.

BACKGROUND.: Urban emergency departments (EDs) seem to be able to detect new hepatitis C virus (HCV) infections at a high rate, but it is unknown the extent to which individuals screened in the ED can progress to treatment and cure. We evaluate the HCV Continuum of Care for patients identified with HCV in 2 urban EDs, and consider the results in the context of outcomes from ambulatory screening venues where 2%-10% of chronically infected patients are treated. METHODS.: This is a multicenter, retrospective cohort study of 2 ED HCV screening programs. Patients who screened HCV antibody reactive between 1 May and 31 October 2014 were followed for up to 18 months. The main outcome was the absolute number and proportion of eligible patients who completed each stage of the HCV Continuum of Care. RESULTS.: A total of 3704 ED patients were estimated to have undiagnosed HCV infection, and screening identified 532 (14.4%) HCV antibody-reactive patients. Of the 532 HCV antibody-reactive patients, 435 completed viral load testing (82%), of whom 301 (69%) were chronically infected. Of the 301 chronically infected patients, 158 had follow-up arranged (52%), of whom 97 attended their appointment (61%). Of these 97, 24 began treatment (25%), and 19 of these 24 achieved sustained virological response (79%). CONCLUSIONS.: Urban EDs serve patients with poor access to preventive care services who have a high prevalence of HCV infection. Because ED patients identified with HCV infection can progress to treatment and cure with rates comparable to ambulatory care settings, implementation of ED HCV screening should be expanded.

Interhospital Facility Transfers in the United States: A Nationwide Outcomes Study.

OBJECTIVES: Patient transfers between hospitals are becoming more common in the United States. Disease-specific studies have reported varying outcomes associated with transfer status. However, even as national quality improvement efforts and regulations are being actively adopted, forcing hospitals to become financially accountable for the quality of care provided, surprisingly little is known about transfer patients or their outcomes at a population level. This population-wide study provides timely analyses of the characteristics of this particularly vulnerable and sizable inpatient population. We identified and compared characteristics and outcomes of transfer and nontransfer patients. METHODS: With the use of the 2009 Nationwide Inpatient Sample, a nationally representative sample of U.S. hospitalizations, we examined patient characteristics, in-hospital adverse events, and discharge disposition for transfer versus nontransfer patients in this observational study. RESULTS: We identified 1,397,712 transfer patients and 31,692,211 nontransfer patients. Age, sex, race, and payer were significantly associated with odds of transfer (P < 0.05). Transfer patients had higher risk-adjusted inpatient mortality (4.6 versus 2.1, P < 0.01), longer length of stay (13.3 versus 4.5, P < 0.01), and fewer routine disposition discharges (53.6 versus 68.7, P < 0.01). In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients (P < 0.05). CONCLUSIONS: Our results suggest that transfer patients have inferior outcomes compared with nontransfer patients. Although they are clinically complex patients and assessing accountability as between the transferring and receiving hospitals is methodologically difficult, transfer patients must nonetheless be included in quality benchmark data to assess the potential impact this population has on hospital outcome profiles. With hospital accountability and value-based payments constituting an integral part of health care reform, documenting the quality of care delivered to transfer patients is essential before accurate quality assessment improvement efforts can begin in this patient population.

Variations in Utilization of Inpatient Rehabilitation Services among Pediatric Trauma Patients.

OBJECTIVE: To assess clinical and nonclinical characteristics associated with the use of pediatric inpatient rehabilitation services among children with traumatic injuries. We hypothesized there would be no nonclinical variations in the use of pediatric inpatient rehabilitation services. STUDY DESIGN: Retrospective analysis of 1139 patients who were injured seriously (0-18 years of age) from our institutional trauma registry (2004-2014). Patients' nonclinical and clinical characteristics were analyzed. We used a full matching technique to compare characteristics between those admitted to rehabilitation (cases) to those discharged home (controls). We matched patients by age category, sex, maximum Abbreviated Injury Scale, and body region of maximum Abbreviated Injury Scale. We used survey-based multivariate logistic regression to identify characteristics associated with inpatient rehabilitation services, controlling for multiple injuries, distance from home to rehabilitation center, year of service, hospital length of stay, and clinically relevant interactions. RESULTS: Ninety-eight patients (8.6%) were admitted to inpatient rehabilitation and 968 (85.0%) were discharged home. Black and other minority patients had increased odds of receiving inpatient rehabilitation compared with white patients (OR, 7.6 [P< .001] and OR, 1.6 [P= .03], respectively). Patients with private compared with public insurance had increased odds of receiving inpatient rehabilitation (OR, 2.4; P< .001). CONCLUSIONS: Pediatric inpatient rehabilitation beds are a scarce resource that should be available to those with the greatest clinical need. The mechanism creating differences in the use of inpatient rehabilitation based on nonclinical characteristics such as race/ethnicity or insurance status must be understood to prevent disparities in access to inpatient rehabilitation services.

Validating the Use of ICD-9 Code Mapping to Generate Injury Severity Scores.

The Injury Severity Score (ISS) is a measure of injury severity widely used for research and quality assurance in trauma. Calculation of ISS requires chart abstraction, so it is often unavailable for patients cared for in nontrauma centers. Whether ISS can be accurately calculated from International Classification of Diseases, Ninth Revision (ICD-9) codes remains unclear. Our objective was to compare ISS derived from ICD-9 codes with those coded by trauma registrars. This was a retrospective study of patients entered into 9 U.S. trauma registries from January 2006 through December 2008. Two computer programs, ICDPIC and ICDMAP, were used to derive ISS from the ICD-9 codes in the registries. We compared derived ISS with ISS hand-coded by trained coders. There were 24,804 cases with a mortality rate of 3.9%. The median ISS derived by both ICDPIC (ISS-ICDPIC) and ICDMAP (ISS-ICDMAP) was 8 (interquartile range [IQR] = 4-13). The median ISS in the registry (ISS-registry) was 9 (IQR = 4-14). The median difference between either of the derived scores and ISS-registry was zero. However, the mean ISS derived by ICD-9 code mapping was lower than the hand-coded ISS in the registries (1.7 lower for ICDPIC, 95% CI [1.7, 1.8], Bland-Altman limits of agreement = -10.5 to 13.9; 1.8 lower for ICDMAP, 95% CI [1.7, 1.9], limits of agreement = -9.6 to 13.3). ICD-9-derived ISS slightly underestimated ISS compared with hand-coded scores. The 2 methods showed moderate to substantial agreement. Although hand-coded scores should be used when possible, ICD-9-derived scores may be useful in quality assurance and research when hand-coded scores are unavailable.