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State Injury Indicators Report:
Instructions for Preparing 2013 Data
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Division of Analysis, Research and Practice Integration

Atlanta, Georgia
May 2015

State Injury Indicators Report: Instructions for Preparing 2013 Data is a publication of the National Center for
Injury Prevention and Control, Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention
Thomas R. Frieden, MD, MPH
Director

National Center for Injury Prevention and Control
Debra Houry, MD, MPH
Director

Division of Analysis, Research and Practice Integration
Rod McClure, MBBS, PhD, FAFPHM
Director

Suggested citation:
Thomas KE, Johnson RL. State injury indicators report: Instructions for Preparing 2013 Data. Atlanta (GA):
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2015.

Editors
Karen E. Thomas, MPH
Division of Analysis, Research and Practice Integration
National Center for Injury Prevention and Control

Renee L. Johnson, RPT, MSPH
Division of Analysis, Research and Practice Integration
National Center for Injury Prevention and Control

Acknowledgements
The editors thank the Safe States Alliance, the Council of State and Territorial Epidemiologists, and their
respective members. These partnerships have facilitated the ongoing advancement and success of the
development of the injury indicators. The editors also thank Angela Marr, Kevin Webb, and Bob Thomas,
Division of Analysis, Research and Practice Integration, and Kelly Sarmiento, Division of Unintentional Injury
Prevention, all with the National Center for Injury Prevention and Control, for their consultation and guidance.

FOREWORD AND UPDATES
The Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control
(NCIPC) is pleased to provide this document to guide you in preparing the 2013 state injury indicators.
Under Funding Opportunity Announcement CE11-1101, 20 states have been funded to collect and submit state
injury indicator data; however, all states and U.S. territories are eligible to voluntarily submit data for inclusion in
the multistate State Injury Indicators products. As more states and U.S. territories voluntarily participate in this
surveillance effort, a broader picture of the burden of injuries can be presented and priorities for prevention can
be targeted. During the 2011 data collection cycle, 35 states participated by submitting data for inclusion in the
multistate products. We look forward to continuing our work together to advance and improve injury surveillance.
The methods outlined in this document are consistent with those used in previous cycles of injury indicator data
collection. These methods are based on recommendations presented in the “Consensus Recommendations for
Using Hospital Discharge Data for Injury Surveillance” and in the National Public Health Surveillance System
(NPHSS) indicators developed by the State and Territorial Injury Prevention Directors Association (STIPDA; now
known as the Safe States Alliance) and the Council of State and Territorial Epidemiologists (CSTE). With partner
feedback, CDC continuously modifies and updates the instructions and methodologies outlined in this document.

Changes for the 2013 data collection cycle include:
There were no changes to the data collection methods for 2013. This document has been updated to include
the appropriate indicators from the additional data sources and more recent background data. Four additional
indicators have also been added from the Youth Risk Behavior Survey:

▪▪ High School Students Who Were Physically Forced to Have Sexual Intercourse
▪▪ High School Students who Experienced Physical Dating Violence
▪▪ High School Students who Experienced Sexual Dating Violence
▪▪ Texting/Emailing and Driving in High School Students

iv | State Injury Indicators: Instructions for Preparing 2013 Data

ABBREVIATIONS
BAC

Blood alcohol concentration

BRFSS

Behavioral Risk Factor Surveillance System

CDC

Centers for Disease Control and Prevention

CSTE

Council of State and Territorial Epidemiologists

FARS

Fatality Analysis Reporting System

HDD

Hospital discharge data

ICD-10

International Classification of Diseases– Tenth Revision

ICD-9-CM

International Classification of Diseases– Ninth Revision– Clinical Modification

MVC

Motor vehicle crash

NCCDPHP

National Center for Chronic Disease Prevention and Health Promotion

NCHS

National Center for Health Statistics

NCIPC

National Center for Injury Prevention and Control

NHTSA

National Highway Traffic Safety Administration

NPHSS

National Public Health Surveillance System

OSELS

Office of Surveillance, Epidemiology, and Laboratory Services

SAVIR

Society for Advancement of Violence and Injury Research

STIPDA

State and Territorial Injury Prevention Directors Association (currently Safe States Alliance)

TBI

Traumatic brain injury

Veterans Affairs

WHO

World Health Organization

WISQARS

Web-based Injury Statistics Query and Reporting System

YRBS

Youth Risk Behavior Survey

State Injury Indicators: Instructions for Preparing 2013 Data | v

CONTENTS
Foreword and Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Background and Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Preparing the Data Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Injury Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
All-Injury Indicator 1: Injury Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
All-Injury Indicator 2: Hospitalizations for All Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
All-Injury Indicator 3: Emergency Department Visits for All Injuries . . . . . . . . . . . . . . . . . . . . . 17
Drowning Indicator 1: Unintentional Drowning Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Drowning Indicator 2: Drowning-Related Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Drowning Indicator 3: Drowning-Related Emergency Department Visits . . . . . . . . . . . . . . . . . . . 20
Fall Indicator 1: Unintentional Fall-Related Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Fall Indicator 2: Unintentional Fall-Related Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . 22
Fall Indicator 3: Unintentional Fall-Related Emergency Department Visits . . . . . . . . . . . . . . . . . . 23
Fall Indicator 4: Hip Fracture Hospitalizations in Persons Aged 65 Years and Older . . . . . . . . . . . . . 24
Fall Indicator 5: Hip Fracture Emergency Department Visits in Persons Aged 65 Years and Older . . . . . 25
Fire-Related Indicator 1: Unintentional Fire-Related Fatalities . . . . . . . . . . . . . . . . . . . . . . . . 26
Fire-Related Indicator 2: Unintentional Fire-Related Hospitalizations . . . . . . . . . . . . . . . . . . . . 27
Fire-Related Indicator 3: Unintentional Fire-Related Emergency Department Visits . . . . . . . . . . . . . 28
Firearm-Related Indicator 1: Firearm-Related Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Firearm-Related Indicator 2: Firearm-Related Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . 30
Firearm-Related Indicator 3: Firearm-Related Emergency Department Visits . . . . . . . . . . . . . . . . 31
Homicide/Assault Indicator 1: Homicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Homicide/Assault Indicator 2: Assault-Related Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . 33
Homicide/Assault Indicator 3: Assault-Related Emergency Department Visits . . . . . . . . . . . . . . . . 34
Homicide/Assault Indicator 4: High School Students Who Were in a Physical Fight . . . . . . . . . . . . . 35

State Injury Indicators: Instructions for Preparing 2013 Data | vii

Homicide/Assault Indicator 5: High School Students Who Were in a Physical Fight
That Required Medical Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Homicide/Assault Indicator 6: High School Students Who Were Physically Forced
to Have Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Homicide/Assault Indicator 7: High School Students Who Experienced Physical Dating Violence . . . . . 38
Homicide/Assault Indicator 8: High School Students Who Experienced Sexual Dating Violence . . . . . . 39
Motor Vehicle Indicator 1: Motor Vehicle Traffic Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Motor Vehicle Indicator 2: Motor Vehicle Traffic Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . 41
Motor Vehicle Indicator 3: Motor Vehicle Traffic Emergency Department Visits . . . . . . . . . . . . . . . 42
Motor Vehicle Indicator 4: Seat Belt Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Motor Vehicle Indicator 5: Drinking and Driving in High School Students . . . . . . . . . . . . . . . . . . 44
Motor Vehicle Indicator 6: High School Students Riding with Someone Drinking and Driving . . . . . . . . 45
Motor Vehicle Indicator 7: Texting/Emailing and Driving in High School Students . . . . . . . . . . . . . . 46
Motor Vehicle Indicator 8: Alcohol-Related Crash Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Poisoning Indicator 1: Poisoning Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Poisoning Indicator 2: Poisoning Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Poisoning Indicator 3: Poisoning Emergency Department Visits . . . . . . . . . . . . . . . . . . . . . . . 50
Poisoning Indicator 4: Drug Overdose Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Suicide/Suicide Attempt Indicator 1: Suicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Suicide/Suicide Attempt Indicator 2: Suicide Attempt Hospitalizations . . . . . . . . . . . . . . . . . . . . 53
Suicide/Suicide Attempt Indicator 3: Suicide Attempt Emergency Department Visits . . . . . . . . . . . . 54
Suicide/Suicide Attempt Indicator 4: Suicide Attempts in High School Students . . . . . . . . . . . . . . 55
Suicide/Suicide Attempt Indicator 5: Suicide Attempts in High School Students
That Required Medical Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Traumatic Brain Injury Indicator 1: Traumatic Brain Injury Fatalities . . . . . . . . . . . . . . . . . . . . . 57
Traumatic Brain Injury Indicator 2: Traumatic Brain Injury Hospitalizations . . . . . . . . . . . . . . . . . 58
Traumatic Brain Injury Indicator 3: Traumatic Brain Injury Emergency Department Visits . . . . . . . . . . 59
Traumatic Brain Injury Indicator 4: Bicycle Helmet Use Among High School Students . . . . . . . . . . . 60

Calculating and Submitting Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

What is an Injury Indicator?
An injury indicator describes a health outcome of an injury, such as hospitalization or death, or a factor
known to be associated with an injury, such as a risk or protective factor among a specified population.

INTRODUCTION
Injury surveillance is one of the most important and basic elements of injury prevention and control. It helps
determine the magnitude of injury morbidity and mortality, the leading causes of injury, and the population
groups and behaviors associated with the greatest risk of injury. Surveillance data are also fundamental
to determining program and prevention priorities. Furthermore, these data are crucial for evaluating the
effectiveness of program activities and for identifying problems that need further investigation.
Injury continues to be the leading cause of death and disability among children and young adults.1 In 2013,
almost 193,000 people died from injuries in the U.S. Among them: 21% died from suicide; 18% died from
motor-vehicle crashes; 20% died from unintentional poisonings; and 8% died from homicide.1 Additionally in
2013, almost 31 million people were treated for injuries in U.S. emergency departments.1 The economic cost
of injuries is also significant. The total cost of the 50 million medically treated injuries sustained in 2000 is
estimated to be $406 billion in medical expenses and productivity losses.2
The mission of public health includes prevention, mitigation, assurance that the injured have access to
treatment, and the reduction of injury-related disability and death.3 The scope of public health encompasses
injuries involving any mechanism (e.g., firearm, motor vehicle, or burn) and includes both violence and
unintentional injuries. An important part of the public health mission is to emphasize that injuries are
preventable and to dispel the misconception that injuries are unavoidable.
Recognizing the need for more comprehensive injury surveillance data, the State and Territorial Injury
Prevention Directors Association (STIPDA) produced Consensus Recommendations for Injury Surveillance
in State Health Departments in 1999.4 These recommendations were developed by a working group
representing STIPDA; the Council of State and Territorial Epidemiologists (CSTE); the Centers for Disease
Control and Prevention (CDC) and its National Center for Injury Prevention and Control (NCIPC); the Society
for Advancement of Violence and Injury Research (SAVIR); and individual state partners. While these
recommendations were updated in 2007,5 they remain a foundational building block for injury surveillance.
The State Health Department Consensus Recommendations identifies specific injuries and injury risk factors to
be placed under surveillance by all states and data sets to monitor these injuries and risk factors. The goal is to
improve state-based injury surveillance to better support injury prevention programs and policies. By enhancing
and standardizing injury surveillance at the state level, its integration with overall public health surveillance as
part of the National Public Health Surveillance System (NPHSS) will be much easier.6 In tandem with the State
Health Department Consensus Recommendations, CSTE and STIPDA developed injury indicators that were
formally adopted for inclusion in NPHSS.7,8 The NPHSS injury indicators add to other indicators developed by
CSTE for chronic diseases and other areas.7

State Injury Indicators: Instructions for Preparing 2013 Data | 1

The Consensus Recommendations for Using Hospital Discharge Data for Injury Surveillance, published
in 2003, provides clear and specific recommendations about the evaluation and use of hospital discharge
data.9 It presents important considerations for the evaluation of data quality and outlines the methodology for
developing an injury hospitalization data set.
Collection and dissemination of injury indicators is built upon the foundation laid by the publication of these
Safe States Alliance (formerly known as STIPDA) and CSTE documents.

2 | State Injury Indicators: Instructions for Preparing 2013 Data

BACKGROUND AND PURPOSE
This manual was created to guide states and U.S. territories in collecting, preparing, and submitting injury
surveillance data. All states and U.S. territories are eligible to voluntarily submit data.
Information obtained from participants will be reviewed and assembled for inclusion in in various State Injury
Indicators products. This process provides state and U.S. territory injury programs with a standardized method
for evaluating injury data and for producing an injury indicator data product that is comparable across states
and U.S. territories.
This manual provides straightforward information to encourage participation of all states and U.S. territories
regardless of their epidemiologic infrastructure and capabilities. Participation in this report should not be seen
as limiting by states of higher capacity, but rather as a place of commonality and a starting point for developing
more sophisticated analyses.
The process of preparing indicators is simplified in that it doesn’t include the merging and unduplicating of
cases found in multiple data sets. It is important to keep in mind that the quality of the injury indicators is
dependent on the completeness and accuracy of external-cause-of-injury coding found within individual state
and U.S. territory data sets.
Statewide, centralized electronic vital statistics, hospital discharge, and emergency department data are
used to calculate the indicators prepared and submitted by states and U.S. territories. Injuries resulting in
or occurring from the following are currently included in the State Injury Indicators: all injury, drowning,
fall-related injury, fire-related injury, firearm-related injury, homicide/assault, motor vehicle-related injury,
poisoning, suicide/suicide attempt, and traumatic brain injury (TBI). Overlap exists among these indicators.
For example, a firearm-related homicide would be included in both the firearm-related death indicator and
the homicide indicator.

State Injury Indicators: Instructions for Preparing 2013 Data | 3

PREPARING THE DATA SETS
Background on State Vital Records
Death registration is the responsibility of individual states. The funeral director and the physician who certify
the cause of death are usually responsible for the personal and medical information recorded on the death
certificate. The cause-of-death section on the certificate is generally the same in all states and is organized
according to World Health Organization (WHO) guidelines and coded with ICD-10.10 Local registrars assure
that deaths in their jurisdictions are registered and that required information is on death certificates before
submitting to the state registrar. State registrars number and file the death certificates; certificates of
nonresidents are sent to their states of residence. All states send death certificate data to the National Vital
Statistics System, managed by CDC’s National Center for Health Statistics (NCHS).11
Data are limited to information reported on death certificates. The degree of detail in reporting varies among
jurisdictions. In general, death certificate data provide limited information about circumstances of injury
incidents or contributing factors. The number and type of cause-of-death fields to which states have access
also vary, and deaths associated with some injuries, especially suicide, may be underreported. States without
access to multiple contributing cause-of-death fields cannot calculate fatality rates for TBI because the
diagnostic codes that make up that case definition reside in the contributing cause-of-death fields.

Instructions for Using Vital Statistics Data
Vital statistics data do not require specific preparation for analysis. Include all records with a date of death
between January 1, 2013 and December 31, 2013. With the exception of the fatal TBI indicator, all fatal
indicators should be calculated by searching the underlying-cause-of-death field only. For the fatal TBI
indicator, first limit the dataset to only deaths with an injury underlying cause of death (V01–Y36, Y85–Y87,
Y89, *U01–*U03), and then search all fields in the multiple cause of death file. Specific code ranges are
identified in the individual indicator pages (see pages 15–60).

Background on State Hospital Discharge Data
At least 90% of all states maintain statewide, centralized, electronic databases of hospital discharge records
for nonfederal, acute care hospitals located within their borders.12 The information collected varies from state
to state. Many states use the standard uniform billing form (UB-04) as the basis for their hospital discharge
database. Others use only a subset of variables from the UB-04 for their databases, and a few collect
additional variables.
The UB-04, developed by the National Uniform Billing Committee, includes the following data elements:13

▪▪ patient’s age,

▪▪ length of stay,

▪▪ sex,

▪▪ total charges,

▪▪ zip code,

▪▪ principal diagnosis, and

▪▪ admission date,

▪▪ up to seventeen additional diagnoses.

State Injury Indicators: Instructions for Preparing 2013 Data | 5

For diagnoses resulting from injuries, an external cause of injury is also coded. External-cause-of-injury codes,
listed in ICD-9-CM, describe several aspects of an injury: intentionality; mechanism; location of occurrence;
external cause status (e.g., civilian activity done for pay, military activity); and activity.14 Completeness of
external-cause-of-injury coding varies by state.

Instructions for Creating and Using the Injury Hospitalizations
Subset of a State Hospital Discharge Data Set
To calculate Injury Hospitalization Indicators, first you need to create an injury subset of hospital discharge
records. Create this subset using the following specifications:

▪▪ Include only nonfederal, acute care, or inpatient facilities in your hospital discharge data (HDD) injury subset.
This excludes Veterans Affairs (VA) and other federal hospitals, rehabilitation centers, and psychiatric
hospitals.

▪▪ Include readmissions, transfers, and deaths occurring in the hospital.
▪▪ Include hospitalizations of state residents only.
▪▪ If the data are available, out-of-state hospitalizations of state residents should be included.
▪▪ Include records that have a date of discharge between January 1, 2013 and December 31, 2013.
▪▪ Based on the principal diagnosis field, create the injury hospitalization subset as follows:
• Select injury cases by searching only the principal diagnostic code field for the included diagnosis
codes. Exclude all other records from the injury hospitalization subset, as shown in the chart below:9
INCLUDE

EXCLUDE

800–909.2,

< 800

909.4, 909.9

909.3, 909.5

910–994.9

995.0–995.4

995.5–995.59

995.6–995.7

995.80–995.85

995.86, 995.89
995.90–995.94
996–999

Once the injury hospitalization subset has been created, calculate the injury indicators case counts as
defined on the individual indicator pages (see pages 15–60). Search for external-cause-of-injury codes
in the following manner:

6 | State Injury Indicators: Instructions for Preparing 2013 Data

and use the next listed valid external-cause-of-injury code. If a case has multiple valid external-cause-ofinjury codes, then only the first one should be used in the analysis. If no other external-cause-of-injury code
is present, report E967 or E869.4 (because these codes provide some information to classify the record to
specific Injury Indicator categories) but not E000-E030, E849, 870-E879, or E930-E949.

▪▪ Hospitalizations (except for hip fracture hospitalizations in persons aged 65 years and older) should be ageadjusted to the 2000 standard using the NCHS population distribution (Table 1, page 62).

Assess the completeness and quality measures of the HDD for the following components:

▪▪ Percentage of HDD injury records with external-cause-of-injury coding (Figure 1, below).
▪▪ Completeness of hospitals participating in the HDD system.
▪▪ Inclusion of readmissions and transfers within the data set used for analysis.
▪▪ A subjective assessment by health department staff if a substantial proportion of state residents injured instate are actually hospitalized in a neighboring state.

Percentage of
HDD Injury
Hospitalizations
with ExternalCause-of-Injury Coding

All Hospital
Discharge
Records with
Injury Principal
Diagnosis and
Associated
External-Cause-ofInjury code

Number of hospital discharge
records identified using the criteria
in the previous table that have a
valid external-cause-of-injury code
other than E000-E030, E849,
E967, E869.4, E870-E879, or
E930-E949

= ________ x 100
All Hospital
Discharge
Records with an
Injury Principal
Diagnosis

Number of hospital discharge
records identified using the
criteria in the previous chart

FIGURE 1

Background on State Emergency Department Data
The availability of statewide, centralized, electronic department (ED) datasets is increasing. In 2011 about
two-thirds of states reported having access to ED data.15 Many of these datasets are standardized around
administrative or billing data. Since many injuries are seen only in the emergency department this is a dataset
of emerging importance for injury surveillance.
The Injury Surveillance Workgroup 5 convened by STIPDA recommended that the ICD-9-CM code-based
definition to be used with administrative ED data to identify an injury visit be broadened from the definition that

State Injury Indicators: Instructions for Preparing 2013 Data | 7

is used to identify cases from HDD. For ED data, the injury subset should include any initial visit where the firstlisted diagnosis reflects an injury based on the Barell matrix definition of an injury,16 regardless of any mention
of an external-cause-of-injury code, or any initial visit with a valid external-cause-of-injury code based on the
recommended framework for external causes of injury.17 Similar to the current HDD methodology, complications
of care and adverse effects should be excluded from both the diagnosis and external-cause-of-injury codes.
For the rationale behind this recommendation, please refer to pages 23–4 of the ISW5 Report.5

Instructions for Creating and Using the Injury Subset of a State Emergency
Department Data Set
To calculate State Emergency Department Indicators, first you need to create an injury subset of emergency
department records. The creation of this subset varies from the creation of the HD subset in that ED injury
cases may be identified not only by an injury primary diagnosis code but also by the presence of a valid
external-cause-of-injury code. Create the ED subset using the following specifications:

▪▪ Include only data from nonfederal, acute care-affiliated facilities in your ED injury subset. This excludes
Veterans Affairs (VA) and other federal hospitals, rehabilitation centers, and psychiatric hospitals.

▪▪ Include ED visits for state residents only.
▪▪ If the data are available, out-of-state ED visits of state residents should be included.
▪▪ Include records that have a date of visit between January 1, 2013 and December 31, 2013.
▪▪ If necessary, exclude records of patients that are seen in the ED and then admitted to the hospital. For most
states, these records are not included in their ED data.

▪▪ Create the ED injury subset by searching the principal diagnosis field for injury diagnostic codes and all
fields for valid external-cause-of-injury codes.
• Select injury cases by searching the principal diagnosis field for the included ICD-9-CM
diagnosis codes.
INCLUDE

EXCLUDE

800–909.2,

< 800

909.4, 909.9

909.3, 909.5

910–994.9

995.0–995.4

995.5–995.59

995.6–995.7

995.80–995.85

995.86, 995.89
995.90–995.94
996–999

• Select additional cases by searching all fields for the included external-cause-of-injury codes.

8 | State Injury Indicators: Instructions for Preparing 2013 Data

SEARCH FOR
THESE E-CODES

DO NOT SEARCH FOR
THESE E-CODES

E800–E848, E850–E869

E849

E880–E929

E870–E879

E950–E999

E930–E949

• Exclude all other records from the injury ED subset.
Once the injury ED subset has been created, calculate the injury indicators case counts as defined on the
individual indicator pages. Search for external-cause-of-injury codes in the following manner:

▪▪ Search all diagnosis fields.
▪▪ If a designated external-cause-of-injury field is in the data set, start with that field.
▪▪ Count the first-listed external-cause-of-injury code, unless it is E000-E030, E849, E967, E869.4, E870–
E879, or E930–E949; in which case, search additional external-cause-of-injury fields and all diagnostic fields
and use the next listed valid external-cause-of-injury code. If a case has multiple valid external-cause-ofinjury codes, then only the first one should be used in the analysis. If no other external-cause-of-injury code
is present, report E967 or E869.4 (because these codes provide some information to classify the record to
specific Injury Indicator categories) but not E000-E030, E849, 870-E879, or E930-E949.

▪▪ ED visits (except for hip fracture ED visits in persons aged 65 years and older) should be age-adjusted to
the 2000 standard using the NCHS population distribution (Table 1, page 62).

Assess the completeness and quality measures of the ED data for the following components:

▪▪ Percentage of ED injury records with external-cause-of-injury coding (Figure 2, below).
▪▪ Completeness of hospitals participating in the ED system.
▪▪ Inclusion of follow up visits and transfers from other EDs
▪▪ A subjective assessment by health department staff if a substantial proportion of state residents injured instate are actually treated in EDs in a neighboring state.

All ED Injury Visit Records
with a Valid ExternalCause-of-Injury code
Percentage of
ED Injury Visits
With External
Cause Coding

= ________ x 100
All ED Records with an
Injury Principal Diagnosis
or a Valid Injury ExternalCause-of-Injury code

Number of ED visit records
identified using the criteria in the
previous tables that have a valid
external-cause-of-injury code other
than E000-E030, E849, E967,
E869.4, E870-E879, or E930-E949

Number of ED visit records
identified using the criteria
in the previous tables

FIGURE 2

State Injury Indicators: Instructions for Preparing 2013 Data | 9

ADDITIONAL RESOURCES
Other Recommended Data Systems
Indicators based on the Behavioral Risk Factor Surveillance System (BRFSS), the Youth Risk Behavior Survey
(YRBS), and the Fatality Analysis Reporting System (FARS) will be calculated at CDC. The data available from
YRBS and BRFSS will be examined annually to determine which survey questions should be included.

Behavioral Risk Factor Surveillance System (BRFSS)
CDC’s Office of Surveillance, Epidemiology, and Laboratory Services (OSELS) currently manages the
BRFSS. (It was previously housed in the National Center for Chronic Disease Prevention and Health
Promotion.) This is a broad ongoing survey that is a state-based, random-digit-dialed telephone survey of the
noninstitutionalized U.S. population over age 17. BRFSS monitors risk behaviors associated with the leading
causes of disease, injury, and death.18
Because BRFSS is telephone-based, population subgroups less likely to have telephones, such as persons of
low socioeconomic status, may be underrepresented. However, beginning in 2011, BRFSS began to include
data from cell phone users to better represent the U.S. population.19 Additionally, data are self-reported and
may be biased. For risk-reduction factors such as self-reported use or testing of smoke alarms, these data
may not uniformly represent safe and effective use.18
Not all BRFSS questions are asked every year. Questions asked during the year for which a current Injury
Indicator Report is being prepared will be reviewed and appropriate questions included in the report. Results
will be reported as a percentage of respondents. For 2013, there is one injury-related BRFSS question that will
be reported.

Youth Risk Behavior Survey (YRBS)
The Youth Risk Behavior Survey (YRBS) is managed by the National Center for Chronic Disease Prevention
and Health Promotion (NCCDPHP) at CDC. The YRBS monitors risk behaviors associated with the leading
causes of injury and death among teenagers.20 State and local departments of education and health conduct
the survey biennially in many locations throughout the country. The school-based survey is administered to 9th
through 12th graders and the data is analyzed by CDC. YRBS data apply only to youth who attend school. The
extent of underreporting or overreporting of behaviors cannot be determined, although the survey questions
demonstrate good test–retest reliability. Interstate comparisons must be interpreted cautiously because the
methods used to collect YRBS data may vary.20
In 2011, 42 states conducted YRBS with overall participation rates of at least 60%.21 CDC requires a minimum
overall participation rate of 60% to generalize the results to the state’s population. States with YRBS data
meeting this criterion will be included. Results will be reported as a percentage of respondents. No age
adjustment will be applied. For 2013, there are 11 injury-related YRBS questions that will be reported.

State Injury Indicators: Instructions for Preparing 2013 Data | 11

Fatality Analysis Reporting System (FARS)
FARS, coordinated by the National Highway Traffic Safety Administration (NHTSA), contains data on all fatal
traffic crashes that occur in the 50 states, the District of Columbia, and Puerto Rico. For inclusion in FARS, a
crash must involve a motor vehicle traveling on a public roadway and result in the death of a person (either
a vehicle occupant or a non-motorist) within 30 days of the crash. The FARS file contains a description of
each fatal crash reported. More than 100 coded data elements characterize each crash, the vehicles, and the
people involved.22
FARS does not include non-traffic crashes such as those occurring on driveways and other private property.
It also does not include deaths occurring more than 30 days after the motor vehicle crash.22

12 | State Injury Indicators: Instructions for Preparing 2013 Data

INJURY INDICATORS
The following pages contain specific case definitions for each of the individual injury indicators. These case
definitions should be applied when determining case counts. Once the case counts are determined, they
should be entered into the provided spreadsheets for rate calculation and submission to CDC.

State Injury Indicators: Instructions for Preparing 2013 Data | 13

ALL-INJURY INDICATOR 1:
Injury Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Injury Fatality ICD-10 Codes
V01–Y36, Y85–Y87, Y89, *U01–*U03

Injury and poisoning

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Injuries are the leading cause of death for people 1 to 44 years of age and the third
leading cause of death overall.1 Over 190,000 people died from injuries in 2013.1

LIMITATIONS OF
INDICATOR

Injuries severe enough to result in death represent only a small proportion of the overall
burden of injury. An evaluation of only these injuries may not present an accurate picture
of the causes of less-severe injuries.

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in vital statistics data is limited by the
completeness and quality of coding. The overall completeness of external cause coding
on death data is uniformly high. Coding criteria specify that all cases of injury death must
contain an injury code in the underlying-cause-of-death field.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-1.1: Reduce fatal injuries.
IVP-11: Reduce unintentional injury deaths.

State Injury Indicators: Instructions for Preparing 2013 Data | 15

ALL-INJURY INDICATOR 2:
Hospitalizations for All Injuries
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations with any of the following ICD-9-CM diagnostic codes. These should be
identified by searching for diagnosis codes only in the principal diagnostic field of the
injury hospital discharge subset (see methods on page 6). The case count for injury
hospitalizations should equal the number of records in your injury hospitalization subset.
Hospitalizations for All Injuries ICD-9-CM Codes
Diagnosis codes
800–909.2, 909.4, 909.9–994.9,
995.5–995.59, 995.80–995.85

Injury and poisoning

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of hospitalizations. Annual incidence—crude and age-adjusted
(standardized by the direct method to the year 2000 standard U.S. population).23 Rates
should be calculated for age and sex.

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

Injury is the leading cause of death and disability among children and young adults in the
United States.1

LIMITATIONS OF
INDICATOR

Injuries that result in a hospital admission represent only a portion of the overall burden of
injury. Evaluations of these injuries should be considered in the context of both less- and
more-severe injuries.

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in hospital discharge data is limited by
the completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-1.2: Reduce hospitalization for nonfatal injuries.
IVP-12: Reduce nonfatal unintentional injuries.

16 | State Injury Indicators: Instructions for Preparing 2013 Data

ALL-INJURY INDICATOR 3:
Emergency Department Visits for All Injuries
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

ED visits with any of the following ICD-9-CM diagnostic or external cause of injury
codes. These should be identified by searching for diagnosis codes only in the principal
diagnostic field of the ED data set or searching all fields for the first valid external cause
of injury code (see methods on page 8). The case count for injury ED visits should equal
the number of records in your injury ED visit subset.
Emergency Department Visits for All Injuries ICD-9-CM Codes
Diagnosis codes and/or
800–909.2, 909.4, 909.9–994.9,
995.5–995.59, 995.80–995.85

Injury and poisoning

External-cause-of-injury codes
E800-E869, E880-E929, E950-E999

Injury and poisoning

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of emergency department visits. Annual incidence—crude and ageadjusted (standardized by the direct method to the year 2000 standard U.S. population).23
Rates should be calculated for age and sex.

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, almost 31 million people were treated in U.S. emergency departments for injuries
with 3 million of them hospitalized or transferred to another facility.1

LIMITATIONS OF
INDICATOR

Injuries that result in emergency department visits represent only a portion of the overall
burden of injury. Evaluations of these injuries should be considered in the context of both
less- and more-severe injuries.

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in emergency department data is limited
by the completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-1.3: Reduce emergency department visits for nonfatal injuries.
IVP-12: Reduce nonfatal unintentional injuries.

State Injury Indicators: Instructions for Preparing 2013 Data | 17

DROWNING INDICATOR 1:
Unintentional Drowning Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Unintentional Drowning Fatality ICD-10 Codes
W65–W74
V90
V92

Accidental drowning and submersion
Accident to watercraft causing drowning and submersion
Water-transport-related drowning and submersion without accident to
watercraft

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Drowning is one of the 10 leading causes of injury death for persons under age 55 years.
In the United States, drowning rates are highest among children under five years of age.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-25: Reduce drowning deaths.

18 | State Injury Indicators: Instructions for Preparing 2013 Data

DROWNING INDICATOR 2:
Drowning-Related Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations with any of the following ICD-9-CM diagnostic or external-cause-of-injury
codes identified from the injury hospital discharge subset (see methods on page 6).
These should be identified by searching for diagnosis codes in all diagnostic fields and by
searching the first valid external-cause-of-injury code.
Drowning-Related Hospitalization ICD-9-CM Codes
Diagnosis code and/or
994.1
Drowning and nonfatal submersion
External-cause-of-injury codes
E830
Accident to watercraft causing submersion
E832
Other accidental submersion or drowning in water transport accident
E910
Accidental drowning or submersion
E954
Suicide and self-inflicted injury by submersion (drowning)
E964
Assault by submersion (drowning)
E984
Submersion (drowning), undetermined whether accidentally or
purposefully inflicted

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

Drowning-related hospitalizations can result in lifelong disability. Among adolescents
and adults, risk factors for drowning include drinking alcohol, swimming alone, and not
wearing a personal flotation device while engaged in water sports or recreation. For
children under age 5, unexpected access to water or brief lapses in adult supervision are
implicated in most drowning incidents.24

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in hospital discharge data is limited by
the completeness and quality of coding. The overall completeness of external-cause-ofinjury is of particular concern and should be reviewed in conjunction with the indicator.

State Injury Indicators: Instructions for Preparing 2013 Data | 19

DROWNING INDICATOR 3:
Drowning-Related Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits with any of the following ICD-9-CM diagnostic or externalcause-of-injury codes identified from the injury emergency department visit subset (see
methods on page 8). These should be identified by searching for diagnosis codes in all
diagnostic fields and by searching the first valid external-cause-of-injury code.
Drowning-Related Emergency Department Visit ICD-9-CM Codes
Diagnosis code and/or
994.1
Drowning and nonfatal submersion
External-cause-of-injury codes
E830
Accident to watercraft causing submersion
E832
Other accidental submersion or drowning in water transport accident
E910
Accidental drowning or submersion
E954
Suicide and self-inflicted injury by submersion (drowning)
E964
Assault by submersion (drowning)
E984
Submersion (drowning), undetermined whether accidentally or
purposefully inflicted

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the
U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, there were an estimated 5,300 emergency department visits for unintentional
nonfatal drowning-related injuries.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in emergency department data is
limited by the completeness and quality of coding. The overall completeness of externalcause-of-injury coding is of particular concern and should be reviewed in conjunction
with the indicator.

20 | State Injury Indicators: Instructions for Preparing 2013 Data

FALL INDICATOR 1:
Unintentional Fall-Related Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Unintentional Fall-Related Fatality ICD-10 Codes
W00–W19

Falls

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Unintentional falls are the third leading cause of injury death overall and the leading cause
of injury death in people 65 years and older.1 In 2013, there were 30,208 unintentional fallrelated deaths.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-23: Prevent an increase in the rate of fall-related deaths.

State Injury Indicators: Instructions for Preparing 2013 Data | 21

FALL INDICATOR 2:
Unintentional Fall-Related Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).
Unintentional Fall-Related Hospitalization ICD-9-CM Codes
E880–E886, E888

Accidental falls

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

More than one third of adults 65 and older fall each year.25, 26 Of those who fall, 20%
to 30% suffer moderate to severe injuries that make it hard to get around or live alone
and increase the chance of early death.27 The total direct cost of nonfatal fall injuries for
people 65 and older in 2000 was $19 billion.28

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in hospital discharge data is limited by the
completeness and quality of coding. The overall completeness of external-cause-of-injury
coding is of particular concern and should be reviewed in conjunction with the indicator.

HEALTHY PEOPLE 2020
OBJECTIVES

No objective.

22 | State Injury Indicators: Instructions for Preparing 2013 Data

FALL INDICATOR 3:
Unintentional Fall-Related Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit
subset with any of the following ICD-9-CM codes as the first valid external cause of injury
code (see methods on page 8).
Unintentional Fall-Related Emergency Department Visit ICD-9-CM Codes
E880–E886, E888

Accidental falls

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the
U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, there were over 8.7 million emergency department visits for unintentional
fall-related injuries, with over 1.1 million resulting in hospitalization or transfer for
additional care.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in emergency department data
is limited by the completeness and quality of coding. The overall completeness of
external-cause-of-injury coding is of particular concern and should be reviewed in
conjunction with the indicator.

HEALTHY PEOPLE 2020
OBJECTIVES

No objective.

State Injury Indicators: Instructions for Preparing 2013 Data | 23

FALL INDICATOR 4:
Hip Fracture Hospitalizations in Persons Aged 65 Years and Older
DEMOGRAPHIC GROUP

Resident persons aged 65 years or older

NUMERATOR

Hospitalizations with the following ICD-9-CM diagnostic code. These should be identified
by searching all diagnostic fields of the injury hospital discharge subset (see methods
on page 6).
Hip Fracture Hospitalization ICD-9-CM Code
Diagnosis code
820

Fracture of neck of femur

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of hospitalizations. Annual incidence—crude. Rates should be calculated
for age and sex.

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

In 2004, there were an estimated 289,000 hospital admissions for hip fractures in people
65 years and older.29 Up to 25% of adults who lived independently before their hip fracture
have to stay in a nursing home for at least a year after their injury30 and as many as 20%
of hip fracture patients die within a year of their injury.31

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in hospital discharge data is limited by
the completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

No objective.

24 | State Injury Indicators: Instructions for Preparing 2013 Data

FALL INDICATOR 5:
Hip Fracture Emergency Department Visits in Persons Aged 65 Years and Older
DEMOGRAPHIC GROUP

Resident persons aged 65 years or older

NUMERATOR

Emergency department visits with the following ICD-9-CM diagnostic code.
These should be identified by searching all diagnostic fields of the injury emergency
department visit subset (see methods on page 8).
Hip Fracture Emergency Department VIsit ICD-9-CM Code
Diagnosis code
820

Fracture of neck of femur

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of emergency department visits. Annual incidence—crude. Rates should
be calculated for age and sex.

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in emergency department data is limited
by the completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

OA-11: Reduce the rate of emergency department visits due to falls among older adults.

State Injury Indicators: Instructions for Preparing 2013 Data | 25

FIRE-RELATED INDICATOR 1:
Unintentional Fire-Related Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Unintentional Fire-Related Fatality ICD-10 Codes
X00–X09

Exposure to smoke, fire, and flames

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death

BACKGROUND

The United States mortality rate from fires ranks sixth among the 25 developed countries
for which statistics are available.32 Four out of five deaths in 2005 occurred in homes33
and approximately half of home fire deaths occurred in homes without fire alarms.34

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in vital statistics data is limited by the
completeness and quality of coding. The overall completeness of external cause coding
on death data is uniformly high. Coding criteria specify that cases of injury death must
contain an injury code in the underlying-cause-of-death field.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-28: Reduce residential fire deaths.

26 | State Injury Indicators: Instructions for Preparing 2013 Data

FIRE-RELATED INDICATOR 2:
Unintentional Fire-Related Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).
Unintentional Fire-Related Hospitalization ICD-9-CM Codes
E890–E899

Accident caused by fire and flames

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

In 2005, fire departments responded to 396,000 home fires in the U.S., which claimed the
lives of 3,030 people (not including firefighters) and injured another 13,825 (not including
firefighters).33 Residential fires disproportionately affect young children, older adults,
African Americans, and Native Americans.35 Working smoke alarms reduce the chance
of dying in a house fire by 40% to 50%; however, about 25% of U.S. households lack
working smoke alarms.36, 37

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

No objective.

State Injury Indicators: Instructions for Preparing 2013 Data | 27

FIRE-RELATED INDICATOR 3:
Unintentional Fire-Related Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit subset
with any of the following ICD-9-CM codes as the first valid external cause of injury code
(see methods on page 8).
Unintentional Fire-Related Emergency Department Visit ICD-9-CM Codes
E890–E899

Accident caused by fire and flames

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, there were over 390,000 emergency department visits for unintentional firerelated injuries, with over 30,000 resulting in hospitalization or transfer for additional care.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

No objective.

28 | State Injury Indicators: Instructions for Preparing 2013 Data

FIREARM-RELATED INDICATOR 1:
Firearm-Related Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Firearm-Related Fatality ICD-10 Codes
W32–W34
X72–X74
X93–X95
Y22–Y24
Y35.0
*U01.4

Exposure to inanimate mechanical forces– firearm discharge
Intentional self-harm by firearm discharge
Assault by firearm discharge
Firearm discharge of undetermined intent
Legal intervention involving firearm discharge
Terrorism involving firearms

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Firearm-related injuries were the third leading cause of injury-related death in the United
States, accounting for over 33,000 deaths in 2013.1 Nationally, the firearm-related death
rate for males is almost seven times higher than that of females.38

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-30: Reduce firearm-related deaths.

State Injury Indicators: Instructions for Preparing 2013 Data | 29

FIREARM-RELATED INDICATOR 2:
Firearm-Related Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).
Firearm-Related Hospitalization ICD-9-CM Codes
E922.0–E922.3, E922.8, E922.9
E955.0–E955.4
E965.0–E965.4
E985.0–E985.4
E970
E979.4

Accident caused by firearm missile
Suicide and self-inflicted injury by firearms
Assault by firearms
Injury by firearms, undetermined whether
accidentally, or purposely inflicted
Injury due to legal intervention by firearms
Terrorism involving firearms

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of hospitalizations. Annual incidence rate—crude and age-adjusted
(standardized by the direct method to the year 2000 standard U.S. population).23 Rates
should be calculated for age and sex.

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

Nonfatal firearm-related injury rates are highest among persons ages 15 to 24 years.
About one fifth of nonfatal firearm-related injuries treated in U.S. hospital emergency
departments are unintentional.39

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-31: Reduce nonfatal firearm-related injuries.

30 | State Injury Indicators: Instructions for Preparing 2013 Data

FIREARM-RELATED INDICATOR 3:
Firearm-Related Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit subset
with any of the following ICD-9-CM codes as the first valid external cause of injury code
(see methods on page 8).
Firearm-Related Emergency Department Visit ICD-9-CM Codes
E922.0–E922.3, E922.8, E922.9
E955.0–E955.4
E965.0–E965.4
E985.0–E985.4
E970
E979.4

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of emergency department visits. Annual incidence rate—crude and ageadjusted (standardized by the direct method to the year 2000 standard U.S. population).23
Rates should be calculated for age and sex.

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, there were over 84,000 emergency department visits for nonfatal firearm-related
injuries. Males comprised 88% of these visits.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-31: Reduce nonfatal firearm-related injuries.

State Injury Indicators: Instructions for Preparing 2013 Data | 31

HOMICIDE/ASSAULT INDICATOR 1:
Homicides
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Homicide ICD-10 Codes
X85–Y09
Y87.1
*U01
*U02

Assault
Sequelae of assault
Terrorism-assault
Sequelae of terrorism-assault

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Homicide is the sixteenth leading cause of death in the United States; it is the third most
common cause of death among persons ages 1 to 4 and 15 to 34 years.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-29: Reduce homicides.

32 | State Injury Indicators: Instructions for Preparing 2013 Data

HOMICIDE/ASSAULT INDICATOR 2:
Assault-Related Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).
Assault-Related Hospitalization ICD-9-CM Codes
E960–E969
E979
E999.1

Injury purposely inflicted by other persons
Terrorism
Late effect of injury due to terrorism

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of persons hospitalized. Annual incidence—crude and age-adjusted
(standardized by the direct method to the year 2000 standard U.S. population).23 Rates
should be calculated for age and sex.

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

In 2013, over 1.6 million people were treated in U.S. emergency departments for assaultrelated injuries with over 169,000 of them hospitalized or transferred for additional care.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-32: Reduce nonfatal physical assault injuries.

State Injury Indicators: Instructions for Preparing 2013 Data | 33

HOMICIDE/ASSAULT INDICATOR 3:
Assault-Related Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit subset
with any of the following ICD-9-CM codes as the first valid external cause of injury code
(see methods on page 8).
Assault-Related Emergency Department VIsit ICD-9-CM Codes
E960–E969
E979
E999.1

Injury purposely inflicted by other persons
Terrorism
Late effect of injury due to terrorism

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, over 1.6 million people were treated in U.S. emergency departments for assaultrelated injuries with over 169,000 of them hospitalized or transferred for additional care.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-32: Reduce nonfatal physical assault injuries.

34 | State Injury Indicators: Instructions for Preparing 2013 Data

HOMICIDE/ASSAULT INDICATOR 4:
High School Students Who Were in a Physical Fight
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported being in a physical fight one or more times in the
past 12 months.

DENOMINATOR

Total respondents in grades 9–12.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

Homicide is the third leading cause of death in young adults aged 15–19, with 1,407
deaths in 2013.1 Additionally, there were an estimated 205,000 nonfatal assault-related
injuries treated in U.S. emergency departments for 15–19 year olds, almost 15,000 of
which required hospitalization or transfer to another facility.1

LIMITATIONS OF
INDICATOR

Self-reported data only represents a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools), nonresponse
(e.g., refusal to participate in the survey or to answer specific questions), or
measurement (e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-33: Reduce physical assaults.
IVP-34: Reduce physical fighting among adolescents.

State Injury Indicators: Instructions for Preparing 2013 Data | 35

HOMICIDE/ASSAULT INDICATOR 5:
High School Students Who Were in a Physical Fight
That Required Medical Attention
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported being in a physical fight in the past 12 months
in which they were injured and had to be treated by a doctor or nurse.

DENOMINATOR

Total respondents in grades 9–12.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

In 2013, there were an estimated 205,000 nonfatal assault-related injuries treated in
U.S. emergency departments for 15–19 year olds, almost 15,000 of which required
hospitalization or transfer to another facility.1

LIMITATIONS OF
INDICATOR

Self-reported data only represents a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-32: Reduce nonfatal physical assault injuries.
IVP-34: Reduce physical fighting among adolescents.

36 | State Injury Indicators: Instructions for Preparing 2013 Data

HOMICIDE/ASSAULT INDICATOR 6:
High School Students Who Were Physically Forced
to Have Sexual Intercourse
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported ever being physically forced to have sexual
intercourse when they did not want to.

DENOMINATOR

Total respondents in grades 9–12.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Ever.

BACKGROUND

Nearly 1 in 5 women and 1 in 59 men in the United States have been raped at some time
in their lives. In a 2013 survey, 7.3% of high school students reported having been forced
to have sex. More female (10.5%) than male (4.2%) students reported experiencing
forced sex in their lifetimes.21

LIMITATIONS OF
INDICATOR

Self-reported data only represents a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools),
nonresponse (e.g., refusal to participate in the survey or to answer specific questions),
or measurement (e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-40.1: (Developmental) Reduce rape or attempted rape.

State Injury Indicators: Instructions for Preparing 2013 Data | 37

HOMICIDE/ASSAULT INDICATOR 7:
High School Students Who Experienced Physical Dating Violence
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported experiencing physical dating violence one
or more times during the 12 months before the survey, including being hit, slammed into
something, or injured with an object or weapon on purpose by someone they were dating
or going out with.

DENOMINATOR

Respondents in grades 9–12 who reported dating or going out with someone during
the previous 12 months.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

A 2011 nationwide survey found that 23% of females and 14% of males who ever
experienced rape, physical violence, or stalking by an intimate partner, first experienced
some form of partner violence between 11 and 17 years of age.39 A 2013 survey found
approximately 10% of high school students reported physical victimization from a dating
partner in the 12 months before they were surveyed.21

LIMITATIONS OF
INDICATOR

Self-reported data only represents a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools),
nonresponse (e.g., refusal to participate in the survey or to answer specific questions),
or measurement (e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-39.1: (Developmental) Reduce physical violence by current or former
intimate partners.

38 | State Injury Indicators: Instructions for Preparing 2013 Data

HOMICIDE/ASSAULT INDICATOR 8:
High School Students Who Experienced Sexual Dating Violence
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported experiencing sexual dating violence one or
more times during the 12 months before the survey, including kissing, touching, or being
physically forced to have sexual intercourse when they did not want to by someone they
were dating or going out with.

DENOMINATOR

Respondents in grades 9–12 who reported dating or going out with someone during
the previous 12 months.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

A 2011 nationwide survey found that 23% of females and 14% of males who ever
experienced rape, physical violence, or stalking by an intimate partner, first experienced
some form of partner violence between 11 and 17 years of age.39 A 2013 survey found
approximately 10% of high school students reported sexual victimization from a dating
partner in the 12 months before they were surveyed.21

LIMITATIONS OF
INDICATOR

Self-reported data only represents a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools),
nonresponse (e.g., refusal to participate in the survey or to answer specific questions),
or measurement (e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-39.2: (Developmental) Reduce sexual violence by current or former
intimate partners.

State Injury Indicators: Instructions for Preparing 2013 Data | 39

MOTOR VEHICLE INDICATOR 1:
Motor Vehicle Traffic Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Motor Vehicle Traffic Fatality ICD-10 Codes
V02–V04 (.1, .9), V09.2
V12–V14 (.3–.9), V19 (.4–.6)
V20–V28 (.3–.9), V29 (.4–.9)
V30–V39 (.4–.9)
V40–V49 (.4–.9)
V50–V59 (.4–.9)
V60–V69 (.4–.9)
V70–V79 (.4–.9)
V80 (.3–.5), V81.1, V82.1, V83–V86
(.0–.3), V87 (.0–.8), V89.2

Pedestrian injured in transport accident
Pedal cyclist injured in transport accident
Motorcycle rider injured in transport accident
Occupant of three-wheeled motor vehicle
injured in transport accident
Car occupant injured in transport accident
Occupant of pick-up truck or van injured in
transport accident
Occupant of heavy transport vehicle injured in
transport accident
Bus occupant injured in transport accident
Other land transport accidents

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Motor vehicle crashes are the second leading cause of injury death in the United States.
They are also the second leading injury cause for years of potential life lost1

LIMITATIONS OF
INDICATOR

Injuries severe enough to result in death represent only a small proportion of the
overallburden of injury. An evaluation of only these injuries may not present an accurate
picture of the causes of less-severe injuries.

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-13: Reduce motor vehicle crash-related deaths.
IVP-18: Reduce pedestrian deaths on public roads.
IVP-20 Reduce pedalcyclist deaths on public roads.

40 | State Injury Indicators: Instructions for Preparing 2013 Data

MOTOR VEHICLE INDICATOR 2:
Motor Vehicle Traffic Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).”
Motor Vehicle Traffic Hospitalization ICD-9-CM Codes
E810–E819

Motor vehicle traffic accidents

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

In 2013, motor vehicle crashes were the cause of over 3.8 million emergency department
visits in the United States with over 365,000 people hospitalized or transferred.1 Seat
belts dramatically reduce risk of death and serious injury. Among drivers and front-seat
passengers, seat belts reduce the risk of death by 45%, and cut the risk of serious
injury by 50%.40

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-14: Reduce nonfatal motor vehicle crash-related injuries.
IVP-19: Reduce nonfatal pedestrian injuries on public roads.

State Injury Indicators: Instructions for Preparing 2013 Data | 41

MOTOR VEHICLE INDICATOR 3:
Motor Vehicle Traffic Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit
subset with any of the following ICD-9-CM codes as the first valid external cause of injury
code (see methods on page 8).”
Motor Vehicle Traffic Emergency Department Visit ICD-9-CM Codes
E810–E819

Motor vehicle traffic accidents

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, motor vehicle crashes were the cause of over 3.8 million emergency department
visits in the United States.1 Seat belts dramatically reduce risk of death and serious injury.
Among drivers and front-seat passengers, seat belts reduce the risk of death by 45%, and
cut the risk of serious injury by 50%.40

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-14: Reduce nonfatal motor vehicle crash-related injuries.
IVP-19: Reduce nonfatal pedestrian injuries on public roads.

42 | State Injury Indicators: Instructions for Preparing 2013 Data

MOTOR VEHICLE INDICATOR 4:
Seat Belt Use
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Resident persons aged 18 years or older.

NUMERATOR

Those respondents reporting wearing their seatbelt “always” or “almost always” when
driving or riding in a car.

DENOMINATOR

Respondents aged 18 years or older.

MEASURES OF
FREQUENCY

Prevalence—crude.

DATA RESOURCES

Data from the Behavioral Risk Factor Surveillance System (BRFSS).18

PERIOD FOR CASE
DEFINITION

No time frame.

BACKGROUND

Seat belts dramatically reduce risk of death and serious injury. Among drivers and frontseat passengers, seat belts reduce the risk of death by 45%, and cut the risk of serious
injury by 50%.40

LIMITATIONS OF
INDICATOR

Self-reported data only represent a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, BRFSS data might be subject to systematic error
resulting from noncoverage (e.g., lower telephone coverage among populations of low
socioeconomic status), nonresponse (e.g., refusal to participate in the survey or to answer
specific questions), or measurement (e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-15: Increase use of safety belts.

State Injury Indicators: Instructions for Preparing 2013 Data | 43

MOTOR VEHICLE INDICATOR 5:
Drinking and Driving in High School Students
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported driving a car or other vehicle when drinking
alcohol in the past 30 days.

DENOMINATOR

Respondents in grades 9–12 who reported driving a car or other vehicle during the
30 days before the survey.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 30 days.

BACKGROUND

At all levels of blood alcohol concentration, the risk of being involved in a crash is greater
for young people than for older people.41 In 2005, 16% of drivers ages 16 to 20 who died
in motor vehicle crashes had been drinking alcohol.42

LIMITATIONS OF
INDICATOR

Self-reported data only represent a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools), nonresponse
(e.g., refusal to participate in the survey or to answer specific questions), or measurement
(e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

SA-17: Decrease the rate of alcohol-impaired driving (.08+ blood alcohol content [BAC])
fatalities.
Sa-20: decrease the number of deaths attributable to alcohol.

44 | State Injury Indicators: Instructions for Preparing 2013 Data

MOTOR VEHICLE INDICATOR 6:
High School Students Riding with Someone Drinking and Driving
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported riding in a car or other vehicle driven by
someone who had been drinking alcohol in the past 30 days.

DENOMINATOR

Total respondents in grades 9–12.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 30 days.

BACKGROUND

LIMITATIONS OF
INDICATOR

Self-reported data only represent a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools), nonresponse
(e.g., refusal to participate in the survey or to answer specific questions), or measurement
(e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

SA-1: Reduce the proportion of adolescents who report that they rode, during the
previous 30 days, with a driver who had been drinking alcohol.
SA-17: Decrease the rate of alcohol-impaired driving (.08+ blood alcohol content [BAC])
fatalities.
SA-20: Decrease the number of deaths attributable to alcohol.

State Injury Indicators: Instructions for Preparing 2013 Data | 45

MOTOR VEHICLE INDICATOR 7:
Texting/Emailing and Driving in High School Students
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported texting or emailing when driving a car or other
vehicle on at least one day during the 30 days before the survey.

DENOMINATOR

Respondents in grades 9–12 who reported driving a car or other vehicle during the 30
days before the survey.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 30 days.

BACKGROUND

In 2011, nearly one in five crashes (17%) in which someone was injured involved
distracted driving.43 In 2012, 3,328 people were killed in crashes involving a distracted
driver and an additional 421,000 people were injured.44

LIMITATIONS OF
INDICATOR

Self-reported data only represents a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic error
resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g.,
refusal to participate in the survey or to answer specific questions), or measurement (e.g.,
social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-13: Reduce motor vehicle crash-related deaths.
IVP-14: Reduce nonfatal motor vehicle crash-related injuries.

46 | State Injury Indicators: Instructions for Preparing 2013 Data

MOTOR VEHICLE INDICATOR 8:
Alcohol-Related Crash Deaths
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Alcohol-related death of a person involved in crash of a motor vehicle traveling on a
public roadway and occurring within 30 days of the crash. Deaths are considered alcohol
related if either a driver or nonoccupant (e.g., pedestrian or bicyclist) had a blood alcohol
concentration (BAC) greater than or equal to 0.01 g/dL.22

DENOMINATOR

Midyear population for the calendar year under surveillance.

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude.

DATA RESOURCES

Fatality Analysis Reporting System (FARS) coordinated by the National Highway Traffic
Safety Administration (NHTSA) (numerator)22 and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on the year of the crash.

BACKGROUND

In 2010, 10,228 people died in alcohol-impaired driving crashes, accounting for nearly
one third (31%) of all traffic-related deaths in the United States. Over half (62%) of the
211 child passengers aged 14 years and younger who died in alcohol-related crashes in
2010 were riding with drivers who had a BAC level of 0.08 g/dL or higher.45

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

FARS does not include nontraffic crashes such as those occurring on driveways and other
private property. In addition, it does not include deaths that occur more than 30 days after
the motor vehicle crash. Because blood alcohol levels are not available on all fatalities,
the estimates are based on a discriminant analysis of information from all cases where
BAC data are available.

HEALTHY PEOPLE 2020
OBJECTIVES

SA-17: Decrease the rate of alcohol-impaired driving (.08+ blood alcohol content [BAC])
fatalities.

State Injury Indicators: Instructions for Preparing 2013 Data | 47

POISONING INDICATOR 1:
Poisoning Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Poisoning Fatality ICD-10 Codes
X40–X49
X60–X69
X85–X90
Y10–Y19
Y35.2
*U01 (.6–.7)

Accidental poisoning by and exposure to noxious substances
Intentional self-poisoning
Assault by poisoning
Poisoning of undetermined intent
Legal intervention involving gas
Terrorism involving biological or chemical weapons

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

In 2013, over 48,500 people in the United States died from poisoning. Unintentional
poisonings are now the leading cause of injury death in the United States and the leading
injury cause for years of potential life lost.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in vital statistics data is limited by the
completeness and quality of coding. The overall completeness of external cause coding
on death data is uniformly high. Coding criteria specify that cases of injury death must
contain an injury code in the underlying-cause-of-death field.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-9: Prevent an increase in the rate of poisoning deaths.
MPS-2.4: (Developmental) Reduce deaths from the use of pain medicines.
SA-12: Reduce drug-induced deaths.

48 | State Injury Indicators: Instructions for Preparing 2013 Data

POISONING INDICATOR 2:
Poisoning Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).”
Poisoning Hospitalization ICD-9-CM Codes
E850–E858
E860–E869
E950–E952
E962
E972
E980–E982
E979 (.6–.7)

Accidental poisoning by drugs, medicinal substances, and biologicals
Accidental poisonings by other solid and liquid substances, gases,
and vapors
Suicide and self-inflicted poisoning
Assault by poisoning
Injury due to legal intervention by gas
Poisoning undetermined whether accidentally or purposefully inflicted
Terrorism involving biological or chemical weapons

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of hospitalizations. Annual incidence—crude and age-adjusted
(standardized by the direct method to the year 2010 standard U.S. population).23 Rates
should be calculated for age and sex.

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

In 2006, 33 states reported that hospitalization rates were 2.5 to 16 times higher than
death rates for poisoning-related injuries.46

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in hospital discharge data is limited
by the completeness and quality of coding. The overall completeness of e-coding is of
particular concern and should be reviewed in conjunction with the indicator.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-10: Prevent an increase in the rate of nonfatal poisonings.
MPS-2.3: (Developmental) Reduce serious injuries from the use of pain medicines.

State Injury Indicators: Instructions for Preparing 2013 Data | 49

POISONING INDICATOR 3:
Poisoning Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit subset
with any of the following ICD-9-CM codes as the first valid external cause of injury code
(see methods on page 8).
Poisoning Emergency Department Visit ICD-9-CM Codes
E850–E858
E860–E869
E950–E952
E962
E972
E980–E982
E979 (.6–.7)

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013 there were over 1.3 million poisoning-related emergency department visits, of
which over 495,000 resulted in hospitalization or transfer for additional care.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-10: Prevent an increase in the rate of nonfatal poisonings.
MPS-2.3: (Developmental) Reduce serious injuries from the use of pain medicines.

50 | State Injury Indicators: Instructions for Preparing 2013 Data

POISONING INDICATOR 4:
Drug Overdose Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.47
Drug Overdose Fatality ICD-10 ICD Codes
X40–X44
X60–X64
X85
Y10–Y14

Accidental poisoning by drugs
Intentional self-poisoning by drugs
Assault by drug poisoning
Drug poisoning of undetermined intent

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

In 2013, drug overdose deaths (43,982) exceeded the number of deaths from motor
vehicle traffic crashes (33,804).1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in vital statistics data is limited by the
completeness and quality of coding. The overall completeness of external cause coding
on death data is uniformly high. Coding criteria specify that cases of injury death must
contain an injury code in the underlying-cause-of-death field.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-9: Prevent an increase in the rate of poisoning deaths.
MPS-2.4: (Developmental) Reduce deaths from the use of pain medicines.
SA-12: Reduce drug-induced deaths.

State Injury Indicators: Instructions for Preparing 2013 Data | 51

SUICIDE/SUICIDE ATTEMPT INDICATOR 1:
Suicides
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Deaths with any of the following ICD-10 codes as an underlying cause of death.
Suicide ICD-10 Codes
X60–X84
Y87.0
*U03

Intentional self-harm
Sequelae of intentional self-harm
Terrorism-intentional self-harm

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).23 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

In 2013, suicide was the second leading cause of death among those ages 15 to 34 years
and the third leading cause of death for adolescents ages 10 to 14 years.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in vital statistics data is limited by the
completeness and quality of coding. The overall completeness of external cause coding
on death data is uniformly high. Coding criteria specify that cases of injury death must
contain an injury code in the underlying-cause-of-death field.

HEALTHY PEOPLE 2020
OBJECTIVES

MHMD-1: Reduce the suicide rate.

52 | State Injury Indicators: Instructions for Preparing 2013 Data

SUICIDE/SUICIDE ATTEMPT INDICATOR 2:
Suicide Attempt Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations identified from the injury hospital discharge subset with any of the
following ICD-9-CM codes as the first valid external cause of injury code (see methods
on page 6).
Suicide Attempt Hospitalization ICD-9-CM Codes
E950–E959

Suicide and self-inflicted injury

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

In 2013, there were over 494,000 hospital emergency department visits for suicide
attempts in the United States, with almost 345,000 hospitalized or transferred.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-41: Reduce nonfatal intentional self-harm injuries.
MHMD-2: Reduce suicide attempts by adolescents.

State Injury Indicators: Instructions for Preparing 2013 Data | 53

SUICIDE/SUICIDE ATTEMPT INDICATOR 3:
Suicide Attempt Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits identified from the injury emergency department visit subset
with any of the following ICD-9-CM codes as the first valid external cause of injury code
(see methods on page 8).
Suicide Attempt Emergency Department Visit ICD-9-CM Codes
E950–E959

Suicide and self-inflicted injury

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

In 2013, there were over 494,000 hospital emergency department visits for suicide
attempts in the United States, with almost 345,000 hospitalized or transferred.1

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in emergency department data is limited
by the completeness and quality of coding. The overall completeness of external-causeof-injury coding is of particular concern and should be reviewed in conjunction with the
indicator.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-41: Reduce nonfatal intentional self-harm injuries.
MHMD-2: Reduce suicide attempts by adolescents.

54 | State Injury Indicators: Instructions for Preparing 2013 Data

SUICIDE/SUICIDE ATTEMPT INDICATOR 4:
Suicide Attempts in High School Students
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported attempting suicide one or more times in the
past 12 months.

DENOMINATOR

Total respondents in grades 9–12.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

Suicide is the second leading cause of death in young adults aged 15–24.1 For every
death in this age group, there are 100–200 suicide attempts.48

LIMITATIONS OF
INDICATOR

Self-reported data only represent a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools), nonresponse
(e.g., refusal to participate in the survey or to answer specific questions), or measurement
(e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

MHMD-2: Reduce suicide attempts by adolescents.

State Injury Indicators: Instructions for Preparing 2013 Data | 55

SUICIDE/SUICIDE ATTEMPT INDICATOR 5:
Suicide Attempts in High School Students
That Required Medical Attention
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported attempting suicide one or more times in the
past 12 months.

DENOMINATOR

Total respondents in grades 9–12.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

Suicide is the second leading cause of death in young adults aged 15–24.1 For every
death in this age group, there are 100–200 suicide attempts.48

LIMITATIONS OF
INDICATOR

Self-reported data only represent a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools), nonresponse
(e.g., refusal to participate in the survey or to answer specific questions), or measurement
(e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

MHMD-2: Reduce suicide attempts by adolescents.

56 | State Injury Indicators: Instructions for Preparing 2013 Data

TRAUMATIC BRAIN INJURY INDICATOR 1:
Traumatic Brain Injury Fatalities
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

First, limit deaths to those with an injury underlying cause of death (V01–Y36, Y85–
Y87, Y89, *U01–*U03). Then select deaths with any of the following ICD-10 codes in
any field of the multiple cause of death file.
Traumatic Brain Injury Fatality ICD-10 Codes
S01.0–S01.9
S02.0, S02.1, S02.3, S02.7–S02.9
S04.0
S06.0–S06.9
S07.0, S07.1, S07.8, S07.9
S09.7–S09.9
T01.0*
T02.0*
T04.0*
T06.0*
T90.1, T90.2, T90.4, T90.5,
T90.8, T90.9

Open wound of head
Fracture of skull and facial bones
Injury of optic nerve and pathways
Intracranial injury
Crushing injury of head
Other and unspecified injuries of head
Open wounds involving head with neck
Fractures involving head with neck
Crushing injuries involving head with neck
Injuries of brain and cranial nerves with injuries
of nerves and spinal cord at neck level
Sequelae of injuries of head

* These codes are not considered valid in the U.S.

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

Annual number of deaths. Annual mortality rate—crude and age-adjusted (standardized
by the direct method to the year 2000 standard U.S. population).22 Rates should be
calculated for age and sex.

DATA RESOURCES

Death certificate data from vital statistics agencies (numerator) and population estimates
from the U.S. Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of death.

BACKGROUND

Of the approximately 1.7 million people who sustained a TBI in the United States each
year, an estimated 52,000 died; 275,000 were hospitalized; and 1.365 million were treated
and released from an emergency department.49

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in vital statistics data is limited by the
completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-2.1: Reduce fatal traumatic brain injuries.

State Injury Indicators: Instructions for Preparing 2013 Data | 57

TRAUMATIC BRAIN INJURY INDICATOR 2:
Traumatic Brain Injury Hospitalizations
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Hospitalizations with any of the following ICD-9-CM diagnostic codes. These should be
identified by searching all diagnostic fields of the injury hospital discharge subset (see
methods on page 6 for developing the injury hospital discharge subset).
Traumatic Brain Injury Hospitalization ICD-9-CM Codes
Diagnosis codes
800.00–801.99
803.00–804.99
850.0–850.9
851.00–854.19
950.1–950.3
959.01
995.55

Fracture of the vault or base of the skull
Other and unqualified or multiple fractures of the skull
Concussion
Intracranial injury, including contusion, laceration, and hemorrhage
Injury to the optic chiasm, optic pathways, or visual cortex
Head injury, unspecified
Shaken infant syndrome

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State hospital discharge data (numerator) and population estimates from the U.S. Census
Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of discharge.

BACKGROUND

An estimated 5.3 million Americans live with a TBI-related disability. According to one
study, about 40% of those hospitalized with a TBI had at least one unmet need for
services one year after their injury.50, 51

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in hospital discharge data is limited by
the completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-2.2: Reduce hospitalization for nonfatal traumatic brain injuries.

58 | State Injury Indicators: Instructions for Preparing 2013 Data

TRAUMATIC BRAIN INJURY INDICATOR 3:
Traumatic Brain Injury Emergency Department Visits
DEMOGRAPHIC GROUP

All residents.

NUMERATOR

Emergency department visits with any of the following ICD-9-CM diagnostic codes.
These should be identified by searching all diagnostic fields of the injury emergency
department visit subset (see methods on page 8 for developing the injury emergency
department visit subset).
Traumatic Brain Injury Emergency Department Visit ICD-9-CM Codes
Diagnosis codes
800.00–801.99
803.00–804.99
850.0–850.9
851.00–854.19
950.1–950.3
959.01
995.55

DENOMINATOR

Midyear population for the calendar year under surveillance (see instructions on page 61).

MEASURES OF
FREQUENCY

DATA RESOURCES

State emergency department data (numerator) and population estimates from the U.S.
Census Bureau or suitable alternative (denominator).

PERIOD FOR CASE
DEFINITION

Calendar year based on date of ED visit.

BACKGROUND

Of the 1.365 million emergency department visits for TBI annually, almost half a
million (473,947 or 34.7% of all TBI emergency department visits) are by children
aged 0 to 14 years.49

LIMITATIONS OF
INDICATOR

LIMITATIONS OF DATA
RESOURCES

The accuracy of indicators based on codes found in emergency department data is limited
by the completeness and quality of coding.

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-2.3: Reduce emergency department visits for nonfatal traumatic brain injuries.

State Injury Indicators: Instructions for Preparing 2013 Data | 59

TRAUMATIC BRAIN INJURY INDICATOR 4:
Bicycle Helmet Use Among High School Students
This indicator will be calculated at CDC.
DEMOGRAPHIC GROUP

Students in grades 9–12.

NUMERATOR

Respondents in grades 9–12 who reported never or rarely wearing a helmet when riding
a bicycle in the past 12 months.

DENOMINATOR

Respondents in grades 9–12 who reported riding a bicycle in the past 12 months.

MEASURES OF
FREQUENCY

Weighted percentage.

DATA RESOURCES

Data from the Youth Risk Behavior Survey (YRBS).20

PERIOD FOR CASE
DEFINITION

Previous 12 months.

BACKGROUND

Wearing an approved bicycle helmet that fits properly can help reduce the risk of brain
injury.

LIMITATIONS OF
INDICATOR

Self-reported data only represent a small portion of the overall burden of injury. An
evaluation of only these injuries may not present an accurate picture of all injuries.

LIMITATIONS OF DATA
RESOURCES

As with all self-reported sample surveys, YRBS data might be subject to systematic
error resulting from noncoverage (e.g., no participation by certain schools), nonresponse
(e.g., refusal to participate in the survey or to answer specific questions), or measurement
(e.g., social desirability or recall bias).

HEALTHY PEOPLE 2020
OBJECTIVES

IVP-21: Increase the number of States and the District of Columbia with laws requiring
bicycle helmets for bicycle riders.

60 | State Injury Indicators: Instructions for Preparing 2013 Data

CALCULATING AND SUBMITTING RATES
Calculation Formula and Instructions
Preformatted rate calculation spreadsheets have been prepared for the hospital discharge, emergency
department, and vital records-based indicators. These spreadsheets can be obtained from Karen Thomas at
[email protected]. Completion of the spreadsheet requires:

▪▪ Answering a few data background questions;
▪▪ Inserting state population data;
▪▪ Entering case counts for individual indicators; and
▪▪ Renaming the spreadsheets to reflect state and submission number.
Rate calculations include several types of rates (i.e., age-specific crude rates and age-adjusted rates). The
following rate calculation specifications have been preprogrammed into the spreadsheet. If you are preparing
these data independent of the spreadsheet, please be sure to follow the same specifications.

▪▪ Use the estimated population for the year of the data. This information may be obtained from several sources:
• http://www.census.gov/popest/data/state/asrh/2013/index.html (preferred)
-- Under “Tables” and “Median Age by Age and Sex”
-- Select “Annual Estimates of the Resident Population by Single Year of Age and Sex:
April 1, 2010 to July 1, 2013
-- From the table, you can choose the state and download the data.
• your state’s demographic center

▪▪ Compute rates per 100,000 population.
▪▪ For each indicator, except hip fracture hospitalizations, report age-adjusted rates stratified by sex
(female and male), and report the overall age-adjusted rate for the state.

▪▪ Report age-specific rates for each indicator in the following age categories:
Under 1
1–4

45–54

5–14

55–64

15–24

65–74

25–34

75–84

35–44

85+

It is possible to obtain the anomalous looking overall age-adjusted rate which
does not fall between the two gender-specific age-adjusted rates. Such
outcomes are mathematically possible and should be included.

State Injury Indicators: Instructions for Preparing 2013 Data | 61

Calculate age-adjusted rates using the age-specific U.S. standard population weights from Table 1.

TABLE 1. AGE ADJUSTMENT TABLE: ALL AGES–ELEVEN AGE GROUPS

Age

U.S. 2000 Standard Population
(1,000’s)

Adjustment Weights

All ages

274,634

1.000000

Under 1

3,795

0.013818

1–4

15,192

0.055317

5–14

39,977

0.145565

15–24

38,077

0.138646

25–34

37,233

0.135573

35–44

44,659

0.162613

45–54

37,030

0.134834

55–64

23,961

0.087247

65–74

18,136

0.066037

75–84

12,315

0.044842

85+

4,259

0.015508

62 | State Injury Indicators: Instructions for Preparing 2013 Data

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State Injury Indicators: Instructions for Preparing 2013 Data | 63

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