A New Technique for Survival Prediction in Trauma Care Using A Neural Network

Michael D. McGonigal MD, University of Minnesota School of Medicine

St. Paul Ramsey Medical Center, Department of Surgery
640 Jackson Street, St. Paul, MN 55 101

Introduction
The provision of medical care to the injured is a dynamic process involving substantial resources. Ensuring
quality of care is of paramount importance to patient and
trauma system administrator alike. The ultimate goal of
both is to achieve the best possible outcome for a given
spectrum of injuries.
The most common type of trauma quality assurance
review involves prediction of survival or death. Although such predictions cannot be applied to individuals
yet, they are useful in comparing an individual outcome
to predicted outcome for a group. If an individual dies
fiom his or her injuries, but the prediction system indicated that the majority of a group with the same injuries
should have survived, then the death is considered to be
an "unexpected death". Conversely, an "unexpected survivor" is one who lives despite the prediction system indicating that the majority in a group with identical
injuries would die.
Numerous attempts at predicting survival have been
documented in the trauma literature. Until the early
1980's, all were too simplistic to account for the vagaries
of injury mechanism and human physiology. During the
last decade, two systems were developed that were reasonably accurate at predicting survival, TRISS and ASCOT (described below).
TRISS was described in 1984' and became widely
accepted. However, clinicians were aware of a number
of shortcomings related to specific areas of injury'. ASCOT was introduced in 1990 in an attempt to address
these weaknesses. Unfortunately, some of those flaws
remain, which is due primarily to the fact that both are
derived using standard statistical techniques.
Both systems are particularly weak in outcome prediction of patients with penetrating injury (stab wounds,
gunshots). Furthermore, both systems were developed
for adult trauma. Neither TRISS nor ASCOT has been
validated for use in children, and no other survival prediction system for pediatric trauma currently exists.
Artificial neural networks have been proven very effective at extrapolation and prediction. They are able to
fit surface features to data points more closely than statistical regression. For these reasons, an artificial neural
network was chosen as the basis for a new survival prediction system for traumatic injury in both children and
adults.
Traditional mathematical models for survival prediction in trauma care (TRISS and ASCOT) were compared

0-7803-1901-X/94 $4.00 01994 E E E

to a new system based upon a multilayer perceptron

neural network.
Data Set
The Pennsylvania Trauma Systems Foundation is a
state agency charged with accrediting trauma centers and
maintaining quality trauma care in Pennsylvania. It
maintains a comprehensive registry of clinical information on injured patients seen at all 24 trauma centers
across the state. The registry contains data on the
mechanism of injury, transport times, initial treatment,
anatomic and physiologic injury, surgical procedures,
complications, and outcome.
Trauma registry records for all individuals sustaining
penetrating injury fiom October 1986 through March
1991 were obtained for study. A total of 92 12 records
were available for analysis. Of these, 9 12 were missing
data elements required for survival prediction using traditional methods, and were discarded.
The remaining 8300 records were divided into two
groups. The training data set consisted of 3500 randomly selected records fiom the full data set. It was
used exclusively for training the neural network used in
this study. The test data set consisted of the remaining
4800 records of the full data set. It was used to compute
the probability of survival by traditional means and by
the trained neural network.
An additional pediatric test data set was derived fiom
the full test data set. All records with an age 5 16 were
extracted for validation of the neural network on a pediatric population.
TRISS
The TRISS method is the first widely accepted technique for calculating probability of survival3. It superseded earlier attempts due to its improved accuracy.
This accuracy was achieved by consolidating three individual variables associated with survival: anatomic severity of injury, physiologic derangement due to injury,
and age.
Anatomic severity of injury is described by the Injury
Severity Score' (ISS). The ISS is derived by assigning
Abbreviated Injury Scores5(AIS) to every injury in each
of six body systems (Figure 1). The three highest system
scores are squared and then summed to arrive at the ISS.
The range of possible values for ISS is 0 (no injury) to
75 (maximal injury). An exception to this method of
sums of squares exists if any system has a score of 6

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IBody Systems 11
Head / Neck

2 - Moderate injury
3 - Serious injury
4 - Severe injury, survival likely

Face
Chest
Abdomen
Extremities
1

AIS System Scores

1 Minor injury

External

6 - Fatal i n i w

5 Critical injury, survival uncertain

II

"

Figure 1. Components of the Injury Severity Score

(fatal injury, e.g. decapitation); a score of 75 is then assigned by default.
The degree of physiologic derangement is described
by the Revised Trauma Score6(RTS). This score was
derived through logistic regression analysis of three variables: systolic blood pressure (SBP), respiratory rate
(RR),and Glasgow Coma Score (GCS). The Coma
Score describes the mental status of an individual by
evaluating eye opening, verbal response, and movement.
It ranges from 3 (deep coma) to 15 (awake and alert).
Each of the three variables in RTS is assigned a
coded value from 1 to 4 (Figure 2). The resulting coded
values are inserted into the regression equation:
RTS= (0.7326 x SBP) + (0.2908 x RR)+ (0.9368 x GCS)
Age is separated into two cohorts: young and old.
Old is defined as 2 55years of age, and is assigned an
age value of 1, versus a value of 0 for those under 55.
Coded
Value

Blood
Pressure

> 89

3
2

13 15

76 - 89
50 - 75

6-9

6-8

Set-Aside
Group
Description
1
Any system AIS = 6, and RTS = 0
2
All AIS < 6, and RTS = 0
3
Any AIS = 6, and RTS > 0
4

All AIS < 3, and RTS > 0

Ps Probability of Survival
Figure 3. ASCOT Set-aside Groups

9 - 12

AGE Variable

1
1-49
1-5
4-5
Figure 2. Components of the Revised Trauma Score

3
> 74
Figure 4. ASCOT Age Stratification

(1)

ASCOT Group

where:
b = (ko X RTS) + (kl x ZSS)+ (k2 x AGE) + k3

Serious head and spinal cord injury

Serious chest and neck injury

and:

k, = -2.6676

k, =-0.1516

k, = -0.6029

Patient Age

65 -74

k,,= 1.143

- 23%

- 100%

55 - 64

Probability of survival is then derived using the

equation:

ps TFUSS = I+e-b

p,

- 0%
- 2%

The AGE variable from TRISS was further stratified

to take into account the poorer outcomes seen with
trauma to the very old (Figure 4).
Three groups of high-risk injuries were identified
(Figure 5). The AIS values of specific injuries from
each group were summed and the square root was
calculated.

Respiratory Glasgow
Rate
Coma Score
10 - 29
29

ASCOT
ASCOT (A Severity Characterization of Trauma) is
very similar to TRISS. Accuracy was improved by four
enhancements: 1) identifying special set-aside groups; 2)
further stratifiing the older age group; 3) adding coefficients for selected high-risk injuries; and 4) using the individual components of the Revised Trauma Score.
A large number of trauma victims have relatively
minor injury and all are expected to survive. A small
number have massive injury and cannot live with their
injury. Set-aside groups were defined in ASCOT in order to incorporate definitions for these degrees of injury
(Figure 3). Survival probabilities are assigned to each
set-aside group by utilizing the actual survival rate in a
standard sample of patients.

Serious injury to the abdomen, pelvis,

or amputations
Figure 5. ASCOT Injury Groups

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Probability of survival by ASCOT is then computed

using the same equation as for TRISS (Equation 1).
However, the coefficient in the exponential is:

b = (ko X SBP) + (kl X RR)+ (k2 x GCS) + (k3 x A ) +

(k4 x B) + (k5 x C) + (k6 x AGE) + k7
and:
k, = -0.2053
k,= 0.3638
k, = 0.3332

k5= -0.3 188

k, = 1.0626
k, = -0.3702

k, = -1.135

k,

= -0.8365

Neural Network
A multilayer perceptron neural network was constructed using two hidden layers. Backpropagation
learning using the delta rule and a hyperbolic tangent
transfer function were used.
Network inputs were the same as for TRISS:Revised
Trauma Score, Injury Severity Score, and AGE. The
RTS and ISS inputs were normalized to values between
0 and 1. Age was represented as a binary 0 for age < 55
and 1 for age> 55.
The first hidden layer consisted of five neurons, and
the second layer six. There were two network outputs:
live and die. The value of each should be theoretically 1
if true and 0 if false.
The network was trained by sequentially presenting
inputs and the outcome (live or die) fiom the training
data set. This process was repeated for 1000 iterations,
at which time the total error was minimal.
Methods
Probability of survival (Ps) was computed on each of
the 4800 data records in the test set using TRISS, ASCOT, and the trained neural network (NET). Sensitivity
(accuracy in predicting death) and specificity (accuracy
in predicting survival) were computed by comparing predicted outcome with actual outcome. A death was ruled
unexpected if the predicted Ps was 2 0.5, and survival
was ruled unexpected if Ps was < 0.5. The total number
of unexpected outcomes was tabulated (misclassification
rate).
Sensitivity and specificity computations were also
performed on the pediatric subset of the test data set (age
< 16).
Comparisons of sensitivity and specificity were made
using Chi-square with Yates' correction. Predictive reliability was tested using the Hosmer-Lemeshow goodness
of fit statistic' (H-L). Significance was presumed forp
values < 0.05 for Chi-square and for H-L values < 15.5.

Results
Results fiom the full test data set are summarized in
Table 1. The TRISS and ASCOT systems accurately
predicted 98.5% of survivors. Mortality predictions
were substantially less accurate: TRISS sensitivity was
84.0% and ASCOT sensitivity was essentially the same
at 84.2%.
The neural network was less specific, predicting
97.2% of survivors. The increase in sensitivity to 90.4%
more than offset this. The differences in sensitivity and
specificity between NET and both TRISS and ASCOT
were statistically significant.
Misclassification rates for TRISS and ASCOT were
very similar (2.9% vs 2.8%). The neural network falsely
classified 3.5% of patients. This was due to the higher
number of improperly classified survivors (lower
specificity).
The H-L statistic measures how well a prediction
system fits the actual data. None of the three systems
tested achieved statistical significance with this statistic.
Thus, no presently available system can yet completely
and accurately predict outcome in large populations.

TRISS

Sensitivity

ASCOT
0.842

0.904*

NET

Specificity

0.985

0.985

0.972*

Misclass. Rate
H-L Statistic

2.9%

2.8%

3.5%

137.7
0.84

47.5

99.51

significant p < 0.05

Table 1. Results fiom full test data set

Results fiom the pediatric subset are summarized in
Table 2. The network was significantly more sensitive
and equally as specific as both conventional methods.
Conclusions
The application of artificial neural networks in survival prediction after trauma is very promising. Although the network was not as accurate at predicting
survival, as evidenced by a higher misclassification rate,
it was superior in predicting death. In actual practice,
proper classification of mortality is more important since
more energy and resources are put into investigating unexpected death than unexpected survival.
In the full test data set, the actual number of unexpected deaths decreased fiom 73 (TRISS) to 44 by the
network. This represents a 40% increase in accuracy, or
a 40% decrease in quality assurance workload. When
translated into real dollars, this would allow a decrease
in quality assurance personnel of over 1 FTE at a typical

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trauma center. Similarly, unexpected deaths in the pediatric data set decreased by 50%, from 12 to 6.
TRISS

ASCOT

NET

Sensitivity

0.833

0.806

0.903*

Specificity

0.972

0.975

0.975

References
' H.R. Champion, C.F. Frey, and W.J. Sacco, "Determination of national normative outcomes for trauma", (abstract) Journal of Trauma 24:65 1, 1984.

M.D. McGonigal, J. Cole, C. W.Schwab, et al, "Pitfalls in the use of TRISS probability of survival analysis
in penetrating injury". Presented at the Resident Competition of the American College of Surgeons, Pennsylvania Chapter, Hershey, PA, 1991.

significant p < 0.05

Table 2. Results from pediatric test data set

Three shortcomings may be noted in the neural network used in this study. First, the input data are, for the
most part, contrived values. The actual values for RTS
and ISS are derived fiom regression equations and are
seriously skewed toward more normal (non-injured) values. This may have impaired the overall training of the
net.
The input layer variables were chosen deliberately to
mimic those of the current standard, TRISS.Both TRISS
and ASCOT can be represented as a neural network with
four or eight inputs respectively, no hidden layer, and a
single output neuron with a sigmoid transfer function
(Equation 1). In theory, a multilayer network with the
same inputs and output mapping should perform better
than an equivalent network without hidden layers.
Second, the overall mortality for the data sets was
only 12%. This results in under-representation of deaths
during training and may have decreased the network sensitivity. Fortunately, TRISS and ASCOT sensitivity are
already far worse than that of the network.
Finally, this neural network was trained only on
penetrating injury data. It is not valid for survival prediction in blunt injury (motor vehicle accident, fall, assault), which represents the majority of trauma
encountered outside of inner city areas. It is valid, however, in predicting survival after penetrating injury to
children.
Despite these weaknesses, probability of survival
prediction is superior to both traditional methods. The
ultimate goal is an accurate system for survival scoring
that relies on inexpensive computer hardware to identify
patient records that do not require review by humans. A
generalized neural network the recognizes both blunt
and penetrating injury, and that utilizes binary data
based upon raw physiology and anatomic injury data is
currently under development.

C.R. Boyd, M.A. Tolson, and W.S. Copes, "Evaluating

trauma care: The TRISS method", Journal of Trauma
27:370, 1987,

' H.R. Champion, W.J. Sacco, R.L. Lepper, et al, "An

Anatomic Index of Injury Severity", Journal of Trauma
20~197-202,1980.

' H.R. Champion, W.J. Sacco, R.L.Lepper, et al, "An

Anatomic Index of Injury Severity", Journal of Trauma
20:197-202, 1980.

H.R. Champion, W.J. Sacco, W.S. Copes, et al, "A revision of the trauma score", Journal of Trauma 29:623-9,
1989.

' S . Lemeshow and D.W. Hosmer, "A review of goodness of fit statistics for use in the development of logistic
regression models", American Journal of Epidemiology
115:92, 1982.

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