Trauma Registry Injury Severity Coding Discordance and Mental Health Referral Omission Among Kenyan Emergency Clinicians: A Multilevel Analysis of Triage Classification Error

Injury severity coding in trauma registries is routinely treated as a neutral descriptor of anatomical damage, yet the same code simultaneously governs clinical escalation and psychological referral. Using a multilevel conceptual framework, the analysis specifies how clinician-level coding behaviour, department-level triage protocols and registry-level abstraction rules interact to generate classification error that is non-random with respect to psychological sequela. The framework distinguishes three mechanisms: physiological anchoring, where discharge-ready vital signs suppress severity scores; temporal displacement, where registry abstraction occurs after clinical stabilisation; and referral pathway decoupling, where mental health referral is indexed to a severity threshold that coding error systematically lowers. The discordance is not measurement noise but a structural feature of registries designed for injury surveillance rather than psychological risk detection. Implications for registry redesign, triage protocol integration and clinician training are developed, with attention to the resource constraints of Kenyan district and referral hospitals.