- Email: [email protected]
Injury Prevention
systematic intervention and injury reduction. This strategy, which considers injury in pre-event, event, and post-event phases, each offering opportunity for intervention, is still relevant today (Table 17-2). Pre-event (primary) prevention measures seek to prevent the event leading to the injury through education, intervention, and/or safety design measures. For example, crosswalks and count-down timers are effective safety engineering actions to make our roadways safer for pedestrians. Measures aimed at altering the event (secondary) seek to lessen the severity of an injury if it occurs. For example, child safety seats are not designed to prevent a motor vehicle collision but rather minimize (or eliminate) the severity of any injuries if a collision occurs. Finally, post-event (tertiary) injury prevention is the strategy used by most health care providers. It seeks to mitigate the consequences of the injury once it has occurred. For example, management of intractable intracranial hypertension through hemicraniectomy is tertiary prevention. Advances in health care have led to marked improvements in outcome for children with traumatic injuries. However, quite clearly, primary prevention, averting the event altogether, is the optimal approach. Haddon provided 10 countermeasures to use when addressing the prevention of a particular injury (Table 17-3).4 These concepts can be applied to most any injury and help break down the problem into potentially actionable steps.
CHAPTER 17
Injury Prevention Gina P. Duchossois and Michael L. Nance “If a disease were killing our children in the proportions that injuries are, people would be outraged and demand that this killer be stopped.” —C. Everett Koop
Injury presents the greatest threat to life of all diseases in the pediatric population. More children die each year from injury than all other causes combined.1 More than one in nine children will require medical attention for an injury each year. Many more children will be injured but not require or seek medical care (Fig. 17-1). The economic costs of injury are staggering. In addition to direct costs for care, there is the additional loss of future productivity as well as loss of productivity by parental caregivers who must provide for the injured child. For the year 2000, these costs were estimated to top $130 billion in total costs, with nearly $25 billion due to direct medical costs.2 The significance of the costs of injury become even more provocative when one considers the potential financial savings that can be realized from injury prevention strategies (Table 17-1). William Haddon, in the 1970s, reported his classic characterization scheme (the Haddon “matrix”) and approach to injury prevention.3 This system argued against the traditional idea that injury was an accident, leaving the burden of prevention on the individual. Rather, he suggested that injuries result from predictable events and thus offer an opportunity for
Prevention Priorities ------------------------------------------------------------------------------------------------------------------------------------------------
Injury prevention resources are finite. As such, priorities for these prevention efforts must be established. These priorities may vary depending on the individual, the community, or perhaps the nation interested in prevention. A variety of factors are integral to the decisions regarding how best to deploy these limited resources. At the individual level, one might favor efforts to minimize in-home injury and “child-proof” the surroundings. A community might work toward pedestrian safety efforts in neighborhoods in which such injuries have been predominant. Finally, a nation (e.g., the United States) might focus efforts to reduce motor vehicle–related injuries, the leading cause of injury death. Simply counting the number of deaths from a particular injury mechanism may not provide an accurate or adequate representation of the burden of injury (by mechanism) in the geographic area of study. For instance, an injury mechanism that is highly lethal (e.g., hanging) but infrequent may not be an optimal prevention target. Nor might efforts to reduce an injury that is common but usually of limited severity (e.g., assault) be the ideal strategy. An injury that is both common and severe would, in most settings, represent the ideal target for mitigation efforts. To help define such injuries, Haider and colleagues used an injury prevention priority score.5 This calculation takes into account both the frequency of an injury and the mean severity of an injury by mechanism. In a comparison of pediatric populations from two geographically distinct trauma centers, they noted differences in injury patterns. In the inner city, auto/pedestrian injuries achieved the highest priority score, while in the community center, motor vehicle–related injuries ranked highest. Wiebe and colleagues applied this methodology to a national trauma center population and demonstrated that motor vehicle–related injuries, falls, and firearm-related 255
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injuries, respectively, were the highest ranking injury mechanisms (Table 17-4).7 In addition, Wiebe and colleagues also created additional scores that take into account the relative mortality of an injury mechanism (mortality priority score), the cost of an injury (hospital cost priority score), and the years of productive life lost (years of productive life lost priority score) to further characterize the burden of a particular injury. As suggested by Haider in his original publication, the methodology is easily applied to individual populations, such as that of a trauma center or a county or a state, to help determine how best to deploy prevention
Deaths 16,937
Hospitalized 189,595
Emergency department 9,365,239
TABLE 17-3 Haddon Measures to Combat Injury and Their Application to Firearm Injury
Treated at home or do not seek care
FIGURE 17-1 Injury pyramid demonstrating fatal injuries, injuries requiring hospitalization, and injuries resulting in an emergency department visit for children age 0 to 19 years, 2007. (Data from National Center for Injury Prevention and Control.1)
TABLE17-1 Potential Financial Savings from Selected Injury Prevention Initiatives Expenditure of $1 Each on:
Savings ($)
Smoke alarms Child restraints Bicycle helmets Prevention counseling by pediatricians Poison control services Road safety improvements
65 29 29 10 7 3
From Peden M, OyegbiteK, Ozanne-Smith J, et al: World report on child injury prevention. Geneva, Switzerland, World Health Organization, 2004. Available at http://www.who.int/violence_injury_prevention/child/injury/ world_report/en/index.html. Accessed November 12, 2010.
Haddon Countermeasure
As Applied to Firearm Injury Prevention
Prevent the creation of the hazard in the first place Reduce the amount of the hazard brought into being Prevent the release of the hazard that already exists Modify the release of the hazard that already exists Separate, in time and space, the hazard and that which is to be protected Separate, by material barrier, the hazard and that which is to be protected Modify the relevant basic qualities of the hazard Make that to be protected more resistant to damage from the hazard Counter damage already done by the hazard
Eliminate handguns
Stabilize, repair, and rehabilitate the object of the hazard
Limit the number of handguns allowed to be sold or purchased Install locks on handguns Eliminate automatic handguns Store handguns only at gun clubs rather than at home Keep guns in locked containers
Personalize guns so they can be fired only by the owner Create and market bullet-proof garments Provide good access to emergency care in the prehospital period Provide high-quality trauma care in hospitals
TABLE 17-2 Haddon Matrix Applied to Motor Vehicle Crashes in Children Child Factors
Vehicle and Safety Equipment
Physical Environment
Socioeconomic Environment
Pre-event
Age; gender; lack of supervision; risk-taking; impulsive behavior; disobedience; lack of police enforcement
Lack of roadworthiness of vehicle; poor lighting; poor state of brakes; speeding; overloading
Event
Size and physical development of child; lack of equipment to protect occupants, or equipment improperly used; underlying conditions in child Child’s lack of resilience; child’s general condition; lack of access to appropriate health care; postinjury complications
Child restraints and seat belts not fitted or incorrectly used; bicycle and motorcycle helmets not used; poor design of vehicle for protection in crashes; no rollover protection Difficult access to victim; lack of trained health care and rescue workers
Poor road design; lack of public transport; no enforcement of speed limits; no safety barriers; lack of alcohol laws; poor infrastructure for pedestrian safety Roadside objects such as trees and poles
Poverty; single-parent family; large family size; poor maternal education; lack of awareness of risks among caregivers, childcare providers, and educators Lack of safety culture in the car and on the road
Lack of availability of adequate pre-hospital care, acute care and rehabilitation
Lack of culture of supporting injured people; no first aid given at scene
Post-event
From Peden M, Oyegbite K, Ozanne-Smith J, et al: World report on child injury prevention. Geneva, Switzerland, World Health Organization, 2004. Available at http://www.who.int/violence_injury_prevention/child/injury/world_report/en/index.html. Accessed November 12, 2010.
CHAPTER 17
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257
TABLE 17-4 Incidence and Characteristics of 13 Injury Mechanisms Presenting to United States Trauma Centers, 2000-2004, and Priority Scores and Priority Rankings by Injury Mechanism Mechanism
Incidence and Characteristics
Priority Scores and Rankings Mortality
Motor vehicle traffic Suffocation Firearm Fall Drowning/ submersion Pedestrian, other Transport, other Fire/burn Struck by, against Cut/pierce Machinery Poisoning Pedal cyclist, other
N
Median Age (Years)
Median ISS
Median Charges
Median YPLL
378,029
32
9
$15,941
37
1,314 53,146 237,500 945
28 26 53 20
1 9 9 4
$12,754 $14,484 $12,922 $10,777
3,100
32
9
45,151
29
17,511 61,962 40,574 12,221 1,041 13,934
Mortality (%)
Injury Severity
Hospital Charges
Rank
YPLL PS{
Rank
74.0
1
74.6
1
12 3 2 10
48.5 54.4 61.1 44.9
6 4 2 10
53.3 57.4 42.9 59.4
4 3 11 2
53.0
5
54.4
3
44.3
9
7
55.1
4
53.5
5
51.2
5
44.4 44.1
8 9
41.2 48.8
11 6
39.6 47.3
12 8
35.5 48.2
13 7
43.0 41.0 41.0 40.1
10 11 12 13
45.9 44.5 38.5 48.2
8 9 13 7
46.4 48.5 34.7 42.8
9 7 13 11
51.8 41.2 45.7 43.6
6 12 8 10
Mort PS}
Rank
IPPS*
Rank
5.0
69.7
1
72.0
1
48 48 10 56
23.0 16.2 3.5 16.5
63.4 59.5 58.4 56.2
2 3 4 5
38.5 55.5 64.9 43.9
$15,936
36
5.9
44.8
6
9
$14,240
42
2.9
44.5
28 30
2 5
$7,412 $10,367
23 35
4.6 1.5
31 40 32 17
4 4 1 6
$10,477 $12,442 $5,201 $9,277
42 31 38 34
1.9 1.8 2.5 0.9
Charge PS{
Years of Life Lost
From Wiebe DJ, Nance ML, Branas CC: Determining objective injury prevention strategies. Inj Prev 2005;12:347-350. *Injury prevention priority score. { Charge priority score. { Years potential life lost priority score. } Mortality priority score. Note: data based on trauma centers participating in the National Trauma Data Bank surveillance system. ISS, injury severity score.
resources. Using data to better understand the scope of the problem is essential to designing effective prevention strategies.
INJURY PREVENTION DESIGN STRATEGIES Effecting behavior change is always a difficult task to accomplish in injury prevention. As the Haddon matrix suggests, a multifaceted approach is necessary when designing effective injury prevention programs. It is important to understand the injury problem, associated risk factors, and the target population. The most successful prevention strategies are those that combine comprehensive methods and models. Most prevention models employ a variety of methods, often referred to as the three “Es”: education, engineering (modification of the environment), and enforcement (policy change).8 The fourth “E” that is often incorporated into prevention strategies is encouragement (e.g., economic incentives). Education is the most common prevention strategy employed, with the goal of affecting behavioral modification. It is hoped that with understanding of risk will come behavior change. However, increased knowledge through education does not always translate readily into a behavior change. For example, although an adult may realize that using a
crosswalk is the safest way to cross a busy street, crossing midblock is much quicker. This strategy incorrectly assumes the public will voluntarily and preferentially adopt a safe behavior. Enforcement (policy change) uses the force of the law to increase compliance and change behavior. This strategy is most effective when combined with education. There are many studies highlighting the positive impact that laws can have on injury prevention. As an example, the use of safety belts in motor vehicles increased by 15% after law enforcement agencies began issuing traffic citations.9 Government regulations and industries have done much to offset poor behavior choices in order to save lives. Safety features have been introduced throughout our everyday lives, from air bags and crumple zones in cars to child-resistant caps on medicines to fire-resistant clothing for children. Other legislation requires an active response from the end user, such as the installation of smoke alarms in the home or wearing a bicycle helmet. Legislation is generally regarded as one of the most powerful tools in injury prevention, and has affected a positive behavior change. Engineering (modification of the environment or product) is often used because this approach eliminates the need to change behavior in the individual. Effective engineering
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modifications for pedestrians include the introduction of sidewalks, barriers, and pedestrian signs. Engineering is often the most expensive strategy and at times even cost prohibitive. To decrease the likelihood of crossing midblock, a roadway barrier can be put in place to eliminate crossing midblock. The cost to a governmental agency or to a product manufacturer must be weighed against the potential societal benefit in determining efficacy of such prevention strategies.
SELECTED INJURY PREVENTION INITIATIVES Child Passenger Safety One of the most dramatic examples of the efficacy of injury prevention strategies is that of child passenger safety efforts (Figure 17-2). Motor vehicle crashes are the leading cause of death for ages 3 to 14 in the United States. However, research has shown that lap/shoulder seat belts and child safety seats, when used, save lives. Vehicle seat belts reduce the risk of fatal injury to front seat occupants of passenger cars by 45%, while child safety seats reduce fatal injury by 71% for infants and 54% for toddlers in passenger cars.10 The challenge is to make sure every passenger (regardless of age) is properly secured, every single ride. Studies suggest that efforts to reduce injury risk to children in a motor vehicle should promote use of child restraint systems through a combination of education, distribution programs, and appropriate laws governing use.11 Pierce and colleagues illustrate the importance of providing ongoing education combined with legislation and enforcement during a booster seat giveaway program in a Head Start program.12 The program measured the knowledge level of Head Start providers, parents, and students regarding booster seats. It combined education along with the provision of age-appropriate restraints and direct observation following the program. The project was successful in increasing the use of booster seats, although the majority (66%), while restrained, were done so suboptimally. Despite the demonstrated efficacy, child passenger restraint misuse and inappropriate use is common (>72%) and offers additional room for prevention efforts.13
In a systematic review of five different interventions designed to increase child safety seat use, Zaza and colleagues demonstrated that the most successful interventions were those that did not stand alone but rather were multifactorial.14 There was insufficient evidence for education-only programs. However, they identified strong evidence for effectiveness of child safety seat laws and distribution plus education programs. Also, community-wide information plus enhanced enforcement campaigns and incentive plus education programs had sufficient evidence of effectiveness.14 Based on these findings, as well as other evidence-based programs designed to reduce injury risk to children in motor vehicles, efforts should promote use of child restraint systems through improved laws combined with education and disbursement programs. Fire Safety Because the causes for residential fires are multifactorial, efforts to prevent fire-related morbidity and mortality should also consider multiple approaches. A smoke alarm is arguably the single most important piece of safety equipment to prevent fire-related morbidity and mortality. The risk of dying in a residential fire is cut in half when a functioning smoke alarm is present.15 Two efforts thought to be essential in reducing firerelated injury are the use of smoke alarms and identifying an escape plan for use in the event of a fire; both require action on the part of the resident. Previous research has demonstrated that the most effective and cost-efficient method to distribute smoke alarms is through direct home visits.16 Harvey and colleagues have proven that direct installation is much more effective than voucher distribution for a free fire alarm.17 There are other passive preventive techniques that are also as effective, such as flame-resistant clothing for children. Half of the persons who start reported fires by playing are 5 years of age and younger. Most child-playing home fires are started with matches or lighters.18 Legislatively, there are a variety of laws and standards that are designed to save lives, such as the requirement of smoke alarms on every level of the home and in every bedroom, sprinkler systems in some dwellings, and cigarette lighter standards. The U.S. Consumer Product
9
8
Crude mortality (per 100,000)
7
6
5
4
3
2
1
0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year
FIGURE 17-2 Decline in crude mortality rate for child occupants (age 0 to 19 years) in motor vehicle crashes for the period 1981 to 2007. (Data from National Center for Injury Prevention and Control.1)
CHAPTER 17
Safety Commission has issued a safety standard for cigarette lighters, which requires that disposable cigarette lighters be resistant to operation by children younger than the age of 5. In an analysis of this standard, it has been proven to reduce fire injuries, deaths, and property loss by children playing with cigarette lighters and can be expected to prevent additional fire losses in subsequent years.19 Some states are now enacting novelty cigarette lighter legislation to protect against lighters that are being mistaken for toys. Continued efforts are necessary to maximize prevention efforts. Firearm Storage Firearm-related injuries have posed significant prevention challenges. With one of the highest case fatality rates of all injury mechanisms, prevention of the initial exposure is vital. However, with more than 250,000,000 firearms in circulation in the United States, that task is daunting.20 The presence of a firearm in the home has been shown to increase the risk of unintentional firearm death (3.7-fold), suicide (3.4-fold), and homicide death (1.4-fold) versus households without firearms.21,22 The effectiveness of educational programs geared to children and firearm use have been questioned. In a classical behavioral study, Hardy and colleagues demonstrated persistence of curious behaviors among children who encountered a firearm despite having undergone prior gun safety education.23 Efforts to limit access to firearms by children have also had mixed results. A survey of parents visiting pediatrics practices revealed unsafe gun storage practices in 70% (gun unlocked 61%, gun loaded 15%, gun unlocked/ loaded 7%, gun locked/unloaded 30%) of the homes.24 The outcome of strategies geared toward parental firearm storage behaviors was summarized by McGee and colleagues, who did note an improvement in reported storage practices following counseling and education.25 However, evidence to demonstrate a reduction in injury related to improved safety measures is limited. Grossman and colleagues were able to demonstrate that several factors were associated with a protective effect when examining the risk of youth unintentional and suicide firearm injuries: keeping a gun locked and unloaded, and storing ammunition locked and in a separate location.26 Although firearm injury mitigation strategies have been of uncertain success, continued efforts are warranted given the ongoing risks that exist. Helmet Use Bicycle riding is enjoyed by millions of children and adults every day. Learning to master the technical challenges of a two-wheeled bicycle is a rite of passage for most children. However, because of its popularity and widespread use, bicycle riding is also a common source of injury in the pediatric population. Helmet use has long been advocated to mitigate the risk of serious head injury. Helmet use has been demonstrated to reduce head injury of all types, serious head injury, and facial injury related to bicycle collisions.27–29 Both educational initiatives as well as legislative mandates have been used to encourage routine helmet use among pediatric riders. Educational programs promoting use of bicycle helmets have been shown to increase their routine use. Rivara and colleagues demonstrated an increase in helmet use from 5.5% baseline to 40.2% after introduction of a communitywide bicycle helmet campaign.30 At the same time, the rate of bicycle-related head injuries decreased by 67%. The effects
INJURY PREVENTION
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of bicycle helmet use campaigns seem to be most effective in the younger-aged children and in the higher socioeconomic status populations.31,32 Parkin and colleagues demonstrated the efficacy of legislative approaches to improving helmet use in children, with a significantly increased observed rate of use from 46% to 68%.33 Interestingly, the least impact of the legislation was noted in the highest socioeconomic groups. However, these groups also had the highest rates of baseline use, suggesting perhaps the efficacy of prior educational campaigns. A side benefit of mandatory laws may be heightened awareness of riders in areas not covered by helmet use laws. For example, in a Canadian study, the risk of bicycle-related head injury declined 45% in areas with mandatory use but also by 27% in areas without mandated use.34 Although a less common issue in the pediatric population, motorcycle helmet use has similarly been shown to reduce the incidence of serious head injury and death related to motorcycle accidents. A Cochrane collaborative reported a reduction in mortality of 42% and serious head injury of 69%.35 Evidence was lacking regarding helmet use and risk of facial injuries. Mandatory motorcycle helmet use laws frequently are met with stiff opposition from riders, but such laws save lives and reduce serious head injuries.36 Pedestrian Injury Pedestrian injuries in children resulted in 573 deaths (2007) and more than 47,000 injuries (2009) in the United States.1 The burden of injury globally is far greater where pedestrians represent the largest category of child road traffic casualties.37 A Cochrane Collaboration review demonstrated the effectiveness of pedestrian education programs geared toward children.38 Programs included direct education of the child by professionals as well as use of the parents as educators. An improvement in knowledge was exhibited along with changes in baseline pedestrian behaviors, but a correlation with risk reduction was not possible. Most studies have been carried out in developed nations. As pedestrian injuries are increasing in developing nations along with an increase in motor vehicle use, effective prevention strategies are warranted. Somewhat paradoxically, most pedestrian injuries in children occur in optimal driving conditions (daylight hours, dry road conditions, no adverse weather conditions).39 The majority of child pedestrians struck were crossing the street at the time of injury, frequently obscured by an obstacle.39,40 Engineering modifications to vehicles offer tremendous hope. Improving sight lines, optimizing visualization of the area surrounding the vehicle (through mirror placement and use of rear-facing cameras), and design changes to mitigate energy transfer at common impact points (e.g., front bumper) may reduce the burden of injury.41 Efforts to change the environment, such as “traffic calming” techniques, have demonstrated efficacy.42,43 The calming measures might include the use of speed humps, lower posted speed limits, traffic circles, installation or enhancement of crosswalks, and use of crossing aids. Poisoning Drug overdose death rates in the United States have never been higher. Rates of unintended ingestions have increased roughly fivefold since 1990, a leading cause of death in the pediatric population.44 In addition, the Drug Abuse Warning Network (DAWN) reports the number of emergency
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department (ED) visits for legal drugs is now comparable to visits from illegal drugs.45 Most fatal poisonings in the United States are from drug misuse (i.e., overdose). Overdose may include attempts at self-harm (suicide), assault (intentional), and accidental ingestion (unintentional).44 Among children, ED visits for medication poisonings are most common in children less than 6 years of age.46 Emergency department visits for medication poisonings are twice as common as poisonings from other household products.47 One of the most effective injury prevention initiatives in poison prevention was the introduction of child-resistant packaging for aspirin and oral prescription medicine that went into effect in the early 1970s.48 For children, caustic agents such as household cleaners that are marked with clear warning labels are not the only items in the home that can be dangerous to children. Everyday items such as cleaning supplies and medicines can be poisonous as well and should be kept out of the reach of children. The national poison control hotline (800-222-1222) provides parents and practitioners with readily accessible information about the toxicity and treatments for specific ingestions.
Measuring Success (Programmatic Evaluation) ------------------------------------------------------------------------------------------------------------------------------------------------
Measuring the success of an injury prevention program or prevention initiative is imperative. There are many injury prevention programs in the community that appear to be effective. However, without adequate evaluation of the efforts, there is no way to verify if a program is actually achieving the goal of injury mitigation. The most important aspect of evaluation is an adequate measurement of the problem conducted before, during, and after the intervention. The evaluation process should be dynamic. Assessment is started early, immediately after a program idea is conceived, and should continue through the intervention phase until the program is complete, when one determines whether the program has met its overall goal. In some cases, evaluation may continue for years after the intervention is complete to assess the durability of the desired outcome. Evaluation is also critical to prove to funding agencies that their support is making a difference. A successful evaluation can also be used to strengthen funding proposals and to continue or replicate the program in other areas. A program that has rigorous, scientifically proven success is much more likely to receive continued funding. The same standards are necessary to publish the work in professional journals and disseminate prevention ideas to professionals in other communities. Evaluation has four essential stages that are intertwined throughout the planning and intervention phase of a program. These stages are formative, process, impact, and outcome evaluation.49 A well-designed formative evaluation will give the
TABLE 17-5 Selected Internet Resources for Injury Prevention The American Association of Poison Control Centers National Fire Protection Association Safe Kids Worldwide Centers for Disease Control and Prevention National Center for Injury Prevention and Control Consumer Product Safety Commission
www.aapcc.org www.nfpa.org www.safekids.org www.cdc.gov www.cdc.gov/ HomeandRecreationalSafety/ Poisoning/index.html www.cpsc.gov
program a better chance at success, along with elucidating areas of improvement. In the formative stage, a targeted issue is identified (e.g., bicycle helmet use to lessen head injury) and may include an assessment of existing resources and deficiencies. During this stage, it is important to identify barriers to success (e.g., age, access to target population, education). Inclusion of community stakeholders at this stage increases the likelihood of long-term success. Through process evaluation, the second stage, a plan is formulated to measure whether or not the program is reaching the desired audience. This stage typically requires documentation of the number of people reached during the educational or interventional program, for instance, the number of bicycle helmets distributed or the number of students taught bicycle safety. Such data will provide the foundation for sound assessment of the program. Impact evaluation is a measure of how well the program is progressing toward its goals. It is a measurement of knowledge, attitudes, and beliefs. This assessment may be through direct observation of a particular behavior, or perhaps though survey or questionnaire. Preintervention and postintervention data collection (e.g., observed bicycle helmet use) will provide insight regarding the success of a program. The final phase, outcome evaluation, measures whether or not the program met its goal of decreasing incidence of injury, morbidity, and/or mortality. Demonstrating long-term success (beyond the intervention stages) is ideal, but such study can be time consuming and resource intensive. However, demonstration of sustained injury reduction is likely to lead to dissemination of practices and ongoing funding. Injury is the leading cause of death and disability in the pediatric population. Although trauma systems have evolved to provide optimal care, prevention is the preferred approach. Prevention strategies should be tailored to the target population and studied to ensure efficacy. For additional Internetbased injury prevention resources, see Table 17-5. The complete reference list is available online at www. expertconsult.com.
CHAPTER 17
Injury Prevention Gina P. Duchossois and Michael L. Nance “If a disease were killing our children in the proportions that injuries are, people would be outraged and demand that this killer be stopped.” —C. Everett Koop
Injury presents the greatest threat to life of all diseases in the pediatric population. More children die each year from injury than all other causes combined.1 More than one in nine children will require medical attention for an injury each year. Many more children will be injured but not require or seek medical care (Fig. 17-1). The economic costs of injury are staggering. In addition to direct costs for care, there is the additional loss of future productivity as well as loss of productivity by parental caregivers who must provide for the injured child. For the year 2000, these costs were estimated to top $130 billion in total costs, with nearly $25 billion due to direct medical costs.2 The significance of the costs of injury become even more provocative when one considers the potential financial savings that can be realized from injury prevention strategies (Table 17-1). William Haddon, in the 1970s, reported his classic characterization scheme (the Haddon “matrix”) and approach to injury prevention.3 This system argued against the traditional idea that injury was an accident, leaving the burden of prevention on the individual. Rather, he suggested that injuries result from predictable events and thus offer an opportunity for
Prevention Priorities ------------------------------------------------------------------------------------------------------------------------------------------------
Injury prevention resources are finite. As such, priorities for these prevention efforts must be established. These priorities may vary depending on the individual, the community, or perhaps the nation interested in prevention. A variety of factors are integral to the decisions regarding how best to deploy these limited resources. At the individual level, one might favor efforts to minimize in-home injury and “child-proof” the surroundings. A community might work toward pedestrian safety efforts in neighborhoods in which such injuries have been predominant. Finally, a nation (e.g., the United States) might focus efforts to reduce motor vehicle–related injuries, the leading cause of injury death. Simply counting the number of deaths from a particular injury mechanism may not provide an accurate or adequate representation of the burden of injury (by mechanism) in the geographic area of study. For instance, an injury mechanism that is highly lethal (e.g., hanging) but infrequent may not be an optimal prevention target. Nor might efforts to reduce an injury that is common but usually of limited severity (e.g., assault) be the ideal strategy. An injury that is both common and severe would, in most settings, represent the ideal target for mitigation efforts. To help define such injuries, Haider and colleagues used an injury prevention priority score.5 This calculation takes into account both the frequency of an injury and the mean severity of an injury by mechanism. In a comparison of pediatric populations from two geographically distinct trauma centers, they noted differences in injury patterns. In the inner city, auto/pedestrian injuries achieved the highest priority score, while in the community center, motor vehicle–related injuries ranked highest. Wiebe and colleagues applied this methodology to a national trauma center population and demonstrated that motor vehicle–related injuries, falls, and firearm-related 255
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injuries, respectively, were the highest ranking injury mechanisms (Table 17-4).7 In addition, Wiebe and colleagues also created additional scores that take into account the relative mortality of an injury mechanism (mortality priority score), the cost of an injury (hospital cost priority score), and the years of productive life lost (years of productive life lost priority score) to further characterize the burden of a particular injury. As suggested by Haider in his original publication, the methodology is easily applied to individual populations, such as that of a trauma center or a county or a state, to help determine how best to deploy prevention
Deaths 16,937
Hospitalized 189,595
Emergency department 9,365,239
TABLE 17-3 Haddon Measures to Combat Injury and Their Application to Firearm Injury
Treated at home or do not seek care
FIGURE 17-1 Injury pyramid demonstrating fatal injuries, injuries requiring hospitalization, and injuries resulting in an emergency department visit for children age 0 to 19 years, 2007. (Data from National Center for Injury Prevention and Control.1)
TABLE17-1 Potential Financial Savings from Selected Injury Prevention Initiatives Expenditure of $1 Each on:
Savings ($)
Smoke alarms Child restraints Bicycle helmets Prevention counseling by pediatricians Poison control services Road safety improvements
65 29 29 10 7 3
From Peden M, OyegbiteK, Ozanne-Smith J, et al: World report on child injury prevention. Geneva, Switzerland, World Health Organization, 2004. Available at http://www.who.int/violence_injury_prevention/child/injury/ world_report/en/index.html. Accessed November 12, 2010.
Haddon Countermeasure
As Applied to Firearm Injury Prevention
Prevent the creation of the hazard in the first place Reduce the amount of the hazard brought into being Prevent the release of the hazard that already exists Modify the release of the hazard that already exists Separate, in time and space, the hazard and that which is to be protected Separate, by material barrier, the hazard and that which is to be protected Modify the relevant basic qualities of the hazard Make that to be protected more resistant to damage from the hazard Counter damage already done by the hazard
Eliminate handguns
Stabilize, repair, and rehabilitate the object of the hazard
Limit the number of handguns allowed to be sold or purchased Install locks on handguns Eliminate automatic handguns Store handguns only at gun clubs rather than at home Keep guns in locked containers
Personalize guns so they can be fired only by the owner Create and market bullet-proof garments Provide good access to emergency care in the prehospital period Provide high-quality trauma care in hospitals
TABLE 17-2 Haddon Matrix Applied to Motor Vehicle Crashes in Children Child Factors
Vehicle and Safety Equipment
Physical Environment
Socioeconomic Environment
Pre-event
Age; gender; lack of supervision; risk-taking; impulsive behavior; disobedience; lack of police enforcement
Lack of roadworthiness of vehicle; poor lighting; poor state of brakes; speeding; overloading
Event
Size and physical development of child; lack of equipment to protect occupants, or equipment improperly used; underlying conditions in child Child’s lack of resilience; child’s general condition; lack of access to appropriate health care; postinjury complications
Child restraints and seat belts not fitted or incorrectly used; bicycle and motorcycle helmets not used; poor design of vehicle for protection in crashes; no rollover protection Difficult access to victim; lack of trained health care and rescue workers
Poor road design; lack of public transport; no enforcement of speed limits; no safety barriers; lack of alcohol laws; poor infrastructure for pedestrian safety Roadside objects such as trees and poles
Poverty; single-parent family; large family size; poor maternal education; lack of awareness of risks among caregivers, childcare providers, and educators Lack of safety culture in the car and on the road
Lack of availability of adequate pre-hospital care, acute care and rehabilitation
Lack of culture of supporting injured people; no first aid given at scene
Post-event
From Peden M, Oyegbite K, Ozanne-Smith J, et al: World report on child injury prevention. Geneva, Switzerland, World Health Organization, 2004. Available at http://www.who.int/violence_injury_prevention/child/injury/world_report/en/index.html. Accessed November 12, 2010.
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TABLE 17-4 Incidence and Characteristics of 13 Injury Mechanisms Presenting to United States Trauma Centers, 2000-2004, and Priority Scores and Priority Rankings by Injury Mechanism Mechanism
Incidence and Characteristics
Priority Scores and Rankings Mortality
Motor vehicle traffic Suffocation Firearm Fall Drowning/ submersion Pedestrian, other Transport, other Fire/burn Struck by, against Cut/pierce Machinery Poisoning Pedal cyclist, other
N
Median Age (Years)
Median ISS
Median Charges
Median YPLL
378,029
32
9
$15,941
37
1,314 53,146 237,500 945
28 26 53 20
1 9 9 4
$12,754 $14,484 $12,922 $10,777
3,100
32
9
45,151
29
17,511 61,962 40,574 12,221 1,041 13,934
Mortality (%)
Injury Severity
Hospital Charges
Rank
YPLL PS{
Rank
74.0
1
74.6
1
12 3 2 10
48.5 54.4 61.1 44.9
6 4 2 10
53.3 57.4 42.9 59.4
4 3 11 2
53.0
5
54.4
3
44.3
9
7
55.1
4
53.5
5
51.2
5
44.4 44.1
8 9
41.2 48.8
11 6
39.6 47.3
12 8
35.5 48.2
13 7
43.0 41.0 41.0 40.1
10 11 12 13
45.9 44.5 38.5 48.2
8 9 13 7
46.4 48.5 34.7 42.8
9 7 13 11
51.8 41.2 45.7 43.6
6 12 8 10
Mort PS}
Rank
IPPS*
Rank
5.0
69.7
1
72.0
1
48 48 10 56
23.0 16.2 3.5 16.5
63.4 59.5 58.4 56.2
2 3 4 5
38.5 55.5 64.9 43.9
$15,936
36
5.9
44.8
6
9
$14,240
42
2.9
44.5
28 30
2 5
$7,412 $10,367
23 35
4.6 1.5
31 40 32 17
4 4 1 6
$10,477 $12,442 $5,201 $9,277
42 31 38 34
1.9 1.8 2.5 0.9
Charge PS{
Years of Life Lost
From Wiebe DJ, Nance ML, Branas CC: Determining objective injury prevention strategies. Inj Prev 2005;12:347-350. *Injury prevention priority score. { Charge priority score. { Years potential life lost priority score. } Mortality priority score. Note: data based on trauma centers participating in the National Trauma Data Bank surveillance system. ISS, injury severity score.
resources. Using data to better understand the scope of the problem is essential to designing effective prevention strategies.
INJURY PREVENTION DESIGN STRATEGIES Effecting behavior change is always a difficult task to accomplish in injury prevention. As the Haddon matrix suggests, a multifaceted approach is necessary when designing effective injury prevention programs. It is important to understand the injury problem, associated risk factors, and the target population. The most successful prevention strategies are those that combine comprehensive methods and models. Most prevention models employ a variety of methods, often referred to as the three “Es”: education, engineering (modification of the environment), and enforcement (policy change).8 The fourth “E” that is often incorporated into prevention strategies is encouragement (e.g., economic incentives). Education is the most common prevention strategy employed, with the goal of affecting behavioral modification. It is hoped that with understanding of risk will come behavior change. However, increased knowledge through education does not always translate readily into a behavior change. For example, although an adult may realize that using a
crosswalk is the safest way to cross a busy street, crossing midblock is much quicker. This strategy incorrectly assumes the public will voluntarily and preferentially adopt a safe behavior. Enforcement (policy change) uses the force of the law to increase compliance and change behavior. This strategy is most effective when combined with education. There are many studies highlighting the positive impact that laws can have on injury prevention. As an example, the use of safety belts in motor vehicles increased by 15% after law enforcement agencies began issuing traffic citations.9 Government regulations and industries have done much to offset poor behavior choices in order to save lives. Safety features have been introduced throughout our everyday lives, from air bags and crumple zones in cars to child-resistant caps on medicines to fire-resistant clothing for children. Other legislation requires an active response from the end user, such as the installation of smoke alarms in the home or wearing a bicycle helmet. Legislation is generally regarded as one of the most powerful tools in injury prevention, and has affected a positive behavior change. Engineering (modification of the environment or product) is often used because this approach eliminates the need to change behavior in the individual. Effective engineering
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modifications for pedestrians include the introduction of sidewalks, barriers, and pedestrian signs. Engineering is often the most expensive strategy and at times even cost prohibitive. To decrease the likelihood of crossing midblock, a roadway barrier can be put in place to eliminate crossing midblock. The cost to a governmental agency or to a product manufacturer must be weighed against the potential societal benefit in determining efficacy of such prevention strategies.
SELECTED INJURY PREVENTION INITIATIVES Child Passenger Safety One of the most dramatic examples of the efficacy of injury prevention strategies is that of child passenger safety efforts (Figure 17-2). Motor vehicle crashes are the leading cause of death for ages 3 to 14 in the United States. However, research has shown that lap/shoulder seat belts and child safety seats, when used, save lives. Vehicle seat belts reduce the risk of fatal injury to front seat occupants of passenger cars by 45%, while child safety seats reduce fatal injury by 71% for infants and 54% for toddlers in passenger cars.10 The challenge is to make sure every passenger (regardless of age) is properly secured, every single ride. Studies suggest that efforts to reduce injury risk to children in a motor vehicle should promote use of child restraint systems through a combination of education, distribution programs, and appropriate laws governing use.11 Pierce and colleagues illustrate the importance of providing ongoing education combined with legislation and enforcement during a booster seat giveaway program in a Head Start program.12 The program measured the knowledge level of Head Start providers, parents, and students regarding booster seats. It combined education along with the provision of age-appropriate restraints and direct observation following the program. The project was successful in increasing the use of booster seats, although the majority (66%), while restrained, were done so suboptimally. Despite the demonstrated efficacy, child passenger restraint misuse and inappropriate use is common (>72%) and offers additional room for prevention efforts.13
In a systematic review of five different interventions designed to increase child safety seat use, Zaza and colleagues demonstrated that the most successful interventions were those that did not stand alone but rather were multifactorial.14 There was insufficient evidence for education-only programs. However, they identified strong evidence for effectiveness of child safety seat laws and distribution plus education programs. Also, community-wide information plus enhanced enforcement campaigns and incentive plus education programs had sufficient evidence of effectiveness.14 Based on these findings, as well as other evidence-based programs designed to reduce injury risk to children in motor vehicles, efforts should promote use of child restraint systems through improved laws combined with education and disbursement programs. Fire Safety Because the causes for residential fires are multifactorial, efforts to prevent fire-related morbidity and mortality should also consider multiple approaches. A smoke alarm is arguably the single most important piece of safety equipment to prevent fire-related morbidity and mortality. The risk of dying in a residential fire is cut in half when a functioning smoke alarm is present.15 Two efforts thought to be essential in reducing firerelated injury are the use of smoke alarms and identifying an escape plan for use in the event of a fire; both require action on the part of the resident. Previous research has demonstrated that the most effective and cost-efficient method to distribute smoke alarms is through direct home visits.16 Harvey and colleagues have proven that direct installation is much more effective than voucher distribution for a free fire alarm.17 There are other passive preventive techniques that are also as effective, such as flame-resistant clothing for children. Half of the persons who start reported fires by playing are 5 years of age and younger. Most child-playing home fires are started with matches or lighters.18 Legislatively, there are a variety of laws and standards that are designed to save lives, such as the requirement of smoke alarms on every level of the home and in every bedroom, sprinkler systems in some dwellings, and cigarette lighter standards. The U.S. Consumer Product
9
8
Crude mortality (per 100,000)
7
6
5
4
3
2
1
0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year
FIGURE 17-2 Decline in crude mortality rate for child occupants (age 0 to 19 years) in motor vehicle crashes for the period 1981 to 2007. (Data from National Center for Injury Prevention and Control.1)
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Safety Commission has issued a safety standard for cigarette lighters, which requires that disposable cigarette lighters be resistant to operation by children younger than the age of 5. In an analysis of this standard, it has been proven to reduce fire injuries, deaths, and property loss by children playing with cigarette lighters and can be expected to prevent additional fire losses in subsequent years.19 Some states are now enacting novelty cigarette lighter legislation to protect against lighters that are being mistaken for toys. Continued efforts are necessary to maximize prevention efforts. Firearm Storage Firearm-related injuries have posed significant prevention challenges. With one of the highest case fatality rates of all injury mechanisms, prevention of the initial exposure is vital. However, with more than 250,000,000 firearms in circulation in the United States, that task is daunting.20 The presence of a firearm in the home has been shown to increase the risk of unintentional firearm death (3.7-fold), suicide (3.4-fold), and homicide death (1.4-fold) versus households without firearms.21,22 The effectiveness of educational programs geared to children and firearm use have been questioned. In a classical behavioral study, Hardy and colleagues demonstrated persistence of curious behaviors among children who encountered a firearm despite having undergone prior gun safety education.23 Efforts to limit access to firearms by children have also had mixed results. A survey of parents visiting pediatrics practices revealed unsafe gun storage practices in 70% (gun unlocked 61%, gun loaded 15%, gun unlocked/ loaded 7%, gun locked/unloaded 30%) of the homes.24 The outcome of strategies geared toward parental firearm storage behaviors was summarized by McGee and colleagues, who did note an improvement in reported storage practices following counseling and education.25 However, evidence to demonstrate a reduction in injury related to improved safety measures is limited. Grossman and colleagues were able to demonstrate that several factors were associated with a protective effect when examining the risk of youth unintentional and suicide firearm injuries: keeping a gun locked and unloaded, and storing ammunition locked and in a separate location.26 Although firearm injury mitigation strategies have been of uncertain success, continued efforts are warranted given the ongoing risks that exist. Helmet Use Bicycle riding is enjoyed by millions of children and adults every day. Learning to master the technical challenges of a two-wheeled bicycle is a rite of passage for most children. However, because of its popularity and widespread use, bicycle riding is also a common source of injury in the pediatric population. Helmet use has long been advocated to mitigate the risk of serious head injury. Helmet use has been demonstrated to reduce head injury of all types, serious head injury, and facial injury related to bicycle collisions.27–29 Both educational initiatives as well as legislative mandates have been used to encourage routine helmet use among pediatric riders. Educational programs promoting use of bicycle helmets have been shown to increase their routine use. Rivara and colleagues demonstrated an increase in helmet use from 5.5% baseline to 40.2% after introduction of a communitywide bicycle helmet campaign.30 At the same time, the rate of bicycle-related head injuries decreased by 67%. The effects
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of bicycle helmet use campaigns seem to be most effective in the younger-aged children and in the higher socioeconomic status populations.31,32 Parkin and colleagues demonstrated the efficacy of legislative approaches to improving helmet use in children, with a significantly increased observed rate of use from 46% to 68%.33 Interestingly, the least impact of the legislation was noted in the highest socioeconomic groups. However, these groups also had the highest rates of baseline use, suggesting perhaps the efficacy of prior educational campaigns. A side benefit of mandatory laws may be heightened awareness of riders in areas not covered by helmet use laws. For example, in a Canadian study, the risk of bicycle-related head injury declined 45% in areas with mandatory use but also by 27% in areas without mandated use.34 Although a less common issue in the pediatric population, motorcycle helmet use has similarly been shown to reduce the incidence of serious head injury and death related to motorcycle accidents. A Cochrane collaborative reported a reduction in mortality of 42% and serious head injury of 69%.35 Evidence was lacking regarding helmet use and risk of facial injuries. Mandatory motorcycle helmet use laws frequently are met with stiff opposition from riders, but such laws save lives and reduce serious head injuries.36 Pedestrian Injury Pedestrian injuries in children resulted in 573 deaths (2007) and more than 47,000 injuries (2009) in the United States.1 The burden of injury globally is far greater where pedestrians represent the largest category of child road traffic casualties.37 A Cochrane Collaboration review demonstrated the effectiveness of pedestrian education programs geared toward children.38 Programs included direct education of the child by professionals as well as use of the parents as educators. An improvement in knowledge was exhibited along with changes in baseline pedestrian behaviors, but a correlation with risk reduction was not possible. Most studies have been carried out in developed nations. As pedestrian injuries are increasing in developing nations along with an increase in motor vehicle use, effective prevention strategies are warranted. Somewhat paradoxically, most pedestrian injuries in children occur in optimal driving conditions (daylight hours, dry road conditions, no adverse weather conditions).39 The majority of child pedestrians struck were crossing the street at the time of injury, frequently obscured by an obstacle.39,40 Engineering modifications to vehicles offer tremendous hope. Improving sight lines, optimizing visualization of the area surrounding the vehicle (through mirror placement and use of rear-facing cameras), and design changes to mitigate energy transfer at common impact points (e.g., front bumper) may reduce the burden of injury.41 Efforts to change the environment, such as “traffic calming” techniques, have demonstrated efficacy.42,43 The calming measures might include the use of speed humps, lower posted speed limits, traffic circles, installation or enhancement of crosswalks, and use of crossing aids. Poisoning Drug overdose death rates in the United States have never been higher. Rates of unintended ingestions have increased roughly fivefold since 1990, a leading cause of death in the pediatric population.44 In addition, the Drug Abuse Warning Network (DAWN) reports the number of emergency
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department (ED) visits for legal drugs is now comparable to visits from illegal drugs.45 Most fatal poisonings in the United States are from drug misuse (i.e., overdose). Overdose may include attempts at self-harm (suicide), assault (intentional), and accidental ingestion (unintentional).44 Among children, ED visits for medication poisonings are most common in children less than 6 years of age.46 Emergency department visits for medication poisonings are twice as common as poisonings from other household products.47 One of the most effective injury prevention initiatives in poison prevention was the introduction of child-resistant packaging for aspirin and oral prescription medicine that went into effect in the early 1970s.48 For children, caustic agents such as household cleaners that are marked with clear warning labels are not the only items in the home that can be dangerous to children. Everyday items such as cleaning supplies and medicines can be poisonous as well and should be kept out of the reach of children. The national poison control hotline (800-222-1222) provides parents and practitioners with readily accessible information about the toxicity and treatments for specific ingestions.
Measuring Success (Programmatic Evaluation) ------------------------------------------------------------------------------------------------------------------------------------------------
Measuring the success of an injury prevention program or prevention initiative is imperative. There are many injury prevention programs in the community that appear to be effective. However, without adequate evaluation of the efforts, there is no way to verify if a program is actually achieving the goal of injury mitigation. The most important aspect of evaluation is an adequate measurement of the problem conducted before, during, and after the intervention. The evaluation process should be dynamic. Assessment is started early, immediately after a program idea is conceived, and should continue through the intervention phase until the program is complete, when one determines whether the program has met its overall goal. In some cases, evaluation may continue for years after the intervention is complete to assess the durability of the desired outcome. Evaluation is also critical to prove to funding agencies that their support is making a difference. A successful evaluation can also be used to strengthen funding proposals and to continue or replicate the program in other areas. A program that has rigorous, scientifically proven success is much more likely to receive continued funding. The same standards are necessary to publish the work in professional journals and disseminate prevention ideas to professionals in other communities. Evaluation has four essential stages that are intertwined throughout the planning and intervention phase of a program. These stages are formative, process, impact, and outcome evaluation.49 A well-designed formative evaluation will give the
TABLE 17-5 Selected Internet Resources for Injury Prevention The American Association of Poison Control Centers National Fire Protection Association Safe Kids Worldwide Centers for Disease Control and Prevention National Center for Injury Prevention and Control Consumer Product Safety Commission
www.aapcc.org www.nfpa.org www.safekids.org www.cdc.gov www.cdc.gov/ HomeandRecreationalSafety/ Poisoning/index.html www.cpsc.gov
program a better chance at success, along with elucidating areas of improvement. In the formative stage, a targeted issue is identified (e.g., bicycle helmet use to lessen head injury) and may include an assessment of existing resources and deficiencies. During this stage, it is important to identify barriers to success (e.g., age, access to target population, education). Inclusion of community stakeholders at this stage increases the likelihood of long-term success. Through process evaluation, the second stage, a plan is formulated to measure whether or not the program is reaching the desired audience. This stage typically requires documentation of the number of people reached during the educational or interventional program, for instance, the number of bicycle helmets distributed or the number of students taught bicycle safety. Such data will provide the foundation for sound assessment of the program. Impact evaluation is a measure of how well the program is progressing toward its goals. It is a measurement of knowledge, attitudes, and beliefs. This assessment may be through direct observation of a particular behavior, or perhaps though survey or questionnaire. Preintervention and postintervention data collection (e.g., observed bicycle helmet use) will provide insight regarding the success of a program. The final phase, outcome evaluation, measures whether or not the program met its goal of decreasing incidence of injury, morbidity, and/or mortality. Demonstrating long-term success (beyond the intervention stages) is ideal, but such study can be time consuming and resource intensive. However, demonstration of sustained injury reduction is likely to lead to dissemination of practices and ongoing funding. Injury is the leading cause of death and disability in the pediatric population. Although trauma systems have evolved to provide optimal care, prevention is the preferred approach. Prevention strategies should be tailored to the target population and studied to ensure efficacy. For additional Internetbased injury prevention resources, see Table 17-5. The complete reference list is available online at www. expertconsult.com.