The use of childhood injury surveillance within a general accident and emergency department

Accident and Emergency Nursing ( 2002) 10, 170–176 ° C 2002 Elsevier Science Ltd. All rights reserved. doi:10.1054/aaen.2002.0346, available online at http://www.idealibrary.com on

The use of childhood injury surveillance within a general accident and emergency department V. Ness, R. Hoskins, A. Robb

The prevention of accidental injury is a government priority in the United Kingdom. Following the recent Government White Paper, towards a Healthier Scotland (Scottish Office 1999), the issue of poverty and inequalities in health has come to prominence. This study, at Glasgow Royal Infirmary, looked at the socio-economic context of injuries and aimed to identify if there was a relationship between the frequency of injuries and the deprivation status of the patient. This paper examines one method of data collection, the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) which is currently being used at the local children’s hospital. The practical difficulties of collecting this data within a busy, general Accident and Emergency (A&E) department are examined. The questionnaire uses narrative and sequence text to provide descriptive information relating to the injury and the events leading up to it. Findings demonstrated that a large percentage of children’s injuries were treated at the child’s local general hospital. Differences between the two hospitals were also found relating to the children’s ages and where the injuries took place. Results also showed that the socio-economic distribution of childhood accidents is still a major problem in this city. Therefore, this study recommends that injury data should be collected at all A&E departments to establish an accurate picture of the pattern of injuries within the C 2002 Elsevier Science Ltd. All rights reserved. city. ° Valerie Ness MN, RN, Robert Hoskins BASS, MSc, RMN, RN, Alna Robb MN, RGN, RM, RNT Correspondence to: Valerie Ness, Accident and Emergency Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, UK Manuscript accepted: 20 January 2002

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Introduction National background Unintentional injury in children is a major public health problem. It is the leading cause of death among children and young people in the industrialised world and is a major contributor to disability (WHO 1995). However, injury mortality in children is the tip of the iceberg. For example, injuries to children account for around 7% of NHS expenditure each year, which amounted to over £2 billion in 1994–1995 (RoSPA 1997). Injuries are also the most commonly presenting complaint in children

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attending the A&E department in the UK (DTI 1999). In 1997–1998, 13 062 children (aged 0–14 years) were admitted to hospitals in Scotland due to injuries (ISD Scotland 1998). There have been many studies into health inequalities and accidents starting with the Black Report (Black 1980) which showed that children in social class V were five times more likely to die from an accident than children in social class I. Nearly 20 years later, The Acheson Report (Acheson 1998) also demonstrated inequalities by socio-economic group and a study by Roberts et al. (1998) demonstrated that social class gradients for

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The use of childhood injury surveillance

injuries between rich and poor have actually widened over the last decade.

Aim of this study

Methods of injury surveillance At present, methods of injury surveillance range from mortality data and international classification of diseases coding (ICD-9) to Home Accident Surveillance System/Leisure Accident Surveillance System (HASS/LASS) (DTI 1999) and road traffic accident and fire statistics. Various qualitative and retrospective, quantitative studies have also been carried out using questionnaires, one of which, The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) was used in this study. CHIRPP is a computerised system that collects information on children presenting to Canadian A&E departments with injuries or ingestions. CHIRPP was devised in 1990 by the Canadian government, based on the software of the Australian National Injury Surveillance and Prevention Project and began being used in 10 children’s hospitals in Canada (CHIRPP News 1998). In April 1994, a pilot study began at the Royal Hospital for Sick Children in Glasgow to investigate whether CHIRPP could be used in the United Kingdom (Stone & Doriaswamy 1996). The CHIRPP surveillance at this hospital is now well established and providing excellent data.

The role of A and E departments So what is done with this data and is injury prevention the role of the A&E department? In the literature, the role of the A&E department is described as giving out preventative advice, discharge advice and, perhaps more appropriately in a holistic way, as taking part in data collection, campaigns and liaising with others. A&E nurses have been shown to recognise that they have a role in health promotion but are undecided as to its extent (Green & Dale 1990). The RCN (1990) working party recommended that children and families should be educated in accident prevention. Other studies have shown the need for parental help in the form of first aid teaching and information on safety issues (Coombes 1991; Jeffs et al. 1996).

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To implement an injury surveillance system within a general A&E department to investigate children’s injuries and their causes and to form a baseline for future research and research based practice. Questions 1. Can the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) be used successfully in a general A&E department? 2. What are the emerging patterns of childhood injuries in this area? 3. Does socio-economic status have an effect on the data? 4. Is injury prevention part of the role of the A&E nurse?

Methodology A quantitative, descriptive, survey design was chosen for the implementation of this research; it was prospective and replicative in nature. This method was chosen in order to collect a wide range of data from a large, representative sample. The sample consisted of all children aged 13 years and under who presented at Glasgow Royal Infirmary A&E department with an injury or ingestion over a three month period in 1999) (n = 790). The following research hypothesis was tested: “children from deprived areas are more likely to have more accidents than children from affluent areas.”

In order to test this hypothesis the questionnaire used in this study included demographic details such as postal code. Similar postcodes were then grouped together and the most common ones were given a Carstairs score which gauges material disadvantage (Carstairs & Morris 1991). The data collection tool used was the CHIRPP questionnaire, a proven reliable and valid tool. The questionnaire included demographic details, accident prevention methods used, narrative text and sequence text which provided details of the events leading up

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to the injury. This latter information highlighted any risk behaviour and circumstances which might have caused the accident and could, therefore, be useful in targeting injury prevention programmes.

The study Over a 3-month period, CHIRPP questionnaires were given out to parents or accompanying adults of the study sample children aged 13 years and under, on arrival at triage by the triage nurse (n = 790). They were then asked to complete one side of the questionnaire giving details of the child’s injury and then return the questionnaire to the nurse for filing in the child’s notes. The attending doctor or Nurse Practitioner completed the reverse side of the questionnaire which contained questions on the nature and intent of the injury, the body part affected and what happened to the patient. Questionnaires were then placed in the designated box and were uplifted by the researcher on a twice-weekly basis. Any missing data from the questionnaire was gained from the patient’s attendance records. All questionnaire demographic data and sequence and narrative text was coded into compatible symbols and analysed using a Microsoft Access statistical package. A two week long pilot study identified some minor problems with the filing of the questionnaires and lack of support on night shift. These problems were addressed by involving reception staff and by improving communication between shifts.

Results A total target population of 1493 children aged 13 years and under, attended the A&E department during this three-month period with an injury or ingestion. The actual number of sample questionnaires completed during this time was 790, which made a pick-up rate of 53%. This rate was improving over time as the study became accepted as a part of the care of the injured child. Other A&E studies have shown that the longer the period of data collection, the better the capture rate (Stone & Doriaswamy 1996; CHIRPP News 1998) therefore, if the study were to continue a

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pick-up rate of nearer 90% would be expected by comparing rates with that of the local children’s hospital. Of the completed questionnaires, only four could not be used because they were outwith the age range or had not sustained an injury. The remainder were completed correctly and completely, confirming the questionnaire’s reliability and validity. 59% of the sample were boys and 41% were girls. This gender breakdown of boys sustaining more injuries than girls is a finding common to all the studies previously mentioned (Office of National Statistics 1997; HASS 1999). 66% of the children were over 5 years of age, with the greatest percentage (11%) aged 10 years old (See Fig. 1). 98% of the sample lived in Glasgow. All postcodes were given a Carstairs DEPCAT score (Carstairs & Morris 1991). This score is comprised of four indicators, male unemployment, no car, overcrowding and low social class. These are variables judged to represent material disadvantage and form a composite score which is then allocated a category ranging from 1, very high to 7, very low deprivation. The six most common postcodes all registered a number 7 on the Carstairs DEPCAT score, indicating the highest areas of deprivation (See Fig. 2). The most common injury when bodypart and type were combined was a facial laceration (n = 102) and the most common fracture was of the radius/ulna (n = 45) (See Table 1). These findings were similar to those of Burke and Thompson (1996) and were also similar to figures at the local children’s hospital. Owing to the large sample size and time constraints, only 10% of the study samples were coded to give further information regarding the breakdown of the injury and where and why it occurred (n = 79). This sample was selected by choosing every 10th questionnaire. The largest number of injuries took place in the child’s own garden, garage or yard, with the second most common location being a public play area. 72% of the injuries occurred outside which was expected as the study took place during the summer months (See Fig. 3). 91% of the sample were physically active when the injury took place. The accident most commonly occurred when the child moved into a dangerous position such as running out in front of a car or

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The use of childhood injury surveillance

Fig. 1

Fig. 2 This sample came from mainly the G33 (n = 166,21%), the G31 (n = 134,17%) and the G32 (n = 126,16%) postcode areas of the city as can be seen in the graph above. The six most common postcodes all score a number 7 on the Carstairs DEPCAT score, meaning areas of highest deprivation.

when something was moved into a dangerous position such as an object being thrown at the child. Again these figures were similar to those found by HASS/LASS (1999) although the terminology used when coding the results was different since this study used a different coding and statistics package. The results were similar to those gained from the local children’s hospital who also use CHIRPP to monitor injuries. The results

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showed that the general hospital used in the study saw just over half the number of children compared to the local children’s hospital. The major differences between the two sets of data were postcode area of residence and the age group attending A&E. For example, both hospitals saw children from their local area. The general hospital, however, saw a greater percentage of older children, whereas the children’s hospital dealt with a larger number

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Table 1 Face

Wrist

Finger

Skull

Ankle

Elbow

Knee

102

1

15

20

2

3

10

Fracture

2

45

16

15

1

Sprain

1

20

15

33

5

13

Bruise

50

1

5

25

1

3

5

Oedema

1

6

6

1

6

3

12

Abrasion

6

1

1

6

1

5

4

Bite

3

Burn

2

Puncture

3

Cut

6 2

3 1

1

Fig. 3

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The use of childhood injury surveillance

of under-fives. This is perhaps not surprising since it may be that the parents of very young children prefer to take them to a designated children’s hospital with a less threatening environment. The other main difference noted was that the general hospital saw a larger percentage of injuries occurring outside the home, which may be related to the age group of the children or to the safety of their external environment. These differences in results show that it is necessary to collect data from the entire city in order to obtain an accurate picture of the pattern of injuries. From such information, focused injury prevention interventions can be implemented and evaluated.

Limitations In this study the major limitation was the short time frame for data collection, as the study was only beginning to become established when it had to end. The pick-up rate of 53% could have been improved upon if the researcher had been involved on a full-time basis to remind staff to collect the data. The pick-up rate was particularly poor at night when the minor injuries side of the department was closed. This meant that most of the target population were seen at the major side of the department along with all other patients (such as medical and surgical conditions) and so more reminders were needed in order that staff remembered to hand out these questionnaires.

Conclusions and recommendations This study has demonstrated that injuries to children remain a major problem and childhood injury in particular remains strongly associated with poverty. General A&E departments treat a large number of children each year. The A&E department studied treats 7500 children aged 14 years and under every year, 80% of which attend with an injury. The literature showed that data collection provides a database of information for proactive monitoring of incidence, the identification of risk factors and the implementation and evaluation of injury prevention programmes (Stone 1996, Beattie 1996). From the data

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collected at this hospital it was concluded that differences existed with regard to the pattern of injuries between two areas of the city. The differences found were the ages of the children attending A&E, where the children came from and where their injuries took place. Therefore, data must be collected at all A&E departments to establish an accurate picture of injuries throughout the city and to identify problem areas. This study has indicated that collecting data on childhood injuries only at paediatric hospitals means that vital information regarding injuries occurring to children is lost. The research and literature (Morrison & Stone, 1998) recommends the collection of injury data within all A&E departments using a valid and reliable tool such as CHIRPP (Stone & Doriaswamy, 1996). Results also showed that the socio-economic distribution of childhood accidents is still a major problem in this city in relation to the number of injuries sustained and so provides the evidence required to make the issue of deprivation and unintentional injury a higher priority for policymakers. The findings of this study highighted other problem areas largely neglected by health promotion groups, such as the high percentage of injuries which occurred outwith the home. This finding would indicate that priority should be given to planning tailored injury prevention programmes, into the problem areas discovered, when carrying our local injury surveillance. The literature suggests the involvement of many different health professionals in child accident prevention, including the health visitor, the school teacher and the A&E nurse. This research proves that injury surveillance can be done successfully within a general A&E department, given time and staff cooperation and, therefore, recommends that the A&E department play a greater role in child injury prevention. The findings from this study have demonstrated that injury surveillance can be carried out successfully within a general A&E department and that given time and staff cooperation, the A&E department could play a greater role in child injury prevention. The findings endorse those of Morrison and Stone (1998), who suggested that not only should data collection be an integral part of the role of

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A&E department, but also that a universal method of data collection be used so that results may be generalised. It has been suggested that a national centre for injury prevention be established from where injury surveillance can be centred (Stone 1996). If a research strategy on child accident prevention were also in place then our understanding of the aetiology of injuries and the effects of interventions would be increased. Hence effective education and the processes which allow children of all backgrounds to lead a safe life could be established (McConnell 1997). Due to the wide diversity of responsibility for child injury prevention and the huge range of health promotion opportunities available, collaboration and networking between professionals must exist if prevention work is to be effective (Towner et al, 1993). Information gained from injury surveillance must be disseminated to the appropriate agencies and used to maximum benefit. Childhood injuries are a huge public health problem which can only be improved with a large multi-agency response. References Acheson D 1998 Independent Inquiry into Inequalities in Health Report HMSO: London Beattie TF 1996 An accident and emergency department based child accident surveillance system: is it possible? Journal of Accident and Emergency Medicine 13: 116–118 Black D 1980 Inequalities in Health. Report of a Research Working Party HMSO: London Burke W, Thompson R 1996 Childhood accident prevention: putting audit into practice Nursing Standard 10(46): 46–48 1998 CHIRPP News Canadian Hospitals Injury Reporting

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and Prevention Program Issue 15 Ottowa: Bureau of Chronic Disease Epidemiology (Health Canada) Carstairs V, Morris R 1991 Deprivation and Health in Scotland Aberdeen University Press: Aberdeen Coombes G 1991 You can’t watch them 24 hours a day CAPT: London DTI 1999 Department of Trade and Industry Home Accident Consumers Safety Unit 21st Annual Report 1997 Data DTI: London Green J, Dale J 1990 Health education and inappropriate use of accident and emergency departments: the views of accident and emergency nurses Health Education Journal 49(4) 157–161 Jeffs J, Taylor R, Sainsbury B, Pordage K 1996 Health alliances in child accident prevention Health Visitor 69(6) 234–235 ISD Scotland 1998 Scottish Health Statistics Scottish Office: Edinburgh McConnell D 1997 Health Promotion for A and E practice Emergency Nurse 5(7) 19–22 Morrison A, Stone DH 1998 Injury Surveillance in accident and emergency departments: to sample or not to sample? Injury Prevention 4 50–53 Office for National Statistics 1997 Mortality statistics: childhood, infant and perinatal Series DH3 No28 HMSO: London Roberts I, Guiseppi C, Ward H 1998 Childhood injuries: extent of the problem, epidemiological trends and costs Injury Prevention 4(4 Suppl.) S10–16 RoSPA 1997 Royal Society for the Prevention of Accidents Factsheets RoSPA: Birmingham Scottish Office 1999 Towards a Healthier Scotland Scottish Office: Edinburgh Stone DH 1996 Research on injury prevention: time for an international agenda? Journal of Epidemiology and Community Health 50 127–130 Stone DH, Doriaswamy NV 1996 The Canadian Hospitals Injury Prevention and Protection Program (CHIRPP) in the UK: a pilot study Injury Prevention 2 47–51 Towner EML, Downwell T, Jarvis S 1993 Reducing childhood accidents. The effectiveness of health promotion interventions: a literature review Health Education Authority: London WHO 1995 World Health Organisation World Health Statistics Annual WHO: Geneva

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