1. Injury Control Injury Prevention Center
Department of Emergency Medicine
Rhode Island Hospital, Hasbro Children’s Hospital &The Miriam Hospital
Brown University School of Medicine

2. Injury in the U.S. Average Day 405 people die as result of injuries
7,500 people hospitalized from nonfatal injuries
Approximately 150,000 people suffer injuries severe enough that they seek medical attention
Injuries are a major health problem in this country.
In 1995 injuries were responsible for 147,.891 deaths, 2.6 million hospitalizations and greater than 36 million emergency department visits.
Fingerhut, LA, Warner M. Injury Chartbook. In: Health, United States, and Injury Chartbook. Hyattsville, MD: US Public Health Service; 1997.

3. Injury in the U.S.
Injury the leading cause of death and disability among children and young adults
Nearly 150,000 die each year from injury
41,000 - motor vehicle crashes
28,000 - fires, drownings, falls, poisonings
30,500 - suicide
25,500 - homicide

4. Injuries - Rhode Island Statistics
ED visits - incidence 112 per 1000 population in 1992
For each injury death
17 hospitalizations
325 outpatient ED visits
500 required some professional treatment

5. The Injury Pyramid EPISODES OF INJURIES REPORTED DEATHS
Fingerhut, LA, Warner M. Injury Chartbook. Health, United States, and Injury Chartbook.
DEATHS
HOSPITAL DISCHARGES
Looking at only deaths or emergency department visits doesn’t allow to appreciate the scope of the injury problem. The scope of injuries can best be appreciated if thought of as a pyramid. Deaths from injuries and hospital discharges, traditionally where the most usable data has been, is only the tip of the problem. There are a far number of greater injuries that seen in emergency departments, clinics and physician offices. There is a greater number of injuries that are never reported and documented.
Fingerhut, LA, Warner M. Injury Chartbook. In: Health, United States, and Injury Chartbook. Hyattsville, MD: US Public Health Service; 1997.
EMERGENCY DEPARTMENT VISTS
EPISODES OF INJURIES REPORTED

6. Injury Control in the ED
37% of all emergency department visits can be attributed to injuries
Injuries utilized a significant amount of emergency department resources.
In examining emergency department visits for 1995, falls were the leading cause of nonfatal injuries with approximately 8 million visits. Motor vehicles injuries was second with 3.8 million visits.
Bonnie, RJ, Fulco, CE, Liverman, CT, editors. Reducing the Burden of Injury - Advancing Prevention and Treatment. National Academy Press, Washington, DC, 1999.

7. Injury Control in the ED
Emergency Personnel
Exposed to this problem by specialty
Opportunity to improve patient care
Improve community care
Control health care costs

8. Cost of Injuries in the U.S.
Approximately 12% of all medical spending
$260 billion dollars was spent in 1995 on injuries
Bonnie, RJ, Fulco, CE, Liverman, CT, editors. Reducing the Burden of Injury - Advancing Prevention and Treatment. National Academy Press, Washington, DC, 1999.
The financial impact of the injuries is enormous. Which also means the potential for savings from prevention is great.

9. Cost of Injuries in the U.S.
Calculating the Costs of Injuries
Direct Costs
Indirect Costs
Direct costs: cost of both acute and long term medical care
cost for home modifications and care
vocational rehabilitation
Indirect costs:the value of the lost of productivity due to death or disability from injuries
psychological effects affecting the injured, their families, and society

10. Injury Costs Costs - Who pays? Financial costs
Public sources (federal, state, local) pay 28%
Private sources pay 72%
Federal Government
$12.6 Billion in medical costs
$18.6 Billion in disability and death benefits
Source: Centers for Disease Control and Prevention

11. Comparing Years of Potential Life Lost (YPLL) of Injuries and Other Diseases
Injury causes more potential years of life lost than any other disease.

12. Injury and Age
Injury is the leading cause of death in children and young adults
Injuries kills more Americans aged 1-34 than all other disease combined.
Injuries kills more Americans aged 1-34 than all other disease combined.
Rivera, FP, Grossman, DC, Cummings, P. Injury Prevention (Part 1). NEJM. 1997; 337:

13. The Five Leading Causes of Death by Age Group for 1996
This CDC chart depicts how injury is the leading cause of death for most of the first four decades of life. Evan later in life it still is a prominent cause of death ranking seventh in those over 65.
Adapted from National Center for Injury Prevention and Control,, CDC

14. Injury Control Concepts
Injuries can be described in the same manner as other diseases
Seasonal variations
Epidemic in certain populations
Affected by environmental conditions
Susceptibility factors identifiable
Predictable patterns
So why am I telling you all of this?
Survey in 1995 showed approximately 10% of all US medical schools are formally teaching concepts of injury control in their curricula

15. Injury Control Concepts
Scientific approach to injuries
Injuries are preventable
Identify and describe problem through surveillance
Study what puts people at risk
Design and evaluate an intervention

16. Myth: Injuries are Accidents
Injuries are no accident
The common reference to injuries as accidents, leads many to mistakenly believe that they are random events that can only be prevented by good luck and prayer. By using accidents as a descriptive term for injuries it implies a fatalistic view of their occurrence. Injuries are actually statistically predictable events. They have definable characteristics including when and where they will occur. They have subsets of the populations that are more at risk for a particular injury. They have distinct patterns of how they occur.
In treating injuries as a diseases we can apply the models of disease prevention that are utilized for aspects of health promotion and prevention.

17. Definition of an Injury
An injury is tissue damage caused by the transfer of energy to the body above or below the tolerance of human tissue
An alternate definition to this simple one is that used by the National Committee for Injury Prevention and Control:
“any injury intentional or unintentional damage to the body resulting from acute exposure to thermal, mechanical, electrical or chemical energy or from the absence of such essentials as heat or oxygen”
National Committee for Injury Prevention and Control. Injury Prevention: Meeting the National Challenge. New York:Oxford University Press (Published as a supplement to the Am J Prev Med. 1989;5:4).

18. Types of Energy Kinetic Thermal Electrical Chemical Radiation
Injuries are caused by acute exposure to a type of energy, such as kinetic or mechanical energy, heat, electricity, chemicals, and ionizing radiation, in amounts that exceed the human threshold of human tolerance.
Haddon, W., Jr.. A note concerning accident theory and research with special reference to motor vehicle accidents. Ann of NY Acad Science 107:
About 75% of all injuries are caused by mechanical energy transfer. (examples: injuries from motor vehicle crashes, falls, sports, firearms)
Baker S.P, O’Niel, B., Ginsburg M.J., The Injury Fact Book. 2nd Ed., New York: Oxford University Press; 1992,
Thermal injuries would be scaldings/burns as well as frostbite/hypothermia.
Electrical are both electrocutions and lightning strikes.
Chemical involves posionings and hazardous spills.
Radiation can be both low level exposure and massive exposures.

19. The Injury Triangle
HOST
VECTOR
The classic epidemiological triangle can be used to study injuries. Epidemiology traditionally uses this approach to assess the causes and distribution of diseases. Then utilizes this information in developing opportunities to control disease affecting a population.
Injuries can be studied through this same framework.
The host is the population at risk of the injury. The agent is one of the five types of energy just mentioned on the previous slide. The environment is the physical and social milieu where the event occurs. The vector or vehicle is the carrier of the energy to the host.
ENVIRONMENT
AGENT

20. Injury Triangle Example Brain Injury in Children
host
Children
vector
Bicycle Riding
environment
agent
Kinetic Energy
Neighborhood Streets
Presented here is an example of an injury that can be studied using the epidemiological triangle. In childhood brain injury the host is children, the agent is kinetic energy distribute by bicycle (vector) and this occurs in the environment of neighborhood bicycle riding. If characteristics of the host are further studies unhelmeted children would be found to be most at risk. If the agent of kinetic energy is examined the role of speed could be elucidated.
This approach could be used to develop interventions such as requiring all children to wear bicycle helmets, limiting the speed that children’s bikes can travel or altering the streets on which they travel.

21. Concepts of Injury Control
Haddon’s Matrix

22. Injury Prevention: The Three E’s
Education
Enforcement
Engineering
The three E’s of injury prevention address the three conceptual approaches to injury prevention. The three are complimentary to each other and can be applied synergistically to the same injury problem.
Christoffel T., and Gallagher S., Injury Prevention and Public Health, Gaithers, Gaithersburg, Maryland: Aspen Publishers, 1999, 30-32,

23. The Three E’s: Education
Aim is to provide community with information on how to avoid injury
Alter attitudes about risk reduction
Modify behaviors by educating community about why they must adopt behavior
The educational approach can be simplified to that if people are given information about the risk of injuries they will avoid those behaviors that will lead to injury. This assumes there is a lack of information about the risk of injuries. This approach is founded on the the rational-empirical strategy (Benne & Chin) that assumes that people are rational and when given information will act to optimize their health. Many public health programs utilize this approach. Examples: “Buckle up”, “Practice Safe Sex”
Chin, R and Benne, K. “general strategies for effective change in human systems” In: Warren Bennis et al.(eds.) The Planning of Change, New York: Holt, Rinehart and Winston, Inc , 1969.

24. The Three E’s: Education
Particularly useful for:
Teaching young children lifelong safety skills
Certain injury patterns where education about hazard is only option
Altering social norms about risk of injury
Promoting societal policy change for safer environment
Educational Strategies have been criticized that they are less effective than other approaches. While this is frequently true they are useful in several situations and as an adjunct with other strategies. The educational approach can be used on several levels. An individual can be educated about their own risk reduction . Society can also be educated about the risk of injury and through this change its normative behaviors.

25. The Three E’s: Engineering
Use modifications in environment to reduce injury risks by providing passive protection
Examples:
Road design: separate bike lanes, rumble strips in road shoulder
Auto design: airbags, padded dashboards, reinforced side panels
The environment can be reengineered (or changed) to reduce the risk of injuries. Some of the greatest successes in injury have been because of engineering a change in the environment. These have not only been limited to motor vehicle safety but diverse applications such as child resistant caps, and safety straps on changing tables.

26. The Three E’s: Enforcement
Enforcement is usually more effective than education
Most injury prevention laws at state level
Laws can have varied focus:
individual behaviors
engineering of environment
consumer products design
Enforcement strategies can be applies at varying levels. They can regulate the environment to make it less risky or they can regulate behavior. This can be done through statue law or tort law. Both have been used successfully.

27. Active Intervention Strategies
Requires repeat action by individual and benefit is only by those individuals performing action
example: seatbelt use
Active intervention are individual strategies that are required to be repeated to be effective. Seatbelt use is a commonly used example of this type.

28. Passive Intervention Strategies
No action required by the individual once it has been put in place
It frequently requires altering the environment to prevent energy transfer or reduce damage from energy transfer
Passive intervention strategies frequently alter the environment or the vehicle/vector to prevent a transfer of energy to the host or to reduce the tissue damage from the energy transfer. It is always present and does not require individuals to activate it. Both airbags and four sided pool fencing are examples of passive interventions.

29. Active vs. Passive Strategies
Active Strategies
Require continual upkeep
Not uniformly accepted
Frequently less expensive to implement
Passive Strategies
Universal application by protecting all members of the community
Don’t decay in efficacy
Avoids individual’s risk values
Doesn’t have to be perfect fit for all individuals
Active Strategies
Require continual reinforcement or its effectiveness diminishes
Not uniformly accepted and those who are most at risk are usually least likely to use active intervention
Frequently less expensive to implement
Passive Strategies
Universal application by protecting all members of the community regardless of the individual’s risk values
Passive strategies do not need to constantly reinforced to remain effective
Doesn’t have to be perfect fit for all individuals
Roberts M., “Public health and health psychology: Two cats of Kilkenny” Professional Psychology: Research and Practice, 1987, 18(2):

30. Haddon’s Ten Strategies for Injury Prevention Countermeasures
1. Stabilize, Repair and Rehabilitate
provide best practice standards of emergency, hospital, and rehabilitation care
2. Counter damage already done
transporting head injured and spinal cord injured appropriately
3. Increase resistance to injury
education about calcium intake in preventing osteoporosis
Increase resistance to injury : example - education about calcium intake in preventing osteoporosis
Counter damage already done : example - transporting head injured and spinal cord injured appropriately
Stabilize, Repair and Rehabilitate : example - Provide best practice standards of emergency, hospital, and rehabilitation care

31. Haddon’s Ten Strategies for Injury Prevention Countermeasures
4. Modify the relevant basic qualities of the hazard
padded dashboards
5. Separate the hazard and its release by a material barrier
four sided pool fencing
6. Separate people from the hazard and its release using time or space
pedestrian crossing lights, bike lanes
Separate people from the hazard and its release using time or space : example - pedestrian crossing lights, bike lanes
Separate the hazard and its release by a material barrier : example - four sided pool fencing
Modify the relevant basic qualities of the hazard : example - padded dashboards

32. Haddon’s Ten Strategies for Injury Prevention Countermeasures
7. Change the rate or spatial distribution at which the hazard is released
release bindings on skis
8. Prevent inappropriate release of hazard
storing firearms in locked cases
9. Reduce Amount of Energy
limiting horsepower in motorized vehicles
10. Prevent Creation of Energy
don’t manufacture firecrackers
Prevent Creation of Energy : example - don’t manufacture firecrackers
Reduce Amount of Energy: example- limiting horsepower in motorized vehicles
Prevent inappropriate release of hazard: example- storing firearms in locked cases
Change the rate or spatial distribution at which the hazard is released: example- release bindings on skis
Christoffel T., and Gallagher S., Injury Prevention and Public Health, Gathers, Gaithersburg, Maryland: Aspen Publishers, 1999, 30-32,
Haddon W., “The basic strategies for reducing damage from hazards of all kinds” Hazard Prevention, Sept/Oct 1980, 8-12.

33. Injury Control - Role of Practitioners
Educate
Injury surveillance
Conduct research
Advocate change
What can you do on a daily basis?
Educate yourself and your patients. Read, Be proactive with your patients.

34. Injury Control - Role of Practitioners
ED data useful to target prevention activities
Number of injuries from a specific cause
Severity of injuries
Likelihood of success or preventative measures

35. Injury Control - Role of Practitioners
Patient care
injury science can be used to improve clinical care
Recognition of injury patterns
Rational approach
Timely definitive therapy
Reduces the possibility of missed injuries

36. Injury Control - Role of Practitioners
Education
Patient specific
Public groups
Legislators
Publish
Involve your patients in discussion about their own injuries. More often than not, they will be able to tell you at least one factor that could have prevented

37. Injury Control - Role of Practitioners
Surveillance
Defines injury patterns in a community
Limited data available on non-fatally injured people
E - Codes
Legislators need good information
Linkages between ME’s office, DPH, ED’s

38. Injury Control - Advocacy
Influence policy
Regional
State
National
Prior legislative involvement
seatbelts
motorcycles
all terrain vehicles

39. Injury control - Partners
Public safety - Police, Fire, EMS
Local government
Schools
Business
Community groups
Health care providers
Public health agencies

40. Past Successes in Injury Control
Seatbelts decrease in motor vehicle crash moralities
Crib design decrease in strangulation's with smaller slat distancing
Child Resistant Caps decrease in childhood poisoning
Blade Brake on Lawn Mowers decrease in hand/foot amputations
Window Guards decrease in window falls for children
There have been many success stories with injury control initiatives. These initiatives have caused decreases in certain injury patterns.

41. Summary Injury is a preventable disease
Involve patients in discussions about their own injuries and their role in prevention
Integrate principles of injury control into your discharge instructions