1. County of San Diego Division of Emergency Medical Services EMS Impact of a New Booster Seat Law Barbara Stepanski, MPH Isaac Cain, MFS; Louise Nichols Leslie Upledger Ray, MA, MPPA David Thompson; Roxanne Hoffman MEd Angela Fix, MPH; Edward Castillo,PhD, MPH Alan Smith, MPH

2. County of San Diego Division of Emergency Medical Services EMS Background Seat Belt Legislation Historically legislation has influenced seat belt use in motor vehicles (MV) –10%-15% from the time safety belts were first installed in MV (1950s) until the early 1980s –Increase to 42% by late 1980s as a result of the passage of seat belt laws in 31 states –Increased to 62% by 1992 - more states passed laws, national enforcement and public education –68% in 1996 ranging from 87% in CA to 43% in ND –75% in 2002

3. County of San Diego Division of Emergency Medical Services EMS Background Child Safety Seat (CSS) Legislation First laws were generalized to all MV occupants (MV seat belt designed for occupants of a minimum size of 4’9” and approximately 80 lbs) First child specific seat belt laws – 1979 TN, 1983 CA Prior to 2002 in CA - No CSS law in place for children too large for infant or toddler seats and too small for MV (adult) seat belts 2002- CA’s new law extended protection for child passengers to age 6 or 60 lbs (need to meet only one criteria) (not considered maximum protection)

4. County of San Diego Division of Emergency Medical Services EMS Background National CSS use estimates (NHTSA) –infant and toddler - 91% –booster seat use - 10% Booster seat use is low for children who have outgrown their infant/convertible/forward-facing seat (Partners for Child Passenger Safety) –29% of 3YO are inappropriately graduated to a booster seat –16% of 3YO are inappropriately moved to a MV seat belt –83% of 4-8YO are inappropriately moved to a MV seat belt

5. County of San Diego Division of Emergency Medical Services EMS Background In the San Diego Prehospital setting –8% of children 0-9 seen by paramedics/EMTs are due to MV crashes 50% 0-4YO are not restrained in a child seat –11% of 0-4YO are completely unrestrained 20% of 5-9YO are completely unrestrained

6. County of San Diego Division of Emergency Medical Services EMS Data Source Buckle Up San Diego/San Diego Safe Kids Coalition child safety seat inspection events, 1999 - 2002 –69 inspection events –1707 seat positions inspected

7. County of San Diego Division of Emergency Medical Services EMS CSS Inspection Logistics NHTSA certified technicians and instructors Each inspection took approximately 30 minutes Various locations (schools, retail stores, health fairs, etc.) Weekend and non-school hour times Volunteers Standard data collection tool

10. County of San Diego Division of Emergency Medical Services EMS Distribution of Seat Type Rear-Facing (764, 45%) –Infant with or without a base –Convertible Forward-Facing (668, 40%) –5-Point Harness –T-Shield –Tray Shield –Toddler/Booster –Integrated Seat (31 were missing seat types) Belt Positioning Boosters (BPB) (87, 5%) –High-back –Backless Shield Booster Seats (11,.7%) Vehicle Safety Belts (38, 2%) Other Child Restraint (3, 0.2%) No Seat (105, 6%)

11. County of San Diego Division of Emergency Medical Services EMS Results Pre & Post Law Comparison Seat InspectedPre 2002 LawPost 2002 Law Belt Positioning5829 Shield*110 Total6929 % of seats inspected510 Avg per month2.239.67 * No longer recommended – does not provide upper body protection

12. County of San Diego Division of Emergency Medical Services EMS Results Booster seats –89% BPB –11% Shield (None Post 2002) Inspection Criteria –3 measures -BPB –7 measures -Shield

13. County of San Diego Division of Emergency Medical Services EMS Results – Inspection Criteria for Belt Positioning Boosters % that meet criteria

14. County of San Diego Division of Emergency Medical Services EMS Results – Inspection Criteria for Shield Boosters % that meet criteria 4 additional criteria added to revised 2002 form however no shield boosters were inspected using this form

15. County of San Diego Division of Emergency Medical Services EMS Results - Age Age %

16. County of San Diego Division of Emergency Medical Services EMS Results - Weight %

17. County of San Diego Division of Emergency Medical Services EMS Results - Siblings %

18. County of San Diego Division of Emergency Medical Services EMS Vehicle Safety Belts (VSB) %

19. County of San Diego Division of Emergency Medical Services EMS Results 27% of booster seats demonstrated at least one error, most frequently: –Shield correct use of the locking clip (33.3% correct) vehicle belt holding seat tight, 1 inch test (37.5% correct) –BPB lap/shoulder belt correctly positioned (82% correct) Significant difference in misuse by booster type –21% misuse for BPB (both Pre and Post 2002 Law) –73% misuse for Shield Booster –3.5 times more likely to have an error using a Shield vs. a BPB (RR = 3.52)

20. County of San Diego Division of Emergency Medical Services EMS Results Number of booster seats inspected increased Slight increase in age of children who’s seats were inspected Slight increase in number of booster seats inspected w/o younger siblings Number of Shield boosters inspected decreased VSB inspections for children <60 lbs or <6YO decreased  Percent of misuse among BPB remained the same

21. County of San Diego Division of Emergency Medical Services EMS Conclusions Efforts to make CSS installation easier include: –Universal LATCH system –NHTSA’s “Ease of Use” CSS rating system gives an “A” “B” or “C” grade for: Pre-assembled or consumer assembly required Clarity of labeling on seat Clarity of written instructions on proper use Ease of securing child in seat If seat has features that make installation in vehicle easier and a overall grade for ease-of-use

22. County of San Diego Division of Emergency Medical Services EMS Conclusions In comparison to other seat types (forward and rear facing) booster seats have a higher percentage of correct use Law has increased awareness/motivation resulting in more booster seats being inspected. However installation errors stayed the same, indicating the need for public health education on “proper use” of booster seats

23. County of San Diego Division of Emergency Medical Services EMS For more information contact: Barbara M. Stepanski, MPH County of San Diego HHSA Division of Emergency Medical Services 6255 Mission Gorge Road San Diego, CA 92120 phone - (619) 285-6429 barbara.stepanski@sdcounty.ca.gov