| | Emergency medicine and injury prevention: meeting at the intersectionAbstract Emergency medicine (EM) physicians need little convincing that injury prevention is a public health priority. Clinical experience alone creates a clear appreciation for the impact that injuries have on children and their families. The role of the EM physician is evolving from primary responsibility for the acute care of injuries to a more expanded prevention role including education, research and advocacy. Many emergency department (ED)-based injury prevention projects have been developed and individual EM physicians have emerged as leaders in the field of injury prevention. However, challenges remain. Development of effective interventions which can realistically be implemented in a busy ED are lacking. Expansion of the role of the emergency health care provider outside the hospital, in the community, has great potential for success. The goal of this paper is to discuss the current status of primary injury prevention within emergency medicine, barriers that exist and areas of opportunity.
TRAUMATIC INJURY IS THE LEADING preventable health problem for children. In the year 2000, trauma claimed the lives of 17,673 US children and adolescents younger than 20 years of age, making it the leading cause of death in this age group. In the same year, 295,820 children were hospitalized for treatment of a non-fatal injury and there were more than 10 million hospital emergency department (ED) visits for injuries in that age group.1 Injuries represent 38.6% of all ED visits for children making it the most common reason a child visits the ED.2 An additional 10 million children visit primary care offices for treatment of injuries each year.3 One of every five US children requires medical care for an injury each year.
More difficult to measure, but just as important, are the emotional, behavioral, and cognitive effects of injury. There is an increasing recognition of the frequency with which acute stress reactions occur in injured children. Winston et al4 found that acute stress reactions were present in 88% of children injured in traffic crashes, independent of injury severity score. Other forms of injury, particularly violence, have well documented short term and lasting consequences for children. A recent study of violently injured youth demonstrated that 15% exhibited posttraumatic stress symptoms up to five months after the injury.5 Although not always thought of as a pediatric health problem, intimate partner violence (also called domestic violence) affects children in significant ways. At least 3.3 million children witness violence between their parents each year resulting in a host of physical, emotional, and behavioral problems.6 Children who grow up in violent homes have a significantly increased risk of academic failure, delinquency, substance abuse, and violence victimization and perpetration. Intimate partner violence (IPV) has been called the single leading precursor of child abuse with concordance rates between abuse of a mother and abuse of her child at least 30% to 50%.7
The financial costs of injury are equally impressive. Fatal and non-fatal injuries to US individuals younger than 20 years generate estimated acute care and lost productivity costs of $228 billion per year. Estimates that include costs caused by a lost quality of life elevate that figure to $880 billion.8 Because of this high cost, it is not surprising that childhood injury prevention is a sound financial investment. For example, the estimated direct medical cost saved by each child safety seat is $85, by each bicycle helmet $395, and by each smoke detector $35.9
Current status  The notion that injury prevention is relevant to pediatric emergency medicine is not a new concept. Numerous position papers and policy statements from professional organizations have identified injury prevention as a priority for the field and called practitioners to action.10, 11 The American Academy of Pediatrics (AAP) included injury prevention public education as an essential component in the guidelines for pediatric emergency care facilities.11 The federal initiative Emergency Medicine System for Children (EMS-C) adopted injury prevention as a vital component and stressed its importance in every step of the delivery of emergency care for children.12 The major goal of the EMS-C initiative is to develop broad-based support for injury prevention and several specific objectives have been developed. These objectives are listed in Table 1.  | Objective I–1 | Increase by 50% the number of states, tribal reservations, or federal territories with established injury prevention programs | |
| Objective I–2 | Increase to 35 the number of states, tribal reservations, or federal territories with programs for prevention of unintentional and intentional injuries in children with special health care needs (CSHCN) | |
| Objective I–3 | Develop model discharge instructions on reducing injury-related risk-taking behavior for computerized discharge instruction systems | |
| Objective I–4 | Increase by 50% the number of states, tribal reservations, or federal territories in which injury-related hospitalizations are coded for external cause of injury | | | | |
Several injury prevention projects have developed in emergency medicine, ranging from surveillance to direct intervention. The ED has commonly been thought as an ideal place for injury prevention because it provides a window of opportunity, or what has been called a “teachable moment,” for children and families who present after an injury event. Whether a family or a child is more receptive to injury prevention messages immediately after sustaining an injury is not known. This hypothesis has been tested in several studies of adult emergency patients with alcohol problems. Screening and brief intervention (SBI) for alcohol problems has been successfully adopted in ED settings and evidence for its effectiveness is very strong. A recent systematic review found 39 studies on SBI, of which 30 were randomized controlled trials and 9 cohort studies. A positive effect of the intervention was demonstrated in 32 of these studies.13 These studies demonstrate that it is feasible to incorporate SBI for alcohol-related problems into clinical practice in the ED. Moreover, high acceptance of such counseling by patients have been demonstrated.14 Despite success in adult populations, the evidence for effective screening and intervention for high-risk behaviors of children or their parents in the ED is scarce. Johnston et al15 evaluated the effects of brief behavioral change counseling in the ED on reduction of injury risk in adolescents. This randomized, controlled trial utilized an ED social worker to counsel injured adolescents on modifying injury-related risk behaviors such as seat belt wearing, driving while drinking, and wearing a bicycle helmet. Self-reported behavior change and re-injury were measured at 3 and 6 months and compared to a non-intervention group. There was a greater likelihood of increased seat belt and bicycle helmet use at 3 and 6 months in the intervention group, but there was no difference in risk of re-injury. It has been documented that parents using ED services for their children lack basic knowledge in child passenger safety.16 Many high-volume hospital EDs make child safety seats immediately available to parents who do not have them or to those whose children who are improperly restrained presenting after an automobile crash. Formal evaluation of the effectiveness of such intervention on long-term behavior change is lacking. Limited experience for other ED-based, direct unintentional injury prevention has yielded disappointing results. A Canadian randomized trial examined the effects of an intervention to increase bicycle helmet use among children presenting to the ED with a bicycle injury. The intervention consisted of physician education and pamphlet distribution. No significant difference between non-intervention and intervention groups was observed.17 Evidence suggests that injury prevention education is uncommonly included as part of routine clinical care in the ED, even among children with preventable injuries. Despite some documented successes of education and a current pro-counseling recommendation by the US Preventive Services Task Force, most children presenting to the ED with preventable injuries do not receive any prevention instruction in the ED. A rural North Carolina study of 1,313 children presenting with preventable injuries found that injury prevention instruction was documented only 3% of the time.18 Barriers There are many barriers preventing emergency medical systems and providers from making injury prevention a “living” part of the emergency care mission. These barriers include lack of time, knowledge, and resources. In recent years, the annual census of most EDs has increased steadily so that never before has the ED functioned as more of a “safety net.” Clinical time is limited now more than ever, therefore emergency providers’ attitudes towards taking on prevention related activities may not be entirely receptive. A survey of Canadian emergency physicians found that the majority viewed injuries as preventable, and believed that counseling by emergency physicians could significantly impact the incidence and severity of injuries to children. However, they also viewed the ED the least valuable venue for injury prevention education when compared to schools, primary care offices, and public health units.19 Reasons for this perception were not explored in the study, but they may relate to high workloads, little financial support for injury prevention programs, or the fact that traditional forms of injury prevention in the ED do not generate direct revenue. An additional barrier to expanding the injury prevention role of emergency physicians may be inadequate preparation. Emergency medicine (EM) residency programs frequently lack training in injury prevention. A survey of 461 graduates of California EM residency programs determined the perceived relevance of injury prevention for emergency physicians as well as training received. Although 97% believed that injury prevention was pertinent to EM, 62% believed that inadequate time was devoted to the subject during residency. Less than half reported having formal lectures and less than one-third said they consistently read articles on injury prevention.20 Lastly, but most importantly, prevention messages and interventions must be acceptable to the targeted groups. Effectiveness is not possible if patients are not receptive to the intervention because they view it as inappropriate or irrelevant. Youth focus groups from several urban sites in the United States have revealed that adolescents uniformly believe that the ED is not the place for adolescent patients to be counseled about violence prevention. This belief was found to be consistent among all ethnic, gender, and socioeconomic groups. They did, however, suggest that EM providers bearing violence prevention messages might be more accepted in neighborhood venues, such as community centers.21 A better understanding of violence and other injuries from the point of view of the patient/family is fundamental to refining an effective role for the emergency health care provider in ED-based prevention. Emerging opportunities Injury prevention should begin at home The ED is a fast-paced, high stress environment. Traditional injury prevention programs are frequently developed in significantly different venues such as public health or primary care environments. Adapting traditional programs to the ED may be difficult at best, and in some cases inappropriate or simply not feasible. In order to be most effective, EM practitioners must develop and promote well-evaluated strategies that are relevant to their own experience. This may mean pursuing non-traditional roles outside of the ED as well as incorporating proven strategies into the clinical area. Injury prevention should begin at home. Missed opportunities for preventing injuries are numerous, with many occurring right in the “backyard” of the ED. For example, ambulance transport of chronically ill or acutely ill or injured patients is often done without regard for proper child passenger safety. Crash testing of ambulances has demonstrated the risks to children who are not properly restrained.22 Further work is needed to develop and implement standards for child passenger safety in ambulances. Recognition of and intervention for the non-physical effects of traumatic injury is clearly within the purview of the ED. Screening injured children for signs and symptoms of acute stress may identify groups at risk of future problems. A recent study of violently injured youth demonstrated a significant relationship between acute stress symptoms exhibited in the ED and posttraumatic stress symptoms up to five months after the injury.5 Better recognition of acute stress reactions and early intervention holds the promise of great benefit to the injured child and the family. There is increasing recognition that the abuse of women is a pediatric health care issue and the ED has been identified as an appropriate place to screen mothers.23 How to best screen the caregiver when the child is the focus of the medical visit remains ill-defined and presents a series of challenges. A recent study assessed the attitudes and perceptions of both health care providers and mothers on the appropriateness of screening for interpersonal violence (IPV) in a pediatric ED. Both groups felt that IPV screening was appropriate in the ED but that screening tools must take into consideration several factors addressing the child’s medical needs first, and clear guidelines on issues pertaining to child protection services.24 Developing screening protocols which take these factors into account will increase acceptability and effectiveness. Lastly, EM physicians have an opportunity to reduce the secondary effect that injuries have on children and their families through provision of excellent, child-oriented trauma care. While this may seem far from a novel idea and is ingrained in all pediatric emergency care providers, there is far from universal adoption of practices which reduce child and family stress. These include rapid attention to pain measurement and treatment, presence of family members in the trauma room, and utilization of other services which help alleviate stress through distraction, play, and developmentally appropriate explanation (eg, Child Life). Media and legislative advocacy Inevitably, EM physicians will be approached by media in their clinical role to comment on a high profile or compelling pediatric trauma case. Each of these media contacts provides an opportunity for educating the community on the importance of childhood injury prevention. Working with the media, the EM physician can highlight important prevention-specific information and provide a link to prevention resources. The credibility of the medical “expert” helps to encourage journalists to seek prevention-oriented information as they prepare their stories. Negative attitudes towards the media and short timelines for story preparation can inhibit the involvement of physicians in media advocacy, but opportunities to reach large numbers of the community with media-based prevention messages should not be ignored. Legislative advocacy is another necessary component in the prevention of injuries. Creating or amending laws that address childhood safety is an effective method, because it is a systemic way to reach a large number of people. Although many EM physicians are not accustomed to engaging in the political process, their potential for affecting change in this venue is enormous. Lawmakers are typically not well-versed in matters of injury prevention and will respect and appreciate the expertise brought to them by physicians. Coordination of these efforts increases effectiveness. For those EM physicians who are employees of hospitals or universities, this usually requires the development of constructive relationships with their institutions’ office of government relations. Alternatively, individuals can work through their state American Academy of Pediatrics or American College of Emergency Physicians chapter. The legislative process is time-consuming and frustrating, but involvement by physicians greatly increases the chances for success. Enhanced collaborations Non-traditional roles of EM physicians have become increasingly common. Fruitful collaborations with a variety of community groups are beginning to mature and demonstrate their successes. One example is the Injury Free Coalition for Kids, which began as the Harlem Hospital Injury Prevention Program in 1984 and subsequently was nationally disseminated with funding from the Robert Wood Johnson Foundation.25, 26 Currently, this unique injury prevention program is established in 27 sites located in 24 US cities. This program is non-traditional in the sense that all program activities are highly dependent on hospital-community partnerships and programs are culturally relevant to the individual site. Programs are housed in trauma centers with emergency physicians, surgeons, and pediatricians playing key leadership roles, but most activities occur out in the community. Schools also share the child safety mission. A childhood injury prevention collaboration between child educators and medical professionals has been formalized in a program called Risk Watch. This comprehensive, school-based injury prevention program teaches children from preschool through eighth grade about safe behaviors for all unintentional injury areas in a developmentally appropriate manner.27 The program links teachers and parents with community safety experts and teaches children and their families the skills and knowledge they need to prevent injuries. While formal evaluation is pending, this program has been embraced by medical-educational collaborators, including pediatric EM professionals. Insurance companies and third party payers have a vested interest in childhood injury prevention, and are often willing collaborators. A large-scale example of such a collaboration is The Partners for Child Passenger Safety (PCPS) program. The project is led by a multidisciplinary research team of experts in medicine, biomechanics, engineering, health education, advocacy, and behavioral science, and is based at The Children’s Hospital of Philadelphia.28 Major funding comes from the State Farm Mutual Automobile Insurance Company which recognized an alarming national problem—motor vehicle crashes are the leading cause of death and disability in children over age 1 in the US. Through this unique research partnership, these organizations began to conduct surveillance of children involved in crashes to determine how and why children are injured or killed. In-depth studies of injury patterns are conducted and published in peer-reviewed literature.29 Research is translated to prevention in that PCPS seeks to impact parent behavior and child passenger safety-related design through consistent communication with targeted audiences, including medical providers, automobile and restraint manufacturers, public policy makers, child advocates, and parents. The social role of the ED The ED has been called the only component of the entire social welfare system protected by law for the most disadvantaged.30, 31 It is open all the time, available to all people, and federal law (EMTALA) mandates evaluation of every individual seeking care.32 For some, the ED is the only contact with the medical care system, putting emergency health care providers in an important position to identify and intervene to prevent injuries among high risk groups. Despite this unique position and opportunity, prevention has not been “mainstreamed” in EM. The most common viewpoint is that the ED is an entity that has the sole role of treating acute medical problems. However, the important role of social workers in emergency care environments is being recognized, and their role in some instances, expanded. Social workers have demonstrated their effectiveness in screening and intervening for risk taking behaviors and are adept at linking community support systems to the ED.33 Both activities are essential to effective childhood injury prevention. The economic benefits of dedicated ED-based social work services may be offset by the annual census with large volume EDs deriving the most benefit.34 Injury surveillance Prioritization and injury program planning require data on mortality, morbidity, risk factors, and injury circumstances. The ED is an excellent site in which to conduct injury surveillance and national ED injury surveillance systems have been developed and their dissemination proposed.35 The Consumer Product Safety Commission’s (CPSC) National Electronic Injury Surveillance System (NEISS) has monitored product-related injuries through hospital EDs for several years and has drawn public attention to the risk associated with many products including trampolines, all terrain vehicles, and infant walkers. The addition of All-NEISS has enhanced this resource. Unfortunately, ED medical chart documentation is limited in the amount of prevention related information collected for injured children that is usual for surveillance. A recent review of ED records specifically examining documentation on child bicyclist injuries discovered that much critical information was lacking. A Philadelphia study found that helmet use was documented in only 23% of all cases.36 Healthy People 2010, in a specific objective on the subject, calls for the expansion of ED-based injury surveillance, with a goal of increasing the number of states with such systems to 50. Currently only 12 states collect ED discharge data which include the external cause of injury or E-code.37 Summary The most highly trained EM physician working in the most sophisticated trauma center will not be able to impact the problem of childhood injury significantly by limiting their practice to the delivery of acute care. The training and experience of the emergency care provider creates a clear advantage for pursuing a variety of opportunities in injury prevention. Appropriate roles for the EM physician include advocate, educator, and researcher. As advocate, the EM physician is a respected and credible public spokesperson for programs and policies supporting injury prevention. The EM physician can be of great assistance to community groups striving to create safer environments for children by providing data and scientific credibility as well as advocacy for funding. As educator, each patient encounter holds the potential for affecting behavior change and attitude. Developing effective educational strategies and other interventions that are realistic and acceptable to both patients and ED staff is one of our greatest challenges. As a researcher, the EM physician can provide and advocate for high quality surveillance data, pose research questions relevant to the ED patient, and develop and evaluate interventions. The intersection of EM and injury prevention creates multiple unique opportunities to impact childhood trauma, the most significant and preventable heath problem for the children of our communities. Table 2 | • http://www.injurycontrol.com/icrin/: Injury Control Resource Information Network. This electronic clearinghouse is an excellent resource for injury data and programmatic and advocacy information. Hyperlinks to major injury prevention research centers are provided. | |
| • http://www.csneirc.org/pubs/costmenu.htm: Children’s Safety Network Economics and Insurance Resource Center. Cost data for US childhood injuries. Includes state-level data. | |
| • http://www.cdc.gov/wisqars/: An interactive website based at the Centers for Disease Control and Prevention that provides national injury mortality data useful for teaching, research, and program planning. | |
| • http://www.depts.washington.edu/hiprc/childinjury/: Harborview Injury Prevention Research Center. Contains systematic reviews of childhood injury prevention interventions. Interventions are categorized by type of injury, type of strategy, and outcomes. | |
| • http://www.childrenssafetynetwork.org/: Children’s Safety Network | |
| • http://www.ems-c.org: Emergency Medical Services for Children (EMS-C). Information available on the priorities of the federal EMS-C initiative, including information on funding opportunities. | |
| • http://www.injuryfree.org: Injury Free Coalition for Kids. This national coalition child injury prevention website provides links to local coalition sites throughout the US. | | | | |
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Healthy People 2010 (Available at http://www.healthypeople.gov. Accessed December 14). 2002;. a Division of Emergency Medicine, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA b Section of Developmental Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA  Address reprint requests to M. Denise Dowd, MD, MPH, Chief, Section of Injury Prevention, Division of Emergency Medicine, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108 USA
PII: S1522-8401(03)00025-9 doi:10.1016/S1522-8401(03)00025-9 © 2003 Elsevier Inc. All rights reserved. | |
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