Preventing Pediatric Injuries: From
Education to Community Interventions
Mike Gittelman, MD
Associate Professor
Division of Emergency Medicine
Cincinnati Children’s Hospital Medical Center
Objectives
• Recognize the burden of childhood injuries
• Identify the 4 E’s in preventing injuries
• Discuss the prevention efforts I have been a
part of locally, regionally, and nationally
Past Top Stories
• Teen wounds six in High
School shooting
• 3 month old improperly
restrained … loses life
• House blaze fatally
injures four children
• Study finds playgrounds
safer, but not enough
Why Injury Prevention?
• Injuries
– Are the # 1 killer of
children > 1 year of age
– Cause more deaths than all
other diseases combined
• Almost all injuries are
preventable
• Prevention
– Is essential
– Saves health care dollars
• Oklahoma City – Smoke
alarm giveaway
– 10,000 smoke alarms $15 million net savings
www.cdc.gov/pub/ncipc
Childhood Injuries - Deaths
90
80
70
1955
1967
1988
1998
2001
2006
60
50
% total mortality 40
30
20
10
0
1-4 yr
5-9 yr
10-14 yr
15-19 yr
Source: National Center for Injury Prevention and Control, 2008
Average Day in U.S.
• > 80,000 injuries
resulting in
hospitalizations and ED
visits; >28,000 in kids
0-19 y.o.
• > 400 deaths due to
injuries; > 50 in kids 019 y.o.
Source: National Center for Injury Prevention and control, 2008
Injury Deaths by Cause – US, 1-19
Years of Age, 2008
Injury Cause
# Deaths
Rate/100,000
MVC
7,139
9.22
Firearm
2,845
3.67
Suffocation
1,307
1.69
Drowning
1,048
1.35
Poisoning
1,001
1.29
Pedestrian
876
1.13
Fire/Burn
607
0.78
Source: National Center for Injury Prevention and Control, 2008
Intervention to Prevent Injuries
4 E’s
• Education
– Media campaigns, school programs
• Enforcement/Legislation
– Child safety laws, speed limit enforcement
• Engineering/Technology
– Airbags, bike helmets, child safety seats
• Environmental Modification
– Bike lanes, safety gaits, speed bumps
Education
Injury Prevention & Advocacy: A
Model Course for Pediatric
Resident Education
Why Should Pediatricians Be Advocates?
• Children have little political voice
• Primarily care for a poor, underserved
population
• Pediatricians have a knowledge-base of “what’s
out there”
• Pediatricians are well respected and accepted in
a community
• Pediatricians are expected to educate families
about Anticipatory Guidance regularly
Pediatricians Lack IP/Advocacy Training
• Residents receive little education about injury prevention
– Residency directors report disease management taught more
than injury prevention
– Zavoski, Arch Peds Adol Med 1990
– Chief Residents Survey - Injury prevention and Advocacy –
only 2-3 informal lectures throughout residency
• Need to educate residents in order to teach families
– Chief residents only counsel on what they were once taught,
barrier = lack of training – Wright, Arch Peds Adol Med 1997
– < 50% of residents discussed injury prevention on audiotaped
encounters
- Gielen, Arch Peds Adol Med 1997
– <40% of parents received any injury counseling at PMD visit
- Miller, Pediatrics 1995
Motivations for Course
• Need for a “structured educational experience to
prepare a resident to be a community advocate”
• 1996 Residency Review Committee for Pediatrics
• Injury prevention should be an “integral educational
experience for pediatric residents”
• 1991 AAP Policy Statement
– Injuries are #1 cause of death in children > 1 year
– Injuries cause more death than all diseases combined
• Anecdotal experiences during residency training
Idea
• Formally educate pediatric residents
about injury prevention to provide
them with a foundation to become
community advocates
Curriculum
• Morning didactic lectures
• Afternoon field experiences
– Complement AM lectures
• Hospital Commitment
– 1996 (First year) – elective for all residents
– 1997-2010
• Two-week mandatory rotation for all pediatric
interns
• Offered six times per year
• No call requirement
Curriculum - Topics
• Injury Prevention
–
–
–
–
–
–
–
–
–
–
–
Car safety seats
Bicycle Safety
Home safety
Toy Safety
Drowning
Firearms
Suicide
Playground safety
Pedestrian Safety
Domestic Violence
Poisonings
• Advocacy
–
–
–
–
–
What is an advocate?
How to give a lecture
Insurance 101
Special health needs
Patient rights
• To health care (meds)
• To special ed evals
–
–
–
–
Reporting abuse
Legislative initiatives
Community resources
Dental and nutrition health
Field Experiences
• IP at childbirth education
classes
• Bike helmet at
elementary schools
• Smoking Cessation
Program
• Local fire station – fire
prevention
• Sports Medicine
• Child Protective Services
• Drug and Poison Center
• Rape Crisis and Abuse
Center
• International Adoption
• Toys R Us – Toy Safety
• Legal aid/Ohio Medicaid
• Child protective services
home visits
• Car seat installations
Requirements
•
•
•
•
•
•
•
Attendance
Parent education pamphlet
Review injury literature
Letter to state official
Participate in field experiences
Evaluations
Propose a 3-year advocacy project
Curriculum - New Developments
• Bi-annual updates (eg. change speakers,
lectures, and experiences) based on
evaluations
• Adult learning model
– Topic reviews
– Debates
• Evaluation tools
– Speakers evaluate residents after each talk
Evaluation of Knowledge
• CCHMC Residents Vs. Two Regional Comparable
Pediatric Residency Programs
• 50 question survey
• 73 residents (29 intervention, 38 control)
• No difference age, experience, schooling
• Injury knowledge obtained
Pre-Test Scores (Mean) Post-Test Scores (Mean)
% Increase
CHMC Residents
55.1%
69.2%
14.1%
Controls
56.3%
59.5%
3.2%
Mean Difference 10.98 (95% CI: 6.5, 15.5), P-value < 0.001
Evaluation of Knowledge Retention
• Repeated survey given after year one
• 38 residents (16 intervention & 22 controls)
• Injury knowledge obtained
Orientation (Mean)
End 3rd yr (Mean)
% Increase
CCHMC Residents
56.6%
68.5%
11.9%
Controls
56%
61.5%
5.5%
Mean Difference 6.4% (95% CI: 1.2, 11.8), P-value < .05
Feedback from Residents
• Enjoyed
– Learning resources in community
– Filling in gaps of needed information
– Hands-on learning experience
• Increased comfort
– Providing anticipatory guidance
– Documenting injuries in ED and clinic
– Community speaking
Future Directions
• Further evaluations of the course
– Improve ways to provide resident feedback
– Impact
•
•
•
•
More anticipatory guidance due to course
Continued anticipatory guidance after residency
More involved in advocacy efforts
More involved in research within injury field
• National influence
– AAP standardized curriculum
Legislation/Enforcement
• Locally
– Speed bumps strategically placed
– Local Ordinances Bicycle Helmets
• Cincinnati, Green Township, Madeira
• State
– Ohio booster seat legislation
– Ohio bicycle helmet legislation
Product Modification/Dispersement
Emergency Department Safety Store
Idea Behind Safety Store
• Proven safety products
–
–
–
–
•
•
•
•
Car safety seats – 70% reduction in death from MVC
Booster seats – 59% safer in MVC
Bike helmets – Reduce head injury by 85%
Smoke alarms – Decrease deaths by 50%
Not accessible at reasonable prices locally
Make families leaving our ED safer
Modeled after Johns Hopkins Injury Center
? ED as a teachable moment
The Emergency Department as a “Teachable
Moment”
• Johnston, et al, Pediatrics 2002
– 12-20 year olds treated in the ED for an injury
– Educated about IP vs. Routine Care
– Increased bike helmet and seat belt usage
• Posner, et al, Pediatrics 2004
– Children < 5 years with an unintentional injury
– Received home safety education and free product vs.
injury specific ED instructions
– Increase in home safety practices after ED intervention
Two Studies Conducted in CCHMC ED
• Gittelman, et al, AEM 2006
– 4-7 year olds presenting to the ED for any complaint
– No family educated about booster seats used one at one month
follow-up
– 98% used booster seat if educated and given a seat
• Gittelman, et al, PEC 2008
–
–
–
–
Parental survey of ED families
93% felt the ED should provide safety information
83% were willing to wait longer in the ED
73% wished for product to be made available to them in the ED
setting
Store Details
• Housed in the ED waiting room
– Collaborative effort
• Items sold at cost
–
–
–
–
Car safety seats, Booster seats
Bike helmets, Wrist guards
Smoke/CO detectors
Window guards
• Sales for
– ED customers
– Hospital staff
– Community
• Evaluation
–
–
–
–
Who is purchasing
Information requested
Follow-up calls of usage
Sustainability
Monthly Sales, 6/1/2005—2/1/2009
$1,800
$1,600
$1,400
$1,200
$1,000
$800
$600
$400
$200
$0
2/1/2009
12/1/2008
10/1/2008
8/1/2008
6/1/2008
4/1/2008
2/1/2008
12/1/2007
10/1/2007
8/1/2007
6/1/2007
4/1/2007
2/1/2007
12/1/2006
10/1/2006
8/1/2006
6/1/2006
4/1/2006
2/1/2006
12/1/2005
10/1/2005
8/1/2005
$ Sales
6/1/2005
Revenue
Monthly Sales
Month/Year
• Up to $1100 sales monthly, 1500 educated monthly
• Operational costs high – Personnel
• Next steps
– Kiosk
– Other prevention items for sale
Customer Satisfaction
• 98.1 % of families ranked the service as 9 or 10
out of 10
• Most families who made a purchase (75%)
heard of the store while at CCHMC
• 70% were in the ED with a patient or family
3 week Follow-Up
• 383/ 786 (49%) customers who made a purchase
were reached for follow-up
• 97% using the purchased product 100% of time
• 107 (28%) made a behavior change in their home
different from the product purchased
• 97% felt the prices were affordable
• 95% believed the store hours were reasonable
and it was located in the appropriate place
Environmental Modifications
Community Involvement in
Preventing Injuries
Community / Service
Injury Free Coalition for Kids® (IFCK)
• Started in Harlem, NY
– Funded by the Robert
Wood Johnson
Foundation
• Decrease injuries by
– Education
– Altering environments
– Increasing supervised
after school activities
• Community-hospital
partnerships
Effectiveness of IFCK Programs
Nationally
• Harlem, NY-55%
reduction in injuries
• Similar injury reductions
at other, moreestablished sites
– Children’s Memorial,
Chicago, IL
– St. Louis Children’s
Hospital
– Children’s Hospital of
Philadelphia
Pedestrian
Hospital
Window
Firearms
Traffic
Falls
/Assaults Admissions
-36%
-45%
-46%
-60%
-96%
Harlem Hospital Injury
Reductions by Mechanism
IFCK of Cincinnati
• Began in 2000
• Public health approach
–
–
–
–
Problem
At-risk
Community needs
Intervention / Evaluation
• Based on
– Data
• Hamilton County Health District
• CCHMC Trauma Registry
– Community concerns
• Social and structural changes
• Evaluations are essential
Hamilton County Injuries
Avondale – Target Community
• Population*
– 20,000 residents
• 5000 < 18 years old
– 4th highest injury rate in Cincinnati
• 1812.5 injuries / 100,000
children / year
– Close proximity to hospital
• Getting started
– 60% injuries 4pm-midnight
– Structural modifications Playground building
*U.S. Census Bureau, 2000
Gain Community Buy-In
• Gain trust of the community
– Meetings, meetings, meetings
– Listen to concerns
• Focus groups to assess needs
– Provide tangible results
– Do what you say you are going to do
– Don’t promise what you cannot deliver
• Provide members with expertise and resources
– Empower communities to thrive
Playgrounds – Before and After
2001
2003
2005
2002
2004
Evaluation – Playground Use
2001 - Blair
% of Children
Use
2002 - Hickory
% of Children
Use
2001 Before
66 (6 per day)
63 (6.3 per day)
2001 After
128 (12.8 per day)
Equipment removed
2002 Before
104 (10.4 per day)
25 (2.8 per day)
2002 After
99 (9.9 per day
120 (10.9 per day)
Significantly more children on new playgrounds compared to old (p<0.001)
Additional Structural Changes
• Football Field
• Speed bumps
• Assisted with other community
developmental projects
Social Changes
• After school programs – ODE grant for 3
Avondale Elementary Schools
– Improve grades
– Educational/cultural/healthy programs
• Basketball program – police-community
interaction
– 33% reduction in juvenile arrests
• Community coalitions/partnerships
• Safety fairs and educational programs
Reduction of Avondale Injuries Since the
Beginning of IFC - Cincinnati
1400
1200
1000
800
600
400
200
0
1999
Avondale
-42%
2000
Controls
-25.7%
2001
Evanston
-9.8%
2002
2003
Mt. Auburn
-9.8%
2004
Walnut Hills
-38.6%
IFCK – 2005 - 2010
• Avondale
– Sustain current programming and develop new structural
and changes
•
•
•
•
Two new playgrounds built this summer
Home safety initiative in daycares – address new ages
Completed a Diabetes and Obesity After School Program
Continue safety fairs and outreach
– Need to assess sustainability of efforts
• Price Hill – Second intervention community
– Playgrounds – built 1 per year, total of 6 to date
– Home safety initiative – approximately 500 homes served
– Teen basketball program – 130 youth engaged
Conclusions
• Injuries are the number cause of morbidity and
mortality to children 1-19 years old
• Injuries are 100% preventable
• Everyone should play their part to prevent them
• Small interventions effecting the 4 E’s can help
to reduce the injury burden
• All it takes is a passion and a little work
“If a disease were killing our children
in the same proportions as injury,
we would be outraged and demand
this killer be stopped”
C. Everett Koop, M.D.
Former Surgeon General of the United States
Questions?