injury prevention anne armstrong-coben, md. overview personal stories/ patients seen epidemiology...
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Injury PreventionInjury Prevention
Anne Armstrong-Coben, MDAnne Armstrong-Coben, MD
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OverviewOverview
• Personal Stories/ Patients seen
• Epidemiology• Basics of Injury Prevention• Prevention
– Office-based• TIPP
– Legislative Advocacy– Community-wide/ building into structure of
society
• Personal Stories/ Patients seen
• Epidemiology• Basics of Injury Prevention• Prevention
– Office-based• TIPP
– Legislative Advocacy– Community-wide/ building into structure of
society
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Personal StoriesPersonal Stories
• My stories• Any stories
• Cases- what have you seen?
• My stories• Any stories
• Cases- what have you seen?
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Epidemiology of Childhood Injuries - United StatesEpidemiology of Childhood Injuries - United States• Unintentional injuries are the leading cause of
death and acquired disability in children from 1 - 19 years of age in the U.S.
• 33 children die every day because of injuries; 12,175 die each year
• Each year, 20-25% of children sustain an injury requiring medical attention, missed school, and/or bedrest
• 9.2 million children age 0 -19 are seen in EDs each year for injuries
• Leading cause of childhood medical spending in U.S.
• Unintentional injuries are the leading cause of death and acquired disability in children from 1 - 19 years of age in the U.S.
• 33 children die every day because of injuries; 12,175 die each year
• Each year, 20-25% of children sustain an injury requiring medical attention, missed school, and/or bedrest
• 9.2 million children age 0 -19 are seen in EDs each year for injuries
• Leading cause of childhood medical spending in U.S.
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Global Problem of Injuries to Children and Adolescents
Global Problem of Injuries to Children and Adolescents• Nearly 1 million deaths annually• >98.4% of the world’s childhood
drowning occur in low- and middle-income countries– US: 1.53 per 100,000 population– Bangladesh age 1 to 4: 156.4 per
100,000
• Nearly 1 million deaths annually• >98.4% of the world’s childhood
drowning occur in low- and middle-income countries– US: 1.53 per 100,000 population– Bangladesh age 1 to 4: 156.4 per
100,000
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Example Specific Injury- Drowning (US)Example Specific Injury- Drowning (US)• In 2002 – 838 children <14 years old
died from accidental drowning• 2003- 4200 children < 14 years old
treated in ERs• Typical medical cost “near drowning”-
$8K for hospital visit up to $250K/year for long-term care
• Other sequelae – the witnesses, the families
• In 2002 – 838 children <14 years old died from accidental drowning
• 2003- 4200 children < 14 years old treated in ERs
• Typical medical cost “near drowning”- $8K for hospital visit up to $250K/year for long-term care
• Other sequelae – the witnesses, the families
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Basics of Injury PreventionBasics of Injury Prevention
• INJURIES ARE NOT ACCIDENTS• Injuries are often understandable,
predictable, and preventable• Specific injuries share similar
characteristics of person, place , and time
• By understanding injuries, interventions can be developed and implemented to prevent or limit the extent of a given injury
• INJURIES ARE NOT ACCIDENTS• Injuries are often understandable,
predictable, and preventable• Specific injuries share similar
characteristics of person, place , and time
• By understanding injuries, interventions can be developed and implemented to prevent or limit the extent of a given injury
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William Haddon and the Phase Factor MatrixWilliam Haddon and the Phase Factor Matrix• First conceptual framework for studying
injuries causes and prevention, developed by William Haddon
• By studying a specific injury with this matrix in mind, one can identify modifiable risk factors and identify points of intervention in the causal sequence
• First conceptual framework for studying injuries causes and prevention, developed by William Haddon
• By studying a specific injury with this matrix in mind, one can identify modifiable risk factors and identify points of intervention in the causal sequence
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Phase-Factor Matrix cont.Phase-Factor Matrix cont.
• Much like an infectious disease:– Host=person experiencing injury– Vector=e.g. a bicycle or car– Environment=physical and socioeconomic
condition surrounding event
• Three Phases during which each factor must be evaluated:– pre-event phase– event phase– post-event phase
• Much like an infectious disease:– Host=person experiencing injury– Vector=e.g. a bicycle or car– Environment=physical and socioeconomic
condition surrounding event
• Three Phases during which each factor must be evaluated:– pre-event phase– event phase– post-event phase
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ExampleExample
Host Vector Environment
Pre-event
Event
Post-event
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Example: IngestionExample: Ingestion
Host (child)
Vector (medicine)
Environment (home)
Pre-event Age of child
How lethal
Where bottle stored
Event Manual dexterity
Child proof package
supervision
Post-event
Other medical problems
How quickly absorbed
Proximity to hospital
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Strategies for PreventionStrategies for Prevention
Intervention or countermeasures are classified based on requirements for behavior change
• Active - rely on actions taken by an individual (e.g. storing meds in high/locked cabinets)
• Passive - do not rely on the efforts of an individual to be successful (e.g. packaging meds in nonlethal amounts/child safety caps)
Intervention or countermeasures are classified based on requirements for behavior change
• Active - rely on actions taken by an individual (e.g. storing meds in high/locked cabinets)
• Passive - do not rely on the efforts of an individual to be successful (e.g. packaging meds in nonlethal amounts/child safety caps)
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Methods of Prevention - Three “Es”Methods of Prevention - Three “Es”• Engineering
• Environmental change
• Education
• Engineering
• Environmental change
• Education
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How do we do it?How do we do it?
• Office-based counseling
• Legislative advocacy
• Multisectorial woven into the fabric of communities as they develop and grow
• Office-based counseling
• Legislative advocacy
• Multisectorial woven into the fabric of communities as they develop and grow
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Primary Care Based Injury Prevention CounselingPrimary Care Based Injury Prevention Counseling
• American Academy of Pediatrics - injury prevention counseling is standard of care
• Residency Review Committee - among educational goals
• American Academy of Pediatrics - injury prevention counseling is standard of care
• Residency Review Committee - among educational goals
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Effectiveness of office-based counselingEffectiveness of office-based counseling• Comprehensive review of the literature
shows positive results– increased knowledge– improved behavior– decreases in number of certain injuries
(Bass et.al.)• Cost effective
– for each dollar invested in effective program, return $13 (Miller and Gailbraith)
• Comprehensive review of the literature shows positive results– increased knowledge– improved behavior– decreases in number of certain injuries
(Bass et.al.)• Cost effective
– for each dollar invested in effective program, return $13 (Miller and Gailbraith)
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Need for Patient EducationNeed for Patient Education
• Parents think they would be most likely to obtain safety information from physician’s office; physicians were cited as parents’ first choice for such info (Eichelberger et.al.)
• Relatively small proportion of households with young children (39.3% of 0 - 14 year olds) report receiving injury prevention counseling (Quinlan et. al.)
• Parents think they would be most likely to obtain safety information from physician’s office; physicians were cited as parents’ first choice for such info (Eichelberger et.al.)
• Relatively small proportion of households with young children (39.3% of 0 - 14 year olds) report receiving injury prevention counseling (Quinlan et. al.)
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AAP Policy Statement on Office-Based CounselingAAP Policy Statement on Office-Based CounselingCounseling as a standard of heath care• “All children deserve to live in a safe
environment”• “Anticipatory guidance for injury
prevention should be an integral part of the medical care provided for all infants, children, and adolescents”
• “appropriate to age and locale”
Counseling as a standard of heath care• “All children deserve to live in a safe
environment”• “Anticipatory guidance for injury
prevention should be an integral part of the medical care provided for all infants, children, and adolescents”
• “appropriate to age and locale”
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The Injury Prevention Program (TIPP)The Injury Prevention Program (TIPP)
• Initiated in 1983 by the American Academy of Pediatrics
• Initially for children ages birth to 4 years• October 1988 expanded to include children
age 5 to 12 years• 1994 - revised and updated to reflect the
current pattern of childhood injuries
• Initiated in 1983 by the American Academy of Pediatrics
• Initially for children ages birth to 4 years• October 1988 expanded to include children
age 5 to 12 years• 1994 - revised and updated to reflect the
current pattern of childhood injuries
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TIPPTIPP
• introduces and reinforces safety concepts in an organized manner
• emphasizes those injuries most important developmentally to help parents anticipate and prevent injuries
• Injuries covered: MV, burns, falls, firearms, drowning, poisoning, choking, bike safety, pedestrian safety
• introduces and reinforces safety concepts in an organized manner
• emphasizes those injuries most important developmentally to help parents anticipate and prevent injuries
• Injuries covered: MV, burns, falls, firearms, drowning, poisoning, choking, bike safety, pedestrian safety
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How to implement in practiceHow to implement in practice• __Discuss importance of injury prevention
to child’s health• __Give parent/child age and language
appropriate safety sheet• __Read through TIPP sheet with parent
and child (approx. 3 topics)• __Ask if any questions• __Ask if any barriers to implementing• __Document counseling in medical record
• __Discuss importance of injury prevention to child’s health
• __Give parent/child age and language appropriate safety sheet
• __Read through TIPP sheet with parent and child (approx. 3 topics)
• __Ask if any questions• __Ask if any barriers to implementing• __Document counseling in medical record
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Implementation continuedImplementation continued
• Counsel at each well child care visit and during any other appropriate patient encounter (“teachable moment”)
• Ask follow-up questions on subsequent visits to see if parents are implementing
• Counsel at each well child care visit and during any other appropriate patient encounter (“teachable moment”)
• Ask follow-up questions on subsequent visits to see if parents are implementing
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Legislative AdvocacyLegislative Advocacy
• Window guard legislation - Deaths fell by 50% in 2 years
• Aspirin packaging - Ingestion rates fell by 50% in 2 years
• Seat Belt laws enforced - Fatality rates dropped 20% vs. 8% in control states
• State booster seat law NY- traffic injuries in children ages 4 to 6 dropped 18%
• Window guard legislation - Deaths fell by 50% in 2 years
• Aspirin packaging - Ingestion rates fell by 50% in 2 years
• Seat Belt laws enforced - Fatality rates dropped 20% vs. 8% in control states
• State booster seat law NY- traffic injuries in children ages 4 to 6 dropped 18%
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Example of LegislationExample of Legislation
• “Children Can’t Fly”• Program developed by NYC DOH in
1970s• Required window bars in apts.• Rates of falls decreased 50%
• “Children Can’t Fly”• Program developed by NYC DOH in
1970s• Required window bars in apts.• Rates of falls decreased 50%
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Example of LegislationExample of Legislation
• Poison Prevention Packaging Act• 45% decrease in poisonings• How?• Childproof containers/ caps• Packaging in nonlethal doses
• Poison Prevention Packaging Act• 45% decrease in poisonings• How?• Childproof containers/ caps• Packaging in nonlethal doses
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One Doctor Can Make a Difference-
Abraham Bergman, MD One Doctor Can Make a Difference-
Abraham Bergman, MD • Flammable fabric burns
– Flammable Fabrics Act ‘67
• Aspirin poisoning– Poison Prevention Packaging Act ‘70
• Power lawn mower injuries– Consumer Product Safety Commission ‘72
• Flammable fabric burns– Flammable Fabrics Act ‘67
• Aspirin poisoning– Poison Prevention Packaging Act ‘70
• Power lawn mower injuries– Consumer Product Safety Commission ‘72
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Individuals Can Make a Difference- “Through Grief to Advocacy”Individuals Can Make a Difference- “Through Grief to Advocacy”
• Cindy Lightner- MADD• Rose Lineweaver- Crib Safety• Jeanette Fennel - Trunk Releases• Terrill Struttmann - Children in Cars• June McCarroll - Highway Center
Markers
• Cindy Lightner- MADD• Rose Lineweaver- Crib Safety• Jeanette Fennel - Trunk Releases• Terrill Struttmann - Children in Cars• June McCarroll - Highway Center
Markers
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Example of LegislationExample of Legislation
• Can occur after family tragedy• Virginian Graeme Baker Pool and
Spa Safety Act• Antientrapment Devices • Vacuum release systems
• Can occur after family tragedy• Virginian Graeme Baker Pool and
Spa Safety Act• Antientrapment Devices • Vacuum release systems
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John Stuart MillJohn Stuart Mill
• “One person with a belief is equal to the force of 99 who have only an interest”
• “One person with a belief is equal to the force of 99 who have only an interest”
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MultisectorialMultisectorial
• Most effective are programs woven into the fabric of communities
• Sweden did this as industrialized- made injury prevention part of urban planning, road construction, transportation, education, and health systems- child injury rates in Sweden are the lowest in the world
• Most effective are programs woven into the fabric of communities
• Sweden did this as industrialized- made injury prevention part of urban planning, road construction, transportation, education, and health systems- child injury rates in Sweden are the lowest in the world
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CasesCases
• A 4 month old is in your office with the parents. What are some of the topics you want to cover.
• Parents of a 5 and 8 year old come to you and want to put a pool in their backyard
• An almost 17 year old is in your office and is describing how excited she is to receive her driver’s license next week
• A 4 month old is in your office with the parents. What are some of the topics you want to cover.
• Parents of a 5 and 8 year old come to you and want to put a pool in their backyard
• An almost 17 year old is in your office and is describing how excited she is to receive her driver’s license next week
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You Can Make a DifferenceYou Can Make a Difference
• Injuries are not accidents
• Gather your “stories” to help give advice
• Patients do listen
• Injuries are not accidents
• Gather your “stories” to help give advice
• Patients do listen