Trauma & Injury Prevention Section Newsletter - August 2011
Chair’s Corner - Trauma & Injury Prevention Section Newsletter, August 2011
Brendan G. Carr, MD, MS
Thanks for your interest in the ACEP Trauma & Injury Prevention Section – we hope you enjoy our newsletter. As you will see below, our section covers a broad range of interests – from injury prevention research to work exploring trauma system design. The section is a home to many of the researchers working at CDC funded injury centers as well as to public health minded practitioners, those interested in injury prevention, trauma management, and the policy issues that touch these domains. I have two requests for the readers of this newsletter and membership of the section. We would like to have a guest speaker again at the 2011 Scientific Assembly, and I would like us to submit a section grant on behalf of the TIPS (deadlines are typically in February). Please contact me with suggestions about speakers or with ideas for proposals for section grants so that we can begin to assemble an agenda for our annual meeting. Thanks for your ongoing support of trauma care and injury research. I look forward to another great year and to seeing you in San Francisco.
Crash Injury Disparities in Latino Youth - Trauma & Injury Prevention Section Newsletter, August 2011
Federico Vaca, MD, MPH
Yale University Department of Emergency Medicine
Recent reports by both the US Department of Health and Human Services and the Institute of Medicine reveal a slow progress towards eliminating health disparities.1-3 This has significant implications for the US Latino population, particularly because this population growth has already outpaced both the elimination of health disparities in several areas as well as the overall US population growth. The 2010 Census shows that the US Latino population grew by 43% as compared to 5% of the non-Latino population to consist of more than 50 million.4 This growth accounted for more than half of the entire U.S. population growth reported from 2000-2010. Latinos now make up 16% of the nation’s population, and that population is expected to triple by 2050.
The ongoing rapid growth of US Latinos continues to drive the interest of public health researchers to more clearly understand social determinants of health (risk and resilience) particularly in this historically vulnerable population. While significantly more is known and published in the area of Latino health in reference to childhood obesity, hypertension, diabetes, and cardiovascular disease, the same cannot be said about traumatic injury. In particular, considerably less is known about injury disparities in US Latinos in the context of motor vehicle crashes despite being the leading cause of death for them from ages 1-44 years.
For over 15 years, the US Department of Transportation’s National Highway Traffic Safety Administration has been calling attention to the eventual greater contribution of fatal crashes involving US Latinos. Two of our recent epidemiological studies that have focused on young Latino males where crash injuries have shown this fatal trend has come to fruition.5,6 Ongoing concern for the well being of Latino adolescent and young adult drivers has prompted broader educational outreach to Latino youth and their parents by both government and non-government agencies. However, much more work is needed to understand the context in which these youth and their families are making decisions about crash injury prevention and initiation to driving.
In an attempt to better understand the dynamics of injury risk and harm reduction that Latino adolescents face in a traffic safety context, we are currently using a mixed-methods approach to study these youth at the “intersection” of Latino culture, youth culture, and developmental factors that influence the risk of crash injury. Taking an ethnographic approach coupled with quantitative measure of acculturation and risk taking propensity factors we hope to gain greater insights that could be integrated into the development of more effective culturally adapted interventions.
- U.S. Department of Health and Human Services. Healthy People 2010 Midcourse Review. Washington, DC: U.S. Government Printing Office, Washington, DC 2006.
- Institute of Medicine (IOM). Examining the Health Disparities Research Plan of the National Institutes of Health. Washington, DC, 2006.
- Institute of Medicine (IOM). Challenges and Successes in Reducing Health Disparities: Workshop Summary. Washington, DC, 2008.
- Humes KR, Jones NA, Ramirez RR. "Overview of Race and Hispanic Origin: 2010, 2010 Census Brief." Washington, D.C.: U.S. Census Bureau; 2011.
- Vaca FE, Anderson CL, Hayes-Bautista DE. The Latino adolescent male mortality peak revisited: attribution of homicide and motor vehicle crash death. Inj Prev. 2011 Apr;17(2):102-7. Epub 2010 Dec.
- Vaca F, Anderson CL. U.S. motor vehicle fatality trends in young Latino males. Ann Adv Automot Med. 2009 Oct;53:77-82.
Child Passenger Safety and the ED - Trauma & Injury Prevention Section Newsletter, August 2011
Michelle L. Macy, MD, MS
Department of Emergency Medicine
University of Michigan
Motor vehicle collisions (MVCs) remain a leading cause of death in children after the first year of life and the leading cause of death among children older than 3 years.1 In addition, more than 140,000 children younger than 13 years old are seen in US hospital emergency departments (EDs) each year for non-fatal injuries sustained as occupants in MVCs.2 At the University of Michigan, we have conducted a national survey of more than 600 emergency physicians and found that 90% agreed with the statement “It is my role as an emergency physician to educate parents about child passenger safety and child safety seats.”3 Nearly half agreed that “Parents should receive information about child passenger safety at ED discharge regardless of the reason for visit.”
Recently, there has been increased interest among emergency care providers and patients in an expanded role of the ED to promote public health, with an emphasis on the vital importance of injury prevention efforts. As MVCs are a leading cause of death and severe injury among US children, ED-based interventions that promote size-appropriate child passenger restraint use must become a top priority.
In April 2011, the American Academy of Pediatrics published updated guidelines for child passenger safety.45 Parents are now encouraged to 1) keep their children rear-facing until 2 years of age or they reach the highest weight or height allowed by the manufacturer of their rear-facing child safety seat, 2) use a forward-facing car seat with a 5-point harness for as long as possible up to the highest weight or height allowed by the manufacturer of the seat, 3) use a booster seat from the time their children outgrow their car seat until they fit in an adult seat belt, typically when they have reached 4’9” tall (the average height of an 11 year old 6), and 4) always ride in the back seat until age 13.
The National Highway Traffic Safety Administration’s 2009 National Survey of the Use of Booster Seats shows that about one-third of 4- to 7-year-old children ride in a seat belt when they would likely benefit from a booster seat and less than 10% of 8- to 12-year-olds use child safety seats.7 In addition, 1 in 5 children under 1 year and less than 20 pounds were prematurely turned to a forward-facing position (based on the historical size to transition from rear to forward-facing). A similar proportion of children were transitioned to a booster seat when they were of a weight that would be appropriate to continue riding in a forward-facing car seat.
Clearly new approaches are needed to motivate size-appropriate child safety seat use in the United States. The ED visit is unique opportunity to reach at-risk children and their parents. ED visits are frequent among children and associated with poor access to primary care. As a result, their parents may not be exposed to injury prevention messages delivered in physician offices, historically, the health care setting for childhood injury prevention programs.
We are currently conducting a pilot study of parents of 1- to 12-year-old children in the EDs at the University of Michigan, Ann Arbor, MI and the Hurley Medical Center, Flint, MI to determine 1) the family characteristics associated with not using a size-appropriate child passenger restraint and 2) the impact of an ED-based referral to a child safety seat inspection program. This pilot work will inform the development of a brief family-centered ED-based child passenger safety intervention focused on motivating parents to use the size-appropriate restraint for their child on every trip. Improving proper child passenger restraint use will lead to reductions in the number of US children who suffer unnecessary death and disability as the result of MVCs.
- Centers for Disease Control and Prevention, Ten Leading Causes of Death and Injury Charts, 2007 Causes of Death By Age Group and Causes of Injury Death: Highlighting Unintentional Injury. Available at: http://www.cdc.gov/injury/wisqars/LeadingCauses.html. Accessed January 25, 2011.
- Injury Prevention and Control: Data & Statistics. Web-based Injury Statistics Query and Reporting System (WISQARS) 2008; http://www.cdc.gov/injury/wisqars/index.html. Accessed January 25, 2011.
- Macy M, Clark S, Freed G. Emergency Physician Perspectives on Child Passenger Safety. Annual Meeting of The Society for Academic Emergency Medicine. Boston 2011.
- Durbin DR. Technical Report Child Passenger Safety. Pediatrics. April 2011;127(4):e1050-1066.
- AAP. American Academy of Pediatrics, Committee on Injury Violence and Poison Prevention. Policy Statement - Child Passenger Safety. Pediatrics. April 2011;127(4):788-793.
- Centers for Disease Control and Prevention, National Center for Health Statistics. CDC growth charts: United States. 2000; http://www.cdc.gov/growthcharts/. Accessed May 3, 2010.
- Pickrell TM, Ye T. The 2009 National Survey of the Use of Booster Seats: National Center for Statistics and Analysis, National Highway Traffic Safety Administration; September 2010.
Mobile Phone Text Message Program - Trauma & Injury Prevention Section Newsletter, August 2011
Brian Suffoletto, MD
Department of Emergency Medicine
University of Pittsburgh
Mobile Phone Text Message Program to Reduce Risky Drinking in Young Adults Discharged from the ED
The majority of young adults and college students drink alcohol at hazardous levels, resulting in a high risk for alcohol-related injury. Young adults seek care in the Emergency Department (ED) more than any other age group, offering a unique opportunity to screen them for hazardous drinking and intervene to reduce future risk. Brief interventions are recommended in the ED and mandated in all Level I trauma centers, but are rarely performed. As well, single session brief interventions for alcohol may not have a lasting effect on alcohol consumption. Mobile phones are ubiquitous and text-messaging (TM) is used as the primary mode of communication among young adults. TM-based drinking assessments have the potential to improve both subject participation and validity of alcohol consumption reports.TM-based interventions can provide real-time feedback with goal setting to improve health behavior and may also be more acceptable to young adults. TM-based programs can utilize health information technology, allowing for low-cost, large scale implementation. We designed an automated system that performed health dialog with participants, collecting weekly alcohol consumption information and providing immediate feedback as well as offering the ability to set short-term drinking reduction goals. We conducted a study where 45 young adults identified as hazardous drinkers in the ED were randomly assigned to receive either an informational packet, weekly TM drinking assessments for 12 weeks, or weekly TM assessments with immediate feedback and goal-setting for 12 weeks. Young adults in the TM groups provided alcohol consumption data with high fidelity and found the program useful and safe. Participants in the TM feedback group had a significant reduction in their binge episodes and drinks per drinking day from baseline to 3-months. Young adults who reported a week of risky drinking in the TM feedback group were willing to set a goal to reduce their drinking half of the time, and when they did set a goal, had a significantly lower rate of risky drinking the following week. These finding support large-scale interventions using TM to reduce hazardous drinking and associated harms in young adults.
This study was funded by the Emergency Medicine Foundation.
News from the Emory Center for Injury Control - Trauma & Injury Prevention Section Newsletter, August 2011
Deb Houry, MD, MPH
Director, Emory Center for Injury Control
This year has been another extremely productive year for the Emory Center for Injury Control. We’ve continued to have 50+ people at our quarterly meetings and great attendance at all of our brown bag lectures and other events. This spring we kicked off the season with a fantastic lecture from Dr. Jackson Katz, a leader in the field of gender violence prevention. Katz spoke about the bystander approach and his strategies to reach out to young men to help prevent men's violence against women. With media clips and discussion around the language used in our culture, Katz brought home the message of men taking responsibility for violence. In addition, Linda Degutis, the new director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, spoke at our spring quarterly meeting about the NCIPC agenda and plans for the upcoming year.
Our research portfolio continues to expand. We funded 5 pilot projects on a range of topics including drowning prevention in children, developing a city wide gang intervention, and screening athletes for concussions. We also funded 3 summer student scholarships to work on a variety of unintentional and intentional injury research projects. Our ongoing projects through our center grant include a Preventive Intervention for Victims of School-Based Bullying; Acute Care Early Intervention to Prevent PTSD in Trauma Patients in the Emergency Department; Valuing Child Maltreatment Outcomes for Use in Economic Evaluations; Young Drivers in Georgia: Before and After the Teenage and Adult Driver Responsibility Act; Preclinical Assessment of Progesterone Treatment for Pediatric Traumatic Brain Injury; and Organizational and Patient Level Factors Associated with the Adoption and Implementation of Unstaffed Computer Kiosks in Emergency Department Waiting Rooms. We published many of our center’s research projects in the July 2011 special Emory Center for Injury Control issue of Western Journal of Emergency Medicine.
On behalf of Emory University, the ECIC is applying for a Safe Communities designation through the Safe Communities America Network, a program of the National Safety Council. We have been holding meetings with campus police, EMS, student health, and other organizations to coordinate campus injury prevention efforts. Finally, this summer we are launching a three and a half day training program for our injury prevention practitioners focused on skill building in grant writing, program evaluation, and injury policy.
For more information on our Center, please check out www.emorycenterforinjurycontrol.org
Mapping access to trauma care - Trauma & injury Prevention Section Newsletter, August 2011
Catherine Wolff, BA EMT-B
Center for Clinical Epidemiology and Biostatistics
Perelman School of Medicine, University of Pennsylvania
Mapping access to trauma care: an interactive tool for system planning and evaluation
Trauma systems have been recognized as a model of care by the Institute of Medicine and have been demonstrated to decrease injury-related mortality. The system includes not only trauma centers but also complicated care systems that attempt to ensure patients receive treatment at an appropriate facility in a timely manner. Despite the many advances in trauma care over the last several decades, however, the system remains in need of improvement.
One of the CDC’s Healthy People 2020 goals is to increase access to trauma care within an hour to 91.4% of the national population. Currently, about 87% of all Americans have access to definitive trauma care within an hour. To reach the CDC goal, planners will need to develop a comprehensive understanding of where trauma care is currently available, and then evaluate potential opportunities to improve access to and optimize care for injured Americans. To that end, using the national inventory of trauma centers maintained by the American Trauma Society’s Trauma Information Exchange Program (TIEP) in conjunction with a national database of all medical helicopter services, the University of Pennsylvania has developed a web-based mapping application that provides a basic visual representation of population and geographic access to trauma centers in the US.
This application allows users to see locations of all levels of trauma centers, both those accredited by the American College of Surgeons (ACS) and by the states. It also includes the locations of acute care hospitals and helipads, as well as geographic borders for states, counties, zip codes, and voting districts. The shaded portions on the map, representing areas where access to a Level I/II trauma center is available by air or ground ambulances within 60 minutes, can be altered to show access within 45 minutes, access with ground ambulances only, or access with air ambulances only. Users can also choose whether to allow crossing of state borders, as well as change the street map to a satellite or basic view. Navigation and measurement tools, as well as export, search, and identify functions, provide further support for those seeking to obtain a comprehensive understanding of trauma system coverage in their area. In upcoming months users will also be able to view actual injury burden at a local level, to further inform where improvements in coverage should be targeted as injury burden is not geographically uniform across states and regions in the US.
To learn more about this research please visit our website at http://venus.cml.upenn.edu/trauma/home.html or email Catherine Wolff at firstname.lastname@example.org
Getting Bang for your Buck from Trauma Care - Trauma & Injury Prevention Section Newsletter, August 2011
M. Kit Delgado, MD
Stanford University School of Medicine
Getting Bang for your Buck from Trauma Care: Insights from Fellowship Research in Cost-Effectiveness Analysis
While trauma is the number one cause of potential life years lost before the age of 65 and has the highest cost of any illness according to the NIH, there is a relative lack of research on the cost-effectiveness of trauma care compared with other specialties such as cardiology or oncology.1,2
One reason for this disparity is that emergency physicians and trauma surgeons have traditionally been under-represented in health services research fellowship programs that offer training in decision and cost-effectiveness analysis. For example, at the national Agency for Health Care Research and Quality (AHRQ) trainee conference this past June, only 3 of the 150 attendees were trained in emergency medicine.
The AHRQ T32 institutional training program funds the most widely available fellowship program in health services research with grants to 25 US universities supporting over 150 fellowship positions.3 TIPS newsletter readers may be surprised to know that most of these institutions are affiliated with academic emergency medicine programs and that there may be a program at their institution.
The AHRQ training programs provide trainees with 2-3 years of support including office space, a National Research Service Award (NRSA) stipend, benefits, tuition for a master’s degree in health services research, and funds for travel and research related expenses. There are no clinical service requirements, but there is time to keep up clinical skills and make some supplemental income in the ED. Coursework includes applied training in biostatistics, health economics, decision analysis and modeling, and technology assessment.
So entering my third year of fellowship at Stanford University, what have I learned so far?
- Transporting trauma victims by helicopter rather than ground ambulance from scene of injury to a trauma center is more cost-effective than dialysis for end stage renal disease if on average more than 1 death is prevented for every 100 transports. These preliminary findings were presented at the National Association of EMS Physicians and Society for Medical Decision Making.
- If a moderately to severely injured patient ends up at non-trauma center ED, it is almost always more cost-effective to transfer them to a trauma-center despite the fact that trauma center care costs almost twice as much as non-trauma center care. These preliminary findings were presented at the SAEM Western Regional Meeting.
- If the U.S. prehospital system could reduce the overtriage of minor trauma victims to trauma centers by 25%, this would save the U.S. around $5 billion dollars.
In summary, there may be an AHRQ training program near you providing hands-on training in cost-effectiveness analysis and health services research, both of which will become increasingly important with the current budget picture. Please contact me if you are interested in learning more about my experience in AHRQ/health services research fellowship training.
- CDC Web-based Injury Statistics Query and Reporting System (WISQARS™). US Department of Health and Human Services, Centers for Disease Control and Prevention
- National Institutes of Health, Costs of Illness and NIH Support For Selected Diseases and Conditions, February 11, 2000.
- Agency for Health Care Research and Quality Institutional Health Services Research Training Programs (T32s): http://www.ahrq.gov/fund/training/t32.htm