Key points

Introduction

Injury is the principal cause of morbidity and mortality in children in the United States. In fact, injuries cause more deaths in children and youth than all diseases combined. Unlike cancer, cardiovascular disease, and other chronic illnesses, injuries disproportionately affect children. It is estimated that more than 9000 children aged 0 to 19 years will die from an injury each year. Unfortunately, deaths are only the tip of the injury problem, as more than 8 million nonfatal injured patients will seek care annually at United States emergency departments (EDs). Injuries requiring any medical attention or resulting in restricted activity affect approximately 20 million children and adolescents, and cost roughly $17 billion annually in medical costs. Injury is the result of any intentional or unintentional damage to the body resulting from some type of external force. Thus, most injuries that may result in catastrophic bodily damage are due to mechanisms of great velocity, or can occur rapidly with minimal exposure. It is necessary to identify the best setting and technique for the prevention of injuries to children because they result in such extensive morbidity and death.

Introduction

Injury is the principal cause of morbidity and mortality in children in the United States. In fact, injuries cause more deaths in children and youth than all diseases combined. Unlike cancer, cardiovascular disease, and other chronic illnesses, injuries disproportionately affect children. It is estimated that more than 9000 children aged 0 to 19 years will die from an injury each year. Unfortunately, deaths are only the tip of the injury problem, as more than 8 million nonfatal injured patients will seek care annually at United States emergency departments (EDs). Injuries requiring any medical attention or resulting in restricted activity affect approximately 20 million children and adolescents, and cost roughly $17 billion annually in medical costs. Injury is the result of any intentional or unintentional damage to the body resulting from some type of external force. Thus, most injuries that may result in catastrophic bodily damage are due to mechanisms of great velocity, or can occur rapidly with minimal exposure. It is necessary to identify the best setting and technique for the prevention of injuries to children because they result in such extensive morbidity and death.

History of injury prevention

The concept that injuries are a public health problem that can be prevented in the same fashion as disease is recent. Most injury-prevention interventions in the past concentrated solely on attempting to have the subject change behavior. Much of the advice offered to parents encouraged them to “be careful.” In the early 1920s and 1930s, most home and traffic safety efforts were primarily in the form of pamphlets and posters attempting to persuade individuals to change their actions. However, these interventions showed little effect, and new ideas to change other external factors besides subject behavior, so that force could be minimized, was sought. This concept was first introduced by Hugh DeHaven, a World War I pilot survivor. He showed that pilots who fell hundreds of feet, despite their individual factors, were more likely to survive if the force was distributed and the impact reduced. Dr John Gordon, an epidemiologist at Harvard in the mid-nineteenth century, studied the distribution and causes of injury in the same way as for classic infectious diseases. He concluded that any effect on the environment, the host, or the agent could minimize the injury suffered by the individual. Dr William Haddon, the “grandfather of injury prevention,” agreed with controlling different factors to prevent injury, and further described that these variables could be controlled before the injury event occurs (primary prevention), at the time of the event (secondary prevention), or after the injury takes place (tertiary prevention) to minimize morbidity and mortality. Many injury-prevention experts use Haddon’s concepts or matrix to determine which interventions can be used at different times, thus to have the greatest impact on reducing injury ( Table 1 ).

As a result of the work of injury-prevention experts such as Gordon and Haddon, many experts today concentrate on the “4 Es” when designing injury-prevention interventions: Education, Engineering/technology, Enforcement/legislation, and Environmental modifications. Although the greatest change in reducing injury has been shown in manufacturing new safety products that address specific concerns (eg, booster seats, changing bicycle handlebars) and legislation to encourage specific safety behaviors (eg, drinking and driving laws), education about potential risks that encourage individuals to actively change their behavior continues to be an important aspect in preventing injuries.

Setting for injury-prevention education: primary care office versus the ED

Typically, the task of educating families and children about injury risks has fallen on the pediatrician/primary care provider (PCP) during well-child visits as anticipatory guidance is discussed. Unlike educational efforts in the form of public service announcements, educational interventions in the office setting have been shown to be effective for certain injury problems, such as car-seat use, smoke-detector ownership, and adjusting the temperature of hot water from taps. Unfortunately, according to most of the literature, the benefits of educating families and encouraging behavioral change in the office setting have been small and commonly dissipate over time.

The American Academy of Pediatrics TIPP (The Injury Prevention Program) is one of the best known office-based injury-prevention programs, as it helped to integrate the developmental stages of infants and children with the types of injuries to which they are susceptible. A combination of screening for risk, provider education for the specific injury, and brochures are used to educate the family at the appropriate time during a well-child visit. Success for the TIPP program included improving family knowledge of injury-prevention topics within diverse groups. Barriers have been the dissemination of the program to pediatric trainees and the cost of the program to the practicing physicians or clinics. In general, barriers cited for not providing adequate injury prevention in the primary setting include time, choice of topic on which to counsel, lack of pediatrician education on the topic, and competing priorities for anticipatory guidance.

Innovative primary physicians have moved from efforts at education alone to providing more hands-on assistance or providing safety products along with education to increase effectiveness. Quinlan and colleagues discussed car-seat use with families while he developed systems in which the primary care visit is linked to car-seat checks. In this study, through the use of car-seat checks at the primary care clinic, use of in-car restraint systems increased from 17% among infants to 50% among toddlers and to 88% among children who should have been using a booster seat. In addition, in a subset that underwent evaluation, researchers found that there was a significant positive effect on use of in-car restraint systems at follow-up. Another innovative intervention in the primary care setting allowed families to practice “hands-on” safety practices. In a randomized trial, Powell and colleagues showed increased injury-prevention knowledge among a group of families with children younger than 6 years, by offering home safety education using a “safe home” toolkit in a dermatology clinic waiting room. In these interventions where education was linked with written or hands-on injury-prevention products, greater behavioral change was demonstrated in the primary care settings.

Recently, physicians have proposed that ED staff, not solely PCPs in their office, should educate families about injury prevention during ED visits. ED physicians care for the more seriously injured patients, making them well suited to discuss prevention. Furthermore, families of lower socioeconomic status are at increased risk for being more seriously injured, and it is these patients who disproportionately use urgent care or EDs for their medical management. Adolescents, an extremely high-risk group for deaths caused by injury, also often use the ED as their sole source of care. If these higher-risk families and patients are seeking care in the ED, they are likely not receiving the appropriate injury-prevention anticipatory guidance from their PCP. The ED has promise as a venue for injury screening and education to occur because it is located in a medical setting that can often meet the needs of the patient, offer resources when appropriate, and even potentially provide safety product(s) if available.

Several investigators have described that families value and use the injury-prevention education they have received in the ED setting. One example of a successful ED primary prevention educational intervention was completed by Quan and colleagues. In this study, parents received computerized discharge instructions regarding 3 drowning-prevention strategies (wear a life vest, swim in safe areas, and do not drink alcohol while swimming and boating). Ninety-seven percent of parents recalled receiving the safety information and 60% found that the information was “very useful” when contacted 1 to 2 weeks later. In addition, 35% of parents reported considering the purchase of life vests for their children. Of note, there were no differences in how parents perceived the information based on their child’s illness severity or other demographics. Another research group examined the time needed to screen for injury-prevention practices and the value of educating a group of patients and families arriving at a pediatric trauma center. Screening took just 2 minutes, the injury-prevention intervention took 9 minutes, and most families remembered the injury-prevention messages 3 months after the intervention. The knowledge that families value injury-prevention interventions, that most EDs have resources to provide injury-prevention messages, and that many at-risk patients present to EDs helps to build the case that the ED is an excellent setting within which to provide educational interventions regarding injury prevention.

Models for education on behavioral change

In focusing on opportunities for the ED staff to provide injury-prevention education, it is important to consider behavioral-change models that may be applicable to addressing the host (patient) described in the Haddon matrix. Several models and theories have been identified to promote injury prevention that can be applied to preventing injuries and other health risks: (1) Health Belief Model, (2) Social Cognitive Theory and Injury, (3) Stages of Change Model, and (4) Teachable Moment.

Successful ED interventions

So, how might behavioral change theory be applied to the pediatric patient seen in the pediatric ED? Using the Teachable Moment model, one may suspect that the visit for an injury may prompt patients and their families to take greater action to prevent future injuries, and providers may be interested in discussing these strategies at the time of the ED visit. One study examining children presenting to the ED after ingestion found that only 25% of families received verbal instruction about poisoning prevention, and that this education was more likely to occur in urban academic EDs rather than in rural or suburban hospitals. Another study using the Teachable Moment theory in the ED was a case-control design among children in minor vehicle crashes. This study actually showed no difference between the injured group and the control group in adopting booster seats following the ED intervention. Most importantly, is that both groups of children, whether injured or not, had improved by almost 50% their ownership and use of booster seats following the ED educational intervention. One limitation noted by the investigators was that the children in the intervention group had such minor injuries that their teachable moment may not have been much different to that of the controls. In examining the teachable moment among assault victims at 2 different urban EDs, Johnson and colleagues noted that youth and parents found their ED visit moderately stressful and that using a Teachable Moment Index may help assess which patients would be most amenable to a violence-prevention intervention.

Some EDs have used computerized kiosks to better screen for risk and to minimize the discussion required by staff while in the ED. The idea behind these kiosks is similar to the notion of the TIPP program used by PCPs; however, by being computerized, tailored printouts about behavioral change can be offered. In one ED, psychologists and ED physicians developed a kiosk in which adolescents responded to a mental health screen to identify youth at risk for suicidal thoughts. Providers could then use the screen to direct resources and care to prevent a potential suicide attempt. Gielen and colleagues conducted a randomized controlled trial of using a kiosk in a pediatric ED. The kiosk tested also allowed for both screening of the risk for injury and the provision of tailored information on injury prevention. The investigators found that low-income families in their study were able to use the kiosk and that those who received injury-prevention information were likely to read and share this information with others. Moreover, the kiosk screening was endorsed by families and did not interfere with patient care. These kiosks offer an opportunity for screening and providing injury-prevention information to families who are waiting for care in the ED, with little need for staff interaction during the educational process.

Similar to work done by Quinlan in the primary care setting, EDs have found that providing education in conjunction with offering safety products entices greater behavioral change by families. Posner and colleagues conducted a randomized home-safety intervention within their ED. In this intervention, parents were provided either with comprehensive home-safety education coupled with free safety equipment or focused, ED-specific discharge instructions on injury prevention. Families who received the more comprehensive education and the free safety equipment improved more in pretesting and posttesting of their injury-prevention knowledge, and were also much more likely to report using the free safety equipment following the ED visit. Another study in which products were provided to families in the ED in conjunction with education was done by Gittelman and colleagues in Cincinnati. In this randomized controlled trial, children of booster-seat age who did not use a booster seat were randomly assigned to 1 of 3 groups: (1) received standard discharge instructions (control); (2) received a 5-minute booster-seat training (education only group); or (3) received a 5-minute booster-seat training and a free booster seat (education and product group). At follow-up, only 1% of the control parents and 9% of the education-only parents purchased and used a booster seat after their pediatric ED visit, whereas 98% of parents in the education and product group reported using the booster seat; 75% of these parents reported using the seat 100% of the time. Providing free or reduced-cost safety equipment with education can promote a greater likelihood that the family will practice optimal injury-prevention strategies after their ED visit.

To provide families with safety equipment in the ED setting as education about injuries is offered, some pediatric EDs have opened safety resource centers, located either in the waiting room of their busy ED or in the lobby of the children’s hospital. While families are waiting to be brought to an ED room, this allows a special opportunity to provide safety education and products to families. In some sites, brochures and safety products such as bicycle helmets, cabinet locks, and car safety seats are available at discounted prices, or in some cases free to low-income families. Some centers are staffed by injury-prevention specialists who are available to answer questions and dispense safety products with advice on how to use them. At present, 29 children’s hospitals have safety centers somewhere in their institution, with varying hours of operation. Although staffing these safety centers is not without cost, the stores who have a staff person available for busy times of the day are more likely to be successful in dispensing both information and safety products.

Although motivational interviewing techniques can be time consuming for the ED staff, several studies have used this model with some success. Initially, successes using this technique were used to alter behavioral risk factors around smoking, diet, and alcohol use, but newer studies have looked at preventing injuries. The patient-centered interview is conducted at a time when the patient may have reasons to change behaviors, “by helping clients to explore and resolve ambivalence.” Johnston and colleagues successfully showed that a brief session of behavior-change counseling offered in the ED changed injury-related risk behaviors and the risk of reinjury with regard to the use of bicycle helmets and seat belts. Although training to perform motivational interviewing demands time and staff interest, many hospitals and EDs have been able to train champions who can then serve in that role when a patient is identified. By investing in motivational interviewing resources, EDs have the opportunity to prevent injuries and decrease future injury costs.