Injury PreventionInjury Prevention

Mazen S. Zenati, M.D., MPH, Ph.D.Mazen S. Zenati, M.D., MPH, Ph.D.

University of PittsburghUniversity of Pittsburgh

Department of Surgery and Department of Surgery and EpidemiologyEpidemiology

Driver Fatality Rates by Age Driver Fatality Rates by Age and Gender, 1996and Gender, 1996

Trauma Death by Age & Trauma Death by Age & GenderGender

National Trauma Data Bank, Report 2002

Trauma DeathTrauma Death

Prevention. Prevention. Prevention. Prevention. Prevention.Prevention.

In Trauma The Only Treatment of In Trauma The Only Treatment of

Immediate Death Immediate Death

is Through Preventionis Through Prevention

• A reduction in therapeutically preventable deaths is the cause of trauma improvement in the past century, the future improvement will be through injury prevention

• A dramatic improvement in trauma (no error, cure most of MODF, sepsis, and pulmonary embolus) would decrease trauma mortality by 13%In contrast more than half of all deaths are potentially preventable with pre-injury behavioral changes

Stewart RM. etal. Seven hundred fifty-three consecutive death in level I trauma center: The argument for injury prevention, Journal of Trauma. 54(1):66-71;2003

Injury DefinitionInjury Definition

Injury is the unintentional or intentional Injury is the unintentional or intentional damage to the body resulting from acute damage to the body resulting from acute

exposure to thermal, mechanical, exposure to thermal, mechanical, electrical, or chemical energy or from the electrical, or chemical energy or from the

absence of such essentials as heat or absence of such essentials as heat or oxygen.oxygen.

Injury is a Major Public Health Injury is a Major Public Health ProblemProblem

The most common cause of death among people The most common cause of death among people 1- 44 years of age1- 44 years of age

The leading cause of disability and a significant The leading cause of disability and a significant contributor to the loss of productive years of life contributor to the loss of productive years of life and a major contributor to health care costand a major contributor to health care cost

Constitutes over 35% of all emergency department Constitutes over 35% of all emergency department visits and 10% of all physician office visitsvisits and 10% of all physician office visits

In the U.S. 90,000 unintentional deaths, 20,000 In the U.S. 90,000 unintentional deaths, 20,000 homicides and 20,000 suicideshomicides and 20,000 suicides

The life time cost of injuries in 1990 is estimated to The life time cost of injuries in 1990 is estimated to reach about $215 billionreach about $215 billion

Injury PyramidInjury Pyramid

Deaths

147,891

______________

Hospital discharges

2,591,000

____________________________

Emergency department visits

36,961,000

________________________________________Episodes of injuries reported

59,127,000

1/181/18

1/141/14

2/32/3

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1/4001/400 ||

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Injuries are one of the most significant public health problems not only in magnitude but also compared with other problems. Injuries kill more American children, adolescents, and young

adults than any other cause.

Source: Fingerhut LA, et al. Advance Data Number 303, October 7 1998, US Source: Fingerhut LA, et al. Advance Data Number 303, October 7 1998, US National Center for Health Statistics, International Comparative Analysis of Injury National Center for Health Statistics, International Comparative Analysis of Injury

Mortality. Findings From the ICE on Injury Statistics.Mortality. Findings From the ICE on Injury Statistics.NB: The number and particular years that go to make up each countries' estimate NB: The number and particular years that go to make up each countries' estimate

differ.differ.

Injury Globally

Injury from a Global PerspectiveInjury from a Global Perspective

Each year > 5 million people die of injuries. 2/3 are males and the majority are young adults aged 15-44

MV crashes are the largest cause of injury death.

General Model for Injury ControlGeneral Model for Injury Control

Epidemiological ModelEpidemiological Model

Injuries and the Factors Underlying

Injuries can be Examined

from an Epidemiological

Framework

Haddon Phase-Factor Matrix

Phase Host(Human)

Vector(Vehicle)

PhysicalEnvironment

CulturalEnvironment

Pre-Event

Event

Post-Event

Haddon Phase-Factor MatrixMotor vehicle crash

Phase Host(Human)

Vector(Vehicle)

PhysicalEnvironment

CulturalEnvironment

Pre-Event

AlcoholExperienceJudgment

BrakestatusTires

Nigh,RainIcy road

Acceptance ofDrinking andDriving

Event No seat belt No air bagHardness ofsurfaces

Tree too close toroad,No guard rail

Speed limitsEnforcement ofseat belt

Post-Event

Physicalcondition

Fuel systemintegrityCell Phone

Distance ofemergencyresponse

Support forTraumasystems,EMS standard

Injury Control StrategiesInjury Control Strategies

1.1. Preventing creation of the agent:Preventing creation of the agent: stop production of the agent before it can present a stop production of the agent before it can present a hazardhazard Examples: Examples:

• Highly toxic pesticides Highly toxic pesticides

• FireworksFireworks

InjuryInjury Control StrategiesControl Strategies

2.2. Reducing the amount of the agent:Reducing the amount of the agent: identifying a hazard and reducing its identifying a hazard and reducing its presence in an environment.presence in an environment.

Package toxic drugs in smaller, safe amounts Package toxic drugs in smaller, safe amounts

Reduce speed limits Reduce speed limits

Injury Control StrategiesInjury Control Strategies

3.3. Preventing release of the agent;Preventing release of the agent; reduce exposure by deterring it reduce exposure by deterring it from entering the environmentfrom entering the environment

Ban very speedy carsBan very speedy cars

Make bathtubs less slipperyMake bathtubs less slippery

Injury Control Strategies–Cont.Injury Control Strategies–Cont.

4.4. Modifying the rate or spatial distribution Modifying the rate or spatial distribution

of the agent;of the agent;

altering the mechanism by which energy is transferred to the altering the mechanism by which energy is transferred to the hosthost

• Adjust the designAdjust the design• Require automobile seatbelts and air bags Require automobile seatbelts and air bags

• Require soft playground surfaces Require soft playground surfaces

Injury Control Strategies–Cont.Injury Control Strategies–Cont.

5.5. Separating the host and agent,Separating the host and agent, in time and spacein time and space: : eliminating eliminating

contact between energy source and hostcontact between energy source and host Install pedestrian sidewalksInstall pedestrian sidewalks Reroute high speed traffic around residential neighborhoods or Reroute high speed traffic around residential neighborhoods or

slow it with speed bumps and roundabouts slow it with speed bumps and roundabouts Spray pesticides at a time of day when people aren’t aroundSpray pesticides at a time of day when people aren’t around use red light cameras use red light cameras

Injury Control Strategies–Cont.Injury Control Strategies–Cont.

6.6. Separating the agent from aSeparating the agent from a susceptible susceptible host by interposition of a material barrierhost by interposition of a material barrier

• Install fences around pools Install fences around pools

• Install cover guards on dangerous machinery Install cover guards on dangerous machinery

• Install proper guardrails along roads Install proper guardrails along roads

• Use child-proof packaging Use child-proof packaging

• Store handguns in a locked metal boxStore handguns in a locked metal box

• Use extension cords with good insulationUse extension cords with good insulation

Injury Control Strategies –ContinuedInjury Control Strategies –Continued

7.7. Modifying relevant qualities of the Modifying relevant qualities of the agentagent

Make crib slat spacing too narrow to strangle a Make crib slat spacing too narrow to strangle a childchild

• Modify equipment by rounding sharp corners Modify equipment by rounding sharp corners

Place a Barrier Between the Place a Barrier Between the Hazard and the Potential Victim:Hazard and the Potential Victim:

Child-Resistant Caps on Baby AspirinChild-Resistant Caps on Baby Aspirin

Injury Control Strategies –Injury Control Strategies –ContinuedContinued

8.8. Strengthening the susceptible Strengthening the susceptible hosthost

Improve physical condition through proper nutrition Improve physical condition through proper nutrition and regular exercise and regular exercise

Injury Control Strategies –Injury Control Strategies –ContinuedContinued

9.9. Countering the injury already Countering the injury already caused by the agentcaused by the agent

Provide emergency medical care Provide emergency medical care

Injury Control Strategies –ContinuedInjury Control Strategies –Continued

10.10. Stabilizing, repairing and Stabilizing, repairing and rehabilitating the injured hostrehabilitating the injured host Provide of appropriate acute care and Provide of appropriate acute care and

rehabilitation facilities and make them rehabilitation facilities and make them available all over the countryavailable all over the country

Proven Injury Prevention InterventionsProven Injury Prevention Interventions

Car safety seats and belts Car safety seats and belts Air bags Air bags Motorcycle helmets Motorcycle helmets Bicycle helmets Bicycle helmets Child resistant packaging Child resistant packaging Swimming pool fencing Swimming pool fencing Smoke detectors Smoke detectors Self extinguishing cigarettesSelf extinguishing cigarettes

Injury Prevention SuccessInjury Prevention Success

Residential Fire InjuriesResidential Fire Injuries • Smoke Alarm Distribution Programs Save LivesSmoke Alarm Distribution Programs Save Lives

Poison Prevention Packaging Act Poison Prevention Packaging Act

• 45% decrease in poisoning deaths 45% decrease in poisoning deaths

• Child-proof containers Child-proof containers

• Packaging in non-lethal doses Packaging in non-lethal doses

Motor Vehicle Injuries: Motor Vehicle Injuries:

• Since 1920’s Six fold increase in number of drivers Since 1920’s Six fold increase in number of drivers

• 11 times the number of motor vehicles 11 times the number of motor vehicles

• 10 times the number of miles traveled 10 times the number of miles traveled

• 90% decrease in the annual death rate per 100 million 90% decrease in the annual death rate per 100 million vehicle miles traveledvehicle miles traveled

Mantra of Injury PreventionMantra of Injury Prevention

EducationEducation TransformationTransformation Regulation Regulation Legislation Legislation Litigation.Litigation.

Injuries and Related Injuries and Related Evidence-Based Strategies for PreventionEvidence-Based Strategies for Prevention

Injury involving Motor VehiclesInjury involving Motor Vehicles• Alcohol-Impaired DrivingAlcohol-Impaired Driving• Seat Belts and Air BagsSeat Belts and Air Bags

MotorcyclistsMotorcyclists PedestriansPedestrians Bicycling InjuriesBicycling Injuries Playground InjuryPlayground Injury PoisoningPoisoning FireFire Injury from FirearmsInjury from Firearms DrowningDrowning FallsFalls

FallsFalls 65% of persons who die 65% of persons who die

from falls are > 65from falls are > 65 Account for 87% of all Account for 87% of all

fractures in older adultsfractures in older adults 1 of 5 falls resulted in direct 1 of 5 falls resulted in direct

impact on the hipimpact on the hip Hip fracture is the most Hip fracture is the most

frequent consequencefrequent consequence Osteoporosis facilitates Osteoporosis facilitates

fracturesfractures The risk of Osteoporosis The risk of Osteoporosis

for 50-years WFW is 40%for 50-years WFW is 40%

Risk Factors:Risk Factors: History of previous fallsHistory of previous falls cognitive impairmentcognitive impairment chronic illnesschronic illness balance and gait balance and gait

impairmentimpairment a low body-mass indexa low body-mass index female sexfemale sex general frailtygeneral frailty use of diureticsuse of diuretics use of psychotropic use of psychotropic

drugsdrugs hazards in the homehazards in the home

Prevention of Falls & its Prevention of Falls & its ConsequencesConsequences

Prevention of osteoporosis,.. Early in lifePrevention of osteoporosis,.. Early in life Adequate Ca intake with vitamin D in ChildhoodAdequate Ca intake with vitamin D in Childhood Ca (1.2g) and Vit. D3 (800 IU) daily, reduces the risk of hip fracture Ca (1.2g) and Vit. D3 (800 IU) daily, reduces the risk of hip fracture

in elderly by 23%in elderly by 23% Hormone-replacement therapy may also be effectiveHormone-replacement therapy may also be effective Hormone-replacement has 25% reduction in hip fractures. (estrogen Hormone-replacement has 25% reduction in hip fractures. (estrogen

or with progesterone)or with progesterone) Thiazide diuretics my prevent hip fracture (Thiazide diuretics my prevent hip fracture (ca excretion)ca excretion) Furosemide may increase that riskFurosemide may increase that risk No evidence of the effect of calcitonin, fluoride & etidroneNo evidence of the effect of calcitonin, fluoride & etidrone

Weight-bearing exercise, Weight-bearing exercise, 40-50% HF reduction40-50% HF reduction

50% of Prevention in Behavior!50% of Prevention in Behavior!

General Determines of Health

Access to Care10%

Environment20%

Genetics20%

Behavior50%

Prevention Through Leading a Prevention Through Leading a Healthy LifeHealthy Life

The 5 “Es” of Incident The 5 “Es” of Incident PreventionPrevention

EEpidemiology: you can’t prevent it if you don’t pidemiology: you can’t prevent it if you don’t understand it. Data collection is key.understand it. Data collection is key.

EEducation: awareness, attitudes, cultural ducation: awareness, attitudes, cultural beliefsbeliefs

EEnforcement: rules, life safety codes etc.nforcement: rules, life safety codes etc. EEngineering: changing the environment to ngineering: changing the environment to

make it safermake it safer EEvaluation: did the changes made in valuation: did the changes made in

education, enforcement, and engineering have education, enforcement, and engineering have the desired outcome on incidence?the desired outcome on incidence?

Mechanism of Injury effects Mechanism of Injury effects Trauma OutcomeTrauma Outcome

Hospital length of stay grouped by mechanism of injury. Blue bars represent blunt mechanisms of injury. Green bars represent violent mechanisms of injury. Red bar represents burns.

National Trauma Data Bank2002 Report

Examples of State and Local Laws

Prohibit Require

Human Factors(People)

Drug racing Seatbelt Use

Vehicle/Agent(Things)

Speedometersregistering over80 m.p.h.

Specified maximumwindow tint

Environment(Places)

Rigid barrierswithin specifieddistance of roadway

Break-away signposts, soft bridgerail end points

Trauma Who is at faultTrauma Who is at fault

GodsGods mortalmortal environmentenvironment designerdesigner governmentgovernment medical teammedical team

Trauma is no accident but is our trainingTrauma is no accident but is our training