Pediatric Injuries in Central Texas
The Journal - September 2009
Tex Med. 2009;105(9):e1.
By Kelly M.K. Johnson, MS; Karla A. Lawson, PhD; Paula Yuma-Guerrero, MPH; Michelle Prince, MD; and R. Todd Maxson, MD
Ms Johnson, Dr Lawson, Ms Yuma-Guerrero, and Dr Maxson, Trauma Services, Dell Children's Medical Center, Austin, Tex; Dr Prince, Central Texas Pediatrics, Austin, Texas. Send correspondence to Karla A. Lawson, PhD, Trauma Services, Dell Children's Medical Center, 4900 Mueller Blvd, Austin, TX 78723; e-mail: firstname.lastname@example.org .
In Texas, more children aged from 1 through 14 years die from injury-related causes than from the next 9 causes of death combined. Injuries to children hospitalized in Central Texas during 2003 and 2004 were caused predominantly by falls and motor vehicle collisions (MVCs) and resulted in a large number of fractures and open wounds. Fifty-six Central Texas children died in 2003 and 2004 after reaching the hospital, out of a total of 175 children killed in injury-related events during this period. Most injury-related deaths were due to a traumatic brain injury. Most of the children suffering injury in MVCs were not restrained at the time of the accident. Injury data are invaluable to injury prevention efforts. These data were gathered from the Public Use Data File maintained by the Injury and EMS/Trauma Registry Group at the Department of State Health Services; limitations of the data set are discussed, and implications for injury prevention are highlighted.
In the United States, unintentional injury has long been the leading cause of death for people between the ages of 1 and 44 years.1 In 2005, injuries accounted for 3.7 million years of potential life lost.2 As a result of injuries that occurred in the United States during the year 2000, an estimated $326 billion in productivity will be lost.3 The injury burden is especially high in the pediatric population. In 2005, there were 4,079 unintentional injury-related deaths in children aged 1 through 14 years.4 In the same year, homicide and suicide accounted for an additional 986 deaths in this age group. The total lifetime medical cost of pediatric injuries in the United States in 2000 reached nearly $12 billion. 3 In Texas in 2004, more children aged 1 through 14 years died from injury-related causes than from the next 9 causes of death combined. 5
The objective of this study was to describe the circumstances surrounding injury-related hospitalizations of pediatric patients within a 46-county Central Texas region, including mechanisms of injury, patient demographics, and medical outcomes. Secondarily, we examined the use of protective devices by patients injured in MVCs, off-road vehicle accidents, and bicycle accidents.
The data set used in this study was obtained from the Injury and EMS/Trauma Registry Group (IETRG), housed within the Texas Department of State Health Services (DSHS), through a request for de-identified data from the Public Use Data File.6 The data included in this registry are submitted by Texas hospitals, which are required to submit data for all trauma cases where the patient died or arrived dead, was admitted to the inpatient setting, was transferred in to the reporting hospital, or was transferred out to another hospital. 7 Detailed requirements for data reporting are described elsewhere.8 Our data request included patient demographics (age, gender, race/ethnicity, and insurance status), injury event specifics (mechanism of injury and use of a protective device), and medical outcomes (injury severity score, length of stay, clinical diagnoses, and condition at discharge). This study was approved by the Institutional Review Boards of the Seton Family of Hospitals and the Texas Department of State Health Services.
The study population consisted of pediatric patients (aged from birth through 14 years) hospitalized for an injury between January 1, 2003, and December 31, 2004. The injury must have occurred within the service area of Dell Children's Medical Center of Central Texas, which includes the following 46 Texas counties: Sterling, Coke, Runnels, Coleman, Brown, Mills, Irion, Tom Green, Concho, McCulloch, San Saba, Schleicher, Menard, Mason, Llano, Sutton, Kimble, Gillespie, Kerr, Lampasas, Coryell, McLennan, Limestone, Falls, Burnet, Bell, Robertson, Milam, Brazos, Williamson, Blanco, Travis, Lee, Burleson, Kendall, Comal, Hays, Guadalupe, Caldwell, Bastrop, Gonzales, Lavaca, Fayette, Colorado, Austin, and Washington.
Injury Event and Medical Outcome Definitions
The mechanism of injury (E-codes) and subsequent diagnoses were coded by using the International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM).9 Traumatic brain injuries (TBI) were identified by using ICD-9-CM diagnosis codes: 800.0-801.9, 803.0-804.9, and 850.0-854.1. For the purposes of this study we classified the patients' injury severity score (ISS), a measure of severity for patients with multiple injuries,10 into these categories: minor (0-7), moderate (8-16), severe (17-25), and very severe (≥ 26). The ISS categories were then analyzed by patient age, gender, race/ethnicity, and insurance status. Age was analyzed as a continuous variable and in these age groups: <1, 1-4, 5-9, and 10-14 years. Use of protective devices, including child safety seats and seat belts for motor vehicle occupants and helmets for pedal cyclists and riders of off-road vehicles (such as all-terrain vehicles), was analyzed. Motor vehicle occupants designated as "unrestrained" or "airbag only" were defined as unrestrained.
Statistical analysis of patient demographics and medical outcomes was conducted by using STATA/SE, version 10 (STATA, Inc, College Station, Texas). Continuous data were described by means and standard deviations, and differences in means were analyzed by using the Student's t test. Differences between groups of categorical data were examined by using frequencies and analyzed by using the chi-squared (χ 2 ) test.
During 2003 and 2004, injuries to children occurring within the study area resulted in 3154 reported hospitalizations. Patients ranged from birth to 14 years of age (mean age = 7.3 ± 4.5). The distribution of patient race/ethnicity in the study population is similar to that of the general population of children in this area: non-Hispanic, 56.4%; Hispanic, 29.8%; African American, 12.1%; and other, 1.7%. 11 The study population is disproportionately male (62.1%), compared with children of the same age group in the general population (51.2% male). 11 The patients' insurance status broke down as follows: privately insured, 39.9%; program with public funding, 35.6%; uninsured, 12.3%; and other (payer sources not classified elsewhere), 12.2%.
Mechanisms of Injury and Medical Outcomes
Falls were the most common mechanism of injury for all patient age groups, accounting for 40.6% (n=1279) of the pediatric trauma hospitalizations ( Table 1 ) [ PDF ]. MVCs were the second most common mechanism for children older than age 1. In infants younger than 1 year, assault was more prominent. Other frequently reported mechanisms of injury included being struck by or against an object, pedal cycle events, and pedestrian events.
Fractures were the most commonly reported diagnosis, occurring in 1726 (54.7%) hospitalizations ( Table 2 ) [ PDF ]; 935 (54.2%) of these were the result of a fall. Open wounds and intracranial injuries without fractures were also common, occurring in 20.7% and 14.5% of the cases, respectively. Most injuries were minor (assigned an ISS < 8), and most patients were discharged from the hospital with full recovery expected.
A total of 784 hospitalizations involved a TBI; 42 of those resulted in patient death. TBI-related deaths accounted for 75% of the total deaths in this population. Falls were the most common mechanism of injury for a TBI diagnosis (37.4%), followed by MVCs (23.5%). Those with a TBI tended to be younger than those without a TBI ( P <.0001) and had significantly longer hospital stays ( P =.004). Males and females were equally likely to be diagnosed with a TBI ( P =.50). Patients with a TBI were more likely to die as a result of their injuries compared with those without a TBI ( P <.001).
Severity and Mortality
Injury severity did not vary by patient gender ( P =.20) or race/ethnicity ( P =.21), though there were differences by age group ( P <.001) and insurance status ( P <.001) ( Table 3 ) [ PDF ]. Patients with higher injury severity were more likely to be younger than 1 year. Patients with higher injury severity were more likely to be uninsured or covered by publicly funded insurance.
Fifty-six (1.8%) hospitalizations ended in death of the patient. MVCs were the most common mechanism of injuries resulting in death (30.4%), followed by assaults (17.9%) and pedestrian events (16.1%). Nine of the 10 assault deaths, all in patients younger than 5 years, were determined to result from child abuse.
Protective device use was not reported consistently across all hospitals. We could only determine restraint use for 167 (38.9%) of the MVC-related hospitalizations. When patient restraint use was recorded, 86 (51.4%) of the patients were reported as being unrestrained. When analyzing the data by age group, older children were more likely to be unrestrained than younger children, especially for those aged from 4 through 7 years. Sixty-six percent of those aged 4 through 7 years were unrestrained at the time of their injury compared with 40% of children aged from birth through 3 years. Helmet use for pedal cyclists and riders of off-road vehicles was also examined. We were able to determine helmet use for 43 (27.9%) of pedal cycle-related and 14 (42.4%) off-road vehicle-related hospitalizations. Of those, only 3 patients (7.0%) injured in pedal cycle-related incidents and 3 patients (21.4%) injured in off-road vehicle-related incidents reported helmet use at the time of the injury.
Pediatric injury is a major concern for the children, families, and health care systems of Central Texas, as it is for the nation. Pediatric injuries resulted in 3154 reported hospitalizations in Central Texas during our 2-year study period. While few of these hospitalizations (n=56, 1.8%) ended in patient death, during the same time frame, a total of 175 children living in the study area were killed in injury-related events. Hospitalization data do not account for most injury-related deaths and, therefore, should not be used in isolation to assess the burden of pediatric injuries.
Falls were the most common mechanism of injury-related hospitalizations in Central Texas, a finding consistent with national estimates.12 Motor vehicle collisions were second for all age groups, except in patients younger than 1 year, in whom assault was more prominent. Hospitalizations caused by MVCs and pedestrian injuries mirror national percentages, except in the group aged 1 through 4 years, where they constitute a larger percentage of hospitalizations than on the national level. Data from the National Trauma Data Bank, a national sample of trauma data, show a similar distribution.13
Traumatic brain injuries were present in 784 hospitalized children during the study period. These injuries were more likely to occur in the very young, were associated with significantly longer lengths of stay, and were responsible for most of the pediatric deaths in children admitted to the hospital for injury. TBI is a major concern in Texas, and prevention measures should focus on associated mechanisms of injury.
Patients with higher injury severity scores were more likely to be uninsured or covered by publicly funded insurance. Insurance status was also related to child safety device utilization, although this was not statistically significant. Uninsured and publicly insured patients were more likely to be unrestrained in MVCs (53.3% vs 47.2%, P =0.44) and to be un-helmeted in a pedal-cycle incident (100.0% vs 86.7%, P =.052). The lower rates of safety device utilization may account for some of the higher injury severity scores seen in the uninsured and publicly insured patients. In this study, insurance status is the only variable relating to the socioeconomic status (SES) of the study population. Other studies have shown that being uninsured or publicly insured is related to increased risk for injury and lower rates of safety device use among both adult and pediatric populations, although this is difficult to isolate from other variables impacting SES (eg, race, parent education levels, poverty, and family size).14-16
Protective device use in Central Texas is low and concerning. Very few pedal-cycle or off-road vehicle riders requiring hospitalization were wearing a helmet at the time of the injury. In hospitalizations caused by MVCs, 51.4% of the patients were completely unrestrained at the time of the incident. This percentage was even higher for the group aged from 4 through 7 years (65.8%). Children in this age group are commonly referred to as "forgotten children," as they have outgrown child safety seats but are too small for adult seatbelts. These children are best protected by a belt-positioning booster seat used in combination with a lap-shoulder seatbelt. This issue was recently addressed in the 81st Texas legislative session, where lawmakers passed an improvement to the transportation code. Under the new legislation, children must ride in an appropriate car seat or booster seat until 8 years of age, unless they are 4 feet 9 inches or taller.17
The data presented in this paper were gleaned from the Texas Department of State Health Services IETRG Public Use Data File. Trauma registries are not population based because of the large number of minor traumas that are excluded,18 either by rule or by practice. Texas statute does not require hospitals to submit reports for injured patients who are seen only in the emergency department or who stay fewer than 48 hours (unless they are transferred to another hospital for additional tertiary care); the result is that many minor injuries are not accounted for at the state level. For example, in its first year of operation, Dell Children's Medical Center of Central Texas had 8860 trauma-related visits to the Emergency Department, but only 728 trauma admissions were required to be reported to the IETRG.19
While Texas does require the submission of trauma data from all hospitals in the state, not all Texas hospitals report data consistently. The IETRG reports that during this study period, approximately 77% of acute-care hospitals in the state submitted reports on trauma admissions. Therefore, these data do not reflect a complete picture of pediatric injury for the study region, even though at the time of this writing, this paper utilizes the most complete and timely trauma data available. In addition, data submissions are often incomplete. For instance, protective device use was not reported for 61% of the patients injured in MVCs. Those that are reported may reflect a reporting bias, in that hospitals may be more likely to report this variable if the patient was unrestrained. Therefore, the data presented here on the use of protective devices should be interpreted cautiously. There is a great need to improve the reporting, collection, analysis, and timely availability of trauma data in the state.
Additionally, two of the leading causes of childhood mortality in infants and young children are not collected by the IETRG: submersion injuries and unintentional suffocation. Therefore, submersion and suffocation-related TBIs due to anoxia are not accounted for in these data, underestimating the incidence of that particular type of TBI in this population. Texas must develop mechanisms for the collection and reporting of these preventable causes of death and disability; both are leading causes of pediatric mortality.
This study highlights two important issues: first, pediatric injury is a significant cause of morbidity and mortality for the children of Central Texas, and substantial resources need to be invested in preventing these events; and, second, Texas lacks a sufficient system for collecting complete data on acute injury and making it available to advance injury prevention efforts in the state. Injury is a major public health issue for all Texans. For our children, injury is by far the leading cause of death and disability, and, ironically, also the most preventable.
In the opinion of these authors, the medical community has a number of opportunities to improve the state of injury epidemiology and prevention in Texas: ensure that your hospitals are reporting timely, accurate, and complete data on injury hospitalizations to the IETRG; draw attention to the lack of surveillance and prevention resources at the state level and advocate for improvements; support efforts to strengthen injury prevention policy; create academic and legislative partnerships around the issue of injury prevention; and utilize local data to set injury prevention priorities and evaluate injury prevention initiatives. The medical community is well positioned to make a significant impact on reducing pediatric injuries in Texas.
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 10 Leading Causes of Death by Age Group, United States - 2004. http://www.cdc.gov/ncipc/osp/charts.htm . Accessed May 13, 2008.
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. WISQARS: Years of Potential Life Lost Reports, 1999-2006. http://webappa.cdc.gov/sasweb/ncipc/ypll10.html . Accessed November 15, 2008.
- Finkelstein EA, Corso PS, Miller TR. The Incidence and Economic Burden of Injuries in the United States . New York, NY: Oxford University Press, Inc; 2006.
- National Center for Injury Prevention and Control Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System). http://www.cdc.gov/injury/wisqars/index.html . Accessed May 14, 2008.
- Center for Health Statistics, Texas Department of State Health Services. Texas Health Data - Deaths of Texas Residents. http://soupfin.tdh.state.tx.us/death10.htm . Accessed October 15, 2008.
- Texas EMS/Trauma Registry. Public Access Data File request form. http://www.dshs.state.tx.us/injury/data/Order%20Form.doc . Accessed May 13, 2007.
- Texas EMS/Trauma Registry. EMS/Trauma Registry Reporting Rules. http://www.dshs.state.tx.us/injury/ruledesc.doc . Accessed November 12, 2008.
- Office of the Secretary of State. Texas Administrative Code, Title 25, Part 1, Chapter 103:Injury Prevention and Control. http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=25&pt=1&ch=103&rl=Y . Accessed November 1, 2008.
- International Classification of Diseases, 9th Revision, Clinical Modification . Chicago, IL: American Medical Association; 2008.
- Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-196.
- Center for Health Statistics, Texas Department of State Health Services. Texas Health Data - Population Data. http://soupfin.tdh.state.tx.us/people.htm . Accessed June 2, 2007.
- WISQARS web-based Injury Statistics Query and Reporting System. National Center for Injury Prevention and Control. http://www.cdc.gov/ncipc/wisqars. Accessed November 12, 2008.
- Fildes JJ, ed. National Trauma Data Bank Report 2005. Chicago, IL: American College of Surgeons; 2005. http://www.facs.org/trauma/ntdb/ntdbannualreport2005.pdf . Accessed November 12, 2008.
- Rangel SJ, Martin CA, Brown RL, Garcia VF, Falcone RA Jr. Alarming trends in the improper use of motor vehicle restraints in children: implications for public policy and the development of race-based strategies for improving compliance. J Pediatr Surg. 2008;43(1):200-207.
- Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE III. Race and insurance status as risk factors for trauma mortality. Arch Surg. 2008;143(10):945-949.
- Marcin JP, Schembri MS, He J, Romano PS. A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates. Am J Public Health. 2003;93(3):461-466.
- Texas Legislature Online. Senate Bill 61, by Sen. Judith Zaffirini. 81st Legislative Session; 2009. http://www.legis.state.tx.us/BillLookup/History.aspx?LegSess=81R&Bill=SB61 . Accessed August 14, 2009.
- MacKenzie EJ, Fowler CJ. Epidemiology of injury. In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma . 6th ed. New York, NY: McGraw-Hill Companies, Inc; 2000;25-37.
- Trauma Registry. Trauma Services, Dell Children's Medical Center. January 5, 2009.
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