Please note: In 2003, the CTF updated its Grades of
Recommendations to include an "I Recommendation" for situations where
insufficient evidence exists to allow a recommendation to be made.
(Formerly, these situations were captured under a "C
Recommendation".) This change is not retroactive, and all
"C Recommendations" made prior to 2003 have not been
reevaluated in light of the new "I" recommendation grade. For a
discussion of these recommendation grades, please link to the 2003 article in
the Canadian Medical Association Journal here.
Prevention of Household and Recreational Injuries in Adults
Prepared by R. Wayne Elford, MD, CCFP, FCFP, Professor,
University of Calgary, Alberta
Objective
To make recommendations regarding the prevention of unintentional household
and recreational injuries (particularly drownings, suffocation, bicycle/sports-related
injuries and firearms) in adults in Canada.
Burden of Suffering
Approximately 9,000 Canadians die annually of unintentional injuries,
about 5% of all deaths. The leading causes of death from household and
recreational injuries include falls (21%), drownings (6.4%), burns and
fire-related injuries (4.8%), suffocation (4.7%), poisonings (4.7%), bicycle/sports-related
deaths (1.7%), and firearms (0.7%). As many of these injuries occur in
the younger age groups the societal burden due to loss of productive years
from prolonged dependency due to disabilities, and due to acute care (7.9%
of all hospital days), is considerable. In 1989 injuries were the second
highest cause of potential years of life lost (PYLL) before 65 years of
age in Canada.
Options
Preventive approaches were classified as individual patient counselling,
legislative/environmental (physician discussions with legislators) and
public health education (physician leadership of programs) (p529).
Outcomes
Injury-related deaths, injury rates, risk of head and brain injury
(p530-31).
Evidence
MEDLINE was searched from 1981 to November 1992 using the major MeSH
heading ‘accidents’ under the subheadings diagnosis, economics, epidemiology,
law and jurisprudence, mortality, prevention and control, standards and
trends; and not aviation, occupational or traffic accidents. Other sources
were Statistics Canada, Health and Welfare Canada and the Insurance Bureau
of Canada. Study results were synthesized in table or graphic format only.
Values
The 13-member Task Force of experts in family medicine, geriatric medicine,
pediatrics, psychiatry and epidemiology used an evidence-based method for
evaluating the effectiveness of preventive health care interventions. Recommendations
were not based on cost-effectiveness of options. Patient preferences were
not discussed.
Background papers providing critical appraisal of the evidence and tentative
recommendations prepared by the chapter author were pre-circulated to the
members. Evidence for this topic was presented and deliberated upon in
1- to 2-day meetings, 2 to 3 times per year from January 1991 to June 1993.
Consensus was reached on final recommendations.
Benefits, Harms, and Costs
Little or no evidence exists regarding the effect of physician counselling
on substance abuse behaviour during water sports, or safe storage of firearms.
An RCT reported that an educational program had no effect on helmet use
among school-aged children (p530).
Evidence from a case-control study suggests that abstaining from alcohol
use during water sports reduces drowning rates among young adults (p532).
A case-control study found that among bicycle riders involved in crashes,
helmet use reduced risk of head injury by 85% (OR 0.15, 95% CI 0.07 to
0.29) and of brain injury by 88% (OR 0.12, 95% CI 0.04 to 0.40). These
results may be confounded by other characteristics associated with riders
who wear helmets (p530).
Expert opinion Some Level III (level III evidence) suggests that safe
storage of guns may reduce unintentional deaths among children.
A review of before and after studies of programs teaching the Heimlich maneuver
suggests a possible reduction in choking deaths of 10% to 45%
(p530).
Recommendations
Recommendation grade [A, B, C, D, E] and level of evidence
[I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations
in support of individual recommendations are identified in the guideline
text.
-
Insufficient evidence exists to include or exclude (in the PHE) physician
counselling related to alcohol use during water sports [C, III],
bicycle helmet use [C, I], and safe storage of firearms in the home
[C, no evidence cited]. However, counselling targeted at high risk
groups (young adults, those involved in water sports, aboriginal people,
elderly people living alone, SES disadvantaged groups, and those who use
alcohol) has been recommended by others and should be considered at the
clinician’s discretion.
-
Fair evidence exists to implement legislation aimed at reducing substance
abuse during water sports [B, II-2] and promoting bicycle helmet
use [B, II-2]. Insufficient evidence exists to implement legislation
regarding safe storage of firearms [C, III].
-
Insufficient evidence exists to implement public health education programs
regarding the use of the Heimlich maneuver to treat persons choking on
objects [C, III].
Validation
This report was externally peer reviewed. The Year 2000 Injury Control
Objectives for Canada include individual counselling targeted at high-risk
groups. The American Academy of Pediatrics recommendations on bicycle helmet
use include physician counselling, product availability and standards,
community-based programs to promote use and presentation of helmet-wearing
role models in the popular media. In 1989, the U.S. Preventive Services
Task Force recommended counselling about alcohol or drug use during potentially
dangerous activities, and other measures to reduce risk of unintentional
injury (p531).
Sponsors
The Canadian Task Force on Preventive Health
Care developed this guideline with funding from Health Canada.
Selected References
Source Document
Elford RW. Prevention of household and recreational injuries in adults.
In: Canadian Task Force on the Periodic Health Examination. Canadian
Guide to Clinical Preventive Health Care. Ottawa: Health Canada,
1994; 526-37.
Other
Canadian Task Force on the Periodic Health Examination: The periodic
health examination. Can Med Assoc J 1979;121:1193-1254.