Full Text Review
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
These recommendations were finalized by the Task Force in June 1993
Contents
Overview
In the 1979
Canadian Task Force report, home and recreational injuries< 1>
were acknowledged to constitute an important proportion of accidents. At
that time there was insufficient literature on the subject to justify a
recommendation on scientific grounds. While there is currently fair evidence
upon which to implement some legislative measures, there remains insufficient
evidence to clarify the effectiveness of individual counselling by physicians
(C Recommendations). Three other chapters deal with unintentional injuries
in children (Chapter 28), the elderly (Chapter 76), and those due to motor
vehicle accidents (Chapter 44).
Burden
of Suffering
Approximately 9,000 Canadians die annually of unintentional
injuries, about 5% of all deaths. This review focuses on the seven leading
causes of death from household and recreational injuries, namely, 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%).<2> Because 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. The impact of these injuries is
felt far beyond the injured person; family members, employers, health care
systems and the community are affected. The individual and family burden
of suffering is large in comparison to other types of unintentional injury
because third party insurance is seldom in effect, and many of the financial
obligations must be borne directly. Injury is probably the most under-recognized
major public health problem facing the nation today, and the study of injury
presents unparalleled opportunities for reducing morbidity and mortality
and for realizing significant savings in both financial and human terms
– all in return for a relatively modest investment.<3> Table 1
summarizes
the mortality and morbidity rates for various types of adult injury. A
brief description of the risk factors associated with each of the leading
causes of unintentional injury in adults follows.
Falls
There were 2,100
deaths due to falls in 1988.<2>
Falls were second only to motor vehicle traffic accidents among the leading
causes of accidental death in Canada and were by far the leading cause
of hospitalization for treatment of accidental injuries. Female exceeded
male deaths, and falls resulting in serious injury or death were much more
frequent among those aged 55 and over.<4>
Drowning
429 Canadians drowned in 1987,
including 135
in boating accidents. Nearly one-quarter of drowning victims were youths
15-24
years of age. Drowning-site profiles varied by age and sex but also by
climate and the accessibility of natural bodies of water and pools. Contributing
factors were inability to swim, swimming outside patrolled areas, unfamiliarity
with the beaches, pre-existing medical conditions and consumption of alcohol.<5>
A review of Ontario coroners’ reports showed that the young adolescent
male was at particular risk of drowning. Among 263 deaths by drowning for
young adults, males outnumbered females 3 to 1
and
alcohol and/or drugs were detected in nearly 20% of victims.<6> For
more information on problem drinking consult Chapter 42. In deaths involving
boats, canoes and sail boats, only 25% of the drowning victims were wearing
a personal flotation device or life-jacket. Diving, surfing and water skiing
also account for a portion of spinal injuries.
Burns, Scalds
and Fire-Related Deaths
There were 402 deaths among Canadians caused by fire
and flames in 1988.<2>
In 1987 there
were 30,735 residential fires in Canada (including hotels), causing property
damage of $382 million. Studies from the early 1980s
indicated that cigarette smoking was associated with about half of residential
fire deaths. The number of residential fires has declined continuously
since 1980.
This reduction in fires has been attributed to better education, more widespread
use of smoke detectors, and fewer people smoking.<7>
Poisoning
Of the 424 fatal poisonings in Canada in 1987,
most were by drugs and medications (58%); 23% were by solid and liquid
substances, and 19%
by gases and vapours.<4> Thirty-one percent were among persons aged
25-34;<4> the majority of these deaths (particularly where drugs and
medication are involved) would be self-inflicted. Canadian poison control
centre data indicates that in 1986
there were 103,459
poisoning cases and 365 deaths (a 0.35% case fatality rate).<8>
Suffocation
Almost two-thirds of the 415
Canadian deaths by suffocation in 1987
resulted from inhalation and aspiration of food; 62% were in adults over
55 years of age.<4>
Bicycle and Other
Sports-Related Injuries
There were 139
fatal pedal cycle injuries in Canada in 1987
and 86% of the casualties were male.<4> In a Calgary study, 67% of 107
patients hospitalized for bicycle-associated injuries had craniocerebral
trauma; 20% overall involved a collision between bicycle and automobile.<9>
Contusions, abrasions, open and crushing wounds and fractures were also
common. Another study found that the most common sports and leisure activities
resulting in death between 1982-88,
were swimming (152
deaths), horse riding (117
deaths), motor sports (95 deaths), air sports (92 deaths among adults)
and fishing (86 deaths). When the number of participants and hours of activity
were taken into account, air sports, mountaineering, motor sports and horse
riding were found to be the most hazardous activities – 10
to 100 times
more hazardous than ball games or water sports.<10>
Firearms
There were 60 deaths by firearms in Canada each year
in 1987 and
1988.<4>
Elevated mortality rates for males aged 15-24
were documented in a study that found almost one-third of unintentional
shooting deaths were hunting-related and that young hunters appeared to
be at greatest risk of injury. There is some evidence (grade III) that
keeping guns in the home unloaded and locked away reduces unintentional
deaths among children.<11>
Alcohol and Drug
Use in Association With Injury
Several studies from different countries have demonstrated
that alcohol is an important contributing factor in many injury deaths,
especially among adults. Higher proportions of positive alcohol readings
occurred among home accident victims (p<.001)
than among a comparison group of accident patients admitted to the same
Boston hospital emergency service. Approximately half of several thousand
deaths by drowning reviewed by autopsy in Auckland, Sacramento County,
Baltimore, and Geelong, Australia showed evidence of alcohol consumption.<12>
Effectiveness
of Prevention Maneuvers
During the past decade numerous descriptive studies
concerning home and recreational injuries have been published. More important
however, is the steady stream of experimental and quasi-experimental studies
demonstrating that unintentional injury and death are not random, unpredictable
events, but are predictable and preventable<13>
and must be looked upon as being a disease whose prevention must be approached
scientifically. One model for organizing preventive measures for unintentional
injury and death is the Haddon Matrix,<14>
named after a leading thinker in injury control. Three widely adopted approaches
to interventions for accidental injury arising from this model are described
in greater detail; namely, public health education, environmental legislation,
and individual counselling.
-
Public Health Education – Health professionals
who wish to direct their efforts toward a major cause of death can give
effective leadership to programs to prevent drowning by counselling patients
that alcohol increases the hazard of water sports.<12>
The well known dictum "do not drink and drive" also applies to water recreational
activity in the modification, "do not drink and dive."
-
Legislative/Environmental – As influential as
physicians may be with patients, they can have a far greater impact on
promoting home safety by discussions with legislators, who in turn can
modify the environment through building codes and safety legislation (see
Table 2, Chapter 76 on Injuries in the Elderly). For example, barriers,
bicycle paths and other design features that separate the cyclist from
traffic and pedestrians or remove through-traffic are effective measures
for reducing bicycle-related injuries.<15>
In general, modifying the environment appears to be more effective than
trying to change human behaviour.
-
Individual Counselling – While the evidence that
physician counselling is effective in preventing injuries is inconclusive
in some areas, minor reductions in injury rates would have major public
health benefits. The evidence for these activities will be presented sequentially
for each major type of home and recreational injury in adults.
Burns and Fire-Related
Injuries
Smoke and carbon monoxide rather than heat or flame
are generally responsible for fire-related deaths. Use of smoke detectors
alone could reduce the residential fire fatality rate by about 50%. The
relative risk of residential fire death rate in homes without a smoke detector
relative to that in homes with one has been reported at 2.0-2.5.<16>
Residential sprinklers are about 20 times more expensive but control the
fire and concentration of combustion products so that those with poor mobility
may not need to escape.
Suffocation
A review of before and after studies of programs teaching
the Heimlich maneuver were reported to have resulted in 10-45%
reductions in choking deaths.<17>
The 1985
Health Promotion Survey in Canada found that only 34% of respondents indicated
they knew how to administer CPR and/or the Heimlich maneuver.
Bicycle and Sports-Related
Injury
A case-control study of injuries among bicycle riders
experiencing crashes in greater Seattle showed that safety helmets reduced
the risk of head injury by 85% (odds ratio 0.15;
95% confidence interval (CI): 0.07-0.29) and of brain injury by 88% (odds
ratio 0.12;
95% CI: 0.04-0.40).<18>
These results are confounded by the fact that those who choose to wear
helmets would tend to have a different overall attitude toward safety;
however, the physics of crashing suggest that helmet wearing is advisable.<19>
In a survey of 894 South Australian bicycling enthusiasts, 197
had crashed and struck their head or helmet within the previous 5 years;
a significant association was found between helmet use and reduced severity
of head injury (p<0.005) which persisted (p<0.05) after adjustment
for crash severity. Based on a cohort of 100
consecutive head injuries in Portsmouth, it was estimated that the wearing
of safety helmets would prevent at least half of the minor head injuries
and reduce the seriousness of major injuries sustained in cycle accidents.
Although bicycle helmets have been shown to reduce
the rate of head and brain injuries from bicycle mishaps, the use of helmets
is still uncommon. Educational programs promoting helmet use have shown
no impact on the proportion of helmet wearers in a school age population.<20>
Helmet design, peer pressure, lack of availability, and cost have been
found to be reasons for non-use.
Alcohol and Substance
Abuse Intervention for Prevention of Injuries
Alcohol testing and history taking in all cases of accidental
injury has been suggested. When alcohol and/or other drugs are implicated
in an injury, a number of expert groups have recommended that the connection
should be authoritatively communicated to the patient with follow-up to
self-help groups. This strategy is based on preliminary evidence that an
appeal to fear fortifies adolescent intentions to eschew alcohol. The effectiveness
of counselling regarding substance abuse to reduce recreational injury
rates has not been evaluated.
Recommendations
of Others
The "Year 2000 Injury Control Objectives for Canada"
recommend that individual counselling be targeted particularly towards
high-risk groups; namely, families with young children, the socio-economically
disadvantaged, aboriginal people, situations where alcohol and/or substance
abuse is suspected, and the elderly living alone.<21>
The American Academy of Pediatrics, based on expert
opinion, makes the following recommendations concerning bicycle helmet
use:<22>
-
Physicians should inform parents and patients of the
importance of wearing bicycle helmets and the dangers of riding without
a helmet.
-
Retail outlets should be urged to carry approved, inexpensive
helmets that are available at the time of purchase of the bicycle.
-
The Consumer Product Safety Commission should develop
mandatory, uniform safety standards for bicycle helmets.
-
Coalitions of physicians, parents, and community leaders
should be encouraged to develop and support community-based programs to
promote bicycle safety and helmet usage.
-
The popular media should be urged to depict the helmeted
bicycle rider on television, in advertisements and in promotional materials.
The Technical Study Group on Fire Safety, in its report
to the U.S. Congress (1987)
advocated decreasing the number of cigarette smokers, flame retardant sleepwear
and promotion of self-extinguishing cigarettes and matches as means to
decreasing fire related injuries and deaths.
In 1989,
the U.S. Preventive Services Task Force recommended the following: "Patients
who use alcohol or other drugs should be warned against engaging in potentially
dangerous activities while intoxicated. It may be clinically prudent to
provide counselling on other measures to reduce the risk of unintentional
household or environmental injuries from falls, drowning, fires or burns,
poisoning, bicycle collisions, sports and firearms."<23>
Conclusion
and Recommendations
There is fair evidence (grade II-2) that bicycle helmet
use for those who ride the roadways reduces the rate of head injury and
death<19>
(B Recommendation).
There is fair evidence (grade II-2) that not drinking while being involved
in water recreational activities reduces the rate of drowning among young
adults<12>
(B Recommendation).
There is some evidence (grade III) that keeping guns in the home unloaded
and locked away reduces unintentional deaths among children<11>
(C Recommendation).
There is some evidence (grade III) that adults learning the Heimlich maneuver
can reduce deaths due to suffocation (C
Recommendation). Expert opinion (grade III) evidence suggests that
many patients seen by clinicians could potentially benefit from counselling
to modify their accident prone behaviors. In actual practice, however,
it is not known how effectively clinicians can alter these behaviors. Since
unintentional injuries represent a leading cause of death and nonfatal
injury, even modest successes through clinical interventions could have
major public health value. Counselling is most relevant for those at increased
risk of injury, such as adolescents and young adults, persons who use alcohol
or other drugs. The optimal frequency for counselling patients about unintentional
injury has not been determined and is left to clinical discretion.
Unanswered
Questions (Research Agenda)
The Haddon Matrix for generating countermeasures provides
a model for planning research. Most of the "energy vector" and "physical
environment" aspects involve environmental design/engineering. Improving
post-event performance is the domain of both formal and informal health
care delivery systems. Provincial, regional, and local health care delivery
effectiveness must constantly be assessed by quality assurance methods,
and areas of poor performance must be addressed. An example of this process
is the setting of the Year 2000 Injury Control Objectives.<15,21>
The "social environment" sector is primarily the jurisdiction of the political/legislative
institutions in our society but is greatly influenced by public pressure.
The norms, values, and laws of our society must be constantly re-evaluated
and revised as a better understanding of the balance between individual
and corporate rights/privileges is derived. The "human" sector presents
a major challenge for behavioral medicine (e.g., medication prescribing
practices in the elderly). Much remains to be learned about lifestyle patterns
and behaviour change strategies. It is in this last area that individual
practitioners spend most of their time and energy. The "timing" of health
education messages, the effectiveness of different motivational techniques,
the counselling skills required by health care providers, and the most
conducive atmosphere for anticipatory care, all require further elucidation.
Evidence
This review deals with household and recreational injuries
without considering occupational or aviation related injuries. These limitations
were incorporated in the MEDLINE search strategy: accidents as a major
MESH heading under the subheadings diagnosis, economics, epidemiology,
law and jurisprudence, mortality, prevention and control, standards and
trends; and not aviation, occupational or traffic accidents. References
were identified for the years 1981
–
November 1992.
Other sources included Statistics Canada, Health and Welfare Canada, the
Insurance Bureau of Canada.
This review was initiated in January 1991
and
recommendations were finalized by the Task Force in June 1993.
Table
1: Canadian Mortality and Morbidity Rates for Unintentional Injury in 19891
(per 100,000 – standardized to 1971 population)
|
Overall (0-85+ yr) |
Adult (15-64 yr) |
|
Mortality |
Morbidity |
Mortality |
Morbidity |
|
M |
F |
M |
F |
M |
F |
M |
F |
| Falls |
6.77 |
4.16 |
425.0 |
384.0 |
3.08 |
.74 |
296.2 |
204 |
| Drownings |
2.31 |
.63 |
2.78 |
1.38 |
2.46 |
.44 |
1.68 |
.51 |
| Burns/Fire related |
2.11 |
.91 |
11.52 |
4.23 |
2.03 |
.73 |
11.60 |
3.56 |
| Poisonings |
1.88 |
.90 |
38.84 |
35.19 |
2.68 |
1.24 |
22.84 |
21.98 |
| Suffocations |
.72 |
.21 |
.39 |
.15 |
.60 |
.09 |
.22 |
.04 |
| Firearms |
.57 |
.04 |
4.69 |
.52 |
.72 |
.01 |
5.79 |
.61 |
1 extracted
from data, Bureau of Chronic Disease Epidemiology, Laboratory Centre for
Disease Control, Health and Welfare Canada
Full Citation
Link to Structured Abstract of
this review
Link to Summary Table of this
review
Link to Selected References list of this review
Link to 1994 chapter:
Prevention of Household and Recreational Injuries in Children (<15 years of
age)
Link to 1994 chapter: Prevention
of Household and Recreational Injuries in the Elderly
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