1. Preventing Pediatric Injuries: From Education to Community Interventions Mike Gittelman, MD Associate Professor Division of Emergency Medicine Cincinnati Children’s Hospital Medical Center

2. Objectives Recognize the burden of childhood injuries Identify the 4 E’s in preventing injuries Discuss the prevention efforts I have been a part of locally, regionally, and nationally

3. Past Top Stories Teen wounds six in High School shooting 3 month old improperly restrained … loses life House blaze fatally injures four children Study finds playgrounds safer, but not enough

4. Why Injury Prevention? Injuries –Are the # 1 killer of children > 1 year of age –Cause more deaths than all other diseases combined Almost all injuries are preventable Prevention –Is essential –Saves health care dollars Oklahoma City – Smoke alarm giveaway –10,000 smoke alarms - $15 million net savings www.cdc.gov/pub/ncipc

5. Childhood Injuries - Deaths % total mortality Source: National Center for Injury Prevention and Control, 2008

6. Average Day in U.S. > 80,000 injuries resulting in hospitalizations and ED visits; >28,000 in kids 0-19 y.o. > 400 deaths due to injuries; > 50 in kids 0- 19 y.o. Source: National Center for Injury Prevention and control, 2008

7. Injury Deaths by Cause – US, 1-19 Years of Age, 2008 Source: National Center for Injury Prevention and Control, 2008 Injury Cause# DeathsRate/100,000 MVC7,1399.22 Firearm2,8453.67 Suffocation1,3071.69 Drowning1,0481.35 Poisoning1,0011.29 Pedestrian8761.13 Fire/Burn6070.78

8. Intervention to Prevent Injuries 4 E’s Education –Media campaigns, school programs Enforcement/Legislation –Child safety laws, speed limit enforcement Engineering/Technology –Airbags, bike helmets, child safety seats Environmental Modification –Bike lanes, safety gaits, speed bumps

9. Injury Prevention & Advocacy: A Model Course for Pediatric Resident Education Education

10. Why Should Pediatricians Be Advocates? Children have little political voice Primarily care for a poor, underserved population Pediatricians have a knowledge-base of “what’s out there” Pediatricians are well respected and accepted in a community Pediatricians are expected to educate families about Anticipatory Guidance regularly

11. Pediatricians Lack IP/Advocacy Training Residents receive little education about injury prevention –Residency directors report disease management taught more than injury prevention –Zavoski, Arch Peds Adol Med 1990 –Chief Residents Survey - Injury prevention and Advocacy – only 2-3 informal lectures throughout residency Need to educate residents in order to teach families –Chief residents only counsel on what they were once taught, barrier = lack of training – Wright, Arch Peds Adol Med 1997 –< 50% of residents discussed injury prevention on audiotaped encounters - Gielen, Arch Peds Adol Med 1997 –<40% of parents received any injury counseling at PMD visit - Miller, Pediatrics 1995

12. Motivations for Course Need for a “structured educational experience to prepare a resident to be a community advocate” 1996 Residency Review Committee for Pediatrics Injury prevention should be an “integral educational experience for pediatric residents” 1991 AAP Policy Statement –Injuries are #1 cause of death in children > 1 year –Injuries cause more death than all diseases combined Anecdotal experiences during residency training

13. Idea Formally educate pediatric residents about injury prevention to provide them with a foundation to become community advocates

14. Curriculum Morning didactic lectures Afternoon field experiences –Complement AM lectures Hospital Commitment –1996 (First year) – elective for all residents –1997-2010 Two-week mandatory rotation for all pediatric interns Offered six times per year No call requirement

15. Curriculum - Topics Injury Prevention –Car safety seats –Bicycle Safety –Home safety –Toy Safety –Drowning –Firearms –Suicide –Playground safety –Pedestrian Safety –Domestic Violence –Poisonings Advocacy –What is an advocate? –How to give a lecture –Insurance 101 –Special health needs –Patient rights To health care (meds) To special ed evals –Reporting abuse –Legislative initiatives –Community resources –Dental and nutrition health

16. Field Experiences IP at childbirth education classes Bike helmet at elementary schools Smoking Cessation Program Local fire station – fire prevention Sports Medicine Child Protective Services Drug and Poison Center Rape Crisis and Abuse Center International Adoption Toys R Us – Toy Safety Legal aid/Ohio Medicaid Child protective services home visits Car seat installations

17. Requirements Attendance Parent education pamphlet Review injury literature Letter to state official Participate in field experiences Evaluations Propose a 3-year advocacy project

18. Curriculum - New Developments Bi-annual updates (eg. change speakers, lectures, and experiences) based on evaluations Adult learning model –Topic reviews –Debates Evaluation tools –Speakers evaluate residents after each talk

19. Evaluation of Knowledge CCHMC Residents Vs. Two Regional Comparable Pediatric Residency Programs 50 question survey 73 residents (29 intervention, 38 control) No difference age, experience, schooling Injury knowledge obtained Pre-Test Scores (Mean) Post-Test Scores (Mean) % Increase CHMC Residents 55.1% 69.2% 14.1% Controls 56.3% 59.5% 3.2% Mean Difference 10.98 (95% CI: 6.5, 15.5), P-value < 0.001

20. Evaluation of Knowledge Retention Repeated survey given after year one 38 residents (16 intervention & 22 controls) Injury knowledge obtained Orientation (Mean) End 3rd yr (Mean) % Increase CCHMC Residents 56.6%68.5% 11.9% Controls 56%61.5% 5.5% Mean Difference 6.4% (95% CI: 1.2, 11.8), P-value <.05

21. Feedback from Residents Enjoyed –Learning resources in community –Filling in gaps of needed information –Hands-on learning experience Increased comfort –Providing anticipatory guidance –Documenting injuries in ED and clinic –Community speaking

22. Future Directions Further evaluations of the course –Improve ways to provide resident feedback –Impact More anticipatory guidance due to course Continued anticipatory guidance after residency More involved in advocacy efforts More involved in research within injury field National influence –AAP standardized curriculum

23. Locally –Speed bumps strategically placed –Local Ordinances Bicycle Helmets Cincinnati, Green Township, Madeira State –Ohio booster seat legislation –Ohio bicycle helmet legislation Legislation/Enforcement

24. Emergency Department Safety Store Product Modification/Dispersement

25. Idea Behind Safety Store Proven safety products –Car safety seats – 70% reduction in death from MVC –Booster seats – 59% safer in MVC –Bike helmets – Reduce head injury by 85% –Smoke alarms – Decrease deaths by 50% Not accessible at reasonable prices locally Make families leaving our ED safer Modeled after Johns Hopkins Injury Center ? ED as a teachable moment

26. The Emergency Department as a “Teachable Moment” Johnston, et al, Pediatrics 2002 –12-20 year olds treated in the ED for an injury –Educated about IP vs. Routine Care –Increased bike helmet and seat belt usage Posner, et al, Pediatrics 2004 –Children < 5 years with an unintentional injury –Received home safety education and free product vs. injury specific ED instructions –Increase in home safety practices after ED intervention

27. Two Studies Conducted in CCHMC ED Gittelman, et al, AEM 2006 –4-7 year olds presenting to the ED for any complaint –No family educated about booster seats used one at one month follow-up –98% used booster seat if educated and given a seat Gittelman, et al, PEC 2008 –Parental survey of ED families –93% felt the ED should provide safety information –83% were willing to wait longer in the ED –73% wished for product to be made available to them in the ED setting

28. Store Details Housed in the ED waiting room –Collaborative effort Items sold at cost –Car safety seats, Booster seats –Bike helmets, Wrist guards –Smoke/CO detectors –Window guards Sales for –ED customers –Hospital staff –Community Evaluation –Who is purchasing –Information requested –Follow-up calls of usage –Sustainability

29. Monthly Sales, 6/1/2005—2/1/2009 Up to $1100 sales monthly, 1500 educated monthly Operational costs high – Personnel Next steps –Kiosk –Other prevention items for sale

30. Customer Satisfaction 98.1 % of families ranked the service as 9 or 10 out of 10 Most families who made a purchase (75%) heard of the store while at CCHMC 70% were in the ED with a patient or family

31. 3 week Follow-Up 383/ 786 (49%) customers who made a purchase were reached for follow-up 97% using the purchased product 100% of time 107 (28%) made a behavior change in their home different from the product purchased 97% felt the prices were affordable 95% believed the store hours were reasonable and it was located in the appropriate place

32. Community Involvement in Preventing Injuries Environmental Modifications

33. Community / Service Started in Harlem, NY –Funded by the Robert Wood Johnson Foundation Decrease injuries by –Education –Altering environments –Increasing supervised after school activities Community-hospital partnerships Injury Free Coalition for Kids ® (IFCK)

34. Effectiveness of IFCK Programs Nationally Harlem, NY-55% reduction in injuries Similar injury reductions at other, more- established sites –Children’s Memorial, Chicago, IL –St. Louis Children’s Hospital –Children’s Hospital of Philadelphia Window Falls Traffic Pedestrian Firearms /Assaults Hospital Admissions Harlem Hospital Injury Reductions by Mechanism

35. IFCK of Cincinnati Began in 2000 Public health approach –Problem –At-risk –Community needs –Intervention / Evaluation Based on –Data Hamilton County Health District CCHMC Trauma Registry –Community concerns Social and structural changes Evaluations are essential

36. Hamilton County Injuries Population * –20,000 residents 5000 < 18 years old –4 th highest injury rate in Cincinnati 1812.5 injuries / 100,000 children / year –Close proximity to hospital Getting started –60% injuries 4pm-midnight –Structural modifications - Playground building *U.S. Census Bureau, 2000 Avondale – Target Community

37. Gain Community Buy-In Gain trust of the community –Meetings, meetings, meetings –Listen to concerns Focus groups to assess needs –Provide tangible results –Do what you say you are going to do –Don’t promise what you cannot deliver Provide members with expertise and resources –Empower communities to thrive

38. Playgrounds – Before and After 2001 2002 20032004 2005

39. Evaluation – Playground Use 2001 - Blair % of Children Use 2002 - Hickory % of Children Use 2001 Before66 (6 per day)63 (6.3 per day) 2001 After128 (12.8 per day)Equipment removed 2002 Before104 (10.4 per day)25 (2.8 per day) 2002 After99 (9.9 per day120 (10.9 per day) Significantly more children on new playgrounds compared to old (p<0.001)

40. Additional Structural Changes Football Field Speed bumps Assisted with other community developmental projects

41. Social Changes After school programs – ODE grant for 3 Avondale Elementary Schools –Improve grades –Educational/cultural/healthy programs Basketball program – police-community interaction –33% reduction in juvenile arrests Community coalitions/partnerships Safety fairs and educational programs

42. Reduction of Avondale Injuries Since the Beginning of IFC - Cincinnati -25.7%-9.8%-42%-38.6%-9.8%

43. IFCK – 2005 - 2010 Avondale –Sustain current programming and develop new structural and changes Two new playgrounds built this summer Home safety initiative in daycares – address new ages Completed a Diabetes and Obesity After School Program Continue safety fairs and outreach –Need to assess sustainability of efforts Price Hill – Second intervention community –Playgrounds – built 1 per year, total of 6 to date –Home safety initiative – approximately 500 homes served –Teen basketball program – 130 youth engaged

44. Conclusions Injuries are the number cause of morbidity and mortality to children 1-19 years old Injuries are 100% preventable Everyone should play their part to prevent them Small interventions effecting the 4 E’s can help to reduce the injury burden All it takes is a passion and a little work

45. “If a disease were killing our children in the same proportions as injury, we would be outraged and demand this killer be stopped” C. Everett Koop, M.D. Former Surgeon General of the United States

46. Questions?