Assessment of the Smoke Free Families Tobacco Screening, Counseling, and Referral Program in Pediatric Primary Care Practices.

OBJECTIVE: The Smoke Free Families (SFF) program trained pediatric providers to use an SFF tool during well-child visits (WCVs) of infants ≤12 months to "Ask" caregivers about tobacco use, "Advise" smokers to quit, and "Refer" smokers to cessation services (AAR). The primary objectives were to assess the prevalence and changes in caregiver tobacco use after being screened and counseled by providers using the SFF tool. A secondary objective was to examine providers' AAR behavior facilitated by using the SFF tool. METHODS: Pediatric practices participated in 1 of 3 6-9-month SFF program waves. Over the 3 waves, all initial SFF tools completed on caregivers during their infant's WCV were evaluated for the caregiver and household tobacco use and providers' AAR rates. An infant's first and next WCV was matched to determine changes in caregiver tobacco product use. RESULTS: In total, the SFF tool was completed at 19,976 WCVs; 2081 (18.8%) infants were exposed to tobacco smoke. A total of 834 (74.1%) caregivers who smoked received counseling: 786 (69.9%) were advised to quit, 700 (62.2%) were given cessation resources, and 198 (17.6%) were referred to the Quitline. In total, 230 (27.6%) of caregivers who smoked had a second visit; 58 (25.2%) self-reported that they quit using tobacco. Among cigarette users (n = 183), 89 (48.6%) reported that they used fewer cigarettes or quit at their infants' second WCV. CONCLUSIONS: Systematic use of the SFF AAR tool during infants' WCVs could improve the health of caregivers and children, resulting in decreases in tobacco-related morbidity.

Types of Tobacco Products Used by Caregivers of Newborns in the Primary Care Setting.

This study determined the types of tobacco products used by caregivers who presented to infant well-child visits (WCVs), tobacco product use by other household members, and caregivers' readiness to quit. The Ohio Chapter of the American Academy of Pediatrics conducted a 10-month quality improvement collaborative to improve providers' tobacco screening and cessation counseling practices. A sub-analysis of the initial screenings was performed to determine types of tobacco products used and caregivers' readiness to quit. Fourteen practices (60 providers) participated, and 3972 initial screens were analyzed; 320 (8.1%) caregivers and 490 (12.4%) household members used tobacco products. Most smoking caregivers and household members exclusively used cigarettes (79% and 72%, respectively). There was no difference in caregiver intention to quit by tobacco type, yet 53% of smoking caregivers were ready to quit. Providers should provide screening and cessation counseling to caregivers of infants at WCVs since many are ready to quit.

A pilot QI primary care practice program to help reduce infant mortality risks.

BACKGROUND: Tobacco smoke exposure (TSE) and inappropriate sleep position/environments contribute to preventable infant deaths. The objective of our quality improvement (QI) program was to increase primary care provider (PCP) screening and counseling for TSE and safe sleep risks at well-child visits (WCVs) and to assess caregiver behavior changes at subsequent visits. METHODS: Pediatric practices, recruited from the Ohio Chapter, American Academy of Pediatrics' database, self-selected to participate in this TSE and safe sleep PCP QI program. At every WCV over a 10-month period, caregivers with children < 1 year old were to be screened and counseled by providers. Caregiver demographics, TSE, and safe sleep practices were assessed. Individual PCP results were paired with subsequent family screening tools at follow up visits to determine changes in TSE and safe sleep practices. Differences in frequencies were determined and paired t-tests were used to compare means. RESULTS: Fourteen practices (60 providers) participated; 7289 screens were completed: 3972 (54.5%) initial screens and 1769 (24.3%) subsequent WCV screens. Caregivers on the initial screen were primarily white (61.7%), mothers (86.0%) with public insurance (41.7%). Within the first month after QI program initiation, PCPs TSE screening was during 80% of WCVs, which increased to > 90% by end of the QI program. A total of 637 /3953 (16.1%) screened positive for home TSE on the initial visit: 320/3953 (8.1%) exposed by at least the primary caregivers, and 317/3953 (8.0%) exposed by a home adult smoker (not the identified caregiver). Of caregivers receiving smoking counseling with subsequent follow-up WCV (n = 100), the mean number of cigarettes smoked daily decreased significantly from 10.6 to 4.6 (p = 0.03). Thirty-four percent of caregivers (34/100) reported they quit smoking at their second visit. A total of 1072 (27%) infants screened at risk for inappropriate sleep position or environment at their initial visit. Of these at-risk infants whose caregivers received safe sleep counseling, 49.1% practiced safer sleep behaviors at follow-up. CONCLUSIONS: PCPs participating in a QI program increased screening at WCVs for infant mortality risks. After counseling and providing resources about TSE and safe sleep, many caregivers reported practicing safer behaviors at their next WCV.

An effective way to utilize daycare organizations to distribute home safety equipment.

BACKGROUND: Safety equipment installed in the home can reduce pediatric injuries. The purpose of this study was to compare the proper use of home safety equipment installed by an injury prevention specialist to equipment installed by a family after distribution at a daycare. METHODS: A prospective study involving two daycare organizations from a high-risk community was performed. Both groups consisted of families with children 4 to 24 months old who received a packet containing: cabinet and drawer latches, carbon monoxide (CO) detector, magnetic phone list, and five other items. After consent was obtained, both groups completed a prescreen survey to determine current equipment use. The self-installation group (SI) from one daycare received home safety equipment and education for self-installation of the equipment. The professional installation group (PI) from a comparable daycare received the same equipment and education; however, equipment was installed for them. Assessments of equipment usage and maintenance were performed at follow-up home visits 6 to 9 months after equipment disbursement. Frequencies and χ analysis were used for comparisons. RESULTS: Seventy-nine SI families and 81 PI families were enrolled. There was no difference in home equipment use between the groups prior to interventions with CO detectors (11.4% vs. 12.3%), cabinet locks (2.5% vs. 11.1%), drawer locks (0% vs. 2.5%), or posted emergency numbers (24.1% vs. 19.8%). Follow-up home visits occurred in 71 SI families (87.7%) and 75 PI families (92.6%). In both groups, there was a significantly increased use of CO detectors (73.2% vs. 89.3%, p = 0.02), cabinet locks (38.0% vs. 78.7%, p < 0.001), and drawer locks (22.5% vs. 62.7%, p < 0.001); posted emergency number increased in both groups, but the difference was not significant (78.9% vs. 89.3%, p = 0.11). CONCLUSION: When provided with home safety equipment, it is used much of the time; however, equipment installed by a professional resulted in higher use than if self-installed. For some equipment, distribution of products in daycare settings may be just as effective as if professionally installed.

Severe unintentional injuries sustained by Ohio children: Is there urban/rural variation?

BACKGROUND: Determining at risk populations is essential to developing interventions that prevent injuries. This study examined the rates of severe unintentional injuries among urban versus rural Ohio children. METHODS: Demographic and injury data for children 0 to 14 years old who had unintentional injuries from January 1, 2003, to December 31, 2012, were extracted retrospectively from the Ohio Trauma Acute Care Registry. Cases with no designated county were excluded. Injury rates per 100,000 children 14 years or younger were calculated annually using county of residence and US census data. Each county was assigned an urbanization level based on population density (A = most urban, D = most rural). RESULTS: There were 40,625 patients from 88 Ohio counties who met the inclusion criteria; the overall annual injury rate was 231.9. The mean age was 6.7 (SD, 4.5) years; 26,035 (64.1%) were male, and 31,468 (77.5%) were white. There were 593 deaths (1.5%). Injury rates by urbanization level were as follows: A: 120.4, B: 196.8, C: 249.1, and D: 247.4 (p = 0.04). Nearly 50% of all deaths occurred in the most urban counties. Those in the most urban areas were more likely to suffer injury from burns, drownings, and suffocations and less likely to be injured by animal bites or motorized vehicle collisions (p < 0.001). Length of stay and injury severity score were highest in the most urban children (p < 0.001). CONCLUSION: While rural counties experienced higher injury rates, urban areas suffered more severe injuries. Specific mechanisms of injury differed by demographics and urbanization in Ohio, suggesting areas for targeted injury prevention. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Evaluating the reliability of an injury prevention screening tool: Test-retest study.

BACKGROUND: A standardized injury prevention (IP) screening tool can identify family risks and allow pediatricians to address behaviors. To assess behavior changes on later screens, the tool must be reliable for an individual and ideally between household members. Little research has examined the reliability of safety screening tool questions. This study utilized test-retest reliability of parent responses on an existing IP questionnaire and also compared responses between household parents. METHODS: Investigators recruited parents of children 0 to 1 year of age during admission to a tertiary care children's hospital. When both parents were present, one was chosen as the "primary" respondent. Primary respondents completed the 30-question IP screening tool after consent, and they were re-screened approximately 4 hours later to test individual reliability. The "second" parent, when present, only completed the tool once. All participants received a 10-dollar gift card. Cohen's Kappa was used to estimate test-retest reliability and inter-rater agreement. Standard test-retest criteria consider Kappa values: 0.0 to 0.40 poor to fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1.00 as almost perfect reliability. RESULTS: One hundred five families participated, with five lost to follow-up. Thirty-two (30.5%) parent dyads completed the tool. Primary respondents were generally mothers (88%) and Caucasian (72%). Test-retest of the primary respondents showed their responses to be almost perfect; average 0.82 (SD = 0.13, range 0.49-1.00). Seventeen questions had almost perfect test-retest reliability and 11 had substantial reliability. However, inter-rater agreement between household members for 12 objective questions showed little agreement between responses; inter-rater agreement averaged 0.35 (SD = 0.34, range -0.19-1.00). One question had almost perfect inter-rater agreement and two had substantial inter-rater agreement. CONCLUSIONS: The IP screening tool used by a single individual had excellent test-retest reliability for nearly all questions. However, when a reporter changes from pre- to postintervention, differences may reflect poor reliability or different subjective experiences rather than true change.

Volunteer driven home safety intervention results in significant reduction in pediatric injuries: A model for community based injury reduction.

BACKGROUND: Home based injuries account for a significant number of injuries to children between 1 and 5years old. Evidence-based safety interventions delivered in the home with installation of safety equipment have been demonstrated to reduce injury rates. The aim of this study was to evaluate the impact of a community based volunteer implemented home safety intervention. METHODS: In partnership with a community with high injury rates for children between 1 and 5years old, a home safety bundle was developed and implemented by volunteers. The safety bundle included installing evidence based safety equipment. Monthly community emergency room attended injury rates as well as emergency room attended injuries occurring in intervention and nonintervention homes was tracked throughout the study. RESULTS: Between May 2012 and May 2014 a total of 207 homes with children 1-5years old received the home safety bundle. The baseline monthly emergency room attended injury rate for children aged 1-5years within our target community was 11.3/1000 and that within our county was 8.7/1000. Following the intervention current rates are now 10.3/1000 and 9.2/1000 respectively. Within intervention homes the injury rate decreased to 4.2/1000 while the rate in the homes not receiving the intervention experienced an increase in injury rate to 12/1000 (p<0.05). When observed vs. expected injuries were examined the intervention group demonstrated 59% fewer injuries while the nonintervention group demonstrated a 6% increase (p<0.05). CONCLUSION: Children in homes that received a volunteer-provided, free home safety bundle experienced 59% fewer injuries than would have been expected. By partnering with community leaders and organizing volunteers, proven home safety interventions were successfully provided to 207 homes during a two-year period, and a decline in community injury rates for children younger than 5years was observed compared to county wide injury rates.

Toward a centralized database for child safety centers: Results of a feasibility pilot study.

BACKGROUND: Safety centers (SCs) are hospital-affiliated outlets that provide families with safety products and personalized education about preventing injuries. Roughly 40 SCs are in operation across the United States, but no single model for staffing, supplying, or sustaining them has emerged. The project aimed to determine the feasibility of a centralized database for SC evaluation as the first step toward growing this proven intervention. METHODS: An Expert Advisory Committee was convened to determine data collection elements and procedures. Representatives from nine hospital-based SCs collected data about car seat and bike helmet sales and education provided between August 1, 2013, to December 31, 2013. RESULTS: A total of 645 study-related safety products were distributed at cost (72%), below cost (10%), or for free (19%). Education was provided for 96% of all products distributed, including receipt of print materials (81%) and product demonstrations (83%). Visitors to SCs were usually referred by a hospital provider (34%), followed by word of mouth (24%) and walk-in (22%). Seven of nine SCs were able to contribute data. Stability of SCs and capacity of staff emerged as facilitators of centralized data collection feasibility. CONCLUSION: We demonstrate that centralized data collection is feasible and that information to compare centers can be obtained. However, for more meaningful comparisons to emerge and to enable all SCs the ability to participate, support is needed institutionally for staff to be able to capture data and nationally to grow and sustain a database that represents the broader diversity of topics and services offered.

Impact of preseason concussion education on knowledge, attitudes, and behaviors of high school athletes.

BACKGROUND: The benefit of preseason concussion education on athletes' knowledge, attitudes, and behaviors is unclear. The purpose of the study was to determine the influence of preseason concussion education on knowledge and self-reported attitudes and reporting behaviors. We hypothesized that preseason education would lead to better knowledge and self-reported attitudes and better reporting of concussion symptoms during the season. METHODS: This study involved a prospective cohort comparing the benefits of a preseason lectured-based concussion education session at one high school with a control school. Participants included males and females age 13 years to 18 years from two community high schools who were participating in higher concussion risk, fall or winter sports (football, soccer, wrestling, and basketball). The education school and control school included 234 and 262 participants, respectively. Outcomes were a preseason and postseason survey assessing knowledge and self-reported attitudes about concussions and an end-of-season questionnaire assessing concussion reporting behaviors during the season. RESULTS: Total scores on the combined (p < 0.0001), knowledge-based (p = 0.016), and behavioral-based (p < 0.0001) questions demonstrated statistically significant improvement in the education group. Scores peaked immediately after education but dissipated at the end of the season. There was a lower proportion in the education school (72%) compared with the control school (88%) that reported continued play despite having concussion symptoms during the season (p = 0.025). A similar proportion of athletes diagnosed with concussion during the season in the education (27%) and control schools (23%) reported returning to play before symptoms resolved (p = 0.81). CONCLUSION: These findings suggest that a didactic-based preseason concussion education likely has minimal benefits. Other factors besides knowledge are likely influencing student-athlete concussion reporting behavior. Future research focused on changing the culture of concussion reporting is needed. LEVEL OF EVIDENCE: Therapeutic study, level III.

A pilot quality improvement program to increase pediatrician injury anticipatory guidance.

BACKGROUND: Because of a lack of time and training, many pediatricians often address few, if any, injury topics during well-child visits. The project goal was to increase the injury anticipatory guidance topics covered by pediatricians during well-child visits by offering screening tools and focused talking points through a quality improvement learning collaborative. METHODS: Screening tools were developed and pretested. Pediatric practices, recruited through the Ohio American Academy of Pediatrics, were taught quality improvement theory and injury prevention strategies at a learning session. Pediatricians worked to implement screening tools and talking points into every well-child visit for children 1 year or younger. Monthly, providers reviewed five random charts for each of the six well-child visits for screening tool use and age-appropriate injury prevention discussion. Providers received maintenance of Certification IV credit. RESULTS: Sixteen pediatricians (six practices) participated. Screening tool use increased from 0% to 97.2% in just 3 months of the program. For each well-child care visit, injury prevention discussion increased by 89.5% for newborn visit, 88.1% for 2-month, 93.6% for 4-month, 94.0% for 6-month, 88.1% for 9-month, and 90.3% for 12-month-old babies. During the quality improvement program, discussion points for all children 1 year or younger increased for all age-appropriate topics. The greatest percent increase in discussions occurred with water safety (from 10.8% to 95.7%, n = 231), play safety (from 17.9% to 93.5%, n = 154), and supervision safety (from 20.8% to 94.4%, n = 251). More commonly addressed topics also had a significant increase in discussions: sleep safety (from 48% to 93.9%, n = 262), choking (from 44.7% to 95.4%, n = 172), and car safety (from 41.2% to 80.1%, n = 332). CONCLUSION: Participation in a maintenance of Certification IV quality improvement program within pediatric offices can increase screening and discussion of injury anticipatory guidance. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

A multicenter study of preventable contact burns from glass fronted gas fireplaces.

Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

Factors that influence concussion knowledge and self-reported attitudes in high school athletes.

BACKGROUND: Many organizations and health care providers support educating high school (HS) athletes about concussions to improve their attitudes and behaviors about reporting. The objectives of this study were to determine if previous education, sport played, and individual factors were associated with better knowledge about concussion and to determine if more knowledge was associated with improved self-reported attitudes toward reporting concussions among HS athletes. METHODS: We conducted a survey of HS athletes aged 13 years to 18 years from two large, urban HSs. Players were recruited from selected seasonal (fall and winter) as well as men and women's sports. During preseason, each participant was given a survey asking about his or her previous education, current knowledge, and self-reported attitudes and behaviors about reporting concussions. Bivariate and multivariate linear regression was used to evaluate the association of age, sex, sport, and previous concussion education with knowledge and self-reported attitudes and behaviors about reporting concussions. RESULTS: Surveys were completed by 496 athletes. The median age was 15 years, and 384 (77.4%) were male. A total of 212 (42.7%) participated in football, 123 (24.8%) in soccer, 89 (17.9%) in basketball, and 72 (14.5%) in wrestling. One hundred sixteen (23.4%) reported a history of concussion. Improved knowledge regarding concussions was not associated with improved self-reported behaviors (p = 0.63) in bivariate regression models. The multivariate model demonstrated that older age (p = 0.01) and female sex (p = 0.03) were associated with better knowledge. Younger age (p = 0.01), female sex (p = 0.0002), and soccer participation (p = 0.02) were associated with better self-reported behaviors around reporting concussions. CONCLUSION: Previous education on concussions was less predictive of knowledge about concussions when controlling for other factors such as sport and sex. Younger age, female sex, and soccer participation were more likely to be associated with better self-reported behaviors. Future studies need to focus on the development of interventions to improve concussion-specific knowledge and behaviors.

A computerized kiosk to teach injury prevention: is it as effective as human interaction?

BACKGROUND: An emergency department (ED) visit may be an effective place to screen and educate families about injury prevention. The purpose of this study was to determine if a computerized kiosk in a pediatric ED can screen families for injury risk and encourage them to make more safety changes at follow-up survey compared with an injury prevention specialist (IPS). METHODS: A prospective, randomized controlled study was performed with families of children younger than 14 years in an ED lobby. Families were screened for injury risk by computerized kiosk based on child's age category at triage (birth to 1 year, 1-4 years, 5-9 years, or 10-14 years). Families were randomized to receive either injury behavior instructions by kiosk printout or by IPS when answers to specific practices were deemed unsafe. Three weeks after intervention, families were telephoned to determine change in safety practices. RESULTS: Three hundred seventeen families completed ED kiosk screen at enrollment (172 kiosk, 145 IPS). On initial screen, kiosk families practiced 79.6% of behaviors safely versus 75.9% in the IPS group (p = 0.011). A total of 221 families (69.7%) were reached for follow-up (121 kiosk, 100 IPS). On average, IPS families improved their safe behavior responses by 8.3% versus 1.0% in the kiosk group (p < 0.0001). Significantly more families in the IPS group than in the kiosk group (36% vs. 23%, p < 0.03) used additional safety equipment after the intervention. CONCLUSION: A computerized kiosk based in a pediatric ED can help screen families for their injury risk. However, to elicit significant behavior change, an IPS discussing safety changes may be more effective.

Intentional injuries in young Ohio children: is there urban/rural variation?

BACKGROUND: Intentional injuries are the third leading cause of death in children 1 year to 4 years of age. The epidemiology of these injuries based on urban/rural geography and economic variables has not been clearly established. The study purposes are (1) to determine the rate of severe intentional injuries in children younger than 5 years in urban versus rural Ohio counties and (2) to determine if poverty within counties is associated with intentional injury rate. METHODS: Demographic and injury data on children younger than 5 years who experienced intentional injuries, from January 1, 2003, to December 31, 2011, were extracted retrospectively from the Ohio Trauma Acute Care Registry. We calculated injury rates using the county of residence and US census data. We assigned each county to an urbanization level based on population density (A, most urban; D, most rural). Mean income and percentage of families with children younger than 5 years living below poverty in Ohio counties were obtained from the US census. Rates are per 100,000 children younger than 5 years per year. RESULTS: A total of 984 patients were included; the overall injury rate was 15.9. The mean age was 0.66 years (SD, 1.02 years); 583 (59.2%) were male and 655 (66.6%) were white. One hundred twenty-nine (13.1%) died. Injury rates by urbanization level were as follows: A, 16.5; B, 10.7; C, 18.7; and D, 15.2 (p = 0.285). There were significant associations between county injury rate and mean income (p = 0.05) and percentage of families with children younger than 5 years living below poverty (p = 0.04). CONCLUSION: We found no association between intentional injury rate and urbanization level in young Ohio children. However, we did find an association between county mean income and percentage of families living below poverty, with intentional injury rate suggesting that financial hardship may be an important risk factor of these injuries.

Prevalence of male adolescent dating violence in the pediatric emergency department.

BACKGROUND: Adolescent dating violence (DV) is a growing problem in the United States. Identifying the most optimal venue for screening and determining risk factors for DV is important for treatment and prevention programs. The purposes of this study were to determine the prevalence of DV among male teens presenting to a Midwestern pediatric emergency department (PED) and to determine risk factors, types of injuries sustained, and interest in social service assistance. METHODS: Males (13-21 year old) presenting to a PED were prospectively enrolled. Exclusions included never dated, non-English speaking, critically ill, active psychosis, or caregiver nonwillingness to leave during study participation. The computerized survey consisted of demographics, a validated DV screen, risk factor assessment, and injuries from DV. At completion, all participants received DV educational materials and were offered social service referral. RESULTS: Of the 262 eligible approached participants, 198 (75.6%) were enrolled. The mean ± SE age of participants was 16.2 ± 0.13 years, with 106 white (53%) and 77 African American (39%). A total of 99 (50%) had DV education in the past; 39 (19.7%) screened positive for DV. Risk factors for those who screened positive include the following: 9 (29%) endorse riding in a car with a dating partner who was driving intoxicated, 27 (87%) admitted to drinking alcohol, and 11 (35%) have been treated for an sexually transmitted infection. Almost all injuries sustained as a result of DV (83%) were minor (scratches or scrapes). Only 2 (5%) accepted social service intervention and none for their DV exposure. CONCLUSION: One in five teen males who present to a PED in our population screened positive for DV. Using specific risk factors could aid practitioners in identifying those children more likely to screen positive. Injuries sustained were mild, and most did not accept social services consultation.

Can the reduction of pediatric injury rates be sustained using a community-based approach?

BACKGROUND: Injuries are the leading cause of morbidity and mortality in US residents aged 1 to 44 years. Community-based interventions are effective in reducing injuries. Using this approach, investigators significantly reduced injuries in Avondale, Ohio, between 1999 and 2004 compared with three control communities (42 vs. 15%, respectively). The objective of this study was to determine if injury reduction was sustained through the 5 years after initial implementation of injury prevention (IP) efforts in Avondale compared with the same three control communities. DESIGN/METHODS: Injury prevention interventions implemented in Avondale, Ohio, during previous study years were sustained. Two new playgrounds were built, but no other new interventions were introduced. Control communities had no programs introduced by the team during the study period. Data were obtained from the Hamilton County Injury Surveillance System from 2005 to 2009 for deaths, hospitalizations, and emergency department visits due to injury for children 0 to 19 years old. Data from the study community were compared with those of the same three control communities as in our previous work, with similar demographics and socioeconomic characteristics, as well as with data obtained previously from 1999 to 2004. Census data based on annual estimates were used to calculate injury rates. RESULTS: The injury rate in Avondale decreased from 17,073 to 11,284 injuries per 100,000 children per year during the 11-year period (33.9% reduction). The injury rate in the control communities decreased from 14,436 to 12,381 injuries per 100,000 children per year in the same period (14.2% reduction). The difference in the injury rate decrease between the intervention and control communities was statistically significant, p < 0.001. From 2005 to 2009, the lower injury rate was sustained in Avondale, p = 0.58. CONCLUSIONS: Community-based strategies to prevent injuries to children in high-risk communities can be successful in reducing overall injury rates. These efforts can result in sustained injury reduction over time despite no new interventions being introduced.

Transition to a novel advanced integrated vitrectomy platform: comparison of the surgical impact of moving from the Accurus vitrectomy platform to the Constellation Vision System for microincisional vitrectomy surgery.

BACKGROUND: Microincisional vitrectomy surgery (MIVS) is the current standard surgical approach for pars plana vitrectomy. Historically, the most common surgical platform for vitrectomy surgery, since its introduction in 1997, has been the Accurus vitrectomy system. Recent introduction of the next generation of vitrectomy platforms has generated concerns associated with transitioning to new technology in the operating room environment. This study compared, in a matched fashion, surgical use of the Accurus vitrectomy system and the next generation Constellation Vision System to evaluate surgical efficiencies, complications, and user perceptions of this transition. METHODS: Electronic health records were abstracted as a hospital quality assurance activity and included all vitreoretinal surgical procedures at the Bascom Palmer Eye Institute, Anne Bates Leach Eye Hospital, during two discrete 12-month time periods. These two periods reflected dedicated usage of the Accurus (June 2008-May 2009) and Constellation Vision (July 2009-June 2010) systems. Data were limited to a single surgeon and evaluated for operating room (OR) total time usage/day, OR case time/case, and OR surgical time/case. Further analysis evaluated all patients undergoing combined MIVS and clear cornea phacoemulsification/intraocular lens (IOL) implantation during each individual time period to determine the impact of the instrumentation on these parameters. All records were evaluated for intraoperative complications. RESULTS: Five hundred and fourteen eligible patients underwent MIVS during the 2-year study windows, with 281 patients undergoing surgery with the Accurus system and 233 patients undergoing surgery with the Constellation system. Combined MIVS and phacoemulsification with IOL implantation was performed 141 times during this period with the Accurus and 158 times during the second study period with the Constellation. Total number of patients operated per day increased from 7.55 with Accurus to 8.53 with Constellation. Surgical room time decreased from 56 minutes with Accurus to 52 minutes with Constellation, and procedure time decreased from 35 minutes with Accurus to 31 minutes with Constellation (P < 0.004). Combined MIVS/phacoemulsification surgery saw similar declines in surgical room time and procedure time (P < 0.001). Subset analysis of procedures limited by case number per day (eg, four cases/day, five cases/day, six cases/day, and seven or more cases/day) showed similar outcomes with a decrease in surgical room time and procedure time. No increases in surgery-related complications were noted by quality assurance review during these time periods. DISCUSSION: Transitioning to advanced surgical technology is a complex issue for the surgeon, the hospital team, and the hospital administration. This study documents improvement in three significant measures of surgical efficiency: operative number of patients per day, operative room time, and surgical procedure time that reflect the positive impact of the novel, combined, integrated, posterior and anterior, ophthalmologic surgical platform of the Constellation Vision System. These data are imperative to evaluate the impact of transition from one surgical platform to another. During this transition, hospital quality assurance review and surgeon evaluation of operative complications showed no increased concerns for the shift from the Accurus to the Constellation Vision System surgical platform. Further, both operative staff and surgeons felt that the transition to the Constellation was not associated with increases in difficulty with setup, turnover, or use and that the Constellation decreased safety concerns for surgical usage. Ultimately, in this case, new technology benefited the surgeon, the patient, and the hospital.

Is an emergency department encounter for a motor vehicle collision truly a teachable moment?

BACKGROUND: Some have suggested that a pediatric emergency department (PED) visit for an injury represents a "teachable moment." Our aim was to determine if a motor vehicle collision (MVC) instigates greater change in booster seat use compared with children presenting for non-injury-related complaints. METHODS: A prospective pilot study of children 4 years to 8 years who never used a booster seat and were in a minor MVC were compared with children presenting to the PED for non-injury-related complaints. After completing a survey of demographics and knowledge about booster seats, all parents received brief, standardized counseling about booster seats. Two weeks after the PED visit, follow-up telephone calls were made to assess behavior change. RESULTS: Sixty-seven youth were enrolled (37 MVC group, 30 controls). Initially, 65 (97%) used a seat belt alone (36 MVC, 29 controls); the rest were unrestrained. There was no difference between the groups in mean age, sex of child, or insurance type. Significantly more families in the MVC group claimed that they would get a booster seat after their PED encounter (46% vs. 19%, p = 0.02) and their child would consistently use a booster seat (54% vs. 23%, p = 0.01). At follow-up, 45 families (67%) were reached (25 cases [68%] and 20 controls [67%]). There was no significant difference between the groups in having a booster seat at follow-up (12 cases [48%] and 9 controls [45%]) and reports of booster seat use more than 75% of the time (9 cases [36%] and 7 controls [35%]). CONCLUSION: A minor MVC did not serve as a teachable moment to entice families to consistently use a booster seat more than families presenting to a PED for non-injury-related complaints. However, more than one third of the families who learned about booster seats in the PED reported using a booster seat regularly. LEVEL OF EVIDENCE: Therapeutic study, level II.

Falls in children birth to 5 years: different mechanisms lead to different injuries.

BACKGROUND: Falls are the most common cause of injury-related hospitalization in children younger than 5 years old. Most anticipatory guidance surrounding falls is around falls from windows or stairs; however, falls from furniture also are important causes of morbidity. The purpose of this study was to compare the number of children injured, ages of injured children, and injuries sustained in falls from furniture and falls from stairs in hospitalized children younger than 5 years. METHODS: All records of individuals from 0 year through 4 years, hospitalized at our institution for a fall from furniture or stairs between January 1, 1996, and December 31, 2006, were retrospectively reviewed. A standard data set was abstracted from each chart. Frequencies were used to characterize the study population. χ and t tests were used to determine differences between groups. RESULTS: A total of 171 patients were hospitalized for falls from stairs and 318 for falls from furniture. There were no differences between the groups with regard to age, sex, race, type of insurance, length of stay, Injury Severity Score, or total cost. The most common pieces of furniture from which children fell were beds (33.0%), couches (18.9%), and chairs (17.9%). Children who fell from stairs were significantly more likely to have injuries to their head (64.3% vs. 38.1%); those that fell from furniture were more likely to sustain arm injuries (33.3% vs. 9.9%). There were significantly more skull fractures in those that fell from stairs (39.8% vs. 20.1%) and humerus fractures in those that fell from furniture (30.8% vs. 9.4%) (p < 0.001). Falls from furniture increased during the study period, while falls from stairs fell; the difference was not statistically significant, however. CONCLUSION: Falls from furniture and stairs are important causes of morbidity in children. More children were hospitalized for falls from furniture than from stairs. Falls down stairs are decreasing while falls off furniture are increasing. More anticipatory guidance should be developed and given to families regarding falls from furniture to help prevent these injuries. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Risk factors for dating violence among adolescent females presenting to the pediatric emergency department.

BACKGROUND: Intimate partner violence (IPV) among the adolescent population is an increasing concern. This study was designed to assess the prevalence, associated risk factors, and best ways to identify IPV among teens presenting to a pediatric emergency room. METHODS: This prospective, convenience study was conducted in a busy, pediatric emergency department. Young women, aged 15 years to 21 years, presenting with any chief complaint were enrolled. Adolescents completed a verbally assisted survey, and responses were recorded. Surveys consisted of three sections: demographic information, an eight-item date violence screening tool, and a risk factor assessment tool. Teens who screened positive for IPV were offered immediate social services assistance. Analysis was performed to compare youth risk factors between young women who were screened positive and negative for IPV. All eight of the date violence screening questions were reviewed to analyze whether a set of questions were consistently positive in all the teens who were screened. RESULTS: A total of 246 of 270 (91%) approached were enrolled. The prevalence of IPV was 36.6%. Many of the risk-taking behaviors assessed correlated with dating violence. The most significant included having tried alcohol (odds ratio [OR], 2.4; confidence interval [CI], 1.3-4.4), having ridden in a car with a partner who was doing drugs (OR, 2.4; CI, 1.1-5.0) or alcohol (OR, 2.5; CI, 1.0-6.3), fighting with peers (OR, 3.5; CI, 1.6-7.8), and history of sexually transmitted disease (OR, 2.2; CI, 1.2-4.2). Four questions were identified that detected 99% of positive screens for adolescent dating violence. CONCLUSIONS: IPV among female adolescents presenting to a pediatric emergency department is high. Certain risk-taking behaviors are correlated with adolescent dating violence. Four specific questions, if asked in this setting, can capture teens at risk.