Parents' Perspectives on Safe Storage of Firearms.

Firearms contribute substantially to leading causes of death among US children ages 10-19 (suicide and homicide). Safe storage of guns is important but poorly adopted. This study sought to understand knowledge, attitudes, beliefs, and firearm storage practices among parents living in households with firearms. Focus groups (FG) were conducted with gun-owning parents/guardians in three US states with high firearm ownership. Participants also completed an anonymous survey which included demographic characteristics, previous gun education, purpose of gun ownership, and storage practices. Eight FG were conducted with 57 parents. 74% of participants stored at least one firearm unlocked, with many loaded. Overall risk perception for firearm injury was low. Many participants believed modeling responsible use within the family would demystify the presence of a firearm and decrease accidental shootings. There was strong perception that safe storage interferes with personal protection needs, especially for handguns. Trigger locks were considered a nuisance and rarely used. Parents were confident in their youth's ability to handle guns safely and did not believe that safe storage would deter suicide. Preferred messengers for safe storage education were military or law enforcement rather than physicians. Participants advocated for safe storage education paired with hands-on use education. Gun-owning parents supported safety education and endorsed education from nonmedical sources. Education about suicide prevention may improve adoption of safe storage by parents. These results will inform the development of a firearm safe storage campaign with improved acceptability for communities with high firearms use and ownership.

Characterization of pediatric golf cart injuries to guide injury prevention efforts.

BACKGROUND: Golf cart injuries represent an increasing source of morbidity and mortality in the United States. Characterization of the circumstances of these injuries can inform injury prevention efforts. METHODS: This study retrospectively reviews a prospective trauma registry at a level-one pediatric trauma center for golf cart-related injuries in patients under 18years of age admitted to the hospital between 2008 and 2016. RESULTS: The 40 identified crashes were associated with 82 hospital days, 17 ICU days, and more than $1 million in hospital charges over the study period. The median hospital stay was 1.5days, and the median hospital charge was $20,489. Severe injuries with an Injury Severity Score of >15 were identified in 25% of patients, and moderate injuries with scores between nine and 15 were identified in an additional 30%. The most common injures were head and neck (60%) and external injuries to the body surface (52.5%). Only a single child was wearing a seatbelt, and the vast majority was not using any safety equipment. Children as young as nine years old were driving golf carts, and child drivers were associated with the cart overturning (p=0.007). CONCLUSIONS: Golf cart crashes were a source of substantial morbidity at a level-one trauma center. Increased safety measures, such as higher hip restraints, seatbelts, and front-wheel breaks could substantially increase the safety of golf carts. Increased regulation of driving age as well as driver education may also reduce these injuries.

Pivoting injury prevention efforts during a pandemic: results of an international survey.

BACKGROUND: The COVID-19 a pandemic changed the world. Public health directives to socially distance with stay-at-home orders altered injury risk factor exposure, resulting injury patterns and conducting injury prevention (IP). The objective of this study was to determine the impact the COVID-19 pandemic on injury and IP at North American trauma centers (TC). RESULTS: Sixty-two responses were received from pediatric (44%), adult (11%), and combined (31%) TC, from 22 American states, 5 Canadian provinces and Australia. The majority (91%) of programs targeted age groups from birth to 15 years old. Nearly one-third reported IP to be less of an institutional priority with funding redistributed in 15% of centers [median (IQR) - 25% (- 43, 1)], and resultant staffing changes at 38% of centers. A decrease in IP efforts was reported at 64% of TC. Overall, the majority of respondents reviewed injury data, with the top reported increased mechanisms mainly intentional: Firearm-related (75%), assaults (72%), and abuse (71%). Leading increased unintentional injuries were injuries occurring in the home such as falls (70%), followed by ATV (62%), and cycling (57%). Sites pivoted by presenting (74%) or participating (73%) in IP education virtually, social media posts (61%) and the addition of technology (29%). Top barriers were redeployment of partners (45%) and staff (31%), as well as lack of technology (40%) in the target population. Facilitators were technology at TC (74%), support of trauma program (63%), and having IP funding maintained (55%). CONCLUSIONS: Nearly two-thirds of TC decreased IP efforts during the pandemic due to staffing and funding reductions. The leading reported increased injuries were intentional, indicating that violence prevention is needed, along with support for mental health. While TC successfully pivoted by using technology, access issues in the target population was a barrier resulting in health inequities.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Age variability in pediatric injuries from falls.

OBJECTIVE: The objective of this study is to examine the nature and circumstances surrounding pediatric fall-related injuries for specific age groups and their implications for age-appropriate injury prevention efforts. METHODS: This is a retrospective analysis of data (October 2006 to April 2009) from the trauma registry of a level 1 pediatric trauma center. Inclusion criteria are patients admitted because of fall-related injury younger than 15 years (n = 675). Injury mechanism specifics were obtained from medical records. RESULTS: Falls were the leading cause of admissions and accounted for 37% of all cases during this period. Most pediatric fall-related injuries (73%) occurred between 1 and 9 years of age. Although infants accounted for only 8% of fall injuries, a greater proportion of these children were more severely injured. The mean Injury Severity Score for infants was significantly greater than the overall average (P < .001). Causes of fall injuries vary by age and have been discussed. CONCLUSIONS: The high incidence of pediatric fall injuries warrants dedicated injury prevention education. Injury prevention efforts need to be age appropriate in terms of focus, target audience, and setting. Recommendations for injury prevention are discussed.

Sledding while towed behind motorized vehicles associates with more severe and lethal injuries☆.

INTRODUCTION: Our institution has recently experienced an increase in sledding-related injuries, particularly when towed behind motorized vehicles. The purpose of this study was to characterize injury severity and clinical outcomes between pediatric patients who sustain injuries owing to motorized sledding accidents to aid in injury prevention messaging. METHODS: This retrospective study queried all patients who presented with a sledding-related injury to a single ACS-verified Level 1 Pediatric Trauma Center located in the Southeastern United States between 01/2015 and 01/2022. Demographics, injury details, and clinical outcomes were compared between two groups: patients towed behind a motorized vehicle (MOTOR) and those who were not (GRAVITY). RESULTS: Of the 67 patients included in our analysis, 15 (22%) were in the MOTOR group. Patients in the MOTOR group presented with significantly higher injury severity (ISS) and lower Glasgow coma scale (GCS) scores. Additionally, patients in this MOTOR group more often received a blood transfusion and intubation, had longer intensive care and overall hospital lengths of stay, and incurred higher hospital costs. In a multivariate analysis, the use of a motorized vehicle to sled was independently associated with increased ISS (OR: 9.7, 95% CI 1.9-17.5; p = 0.02). Two deaths occurred after sledding while being towed behind a motorized vehicle. CONCLUSION: Children experiencing sledding accidents while being towed by motorized vehicles sustain significantly more severe injuries and require more intensive treatments that together lead to increased hospital costs. These findings provide the framework for community educational initiatives and injury prevention measures to mitigate risk among children engaged in sledding. LEVEL OF EVIDENCE: IV retrospective cohort study.

Socioeconomic factors associated with helmet use in pediatric ATV and dirt bike trauma.

Objectives: Recreational off-road vehicle crashes can produce severe injury and death among children, often from head trauma sustained while riding unhelmeted. Although required for competition, recreational riders commonly forego helmets. This study aimed to identify socioeconomic factors associated with unhelmeted injuries among children riding all-terrain vehicles (ATVs) and dirt bikes recreationally, thus informing injury prevention efforts. Methods: A retrospective review was completed of patients younger than 18 years who presented after recreational ATV or dirt bike crash to a single American College of Surgeons-verified level 1 pediatric trauma center (2010-2019). Demographic, injury, and outcome data were collected. US Census data regarding median and per capita income, poverty prevalence, and scholastic graduation rates were recorded for each patient's home county. Relationships between helmet use at the time of injury, demographics, and socioeconomic variables were examined. Results: The cohort comprised 680 injured recreational ATV (n=510; 75%) and dirt bike (170; 25%) riders. Unhelmeted riders (n=450) were significantly older (median age 13 vs 11 years; p=0.008) and more often rode ATVs (n=399). Significantly greater percentages of females (77.9%; p<0.001) and passengers (89.5%; p<0.001) were unhelmeted at the time of injury. Residents of counties with lower median and per capita income, higher poverty prevalence, and lower high school and college graduation rates were significantly more likely to be unhelmeted at the time of their crash (p=0.003). In multivariable analysis, unhelmeted injuries were independently associated with ATV use (OR=6.757; p<0.0001), passenger status (OR=6.457; p<0.0001), and older age (OR=1.219; p<0.0001). Conclusion: In children, ATV use, passenger status, and older age associated independently with unhelmeted riding in recreational vehicle crash. Residence in a county with both lower median income and scholastic graduation rates associated with unhelmeted crashes, and lower median income significantly predicted unhelmeted crashes. This study revealed socioeconomic factors that identify communities with greatest need for injury prevention initiatives. Level of evidence: III-retrospective comparative epidemiological study.

The impact of helmet use on neurosurgical care and outcomes after pediatric all-terrain vehicle and dirt bike crashes: a 10-year single-center experience.

OBJECTIVE: All-terrain vehicle (ATV) and dirt bike crashes frequently result in traumatic brain injury. The authors performed a retrospective study to evaluate the role of helmets in the neurosurgical outcomes of pediatric patients involved in ATV and dirt bike crashes who were treated at their institution during the last decade. METHODS: The authors analyzed data on all pediatric patients involved in ATV or dirt bike crashes who were evaluated at a single regional level I pediatric trauma center between 2010 and 2019. Patients were excluded if the crash occurred in a competition (n = 70) or if helmet status could not be determined (n = 18). Multivariable logistic regression was used to analyze the association of helmet status with the primary outcomes of 1) neurosurgical consultation, 2) intracranial injury (including skull fracture), and 3) moderate or severe traumatic brain injury (MSTBI) and to control for literature-based, potentially confounding variables. RESULTS: In total, 680 patients were included (230 [34%] helmeted patients and 450 [66%] unhelmeted patients). Helmeted patients were more frequently male (81% vs 66%). Drivers were more frequently helmeted (44.3%) than passengers (10.5%, p < 0.001). Head imaging was performed to evaluate 70.9% of unhelmeted patients and 48.3% of helmeted patients (p < 0.001). MSTBI (8.0% vs 1.7%, p = 0.001) and neurosurgical consultation (26.2% vs 9.1%, p < 0.001) were more frequent among unhelmeted patients. Neurosurgical injuries, including intracranial hemorrhage (16% vs 4%, p < 0.001) and skull fracture (18% vs 4%, p < 0.001), were more common in unhelmeted patients. Neurosurgical procedures were required by 2.7% of unhelmeted patients. One helmeted patient (0.4%) required placement of an intracranial pressure monitor, and no other helmeted patients required neurosurgical procedures. After adjustment for age, sex, driver status, vehicle type, and injury mechanism, helmet use significantly reduced the odds of neurosurgical consultation (OR 0.250, 95% CI 0.140-0.447, p < 0.001), intracranial injury (OR 0.172, 95% CI 0.087-0.337, p < 0.001), and MSTBI (OR 0.244, 95% CI 0.079-0.758, p = 0.015). The unadjusted absolute risk reduction provided by helmet use equated to a number-needed-to-helmet of 6 riders to prevent 1 neurosurgical consultation, 4 riders to prevent 1 intracranial injury, and 16 riders to prevent 1 MSTBI. CONCLUSIONS: Helmet use remains problematically low among young ATV and dirt bike riders, especially passengers. Expanding helmet use among these children could significantly reduce the rates of intracranial injury and MSTBI, as well as the subsequent need for neurosurgical procedures. Promoting helmet use among recreational ATV and dirt bike riders must remain a priority for neurosurgeons, public health officials, and injury prevention professionals.

Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019.

OBJECTIVE: Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. METHODS: Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. RESULTS: Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). CONCLUSIONS: Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.

A multiyear assessment of a hospital-school program to promote teen motor vehicle safety.

BACKGROUND: Motor vehicle crashes are the leading cause of death among teen drivers. The main goal of this program was to reduce texting while driving among high school teens through a unique peer-generated anti-texting campaign. METHODS: The program consisted of two phases. In phase 1, student leaders participated in a half-day, hospital-based experiential program that emphasized safe teen driving. In phase 2, these students conceptualized and implemented an anti-texting while driving campaign during the school year. The program enrolled 32 schools with 137 student participants in phase 1. This study uses a prospective quasi-experimental pre-post design. A presurvey and a follow-up online survey were used. Response rate was 81%. In phase 2, two rounds of observations of drivers were made near the participating schools at the beginning and end of the phase 2 campaign. The results were analyzed using proportion tests. RESULTS: There was a strong belief (6.49 on a seven-point scale) that texting while driving could result in a crash. About 58% had texted while driving in the previous 7 days in the pre-survey. This proportion decreased significantly to 44% in the follow-up (p < 0.05). Knowledge of Tennessee Graduated Driver Licensing laws and feeling of empowerment to take action with a teen driver who was texting improved significantly (p < 0.05). In phase 2, 12,309 drivers (adults and teens) were observed in the first round, and 13,153 were observed in the second round of observations. Significant reduction in the proportion of drivers texting while driving (from 13% to 9%; p < 0.0001) was observed. CONCLUSION: Results of driver observations support the effectiveness of this program in meeting the key objective of reducing texting while driving. The program also influenced teenagers' willingness to take positive steps when faced with a driver who was texting. Future efforts should aim to influence social and peer norms. LEVEL OF EVIDENCE: Therapeutic study, level IV.

A multiyear assessment of a hospital-school program to promote teen motor vehicle safety.

BACKGROUND: Motor vehicle crashes are the leading cause of death among teen drivers. The main goal of this program was to reduce texting while driving among high school teens through a unique peer-generated anti-texting campaign. METHODS: The program consisted of two phases. In phase 1, student leaders participated in a half-day, hospital-based experiential program that emphasized safe teen driving. In phase 2, these students conceptualized and implemented an anti-texting while driving campaign during the school year. The program enrolled 32 schools with 137 student participants in phase 1.This study uses a prospective quasi-experimental pre-post design. A presurvey and a follow-up online survey were used. Response rate was 81%. In phase 2, two rounds of observations of drivers were made near the participating schools at the beginning and end of the phase 2 campaign. The results were analyzed using proportion tests. RESULTS: There was a strong belief (6.49 on a seven-point scale) that texting while driving could result in a crash. About 58% had texted while driving in the previous 7 days in the pre-survey. This proportion decreased significantly to 44% in the follow-up (p < 0.05). Knowledge of Tennessee Graduated Driver Licensing laws and feeling of empowerment to take action with a teen driver who was texting improved significantly (p < 0.05). In phase 2, 12,309 drivers (adults and teens) were observed in the first round, and 13,153 were observed in the second round of observations. Significant reduction in the proportion of drivers texting while driving (from 13% to 9%; p < 0.0001) was observed. CONCLUSION: Results of driver observations support the effectiveness of this program in meeting the key objective of reducing texting while driving. The program also influenced teenagers' willingness to take positive steps when faced with a driver who was texting. Future efforts should aim to influence social and peer norms. LEVEL OF EVIDENCE: Therapeutic study, level III.

A pilot hospital-school educational program to address teen motor vehicle safety.

BACKGROUND: Texting while driving has emerged as a significant distracted driving behavior among teenage drivers. A unique hospital-school collaborative pilot intervention (called "Be in the Zone" or "BITZ") was implemented to combat this growing problem. This intervention was hypothesized to lead to a decline in texting while driving among high school students. METHODS: This collaborative intervention consisted of two separate phases. In Phase 1, small groups of high school student leaders participated in a half-day interactive educational session in a pediatric hospital. Pre- and post-follow-up surveys were administered to this group. In Phase 2, these same students took the lessons they learned from the hospital to plan and implement a yearlong peer-to-peer campaign that focused on a clear "no texting while driving" message at their schools. Two unannounced driver observations were conducted to evaluate the effectiveness of the pilot program. RESULTS: Sixty-one high school students participated in Phase 1. Self-reported texting while driving rates decreased significantly among the participants after Phase 1. Two schools were recruited to participate in Phase 2. Unannounced driver observations were conducted before the campaign and toward the end of the campaign. Postintervention, there was a significant decrease in the percentage of drivers who texted while driving. CONCLUSION: Preliminary results from this pilot program suggest that a strategy of combining hospital-school partnerships with a peer-driven educational approach can be effective in reducing texting while driving among teenagers in the short-term.

Analysis of pediatric all-terrain vehicle trauma data in Middle Tennessee: implications for injury prevention.

BACKGROUND: Trauma registries capture data about injuries that can be used to objectively guide injury prevention initiatives. This article analyzes trauma registry data to describe the nature and distribution of all-terrain vehicle (ATV) injuries in Middle Tennessee. A community injury prevention effort, based on this analysis, is also presented. METHODS: A retrospective analysis of data (2007-2009) from the trauma registry of a Level I pediatric trauma center in Middle Tennessee was conducted. Patients younger than 16 years with ATV-related injuries were included in the analysis (n = 163). The key variables examined were demographics, injury severity, helmet use, injury mechanism, length of stay, and patient's county of residence. In addition, Geographic Information Systems software was used to examine the distribution of injuries and graphically represent counties with highest injury rates in the youth population. RESULTS: ATV injuries were more prevalent among boys than girls (66% vs. 34%; p < 0.001). Approximately 64% of the ATV injuries were in the age group 10 years to 15 years. Most injuries were either moderately severe (44%) or severe (30%). Injury mechanism varied by age; younger children experienced more rollovers while older children tended to be injured from ejections (p < 0.05). Helmet use was low (33%). Data from this study suggest that helmet use resulted in fewer injuries to the head, neck, and face. Counties with high rates of ATV injuries were targeted for ATV training programs. 4-H agents trained by the ATV Safety Institute provided ATV training classes. CONCLUSION: Rural youth are clearly at greater risk for ATV injuries than urban populations. Young ATV riders are often self-taught and lack the knowledge to ride ATVs safely. Organizations such as the 4-H, provide effective injury prevention outreach. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Race disparities in firearm injuries and outcomes among Tennessee children.

PURPOSE: The aim of this study was to identify race and socioeconomic factors associated with worse outcomes among Tennessee children who sustain firearm injuries. METHODS: We queried our institutional pediatric trauma registry and the Davidson County Regional Medical Examiner database for children ages 15 years and younger who sustained firearm injuries between July 1998 and July 2010. Descriptive statistics and logistic regression modeling were used to analyze demographic data, circumstance of injury (unintentional or intentional), odds of death, and characteristics of zip codes (total population, race distribution, and median income) where injuries occurred. RESULTS: One hundred eighty-eight children (median age, 13.2 years; range, 1.1-15.8 years) sustained a firearm injury and were either admitted to our institution or were referred directly to the medical examiner. More whites (n = 109, or 58%) sustained a firearm injury than blacks (n = 79, or 42%), but blacks were overrepresented 2.5-fold more compared with the general Tennessee population. Fifty-four children (29%) died, of whom 35 (65%) were black and 19 (35%) were white (P < .001). Ninety-three children sustained unintentional firearm injuries, and 84 were intentional (n = 67, assault; n = 17, suicide). When data were stratified by intent, 67% of blacks and 12% of whites were assaulted (P < .001). After controlling for age and intent, black children were 4 times more likely to die of firearm injuries than whites (P = .008; 95% confidence interval, 1.4-11.3). CONCLUSION: In a sample of firearm-injured Tennessee children, blacks were notably overrepresented and far more likely to die than whites. Using zip code data will help to establish firearm injury prevention programs specific to disparate populations and to reduce both violent and accidental childhood firearm injuries.