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[Preprint]. 2024 May 7:rs.3.rs-4202941. [Version 1] doi: 10.21203/rs.3.rs-4202941/v1

Clinical Trauma Severity of Indoor and Outdoor Injurious Falls Requiring Emergency Medical Service Response

Kathryn G Burford 1, Nicole G Itzkowitz 2, Remle P Crowe 3, Henry E Wang 4, Alexander X Lo 5, Andrew G Rundle 6
PMCID: PMC11100870  PMID: 38766041

Abstract

Background:

Injurious falls represent a significant public health burden. Research and polices have primarily focused on falls occurring indoors despite evidence that outdoor falls account for 47–58% of all falls requiring some medical attention. This study compared the clinical trauma severity of indoor versus outdoor injurious falls requiring Emergency Medical Services (EMS) response.

Methods:

Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset, we identified the location of patients injured from falls that required EMS response. We classified injury severity using 1) the Revised Trauma Score for Triage (T-RTS): ≤ 11 indicated the need for transport to a Trauma Center; 2) Glasgow Coma Scale (GCS): ≤8 and 9–12 indicated moderate and severe neurologic injury; and 3) patient clinical acuity by EMS: Dead, Critical, Emergent, Low.

Results:

Of 1,854,909 encounters for patients with injurious falls, the vast majority occurred indoors (n=1,596,860) compared to outdoors (n=152,994). The proportions of patients with moderate or severe GCS scores, were comparable between those with indoor falls (3.0%) and with outdoor falls on streets or sidewalks (3.8%), T-RTS scores indicating need for transport to a Trauma Center (5.2% vs 5.9%) and EMS acuity rated as Emergent or Critical (27.7% vs 27.1%).Injurious falls were more severe among male patients compared to females: and males injured by falling on streets or sidewalks had higher percentages for moderate or severe GCS scores (4.8% vs 3.6%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 6.5%) compared to indoor falls. Young and middle-aged patients whose injurious falls occurred on streets or sidewalks were more likely to have a T-RTS score indicating the need for Trauma Center care compared to indoor falls among this subgroup. Yet older patients injured by falling indoors were more likely to have a T-RTS score indicating the need for Trauma Center than older patients who fell on streets or sidewalks.

Conclusions:

There was a similar proportion of patients with severe injurious falls that occurred indoors and on streets or sidewalks. These findings suggest the need to determine outdoor environmental risks for outdoor falls to support location-specific interventions.

Keywords: Falls, Injuries, Outdoor Falls, Surveillance

Background

Falls represent an enormous global public health burden associated with significant disability and mortality, with a worldwide age-standardized incidence of 2,238 falls per 100,000 persons per year in 2017, over 16.6 million years of life lost, and an average loss of 4% of one’s full health status from one fall (James et al., 2020). For the U.S., the Centers for Disease Control (CDC) reported 7.9 million unintentional injurious falls in 2019 that was associated with 131.5 billion USD in medical costs (WISQARS (Web-Based Injury Statistics Query and Reporting System) | Injury Center | CDC, 2023). Although falls affect all ages, the burden of falls in the U.S. is disproportionately borne by older persons, for whom falls are the leading cause of disability and functional decline (James et al., 2020; Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011).

Research and policy attention has been primarily devoted to falls occurring indoors,(“Guideline for the Prevention of Falls in Older Persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention,” 2001; Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011) despite reports of outdoor falls accounting for 47–58% of all falls among community-dwelling adults (Li et al., 2006; Timsina et al., 2017). Risk factors for indoor and outdoor falls also tend to differ. Indoor falls are more likely to be influenced by personal risk factors, the indoor environment, and underlying health conditions (Schepers et al., 2017). Outdoor falls occur among more active individuals and are primarily influenced by outdoor environmental factors (Schepers et al., 2017). These associated outdoor environmental factors have included weather conditions (e.g., snow and ice or extreme heat) and the physical environment (e.g., uneven surfaces, slippery surfaces, stairs) (Timsina et al., 2017). However there remains limited understanding for the role of urban design and the environment on the risk of outdoors falls, especially for falls on streets and sidewalks, where 85% of outdoor falls requiring an Emergency Medical Services (EMS) response were found to occur (Rundle et al., 2023, 2024). Additionally, there is an abundance of literature addressing the risk factors for falls related to the older population, but even for this demographic subgroup, research studies for outdoor falls were far fewer (Chippendale et al., 2023), with substantially greater focus on person-level and indoor environment characteristics (e.g. home trip hazards) (“Guideline for the Prevention of Falls in Older Persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention,” 2001; Montero-Odasso et al., 2022; Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). These major knowledge gaps have hampered the development of community-specific and person-centered prevention strategies to reduce the burden of outdoor injurious falls (Chippendale et al., 2017; Li et al., 2006).

A primary reason for the lack of evidence to determine environmental risk factors for outdoor falls, and particularly at the population-level, is limitations in the surveillance of falls. The three primary public health surveillance systems in the U.S. for fall-related injuries are the CDC’s Web-Based Injury Statistics Query and Reporting System (WISQARS), the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health Interview Survey (NHIS) and yet none of these systems routinely provide data on the locations in which falls occur (Moreland et al., 2020; Timsina et al., 2017; WISQARS (Web-Based Injury Statistics Query and Reporting System) | Injury Center | CDC, 2023). While the NHIS has been used to examine outdoor falls, these analyses are 10–25 years old, likely because the location of the fall is determined by intensive coding of unstructured narrative texts, which makes use of these data cumbersome to analyze (Timsina et al., 2017). To improve the surveillance of outdoor falls, Rundle et al. (2023) developed a methodology to identify injurious falls by indoor versus outdoor location using EMS clinical and administrative data from the National Emergency Medical Services Information System (NEMSIS) (Rundle et al., 2023). Among the 1,854,909 injuries from falls that required an EMS response in 2019, 129,408 of these fall injuries were identified as occurring outdoors on streets and sidewalks, a number which is 70% higher than the number of pedestrians reportedly injured by automobiles (Li et al., 2006; National Highway Traffic Safety Administration, n.d.; Timsina et al., 2017). While establishing this surveillance method was a critical first step towards developing interventions to reduce outdoor falls, epidemiological data are needed to improve understanding of the public health and clinical burden of outdoor falls.

There are very few available studies to compare the severity of indoor and outdoor falls, with the focus of these being among the older adult population (Bath & Morgan, 1999; Chippendale et al., 2017; Kelsey et al., 2010, 2012; Kim, 2016; Lee, 2021; O’Loughlin et al., 1994). Chippendale et al.’s (2016) study of older U.S. trauma center patients who sustained outdoor falls had a higher frequency of open wounds and head injuries compared to indoor falls, but no significant difference on the injury severity score (ISS) (Chippendale et al., 2017). Kim (2016) found that outdoor falls led to a higher proportion of head and neck injuries than indoor falls among older emergency department patients across 20 hospitals in Korea (Kim, 2016). Jung et al. (2017) determined that the likelihood of severe injury, as determined by level of care, from outdoor falls in older adults was higher in men compared to women (Jung et al., 2018). These studies were limited by examining only individuals admitted to a hospital, and none were of a nationally representative sample. Furthermore, assessment of outcomes and severity of falls varied across these studies. Improved understanding of the clinical severity for fall injuries is critical to determining the short- and long-term burdens of 1) morbidities and disability among individuals (Stewart Williams et al., 2015) and 2) health care utilization needs of different communities (Eliacin et al., 2021; Korley et al., 2016), particularly in light of potential differences across sociodemographic groups (Chun Fat et al., 2019; Sharma et al., 2018). In the immediate setting following an injury, clinical severity scoring tools have been recommended, including the Revised Trauma Score for Triage (T-RTS) and Glasgow Coma Scale (GCS), to help guide on-scene EMS to determine the severity of the injury and optimal care response for the individual (Champion et al., 1989; Newgard et al., 2022). However, there are no population-level studies that have characterized the distribution of such scores in the assessment of severity of indoor versus outdoor injurious falls.

National surveillance data comparing indoor and outdoor injurious falls are critical to the development of person-centered, community-specific programs and policies to prevent serious falls. Data from EMS responses on the severity and level of care for indoor and outdoor injurious falls could be particularly informative from a healthcare resource perspective. Here we use 2019 national U.S. EMS data to compare the clinical trauma severity of indoor versus outdoor injurious falls, and further to examine these patterns by patient demographic characteristics.

Methods

Study Design

This cross-sectional study of EMS records from the 2019 National Emergency Medical Services Information System (NEMSIS) Public-Release Research Dataset included 1,854,909 occurrences of falls requiring EMS response across US states and territories (Rundle et al., 2023).

Data Source

NEMSIS is the national system to collect and standardize data from EMS agencies across the US. The National Highway Traffic Safety Administration Office for Emergency Medical Services provides these NEMSIS data are public release, de-identified, and HIPAA exempt data released by the University of Utah, as such further Institutional Review Board (IRB) review was not requested (Dawson, 2006; Ehlers et al., 2023). The use of NEMSIS to identify falls and locations of falls have been previously described and includes a robust approach to identifying overall injurious falls and to identifying falls for which syncope (heat-related and non-heat related syncope) and heat illness were contributing factors. (Rundle et al., 2023). EMS data entry into NEMSIS must abide by the standards set forth by the NHTSA Office of EMS and outlined in the NEMSIS data dictionary (https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDictionary/PDFHTML/EMSDEMSTATE/index.html) (V3 Data Dictionaries & XSD, n.d.).

Study Variables and Inclusion Criteria

Detailed methods for inclusion criteria and coding of fall locations (indoor, outdoor – not on street or sidewalk, outdoor – on street or sidewalk, indoor/outdoor unclear), patient demographic variables, and on-scene clinical measures (e.g. patient acuity) can be found in Rundle et al (Rundle et al., 2023). Briefly, we used NEMSIS variables ePatient 13, ePatient 15 and eSituation 13 to define patient sex (male, female), and age groups (0–20, 21–30, 31–40, 41–50, 51–60, 61–65, 66–70, 71–75, 76–80, 81–85, 86–90 and 91 + years), respectively. Falls with EMS notations of seizures have been removed from the analyses. NEMSIS data includes the patient’s clinical acuity, rated by EMS, which is classified as: Dead Without Resuscitation Efforts, Critical, Emergent, Low, Unknown. NEMSIS data were also used to calculate the Revised Trauma Score for Triage (T-RTS) and the Glasgow Coma Scale (GCS). The T-RTS, GCS and patient acuity data were used to characterize the severity of the injuries as observed by the EMS clinician on scene. When the tests used to calculate the GCS and the T-RTS were administered multiple times for a patient, the mean of all administrations were used.

Revised Trauma Score for Triage (T-RTS)

The Revised Trauma score for Triage to a Trauma Center (T-RTS) is a modified version of the original Trauma Score, that is more reliable and excludes capillary refill and respiratory expansion which are more difficult to assess in the field by EMS (Champion et al., 1989). The T-RTS can be used by EMS to make decisions on trauma care based on the severity of patient injuries (Lichtveld et al., 2008). For each patient, we calculated the mean T-RTS by summing the average value for GCS, systolic blood pressure, and respiratory rate. Champion and colleagues evaluated T-RTS cut-points based upon survival probabilities to create decision rules for patients to be triaged to a trauma center (Champion et al., 1989). Decision Rule 2 was used for the present study to categorize the T-RTS score into: ≤11, indicated need for immediate transport to a Trauma Center designated hospital; >11 does not. As blood pressure may be artificially lowered by anti-hypertensive medications, the use of which differs by age group, the validity of the T-RTS may vary by age. Therefore, assessment of the GCS alone offers a second measure of injury severity that is independent of blood pressure.

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) is a well-established measure of neurological status used for risk stratification in acute neurosurgical or traumatic injuries; the scale ranges from 3 to 15 and is calculated by summing the values for eye opening, verbal response, and motor response for each patient.11 In contemporary clinical practice, the GCS is used to determine the risks of mortality and morbidity, and more urgently to guide acute clinical management. We calculated the mean Glasgow Coma Scale (GCS) by summing the average value for eye opening, verbal response, and motor response for each patient. GCS ranges from 3 to 15, and for this analysis, GCS we use the widely used classifications for injury severity: as severe, ≤ 8; moderate, 9–12; and minor, ≥ 13 (Jain & Iverson, 2024).

Statistical Analyses

We conducted descriptive analyses for all EMS encounters for injurious falls by comparing the T-RTS, GCS, and patient acuity classifications by fall location, and further described these analyses by patient demographics. Due to the large size of this dataset, we did not include measures of statistical significance and instead allow the readers to make interpretations based on practical relevance in the differences. We conducted all analyses in R statistical software (v4.3.1; R Core Team 2023).

Results

In total 1,854,909 injuries from falls that required an EMS response were identified in the 2019 NEMSIS data. As reported previously (Rundle et al., 2023) and here in Table 1, of these falls the majority, 1,596,860, occurred indoors, 152,994 falls occurred outdoors, of which 129,408 occurred on streets and sidewalks. For 53,700 falls, the indoor versus outdoor status of the fall location could not be ascertained from the coded data, and for 51,355 the location data were not reported. Overall, 28% of fall patients injured by a fall had an EMS acuity rating of Critical or Emergent and 0.1% Dead at Scene (see Table 1). There were a minority of injured fall patients (n = 51,422; 3.0%) who had moderate or severe GCS scores and a minority of patients (n = 84,220; 5.2%) who had a T-RTS score indicating the need for transport to a Trauma Center. The proportion of patients injured by falling indoors who had an Emergent or Critical acuity rating was similar to the proportion of patients injured by falls occurring outdoors on streets or sidewalks (27.7% vs. 27.1%). Similarly, the proportion of patients injured by falling indoors and having moderate or severe GCS scores was comparable to the proportion of patients with moderate or severe GCS scores injured by falling on a street or sidewalk (3.0% vs. 3.8%). Likewise, the proportion of injured patients who fell indoors and who had a T-RTS score indicating the need for transport to a Trauma Center was comparable to the proportion of injured patients who had a T-RTS score indicating the need for transport to a Trauma Center and fell outdoors on a street or sidewalk (5.2% vs 5.9%). Patients injured by falling outdoors not on a street or sidewalk had a lower percentage for moderate or severe GCS scores (2.2% vs. 3.8%) and for T-RTS scores indicating the need for transport to a Trauma Center (4.4% vs 5.9%) compared to percentages for those injured by falling outdoors on streets or sidewalks, but the reverse pattern was true for patients injured by falls with an Emergent or Critical patient acuity (31.1% vs 27.1%).

Table 1.

Descriptive statistics for EMS Encounters for Reported Location of Fall Injuries by Patient Acuity, GCS and T-RTS scores.1

Overall Indoor Outdoor- Street or Sidewalk Outdoor- Not on Street or Sidewalk Indoor/outdoor unclear Missing
N = 1854909 N = 1596860 N = 129408 N = 23586 N = 53700 N = 51355
Patient Acuity
Dead 1600 0.1% 1432 0.1% 92 0.1% 29 0.2% 32 0.1% 15 0.1%
Critical 40609 3.0% 35267 2.9% 3044 3.2% 890 4.8% 1073 4.2% 335 2.1%
Emergent 339764 24.8% 302119 24.8% 22522 23.9% 4840 26.3% 6955 27.2% 3328 21.0%
Low 991674 72.3% 880467 72.3% 68834 72.9% 12681 68.9% 17498 68.5% 12194 76.9%
Unknown 481262 25.9% 377575 23.6% 34916 27.0% 5146 21.8% 28142 52.4% 35483 69.1%
GCS
Severe 16508 1.0% 13753 0.9% 1614 1.4% 214 1.0% 613 1.2% 314 0.8%
Moderate 34914 2.0% 30227 2.0% 2922 2.5% 257 1.2% 848 1.7% 660 1.6%
Minor 1663581 97.0% 1439013 97.0% 114490 96.2% 20843 97.8% 49624 97.1% 39611 97.6%
Unknown 139906 7.5% 113867 7.1% 10382 8.0% 2272 9.6% 2615 4.9% 10770 21.0%
T-RTS
Need for transport to Trauma Center 84220 5.2% 72748 5.2% 6494 5.9% 849 4.4% 2408 5.0% 1721 4.5%
Does not 1528682 94.8% 1324148 94.8% 104366 94.1% 18250 95.6% 45534 95.0% 36384 95.5%
Unknown 242007 13.0% 199964 12.5% 18548 14.3% 4487 19.0% 5758 10.7% 13250 25.8%
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1

GCS, Glasgow Comma Scale; T-RTS, Revised Trauma Score for Triage

Male patients injured by falls were more likely to have an acuity rated as Critical or Emergent (29.4% vs. 26.4%), moderate to severe GCS scores (3.7% vs. 2.3%) and have a T-RTS score indicating the need for transport to a Trauma Center (6.5% vs. 4.3%) than female patients injured by falls (see Table 2). The proportions for male patients injured by falls who had moderate or severe GCS scores (4.8% vs 3.6%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 6.5%) were higher for outdoor falls on streets or sidewalks compared to indoor falls. While among female patients injured by falls, the percentages for moderate or severe GCS scores (1.8% vs 2.2%) and T-RTS scores necessitating care at a Trauma Center (3.9% vs 4.3%) were similar for falls on streets or sidewalks and indoors locations. The proportions for injurious falls for which patient acuity was rated Critical or Emergent were similar for falls occurring on streets or sidewalks and for falls occurring indoors among both male (28.2% vs 29.4%) and female patients (25.4% vs 26.5%).

Table 2.

Descriptive Statistics for EMS Encounters for Reported Location of Fall Injuries by Patient Acuity, GCS and T-RTS Scores, Categorized by Sex.1

Overall Indoor Outdoor- Street or Sidewalk Outdoor- Not on Street or Sidewalk Indoor/outdoor unclear Missing
N = 1854909 N = 1596860 N = 129408 N = 23586 N = 53700 N = 51355
Acuity
Male
Dead 983 0.2% 868 0.2% 56 0.1% 27 0.3% 26 0.2% 6 0.2%
Critical 21729 3.8% 18137 3.7% 2098 3.8% 572 5.9% 727 5.5% 195 3.8%
Emergent 147941 25.6% 126701 25.7% 13331 24.4% 2703 27.9% 3762 28.6% 1444 25.6%
Low 406624 70.4% 347588 70.5% 39171 71.7% 6402 66.0% 8626 65.6% 4837 70.4%
Unknown 202742 26.0% 151433 23.5% 20051 26.8% 2709 21.8% 13809 51.2% 14740 69.5%
Female
Dead 559 0.1% 36 0.1% 2 0.1% 6 0.0% 8 0.0% 611 0.0%
Critical 16981 2.4% 930 2.3% 311 2.4% 340 3.6% 138 2.8% 18700 1.5%
Emergent 174488 24.1% 9105 24.1% 2115 23.0% 3153 24.4% 1830 25.6% 190691 20.0%
Low 530657 73.5% 29465 73.4% 6244 74.5% 8799 72.0% 7160 71.5% 582325 78.4%
Unknown 223437 25.8% 14541 23.6% 2395 26.9% 14227 21.6% 20503 53.6% 275103 69.2%
Missing Sex 7460 0.4% 6011 0.4% 624 0.5% 106 0.4% 225 0.4% 494 1.0%
GCS
Female
Severe 5916 0.6% 5295 0.6% 301 0.6% 48 0.4% 160 0.6% 112 0.4%
Moderate 16757 1.7% 15398 1.6% 659 1.2% 75 0.7% 281 1.1% 344 1.2%
Mild 966752 97.7% 860083 90.9% 48921 90.5% 9908 89.5% 24860 93.7% 22980 77.5%
Missing 78005 7.3% 65346 6.9% 4196 7.8% 1036 9.4% 1224 4.6% 6203 20.9%
Male
Severe 10540 1.4% 8416 1.3% 1309 1.8% 165 1.3% 451 1.7% 199 0.9%
Moderate 18041 2.3% 14732 2.3% 2250 3.0% 182 1.5% 565 2.1% 312 1.5%
Mild 691717 88.7% 574772 89.1% 65211 87.3% 10862 87.5% 24697 91.3% 16275 76.7%
Missing 59721 7.7% 46807 7.3% 5937 7.9% 1204 9.7% 1337 4.9% 4436 20.9%
Missing Sex 7460 0.4% 6011 0.4% 624 0.5% 106 0.4% 225 0.4% 494 1.0%
T-RTS
Male
Need for transport to Trauma Center 43,823 6.5% 36,305 6.5% 4,659 7.3% 539 5.4% 1,471 6.1% 849 5.4%
Does not 628,624 93.5% 522,887 93.5% 59,069 92.7% 9,444 94.6% 22,451 93.9% 14,773 94.6%
Missing 107,572 13.8% 85,535 13.3% 10,979 14.7% 2,430 19.6% 3,028 11.2% 5,600 26.4%
Female
Need for transport to Trauma Center 40132 4.3% 36222 4.3% 1811 3.9% 310 3.4% 929 3.9% 860 3.9%
Does not 895796 95.7% 797768 95.7% 45008 96.1% 8748 96.6% 22944 96.1% 21328 96.1%
Missing 131502 12.3% 112132 11.9% 7258 13.4% 2009 18.2% 2652 10.0% 7451 25.1%
Missing Sex 7460 0.4% 6011 0.4% 624 0.5% 106 0.4% 225 0.4% 494 1.0%
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1

GCS, Glasgow Comma Scale; T-RTS, Revised Trauma Score for Triage

Tables 3–5 report on the injury severity measures by location of fall and by patient age. Young and middle-aged patients (≤ 60 years) who were injured by falls on streets and sidewalks were more likely to have a T-RTS score indicating the need for transport to a Trauma Center compared to young and middle-aged patients injured by falls occurring indoors. However, older patients (> 60 years) who were injured by falls indoors were more likely to have a T-RTS score indicating the need for transport to a Trauma Center than older adults who fell on streets or sidewalks. Similar patterns were observed for patients injured by falls who had moderate or severe GCS scores.

Table 3.

Descriptive Statistics for EMS Encounters for Reported Location of Fall Injuries by GCS, Categorized by Age.1

Overall Indoor Outdoor- Street or Sidewalk Outdoor- Not on Street or Sidewalk Indoor/outdoor unclear Missing
N = 1854909 N = 1596860 N = 129408 N = 23586 N = 53700 N = 51355
0–20
 Severe 809 0.8% 572 0.7% 133 1.5% 29 0.5% 64 0.7% 11 0.5%
 Moderate 1602 1.5% 1234 1.5% 221 2.5% 48 0.8% 77 0.9% 22 0.9%
 Mild 104081 97.7% 78333 97.7% 8584 96.0% 6252 98.8% 8584 98.4% 2328 98.6%
 Missing 10713 9.1% 7963 9.0% 919 9.3% 692 9.9% 629 6.7% 510 17.8%
22–30
 Severe 894 1.5% 563 1.3% 242 2.3% 21 1.3% 55 1.4% 13 1.0%
 Moderate 1483 2.5% 974 2.3% 362 3.4% 38 2.3% 86 2.2% 23 1.7%
 Mild 56894 96.0% 40338 96.3% 9915 94.3% 1620 96.5% 3731 96.4% 1290 97.3%
 Missing 4811 7.5% 3216 7.1% 936 8.2% 188 10.1% 218 5.3% 253 16.0%
31–40
 Severe 1205 1.6% 829 1.5% 255 2.1% 26 1.4% 73 1.7% 22 1.4%
 Moderate 1994 2.6% 1349 2.4% 495 4.0% 31 1.7% 88 2.1% 31 2.0%
 Mild 72806 95.8% 53734 96.1% 11678 94.0% 1805 96.9% 4053 96.2% 1536 96.7%
 Missing 6004 7.3% 4198 7.0% 1104 8.2% 181 8.9% 213 4.8% 308 16.2%
41–50
 Severe 1404 1.5% 1037 1.4% 236 1.7% 35 1.9% 75 1.7% 21 1.1%
 Moderate 2334 2.4% 1690 2.3% 472 3.5% 20 1.1% 116 2.6% 36 1.8%
 Mild 93031 96.1% 72137 96.4% 12839 94.8% 1807 97.0% 4343 95.8% 1905 97.1%
 Missing 7444 7.1% 5452 6.8% 1174 8.0% 195 9.5% 203 4.3% 420 17.6%
51–60
 Severe 2271 1.2% 1851 1.2% 262 1.2% 31 1.2% 89 1.2% 38 1.0%
 Moderate 3990 2.1% 3086 2.1% 639 2.9% 43 1.7% 150 2.1% 72 1.9%
 Mild 180072 96.6% 145551 96.7% 21454 96.0% 2477 97.1% 6935 96.7% 3655 97.1%
 Missing 14168 7.1% 10975 6.8% 1767 7.3% 311 10.9% 301 4.0% 814 17.8%
61–65
 Severe 1417 1.1% 1203 1.1% 113 1.0% 13 0.9% 61 1.4% 27 1.0%
 Moderate 2384 1.9% 2016 1.9% 243 2.1% 17 1.1% 72 1.7% 36 1.4%
 Mild 124861 97.0% 105365 97.0% 11367 97.0% 1487 98.0% 4100 96.9% 2542 97.6%
 Missing 9724 7.0% 7922 6.8% 924 7.3% 146 8.8% 173 3.9% 559 17.7%
66–70
 Severe 1497 1.0% 1304 1.0% 99 1.0% 17 1.2% 54 1.4% 23 0.8%
 Moderate 2553 1.8% 2320 1.8% 123 1.3% 14 1.0% 44 1.1% 52 1.8%
 Mild 140898 97.2% 123198 97.1% 9534 97.7% 1420 97.9% 3860 97.5% 2886 97.5%
 Missing 11168 7.2% 9360 6.9% 808 7.6% 146 9.1% 183 4.4% 671 18.5%
71–75
 Severe 1493 0.9% 1337 0.9% 84 1.0% 16 1.2% 38 1.0% 18 0.5%
 Moderate 3062 1.8% 2856 1.9% 99 1.1% 10 0.7% 46 1.2% 51 1.4%
 Mild 163497 97.3% 146552 97.2% 8464 97.9% 1351 98.1% 3610 97.7% 3520 98.1%
 Missing 13134 7.2% 11195 6.9% 689 7.4% 104 7.0% 154 4.0% 992 21.7%
76–80
 Severe 1578 0.9% 1451 0.9% 51 0.7% 13 1.2% 27 0.8% 36 0.8%
 Moderate 3471 1.9% 3257 2.0% 91 1.2% 7 0.6% 47 1.4% 69 1.6%
 Mild 178017 97.2% 162117 97.2% 7397 98.1% 1072 98.2% 3233 97.8% 4198 97.6%
 Missing 14677 7.4% 12491 7.0% 647 7.9% 107 8.9% 175 5.0% 1257 22.6%
81–85
 Severe 1386 0.7% 1273 0.7% 46 0.7% 3 0.4% 28 0.9% 36 0.7%
 Moderate 3889 2.0% 3725 2.0% 37 0.6% 9 1.2% 40 1.3% 78 1.5%
 Mild 192234 97.3% 177428 97.3% 6189 98.7% 741 98.4% 2956 97.8% 4920 97.7%
 Missing 15326 7.2% 13146 6.7% 521 7.7% 68 8.3% 134 4.2% 1457 22.4%
86–90
Severe 1281 0.7% 1211 0.7% 26 0.6% 3 0.7% 18 0.8% 23 0.4%
Moderate 3845 2.0% 3677 2.1% 45 1.1% 9 2.0% 39 1.7% 75 1.4%
Mild 185542 97.3% 173300 97.3% 4209 98.3% 446 97.4% 2299 97.6% 5288 98.2%
Missing 15636 7.6% 13391 7.0% 342 7.4% 59 11.4% 110 4.5% 1734 24.4%
91+
Severe 1034 0.6% 951 0.6% 25 1.1% 4 1.6% 18 1.0% 36 0.7%
Moderate 3890 2.3% 3714 2.4% 39 1.7% 5 1.9% 31 1.8% 101 1.9%
Mild 162219 97.1% 152813 97.0% 2242 97.2% 248 96.5% 1677 97.2% 5239 97.5%
Missing 13867 7.7% 11931 7.0% 187 7.5% 33 11.4% 56 3.1% 1660 23.6%
Missing Age 13319 0.7% 11274 0.7% 1080 0.8% 168 0.7% 334 0.6% 463 0.9%
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1

GCS, Glasgow Comma Scale

Table 5.

Descriptive Statistics for EMS Encounters for Reported Location of Fall Injuries by Need for Triage to a Trauma Center, Categorized by Age.1

Overall Indoor Outdoor- Street or Sidewalk Outdoor- Not on Street or Sidewalk Indoor/outdoor unclear Missing
N = 1854909 N = 1596860 N = 129408 N = 23586 N = 53700 N = 51355
0–20
Need for transport to Trauma Center 6209 7.0% 4856 7.3% 609 7.8% 225 4.3% 389 5.1% 130 6.7%
Does not 82721 93.0% 61452 92.7% 7209 92.2% 5026 95.7% 7230 94.9% 1804 93.3%
Missing 28275 24.1% 21794 24.7% 2039 20.7% 1770 25.2% 1735 18.5% 937 32.6%
22–30
Need for transport to Trauma Center 3229 5.8% 2166 5.5% 722 7.5% 76 5.0% 201 5.5% 64 5.1%
Does not 52521 94.2% 37470 94.5% 8953 92.5% 1453 95.0% 3459 94.5% 1186 94.9%
Missing 8332 13.0% 5455 12.1% 1780 15.5% 338 18.1% 430 10.5% 329 20.8%
31–40
Need for transport to Trauma Center 4417 6.2% 3152 6.0% 908 7.9% 82 4.8% 205 5.1% 70 4.7%
Does not 67245 93.8% 49813 94.0% 10596 92.1% 1637 95.2% 3781 94.9% 1418 95.3%
Missing 10347 12.6% 7145 11.9% 2028 15.0% 324 15.9% 441 10.0% 409 21.6%
41–50
Need for transport to Trauma Center 5493 6.0% 4167 5.9% 886 7.0% 82 4.7% 269 6.3% 89 4.8%
Does not 86218 94.0% 67011 94.1% 11781 93.0% 1646 95.3% 4028 93.7% 1752 95.2%
Missing 12502 12.0% 9138 11.4% 2054 14.0% 329 16.0% 440 9.3% 541 22.7%
51–60
Need for transport to Trauma Center 10231 5.8% 8262 5.8% 1305 6.2% 114 4.8% 372 5.4% 178 5.0%
Does not 166488 94.2% 134674 94.2% 19704 93.8% 2258 95.2% 6464 94.6% 3388 95.0%
Missing 23782 11.9% 18527 11.5% 3113 12.9% 490 17.1% 639 8.5% 1013 22.1%
61–65
Need for transport to Trauma Center 6664 5.5% 5710 5.5% 573 5.2% 60 4.3% 208 5.1% 113 4.6%
Does not 115516 94.5% 97482 94.5% 10496 94.8% 1349 95.7% 3853 94.9% 2336 95.4%
Missing 16206 11.7% 13314 11.4% 1578 12.5% 254 15.3% 345 7.8% 715 22.6%
66–70
Need for transport to Trauma Center 7073 5.1% 6303 5.2% 387 4.2% 58 4.3% 177 4.6% 148 5.3%
Does not 130439 94.9% 114077 94.8% 8781 95.8% 1300 95.7% 3633 95.4% 2648 94.7%
Missing 18604 11.9% 15802 11.6% 1396 13.2% 239 15.0% 331 8.0% 836 23.0%
71–75
Need for transport to Trauma Center 7729 4.8% 7089 5.0% 308 3.8% 50 3.9% 145 4.1% 137 4.1%
Does not 151707 95.2% 135990 95.0% 7862 96.2% 1241 96.1% 3387 95.9% 3227 95.9%
Missing 21750 12.0% 18861 11.6% 1166 12.5% 190 12.8% 316 8.2% 1217 26.6%
76–80
Need for transport to Trauma Center 8219 4.7% 7617 4.8% 262 3.7% 32 3.2% 135 4.3% 173 4.2%
Does not 165532 95.3% 150722 95.2% 6884 96.3% 983 96.8% 3040 95.7% 3903 95.8%
Missing 23992 12.1% 20977 11.7% 1040 12.7% 184 15.3% 307 8.8% 1484 26.7%
81–85
Need for transport to Trauma Center 8200 4.4% 7723 4.4% 159 2.7% 23 3.3% 105 3.6% 190 3.9%
Does not 179791 95.6% 165930 95.6% 5765 97.3% 676 96.7% 2795 96.4% 4625 96.1%
Missing 24844 11.7% 21919 11.2% 869 12.8% 122 14.9% 258 8.2% 1676 25.8%
86–90
Need for transport to Trauma Center 7907 4.3% 7500 4.4% 127 3.1% 20 4.7% 90 4.0% 170 3.3%
Does not 174027 95.7% 162504 95.6% 3933 96.9% 410 95.3% 2179 96.0% 5001 96.7%
Missing 24370 11.8% 21575 11.3% 562 12.2% 87 16.8% 197 8.0% 1949 27.4%
91+
Need for transport to Trauma Center 7095 4.4% 6707 4.5% 95 4.4% 15 6.3% 72 4.3% 206 4.0%
Does not 152599 95.6% 143729 95.5% 2082 95.6% 222 93.7% 1602 95.7% 4964 96.0%
Missing 21316 11.8% 18973 11.2% 316 12.7% 53 18.3% 108 6.1% 1866 26.5%
Missing Age 13319 0.7% 11274 0.7% 1080 0.8% 168 0.7% 334 0.6% 463 0.9%
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1

T-RTS, Revised Trauma Score for Triage

Discussion

The majority of fall injuries to which EMS responded in 2019 occurred indoors, with the second largest category occurring outdoors on streets or sidewalks. However, the proportions for patients who had fall injuries rated as Emergent or Critical, having moderate or severe GCS scores and having a T-RTS score indicating the need for transport to a Trauma Center were similar across indoor and outdoor locations of falls. Given the large numbers of falls that occur indoors and among older persons, it is appropriate that falls prevention guidelines and recommendations have focused on these falls (“Guideline for the Prevention of Falls in Older Persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention,” 2001; Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011). However, the comparable trauma severity of outdoor injurious falls to those that occur indoors and the greater severity of falls on streets and sidewalks among young and middle-aged patients suggests that additional public health attention is needed to identify modifiable outdoor environmental risk factors to prevent outdoor falls.

This study found that the proportion of severe outdoor falls on streets and sidewalks was higher among men compared to women. This finding may be explained by differences in the age and physical activity status for men and women falling outside versus inside (Duckham et al., 2013; Kelsey et al., 2012; Timsina et al., 2017). Timsina and colleagues (2017) found that young and middle-age men were more likely to fall outside, whereas older females are were more likely to fall inside (Timsina et al., 2017). Young men were also most likely to fall while engaging in vigorous activity, and thus the potentially higher speed and impact of the activities at the time of falling may result in more serious fall injuries for this subgroup. An additional explanation is that men of all ages tend to consume more alcohol than women, and acute alcohol consumption is associated with greater risk of injurious falls by impacting balance control and cognition (Taylor et al., 2010). One study found that alcohol-related fall injury presentations to emergency departments (ED) were more prevalent among men and younger patients, and were more severe based on triage scale ratings and admissions to the ED compared to non-alcohol-related injuries (Woods et al., 2019). An additional study of outdoor falls similarly found that the proportion of men and the rate of alcohol consumption were higher in severe outdoor falls compared to non-severe falls (Jung et al., 2018). Future work in this area should examine the role of alcohol in the severity of injurious falls by location to support place-based intervention strategies and policies. Falls that occur on streets and sidewalks that involve alcohol may be in close proximity to businesses that serve alcohol, which is consistent with a higher density of alcohol serving establishments being linked to increased alcohol consumption and increased pedestrian injury from motor vehicles (Gruenewald et al., 1993). However, the association between injurious falls on streets and sidewalks and proximity to alcohol serving establishment has yet to be examined and is an area ripe for future research (DiMaggio et al., 2016; LaScala et al., 2001; Lasota et al., 2020; Sebert Kuhlmann et al., 2009; Treno et al., 2007; White, 2020).

We also found that outdoor falls on streets or sidewalks were more likely to result in severe injury among young and middle-aged individuals compared to indoor falls among this age subgroup, but this pattern was reversed for older adults. This finding may also be explained by the evidence showing a higher proportion of alcohol involved falls among younger adults and greater severity of these falls, which may be occurring on streets or sidewalks near alcohol serving establishments or nightlife districts (Woods et al., 2019). Indoor falls may appear to be more frequently severe among older adults due to a form of selection bias. The population of older adults that fall indoors may be more likely to be frail, while those who fall while outdoors may be in better overall health (Kelsey et al., 2012). This is consistent with findings that suggest that outdoor falls are experienced more by healthy and activity individuals, compared to greater risk of falling indoors for individuals in poorer health who may experience worse injury outcomes. (Kelsey et al., 2010; Li et al., 2006). There may also be differences in the types of surfaces (e.g., wooden floor, grass) or floor characteristics adults are falling on indoors compared to outdoors which could influence injury severity; however, studies are lacking in this area of research (Jung et al., 2018).

This analysis suggests that outdoor falls, particularly on streets and sidewalks, present a significant medical and public health burden. Current fall prevention guidelines did not explicitly examine the impact of outdoor environments falls (Montero-Odasso et al., 2022; Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011) and pedestrian safety policies are largely centered around pedestrian injuries from motor vehicles with minimal attention to outdoor falls, even though these two injury types occur in the same or adjacent physical environments (Evenson et al., 2018). This may be due to the limited empirical evidence available to determine modifiable environmental risk factors for outdoor falls (Schepers et al., 2017). Li et al. (2006) found that among a sample of U.S. adults, participants subjectively reported that most (73%) of outdoor falls were due to environmental factors such as the condition of the walking surface, and usually occurred on sidewalks, curbs and streets (Li et al., 2006).Yet, rigorous epidemiological studies are needed to identify potential environmental hazards on sidewalks and streets such as street trees that may cause buckling or damage to sidewalks and increase fall risk (Bentley, 1998; Bentley & Haslam, 2001; David & Freedman, 1990; Fothergill et al., 1995; Hunt et al., 1991). This evidence would inform policy interventions to prevent outdoor fall injuries that we show are comparably severe to indoor fall injuries.

The primary strength of this study is the use of NEMSIS data, which provides a well-documented national census of health encounters requiring an EMS response. The data include pertinent sociodemographic and clinical information, and variables that can be used to code the location of the encounter, eliminating the need to incorporate additional data sources. The severity outcomes used in this analysis relied on data recorded in the EMS notes with varying degrees of missingness. We were unable to calculate GCS for 7.5% of patients and T-RTS for 13.0% of patients, and 25.9% of patients did not have an acuity measure reported. This study is also limited by missing data on fall location. The coding schema used to classify fall location does not make use of narratives and text notes created by EMS personnel, and therefore may result in misclassification of fall location. Machine learning for natural language processing applied to EMS narrative notes could supplement the ICD 10-based case-finding algorithm used in this study and increase the sensitivity of identifying fall location from EMS data (Mayampurath et al., 2021; Zhao et al., 2021). Lastly, the quality of data provided to NEMSIS may vary by region, EMS service and third-party data management systems. Combined these limitations may have caused underestimates of the numbers of falls occurring outdoors and the severity of falls by location.

Conclusion

In conclusion, these data show that there is a significant clinical burden associated with outdoor falls, and that the proportion of severe life-threatening injuries from falls that occur outdoors is comparably substantial to that for falls that occur indoors. These findings represent a major public concern as the aging population projects an expected growth of persons 65 years and older by 22% by 2040, and the number of injurious falls and associated healthcare costs will simultaneously increase (2021 Profile of Older Americans, 2022). Indeed, recent data already shows this rising incidence of falls of 1.5% per year from 2016–2019 (Hoffman et al., 2022). These concerns emphasize the need to address outdoor falls in current fall prevention guidelines, and to improve surveillance tools for monitoring outdoor falls and associated risk factors and outcomes.

Table 4.

Descriptive Statistics for EMS Encounters for Reported Location of Fall Injuries by Patient Acuity, Categorized by Age.

Overall Indoor Outdoor- Street or Sidewalk Outdoor- Not on Street or Sidewalk Indoor/outdoor unclear Missing
N = 1854909 N = 1596860 N = 129408 N = 23586 N = 53700 N = 51355
0–20
Dead 54 0.1% 42 0.1% 7 0.1% 2 0.0% 2 0.0% 1 0.1%
Critical 2205 2.6% 1592 2.4% 241 3.3% 164 3.0% 191 3.4% 17 1.8%
Emergent 18704 21.8% 14293 21.5% 1520 20.9% 1285 23.3% 1397 24.7% 209 22.1%
Low 64928 75.6% 50590 76.1% 5501 75.7% 4055 73.6% 4064 71.9% 718 76.0%
Missing 31314 26.7% 21585 24.5% 2588 26.3% 1515 21.6% 3700 39.6% 1926 67.1%
22–30
Dead 44 0.1% 30 0.1% 10 0.1% 3 0.2% 0 0.0% 1 0.2%
Critical 1648 3.5% 1139 3.3% 295 3.5% 94 6.5% 103 4.9% 17 3.3%
Emergent 10996 23.4% 8009 23.3% 1834 21.8% 410 28.3% 605 28.8% 138 27.2%
Low 34217 72.9% 25262 73.4% 6265 74.5% 943 65.0% 1395 66.3% 352 69.3%
Missing 17177 26.8% 10651 23.6% 3051 26.6% 417 22.3% 1987 48.6% 1071 67.8%
31–40
Dead 81 0.1% 51 0.1% 18 0.2% 5 0.3% 7 0.3% 0 0.0%
Critical 2224 3.7% 1685 3.7% 357 3.6% 65 4.1% 103 4.8% 14 2.2%
Emergent 14845 24.7% 11401 24.9% 2272 23.0% 415 26.3% 598 27.7% 159 25.0%
Low 42917 71.4% 32659 71.3% 7249 73.3% 1095 69.3% 1452 67.2% 462 72.8%
Missing 21942 26.8% 14314 23.8% 3636 26.9% 463 22.7% 2267 51.2% 1262 66.5%
41–50
Dead 98 0.1% 77 0.1% 14 0.1% 5 0.3% 2 0.1% 0 0.0%
Critical 2866 3.7% 2250 3.7% 385 3.6% 91 5.8% 106 5.0% 34 4.3%
Emergent 19459 25.4% 15762 25.6% 2499 23.4% 417 26.5% 602 28.2% 179 22.7%
Low 54304 70.8% 43446 70.6% 7793 72.9% 1061 67.4% 1428 66.8% 576 73.0%
Missing 27486 26.4% 18781 23.4% 4030 27.4% 483 23.5% 2599 54.9% 1593 66.9%
51–60
Dead 218 0.1% 194 0.2% 10 0.1% 6 0.3% 7 0.2% 1 0.1%
Critical 5277 3.6% 4399 3.6% 542 3.1% 143 6.4% 150 4.6% 43 2.8%
Emergent 37159 25.0% 31178 25.2% 4064 23.0% 639 28.7% 919 27.9% 359 23.3%
Low 105835 71.3% 87952 71.1% 13086 73.9% 1441 64.6% 2218 67.3% 1138 73.8%
Missing 52012 25.9% 37740 23.4% 6420 26.6% 633 22.1% 4181 55.9% 3038 66.3%
61–65
Dead 183 0.2% 166 0.2% 7 0.1% 2 0.2% 4 0.2% 4 0.4%
Critical 3314 3.2% 2889 3.2% 253 2.7% 59 4.4% 81 4.2% 32 2.8%
Emergent 26404 25.5% 23022 25.7% 2220 23.8% 354 26.7% 528 27.3% 280 24.9%
Low 73459 71.1% 63559 70.9% 6855 73.4% 913 68.8% 1322 68.3% 810 71.9%
Missing 35026 25.3% 26870 23.1% 3312 26.2% 335 20.1% 2471 56.1% 2038 64.4%
66–70
Dead 156 0.1% 146 0.1% 5 0.1% 2 0.2% 2 0.1% 1 0.1%
Critical 3733 3.2% 3268 3.1% 271 3.5% 78 6.3% 84 4.3% 32 2.5%
Emergent 29925 25.6% 26894 25.7% 1891 24.4% 308 24.9% 567 29.1% 265 20.8%
Low 82986 71.0% 74271 71.0% 5593 72.1% 847 68.6% 1298 66.5% 977 76.6%
Missing 39316 25.2% 31603 23.2% 2804 26.5% 362 22.7% 2190 52.9% 2357 64.9%
71–75
Dead 154 0.1% 140 0.1% 7 0.1% 3 0.3% 3 0.2% 1 0.1%
Critical 3979 3.0% 3617 2.9% 198 2.9% 69 5.9% 68 3.9% 27 1.8%
Emergent 34609 25.7% 31780 25.7% 1693 24.9% 339 29.1% 505 28.8% 292 20.0%
Low 96078 71.3% 88117 71.3% 4888 72.0% 752 64.7% 1178 67.2% 1143 78.1%
Missing 46366 25.6% 38286 23.6% 2550 27.3% 318 21.5% 2094 54.4% 3118 68.1%
76–80
Dead 174 0.1% 167 0.1% 5 0.1% 1 0.1% 0 0.0% 1 0.1%
Critical 4147 2.8% 3836 2.8% 170 2.9% 45 4.8% 71 4.5% 25 1.5%
Emergent 37589 25.6% 34923 25.6% 1637 27.5% 265 28.1% 448 28.2% 316 18.9%
Low 104879 71.4% 97704 71.5% 4143 69.6% 633 67.1% 1071 67.4% 1328 79.5%
Missing 50954 25.8% 42686 23.8% 2231 27.3% 255 21.3% 1892 54.3% 3890 70.0%
Dead 174 0.1% 167 0.1% 5 0.1% 1 0.1% 0 0.0% 1 0.1%
81–85
Dead 149 0.1% 141 0.1% 5 0.1% 0 0.0% 1 0.1% 2 0.1%
Critical 4144 2.6% 3884 2.6% 138 2.8% 34 5.2% 58 4.4% 30 1.6%
Emergent 39227 24.9% 37019 24.9% 1318 26.8% 166 25.6% 330 25.2% 394 20.6%
Low 114226 72.4% 107913 72.4% 3459 70.3% 448 69.1% 918 70.2% 1488 77.7%
Missing 55089 25.9% 46615 23.8% 1873 27.6% 173 21.1% 1851 58.6% 4577 70.5%
86–90
Dead 142 0.1% 139 0.1% 2 0.1% 0 0.0% 0 0.0% 1 0.1%
Critical 3658 2.4% 3491 2.4% 102 3.0% 23 5.4% 21 2.2% 21 1.1%
Emergent 37176 24.3% 35490 24.3% 915 27.3% 136 32.1% 274 28.8% 361 18.5%
Low 111970 73.2% 107146 73.3% 2333 69.6% 265 62.5% 656 69.0% 1570 80.4%
Missing 53358 25.9% 45313 23.7% 1270 27.5% 93 18.0% 1515 61.4% 5167 72.6%
91+
Dead 120 0.1% 117 0.1% 1 0.1% 0 0.0% 0 0.0% 2 0.1%
Critical 3084 2.3% 2956 2.3% 54 3.1% 18 7.6% 23 4.0% 33 1.7%
Emergent 31846 23.7% 30788 23.7% 487 27.5% 72 30.4% 146 25.7% 353 18.4%
Low 99137 73.9% 95831 73.9% 1227 69.4% 147 62.0% 399 70.2% 1533 79.8%
Missing 46823 25.9% 39717 23.4% 724 29.0% 53 18.3% 1214 68.1% 5115 72.7%
Missing Age 13319 0.7% 11274 0.7% 1080 0.8% 168 0.7% 334 0.6% 463 0.9%
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Acknowledgements

National Highway Traffic Safety Administration (NHTSA), National Emergency Medical Services Information System (NEMSIS). The content reproduced from the NEMSIS Database remains the property of the National Highway Traffic Safety Administration (NHTSA). The National Highway Traffic Safety Administration is not responsible for any claims arising from works based on the original Data, Text, Tables, or Figures.

Funding

AGR is supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R01AA028552) and the Columbia Center for Injury Science and Prevention, Centers for Disease Control and Prevention (CDC) grant no. R49CE003094. AXL is supported by a grant from the Davee Foundation (Excellence in Emergency Medicine Grant). KGB and NGI are funded by the National Institute of Environmental Health Sciences (KGB: 5T32ES007322-21; NGI: 5T32ES007322-22).

Abbreviations

BRFSS

Behavioral Risk Factor Surveillance System

EMS

Emergency Medical Services

WISQARS

Web-Based Injury Statistics Query and Reporting System

ICD 10

International Classification of Diseases 10th Revision

NHIS

National Health Interview Survey

NEMSIS

National Emergency Medical Services Information System

ISS

Injury Severity Score

GCS

Glasgow Coma Scale

T-RTS

Revised Trauma Score for Triage

ED

Emergency Departments

Footnotes

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Not applicable. This study utilized publicly available data.

Availability of data and material

The data sets analyzed during the current study are publicly available at https://nemsis.org.

Contributor Information

Kathryn G. Burford, Columbia University Mailman School of Public Health

Nicole G. Itzkowitz, Columbia University Mailman School of Public Health

Remle P. Crowe, ESO Solutions LLC

Henry E. Wang, Ohio State University

Alexander X. Lo, Northwestern University Feinberg School of Medicine

Andrew G. Rundle, Columbia University Mailman School of Public Health

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