Injury surveillance in paediatric hospitals: The Canadian experience

INTRODUCTION AND HISTORY

The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) began in 1990 with all ten children’s hospital emergency departments (1). The program was devised to provide a new source of information on injuries that would complement already available surveillance data on fatalities and hospital admissions. It complements these by including injuries treated in emergency departments, many of which are relatively minor, although some are serious. CHIRPP was specifically designed to enhance injury prevention efforts by including data on the circumstances in which injuries occurred. Detailed information on “what went wrong” helps prevention partners focus their efforts. Paediatricians are an essential component of this partnership and need to be aware of what CHIRPP has to offer.

Although CHIRPP collects information on a wide range of injuries, including poisonings and intentional (abusive and self-inflicted) injuries, its main focus is unintentional injuries.

Paediatric health care professionals are among the important audiences for information from CHIRPP. This information may be obtained directly from the program (by phone or on the web) or may come indirectly through organizations such as the Canadian Paediatric Society (2), injury prevention centres, and nongovernment organizations such as Safe Kids Canada. All these organizations use the data to gain a better understanding of how injuries occurred, with a view to identifying hazards and developing preventive strategies. The media are also frequent users of CHIRPP data.

In addition to the original 10 paediatric facilities, CHIRPP also collects information at several general hospitals. Current CHIRPP centres include 14 hospitals and one northern health station located in all but two provinces and one territory in Canada. Despite these changes, the majority of CHRPP data relate to children.

HOW CHIRPP WORKS

When an injured patient presents at an emergency department participating in CHIRPP, the patient or accompanying adult is asked to complete a one-page questionnaire describing the circumstances that led to the injury. Clinical staff fill in the back of the page, checking boxes to describe the type(s) of injuries, body part(s) affected and disposition (eg, admitted to hospital). In most participating centres, data for patients who did not receive the questionnaire are extracted from medical records. This data collection is facilitated by a paid coordinator at each site. There is also a clinical director at each centre; typically, an emergency physician holds this voluntary position as the person responsible for CHIRPP within the hospital and community. Recently, the program has begun to benefit from a codirector arrangement at several hospitals that have affiliated injury prevention centres. In these centres, a senior staff member of the injury prevention centre shares the director’s responsibilities with an emergency physician.

Information from the CHIRPP questionnaires is entered into an electronic database at Health Canada, which now includes approximately 1.5 million records. The database provides information on two levels: national (data from all centres), and local (data specific to each hospital). The latter are used to address injury surveillance needs in the community.

CHIRPP is a partnership between Health Canada and the participating hospitals. Health Canada provides financial support for the coordinators while the hospitals promote the program, provide office space and encourage the cooperation of their staff. The program has an advisory body made up of CHIRPP hospital directors along with surveillance and epidemiology experts from Health Canada.

WHAT TYPES OF INFORMATION DOES CHIRPP PRODUCE AND WHO DOES IT SERVE?

CHIRPP produces reports on a wide range of injury issues and the basic data are available without cost to qualified researchers. Analysts at Health Canada answer injury-related inquiries and the hospital coordinators provide similar responses at the community level. Many of the short reports, fact sheets and monographs from the national database are posted on Health Canada’s Web site (3). Users of this Web site will find a direct link to Injury Surveillance On-Line. This is an interactive application that allows users to choose the type of injury information required, select parameters such as age and geographical location, and receive selected CHIRPP data, as well as injury mortality and hospitalization data in tabular or graphical format.

Because CHIRPP collects detailed information, it is able to produce reports on injuries not specifically classified by other data sources, such as injuries associated with particular sports or products. Several of these types of injury were discussed in a major publication entitled, For the Safety of Canadian Children and Youth: From Injury Data to Preventive Measures (4), which highlighted data from CHIRPP and other sources. Research papers based on CHIRPP data have been published in peer-reviewed (5–10) and other (11–13) literature. CHIRPP information also serves voluntary organizations, injury prevention centres, public health units and the media. Health Canada’s Product Safety Programme is another important user.

EXAMPLES OF THE USE OF CHIRPP DATA

Display hooks

In 1991, CHIRPP was contacted by the parent of a two-year-old who had suffered a serious injury when she tripped and was poked in the eye by a metal hook used to support merchandise on a store display. The question was whether CHIRPP had any records of other injuries caused by such hooks. Among the 85,000 records held at the time, there were six records of similar injuries. Although the injuries were not numerous, all of the children were less than five years old and all had injuries of the eye or ocular adnexa.

The parents contacted Consumer and Corporate Affairs Canada who referred the matter to the provincial Department of Labour. This department determined that a safety hazard existed and wrote to the Retail Council of Canada outlining the problem. In response, the council published an advisory on the dangers of hooks on retail displays. In addition, the Member of Parliament for the riding in which the family lived tabled a Private Member’s Bill to amend the Hazardous Products Act by adding a section prohibiting the display of goods in a manner likely to be hazardous to children.

The father of the injured child continues to work toward having safer hooks used in all stores and there have been improvements. Instead of the old spikes, displays often use a U-shaped prong and/or cover the end of hook by a label that provides product identification and price.

Every few years, the father asks CHIRPP for an update on the number of injuries associated with hooks. In May 2002, when CHIRPP contained more than 1.2 million records, there were 39 injuries associated with hooks on retail displays. A comparison of the number of injuries associated with hooks among all injuries to children less than five years old revealed a rate of seven hook injuries/100,000 injuries of any kind before December 1991 and 3/100,000 between December 1991 and May 2002. In the latter period, 54% of the injuries affected the eye (SG Mackenzie, unpublished data, 2002).

Baby walkers

It will come as no surprise to readers of this journal that baby walkers are associated with injuries of young children, particularly with falls down stairs.

In 1989, the Canadian Juvenile Products Association adopted a voluntary standard for baby walkers. Its stringent requirements resulted in an effective ban on the retail sale of walkers in Canada. However, they could still be obtained as hand-me-down gifts, at garage sales and as imports from the United States. In 1997, the Canadian Juvenile Products Association ceased to exist and baby walkers began to reappear in some Canadian retail outlets.

Study of CHIRPP data revealed that most baby walker injuries happened to children who were between the ages of five and 14 months. Their percentage among all CHIRPP injuries in children of this age fell from 6.5% to 2% between 1990 and 2000. It remained at 2% in 2001 to 2002 (SG Mackenzie, unpublished data, 2003). These and other findings from the same work contributed to the conclusion by Health Canada’s Product Safety Programme that baby walkers pose significant and unnecessary risks to young children. In September 2003, the Product Safety Bureau solicited Canadians’ comments on a proposed ban on the sale, advertisement and importation of baby walkers. In April 2004, the federal Health Minister announced the government’s immediate prohibition of the sale, advertisement and importation of baby walkers in Canada. We look forward to a further decrease in the number of injuries associated with these products over the next few years.

Playground equipment

CHIRPP data are also useful in the study of more common injuries. For the year 1996, CHIRPP received 4261 reports of injuries associated with playground equipment among people less than 20 years old (80% of whom were two to nine years old). Analysis of how the injuries occurred revealed that 65% were due to falls from equipment, highlighting the importance of providing energy absorbing surfaces. The number of injuries was sufficient to permit an analysis of the patterns of injury by the main types of equipment (slides, monkey bars, swings, play structures, see-saws, and merry-go-rounds) (14). The results of this work were made available to experts on playground safety who advised the Canadian Standards Association on the 1998 revision of its guidelines on children’s playspaces and equipment (15). These guidelines underwent further revision in 2003 (16). Health Canada has undertaken a follow-up study on injuries associated with playground equipment to look for changes in the patterns of injuries after the 1998 guidelines were widely implemented.

Bicycle handlebars

In preparing a report on bicycling injuries that required admission to hospital, a CHIRPP analyst noticed an association between bicycle handlebars and abdominal injuries. This finding prompted a detailed analysis of the 650 injuries of this type in the 1998 data (17). Most of these injury events did not involve motor vehicles and the patients were six- to 11-year-old children who were riding relatively slowly when they encountered a surface irregularity or obstruction. The surface problem caused a fall onto the handlebars, and often (40%) spearing by the end of the handlebar. Of these cases, about 20% resulted in injury to an abdominal organ or blood vessel. Research inspired by these findings is currently underway in collaboration with a colleague at a university biomechanics laboratory. The aim of the research is to directly measure impact forces in a simulated handlebar injury scenario and to determine the influences of a child’s weight, the riding speed and the handlebar configuration, including the end cover. We are hopeful that this research will lead to improved designs of the handlebars on children’s bicycles.

CONCLUSION

These few examples illustrate some of the ways in which CHIRPP data are used. There are many more: some as simple as provision of information on infant choking to the media, others as complex as a comparative analysis of sports-related injuries.

Surveillance information is useful to those who are able to take action to prevent problems, improve health care, and mobilize resources and services. Much of the work to reduce the burden of injury in Canada rests with prevention partners, including child health professionals. Since health professionals interact with young patients and their families they have a unique opportunity to add value to their care by including injury prevention advice. We invite child health professionals to study information resources related to CHIRPP and other surveillance programs, and to translate this information into safety messages for their patients.