The emergency care setting for screening and intervention for alcohol use problems among injured and high-risk drivers: a review

Each year thousands of people are treated in emergency departments and trauma centers for alcohol-related injuries, including those sustained in drinking driving crashes. Emergency departments and trauma centers provide an opportunity to screen for alcohol use problems and intervene with injured or high-risk drivers to reduce future alcohol-related traffic and injury risk. Recently physicians have expressed interest in exploring screening and intervention for alcohol use problems in these venues as a means of improving clinical care. This article reviews the literature that has examined screening and brief interventions in acute care settings to reduce future alcohol consumption and alcohol-related injury. The methodological and practical issues inherent in conducting these studies as well as in actual practice are discussed. The chaotic environment of acute care, the large numbers of patients required to be screened to obtain an adequate study sample, and high attrition rates make study in these settings difficult at best and are methodological problems that should be addressed in future research. A basic question that has not been adequately answered by research to date is whether reduction in alcohol consumption will translate to reduced alcohol-related harm, such as driving while impaired, or injurious or fatal crashes. Long-term studies that assess records-based outcomes in addition to alcohol-consumption levels are needed.     

Estimated Injury Risk for Specific Injuries and Body Regions in Frontal Motor Vehicle Crashes

Objective: Injury risk curves estimate motor vehicle crash (MVC) occupant injury risk from vehicle, crash, and/or occupant factors. Many vehicles are equipped with event data recorders (EDRs) that collect data including the crash speed and restraint status during a MVC. This study's goal was to use regulation-required data elements for EDRs to compute occupant injury risk for (1) specific injuries and (2) specific body regions in frontal MVCs from weighted NASS-CDS data.

Methods: Logistic regression analysis of NASS-CDS single-impact frontal MVCs involving front seat occupants with frontal airbag deployment was used to produce 23 risk curves for specific injuries and 17 risk curves for Abbreviated Injury Scale (AIS) 2+ to 5+ body region injuries. Risk curves were produced for the following body regions: head and thorax (AIS 2+, 3+, 4+, 5+), face (AIS 2+), abdomen, spine, upper extremity, and lower extremity (AIS 2+, 3+). Injury risk with 95% confidence intervals was estimated for 15–105 km/h longitudinal delta-Vs and belt status was adjusted for as a covariate.

Results: Overall, belted occupants had lower estimated risks compared to unbelted occupants and the risk of injury increased as longitudinal delta-V increased. Belt status was a significant predictor for 13 specific injuries and all body region injuries with the exception of AIS 2+ and 3+ spine injuries. Specific injuries and body region injuries that occurred more frequently in NASS-CDS also tended to carry higher risks when evaluated at a 56 km/h longitudinal delta-V. In the belted population, injury risks that ranked in the top 33% included 4 upper extremity fractures (ulna, radius, clavicle, carpus/metacarpus), 2 lower extremity fractures (fibula, metatarsal/tarsal), and a knee sprain (2.4–4.6% risk). Unbelted injury risks ranked in the top 33% included 4 lower extremity fractures (femur, fibula, metatarsal/tarsal, patella), 2 head injuries with less than one hour or unspecified prior unconsciousness, and a lung contusion (4.6–9.9% risk). The 6 body region curves with the highest risks were for AIS 2+ lower extremity, upper extremity, thorax, and head injury and AIS 3+ lower extremity and thorax injury (15.9–43.8% risk).

Conclusions: These injury risk curves can be implemented into advanced automatic crash notification (AACN) algorithms that utilize vehicle EDR measurements to predict occupant injury immediately following a MVC. Through integration with AACN, these injury risk curves can provide emergency medical services (EMS) and other patient care providers with information on suspected occupant injuries to improve injury detection and patient triage.     

Back injuries among nursing personnel — identification of work conditions with cluster analysis

The aim of the present study was to identify work conditions that are typical for nursing personnel and relevant for the risk of back injuries, and to analyse how individual characteristics contribute to the risk of injuries in these situations. Six well-defined clusters were identified by cluster analysis. Two clusters had an over-representation of injuries and they were characterised by a combination of full-time work, work on a rolling schedule, regular patient transfers and a high proportion of assistant nurses. In the three clusters with a lower proportion of injuries the nurses worked part-time. In the cluster with the lowest rate of injuries no one performed regular patient transfers. Working part-time seemed to be a preventive factor for back injury, even when regular patient transfers were performed. The decreased risk of injury among the general registered nurses may thus be a joint effect of fewer working hours, fixed working schedule and less patient handling. The advantages of cluster analysis for detecting the pattern of interacting risk indicators and modifiers are discussed.     

Local vs. national: Epidemiology of pedestrian injury in a mid-Atlantic city

Objective: Understanding pedestrian injury trends at the local level is essential for program planning and allocation of funds for urban planning and improvement. Because we hypothesize that local injury trends differ from national trends in significant and meaningful ways, we investigated citywide pedestrian injury trends to assess injury risk among nationally identified risk groups, as well as identify risk groups and locations specific to Baltimore City.

Methods: Pedestrian injury data, obtained from the Baltimore City Fire Department, were gathered through emergency medical services (EMS) records collected from January 1 to December 31, 2014. Locations of pedestrian injuries were geocoded and mapped. Pearson's chi-square test of independence was used to investigate differences in injury severity level across risk groups. Pedestrian injury rates by age group, gender, and race were compared to national rates.

Results: A total of 699 pedestrians were involved in motor vehicle crashes in 2014—an average of 2 EMS transports each day. The distribution of injuries throughout the city did not coincide with population or income distributions, indicating that there was not a consistent correlation between areas of concentrated population or concentrated poverty and areas of concentrated pedestrian injury. Twenty percent (n = 138) of all injuries occurred among children age ≤14, and 22% (n = 73) of severe injuries occurred among young children. The rate of injury in this age group was 5 times the national rate (Incident Rate Ratio [IRR] = 4.81, 95% confidence interval [CI], [4.05, 5.71]). Injury rates for adults ≥65 were less than the national average.

Conclusions: As the urban landscape and associated pedestrian behavior transform, continued investigation of local pedestrian injury trends and evolving public health prevention strategies is necessary to ensure pedestrian safety.     

Fun ride or risky transport: Golf cart-related injuries treated in U.S. emergency departments from 2007 through 2017

Introduction: Golf cart-related injuries constitute a substantial source of morbidity, most notably in pediatric populations. Despite the high rate of injuries, there have been no meaningful changes in golf cart design or legislation to reduce the overall burden of these injuries. This study sought to characterize the epidemiology of golf cart-related injuries treated in United States hospital emergency departments. Method: A retrospective analysis was conducted by using data from the National Electronic Injury Surveillance System for patients of all ages who were treated in emergency departments (EDs) (2007–2017) for a golf cart-related injury. Results: From 2007 through 2017, an estimated 156,040 (95% CI = 102,402–209,679) patients were treated in U.S. EDs for golf cart-related injuries. The average rate of traumatic brain injuries (TBIs) in children (1.62 per 100,000 children) was more than three times that of TBIs in adults (0.52 per 100,000 adults; rate ratio = 2.38; 95% CI = 2.36–2.41) and nearly twice that of TBIs in seniors (1.11 per 100,000 seniors; rate ratio = 1.21; 95% CI = 1.19–1.22). The rate of injuries in seniors increased significantly by 67.6% from 4.81 per 100,000 seniors in 2007 to 8.06 per 100,000 seniors in 2017 (slope = 0.096; p = 0.041). Conclusions: Golf cart use remains an important source of injury for people of all ages, especially in children. As use continues to increase, it is unlikely that golf cart-related injuries will decrease without substantial changes to product design, regulation, and/or legislation. Practical Applications: Use of golf carts pose a considerable risk of injury and morbidity; safety recommendations should be followed.     

Time of day effects on railroad roadway worker injury risk

IntroductionThe purpose of this study is to examine how time of day affects injury risk of railroad maintenance of way employees and signalmen (roadway workers). Railroads reported 15,654 serious roadway worker injuries between 1997 and 2014. Roadway workers primarily work outdoors on or near railroad tracks and frequently encounter hazardous conditions. To avoid closing an active rail line during peak hours, railroads sometimes require roadway workers to work at night. Previous studies of roadway worker injury have not adequately accounted for exposure to time of day effects, nor have they investigated the human factors issues contributing to roadway worker injury.MethodThe Federal Railroad Administration (FRA) database of injury reports provided data for circadian rhythm models of the odds of fatal and nonfatal injuries. The FRA database and fatal injury investigation reports also permitted an analysis of the circumstances and the human factors issues associated with injuries that occur at different times of day.ResultsOdds of injury increased during nighttime work. The odds of nonfatal injury for both roadway worker crafts rose above 9:1 in the early morning hours. The relative odds of a fatal injury also increased significantly at night. A human factors analysis suggested that during all three shifts most nonfatal injuries involve workload, but workload was not identified as a factor in fatal injuries.ConclusionsNighttime work is more hazardous for roadway workers than daytime work. Several factors related to fatigue and other conditions appear to increase the risk of injury during the outdoor, nighttime work required of roadway workers.Practical applicationFor practical reasons, nighttime roadway work is sometimes unavoidable. Therefore, new practices for nighttime work must be developed to adequately address fatigue and protect roadway workers from harm.     

Exploratory factor analysis of adolescent attitudes toward alcohol and risk

This 2-year longitudinal study of 302 high school students in the state of Indiana examined attitudes toward the use of alcohol in 25 potentially hazardous settings, varying from riding in a car, to swimming, to simply drinking at home. Student ratings indicated that they were capable of rationally evaluating alcohol-related risks. Principal components factor analysis identified three factors underlying student responses: propensity/desirability of the behavior, choice/control of the risk, and fear/consequences/likelihood of the risk. Each of these factors was comparable to factors found to be important in past studies of adult risk perception. The finding that self-reported behavioral propensity and desirability were weakly correlated with the measures of perceived risk is of particular interest. Attempts to reduce the use of alcohol by adolescents have traditionally focused on risk awareness. The implication of this study is that intervention programs might be more successful if they focused on modifying perceived value.     

Factors affecting the severity of injuries among young motorcyclists--a Swedish nationwide cohort study

OBJECTIVES: To determine factors affecting the severity of motorcycle injuries, considering variables related to the individual, the environment, the vehicle, and the crash. METHODS: This is a register-based retrospective cohort study. All individuals born in 1970-1972 (n = 334,070) were extracted from the Swedish Population and Housing Census of 1985 and followed up from 1988 to 2000, when aged 16-30. All subjects whose records indicated an injury as a motorcycle driver in the Swedish National Road Administration Accident Database were selected, and constituted the study population (n = 1,748). Factors related to the individual, the environment, the vehicle, and the crash were considered as exposure measures, whereas the outcome measure was the level of injury severity, based on assessments made on-site by police officers, in two categories: fatal/severe and minor. Associations between individual, environmental, vehicle and crash factors and injury severity were measured, using Chi-square, and through univariate and multivariate stepwise logistic regression. RESULTS: Factors such as alcohol consumption, traffic environment, speed limit, and type of crash were significantly associated (p < 0.0001) with injury severity. More specifically, a positive suspicion of alcohol consumption, driving in a rural area, and a posted speed limit over 50 km/hour were all factors positively associated (OR > 1.0) with the likelihood of being severely injured. On modeling all the variables together through stepwise logistic regression, positive suspicion of alcohol emerged as the strongest determinant (adjusted OR = 2.7) of a severe outcome. CONCLUSIONS. Motorcycle crashes still place a heavy burden on young drivers. Increased efforts are needed to prevent alcohol-related crashes-through law enforcement and a multiplicity of policies at local and national levels.     

Epidemiology of occupational acute traumatic hand injuries: a literature review

The purpose of this review was to summarize the literature on occupational, acute, traumatic hand injury and suggest directions for future research. In 1996, the leading occupational injury treated in United States' hospital emergency departments was an acute hand injury (e.g. laceration, crush or fracture). These injuries affected 30% of an estimated 3.3 million injured workers (990,000). Cuts and lacerations of the fingers ranked third after back and leg strains in the number of lost workday cases in the USA in 1994. The incidence rate of hand injuries studied in seven manufacturing environments around the world ranged from 4 to 11 per 100 workers per year. Workers aged 24 years or less had the highest risk of hand injury. Men had higher rates of severe hand injury than women.Despite the high frequency and significant amount of lost work time associated with these injuries, they are poorly understood from an etiological perspective. There is only one case-control study of occupational hand injury in the literature. That study suggested an important role for both fixed (age) and transient risk factors (doing an unusual task) at the time of the injury. More analytic epidemiological research is needed to identify potentially modifiable risk or protective factors (e.g. glove use) for acute hand injuries. In this regard, the case-crossover design, a relatively new epidemiological approach using cases as their own controls, could prove an efficient method for determining transient, modifiable risk factors for acute, occupational hand injury.     

Evaluating repeated patient handling injuries following the implementation of a multi-factor ergonomic intervention program among health care workers

Objective

The objective of this study was to evaluate repeated patient handling injuries following a multi-factor ergonomic intervention program among health care workers.

Methods

This was a quasi-experimental study which had an intervention group and a non-randomized control group. Data were collected from six hospitals in Saskatchewan, Canada from September 1, 2001 to December 1, 2006.

Results

A total of 1,480 individuals who had a previous injury were eligible for the study. Medium and small size hospitals in the intervention group had significantly fewer repeated injuries than in the control group. Multivariate analysis showed that the intervention group had 38.1% lower odds of having repeated injury compared to the control group, after adjusting for hospital size.

Conclusions

The work-related repeated injury after a multi-factor intervention program was reduced. The synergistic relationships between components of multi-factor intervention and applicability of injury prevention programs to different settings need to be further explored.

Impact on Industry

Implementing a multi-factor program with the right equipment and training can lower the risk of injury among health care workers.     

The effects of minimum legal drinking age 21 laws on alcohol-related driving in the United States

Objective

To examine trends in alcohol consumption and alcohol-related crashes among people younger than 21 in the United States and to review evidence on the effects of minimum legal drinking age (MLDA) laws.

Methods

Trends in alcohol-related crashes and alcohol consumption among young people were examined, and studies on the effects of lowering and raising the drinking age were reviewed.

Results

MLDA laws underwent many changes during the 20th century in the United States. Since July 1988, the MLDA has been 21 in all 50 states and the District of Columbia. Surveys tracking alcohol consumption among high school students and young adults found that drinking declined since the late 1970 s, and most of the decline occurred by the early 1990 s. These were the years when states were establishing, or reinstating, a MLDA-21. Among fatally injured drivers ages 16-20, the percentage with positive BACs declined from 61% in 1982 to 31% in 1995, a bigger decline than for older age groups; declines occurred among the ages directly affected by raising MLDAs (ages 18-20) and among young teenagers not directly affected (ages 16-17). Almost all studies designed specifically to gauge the effects of drinking age changes show MLDAs of 21 reduce drinking, problematic drinking, drinking and driving, and alcohol-related crashes among young people. Yet many underage people still drink, many drink and drive, and alcohol remains an important risk factor in serious crashes of young drivers, especially as they progress through the teenage years. Stepped-up enforcement of MLDA and drinking and driving laws can reduce underage drinking. Recent efforts to lower MLDAs to 18 and issue licenses to drink upon completion of alcohol education have gained local and national media attention. There is no evidence that alcohol education can even partially replace the effect of MLDA-21.

Conclusions

The cause and effect relationship between MLDAs of 21 and reductions in highway crashes is clear. Initiatives to lower the drinking age to 18 ignore the demonstrated public health benefits of MLDAs of 21.

Impact on Industry

Lowering the drinking age to 18 will increase highway crash deaths among young people.     

Investigation of Motorcyclist Cervical Spine Trauma Using HUMOS Model

Objective: With 16 percent of the total road user fatalities, motorcyclists represent the second highest rate of road fatalities in France after car occupants. Regarding road accidents, a large proportion of trauma was on the lower cervical spine. According to different clinical studies, it is postulated that the cervical spine fragility areas are located on the upper and lower cervical spine. In motorcycle crashes, impact conditions occur on the head segment with various orientations and impact directions, leading to a combination of rotations and compression. Hence, motorcyclist vulnerability was investigated considering many impact conditions. Method: Using the human model for safety (HUMOS), a finite element model, this work aims to provide an evaluation of the cervical spine weaknesses based on an evaluation of injury mechanisms. This evaluation consisted of defining 2 injury risk factors (joint injury and bone fracture) using a design of experiment including various velocities, impact directions, and impact orientations. Results: The results confirmed previously reported clinical and epidemiological work on the fragility of the lower cervical spine and the upper cervical spine segments. Joint injuries appeared before bone fractures on both the upper and lower cervical spine. Bone fracture risk was greater on the lower cervical spine than on the upper cervical spine. The compression induced by a high impact angle was identified as an important injury severity factor. It significantly increased the injury incidence for both joint injuries and bone fractures. It also induced a shift in injury location from the lower to the upper cervical spine. The impact velocity exhibited a linear relationship with injury risks and severity. It also shifted the bone fracture risk from the lower to upper spinal segments.     

Fatal motorcycle crashes in wide urban area of Zagreb,Croatia—A 10-year review

Objective: The objective of our study was to determine the prevalence of alcohol and drug intoxication among fatally injured motorcyclists in a wide urban area of Zagreb, Croatia.

Methods: We conducted a single-center observational retrospective study over a 10-year period (2007–2016) in 3 counties covering an area including 1.2 million residents. We reviewed the records on fatally injured motorcyclists, collecting information relating to sex, age, cause of death, time of death in relation to the time of the crash, and the circumstances of the crash (time of day, day of the week, season). Blood alcohol concentration (BAC) and toxicology analysis results were collected and analyzed.

Results: We identified 163 deaths (95.7% males, 4.3% females). Overall, 64.2% of the victims were 20 to 39 years old. The majority (50.9%) of those fatally injured were responsible for causing the traffic crash; the rest were determined not to be responsible or the responsibility could not be determined. The most frequent causes of death were multiple injuries (55.8%) and isolated head trauma (23.3%). The rider’s BAC was above the legal limit for driving (>0.50?g/kg) in 53.8% of cases, with a mean BAC of 1.91?g/kg. There was no difference in riding a motorcycle with a BAC above the legal limit between groups defined as younger (≤39 years of age) and older (≥40 years of age). The number of people with an illegal BAC was significantly higher during weekends than during the work week. The BAC of riders who were responsible for the crash was significantly higher than that of those who were not responsible or whose responsibility could not be determined. Use of illegal drugs or nontherapeutic use of legal drugs was not common and was detected in 10.4% of fatally injured riders.

Conclusions: Alcohol intoxication has a major role in motorcycle crash–related mortality. A significant difference in BAC between fatally injured riders responsible for the accident and those who were not responsible implies that measures directed toward prevention of drinking and driving behavior could lower the number of fatal motorcycle crashes. Weekend measures, especially during spring and summer, could have particularly significant effects.     

Severity of e-scooter rider injuries associated with trip characteristics

Introduction: E-scooter rider injuries have been growing, but little is known about how trip and incident characteristics contribute to their severity. Method: We enrolled 105 adults injured while riding e-scooters who presented to an emergency department in Washington, DC, during 2019. Enrolled participants completed an interview during the emergency department visit, and their charts were abstracted to document their injuries and treatment. Logistic regression examined the association of incident location and circumstances with the likelihood of sustaining an injury on the Abbreviated Injury Scale (AIS) ≥ 2, while controlling for rider characteristics. Results: The most common locations of e-scooter injuries in our study sample occurred on the sidewalk (58%) or road (23%). Accounting for other trip and rider attributes, e-scooter riders injured on the road were about twice as likely as those injured elsewhere to sustain AIS ≥ 2 injuries (RR, 1.96; 95% CI, 1.23–2.36) and those who rode at least weekly more often sustained AIS ≥ 2 injuries compared with less frequent riders (RR, 1.86; 95% CI, 1.11–2.32). Conclusions: Greater injury severity for riders injured on the road may reflect higher travel speeds. Practical applications: Injury severity associated with riding in the road is one factor that jurisdictions can consider when setting policy on where e-scooters should be encouraged to ride, but the risk of any crash or fall associated with facilities should also be examined. Although injuries are of lower severity on sidewalks, sharing sidewalks with slower moving pedestrians could potentially lead to more conflicts.     

Factors associated with motorcycle traffic crash fatalities among active duty U.S. Army personnel

Objective: Research on factors associated with motorcycle fatalities among active duty U.S. Army personnel is limited. This analysis describes motorcycle crash–related injuries from 1995 through 2014 and assesses the effect of alcohol use and helmet use on the risk of fatal injury among active duty U.S. Army motorcycle operators involved in a traffic crash, controlling for other factors shown to be potentially associated with fatality in this population.

Methods: Demographics, crash information, and injury data were obtained from safety reports maintained in the Army Safety Management Information System. Traffic crashes were defined as crashes occurring on a paved public or private roadway or parking area, including those on a U.S. Army installation. Analysis was limited to motorcycle operators. Odds ratios (ORs) and 95% confidence intervals (95% CIs) from a multivariable analysis estimated the effect of alcohol use and helmet use on the risk of a fatal injury given a crash occurred, controlling for operator and crash characteristics.

Results: Of the 2,852 motorcycle traffic crashes, most involved men (97%), operators aged 20–29 years of age (60%), and operators who wore helmets (95%) and did not use alcohol (92%). Two thirds of reported crashes resulted in injuries requiring a lost workday; 17% resulted in fatality. Controlling for operator and crash characteristics, motorcycle traffic crashes involving operators who had used alcohol had a 3.1 times higher odds of fatality than those who did not use alcohol (OR =3.14; 95% CI, 2.17–4.53). Operators who did not wear a helmet had 1.9 times higher odds of fatality than those who did wear a helmet (OR =1.89; 95% CI, 1.24–2.89).

Conclusions: Among U.S. Army motorcycle operators, alcohol use and not wearing a helmet increased the odds of fatality, given that a crash occurred, and additional modifiable risk factors were identified. Results will help inform U.S. Army motorcycle policies and training.     

A preliminary analysis of aortic injuries in lateral impacts

Injuries to the aorta are among the more serious injuries that result from vehicle impacts, and often may be fatal. This article examines the incidence of aortic injuries in the United States and United Kingdom by using two international databases of real-world crashes. The main outcome of interest was the level of risk associated with each principal direction of force for drivers and front-seat passengers with respect to sustaining aortic injuries. The results indicate that the risk of sustaining an injury to the aorta is greater for near-side crashes than for far-side crashes. Further it is apparent that, given a near-side crash, the risk of an aortic injury is greater on the left side of the body (and left side of the vehicle) than on the right. It also was found that the delta-V of crashes where occupants sustained an injury to the aorta was considerably higher than crashes where occupants did not sustain aortic injuries. It is speculated that the anatomical asymmetry of the thorax might play a role in the differences seen in injury risk associated with different impact directions. The results presented in this article could be of use to both the emergency physician treating patients involved in motor vehicle collisions as well as the engineer involved in occupant design countermeasures. Limitations and further planned research are discussed.