Collecting data to prevent drownings - includes related article on methods of collecting data

The teenager sat in a wheelchair in the middle of a stage and looked out at the hundreds of high school students that had come to hear her talk. The students listened intently as the teenager talked about the car crash that left her without the use of her legs. They listened when she said that her life may have been different if she had thought to buckle her seat belt before she got into the car that night. When the teenager had finished talking, the students left the auditorium and got into their cars and pickups to go home. As they left the school parking lot that day, more had their seat belts buckled than when they had arrived that morning.

Why was the teenager at the high school talking to the students about her spinal cord injury? The answer is simple. She was part of a program run by the Oklahoma State Department of Health's Injury Prevention Service to help prevent similar injuries. Department staff had collected data on injuries in the state and found that motor vehicle injuries are the leading cause of death and disability among Oklahoma teenagers. Consequently, they developed a prevention program using the information they had learned, implemented it at selected high schools across the state and evaluated the results.

"The first step in injury prevention is determining what the problem is," says Sue Mallonee, R.N.M.P.H., chief of the Injury Prevention Service. "We must identify high-risk groups and activities by determining the chain of events leading to the injury." The authors of Injury in America: A Continuing Public Health Problem echo Mallonee's statements. The authors note that "high-quality, epidemiologic data are essential for the planning, development and evaluation of efforts to prevent injuries."

Injury mortality data is relatively easy to obtain because death records are maintained in every state, usually in the vital records division of the state health department. These records include the date, place and cause of death as well as the victim's age, sex, race and residence. Medical examiner's and coroners reports are also completed for all people who died as a result of an injury or an unexpected natural death.

During the mid 1980s, the Oklahoma State Department of Health began studying the impact of injuries in Oklahoma by reviewing death certificate data. Staff used the data to calculate for premature death. Because the burden of injury falls disproportionately on the young, comparing the total number of injury deaths with deaths from other causes can be misleading. Researchers say it is also important to consider how the deaths of many young people may affect the future of the society; therefore, it is important to consider the impact of premature death. Deaths occurring prior to age of life expectancy, most often 65 years of age, are called premature. The number of years of life that would have remained are considered years of potential life lost. In Oklahoma in 1983 and 1984, there were more years of potential life lost from injuries than any other cause, says Mallonee. "In fact, the proportion of total years of potential life lost due to unintentional injuries in Oklahoma was substantially higher than for the U.S. as a whole," she says.

Tip of the Iceberg

However, injuries resulting in deaths are only the tip of the iceberg. One study of childhood injuries found that for every death due to injuries among children zero-to-nineteen years old, there are 45 hospitalizations and 1,300 visits to emergency rooms. The researchers estimated that the number of injuries treated at home and in physicians' offices may be double those treated in emergency facilities.

With this information in mind, the state health department applied for and received a federal grant from the Centers for Disease Control in Atlanta in 1987 to establish a surveillance system for submersion injuries, hospitalized and fatal burn injuries and hospitalized traumatic spinal cord injuries. At the time, there was no surveillance of nonfatal injuries in Oklahoma, with the exception of routine data collected about motor vehicle crashes by the Oklahoma Department of Public Safety. Submersions, burns and spinal cord injuries were selected for study due to their frequency, severity and disability.

In November 1986, then Oklahoma Commissioner of Health Joan K. Leavitt, M.D., mandated that hospitalized burn injuries be made a reportable condition to the state health department; hospitalized spinal cord injuries and submersion injuries were made reportable in May 1987. In 1987, the Injury Epidemiology Division was organized within the Epidemiology Service at the state health department to conduct injury surveillance. Surveillance for burns began in September 1987; data collection began in October and November 1987 for spinal cord injuries and submersions, respectively.

"It is clear that in order to develop better prevention programs for injuries such as drowning, better epidemiologic data is essential," says Mallonee. "Deaths from drowning may not accurately reflect the total number of submersion injury cases. The inclusion of nonfatal, or near drowning, events are important in defining the critical chain of events which lead to better prevention. Near drowning cases often have neurologic sequelae."

To establish the submersion surveillance system in Oklahoma, state health department staff contacted the state medical examiner's office weekly to monitor deaths from drowning. Medical examiner reports reveal descriptive data such as age, race and sex, as well as circumstances surrounding the submersion injury such as the activity prior to the injury and contributing factors such as alcohol and drug use.

In order to identify nonfatal submersion injuries, hospitals and physicians statewide report hospitalized injuries on reporting postcards. In addition, beginning in 1992, medical records departments in hospitals statewide reported submersion injuries based on discharge codes. The health department identified other injuries, fatal and nonfatal, through reporting from the Oklahoma Lake Patrol, ambulance run reports and newspaper clippings. Supplemental data is collected from the Oklahoma Department of Public Safety on motor vehicle-related submersions.

Demographic Report Form

Staff developed a report form which identified the causes of events leading to submersion injuries and characteristics of the injuries. Demographic information, time and location of the injury, activity preceding the injury and contributing factors such as alcohol and drug use is collected on the report form.

In 1993, the Injury Prevention Service (the name was changed from Injury Epidemiology Division in July 1993) prepared a five,year summary of reportable injuries in Oklahoma analyzing surveillance data from 1988 to 1992. During that period, 573 Oklahoma residents suffered a submersion injury for an average annual rate of 3.6 inches per 100,000 population. Seventy-two percent of injuries were fatal. Submersion rates were highest for children less than five years old (Figure 1). Rates were higher for males in all age groups; the male/female ratio was four-to-one. African American males had the highest submersion rates with 7.4 per 100,000 population compared to 5.4 for white males and 3.6 for Native American males.

The location of injury varied considerably by age. Nearly two-thirds of injuries among children less than five years old occurred in a swimming pool or tub, while 18 percent occurred in lakes, rivers, creeks or ponds, or recreational water (Figure 2). For people older than five, three-quarters of submersions occurred in recreational water; only four percent of people in that age group injured in recreational water were reported to be wearing a personal flotation device.

Fatality rates varied considerably by location of injury. More than 84 percent of injuries occurring in recreational water were fatal compared to 34 percent of injuries occurring in swimming pools (Figure 3). Injuries in demographic sub-groups were associated with specific activities. For example, males accounted for more than 90 percent of fishing-related injuries and 80 percent of swimming injuries; females accounted for 48 percent of bathing injuries. Eighty-nine percent of motor vehicle-related submersion injuries were among whites.

Submersions are among the most seasonal of injuries. As expected, more than half of submersion injuries occurred between May and September. Forty-four percent of submersions occurred between 12:00 p.m. and 6:00 p.m.; 39 percent occurred on Saturday or Sunday.

Among people older than 14, we found alcohol to be a contributing factor in 37 percent of submersion injuries. Alcohol was associated with 59 percent of submersions among Native Americans, 37 percent among whites and 33 percent among African Americans. Alcohol-related submersions were highest among people 25-to-34 years old (Figure 4). Alcohol contributed to 73 percent of diving-related submersions, 58 percent of motor vehicle submersions and 45 percent of boating-related submersions.

Individual circumstances surrounding submersion injury differed for each case, but we noted factors common to specific age groups. The lack of continuous supervision by caregivers and the absence of barriers to pools and farm ponds contributed to submersions among children, while alcohol use around water and non-use of protective methods such as personal flotation devices were contributing factors among adults. Limited/non-use of resuscitation and the solitariness of fatal injuries were common factors among all age groups. Eighty-three percent of people reportedly submerged for less than four minutes survived; survival rates decreased as length of submersion increased.

The Oklahoma data suggests that submersion injuries vary by age group, location and circumstances surrounding the injuries. As consequence, the state is developing several prevention programs targeting specific populations and activities. Currently, the Injury Prevention Service is using surveillance data to develop the State Strategic Plan for the Prevention of Injuries. The purpose of the State Strategic Plan is to make recommendations about implementing proven prevention programs to assist the state and improve the health status of Oklahomans by the year 2000. The State Strategic Plan will include sections on specific injuries, including submersions, and will be distributed to injury-prevention professionals and policymakers in the state.

Target Childhood Submerslons

Because submersion injury rates are high for children younger than five, many recommended prevention programs target issues surrounding childhood submersions. During the next few years, Oklahoma communities will be encouraged to consider enacting local ordinances requiring fencing which restricts entry to residential swimming pools from the yard or residence.

We are planning educational campaigns to teach parents and caregivers about the characteristics of childhood drowning and promote constant supervision of children when they are around all water, including swimming pools, hot tubs, bathtubs, toilets, puddles, buckets, drainage ditches and recreational water.

The Drowning Prevention Committee of the Oklahoma SAFE KIDS Coalition is developing a drowning prevention curriculum for owners of residential pools. The curriculum will be taught during a two-hour workshop and will be promoted by retail distributors of residential pools, the YMCA and the American Red Cross. Plans arc also underway to develop a similar curriculum targeting farm pond submersions; the curriculum will be implemented with the help of rural fire departments.

Additionally, we will encourage local health departments, Indian health centers, local physicians and health care providers, to teach clients about the characteristics of childhood drowning, the importance of supervision, basic rescue techniques and cardiopulmonary resuscitation (CPR). Several educational materials are available through the Injury Prevention Service, Oklahoma SAFE KIDS Coalition, American Red Cross, National Spa and Pool Institute and American Academy of Pediatrics.

We will encourage communities to implement programs that promote or require life preservers, ropes and a telephone with local emergency medical services numbers at swimming pools and controlled waterfront areas; train pool owners and waterfront personnel; teach pool owners the proper use of pool covers; educate people owning or installing hot tubs, spas and Jacuzzis about safety measures; and encourage the use of personal flotation devices during aquatic activities.

We will develop alcohol-awareness programs as well, discouraging alcohol consumption during water-related activities. At the 1991 National Conference on Injury Control, participants recommended restricting the sale and consumption of alcoholic beverages at boating, pool, harbor, marina and beach areas. The Oklahoma Boating Safety Regulation Act states that no person should operate a boat or manipulate any parasail, water skis, surfboard or similar device while intoxicated or under the influence of any substance included in the Uniform Controlled Dangerous Substances Act. However, Oklahoma's current boating law does not require a boat operator's license, thus boat operators may not even be aware of the current law. The Oklahoma Legislature will be encouraged to revise the Oklahoma Boating Safety Regulation Act to require operating licenses for recreational boats, with operator competency requirements for recreational boating based on boat size and engine power. It is also recommended the act be revised to specify .10 blood alcohol concentration as evidence of intoxication with resulting fines and penalties.

Helps Injury Prevention

Oklahoma's submersion surveillance system not only identifies recurrent submersion problems and characterizes populations at risk for submersions in the state, it also allows state health officials and other injury prevention specialists to implement programs that are the most beneficial and cost effective. It is the foundation on which most of the state's injury prevention programs are built. Submersion surveillance data has already provided a basis for current drowning prevention programs in Oklahoma such as the educational curriculums being developed by the Oklahoma SAFE KIDS Coalition. As a result of surveillance data, the Injury Prevention Service is developing the State Strategic Plan for the Prevention of Injuries which will be used to design future injury-prevention programs. Surveillance data will continue to refine analysis of the submersion problem in Oklahoma and provide a means of evaluating current and future programs.

WHERE TO COLLECT SUBMERSION DATA

The first step in developing a drowning prevention program is to determine the nature and extent of submersion injuries in the area. Many localities have dramatically different injury problems due to the varied geographic, racial, economic and social characteristics of the community or state. "Local data allows an injury-prevention program to be more in tune with the community's needs and desires thereby allowing the program to better address the political, social and economic conditions of the community," says Sue Mallonee, R.N., M.P.H., chief, Injury Prevent Service, Oklahoma State Department of Health.

There are several sources of mortality and morbidity data available to communities and states. These include:

* The state vital records division has data which includes the age, sex, race and residence of the victim as well as the date, place and cause of death.

* Medical examiner reports also contain information about deaths, including information about whether alcohol or drugs were involved in the victim's death and where the injury occurred, as well as demographic data.

* Hospital discharge records are a good source of injury morbidity data. These records contain information on the age and sex of the patient, length of hospital stay, diagnosis and medical costs. All hospital records contain an International Classification of Disease N-code (nature of the disease or injury) specifying the type of physical injury sustained (e.g., skull fracture, spinal cord injury and so forth). Medical records for people sustaining an inj ury may also include a code to describe the external cause of the injury (e.g., gunshot, bicycle crash and so forth). These codes are called E-codes; E-codes can also be used to identify the location of the injury (i.e., differentiate drowning or near-drowning injuries that occurred in a natural body of water or in a bathtub).

* Emergency medical services (EMS) run sheets will provide information about the circumstances of an injury.

* Other sources of morbidity data include the state lake patrol, parks and recreation departments and newspaper clipping services.

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