Medicine, Faculty of
Non UBC
Pediatrics, Department of
DSpace
Pike, I. et al. (2010). Measuring Injury Matters: Injury Indicators for Children and Youth in Canada. Vancouver, BC: UBC.
B.C. Injury Research and Prevention Unit
B.C. Child and Youth Health Research Network
Canadian Institutes of Health Research
Canadian Injury Indicators Development Team
Pike, Ian, 1958-
Macpherson, Alison
Warda, Lynne
Yanchar, Natalie L.
Hewitt, Allyson
Fuselli, Pamela
Babul, Shelina
Desapriya, Ediriweera
Macarthur, Colin
Hameed, S. Morad
Barr, Ronald G.
Raina, Parminder
Piedt, Shannon
Measuring Injury Matters is intended to be a practical resource for injury prevention professionals and practitioners, policymakers and non-governmental organizations with an interest or mandate in injury prevention programming.
Measuring Injury Matters Injury Indicators for Children and Youth in Canada – Vol. 2 The Canadian Injury Indicators Development Team: Children and Youth is a multidisciplinary team funded by CIHR. The team’s work takes the first steps in addressing gaps in injury surveillance through the development of a set of national injury indicators for Canadian children and youth which reflect and monitor identified prevention priorities. MEASURING INJURY MATTERS – VOL. 2 Injury Indicators for Children and Youth in Canada Copyright: Canadian Injury Indicators Development Team, 2010 ISBN: 978-1-55058-416-5 British Columbia Injury Research and Prevention Unit L408 4480 Oak Street Vancouver, BC V6H 3V4 For enquiries, please email: bcinjury1@cw.bc.ca www.injuryresearch.bc.ca The Canadian Injury Indicators Development Team: Ian Pike, PhD Alison Macpherson, PhD Lynne Warda, MD, PhD, FRCPC Natalie Yanchar, MD, MSc, FRCSC Allyson Hewitt, MA, LLB Pamela Fuselli, BSc, BHA, MSc Shelina Babul, PhD Edi Desapriya, PhD Colin Macarthur, MBChB, PhD Morad Hameed, MD, FRCPC Ronald Barr, MDCM, FRCPC Parminder Raina, PhD Shannon Piedt, BA CORRESPONDING AUTHOR Dr. Ian Pike BC Injury Research and Prevention Unit University of British Columbia L408-4480 Oak Street Vancouver, BC V6H 3V4 ipike@cw.bc.ca SUGGESTED CITATION: Pike, I. et al. (2010). Measuring Injury Matters: Injury Indicators for Children and Youth in Canada. Vancouver, BC: UBC. LAYOUT AND DESIGN: Alison Lynch, BC Child and Youth Health Research Network University of Victoria | Victoria, BC V8W 3P5 www.cyhrnet.ca | cyhrnet@uvic.ca Ph: 250-472-4823 | Fax: 250-721-8929 CONTENTS Acknowledgements......................................................................................................................... 4 List of Injury Indicators .................................................................................................................... 5 Abbreviations ................................................................................................................................... 6 How to Use this Report ................................................................................................................... 7 Overview .......................................................................................................................................... 8 Indicator Specification Tables ......................................................................................................... 9 Understanding the format for the Indicator Specification Tables .......................................... 10 Indicators Spanning Across All Domains ................................................................................... 13 Overall Health Service Implications Indicators ........................................................................ 19 Motor Vehicle Injury Indicators ................................................................................................. 28 Sport, Recreation and Leisure Injury Indicators....................................................................... 48 Other Policy Indicators .............................................................................................................. 58 Violence Indicators .................................................................................................................... 61 Trauma Care, Quality and Outcomes Indicators ...................................................................... 69 References ..................................................................................................................................... 80 Appendix ........................................................................................................................................ 87 Participating Facilities and Provinces, National Trauma Registry Comprehensive Data Set . 87 4 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 ACKNOWLEDGEMENTS Firstly, we would like to acknowledge the Canadian Institutes of Health Research (CIHR) and the BC Child and Youth Health Research Network (CYHRNet) for providing funds to conduct and support this study. We are very grateful for their support. The development of injury indicators for children and youth was conducted by a team of qualified and experienced researchers and practitioners from across Canada. Team members were selected with a view to building future capacity by matching experienced researchers with newer investigators in a collaborative mentorship model. This model worked well, and we are especially grateful to Drs. Ronald Barr, Colin Macarthur and Parminder Raina for their guidance during the project. As well, Ms. Allyson Hewitt was instrumental in ensuring that indicators related to policy were included in this project. All members of the team contributed to a supportive network that resulted in a truly successful collaboration. We were fortunate to have Ms. Joanne Vincenten and Ms. Morag MacKay, European Child Safety Alliance, as international consultants to the project. As well, Dr. Rod McClure of Monash University, Melbourne, Australia provided continual support throughout the project and enlightened us with a comprehensive overview of indicators as our keynote speaker in Alliston, Ontario. His expertise was an invaluable asset to our panel of 35 policy makers, advocates and practitioners as they determined our initial list of indicators. Above all, we would like to recognize those 35 individuals who gave of their time, expertise and recommendations on Injury Indicators Day. Without their help, the team would not have been able to conduct this research. Many of those individuals went further to assist the project during the two stages of the modified Delphi process that followed. We are most grateful. We wish also to acknowledge the Canadian Collaborative Centres for Injury Prevention and Control (CCCIPC), ThinkFirst Canada, Safe Communities Canada, Safe Kids Canada, SMARTRISK Foundation and Injury Prevention across the Life Span (IPALS) for engaging their memberships in the completion of the injury indicators survey. Finally, the investigators owe a debt of gratitude to Ms. Shannon Piedt, Project Co-ordinator, for her continuing excellent work in ensuring the timely progress of the project, to Ms. Kate Turcotte for her clear thinking and writing that was instrumental in garnering needed resources, and to Ms. Alison Lynch whose skills in writing and editing allowed for this document. Thank you. Canadian Injury Indicators Development Team: Children and Youth 5 LIST OF INJURY INDICATORS Indicators Spanning Across All Domains 1. Mortality Rate 2. Potential Years of Life Lost 3. Hospital Separations Rate Overall Health Service Implications Indicators 4. Diagnosis-Specific Hospital Separations 5. Hospital Admission - Injury Severity 1 6. Hospital Admission - Injury Severity 2 7. Length of Stay in Hospital Motor Vehicle Injury Indicators 8. Cost of Motor Vehicle Injuries 9. Crash Rate 10. Intersection Crash Rate 11. Rural Roadways 12. Drunk Driving 13. Speed 14. Young Drivers 15. Graduated Driver Licensing 16. Child Restraints 17. Unrestrained Injuries 18. Child Restraint Laws Sport, Recreation and Leisure Injury Indicators 19. Bicycle Helmet Laws 20. Cost of Sport, Recreation and Leisure Injuries 21. Percentage of Sport Specific Injuries (Participation Rates) 22. Requirements that Playgrounds Meet CSA Standards 23. Legislations Requiring Pool Fencing Other Policy Indicators 24. Window Guard By-law 25. Provincial Standards for Hot Water Tap Temperature Violence Indicators 26. Violent Crime Rate 27. Abusive Head Trauma Rate 28. Suicide Prevention 29. Anti-Violence/Anti-Bullying Policies Trauma Care, Quality and Outcomes Indicators 30. Access to Pediatric Trauma Centre (PTC) 31. Appropriate Use of Pediatric Trauma Centre (PTC) 32. Quality of Trauma System 33. Pre-hospital Transport Time 34. Presence of a Coordinated Pediatric Trauma System 6 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 ABBREVIATIONS AFN Assembly of First Nations AHT Abusive Head Trauma AIS Score Abbreviated Injury Severity Score BAC Blood Alcohol Content CANSIM Canadian Socioeconomic Information Management System CCHS Canadian Community Health Survey CCMTA Canadian Council of Motor Transport Administrators CDS Comprehensive Data Set CIHI Canadian Institute for Health Information CIHR Canadian Institutes of Health Research CSA Canadian Standards Association CYHRNet BC Child and Youth Health Research Network DAD CIHI Discharge Abstract Database ESESP Elementary-Secondary Education Statistics Project FNIHB First Nations and Inuit Health Branch, Health Canada GDL Graduated Driver Licensing HCN Health care number ICD-10-CA International Statistical Classification of Diseases and Health Related Problems 10th Revision – Canadian Enhancement ICISS ICD-derived Injury Severity Score IPALS Injury Prevention Across the Life Span ITK Inuit Tapiriit Kanatami MDS Minimum Data Set NORP National Occupant Restraint Program NTR National Trauma Registry OIPRC Ontario Injury Prevention Resource Centre PTC Pediatric Trauma Centre PYLL Potential Years of Life Lost RGN Resource Group Number RIW Resource Intensity Weight SBS Shaken Baby Syndrome TAC Trauma Association of Canada TRAID Traffic Accident Information Database (Transport Canada) TT Trauma team TTC Trauma Treatment Centre UCR Uniform Crime Reporting YPLL Years of Potential Life Lost Canadian Injury Indicators Development Team: Children and Youth 7 HOW TO USE THIS REPORT Measuring Injury Matters is intended to be a practical resource for injury prevention professionals and practitioners, policymakers and non-governmental organizations with an interest or mandate in injury prevention programming. It aims to promote a common set of child and youth injury indicators to be used across Canada. This allows comparisons to be easily made between all communities, regions or jurisdictions in Canada. It also encourages systematic injury surveillance and monitoring, allowing community practitioners, in particular, to think about the data and information they gather in their communities, effectively monitor the injury prevention systems in place and develop local initiatives based on what they learn. The indicators can then be used to monitor the effectiveness of these newly-established initiatives MEASURING INJURY MATTERS – VOL. 1 This document provides some background information on the Canadian Injury Indicators Development Team’s work. It explains the need for injury indicators in the nation, the process the team employed to define this set of indicators and the team’s next steps and future directions. MEASURING INJURY MATTERS – VOL. 2 This volume contains the report’s Indicator Specification Tables, which clearly define and specify all 34 injury indicators. The goal is that these tables will enable injury prevention professionals and practitioners, policymakers and non-governmental organizations with an interest or mandate in injury prevention programming to understand the indicators and apply them in a consistent manner. This volume also includes special Indicators in Action sections. These sections showcase real-life examples from across the country about how indicators have been used to support the implementation of injury prevention policies and practices. Icons Used in This Report LEARN MORE: This icon is used to point to additional sources of information online. NOTE: This icon provides further explanation of a term used in the document. These terms will appear in green in the main text. 8 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 OVERVIEW In Canada, injury is the leading cause of death and a major cause of hospitalization for children and youth, aged one to 19. It kills an average of 290 children ages 14 and under, and hospitalizes an estimated 21,000 each year. Every year, approximately one in every 300 Canadian children, age 14 and under, is hospitalized for a serious injury (Public Health Agency of Canada, 2009). Recent national consultations on injury research and a national injury prevention strategy have consistently highlighted the need for ongoing surveillance and support of evidence-based practice. Responding to the need to develop indicators with which to monitor and measure progress, the Canadian Injury Indicators Development Team, a national team of new and seasoned researchers, policymakers and injury prevention practitioners, identified 51 indicators in key child and youth injury areas. Using criteria identified by Cryer (2005) and Rigby, Kohler, Blair, et al. (2003), 34 indicators were selected through a modified-Delphi process involving Canadian and international experts in injury prevention research, policy and practice (Pike, Piedt, Warda et al., in press). This process identified the importance of clear definitions and specifications of each indicator. Volume 2 of the report, Measuring Injury Matters, provides definition and full specification of each of the 34 child and youth injury indicators. Canadian Injury Indicators Development Team: Children and Youth 9 INDICATOR SPECIFICATION TABLES The purpose of the Injury Indicator Specification Tables which follow is to clearly define and specify each of the 34 child and youth injury indicators. These tables are intended to provide injury prevention professionals and practitioners, policymakers and non-governmental organizations with an interest or mandate in injury prevention programming with greater understanding of the indicators and their application in a consistent manner. The detailed injury indicator specification tables provide information on the key components of each indicator, including:  A clear definition of the indicator itself, as well as definitions of important key terms  Inclusion and/or exclusion criteria  The underlying rationale for each indicator, including why it is important, what it means and how it should be interpreted. It should be noted, however, that although each indicator is fully defined and specified, not all of the suggested or required data and/or information are available in Canada at this time. Further, the indicators lack formal validation, which may prove difficult due to the lack of a ‘gold standard’ as a basis for comparison. Future research will serve to demonstrate the utility of these indicators to monitor and further injury prevention research, policy and practice. In essence, it is hoped that these indicator specification tables will encourage community practitioners, in particular, to think about the data and information they gather in their own communities, allow them to monitor their own local injury prevention systems and enable them to develop new local injury prevention initiatives based on what they learn. INDICATORS IN ACTION: Blue boxes feature real-life examples As you peruse the Indicator Specification Tables, keep an eye out for blue boxes like this one. These ‘Indicators in Action’ sections feature real-life examples from across the country about how indicators have been used to support the implementation of injury prevention policies and practices. Learn about how hospitalization data has inspired a movement toward safe playgrounds in Manitoba, how data on car crash rates has encouraged an Ontario district health unit to ensure child pedestrians aren’t ‘monkeying’ around and how indicators have helped some injury prevention organizations lobby for better policies. In some cases, website links will help you connect with the injury prevention program creators to find out how you can adopt their practices in your own community. In others, these stories will simply provide inspiration for creating your own initiatives. 10 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 UNDERSTANDING THE FORMAT FOR THE INDICATOR SPECIFICATION TABLES The Indicator Specification Tables describe a number of attributes for each indicator. The diagram below numbers each individual attribute and is followed by corresponding definitions. Canadian Injury Indicators Development Team: Children and Youth 11 1. Type of Indicator: Indicators are classified using three types of indicators.  Policy - captures data regarding legislation and policies currently in place. Further work is needed to develop a score or index which reflects the degree to which best practice is reflected within legislation and policy. Graduated Driver Licensing or helmet laws and the degree to which they reflect best practice are examples of policy indicators.  Risk - captures data regarding the use or non-use of protective equipment. Child restraint use, seatbelt use, bicycle helmet use and measurable aspects of playground safety such as surface performance are all examples of risk indicators.  Outcome - captures the sequelae of injuries. The number of children and youth who die or who are injured and the causes of those injuries give us a picture of the burden of injury in Canada. Mortality rate and hospital separations rate (with specific injuries as the cause of death or hospitalization) are examples of outcome indicators. Note: This is also where indicators that are still under development are labeled. These indicators may require some additional analysis or methodological improvements, or the necessary data may not as of yet be widely available in Canada. 2. Indicator Domain: Indicators are grouped in seven domains, based upon the burden of injury and the collective expertise of the research team. The indicator specification tables are organized by domain, in the following order:  All Domains  Overall Health Service Implications  Motor Vehicle Injury  Sport, Recreation and Leisure  Other Policy  Violence  Trauma Care, Quality and Outcomes 3. Indicator Number and Title: Each indicator is identified by a title and a number, assigned sequentially. 4. Description of Indicator: Provides a concise statement of the specific aspects that the indicator addresses. 5. Why is it important? Provides a justification for the indicator and identifies why it is important 6. How should it be used? Explains how the results of the indicator should be interpreted and used. 7. Key Terms: Definitions of key words or phrases. 12 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 8. How is it calculated? Provides a method of calculation and, for rate-based indicators, provides the description of the general specifications of any component that is the basis for inclusions and exclusions in the numerator and denominator needed to calculate it. Note: Some indicators will state ‘To be determined’ in this section; this indicates that the necessary data may not as of yet be available in Canada. 9. What data is needed? Specifies what data is needed to calculate the indicator 10. Where can it be found? Identifies data sources at the national level that could be used to calculate the indicator Note: These indicators were written as national level indicators; however, most of them could be easily adapted to be provincial, regional or community level indicators. If adapting them, it would be essential to find systematic provincial, regional or community-level data to support them. 11. Limitations: Identifies limitations specific to each indicator. Canadian Injury Indicators Development Team: Children and Youth 13 INDICATORS SPANNING ACROSS ALL DOMAINS ALL DOMAINS Outcome INDICATOR #1: MORTALITY RATE The cause-specific child and youth mortality rate per 100,000 population for a particular year. Where data exists, rate can be stratified by injury cause (excluding patient safety/complications/ medical misadventures), sex, age, socioeconomic status and geographic place. Why is it important? Injury is a serious public health issue with a major impact on the lives of Canadians. It is the number one cause of hospitalization and death among Canadians between the ages of one and 34 (Health Canada, 2009) and kills more children and young adults than all diseases combined. But, these injuries in children and youth are largely avoidable; moreover, deaths from injury are avoidable and reflect aspects of society and its view of children. The mortality rate is perhaps the best indication of the burden of severe childhood injury. It is essential to track the mortality rate over time to assess trends in childhood injury. How should it be used? The mortality rate per 100,000 population indicates how many children and youth die from injury annually, which can be further articulated by each cause of injury. An increase in mortality due to a specific injury would indicate the need for more effective injury prevention in that specific area. A decrease in mortality may indicate injury prevention strategies in place are working. For example, if it is determined that fewer youth die in motor vehicle crashes after graduated driver licensing is legislated, this may be evidence for graduated driver licensing as an effective injury prevention strategy. Key terms Injury is the damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essential energy as heat or oxygen. Unintentional injuries are those injuries where there is no intent to do harm. They are typically classified according to the means of their occurrence (e.g., poisoning, burns and scalds, drowning, falls and transport-related). Violent injuries (intentional injuries) resulting in child or youth death are also included in this definition of mortality and are classified according to intentional self-harm, maltreatment or assault. Mortality data is based on children and youth killed immediately or dying within 30 days as a result of an unintentional or violent injury. How is it calculated? Numerator: Number of unintentional injury and violent injury deaths stratified by cause of injury, age, sex, socioeconomic status and geographic place (where data is available). 14 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Denominator: Total resident population stratified by cause of injury, age, sex, socioeconomic status and geographic place (where data is available). Method of calculation: (Numerator/Denominator) x 100,000 What data is needed?  Total number of deaths due to injury for all causes for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female, socioeconomic status and geographic place (if available).  Population of children and youth broken down by age (<1, 1-4, 5-9, 10-14, 15-19), male, female, socioeconomic status and geographic place (if available).  Mortality data broken down by external cause of death (ICD-10 Codes V01-Y98). Where can it be found? The central Vital Statistics Registry in each province and territory provides data from death registrations to Statistics Canada. Statistics Canada has numbered all health regions in Canada. National death datasets could also be collected through the Canadian Institute for Health Information ’s (CIHI) National Trauma Registry (NTR) as plans are underway to incorporate data from the Chief Coroners Office pending the development of a national coroner’s database. For more information on participating facilities and provinces for NTR’s Comprehensive Data Set (CDS), see Appendix A. Limitations Statistics Canada will not provide mortality data if data requested is less than 5 deaths (due to privacy issues). For more information on the National Trauma Registry, available data and how to request it, visit http://www.cihi.ca/ntr. Canadian Injury Indicators Development Team: Children and Youth 15 ALL DOMAINS Outcome INDICATOR #2: POTENTIAL YEARS OF LIFE LOST Potential Years of Life Lost (PYLL) is an indicator of premature mortality. It represents the total number of years NOT lived by an individual who died before age 75. Why is it important? PYLL allows us to measure the loss of life due to ‘premature’ death attributable to unintentional or violent injury. PYLL gives more importance to the causes of death that occurred at younger ages than those occurred at older ages, and highlights the proportional impact of childhood deaths in a way that is more evident than mortality rates alone, particularly when comparing to other major causes of death (such as cardiovascular disease or cancer). How should it be used? Potential Years of Life Lost (PYLL) is the number of years NOT lived by children/youth because of premature death resulting from injury. It can help us understand what injuries leading to death result in the largest number of years not lived by children who died prematurely. For example, if it is determined that drowning results in the most potential years of life lost (because children are more likely to drown when very young vs. when they get older), injury prevention efforts focused on drowning would be justified. Key terms Potential Years of Life Lost (PYLL) or Years of Potential Life Lost (YPLL) is an indicator of premature mortality. It represents the total number of years NOT lived by an individual who died prior to age 75. How is it calculated? PYLL can be calculated in two ways: 1) The first addresses PYLL at an individual level. PYLL due to death is calculated for each person who died before age 75. For example, a person who died at age 20 would contribute 55 potential years of life lost. Potential years of life lost correspond to the sum of the PYLL contributed for each individual. The rate is obtained by dividing total potential years of life lost by the total population less than 75 years of age. Numerator: Sum of differences between age at death and 75 for all deaths in a given year. Can be stratified by cause of injury (ICD-10 Codes V01-Y98), sex, socioeconomic status and geographic place (if available) Denominator: Estimates of total resident population under age 75 stratified by cause of injury (ICD-10 Codes V01-Y98), sex, socioeconomic status and geographic place (if available). Method of calculation: (Numerator/Denominator) x 100,000 2) The second method addresses PYLL by age group. PYLL due to death is calculated for each age group (< 1, 1-4, 5-9, … and 70-74) by multiplying the number of deaths by the difference between age 75 and the mean age at death in each age group. PYLL correspond to the sum of the products obtained for each age group. The rate is obtained by dividing total potential 16 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 years of life lost by the total population under 75 years old. Numerator: Sum of the products obtained for each age group after multiplying the number of deaths by the difference between age 75 and the mean age at death in each age group. Can be stratified by cause of injury (ICD-10 Codes V01-Y98), sex, socioeconomic status and geographic place (if available) Denominator: Estimates of total resident population for the age group of age groups selected stratified by cause of injury (ICD-10 Codes V01-Y98), sex, socioeconomic status and geographic place (if available). Method of calculation: (Numerator/Denominator) x 100,000 The upper age limit of 75 is used to approximate the life expectancy of Canadians for both sexes combined. For example, an individual in good health is expected to live up to age 75 in Canada. Deaths occurring in individuals age 75 or older are NOT included in the calculation. What data is needed?  Total number of deaths due to injury for all causes for children aged <1, 1-4, 5-9, 10-14, 15-19 by cause of injury (ICD-10 Codes V01-Y98), sex, socioeconomic status and geographic place (if available).  Population of children and youth broken down by age (<1, 1-4, 5-9, 10-14, 15-19), cause of injury (ICD-10 Codes V01-Y98), sex, socioeconomic status and geographic place (if available)  Mortality data broken down by cause of death (ICD-10 Codes V01-Y98). Where can it be found? The central Vital Statistics Registry in each province and territory provides data from death registrations to Statistics Canada. National death data sets could also be collected through the Canadian Institute for Health Information’s (CIHI) National Trauma Registry (NTR) as plans are underway to incorporate data from the Chief Coroners Offices pending the development of a national coroner’s database. For more information on participating facilities and provinces for NTR’s Comprehensive Data Set (CDS), see Appendix A. Limitations PYLL is criticized for skewing the deaths that occur to younger children as having more ‘weight’ than deaths to older people. Canadian Injury Indicators Development Team: Children and Youth 17 ALL DOMAINS Outcome INDICATOR #3: HOSPITAL SEPARATIONS RATE The number of child and youth hospital separations per 100,000 population for a particular year, for all injuries by male, female and total, stratified by age, socioeconomic status and geographic health region when available (excluding patient safety/complications/medical misadventures). Why is it important? The hospital separation rate is a key measure of the use of health services related to injury. It can give a sense of the burden of injury to the health care system, children and their families. The direct costs of injury in 2004 were $10.72 billion (SMARTRISK, 2009). There were 39,367 hospital separations for children, ages 19 and under, due to injury in 2001-02 alone (Public Health Agency of Canada, 2005). Much of the $10.72 billion would have been spent on young patients admitted to hospital due to injury. How should it be used? The hospital separations rate indicates the number of children/youth who are discharged from hospital following treatment for injury each year. An increase in hospital separations for a specific injury would indicate the need for more effective injury prevention in that specific area. A decrease in hospital separations would give a sense that injury prevention strategies in place are working. For those causes of injury that tend to have a relatively lower mortality risk (such as skateboarding), but can still result in significant injury among children requiring hospitalization (such as fractures requiring operative reduction/management), this indicator highlights their impact to the overall injury burden. It is also important to highlight the injury burden of mechanisms with relatively low exposure – and hence, low numbers of deaths – but high risk of serious injury (i.e. dirt bikes). Key terms Hospital Separation is defined as the number of in-patients (having spent at least one night following admission to a hospital) who leave hospital through discharge. Spending a night in a hospital emergency room/department does not qualify as admission to hospital. How is it calculated? Numerator: Total number of child/youth hospital separations in Canada assigned to relevant ICD-10-CA codes for a particular year. Denominator: Mid-year total for Canadian children and youth population for the same year as the numerator. Method of calculation: SR = Σ(ri Pi ) /Σ(Pi) where  SR is the age-standardized rate for the population being studied  ri is the age-group specific rate for age group i in the population being studied  Pi is the population of age group i in the standard population What data is needed?  Number of hospital separations due to injury for all causes for 18 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 children/youth aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available)  Population of children and youth broken down by age group (<1, 1-4, 5-9, 10-14, 15-19), male, female and socioeconomic status (if available).  Hospital Separations data broken down by external cause of injury (injury codes V01-Y98). Where can it be found? Separation data are found on Injury Surveillance On-Line and are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Classification of hospital separation data using ICD-10-CA has been implemented gradually beginning in fiscal year 2001-02. Since a small proportion of the records sent to CIHI are not subject to verification for inclusion of an E-code, the separation data provided by Injury Surveillance On-Line should be considered a minimum estimate of the number of hospitalizations for treatment of injuries. Hospital separation data are presented for fiscal years (e.g. April 1, 2001 - March 31, 2002). Limitations It should be noted that an individual can be admitted to hospital more than once for treatment of the same injury and that injury separation data are simply the numbers of discharges following admission for treatment of injury. They do not represent either the number of injuries that led to the separations or the number of injured people who were discharged from hospital. Hospital admission policies differ among hospitals and over time. Consequently, injuries that might be admitted in one hospital may not be in another and may differ over time depending on such things as changing medical treatment practices, available beds, institutional policies and other resources. Check out Injury Surveillance On-Line at the Public Health Agency of Canada’s website at http://dsol-smed.phac-aspc.gc.ca/dsol-smed/is-sb/index_e.html. Canadian Injury Indicators Development Team: Children and Youth 19 OVERALL HEALTH SERVICE IMPLICATIONS INDICATORS OVERALL HEALTH SERVICE IMPLICATIONS Outcome INDICATOR #4: DIAGNOSIS-SPECIFIC HOSPITAL SEPARATIONS The rate of child/youth hospital separations per 100,000 population for a particular year, for specific diagnoses by male, female and total. Some of the specific diagnoses that will be addressed are head injuries, fractures, spinal cord injuries and other specific diagnoses as requested. Why is it important? It is important to track trends in specific diagnoses to inform prevention programs. For example, many head injuries can be prevented by the use of helmets in sporting activities. It is important to track the injuries and see where emphasis on prevention should be placed. How should it be used? The hospital separations rate by specific diagnosis indicates how many children/youth are discharged from hospital for each type of injury each year. An increase in hospital separations for a specific injury would indicate the need for more effective injury prevention in that specific area. A decrease in hospital separations would indicate that the injury prevention strategies in place are working. For example, if it is determined that head injuries from skiing/snowboarding are diagnosed more frequently than other injuries there would be evidence for targeting injury prevention strategies at regulated helmet use for skiers and snowboarders. Key terms Hospital Separation is defined as the number of in-patients who leave hospital through discharge or death. How is it calculated? Numerator: Total number of hospital separations for the specific diagnostic code(s) per child/youth age group in Canada assigned to relevant ICD-10-CA codes for a particular year. Denominator: Mid-year total for Canadian children and youth population for the same year as the numerator. Method of calculation: SR = Σ(ri Pi ) /Σ(Pi) where  SR is the age-standardized rate for the population being studied  ri is the age-group specific rate for age group i in the population being studied  Pi is the population of age group i in the standard population What data is needed?  Number of hospital separations due to injury for specific causes for children and youth aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available). 20 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2  Population of children and youth broken down by age (<1, 1-4, 5-9, 10-14, 15-19), male, female and socioeconomic status (if available).  Hospital Separations data broken down by external cause of death (injury codes V01-Y98). Where can it be found? Separation data are found on Injury Surveillance On-Line and are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Classification of hospital separation data using ICD-10-CA has been implemented gradually beginning in fiscal year 2001-02. Since a small proportion of the records sent to CIHI are not subject to verification for inclusion of an E-code, the separation data provided by Injury Surveillance On-Line should be considered a minimum estimate of the number of hospitalizations for treatment of injuries. Hospital separation data are presented for fiscal years (e.g. April 1, 2001 - March 31, 2002). Limitations It should be noted that an individual can be admitted to hospital more than once for the treatment of the same injury and that injury separation data are simply the numbers of discharges or deaths following admission for treatment of injury. They do not represent either the number of injuries that led to the separations or the number of injured people who separated from the hospital. INDICATORS IN ACTION: Data drives injury prevention on playgrounds Sometimes hospitalization data work best when coupled with other sources. The Brandon & Area Safe Community Coalition can attest to that. This Manitoba group is part of Safe Communities Canada, a national charitable organization dedicated to helping communities across the country build the capacity and resources needed to mount coordinated, collaborative programs to reduce the pain and cost of injury and promote a culture of safety. Brandon and its surrounding areas were designated a Safe Community in June 2004 and the coalition quickly set to work on developing its strategic priorities, reviewing hospitalization and mortality data for local children. “These data showed that falls are the main type of injury for children, but didn’t tell us what to do about it,” said coalition member Fiona Jeffries. The coalition began examining injury reports from daycares and from the school division, both of which are submitted provincially. These reports showed that most falls were happening on playgrounds. Continued on following page Canadian Injury Indicators Development Team: Children and Youth 21 “Now we knew what to tackle!” said Jeffries. The coalition decided to assess public playgrounds throughout the region and find funds to fix the equipment where it was in poor repair. Three nursing students from a local university joined in to assess the playgrounds across the region and make repair recommendations. The result? A prioritized list of playground repairs and a partnership between the city, school division, local daycares and province's department of tourism to make this happen. Now the group is focused on a data collection and review process with the Brandon Regional Health Authority to build a better understanding of the extent of injury situations in the community's playgrounds. "We couldn’t have gotten here without knowing where and how our children were falling," said Jeffries. 22 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 OVERALL HEALTH SERVICE IMPLICATIONS Outcome INDICATOR #5: HOSPITAL ADMISSION – INJURY SEVERITY 1 The rate of hospital separations for severe injuries with a principal diagnosis of fractures, burns and poisonings. Why is it important? Fractures, burns and poisonings almost always require hospital admission in children, and as such, are not likely to be biased by changes in practice patterns. Further, these indicators are captured by other indicator projects (e.g. European Child Safety Alliance) and can provide international comparisons. How should it be used? Knowing the hospital separations rate of severe injuries such as fractures, burns and poisonings in Canadian children and youth allows comparison of Canadian data more accurately from year to year (because these three are less likely to be biased by changes in practice patterns such as recommended length of hospital stay). As well, this particular indicator definition is the same as the definition used by Europe allowing international comparisons of hospital separations rate. Key terms Number of injuries representing a ‘threshold’ of injury severity : For this proposed indicator, the severe injuries will be long bone fractures (representing ICD-10-CA codes S02.7-T02.9), burns (T20-32), and poisonings (T35-T65.9, X40-49, X60-83, X85-90, and Y10-19). How is it calculated? Numerator: Total number of hospital separations for the specific diagnostic code(s) per child/youth age group in Canada assigned to relevant ICD-10-CA codes for a particular year. Denominator: Mid-year total for Canadian children and youth population for the same year as the numerator. Method of calculation: SR = Σ(ri Pi ) /Σ(Pi) where  SR is the age-standardized rate for the population being studied  ri is the age-group specific rate for age group i in the population being studied  Pi is the population of age group i in the standard population What data is needed?  Number of hospital separations due to injury for long bone fractures, burns and poisoning for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available).  Population of children and youth broken down by age (<1, 1-4, 5-9, 10-14, 15-19), male, female and socioeconomic status (if available).  Hospital Separations data broken down by external cause of death Canadian Injury Indicators Development Team: Children and Youth 23 (injury codes V01-Y98). Where can it be found? Separation data are found on Injury Surveillance On-Line and are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Limitations Using this type of indicator would miss some severe injuries, such as hypothermia, intracranial injury (excluding concussion), injuries of the neck or spinal cord at neck level, multiple fractures of ribs and asphyxiation. The European Child Safety Alliance is a program of the European Association for Injury Prevention and Safety Promotion (EuroSafe) which aims to make life safer for children through advocating for consistency of standards, policies and legislation throughout Europe that impact on children’s safety as well as assisting Europeans to be informed consumers in order to ensure the right choice for children. For more information on the European Child Safety Alliance and its initiatives, visit EuroSafe’s website at http://www.eurosafe.eu.com. 24 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 OVERALL HEALTH SERVICE IMPLICATIONS Outcome Indicator under development INDICATOR #6: HOSPITAL ADMISSION – INJURY SEVERITY 2 Methodology is proposed to identify severe injuries and track them per 100,000 population, by age and sex, over time. A scoring calculation for severe injuries will be developed. The threshold for severe injuries will be based on the probability of in-hospital death for each diagnosis. Diagnoses with the lowest probability of survival will be included. Why is it important? This indicator will allow capture of all serious injuries sustained by children and youth and can be compared internationally. Overall hospital admissions are subject to variation between regions and over time, and are strongly influenced by changes in practice patterns. Selecting the most severe injuries will remove some of this bias and portray trends in severely injured children. How should it be used? Once a Canadian version of an ICISS score is developed, it will allow the determination of which injuries are most likely to result in death , and consequently, which injuries are most in need of injury prevention strategies. Key terms Severe injuries will likely include S00-T78 and a first external cause code in the range V01-Y36, where diagnoses and external cause codes are coded using the ICD-10-CA classification. Currently, Cryer et al. proposed defining serious injuries based on an ICISS score of less than or equal to 0.941. This score is based on the probability of a patient surviving the injury. This indicator aims to define a Canadian ICISS score based on the methodology used by Cryer et al. This includes, but is not limited to, fracture of the neck or femur, intracranial injury (excluding concussion), injuries of the neck or spinal cord at neck level, multiple fractures of ribs and asphyxiation. How is it calculated? Numerator: Number of severe injuries as identified above. Denominator: Mid-year total for Canadian children and youth population for the same year as the numerator. Method of calculation: SR = Σ(ri Pi ) /Σ(Pi) where  SR is the age-standardized rate for the population being studied  ri is the age-group specific rate for age group i in the population being studied  Pi is the population of age group i in the standard population What data is needed?  Number of hospital separations due to injury for severe injuries for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available).  Population of children and youth broken down by age (<1, 1-4, 5-9, 10-14, 15- Canadian Injury Indicators Development Team: Children and Youth 25 19), male, female and socioeconomic status (if available).  Hospital Separations data broken down by external cause of death (injury codes V01-Y98). Where can it be found? Separation data are found on Injury Surveillance On-Line and are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Limitations This indicator is not yet developed, requires use of an ICISS score and may not be comparable to other jurisdictions as not all countries have calculated ICISS scores to date. ICISS score is an ICD-derived Injury Severity Score. It can be used for outcomes analysis by deriving predicted values of mortality, hospital complications or other dependent values such as length of stay based on statistics from previous patients with similar injuries as classified by the ICD. 26 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 OVERALL HEALTH SERVICE IMPLICATIONS Outcome INDICATOR #7: LENGTH OF STAY IN HOSPITAL The average number of days spent in hospital for a particular year, for specific diagnoses by male, female and total and by age-group Why is it important? It is important to track trends in length of stay as a measure of burden to the health care system. Broadly, length of stay can give some indication of the resources necessary for the treatment of injuries. Length of stay is not a measure of injury incidence, nor is it an accurate measure of severity. How should it be used? A standardized measure of length of hospital stay will allow comparisons across jurisdictions and regions. These data can also be used to monitor the impact of prevention programs and policies over time. If measuring the burden on the health care system overall, longer length of hospital stay results in large costs. Appropriately targeted injury prevention strategies that reduce child and youth injury for causes associated with long length of stay (e.g. burns) could result in financial savings for the health care system. Key terms Average length of stay is defined as the total number of hospital days divided by the total number of hospital separations (patients who leave hospital through discharge or death). How is it calculated? Numerator: Number of hospital days for each injury diagnostic code(s) per child/youth age group in Canada assigned to relevant ICD-10-CA codes for a particular year. Denominator: Total number of hospital separations for all injury diagnoses per child/youth age group in Canada. Method of calculation: Numerator/Denominator What data is needed?  Number of hospital days due to injury for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available).  Number of hospital separations due to injury for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available)  Hospital Separations data broken down by external cause of death (injury codes V01-Y98). Where can it be found? Hospital days and separation data are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Hospital separation data are presented for fiscal years (e.g. April 1, 2001 - March Canadian Injury Indicators Development Team: Children and Youth 27 31, 2002). Limitations It should be noted that an individual can be admitted to hospital more than once for the treatment of the same injury and that injury separation data are simply the numbers of discharges or deaths following admission for treatment of injury. They do not represent either the number of injuries that led to the separations or the number of injured people who separated from the hospital. Another limitation is that length of stay in hospital varies based on availability of resources, beds, and changes in health care policy. It may not accurately measure how long an injury should be treated in hospital. 28 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 MOTOR VEHICLE INJURY INDICATORS MOTOR VEHICLE INJURY Outcome Indicator under development INDICATOR #8: COST OF MOTOR VEHICLE INJURIES The calculation of the annual direct and indirect costs related to child/youth motor vehicle injury in Canada. Why is it important? Transport incidents cost Canada $3.7 billion in 2004 (SMARTRISK, 2009). Estimates of the costs of fatal and nonfatal motor vehicle injuries illustrate their impact on the nation's economy and impact on the health system. These costs are a measure of the dollars spent and income not received due to motor vehicles crashes, injuries and fatalities. How should it be used? A standardized measure of the cost of motor vehicle-related injury can be used to compare cost/burden by province, region and/or target group of interest. Cost data can also be used to rationalize and advocate for prevention programming, both general (motor vehicle) and specific (e.g. young drivers). Key terms The definitions of cost and method of estimation will be those defined in previous economic burden of injury studies. An incidence costing, human capital approach was used, in which the incident population injured in a given year is costed over their lifetimes. Costs were discounted to a present value at a defined percentage per annum. Direct costs are comprised of all the goods and services used for treatment, continuing care, rehabilitation and terminal care of people experiencing a major illness of impairment (SMARTRISK, 2009). Indirect costs represent the losses due to goods and services that are not produced as a result of the impairment. The value of time lost from work and homemaking due to morbidity, disability and premature mortality is measured by earnings data and the market value of unperformed homemaking services (SMARTRISK, 2009). The economic burden of injury studies used mortality data, hospitalized injury data, and estimated non-hospitalized injuries and disability using Miller’s Databook on Nonfatal Injury. How is it calculated? To be determined. Please see SMARTRISK Canada’s The Economic Burden of Injury in Canada. Another useful reference would be Transport Canada’s Analysis and Estimation of the Social Cost of Motor Vehicle Collisions in Ontario: Final Report. The study is available online at http://www.tc.gc.ca/eng/roadsafety/tp-tp14800-menu-159.htm. Canadian Injury Indicators Development Team: Children and Youth 29 What data is needed?  Deaths  Hospitalizations – cases, average age, average hospital costs per resource group number (RGN) or Resource Intensity Weight (RIW), average Length of Stay in Hospital  Population denominators – age/sex  Stats Canada CANSIM database – employment statistics Where can it be found? Statistics Canada - Vital Statistics, population data, employment data Canadian Institute for Health Information – Hospitalization data Limitations See The Economic Burden of Unintentional Injury in Canada for a full discussion of limitations related to this indicator. Resource Intensity Weight (RIW) is a measure of the resources used during a particular hospital separation relative to the resources used by the average separation. To view the report The Economic Burden of Injury in Canada, visit SMARTRISK’s website at http://www.smartrisk.ca/. The CANSIM (Canadian Socioeconomic Information Management System) is Statistic Canada’s key socioeconomic database. It contains numerous time series covering a wide variety of data on such topics as labour, manufacturing, trade, agriculture, finance, demographics and crime. The Economic Burden of Injury in Canada is a 2009 report coordinated by the SMARTRISK Foundation which examined the real costs of injury in Canada. The Databook on Nonfatal Injury examines selected costs of injury by body region, body part, and by nature of injury (e.g., fracture, laceration). It estimates long-term consequences and addresses the costs of occupational injuries, consumer product injuries, intentional interpersonal injuries, motor vehicle crash injuries and suicide 30 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 MOTOR VEHICLE INJURY Crashes are the Risk Factor Injuries due to crashes are the Outcome INDICATOR #9: CRASH RATE The motor vehicle crash rates per 100,000 population (total, proportion of children and youth 19 years and under with nonfatal injury, proportion of children and youth 19 years and under with fatal injury, number/proportion by road user type – driver/passenger, pedestrian, cyclist). Why is it important? Motor vehicle crashes are the leading cause of unintentional injury hospitalization and death among Canadian children and youth. How should it be used? Standardized crash and injury rates can be used to compare burden and patterns of motor vehicle related injuries across provinces and regions or target groups and to monitor the impact of prevention programs and policies over time. Key terms A motor vehicle traffic crash is any crash on a public road involving at least one moving motorized vehicle. A crash is assumed to have occurred on a public road unless another place is specified, except in the case of crashes involving only off-road motor vehicles (WHO, 1992). This definition excludes all cases where there is no motor vehicle involvement, including pedal cycle only crashes, collisions between pedal cyclists and pedestrians, etc. (Cryer, 2004). Police collision reports use the following definitions:  Fatal collisions include all reportable motor vehicle crashes which resulted in at least one fatality, where death occurred within 30 days of collision, except in Quebec (eight days).  Personal injury collisions include all reportable motor vehicle crashes which resulted in at least one injury but not death within the timeframes set out above in "fatal collisions".  Fatalities include all those who died as a result of involvement in a reportable traffic collision within 30 days of its occurrence, except in Quebec (eight days).  Serious injuries include persons admitted to hospital for treatment or observation.  Total injuries include minimal, minor, moderate, serious and unspecified severities. How is it calculated? Numerator: Number of motor vehicle crashes (stratified by age, sex, road user type – driver/passenger/pedestrian/cyclist) Denominator: Population (for crash rates), collisions, road user type (for proportions) Method of calculation: Crash rates = (Number of motor vehicle crashes divided Canadian Injury Indicators Development Team: Children and Youth 31 INDICATORS IN ACTION: Child pedestrians learn not to ‘monkey around’ Every week in Canada, an average of 80 child pedestrians are involved in collisions with a motor vehicle while playing outside or walking to school, to a friend’s house or to a neighbourhood store. At least one of them will die and 10 will have major injuries (Safe Kids Canada). That’s why the Simcoe Muskoka District Health Unit in central Ontario has teamed up with local schools to teach young children how to walk, bike and play safely. The storybook There’s A Monkey On My Street is part of a safety campaign targeting three to six-year-old children. The book features a girl named Hannah, her older brother Jack and her new friend Little Monkey as they explore walking, biking and playing safely. The book is coupled with songs by Muskoka-born performer Mary Lambert, who has written music to complement the messages about safe walking, biking, rollerblading and skateboarding. Continued on following page by population of relevant age group) x 100,000 Proportions (fatal/nonfatal, road user affected) = e.g. fatal collisions/total collisions x 100 or road user of interest/total road users x 100 What data is needed?  Type of injury data for each collision – age, sex, province, rural/urban, road user type, injury severity as defined above  Population data Where can it be found? Transport Canada Traffic Accident Information Database (TRAID) has quality data available; however, unlike crashes involving injuries and/or fatalities, crashes without injuries and fatalities tend to be underreported in police data. Serious injuries are published in TRAID for the first time due to non-reporting in British Columbia prior to 2004. Serious injuries for British Columbia are estimated from 1985 to 2003 and for January, February and March 2004. Limitations Related to accuracy and completeness of reporting by drivers/passengers, police, jurisdictions. The Transport Canada Traffic Accident Information Database (TRAID) is generated from provincial and territorial aggregations of police-reported crashes and compiled by Transport Canada in a standardized format. 32 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 These lessons are especially important for children ages four and under because they don’t understand the risks associated with motor vehicles and because their small size makes them less visible to drivers. However, those aged five to nine also face unique risks. At that age, children often want to cross streets on their own to show their independence; yet, they are still endangered due to immature judgment and perceptual skills. “Research shows that by the ages of three to six, children can begin to learn the skills needed to choose the risks that they can manage safely and those risks they should avoid,” says Cindy Baker-Barill, a public health nurse with the health unit’s violence and injury prevention program. “By bringing these tools into our schools, we hope to begin to teach young children how to take an active role in their own safety by giving them the skills they need to avoid risk.” The book went home with every kindergarten student in Simcoe and Muskoka, as well as to libraries and daycares. The book is also available online in English and French at the health unit’s website: http://www.simcoemuskokahealth.org. Canadian Injury Indicators Development Team: Children and Youth 33 MOTOR VEHICLE INJURY Intersections are the Risk Factor Injuries in intersection crashes are the Outcome INDICATOR #10: INTERSECTION CRASH RATE The number and proportion of road users, aged 19 and under, seriously injured or killed in intersection-related crashes. Why is it important? Signalized and un-signalized intersections constitute only a small part of the overall highway system, yet intersection-related crashes constitute a significant proportion of serious injury and fatal crashes. How should it be used? A standardized measure of intersection-related motor vehicle injuries can be used to compare provinces, regions and target groups and can be used to monitor response to prevention programs and policies. Key terms Serious Injuries include persons admitted to hospital for treatment or observation. Intersections include public roads only, with and without signals. How is it calculated? Numerator: Drivers and occupants (0-19 years of age) involved in intersection-related crashes resulting in serious injuries or death. Denominator: Total number of serious injuries (0-19 years of age). Method of calculation: Intersection-related serious injuries and deaths divided by total serious injuries and deaths What data is needed? For each collision victim: age, sex, road user type, severity of injury, whether crash occurred at an intersection Where can it be found?  Police crash data  Transport Canada (TRAID) Quality data are available; however, we need to have an effective statistical mechanism in place to capture underreported and missing intersection-related serious injury crashes. Limitations Accuracy of data due to underreporting and missing data. 34 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 MOTOR VEHICLE INJURY Rural Roadways are the Risk Factor Injuries on rural roadways are the Outcome INDICATOR #11: RURAL ROADWAYS The number and proportion of road users, aged 19 and under, seriously injured or killed on rural roadways. Why is it important? There were 1,539 fatalities on rural roadways in 2003 compared to 936 fatalities on urban roadways. Although this statistic does not break down the number of children and youth who died, it does tell us that motor vehicle crashes on rural roadways have very serious consequences to vehicle occupants. How should it be used? A standardized measure of rural motor vehicle injuries can be used to compare provinces, regions and target groups and can be used to monitor response to prevention programs and policies. Key terms Road users include drivers, passengers, pedestrians, bicyclists, etc. Serious injuries include persons admitted to hospital for treatment or observation. Rural roadways refer to primary or secondary highways, as well as local roads, or a speed limit at the collision site exceeding 80 km/h. How is it calculated? Numerator: Rural road users (0-19 years of age) involved in rural crashes resulting in serious injury or death. Denominator: Total number of serious injuries and deaths (0-19 years of age). Method of calculation: Rural serious injuries and deaths divided by total serious injuries and deaths. What data is needed? For each collision victim: age, sex, road user type, severity of injury, whether crash occurred on a rural road Where can it be found?  Police crash data  Transport Canada (TRAID) Quality data are available; however, we need to have an effective statistical mechanism in place to capture underreported and missing rural serious injury crashes. Limitations Related to accuracy and completeness of reporting by drivers/passengers, police, jurisdictions. Canadian Injury Indicators Development Team: Children and Youth 35 MOTOR VEHICLE INJURY Drunk Driving is the Risk Factor Injuries due to drunk driving are the Outcome INDICATOR #12: DRUNK DRIVING The number and proportion of road users, aged 19 and under, seriously injured or killed in crashes involving drinking drivers. Why is it important? Road Safety Vision 2010 has identified alcohol impaired driving as one of several target areas for reducing the number and severity of road user injuries. In the year 2001, 38% of fatally injured drivers who were tested had been drinking alcohol, and of these almost 85% had blood alcohol levels in excess of the Criminal Code legal limit of 80 mg%. Although alcohol use among drivers killed in collisions is less than what was seen even a decade ago, current levels of impaired driving remain unacceptably high. In 2004, 815 persons were killed in alcohol fatalities in Canada. Recent Canadian traffic fatality crash data estimates show that 38 percent of all traffic deaths occurred due to drinking and driving. How should it be used? A standardized measure of alcohol-related motor vehicle injuries can be used to compare provinces, regions and target groups and can be used to monitor response to prevention programs and policies. Key terms Road users include drivers, passengers, pedestrians, bicyclists, etc. Serious injuries include persons admitted to hospital for treatment or observation. A Drinking driver is defined as having a Blood Alcohol Content (BAC) greater than zero. How is it calculated? Numerator: Number of road users (0-19 years of age) seriously injured or killed in crash with +BAC driver. Denominator: Total number of serious injuries (0-19 years of age). Method of calculation: Number of road users seriously injured or killed in crash with +BAC driver divided by all serious injuries What data is needed?  For each collision victim: age, sex, road user type, severity of injury, whether driver of one of the vehicles involved had a BAC>0  Total number of serious injuries or deaths (0-19 years of age) Where can it be found?  Transport Canada (TRAID) Quality data are available; however, international data sources show that alcohol-related crashes fail to determine the involvement of alcohol in a majority of cases, and researchers often rely on proxy measures of alcohol involvement. An approach 36 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 is to consider ways in which “surrogate” or “proxy” measures of alcohol-related motor vehicle crashes can be created from existing official statistics. Much of the previous international research has found a strong relationship between alcohol and single vehicle nighttime crashes. Measures of single vehicle nighttime crashes have become the surrogate of choice for indexing alcohol involvement in traffic crashes. In general, single vehicle crashes are fully reported and are not subject to problems of police officers’ discretion in reporting. Furthermore, this measure has been shown to include not only drunken drivers but is also sensitive to changes in alcohol use and availability where it has been used in studies of minimum age for alcohol purchase as well as changes in patterns of alcohol sales. Coroner’s Data would be a very useful data source for this indicator. Limitations Related to accuracy and completeness of reporting by drivers/passengers, police, jurisdictions. For more information on Road Safety Vision 2010 and its aims and activities, visit the CCMTA website at http://www.ccmta.ca. Road Safety Vision 2010 is a national effort by the Canadian Council of Motor Transport Administrators (CCMTA) at making Canada’s roads the safest in the world, providing benchmarks for developing strategies and measuring intervention efforts. INDICATORS IN ACTION: High school teens attend a P.A.R.T.Y. to remember For Canadian teens, injury is the leading cause of death and disability; yet, most of these injuries are both predictable and preventable. That’s the message behind the P.A.R.T.Y. program. The acronym stands for Preventing Alcohol and Risk-Related Trauma in Youth and the program was developed over 20 years ago by staff at Toronto’s Sunnybrook Health Sciences Centre. Its goal is to provide young people with information about trauma that will enable them to recognize potential injury-producing situations, make prevention-oriented choices and adopt behaviour to minimize risk. To drive the message home, students spend the day in-hospital, following the course of an injury from occurrence through transport, treatment and rehabilitation. Continued on following page Canadian Injury Indicators Development Team: Children and Youth 37 The program is now staged in more than 80 sites across Canada, Australia and the U.S. and for communities who lack the resources for a traditional P.A.R.T.Y. presentation a new outreach opportunity is also available. In spring 2005, CBC TV’s Street Cents developed an award-winning DVD version of the P.A.R.T.Y. program. The program takes students on a realistic, graphic journey from the scene of a mock car crash through emergency and intensive care and into rehabilitation. The DVD is coupled with interactive exercises and testimonials from people affected by injury. “I seriously thought I was untouchable. I was a big daredevil,” says the testimonial from one young man whose injury left him paralyzed. “But it came back to bite me in the end.” The DVD P.A.R.T.Y. program was piloted in Atlantic Canada in November 2005 and has expanded to include many schools in New Brunswick and Nova Scotia. “It’s important for youth to understand that there are few true accidents,” says Atlantic Health Science Coordinator Ann Hogan who helped bring the P.A.R.T.Y. DVD program to NB. “If we can change behaviour now, hopefully we won’t see these kids in our emergency department later.” FROM LEFT, AN INJURY SURVIVOR AND THREE NURSING STUDENTS DELIVER THE P.A.R.T.Y. PROGRAM TO GRADE 9 STUDENTS IN SAINT JOHN, NB. THE MANNEQUIN IS USED TO DEMONSTRATE EMERGENCY DEPARTMENT TRAUMA EQUIPMENT SO STUDENTS SEE FIRST-HAND WHAT INJURY TREATMENT INVOLVES. 38 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 MOTOR VEHICLE INJURY Speed is the Risk Factor Injuries due to speed are the Outcome INDICATOR #13: SPEED The number and proportion of road users, aged 19 and under, seriously injured or killed in crashes exceeding speed limits. Why is it important? Excessive speed or inappropriate speed for the driving conditions was cited as a contributing factor for more than 20% of all traffic fatalities during 2004. Among drivers killed in single-vehicle crashes, speed was cited for 30% of 16- to 24-year-old victims (Transport Canada, 2005). How should it be used? A standardized measure of speed-related motor vehicle injuries can be used to compare provinces, regions and target groups and can be used to monitor response to prevention programs and policies. Key terms Road users include drivers, passengers, pedestrians, bicyclists, etc. Serious injuries include persons admitted to hospital for treatment or observation. How is it calculated? Numerator: Drivers and occupants (0-19 years of age) involved in speed-related crashes resulting in serious injuries or deaths. Denominator: Total number of serious injuries (0-19 years of age). Method of calculation: Speed-related serious injuries divided by total serious injuries What data is needed?  For each collision victim: age, sex, road user type, severity of injury, whether crash involved exceeding speed limit.  Total number of serious injuries or deaths (0-19 years of age) Where can it be found?  Police crash data  Transport Canada (TRAID) Quality data are available; however, we need to have an effective statistical mechanism in place to capture underreported and missing speed-related serious injury crashes. Limitations Related to accuracy and completeness of reporting by drivers/passengers, police, jurisdictions. The true speed of crashes is difficult to determine in police report databases. Police reports state that the cause of crash was speed unsuited for traffic conditions. In addition, the extent of enforcement may vary across provinces and may provide biased data. Canadian Injury Indicators Development Team: Children and Youth 39 INDICATORS IN ACTION: Pace Car Program tames traffic Each year in Canada, more than 4,000 children are hit by motor vehicles; however, by simply reducing speed, drivers can decrease the severity of injuries experienced and even prevent injuries from occurring at all. Indeed, even small reductions in speed can be significant. Safe Kids Canada reports that for each 1.6 km/hr reduction in average speed, collision frequency is reduced by five per cent! Enter the Pace Car Program – an opportunity for communities concerned about safety, speeding vehicles and unsafe driving to take control of their streets and tame traffic. The program is a grassroots, anti-speeding community-based initiative that aims to help residents take back their streets. Participants sign up and pledge to drive at or below the speed limit. Drivers are then given a yellow bumper sticker for their vehicles that identifies them as a Pace Car driver. The designated drivers be-come ‘mobile speed bumps’ as they drive through their neighbourhood. Drivers also pledge to be more courteous to other drivers, pedestrians and cyclists. The Pace Car Program was invented by David Engwicht in Queensland, Australia, but the program has now been adopted by cities across North America. In Nova Scotia alone, there are now over 2,500 pace car drivers in 20 communities. For more information or to learn how your neighbourhood can become a Pace Car Community, visit http://www.pacecar.ca. 40 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 MOTOR VEHICLE INJURY Young Drivers are the Risk Factor Proportion injured is the Outcome INDICATOR #14: YOUNG DRIVERS The number and proportion of drivers aged 16-19 seriously injured or killed in crashes. Why is it important? Young drivers or riders, aged 16 -19, are consistently overrepresented in victim statistics. They comprise approximately five per cent of the licensed driver/rider population but 10% of fatally injured drivers and about 13% of those that are seriously injured. When comparisons are made on the basis of kilometres traveled, they are seven times more likely to be killed in a crash than the general driving population (Transport Canada, 2005). How should it be used? A standardized measure of young driver-related motor vehicle injuries can be used to compare provinces, regions and target groups and can be used to monitor response to prevention programs and policies. Key terms Serious injuries include persons admitted to hospital for treatment or observation. How is it calculated? Numerator: 16 to 19-year-old drivers with serious injuries/fatalities. Denominator: All motor vehicle occupants with serious injuries (all ages). Method of calculation: Drivers 16-19 years of age with serious injuries/fatalities divided by all motor vehicle occupants with serious injuries/fatalities (0-19 years of age and all ages). What data is needed?  For each collision victim: age, sex, road user type, severity of injury  Total serious injuries/fatalities (0-19 years of age and all ages) Where can it be found?  Police crash data  Transport Canada (TRAID) Quality data are available; however, we need to have an effective statistical mechanism in place to capture underreported and missing young driver-related serious injury crashes. Limitations Related to accuracy and completeness of reporting by drivers/passengers, police, jurisdictions. Canadian Injury Indicators Development Team: Children and Youth 41 MOTOR VEHICLE INJURY Policy INDICATOR #15: GRADUATED DRIVER LICENSING The percentage of provinces and territories with graduated driver licensing program that meet best practice guidelines. Why is it important? Young drivers aged 16 -19 are consistently overrepresented in victim statistics. They comprise approximately five per cent of the licensed driver/rider population but 10% of fatally injured drivers and about 13% of those that are seriously injured. When comparisons are made on the basis of kilometres traveled, they are seven times more likely to be killed in a crash than the general driving population (Transport Canada, 2005). Teens’ elevated crash rates are due to a number of factors including age, lack of practical driving experience, impulsiveness and immature judgment and decision-making (Preusser, 1996; Simpson, 1996). How should it be used? These data could be used to determine the degree of compliance to the graduated driver licensing restrictions in provinces that require them. Using the defined criteria, a scale or score could also be developed to reflect the degree of compliance. Key terms Graduated Driver Licensing (GDL) is a form of driver licensing in which novice drivers gain experience under restricted driving conditions and must meet defined criteria for each stage. Best practice guidelines for GDL have been defined on the basis of current research and include minimum age recommendations, zero alcohol tolerance, passenger and night driving restrictions and other criteria. These vary by province. How is it calculated? Numerator: Provinces will be categorized as follows: 1. GDL with restrictions according to ‘best practice’ guidelines as defined by Traffic Injury Research Foundation (2005) (at least 80% of criteria met) 2. GDL that does not meet ‘best practice’ guidelines (less than 80% criteria met) 3. No GDL Denominator: Number of provinces and territories (13) Method of calculation: (Numerator/denominator) x 100 What data is needed? GDL program components for each province and territory. Where can it be found? Provincial/territorial graduated driver licensing agencies Limitations It is difficult to evaluate every GDL component in each province. GDL policy has 42 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 three major components: 1. lower or zero blood alcohol content; 2. passenger restrictions; and 3. nighttime driving restrictions. These may be different for each province/territory making it difficult to compare. Only one province has handheld cell phone restrictions with MP3 and headphones specifically for GDL drivers (Prince Edward Island). Some provinces prohibit all drivers from using cell phones. Canadian Injury Indicators Development Team: Children and Youth 43 MOTOR VEHICLE INJURY Risk Factor INDICATOR #16: CHILD RESTRAINTS The percentage and proportion of proper use of child restraints and booster seats. Why is it important? Road crashes are the leading cause of death and injury in children in Canada, despite mandatory use of vehicle restraints (Snowdon et al., 2006). The National Occupant Restraint Program (NORP) is an important element of Road Safety Vision 2010 – an ambitious partnership approved by the federal, provincial and territorial ministers responsible for transportation and highway safety to make Canada’s roads the safest in the world. The objective of NORP is to achieve a minimum rate of 95% in seat belt usage and in the proper use of child restraints by all motor vehicle occupants by 2010. How should it be used? A standardized measure of child restraint will allow comparisons across jurisdictions and regions, and will facilitate identification of target groups or Transport Canada stages with the lowest use and/or proper use. These data can also be used to monitor the impact of prevention programs and policies over time. Key terms Proper use is correct selection and use as defined by Transport Canada in Car Time 1-2-3-4 and national child restraint survey design and will be reported by age in years. In Transport Canada’s national child restraint surveys, proper use is determined according to the criteria for each of the restraint types: “An infant carrier is considered to be properly used only if the harness is in use, the vehicle belt is used to restrain the carrier to the vehicle (for infant-only seats) and the carrier is installed facing the rear of the vehicle. A child seat is considered to be properly used only if the harness is in use, the child seat is secured with the vehicle seat belt and tether strap is used. A booster seat is considered to be properly used if the vehicle seat belt is used to secure the seat.” Type of restraint is defined by Transport Canada’s national child restraint surveys as infant carrier, child seat, booster seat and seat belt. Appropriate use for weight and height is defined by Transport Canada in Car Time 1-2-3-4. They recommend following the manufacturer’s instructions for use. The child’s weight and height determine which seat is appropriate. How is it calculated? Numerator: Children properly restrained in the specified age group (appropriate use for weight and height and proper use can be calculated separately or combined). Denominator: Children observed in the specified age group. 44 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Method of calculation: Children properly restrained divided by total number of children observed in that age group. What data is needed?  Age of child observed  Type of restraint used  Proper use (as defined above)  Location (province, rural/urban) Where can it be found? Transport Canada conducts periodic national child restraint surveys. The most recent year of data is for 2006. Limitations The national survey listed above does not capture information specific to First Nations/Inuit populations. Safe Kids Canada’s Kids that Click is another program to help parents and caregivers ensure children are buckled in safely. Learn more at http://www.safekidscanada.ca or view informational videos on Safe Kids Canada’s YouTube channel: http://www.youtube.com/user/SafeKidsCanada. For more information on Car Time 1-2-3-4 visit http://www.tc.gc.ca/roadsafety/safedrivers/childsafety/car/ index.htm. Car Time 1-2-3-4 is a four-stage safety program designed by Transport Canada to help parents understand the child restraint systems needed to safely transport children in a motor vehicle. Stage 1 is a rear-facing infant seat for children less than one year old; Stage 2 is a forward-facing child car seat for children one to four-and-a-half years old; Stage 3 is a booster seat for children four-and-a-half to eight years old; and Stage 4 is an adult belt in the rear seat of the vehicle for children eight to 13 years old. Canadian Injury Indicators Development Team: Children and Youth 45 MOTOR VEHICLE INJURY Non-use of restraints is the Risk Factor Proportion injured is the Outcome INDICATOR #17: UNRESTRAINED INJURIES The number and proportion of seriously injured or killed occupants, ages 19 and under, who were unrestrained Why is it important? Road crashes are the leading cause of death and injury in children in Canada, despite mandatory use of vehicle restraints (Snowdon et al., 2006). Non-use of occupant restraint and child restraint systems are leading causes for fatal and serious injury. How should it be used? A standardized measure of unrestrained motor vehicle injuries can be used to compare provinces, regions and target groups and can be used to monitor response to prevention programs and policies. Key terms Unrestrained is not wearing a seat belt or not using a child restraint or booster seat. Serious injuries include persons admitted to hospital for treatment or observation. How is it calculated? Numerator: Unrestrained drivers and occupants (0-19 years of age) with serious injuries/fatalities. Denominator: Total number of serious injuries/fatalities (0-19 years of age). Method of calculation: Unrestrained serious injuries divided by total serious injuries. What data is needed?  For each collision victim: age, sex, road user type, severity of injury, restraint use  Total number of serious injuries or deaths (0-19 years of age) Where can it be found?  Police crash data  Transport Canada (TRAID) Limitations Due to underreporting and missing data, it is difficult to capture accurate data on unrestrained injuries. 46 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 MOTOR VEHICLE INJURY Policy INDICATOR #18: CHILD RESTRAINT LAWS The percentage of provinces/territories with comprehensive laws requiring use of child restraints and booster seats that meet the ‘best practice’ of restraint laws, currently set by those enacted in Ontario and Québec (2007). Why is it important? Road crashes are the leading cause of death and injury in children in Canada, despite mandatory use of vehicle restraints (Snowdon et al., 2006). The National Occupant Restraint Program (NORP) is an important element of Road Safety Vision 2010 – an ambitious partnership approved by the federal, provincial and territorial ministers responsible for transportation and highway safety to make Canada’s roads the safest in the world. The objective of NORP is to achieve a minimum rate of 95% in seat belt usage and in the proper use of child restraints by all motor vehicle occupants by 2010. Laws requiring restraint use for all children may make an important contribution to this goal. How should it be used? Ideally child restraint laws would be used with the previous two indicators, “Proper Use of Child Restraints” and “Unrestrained Injuries,” to provide a full picture of the need for injury prevention in this area. In addition, this indicator can determine: 1. How many injuries and deaths due to improper use or non-use of child restraints took place in provinces that had a ‘best practice’ child restraint law? 2. How many of those injuries and deaths took place in provinces with a law that contained only some of the elements of the ‘best practice’ law? Key terms Ontario - Bill 73: Child Restraint/Booster Seat: 1980—Infants under 9kg are to travel rear-facing Dec. 6, 2004—Toddlers who weigh 9-18kg (20-40lbs.) are to travel forward-facing Sept. 1, 2005—Children under 8yrs or 18-36kg (40-80lbs.) or stand <145cm (4’, 9”) tall must use a booster seat Québec - Highway Safety Code S.397—Child Restraint/Booster Seat: 2002—Children whose sitting height is <63cm (measured from the seat to the top of the head) must be restrained by a restraint system or booster cushion that complies with the regulations under the Motor Vehicle Safety Act 1993. How is it calculated? Numerator: Province or territory in each category. Denominator: Total number of provinces and territories (13). Method of calculation: (Number of provinces and territories in each category/total number of provinces and territories) x 100 Canadian Injury Indicators Development Team: Children and Youth 47 What data is needed? Detailed information on child restraint laws. Where can it be found? Provincial legislation is available on relevant websites. Limitations Lack of evidence related to effectiveness of laws in improving restraint use and preventing injuries. Many provinces are yet to implement booster seat laws. Provincial legislative requirements for child safety seat laws vary in their regulations for age, weight, height or seating height as well as exemptions. INDICATORS IN ACTION: Boosting child safety in motor vehicles The rate of death and injury in motor vehicles among children under five years old and between the ages of 10 and 14 has been falling since the 1980s, but has remained largely unchanged among children between five and nine years old (Safe Kids Canada, 2004). The issue? Booster seats. Research has shown that booster seats reduce injury to four- to seven-year-old children by 59% compared to seat-belt use alone. Yet, national telephone surveys conducted in 2003 and 2004 on behalf of Safe Kids Canada found that just 28% of Canadian families reported using booster seats for their four- to nine-year-old children. The surveys further revealed that 53% of parents believe children are big enough to use only an adult seat belt by the age of six. To address these serious statistics, Quebec, Ontario and Nova Scotia have led the way, enacting booster seat regulations in 2002, 2005 and 2007 respectively. Booster seat legislation was announced in British Columbia and Newfoundland, effective July 2008. A new law in PEI came into effect Jan. 1, 2008. The latest to jump on board is New Brunswick. “Traffic accident statistics tell us that children are being injured because they are being moved too quickly from booster seats to using seat-belts alone,” said New Brunswick Medical Society President Dr. David Flower. “Seatbelts save lives but they are designed for adults. Booster seats position a child to simulate the height of an adult so that they will get the full benefit of the protection provided by a seat-belt.” NEW BRUNSWICK MEDICAL SOCIETY PRESIDENT DR. DAVID FLOWER, LEFT AND NB PUBLIC SAFETY MINISTER JOHN FORAN, CENTRE, DEMONSTRATE THE PROPER USE OF A BOOSER SEAT. 48 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 SPORT, RECREATION AND LEISURE INJURY INDICATORS SPORT, RECREATION AND LEISURE Policy INDICATOR #19: BICYCLE HELMET LAWS The percentage of provinces/territories with comprehensive laws requiring use of bicycle helmets that meet the ‘best practice’ helmet laws, currently set by the one enacted in Nova Scotia (2007). Why is it important? Helmet laws have been shown to be effective in increasing the use of bicycle helmets and reducing the incidence of bicycle-related head injuries (Macpherson et al., 2000). Helmet laws that require bicyclists of all ages to wear helmets, as well as those using in-line skates, skateboards and scooters, are now considered to be the ‘best practice’ laws. About 50 Canadian children and adolescents die each year from bicycle-related injuries, and 75% of all bicycle-related deaths are due to head injuries. Although the use of helmets can reduce the risk of head injury by 85%, the rate of voluntary helmet use continues to be low (LeBlanc, 2002). How should it be used? Ideally bicycle helmet laws would be further developed to compare the following: 1. How many children and youth are injured or killed due to not wearing a helmet while cycling, in-line skating, skateboarding or scootering? 2. How many of those injuries and deaths took place in provinces that had a ‘best practice’ helmet law? 3. How many of those injuries and deaths took place in provinces with a law that contained only some of the elements of the ‘best practice’ law? 4. How many of those injuries and deaths took place in provinces with no law? Separately, it would also be ideal to determine how many children and youth actually wear their helmets while cycling, in-line skating, skateboarding or scootering; this could be accomplished through a Risk Factor Survey. Key terms ‘Best practice’ means that the following law was adopted based on evidence. Bike Helmet Law: July 1, 1997—Bike helmet use is required for all ages. ($25 fine) May 30, 2002—Anyone using inline skates, scooters and skateboards is required to wear a safety helmet. (minimum $25 fine) How is it calculated? Numerator: Province or territory in each category Denominator: Total number of provinces and territories (13) Canadian Injury Indicators Development Team: Children and Youth 49 Method of calculation: (Number of provinces and territories in each category/total number of provinces and territories) x 100 What data is needed? Detailed information on helmet laws. Where can it be found? Contact Safe Kids Canada at http://www.safekidscanada.ca for the most up-to-date information on current provincial laws and municipal by-laws relating to this policy indicator. Limitations This law does not cover Heelys. At this time there is not enough evidence to include these in a policy indicator. As well, not all sport helmets are regulated, therefore it is possible to use a helmet and still not protect the head properly. Injuries from the use of non-regulated helmets would skew the injury outcome statistics. Heelys are running shoes with wheels embedded in the soles. They convert into an inline skate when weight is shifted to the heel. INDICATORS IN ACTION: Boarders receive incentives to skate safe Injury statistics have yet to catch up to skateboarding’s explosion in popularity, but ThinkFirst Canada estimates that skateboarding accounts for 41.9% of all hospitalizations due to wheeled recreation activities. Head injuries are the #1 cause of serious injury and death to kids on wheels. Because experts agree that wearing a helmet certified for skateboarding and fitted properly can reduce the incidence of brain injuries for skateboarders, the Fundy Skateboard Association (FSA) in Saint John, NB is encouraging skateboarders to protect themselves. The FSA, a not-for-profit organization dedicated to the safety and growth of skateboarding, led the charge to get a skate park built in Saint John, organizing a bunch of skaters to lobby government support. Their vision was realized in October 2008 when the skate park nicknamed Station 1 celebrated its grand opening, providing the area’s growing skateboard population a professionally designed safe facility to practice their sport. Next, on the FSA’s agenda was to encourage skaters to protect themselves from head injuries. All competitions held in the park stipulate mandatory helmet use; moreover, the FSA provides prizes to skateboarders caught with their helmets on. And to ensure cost is no barrier to safe skateboarding, Canadian Tire has donated $5,000 to purchase protective gear which is loaned out free-of-charge to any kids who want to skate in the park. Now that’s using your head! 50 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 SPORT, RECREATION AND LEISURE Outcome Indicator under development INDICATOR #20: COST OF SPORT, RECREATION AND LEISURE INJURIES The annual cost of sport, recreation and leisure injury to children and youth in Canada, including both direct (medical) and indirect (loss of productivity). Why is it important? Estimates of the costs of fatal and nonfatal sport, recreation and leisure injuries to illustrate their impact on the nation's economy and health system. These costs are a measure of the dollars spent and income not received due to sport, recreation and leisure injuries and fatalities. How should it be used? A standardized measure of the cost of sport, recreation and leisure-related injury can be used to compare cost/burden by province, region and/or target group of interest. Cost data can also be used to rationalize and advocate for prevention programming, both general (sport and recreation) and specific (e.g. hockey). Key terms The definitions of cost and method of estimation will be those defined in previous economic burden of injury studies. An incidence costing approach was used, in which the incident population injured in a given year is costed over their lifetimes. Costs were discounted to a present value at a defined percentage per annum. Direct costs are comprised of all the goods and services used for the diagnosis, treatment, continuing care, rehabilitation and terminal care of people experiencing a major illness of impairment (SMARTRISK, 2009). Indirect costs represent the losses due to goods and services that are not produced as a result of the impairment. The value of time lost from work and homemaking due to morbidity, disability and premature mortality is measured by earnings data and the market value of unperformed homemaking services (SMARTRISK, 2009). The economic burden of injuries studies used mortality data, hospitalized injury data, and estimated non-hospitalized injuries and disability using Miller’s Databook on Nonfatal Injury. How is it calculated? To be determined. Please see SMARTRISK Canada’s The Economic Burden of Injury in Canada. (Additional information on this available in Indicator #8) What data is needed?  Deaths  Hospitalizations – cases, average age, average hospital costs per resource group number (RGN) or Resource Intensity Weight (RIW), average Length of Stay in Hospital Canadian Injury Indicators Development Team: Children and Youth 51  Population denominators – age/sex  Stats Canada CANSIM database – employment statistics Where can it be found?  Statistics Canada - Vital Statistics, population data, employment data  CIHI – Hospitalization data Limitations Children and youth who are injured may miss school, stop playing sports or may need to stop playing all together for the duration of the injury or the length of their resulting disability. This estimate of cost used here does not include an estimate of lost leisure time or lost activity time. In addition, the ICD-10-CA coding system does not currently capture all sport, recreation and leisure injuries, therefore many injuries will be missed by this lack of sport-specific data capturing. INDICATORS IN ACTION: STRATFORD GETS SAFE WITH INFORMED PRIORITY-SETTING Even with the best of intentions, injury prevention practitioners sometimes fail to make the biggest impact possible by focusing only on what they think their community’s biggest injury issue is. The Perth District Health Unit in Stratford, Ontario avoided this pitfall through a data-informed priority-setting process. Instead of focusing on injury prevention initiatives based only on their beliefs, they were able to initiate action based on knowledge. The process was nurtured by the Ontario Injury Prevention Resource Centre (OIPRC). Operated by the national non-profit injury prevention organization SMARTRISK, the OIPRC offers injury prevention priority-setting exercises to Ontario health units. Using an approach developed by Dr. Sande Harlos, the Winnipeg Regional Health Authority’s Medical Officer of Health, the OIPRC helps communities use local data to identify injury issues most affecting their populations and plan activities and interventions. The Perth District Health Unit invited OIPRC staff to lead this exercise in their community during a session with a variety of stakeholders, including the health unit’s epidemiologist, program manager and staff members, as well as representatives from police and fire services, minor sport council, city council, seniors’ care, farm safety and citizens. The group considered five injury areas: motor vehicle collisions, drowning, ATVs/snowmobiles and farm safety. Continued on following page 52 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Initially the group believed ATVs were a particular priority; however, as the OIPRC presented data on hospitalizations and emergencies (from the Discharge Abstract Database and National Ambulatory Care Reporting System through CIHI) as well as death (from Vital Stats compiled by the health unit’s epidemiologist), they began to see the community was facing more pressing issues. After examining the data and thinking about available interventions, political will, resources, and stakeholder commitment, the practitioners were able to use qualitative and quantitative data, along with their own experiences, to prioritize the community’s injury issues. They concluded that their top priority should be improving safety for motor vehicles and other road-users and are now working toward the creation of a multipurpose lane that would offer safe access for both bikers and pedestrians – an initiative that addressed the data and would benefit all age groups in the community, including children. Canadian Injury Indicators Development Team: Children and Youth 53 SPORT, RECREATION AND LEISURE Outcome INDICATOR #21: PERCENTAGE OF SPORT SPECIFIC INJURIES (PARTICIPATION RATES) The percentage of children and youth injured in specific sport, recreation, and leisure activities. Why is it important? In order to evaluate the burden of injury to children and youth in Canada, it is important to know how many children/youth get injured in each sport. How should it be used? This is an important indicator at a time when obesity rates are high in Canadian children and youth, and physical activity is being promoted. If it is determined that most sport injuries take place in a specific sport or activity, injury prevention can be targeted at sports with the most risk of injury. For example, if hockey and in-line skating cause a much higher percentage of injury than soccer and basketball, injury prevention will be targeted at children, youth and families who engage in hockey and in-line skating. Key terms Specific sport, recreation and leisure activities include organized activities such as soccer, hockey and basketball and non-organized activities such as street hockey, running, inline skating, etc. How is it calculated? Numerator: Number of children and youth (0-19 years of age) injured in each sport. Denominator: Total number of children and youth (0-19 years of age) participating in sport, recreation, and leisure activities in a specific year. Method of calculation: (Numerator/Denominator) x 100. What data is needed?  Number of children and youth participating in organized and non-organized sport, recreation, and leisure activities.  Number of hospital separations due to injury causes by specific sports for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female and socioeconomic status (if available). Where can it be found?  Provincial sporting associations (e.g. Sport BC)  Separation data are found on Injury Surveillance On-Line and are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Limitations Data is currently unavailable for non-organized sport, recreation and leisure activities. Some data is already collected on physical activity by the Canadian Community Health Survey (CCHS). The survey asks what types of physical activities respondents do during their leisure time and also if respondents walk or bike to school/work. No information is currently collected on injuries. 54 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Another limitation is that ICD-10-CA codes for sport, recreation and leisure injuries are inadequate. As well, many sport injuries are treated in the emergency department but do not require hospital admission. These injuries are currently not captured in any national data set. The Canadian Community Health Survey (CCHS) is a cross-sectional population survey that provides cross-sectional estimates of health determinants, health status and health system utilization for community health regions and special populations across Canada. Canadian Injury Indicators Development Team: Children and Youth 55 SPORT, RECREATION AND LEISURE Policy INDICATOR #22: REQUIREMENTS THAT PLAYGROUNDS MEET CSA STANDARDS The percentage of provinces and territories with a requirement that playgrounds meet CSA standards. Why is it important? Compliance with CSA standards has been shown to prevent playground-related injuries (Howard et al., 2005). How should it be used? Ideally this indicator would be further developed to compare the following: 1. How many children are injured on playgrounds? 2. How many of those injuries took place in provinces that required all playgrounds to meet CSA standards? 3. How many of those injuries and deaths took place in provinces with no requirement for playgrounds to meet CSA standards? Separately, it would also be ideal to determine the rate of compliance to CSA playground standards in provinces that require them. Key terms The Canadian Standards Association (CSA) provides standards related to play spaces for children of different ages. How is it calculated? Numerator: Provinces with requirements for playgrounds to meet CSA standards in one of the following categories: 1. Has a law requiring all playgrounds to meet CSA standards 2. Has a law requiring some playgrounds (e.g., childcare centres) meet CSA standards 3. Does not have a law requiring playgrounds to meet CSA standards. Denominator: Number of provinces and territories (13) Method of calculation: (Numerator/Denominator) x 100 What data is needed? Data on provincial playground standards and applicable laws Where can it be found? Provincial laws related to playgrounds. Limitations Some playgrounds (e.g., private, hotel) may fall outside provincial regulations. 56 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 SPORT, RECREATION AND LEISURE Policy INDICATOR #23: LEGISLATIONS REQUIRING POOL FENCING The percentage of provinces, territories, or municipalities that require four-sided fencing with self-closing gates that meet ‘best practice’, currently the Bill proposed in Ontario Why is it important? Four-sided pool fencing has been shown to be an effective means for prevention of drowning, particularly among young children (Stevenson et al., 2003). How should it be used? Ideally this indicator would be further developed to compare the following: 1. How many children are injured or killed due to drowning in in-ground swimming pools? 2. How many of those injuries and deaths took place in provinces that had ‘best practice’ pool fencing requirements? 3. How many of those injuries and deaths took place in provinces with only some of the elements of the ‘best practice’ requirements? 4. How many of those injuries and deaths took place in provinces with no bill requiring pool fencing? Separately, it would also be ideal to determine the rate of compliance to pool fencing requirements in jurisdictions that require them. Key terms Bill 74: An Act Respecting Safety Around Swimming Pools: Requires owners of in-ground swimming pools to build and maintain a fence around the pool. The fence must be of sufficient construction to ensure that children cannot enter pool area unless through a gate that must be kept locked and/or unless there is an adult in the immediate pool area. How is it calculated? Numerator: Number of Canadian provinces or municipalities in each of the following categories: 1. Requires four-sided fencing with a self-closing gate 2. Requires pool fencing, but not four-sided 3. Does not have a law requiring pool fencing Denominator: Total number of provinces (13) or municipalities (1,400 members of Canadian Federation of Municipalities) Method of calculation: (number in category/total number of municipalities) x 100 What data is needed? Total number of provincial laws or municipal by-laws for pool fencing and the nature of fencing required. Where can it be found? Provincial or municipal by-laws Limitations Data may be difficult to obtain and keep up-to-date. Canadian Injury Indicators Development Team: Children and Youth 57 INDICATORS IN ACTION: Safe Kids Canada fights for safer pool fencing Drowning is the second leading cause of injury-related death to Canadian children, and swimming pools are the site of nearly half of all drowning and near-drowning incidents for children ages 14 and under. Researchers estimate that safer pool fencing could prevent seven out of 10 drowning incidents in home swimming pools for children under age five. That’s why Safe Kids Canada began advocating for safer pool fencing laws in 2008. “In Canada, most municipalities require home pools to be closed off by a three-sided fence, but that is not enough,” says Pamela Fuselli, Safe Kids Canada Executive Director and Canadian Injury Indicators Development Team member. “Children should not be able to get to the pool directly from the house.” Homeowners often put up three sides of fencing and use their house as the fourth side. While this protects outsiders, it puts children in the home at risk. Safer pool fencing works by completely separating the pool from the home with a four-sided fence and self-closing, self-latching gates. Fortunately, progress is being made in improving pool fencing bylaws. Quebec is consulting on Bill 18 to set a minimum standard for pool fencing. The Ontario municipalities of Toronto, Mulmur and Elmira have already improved their pool fencing bylaws and a provincial Ontario bill is also being considered. 58 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 OTHER POLICY INDICATORS POLICY Policy INDICATOR #24: WINDOW GUARD BY-LAW The percentage of Canadian municipalities with window guard by-laws complying (fully or partially) with the ‘best practice’ by-law currently measured against the Toronto Municipal Code Property standards (2007). Why is it important? Window guards are effective at preventing falls from heights, particularly among children living in multi-family dwellings. Compliance with a by-law places the responsibilities on landlords to ensure that children cannot fall from building windows. How should it be used? Ideally this indicator would be further developed to compare the following: 1. How many children and youth are injured or killed due to falls from windows? 2. How many of those injuries and deaths took place in municipalities that had a by-law with all elements of the ‘best practice’ bylaw above? 3. How many of those injuries and deaths took place in municipalities that had a by-law with some of the elements of the ‘best practice’ bylaw above? 4. How many of those injuries and deaths took place in municipalities that had no by-law? Separately, it would also be ideal to measure the rate of compliance to the window-guard by-law by landlords and home-owners. Key terms The Toronto by-law requires: Window Guard By-Law Article 629-21 (E & F) of the Toronto Municipal Code Property Standards: (E) In every multiple-dwelling, every window, any part of which is capable of being opened, that does not lead to a balcony and that is located two metres or more above a finished grade of land upon which it faces, shall be equipped with a safety device to prevent an opening in any part of the window greater than 100 millimetres. (F) All windows in any common area of multiple-dwelling that are greater than two metres above grade and do not lead to a balcony must have a guard that complies with the Ontario Building Code, if the lower sill is less than one metre from the floor. How is it calculated? Numerator: Number of Canadian municipalities in each of the following categories: 1. Has a by-law that includes the elements above 2. Has a by-law that does not include all of the elements 3. Does not have a by-law Canadian Injury Indicators Development Team: Children and Youth 59 Denominator: Total number of Canadian municipalities (1,400 members of Canadian Federation of Municipalities). Method of calculation: (number in category/total number of municipalities) x 100. What data is needed?  Total number municipal by-laws for window guards  Requirements listed in the by-laws  Total number of Canadian municipalities. Where can it be found? Municipal by-laws information found online or by contacting each municipality. Limitations Data may be difficult to obtain and keep up-to-date. 60 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 POLICY Policy INDICATOR #25: PROVINCIAL STANDARDS FOR HOT WATER TAP TEMPERATURE The number of provinces and territories with a provision in the building code that requires the maximum tap water temperature not to exceed 49 degrees Celsius. Why is it important? Hot tap water scalds can be serious and are 100% preventable by lowering the temperature of the water coming out of the tap. Ontario added an amendment to the building code in 2004 to specify that the maximum hot water temperature supplied to fixtures in residential occupancies shall not exceed 49 degrees Celsius. How should it be used? Ideally this indicator would be further developed to compare the following: 1. How many children/youth are injured or killed due to tap water scalds? 2. How many of those injuries and deaths took place in provinces that had a building code specifying the maximum hot water temperature supplied to fixtures in residential occupancies shall not exceed 49 degrees Celsius? 3. How many of those injuries and deaths took place in provinces with no building code? Key terms A building code is a set of rules that specify the minimum acceptable level of safety for constructed objects such as buildings. The main purpose of the building codes is to protect public health, safety and general welfare as they relate to the construction and occupancy of buildings and structures. The building code becomes law of a particular jurisdiction when formally enacted by the appropriate authority. How is it calculated? Numerator: Provinces and territories will fall into one of three categories: 1. Has a requirement that tap water does not exceed 49 degrees Celsius 2. Has a tap water requirement, but exceeds 49 degrees Celsius. 3. Does not have a tap water requirement Denominator: N/A Method of calculation: Addition of the number of provinces and territories in each of the three categories (total of 13). What data is needed? Data on tap water guidelines from provincial building codes. Where can it be found? Data on provincial building code standards will be recorded annually. Contact Safe Kids Canada at http://www.safekidscanada.ca for the most up-to-date information on current provincial laws and municipal by-laws relating to this policy indicator. Limitations Many provinces fall under the national building codes and plumbing codes. If the national codes are changed, this indicator may be unnecessary. Canadian Injury Indicators Development Team: Children and Youth 61 VIOLENCE INDICATORS VIOLENCE Outcome INDICATOR #26: VIOLENT CRIME RATE Violent crime rate is a measure of the number of homicides, sexual assaults, assaults, bodily harms and acts of omission (e.g. abandonment and neglect) perpetrated on children and youth, ages 19 and under, per 100,000 population in a particular year and, where data is available, stratified by sex, age, socioeconomic status and geographic place. Why is it important? Children and youth are overrepresented as victims of police-reported sexual assaults. Although they represent only 21% of the population, six out of every 10 sexual assaults reported to police involved a child or youth. They were also victims of 21% of physical assaults and 17% of other crimes involving violence or the threat of violence reported to police in 2003 (Statistics Canada, 2005). Infants under the age of one year were at highest risk of homicides, according to national data on homicides collected between 1998 and 2003. During this six-year period, the average homicide rate for infants under the age of one was 25 for every million of population. This was about double the second highest rate (14 for every million of population for males aged 14 to 17). During this six-year period, 401 children aged 17 and under were victims of homicide (Statistics Canada, 2005). Police data showed that the youngest victims, those under six years of age, were usually the victims of some form of physical force, such as strangulation or suffocation, beatings or forceful shaking. How should it be used? This indicator allows a comparison of the violent crime rate from year to year, and for making comparisons by age, sex, socioeconomic status and geographic place (where available). If injury and crime prevention strategies are working, declines and differences in the violent crime rates should be observed. Key terms Assault includes both fatal and nonfatal interpersonal violence which is used with the intent of causing harm, injury or death to another. Homicide is death due to injuries inflicted through any means by another person with the intent to injure or kill. It includes sexual assault and acts of omission (e.g. abandonment and neglect) where injury has occurred (Rosenberg, 1991). This definition does not include injuries due to legal intervention and operations of war. Assault hospitalizations are injury hospitalizations with a first external cause code in the range X71-Y08. How is it calculated? Numerator: Number of violent crimes to children and youth (0-19 years of age) in a given year (can be stratified by sex, age, socioeconomic status and geographic place where data is available). 62 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Denominator: Mid-year total population for Canadian children and youth (0-19 years of age), for the same year as the numerator (can be stratified by sex, age, socioeconomic status and geographic place where data is available). Method of calculation: SR = Σ(ri Pi ) /Σ(Pi) where  SR is the age-standardized rate for the population being studied  ri is the age-group specific rate for age group i in the population being studied  Pi is the population of age group i in the standard population What data is needed?  Child and youth rates of victimization of homicides, sexual assaults, assaults, bodily harms and acts of omission (e.g. abandonment or neglect) reported to a subset of police departments  Population of children and youth , by age (<1, 1-4, 5-9, 10-14, 15-19), sex, socioeconomic status and geographic place (if available). Where can it be found? Statistics Canada, Canadian Centre for Justice Statistics, Incident -based Uniform Crime Reporting (UCR2) Survey. The UCR Trend Database contains data from 71 police services that have reported to the Incident-based Uniform Crime Reporting Survey since 1998 and which represent 46% of the national volume of crime in Canada in 2003. Limitations Because national population data and violent crime data are broken down by different age groupings, some data reconciliation is required prior to rate calculations. Crime statistics are often better indicators of prevalence of law enforcement and willingness to report crime than actual prevalence of crime. Canadian Injury Indicators Development Team: Children and Youth 63 VIOLENCE Outcome INDICATOR #27: ABUSIVE HEAD TRAUMA RATE Abusive Head Trauma (AHT) rate is a measure of the number of inflicted head and brain injuries among children four years of age and under per 100,000 population in a particular year. Where data permits, the rate can be stratified by sex, age, socioeconomic status and geographic place. Why is it important? Abusive head trauma (AHT) results from injuries caused by someone vigorously shaking a child (also called shaken baby syndrome or SBS). The outcome for infants with AHT can range from no apparent effects to permanent disabling brain damage, blindness, seizures and/or paralysis and sometimes death. Most children who survive require special services for the duration of their lives. Homicide statistics released by Statistics Canada reported that seven infants were killed by shaking alone in 1999. Social isolation, family violence, substance abuse, poor parental attachment and inadequate knowledge of child development are some of the risk factors associated with child abuse, including AHT. However, AHT may also occur in families with no apparent risk factors (Health Canada, 2001). How should it be used? Abusive head trauma is preventable. Having statistics on the number of children injured in this manner should motivate injury prevention strategies to protect the most vulnerable in our society: children ages four and under. Key terms AHT is an injury resulting from external forces leading to central nervous system deficits, including motor and/or sensory dysfunction, cognitive impairment, emotional difficulties or behavioural problems. Simply expressed, it is damage to the brain or spinal cord. How is it calculated? Numerator: Total number of deaths and hospital separations due to abusive head trauma for children four years of age and under in Canada for a particular year, stratified by sex, age, socioeconomic status and geographic place (where data is available). Denominator: Mid-year total population for Canadian children under four years of age and under (<1; 1-2; 2-3, 3-4, 0-2 and 0-4) for the same year as the numerator, stratified by sex, age, socioeconomic status and geographic place (where data is available). Method of calculation: SR = Σ(ri Pi ) /Σ(Pi) where  SR is the age-standardized rate for the population being studied  ri is the age-group specific rate for age group i in the population being studied  Pi is the population of age group i in the standard population What data is needed?  Number of deaths due to abusive head trauma for children aged <1; 1-2; 2-3, 3-4, 0-2 and 0-4, stratified by sex, age, socioeconomic status and geographic 64 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 place (where data is available).  Number of hospital separations following abusive head trauma for children aged <1; 1-2; 2-3, 3-4, 0-2 and 0-4, stratified by sex, age, socioeconomic status and geographic place (where data is available).  Population of children aged <1; 1-2; 2-3, 3-4, 0-2 and 0-4, stratified by sex, age, socioeconomic status and geographic place (where data is available). Where can it be found? Hospital separation data are found on Injury Surveillance On-Line and are provided by the Canadian Institute for Health Information (CIHI) and analyzed by Health Canada. Hospital separation data are presented for fiscal years (e.g. April 1, 2001 - March 31, 2002). Mortality data is available through Statistics Canada. Limitations This condition may be severely underestimated due to missed diagnosis and underreporting. Currently, specific ICD codes do not exist for AHT. Research currently underway is likely to lead to a small cluster of ICD codes that will provide accurate estimates of the prevalence of AHT among children four years of age and under. Canadian Injury Indicators Development Team: Children and Youth 65 VIOLENCE Policy INDICATOR #28: SUICIDE PREVENTION The percentage of children and youth (6-19 years of age) attending schools where suicide prevention programs are in place. Why is it important? Suicide/self-harm is a leading cause of all injury deaths (3,616) in Canada (SMARTRISK, 2009). Suicide attempts and completions constitute a large number of emergency department visits and injuries to youth. In Canada, suicide accounts for 24% of all deaths among 15-24 year olds and 16% among 16-44 year olds. Seventy-three per cent of hospital admissions for attempted suicide are among people between the ages of 15 and 44. Diminishing the risk of suicide and intentional self-harm is a desirable outcome. It may not be possible to entirely eliminate the risk of suicide, but it is possible to reduce this risk. Suicide should not be viewed solely as a medical or mental health problem, since protective factors such as social support and connectedness appear to play significant roles in the prevention of suicide. How should it be used? This indicator provides a picture of the degree to which society and schools are committed and willing to work to prevent suicide. Ideally, this indicator would be further developed to capture the following: 1. What is the most effective type of suicide prevention program? 2. How many schools have all of the elements of the ‘best practice/most effective’ suicide prevention program? 3. How many schools have some of the elements of the ‘best practice/most effective’ suicide prevention program? 4. Does the number of attempted and completed suicides change with the existence of any suicide prevention policy/program? Do statistics change in the presence of a ‘best practice’ suicide prevention policy/program? Key terms Suicide refers to purposely inflicted self-harm that results in death. Intentional self-harm can also result in nonfatal injury. Suicide prevention programs include strategies to identify and refer suicidal children, adolescents and young adults for care. Some examples of active strategies are general screening programs and targeted screening in the event of a suicide. Passive strategies include training school and community gatekeepers, providing general education about suicide and establishing crisis centres and hotlines. Some passive strategies are designed to lower barriers to self-referral and others seek to increase referrals by persons who recognize suicidal tendencies in someone they know (O’Carroll and Potter, 1994). Programs can also include promoting self-esteem and teaching stress management (e.g., general suicide education and peer support programs); developing support networks for high-risk adolescents and young adults (peer support programs); and 66 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 providing crisis counseling (crisis centres, hotlines, and interventions to minimize contagion in the context of suicide clusters). Restricting access to the means of committing suicide may be critically important in reducing risk, though it may be more difficult to include in a school prevention program (O’Carroll and Potter, 1994). How is it calculated? Numerator: Number of children and youth (6-19 years of age) attending a school with a suicide prevention program. Denominator: Total number of children and youth (6-19 years of age) attending schools. Method of calculation: (Numerator/Denominator) x 100 What data is needed?  Number of children and youth (6-19 years of age) attending schools with a suicide prevention program in place. Where data is available, stratified by sex, age, socioeconomic status and geographic place.  Number of schools with a suicide prevention program and their enrollment statistics  Total number of children and youth attending schools Where can it be found? Calculations by the Canadian Council on Social Development using data from Statistics Canada's Summary of Public School Indicators for the Provinces and Territories, 1996/97 to 2002/03 The Elementary-Secondary Education Statistics Project (ESESP) is a national pilot survey that enables Statistics Canada to provide information on enrollments. School board and provincial data will be required in order to identify the number of schools within their jurisdictions that have a suicide prevention policy/program in place. School board and provincial enrollment data provide the total number of children and youth attending each of these schools. Limitations This indicator suffers from the limitation of all policy indicators related to the semi-quantitative definitions and difficulties of precise assessment of actual implementation/coverage of programs (Carroquino, 2004). An assumption is made here that the existence of suicide prevention policies/programs results in a decrease in the number of self-inflicted violent acts and, therefore, the number of attempted and completed suicides among children and youth. Canadian Injury Indicators Development Team: Children and Youth 67 VIOLENCE Policy INDICATOR #29: ANTI-VIOLENCE/ANTI-BULLYING POLICIES The percentage of students, 19 years of age and under, attending schools whose school boards have adopted an anti-violence/anti-bullying policy. Where data exists, this indicator will also capture the percentage of children in licensed childcare settings with an anti-violence/anti-bullying policy. Why is it important? In 2004, violent injuries accounted for 507 deaths and 8,050 hospitalizations in Canada (SMARTRISK, 2009). District-level policies and programs reflect political will; people develop policy and programs to deal with problems as they understand them. The allocation of resources and effort implied by these policy and program frameworks reflect the concerns and priorities of the leadership and citizens - albeit not all equitably represented - in each daycare and school system community (Bickmore, 2004). How should it be used? This indicator provides a picture of the degree to which society, schools and licensed daycares are committed and willing to work to prevent bullying and violence. Ideally this indicator would be further developed to capture the following: 1. What is the most effective type of anti-violence policy to have (‘best practice’)? 2. How many schools or daycares have all of the elements of the ‘best practice/most effective’ policy? 3. How many schools or daycares have some of the elements of the ‘best practice/most effective’ policy? 4. Does the number of injuries due to violence in schools or childcare centres change with the existence of and compliance with an anti-violence/anti-bullying policy? Key terms Anti-bullying policies define what bullying is, what behaviours are considered to be bullying behaviours, and outline what students and staff will do to prevent bullying. Any licensed childcare or school can be covered by an anti-bullying policy. Anti-violence policies can be adopted by individual licensed childcare and school boards and can emphasize the importance of proactive education over punishment, discourage the use of violent computer games, and encourage activities “that promote peace and understanding among the people of the world”. They also specify what particular behaviors are “not tolerated” and detail the consequences related to the offensive behaviours (Bickmore, 2004). This definition of violence refers to interpersonal violence that may result in injury; property damage is not included in this definition. How is it calculated? Numerator: Number of children and youth (0-19 years of age) attending licensed childcare or schools where an anti-violence/anti-bullying policy is in place. 68 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Denominator: Total number of children and youth (0-19 years of age) attending licensed childcare or schools. Method of calculation: (Numerator/Denominator) x 100 A policy scoring tool for this indicator needs to be developed, validated, and integrated into this calculation. Best practice will be evaluated; schools and childcare centres could then be scored as to whether they meet all or part of the ‘best practice’ requirements. What data is needed?  Number of children and youth (0-19 years of age) attending licensed childcare or schools where an anti-violence/anti-bullying policy is in place. Where data is available, stratified by sex, age, socioeconomic status and geographic place.  Number of licensed childcare or schools with anti-violence/anti-bullying policies and their enrollment statistics  Total number of children and youth attending licensed childcare or schools Where can it be found? Calculations by the Canadian Council on Social Development using data from Statistics Canada's Summary of Public School Indicators for the Provinces and Territories, 1996/97 to 2002/03 The Elementary-Secondary Education Statistics Project (ESESP) is a national pilot survey that enables Statistics Canada to provide information on enrollments. School board and provincial data will be required in order to identify the number of licensed daycares and schools within their jurisdictions that have an anti-bullying/anti-violence policy in place. School board and provincial data provides total number of children and youth enrolled. Ministry program advisers in the Regional Licensing Offices are responsible for inspecting licensed childcare centres. Each province’s Regional Licensing Offices can provide total number of children attending childcare centres with an anti-violence policy in place as well as total number of children enrolled in licensed childcare centres. Limitations This indicator suffers from the limitation of all policy indicators, related to the semi-quantitative definitions and difficulties of precise assessment of actual implementation/coverage of programs. It provides a general measure of the capability to implement policies for reducing child injury: an increase in the percentage should be taken as a broad indication of increased capability (Carroquino, 2004). An assumption is made here that the existence of anti-violence and anti-bullying policies result in a decrease in the number of violent acts and, therefore, the number of injuries to children and youth. Canadian Injury Indicators Development Team: Children and Youth 69 TRAUMA CARE, QUALITY AND OUTCOMES INDICATORS TRAUMA CARE, QUALITY AND OUTCOMES Risk Factor INDICATOR #30: ACCESS TO PEDIATRIC TRAUMA CENTRE (PTC) The proportion of major pediatric trauma cases that are managed in a Pediatric Trauma Centre (PTC) in a timely fashion. Why is it important?  Care of major trauma patients in designated tertiary-level trauma centres is associated with a lower risk of death than when treated in non-trauma centres (Mackenzie 2006).  Some studies have suggested that children treated at a PTC have better outcomes than those treated at adult trauma centres (Potoka 2000 )  Some studies have suggested that children and adolescents undergo fewer “unnecessary” interventions (i.e. invasive monitoring, splenectomy) when treated at a PTC versus an adult trauma centre (Sanchez 2001; Potoka 2000; Davis 2005) How should it be used? This indicator needs to be viewed in the context of having a coordinated trauma system in which, ideally, all children and youth have access any time they experience trauma. This indicator determines what proportion of children and youth get to a trauma system when they need it, as well as what proportion of children and youth do not reach a trauma system. If the proportion is determined geographically, this indicator tells us which geographic areas have better and worse access to a trauma system. Key terms Major Trauma: This will be defined in three different ways: (a) Injury severity score of >12 (this is the score utilized by the National Trauma Registry for “major trauma”) (b) Long bone fracture of the lower extremity in combination with a head injury of any degree (c) Spinal cord injury with neurologic deficit (incomplete or complete cord syndrome) Pediatric Trauma Centre: The designated Level I or Level II PTC within a regional healthcare system/authority (in Canada) which has demonstrated a commitment to the care of major pediatric trauma. Designation may be made by the regional health authority with or without accreditation by the Trauma Association of Canada (TAC). Designation definition will be in accordance with the TAC definitions of Level I and Level II PTCs. Access: Recognizing limitations of travel in Canada in some areas, access indicates admission to tertiary level care within four time frames: one, four, 12 and 24 hours since the injury event. How is it calculated? Numerator: Number of children aged 0-15 years, inclusive, that sustain a major injury as defined above that reach tertiary level care at the regional PTC within one, 70 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 four, 12 and 24 hours of the injury event (if time is available) Denominator: Number of children aged 0-15 years that sustain a major injury by that same definition Method of calculation: Numerator/Denominator (within a defined geographical region over a defined period) x 100 What data is needed? Over a one year period, number of children aged 0-15 years, inclusive, with:  ISS>12 (if able to map from ICD-10 codes) OR  # long bone lower extremity + intracranial injury OR  Spinal cord injury Discharged from a PTC AND Discharged from any health centre (regardless of level of care) Where can it be found? 1. The NTR CDS – collects data on major trauma (ISS>12) including age, ISS scores and injuries sustained by body system, on cases discharged primarily from major trauma centres. 2. The NTR Minimum Data Set (MDS) – collects ICD-10 codes and minimal demographic data on all trauma cases discharged from any health care centre in Canada Recently, a crosswalk to map ICD-10 codes into abbreviated injury severity scores (AIS scores) has been developed. It can potentially be used to identify major trauma cases (ISS>12) from the MDS. Limitations  In some provinces, centres with TC designation of Level III or lower provide data that is entered into their provincial trauma registries, thereby becoming available for collection into the NTR (BC, ON, NS) and therefore can be considered to be almost population-based. In NS, all hospitals receiving any major trauma participate in the provincial trauma registry, rendering data from this province as virtually population-based.  For some provinces (MB, NB, NL) the only participating institution is the one that would be the – or one of the – tertiary care centre(s) for the region/province. For other provinces (AB, ON, QC), the majority of the tertiary care centres in the province participate, including pediatric tertiary care, but there are no district or more regional-level centres. (Participating institutions are show in Appendix A).  The ability to translate ICD-10 codes to AIS codes using a recently developed crosswalk, in order to calculate an ISS for each case in the NTR MDS, is possible; however, its feasibility is limited as the size of the MDS would make this task extremely onerous without a prior method to screen out cases with only minor injuries.  Identification of PTCs from all geographic areas of the country, especially those which have not undergone an accreditation through TAC, will be dependent on use of TAC guidelines/definitions of Level I and II PTCs.  Determining ‘timeliness’ of access to a PTC on a population-basis is currently not possible with the Canadian datasets available as day and time of injury is collected only by the NTR CDS and, therefore, cannot be analyzed on a population-basis. Day of admission to any institution is collected into both the Canadian Injury Indicators Development Team: Children and Youth 71 MDS and the CDS. Admission time (time at which the patient was admitted to the facility) and date and time of decision to admit from ER are available as separate data elements in the CIHI hospitalization database (the latter being mandatory collected data elements only in ON, NB, NS and NF).  For cases admitted first at one or more peripheral institutions prior to transfer to a PTC, each hospital admission is counted as a separate case in the MDS and CDS, making it possible that such cases may be counted twice. This can be teased out using the health care number (HCN) of the patients, but because of confidentiality issues, this must be done at the CIHI level prior to data release. 72 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 TRAUMA CARE, QUALITY AND OUTCOMES Risk Factor INDICATOR #31: APPROPRIATE USE OF PEDIATRIC TRAUMA CENTRE (PTC) The proportion of grade III or greater splenic and liver injuries in children aged 0 to 15 years, inclusive, that are managed in a Level I of Level II PTC. Proportion of these that undergo a splenectomy or liver resection. Why is it important? Although, from an ISS point of view, these in isolation do not meet the definition of major trauma (unless they are grade IV in which case the ISS is, at a minimum, 16), they are injuries with potential acute complications and currently, would be recommended to be observed/managed in a PTC with the availability of critical care and pediatric general surgery expertise. The management of blunt splenic trauma by pediatric general surgeons/in a pediatric tertiary care setting has been found to be associated with a lower splenectomy rate, compared to when they are managed at adult centres, when controlling for other factors, (Potoka, 2000, Davis, 2005). How should it be used? This indicator aims to capture the following:  Are the appropriate injuries going to a Level I or Level II PTC?  Is the management of these cases, controlling for inju ry severity, different in a PTC than at other centres? Key terms Major Splenic and/or Liver Injury Splenic: subcapsular hematoma involving >50% of surface, or intraparenchymal hematoma >5cm, capsular laceration >3cm or involving travecular vessel (grade III), or greater Liver: subcapsular liver hematoma involving greater than 50% of surface, or intraparenchymal hematoma greater than 10cm, capsular laceration >3cm in depth (grade III) or greater How is it calculated? Numerator: Cases with splenic and/or liver injuries (grade III or greater) managed in PTCs or, when age-appropriate, Trauma Treatment Centres (TTC) Denominator: Cases (same definition) managed in the same geographical jurisdiction covered by the PTC Method of calculation: Numerator/Denominator What data is needed?  CIHI Discharge Abstract Database (DAD) data which includes all injuries requiring acute care hospitalization in Canada – essentially the NTR MDS database  Can identify cases with grade III or greater liver and splenic trauma based on ICD-10 codes  Will be able to determine if was direct to the PTC or was a transfer from a Canadian Injury Indicators Development Team: Children and Youth 73 different institution using the “XFER_FROM_INST_ID field name (DAD2003-4.04) Where can it be found? CIHI DAD data (MDS of the NTR) Limitations Because we are only looking at one form of injury, this may not be applicable to other injuries (i.e. orthopedic, neurosurgical, burns). Also, a big factor that will determine if patients are always or never referred to PTCs for specific pediatric injury patterns will be the availability of that specialized pediatric specialist in the PTC combined with the relative non-availability of that specialized form of care in the periphery. This will vary from region to region. Once the data are stratified into geographic regions, the number of cases in some cells (i.e. regions) may be too small to permit reporting, limiting the ability to compare access between regions. 74 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 TRAUMA CARE, QUALITY AND OUTCOMES Policy/Risk Factor Indicator under development INDICATOR #32: QUALITY OF TRAUMA SYSTEM The quality/sophistication of the organization of Trauma Care at all Level I and level II PTCs in Canada. It is desirable to have a mature trauma system that reduces the second peak of mortality (12-48 hours after the injury). Why is it important?  Care of major trauma patients in designated tertiary-level trauma centres is associated with a lower risk of death than when treated in non-trauma centres (Mackenzie, 2006).  Some studies have suggested that children treated at a PTC have better outcomes than those treated at adult trauma centres (Potoka 2000, Vernon, 1999 )  Some studies have suggested that children and adolescents undergo fewer “unnecessary” interventions (i.e. invasive monitoring, splenectomy) when treated at a PTC versus an adult trauma centre (Sanchez, 2001, Potoka, 2000, Davis, 2005)  The movement of trauma care, in general, to become “system-based” recognizes the importance of designating centres with dedication to tertiary-level pediatric trauma care within the “system.” How should it be used? Once developed, this indicator will be used to evaluate the quality/maturity of Canadian trauma systems (by geographic area). If some trauma systems are more sophisticated and result in better outcomes for children and youth, resources can focus on improving the quality of the less sophisticated trauma systems. Key terms PTC trauma system organization quality (a) Protocols in place to identify/triage major pediatric trauma patients from the periphery and establish rapid communication to the nearest Level I or II PTC (b) Defined criteria in place to activate the trauma team (c) Organized trauma team response in place 24 hours a day, 7 days a week (d) Trauma team (TT) activation over and under-triage rates as based on ISS – i.e. Was the TT activated for patient with ISS>12? Was the TT activated for a patient with ISS12? Are recommendations by the ACS met of an undertriage rate of 10% and an overtriage rate of 30%? How is it calculated? Numerator: Number of cases meeting the quality indicator in that centre Denominator: Total number of cases in that centre Method of calculation: Numerator/Denominator What data is needed?  Date/time patient left the emergency department (DAD field name: ER-LEAVING DATE and ER-LEAVING TIME)  Date/time patient admitted to the hospital (DAD field name: ADMISSION Canadian Injury Indicators Development Team: Children and Youth 75 TIME)  All CIHI/NTR MDS cases with ISS>12  All CIHI/NTR MDS cases with major trauma (long bone # plus head injury) Where can it be found? 1. The NTR CDS – collects data on major trauma (ISS>12) including age, ISS scores and injuries sustained by body system, on cases discharged primarily from major trauma centres. 2. The NTR MDS – collects ICD-10 codes and minimal demographic data on all trauma cases discharged from any health care centre in Canada Recently, a crosswalk to map ICD-10 codes into abbreviated injury severity scores (AIS scores) has been developed. It can potentially be used to identify major trauma cases (ISS>12) from the MDS. Limitations  Because major trauma is defined as ISS>12 and we will use the NTR CDS or the regional PTC Quality Indicator databases, we will only look at quality of care of these major trauma patients within a tertiary trauma setting and are unable to look at those at other centres on a national level.  It would be possible to look at all injury admissions if only the ‘time in the ED’ is used as the Quality Indicator. To do so would require using the NTR MDS database and identifying all major trauma with an ISS>12 as calculated using a computerized crosswalk program. This would be very labour-intensive and would only provide one proxy measure of quality.  Day and time of injury is collected only by the NTR CDS and, therefore, cannot be analyzed on a population basis. Day of admission to any institution is collected into both the MDS and CDS. Admission time (time at which the patient was admitted to the facility) and date and time of decision to admit from ER are available as separate data elements in the CIHI hospitalization database (the latter being mandatorily collected only by ON, NB, NS and NF). 76 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 TRAUMA CARE, QUALITY AND OUTCOMES Risk Factor Indicator under development INDICATOR #33: PRE-HOSPITAL TRANSPORT TIME The time from injury to arrival at a trauma centre. Why is it important? Prompt optimization of oxygen delivery to vital organs has been shown to be an important determinant of outcome in traumatic brain injury (TBI) and hemorrhagic shock. In adults with TBI, a single episode of hypotension has been shown to double the mortality rate. In children, hypotensive episodes in the first 24 hours following TBI have been found to be associated with worse neurologic outcomes and longer hospital stays (Kokoska, 1998). Although rapid correction of hypoxia and hypo perfusion in the immediate post-injury period may improve long term outcomes and reduce mortality, interventions such as endotracheal intubations for definitive airway control and fluid resuscitation for the correction of shock are associated with significant complications. Recent Emergency Medical Services studies have provided compelling evidence that sophisticated care (such as endotracheal intubations) provided to patients with traumatic brain injury in the pre-hospital setting may not improve, and may actually worsen outcome, both in urban and rural settings (Davis, 2003, Ehrlich, 2004, Stockinger, 2004, & Cooper, 2001). Even adding general advance life support skills to the armamentarium of paramedics may not improve outcomes (Eckstein, 2000). This may be due, in part, to the infrequent need to apply and therefore maintain these skills in pediatric patients (Richard, 2006). EMS providers have therefore begun to focus on rapid transportation to trauma centres, where life-saving interventions can be applied in closely monitored conditions. Where helicopter transport is available to minimize pre-hospital time, mortality reductions have been demonstrated (Thomas). Despite the critical role of definitive trauma care within the first hour after injury, even in the US, over 40 million people live more than 60 minutes from a level I or II trauma centre (Mackenzie, 2004), and therefore do not have access to the survival benefits of care in an organized trauma system (Nathens, 2004). The most sophisticated EMS systems then would likely be the ones that minimize transport to definitive care, rather than those with more clinical capabilities. Mode of transportation is likely not as important as time to definitive care, which is dependent on numerous pre-hospital and referring clinic and hospital-related factors. How should it be used? Serial measurements of region-specific transport time or velocity can be used as global indicators of the efficacy and sophistication of the pre-hospital system. Where transport times appear high, or velocities low, regions will be able to focus on and address specific contributors to delay. Key terms Time: Hours/minutes Injury time: Time of day (24 hours) at which injury occurs Canadian Injury Indicators Development Team: Children and Youth 77 Time of arrival at definitive care: Time of day (24 hours) of arrival at regional PTC where definitive care of injuries is received Time to definitive care: Time elapsed between injury and arrival to PTC How is it calculated? Time to definitive care (TDC) = Time of arrival to PTC minus time of incident. Mean time to definitive care = Individual times divided by # total transports in this group For regions with geographic variation and long distances, time to definitive care can be adjusted for distance from definitive care: Transport velocity = Distance from point of injury to regional PTC divided by time to definitive care (TDC) These measures will also be provided for specific geographic areas (Dissemination Areas). What data is needed?  Time of injury  Time of arrival to definitive care (trauma centre)  Location of injury/residence  Distance from injury location to trauma centre (calculated) Where can it be found? 1. The NTR CDS – collects data on major trauma (ISS>12) including age, ISS scores and injuries sustained by body system, on cases discharged primarily from major trauma centres. 2. The NTR MDS – collects ICD-10 codes and minimal demographic data on all trauma cases discharged from any health care centre in Canada Recently, a crosswalk to map ICD-10 codes into abbreviated injury severity scores (AIS scores) has been developed. It can potentially be used to identify major trauma cases (ISS>12) from the MDS. Limitations  Day and time of injury is collected only by the NTR CDS and, therefore, cannot be analyzed on a population-basis. Day of admission to any institution is collected into both the MDS and CDS. Admission time (time at which the patient was admitted to the facility) and date and time of decision to admit from ER are available as separate data elements in the CIHI hospitalization database (the latter being mandatory collected data elements only in ON, NB, NS and NF).  For cases first at one or more peripheral institutions, prior to transfer to a PTC, each hospital admission is counted as a separate case in the MDS and CDS, making it possible that such cases could be counted twice. This can be teased out using the health care number (HCN) of the patients, but because of confidentiality issues this must be done at the CIHI level prior to data release. 78 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 TRAUMA CARE, QUALITY AND OUTCOMES Policy/Risk Factor Indicator under development INDICATOR #34: PRESENCE OF A COORDINATED PEDIATRIC TRAUMA SYSTEM The presence of a mature trauma system in each geographic region in Canada. It is desirable to have a mature trauma system that reduces the second peak of mortality (12-48 hours after the injury). Why is it important?  Care of major trauma patients in designated tertiary-level trauma centres is associated with a lower risk of death than when treated in non-trauma centres (Mackenzie, 2006).  Some studies have suggested that children treated at a pediatric trauma centre have better outcomes than those treated at adult trauma centres (Potoka 2000, Vernon, 1999 )  Some studies have suggested that children and adolescents undergo fewer “unnecessary” interventions (i.e. invasive monitoring, splenectomy) when treated at a pediatric trauma centre versus an adult trauma centre (Sanchez, 2001, Potoka, 2000, Davis, 2005)  The movement of trauma care, in general, to become “system-based” recognizes the importance of designating centres with dedication to higher-level pediatric trauma care within the “system”. How should it be used? Once developed, this indicator will be used to evaluate the presence of and quality/maturity of Canadian trauma systems (by geographic area). If some trauma systems are more sophisticated and result in better outcomes for children and youth, resources can focus on improving the quality of the less sophisticated trauma systems. This indicator will also highlight which geographic regions need improved access to trauma systems. Key terms A mature trauma system has the following elements: a) Protocols in place to identify/triage major pediatric trauma patients from the periphery and establish rapid communication to the nearest Pediatric Trauma Centre (PTC), as defined by the Trauma Association of Canada b) Defined criteria in place to activate the trauma team c) Organized trauma team response in place 24 hours a day, seven days a week d) Trauma team (TT) activation over and under-triage rates as based on ISS (see ‘Quality of Trauma System’ indicator) e) Sophisticated pre-hospital transport f) Access to PTC g) Appropriate use of PTC h) Access to rehabilitation following the trauma How is it calculated? A trauma system evaluation template would be developed and applied to current trauma facilities. Canadian geographic regions would be assessed according to whether or not they offered a mature trauma system to their children and youth. Canadian Injury Indicators Development Team: Children and Youth 79 What data is needed?  List of geographic health regions in Canada  List of trauma facilities and the region that each serves  Information for the evaluative template of each trauma system Where can it be found? Each trauma facility listed in Appendix A would provide information for the evaluative template. Limitations Dependent on consistency in responding to the information-gathering survey that will determine the presence of a mature trauma system as identified above (elements (a) to (d) and (g)). Presence of element (f) (Appropriate use of PTC/Regional PTC) is dependent upon successful measurement of Indicators #30 and #31. INDICATORS IN ACTION: Injury treatment no match for injury prevention As a brain surgeon, Dr. Charles Tator has a lot of first-hand experience in brain and spinal cord trauma. “I treated paralyzed youngsters after diving or driving mishaps who never recovered the ability to scratch their noses or feed themselves,” the University of Toronto neurology professor says. “I tried to console the deeply disappointed injured people and their relatives and friends when it became clear that there would be no recovery.” And although injury treatment is one of Dr. Tator’s specialties, he’d be quick to tell you that injury prevention is a superior solution. That’s why he founded ThinkFirst Canada, a national non-profit organization dedicated to the prevention of brain and spinal cord injuries. Key to ThinkFirst’s efforts is research into the epidemiology and prevention of spinal cord injury – work that has revealed the effectiveness of injury prevention programs. Among them is ThinkFirst’s Smart Hockey – a five-segment concussion and spinal injury prevention DVD program in which hockey stars share tips and demonstrate how to avoid causing and sustaining injuries. Randomized control trials indicated that groups who watched the video showed a significant decrease in checking penalties and maintained improved concussion knowledge three months after seeing the program. But hockey is only the tip of the iceberg. Research suggests prevention efforts can end most types of traumatic injuries, says Dr. Tator. “Although we have still not learned how to put the pieces of the lacerated brain or spinal cord together again, we have learned how to prevent the vast majority of catastrophic injuries. Society now has the additional responsibility of ensuring that these injury prevention breakthroughs are available to all. 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Canadian Injury Indicators Development Team: Children and Youth 87 APPENDIX PARTICIPATING FACILITIES AND PROVINCES, NATIONAL TRAUMA REGISTRY COMPREHENSIVE DATA SET TABLE 1: PARTICIPATING FACILITIES AND PROVINCES, NTR CDS 2004-2005 PROVINCE NAME British Columbia Vancouver General Hospital Children’s & Women’s Health Centre of BC Royal Columbian Hospital St. Paul’s Hospital Lions Gate Hospital Victoria General Hospital Prince George Regional Hospital Kelowna General Hospital Royal Inland Hospital Alberta Foothills Medical Centre Royal Alexandra Hospital Alberta Children’s Hospital University of Alberta Hospital (includes Stollery Children’s Hospital) Manitoba Health Sciences Centre Ontario Hamilton Health Sciences Corporation Hospital for Sick Children Hotel Dieu-Grace Hospital Kingston General Hospital London Health Sciences Centre Ottawa Hospital St. Michael’s Hospital St. Joseph’s Health Centre Sunnybrook and Women’s College Health Science Centre Thunder Bay Regional Hospital Children’s Hospital of Eastern Ontario Quebec Hôpital Charles-Lemoyne Hôpital de Montréal pour enfants Hôpital du Sacré-Coeur de Montréal 88 Measuring Injury Matters: Injury Indicators for Children and Youth in Canada – Vol. 2 Hôpital Général de Montréal Hôpital Ste-Justine CHA Pavillon Enfant-Jésus New Brunswick Atlantic Health Sciences Corporation Nova Scotia IWK Health Centre Queen Elizabeth II Health Sciences Centre Aberdeen Hospital Cape Breton Health Care Complex Colchester Regional Hospital Health Services Association of the South Shore St. Martha’s Regional Hospital Valley Regional Hospital Yarmouth Regional Hospital Cumberland Regional Health Care Centre Newfoundland Health Science Centre St. Clare’s Mercy Hospital Dr. Charles A. Janeway Child Health Center In previous years, the number of participating provincial/regional trauma registries and facilities has differed slightly in the NTR CDS. Therefore, trends over time should be interpreted with caution. Table 2 lists participating provincial/regional trauma registries by fiscal year of data. TABLE 2: PARTICIPATING PROVINCES, NTR CDS 1996-1997 THROUGH 2003-2004 PROVINCE NAME 1996-1997 BC, AB, ON, QC, NS, NL 1997-1998 BC, AB, ON, QC, NS, NL 1998-1999 BC, AB, ON, NS, NL 1999-2000 BC, AB, MB, ON, NS 2000-2001 BC, AB, MB, ON, QC, NB, NS 2001-2002 BC, AB, MB, ON, QC, NB, NS 2002-2003 BC, AB, MB, ON, QC, NB, NS 2003-2004 BC, AB, MB, ON, QC, NB, NS, NL 2004-2005 BC, AB, MB, ON, QC, NB, NS, NL Canadian Injury Indicators Development Team: Children and Youth 89
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Children and youth (0-19)
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Injury indicators
Measuring Injury Matters : Injury Indicators for Children and Youth in Canada, Vol. 2
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