58.  Counseling to Prevent Household and Recreational Injuries

RECOMMENDATION

Periodic counseling of the parents of children on measures to reduce the risk of unintentional

household and recreational injuries is recommended. Counseling to prevent household and

recreational injuries is also recommended for adolescents and adults based on the proven efficacy

of risk reduction, although the effectiveness of counseling these patients to prevent injuries has

not been adequately evaluated. Persons with alcohol or drug problems should be identified,

counseled, and monitored (see Chapters 52 and 53). Those who use alcohol or illicit drugs should

be warned against engaging in potentially dangerous activities while intoxicated. Counseling

elderly patients on specific measures to prevent falls is recommended based on fair evidence that

these measures reduce the risk of falls, although the effectiveness of counseling elders to prevent

falls has not been adequately evaluated. More intensive individualized multifactorial intervention

is recommended for high-risk elderly patients in settings where adequate resources to deliver

such services are available. There is insufficient evidence to recommend for or against the use of

external hip protectors to prevent fall injuries. Counseling to prevent motor vehicle and

pedestrian injuries is discussed in Chapter 57.

Burden of Suffering

Unintentional injuries accounted for nearly 89,000 deaths (34.4/100,000 population) in the

U.S. in 1993, making them the fifth leading cause of death.1 Although the age-adjusted

unintentional injury death rate has declined by 28% since 1979,2 such injuries remain the

leading cause of death in all age groups from 1 to 34 years1 and the leading cause of years of

potential life lost before age 65.3 In the U.S. in 1992, injuries accounted for 2.7 million

hospitalizations (10.7/1,000 population),4 34 million emergency department visits,5 and 62

million visits to office-based physicians and hospital outpatient departments (nearly 10% of all

such visits).6,7 The lifetime economic cost for injuries that occurred in the U.S. in 1985,

updated to 1988, has been estimated at $182 billion.8 Almost half of all unintentional

injury-related deaths occur in motor vehicle crashes (see Chapter 57).1 The remainder, about

48,000 each year,1 are household, recreational, and other unintentional injuries. Falls,

poisoning, fires and burns, drowning, suffocation and aspiration, firearms, and bicycling cause

nearly two thirds of these deaths.9 Almost 90% of deaths relating to sports and recreation occur

during swimming, boating, bicycling, riding off-road vehicles such as all-terrain vehicles

(ATVs), or using firearms.9

Each year about 12,000 Americans, primarily older persons, die as a result of falls.9 Falls are

the second leading cause of unintentional injury death in the U.S. (after motor vehicle injuries)

and the leading cause of nonfatal injuries.5,9,10 The death rate due to falls in the general

population is 5.1/100,000 persons, increasing to 10.2/100,000 for those aged 65-74 and to

147.0/100,000 for persons aged 85 and over.10 Population-based studies of

community-dwelling elderly persons have estimated an annual total injurious fall rate of

229/1,000 persons,11 serious fall injury rate of 84-96/1,000,12 and fall injury

hospitalization rate of 13.5/1,000.13 Half of serious fall injury events in elderly persons result

in discharge to a nursing home.12 Hip fractures are an especially grave complication of falls in

older adults, resulting in more hospital admissions than any other injury, and accounting for

254,000 hospital admissions in 1988.9 There is a 10-20% reduction in expected survival in the

first year following a hip fracture,14-17 and roughly half of survivors never recover normal

function.15

Unintentional poisonings, the third leading cause of unintentional injury deaths, account for

5,300 deaths each year, the vast majority of these among adults.9 The mortality rate for

poisonings among children 0-4 years of age was 0.2/100,000 in 1988, a >90% decline from

1960.9 Fires and burns are the fourth leading cause of unintentional injury death in the U.S. Each

year, fires and burns are responsible for at least 5,000 deaths and 1.4 million injuries.9

Residential fires account for 73% of these deaths. The lifetime cost of fire and burn injuries

occurring in 1985 was estimated to be $3.8 billion.8 Nearly 5,000 Americans die each year by

drowning, including 1,000 boating-related drownings.9 Death rates from drowning are highest in

children <5 years old and in young men aged 15-24 years.10,18,19 It has been estimated that for

each childhood drowning fatality, about 4 children are hospitalized and 14 are seen in the

emergency department and released.19 From 1971 to 1988, drowning rates declined

substantially among older children and adolescents, but declined only slightly in toddlers and

actually increased in infants.18 Some 4,700 deaths attributable to mechanical suffocation (e.g.,

strangulation on clothing) and aspiration of food and other foreign materials occur annually, most

of these in infants and in elderly persons.9 Firearm injuries resulted in 1,740 unintentional

deaths (5% of all firearm fatalities) in 1993,1 and cause 12,000 to 30,000 nonfatal injuries

each year.9,20,21 BB guns and other air-powered firearms are estimated to injure an additional

19,500-34,500 people each year.21 Bicycling injuries accounted for about 550,000 emergency

room visits and 1,000 deaths annually between 1984 and 1988, mostly in children and

adolescents.22 The injury rate has been estimated at 187/100,000 and the head injury rate at

51-75/100,000, with peak rates occurring among children aged 5-14 years.22,23 Data

regarding bicyclists involved in traffic crashes suggest declines in both injuries and fatalities in

the last 5 yars.24 Between 1982 and 1988 more than 1,100 fatalities and 400,000 emergency

room-treated injuries related to ATVs were reported to the Consumer Product Safety

Commission.25

Efficacy of Risk Reduction

Certain injury-specific risk factors have been identified for household and recreational injuries.

These are discussed below. In general, injury control strategies based on these risk factors are

derived from evidence of association observed in retrospective studies rather than from

prospective trials demonstrating efficacy. There have been only a few cohort studies or clinical

trials measuring the impact on injury rates of eliminating risk factors for household and

recreational injuries.

Children.  Fires and burns were the second leading cause of unintentional injury-related death

among children aged 0-9 years in 1991.26 Most injuries and 75-90% of deaths from fires occur

in residential fires.27,28 The risk of fatality in the event of a house fire is significantly

increased when children <5 years old are present in the household.29 Smoke detectors are

effective in preventing deaths in residential fires. Death in a residential fire is 2-3 times more

likely in homes without smoke detectors than in those with such devices.29-31 Smoke detectors

often fail to operate, however, due to incorrect installation or inadequate testing.28,32 Correct

installation and periodic testing are necessary to ensure proper operation.

Measures to prevent residential fires from occurring are also important for reducing fire and

burn injuries. Residential fires occur more frequently in the winter, associated with the use of

portable heaters, fireplaces, and Christmas trees.26,29 Some attention has been given to the

hazards of certain stoves and heaters,33 but the effectiveness of clinical intervention to reduce

these hazards has not been evaluated. Cigarette smoking by household members is a leading cause of

residential fires, many of which may be preventable (see Adolescents and Adults, below). A large

proportion of residential fire deaths in children <5 years of age is caused by children playing with

matches and lighters.26 The development of child-resistant cigarette lighters has been proposed

as a preventive measure.34 For children, wearing flame-retardant clothing is effective in

reducing injury from clothing ignition due to, for example, residential fires, cigarettes, matches,

or lighters.10,35,36

Hot tap water burns, which account for 2,600 hospitalizations each year and 24% of all scald

burn hospitalizations in children, are preventable by setting household water heaters at or below

120-130 degrees F.10,37-39 Anti-scald devices can be installed to cut off water flow when the

water temperature exceeds 120 degrees F, although their efficacy in reducing burn rates has not

been evaluated adequately. In one pilot study, 85% of such devices had been removed within 9

months of installation because of sediment build-up, and there were too few outcomes to assess any

impact on scald burn rates.40

The causes of drowning, and thus preventive strategies, depend on the age of the patient. In small

children, 40-90% of drownings (depending on locale) occur in swimming pools, usually located

in the victim's backyard.41-47 In about two thirds of these cases, the children are supervised by

one or both parents at the time of drowning and the adult caretakers are unaware that the toddler

has wandered near the pool or entered the water.42,46,48 Observational studies suggest that 50-

80% of such drownings can be prevented by enclosing swimming pools with 4-foot, four-sided

fences with self-latching, self-closing gates that isolate the pool from the house and yard

("isolation fences") to protect children from wandering into the pool area.42,48-52a Some have

recommended infant and toddler swimming lessons as a means of improving survival after

submersion. The effectiveness of lessons at this age has never been proved convincingly,

however;53 their safety has been questioned on the basis of case reports of water intoxication and

hyponatremia.54 Bathtub-related drowning is an important problem in children <5 years old.55

The majority of infant drownings occur in bathtubs.46,47 These drownings are often associated

with a history of inadequate supervision.46,47,55 Interventions to improve bathing supervision

have not been evaluated, however. Immediate initiation of cardiopulmonary resuscitation (CPR) in

children with submersion injury has been associated with improved outcome,44,48,56,57

suggesting that CPR training for pool owners, parents, and children's caretakers may reduce the

likelihood of drowning or neurologic injury after submersion.

Among children under 15 years, 35-40% of firearm deaths are unintentional.21 Over 90% of

firearm incidents involving children occur at home; a study in children aged 0-14 years found

that 40% involved a firearm stored in the room where the shooting occurred.58 Persons who keep

guns for the purpose of protection are more likely to keep their guns loaded,59 but for each case of

a firearm being successfully used for self-protection (i.e., shooting an intruder), firearms in the

home are estimated to be 1.3-6 times more likely to cause an unintentional fatality and 10 times

more likely to cause an unintentional injury, many of these in children.21,60 The U.S. General

Accounting Office estimated that nearly one third of unintentional firearm deaths might be

prevented by the use of trigger locks and loading indicators.61 These and other potential clinical

preventive strategies to prevent firearm injuries (e.g., removing guns from the home, storing

weapons unloaded and in a locked compartment) would appear to be effective but have not been

studied adequately. Receipt of firearm training (usually covering firearm storage) has been

associated with an increased likelihood of storing guns loaded and unlocked.59 It is unknown

whether this increase was because the training was ineffective, did not teach appropriate storage,

or was received by persons who were inherently less likely to store firearms safely than were

those who did not receive training. The association between firearm availability and violent injury

is discussed in Chapters 50 and 59.

A substantial proportion of childhood poisonings can be prevented by keeping medications in

child-resistant containers. Federal legislation requiring such containers for aspirin,

acetaminophen, prescription drugs, and household chemicals has been associated with a subsequent

decrease in childhood poisoning from these substances.62-64 Poisoning with children's aspirin

has also been reduced by limiting the number of tablets packaged in each bottle.62,65 In contrast,

poison-warning labels designed for children do not appear to be efficacious. Controlled trials have

demonstrated that poison warning stickers (such as the "Mr. Yuk" series) do not deter children

from playing with medication containers66 or reduce the rate of childhood poisoning.67 The use of

aversive bittering agents may reduce ingestion of the substance to which the agent was

added,68,69 but the ability of these agents to reduce the incidence or severity of childhood

poisoning is unproven.70

Bicycling injuries are important causes of morbidity and mortality, particularly among

school-age children.22 Nearly half of all Americans and 80-90% of U.S. children ride

bicycles.71,71a Potential interventions include wearing safety helmets, having bicycle safety

training, and avoiding riding near motor vehicle traffic. Between 50% and 85% of bicycle

fatalities and hospitalizations are the result of head trauma.22,72,73 Cross-sectional studies of

persons involved in bicycling crashes suggest that bicycle helmets reduce head injuries by at least

40%.74-77 Case-control studies estimate that the risk of head injury among bicyclists is

reduced by 63-85% by the use of bicycle helmets.78,79 Control for factors such as estimated

crash severity, motor vehicle involvement, non-head injury severity, rider experience or age, or

other sociodemographic characteristics, did not eliminate the protective effect of bicycle helmets

found in these studies.78,79 In multiple time-series studies, mandatory bicycle helmet use laws

and community-based education programs have been associated with substantial increases in

helmet use and with reductions in bicycle-related fatalities, head-injuries, and

hospitalizations.80-84 These studies provide strong support for the routine use of helmets while

bicycling.

An additional potential intervention to prevent bicycling injuries, bicycle safety training, is

suggested by surveys showing that many bicycle crashes among children result from cyclist

error.79,85-87 One small controlled trial in children aged 8-9 years reported a positive

short-term effect of training on bicycling behavior,88 but no controlled studies have evaluated

the effectiveness of formal training in preventing crashes or injury. A recommendation for

counseling bicyclists to avoid riding near motor vehicle traffic is based on evidence that some 95%

of bicycle fatalities occur as a result of a collision with a motor vehicle.72,73 Efforts to separate

bicyclists from motor vehicle traffic, such as designated bicycle lanes and paths, have met with

some success in reducing bicycle crashes,89 although a metaanalysis based on cross-sectional and

before-after studies suggested that bicycle paths may increase the risk to bicyclists at certain

intersections.90

In children under age 5, falls are a common cause of injury, although few of these injuries lead to

death or permanent sequelae.9,91 These injuries often involve falls from stairs or furniture.92

Baby walkers are an important cause of injuries in young children, many of which result from

falls down stairs.93-95 Collapsible gates have been advocated as a means of protecting children

from stairways,92 although the efficacy of stairway gates has not been studied. Children can fall

from windows even when there are screens in place. There is evidence that window guards can

reduce child falls from apartment windows.96

Adolescents and Adults.  Intoxication with alcohol or other drugs and problem drinking are

important risk factors for injuries and injury deaths.9,29,97-104 In addition to its role in

motor vehicle crashes, which has been most thoroughly studied (see Chapter 57), alcohol

intoxication is involved in 40% of all fatal fires and burns and an estimated 25-50% of adolescent

and adult deaths from drowning, boating mishaps, and shootings, and is also associated with

asphyxiation by choking.9,10,47,105-108 Problem drinking by mothers has been associated

with increased risk of serious injury in their children.108a Chronic alcohol abuse is a risk factor

for poorer health outcome when trauma does occur.109 In national surveys, 30% of all

high-school students had had five or more drinks on at least one occasion (i.e., episodic heavy

drinking) during the preceding 30 days,110 and 5% of adults reported regular heavy drinking

(more than five drinks per day more than five times per week).111 The large body of evidence

linking alcohol intoxication to injuries, and the high prevalence of heavy drinking, argues

strongly for screening for problem drinking (see Chapter 52) and for counseling on the safe use of

alcohol as important measures to prevent injuries.

The highest unintentional poisoning mortality rate occurs in young adult men (20-39 years of

age), who account for 40% of unintentional poisoning deaths.112 A large proportion of these

deaths are attributable to overdoses of alcohol, heroin, and cocaine,9,112 at least some of which

may be preventable by identification and treatment of problem drinking and illicit drug abuse (see

Chapters 52 and 53). Intentional self-poisoning is discussed in Chapter 50.

Drownings of adolescents and adults are most common among young males, and occur under

different circumstances from those of toddlers.18,19,47,113 Most such drowning occurs in

lakes, rivers, and ponds in association with water activities, including swimming, diving, boating,

and fishing.47,113,114 The highest rate of fatal recreational boating incidents occurs in

adolescents (8.1/million operator-hours compared to 1.0/million for all ages).115 Intoxication

by alcohol or other drugs is common in both drowning and boating mishaps; about 25-50% of all

victims have a significant blood alcohol level, and as many as 10% have evidence of other drugs

with central nervous system effects.47,113,116,117 In a national survey of adolescents and

adults who participated in aquatic activities, 42% had used alcohol during such activities, with

males aged 16-20 reporting the highest level of alcohol consumption.118 Discouraging swimming

or boating while intoxicated would therefore appear to be appropriate, but there has been little

research on the impact of such a clinical intervention. More than three fourths of boating-related

drownings are associated with nonuse of personal flotation devices,119 but there are few data on

the impact of promoting the use of these devices. Higher rates of fatal recreational boating

incidents have been associated with fewer hours of operator experience, suggesting that supervised

experience and training programs might be beneficial in preventing drowning, but these have not

been evaluated.115 Swimming lessons may also offer some protection against drowning, but this

has never been proved convincingly.

Most unintentional injuries from firearms involve adolescent and young adult males, with the

highest rate of unintentional firearm deaths (3.4/100,000) occurring in males aged 15-

24.1,21 Unintentional firearm death rates are 4 times higher in rural compared with suburban

and urban settings,9 which probably reflects increased gun ownership for hunting and

recreation.120 After the home, where at least 65% of unintentional firearm injuries occur (see

Children, above), the most common location for unintentional firearm injuries is the hunting

site.10 In 1987, 9.2 firearm injuries were reported per 100,000 hunting licenses sold.121

These incidents often involve members of the same hunting party and result from accidental

discharge or unsafe handling of the firearm, and from the victim being out of sight or mistaken for

game.53,123 In a small sample of unintentional self-inflicted hunting fatalities, one third of

victims had positive blood alcohol concentrations.123 National data suggest that one-fourth of

injured hunters are <21 years of age.121 One population-based study found that 40% of shooters

in hunting accidents were less than 20 years of age and fewer than half were supervised by adults;

unsafe hunting practices such as carrying the firearm incorrectly were significantly more

common in shooters who were 8-19 years of age.123 Hunting firearm injuries might be reduced

by adult supervision of child and adolescent hunters and by wearing fluorescent orange clothing

while hunting to increase visibility, but the effectiveness of these measures has not been studied

adequately. Education programs for hunters on the safe use of firearms have had mixed effects on

fatality rates.53

Cigarette smoking is a leading cause of fire and burn injuries and fatalities.29,124,124a

Cigarette smoking causes about 25% of residential fires, usually through unintentional ignition of

bedding or upholstery. Smoke detectors are effective interventions for preventing fire and burn

injuries and deaths in adults as well as children (see Children, above). Many advocate counseling

regarding careless smoking practices and the promotion of self-extinguishing cigarettes, neither

of which has been adequately evaluated. 

Bicycle deaths and head injuries remain an important problem in older adolescents and young

adults, with nearly 400 deaths and more than 150,000 injuries occurring each year among

persons aged 15-39.22 Use of bicycle helmets is an effective preventive intervention (see

Children, above), yet only 7% of older adolescents and 18% of all bicyclists wear bicycle helmets

sometimes or always.110,124b ATV injuries primarily occur in adolescence and young adulthood.

A multivariate analysis based on nationally reported data on ATV injuries suggested that given a

crash resulting in injury, helmet use reduces the risk of death by about 42%.125 Similar

analyses have reported reduced risks from ATVs with smaller engines and four rather than three

wheels.125,126 In 1987, the marketing and sale of three-wheeled ATVs was banned (although

those already in use were not recalled), changes were made in marketing to reduce sales of

larger-engined machines to children and adolescents, and educational features such as safety

warnings and rebates for safety education were introduced.127 These interventions have been

associated with a decline in injury rates (but not fatalities).127

Elderly Adults.  Falls are the leading cause of nonfatal injuries and unintentional injury deaths in

older persons in the U.S.9,10 Physiological changes with age and environmental agents are the

principal risk factors for falls in older persons. Among the physiological factors that have been

associated with falls are postural instability, gait disturbances, diminished muscle strength and

proprioception, poor vision, cognitive impairment, number of medications, and the use of

psychoactive and antihypertensive drugs.11,128-136 Frail elderly persons, who have multiple

physiologic deficiencies, are at significantly increased risk for falls compared with vigorous older

persons.137 Environmental risk factors identified retrospectively by fallers as contributory

include stairs, pavement irregularities, slippery surfaces (including loose rugs), inadequate

lighting, unexpected objects, low chairs, and incorrect footwear.128,129,138-140 Controlled

studies have not consistently reported significant associations between falls and environmental

hazards when adjustments are made for other risk factors;128-130,137 several studies suggest

that risk from home hazards may vary with underlying functional status.137,141 Among the risk

factors associated with injury after a fall are osteoporosis (see Chapter 46), syncope, impaired

cognitive function, use of diuretics or vasodilators, and falling on hard surfaces such as

concrete.129,134,142 These physiological and environmental risk factors for falls and fall

injuries serve as the basis for potential preventive interventions: exercise programs to enhance

strength, balance and mobility; external protection against falls on hard surfaces; monitoring and

adjustment of medications; correction of environmental hazards; and measures to increase bone

density (see Chapters 46 and 68). Several trials have evaluated the ability of various measures to

reduce falls or risk factors for falls. The efficacy of these measures in preventing fall injuries and

consequent deterioration in ambulatory funtion has not been fully evaluated.

Randomized controlled trials of exercise programs for elderly persons have generally shown

improved strength and mobility; effects on balance have been less consistent.143-148 Two

controlled trials of exercise programs for elderly ambulatory or institutionalized persons found

no reduction in falls (although this was not a primary outcome in the latter study).143,144 These

exercise programs may have been inadequate, however, since neither study reported significantly

improved strength or balance as a result of the intervention. A preplanned meta-analysis of

individual data from seven randomized controlled trials concluded that interventions that included

an exercise component reduced the adjusted risk of falling by 10% in elderly subjects.149 Of the

exercise components studied (resistance, balance, endurance, flexibility), only balance training

had a significant individual effect on risk of falls. The types and modes of exercise were not

standardized across trials, however. Since fall assessment was based on self-report and patients

were not blinded to the intervention, the possibility of biased results exists. The meta-analysis

suggested a slight nonsignificant increase in the risk of injurious falls with exercise; neither the

individual trials nor the meta-analysis had sufficient sample size to assess adequately the effect of

exercise on injurious falls.

Only one study has evaluated external protection against falls on hard surfaces. In a trial

evaluating external hip protectors fixed in special undergarments, the risk of hip fracture was

reduced by 56% among elderly men and women who were resident on nursing home wards that

were randomly assigned to receive the protectors.150 None of the eight intervention subjects who

had a hip fracture wore the protectors at the time of the fracture; compliance with regular

wearing was only 24%. Ward assignment of new arrivals could have been influenced by knowledge

of the ward intervention status, potentially invalidating the randomization. There were no

differences in non-hip fracture rates in the two groups, however, or in the rates of falls or falls

on hips in a subset of intervention and control wards that used a prospective falls register,

supporting the validity of the results.

Several trials have evaluated multifactorial interventions to reduce falls and fall injury rates in

elderly adults, targeted to a variety of physiologic and environmental risk factors. In a randomized

controlled trial in community-dwelling persons aged 70 or older, the intervention group received

medication review and adjustment, behavioral instruction and training, environmental alterations

(e.g., installation of grab bars), and exercise to improve gait, balance, and strength; the

interventions were delivered during multiple home visits by a nurse practitioner and a physical

therapist over a 3-month period.151 Controls received a similar number of structured home

visits from social-work students. At 1-year follow-up, the intervention group had a significantly

longer time to first fall, smaller proportion of subjects who fell (35% vs. 47%), and lower

incidence of falls (0.012 vs. 0.018 falls/person-week), with favorable trends for falls requiring

medical care and falls resulting in serious injury. In multivariate analysis, the risk of falling

declined by 11% for each 1.0 decrease in the number of fall-related risk factors. No adverse

effects from the intervention were reported except self-limited musculoskeletal symptoms in 7%

of subjects. In the institutional setting, multidisciplinary postfall assessment designed to address a

variety of risk factors for falls substantially reduced subsequent falls in a small uncontrolled

experiment.152 A randomized controlled trial of postfall assessment in a nursing home, however,

found little effect on falls.153 The assessment did significantly reduce hospitalizations and

hospital days, suggesting that falls served mainly as a marker for treatable underlying disorders.

Additional trials related to preventing falls and fall injuries in elderly persons are currently

under way.154

Another leading cause of unintentional injury death in persons over 65 years of age is

asphyxiation by choking from foreign materials in the respiratory tract, with 2,500 deaths

annually, including 270 in institutions.9 Poor dentition, use of sedative drugs, dementia, and

reduced motor coordination may contribute to this high rate.9 Interventions such as correcting

denture fit, adjusting medications, dietary changes related to food size and consistency, and

training those who care for elderly persons in use of the Heimlich maneuver and cardiopulmonary

resuscitation may be effective interventions, but data evaluating these or other interventions to

prevent aspiration and asphyxiation are lacking.

Fires and burns are also leading causes of death in older adults.9,155 Compared with younger

hospitalized burn victims, the mortality rate is higher for elderly hospitalized burn patients (0.4

vs. 2.6 deaths/100,000 person-years).156 The risk of fatality in the event of a house fire is

significantly increased when persons over 65 years old are present in the household.29 Older

persons may be at increased risk of dying in residential fires because of impaired vision, hearing,

mobility, or mental status, which can lead to greater difficulty in avoiding burns.29 More than

three fourths of deaths from clothing ignition occur among persons aged 65 and older, which may

be due in part to decreased coordination in handling cigarettes, lighters, etc.9,155 Smoking

materials have been implicated in 10% of severe burn injuries and 33% of residential-fire

deaths among elderly persons.26,156 Scald burns account for 42% of hospitalizations for burn

injuries in persons aged 65 years and older and primarily involve hot tap water, food, and

drinks.156 Interventions similar to those discussed for children and younger adults are likely to

be effective in preventing fire and burn injuries in elderly adults (see above). Efforts to improve

mobility, coordination, and sensory function may also be effective in reducing burn injuries,

although these have not been evaluated.

Effectiveness of Counseling

The most effective measures to control injuries are passive interventions, those that do not rely

on the potential victim to adopt new behaviors voluntarily. Examples of effective passive

interventions include window guards in high-rise apartments, nonflammable sleepwear,

automatic sprinkler systems, and child-resistant packaging to prevent poisoning.157 Since

injury prevention advice from clinicians usually requires active cooperation from patients (e.g.,

changing smoking practices in bed, installing and testing smoke detectors), counseling faces

inherent limitations. It is therefore not surprising that counseling is most effective in

combination with other measures that promote compliance, such as safety regulations.96,158

Children.  Clinical counseling by itself appears to be of some benefit when offered to parents of

young children.159 Only a few studies have evaluated the effects of counseling on injury rates as

well as on knowledge and behavior. A small randomized controlled trial found that parents who

received an individualized course on child safety during well-baby visits demonstrated greater

knowledge about home hazards and had fewer hazards in the home when tested 1 month after the

last visit; there was no difference in the rate of injuries reported by the parents or recorded in

hospital records.160 A nonrandomized controlled trial found that infants of mothers who received

counseling on fall prevention had fewer falls over the course of a year than did those whose

mothers were not counseled.161 In a controlled demonstration project, clinical counseling

resulted in significantly improved knowledge and behavior related to poisoning prevention, but had

no effect on poisoning rates.162 In a well-designed prospective cohort study, the children of

urban, adolescent mothers who reported having received home safety information at 3 months

postpartum were half as likely to have been injured at follow-up about 1 year later.163 There

was a dose-response relationship between the number of home safety information sources and

reduced injury risk; 71% reported receiving their information from health professionals.

Several ecologic studies that included both primary care and community interventions have

reported improvements in safety knowledge and behavior compared to control communities;

significant improvements or favorable trends in injury rates were also reported in the

intervention communities.164-166

A number of other trials have assessed behavioral outcomes related to injury prevention. A

randomized controlled trial found that couples who received information on burn prevention

during well-child care classes were more likely to have their hot water heaters set at 130F or

lower when checked by investigators during a home visit.167 In a nonrandomized trial, parents

who received counseling along with the opportunity to purchase a smoke detector at cost were more

likely to have an operational smoke detector 4-6 weeks later, compared with controls.168 In

another small nonrandomized trial of low-income parents, those who received detailed safety

advice during a home visit by a health worker were found to have corrected significantly more

home hazards compared to controls.169 Education has also been shown to motivate parents to

obtain syrup of ipecac, to display poison control center telephone numbers, and to learn more

about the proper use of ipecac.170-172 Thus, the evidence supports a beneficial effect of

clinician counseling on safety-related knowledge and behavior. It is less clear from direct evidence

whether counseling results in lower injury rates.

Not all studies have found counseling parents to be effective in promoting safety. One randomized

controlled trial found that a program providing mothers with counseling on household hazards, a

safety booklet, and free safety devices was unsuccessful in changing either the knowledge of the

subjects or the number of home hazards detected in an unannounced home visit, although in this

study the counseling was administered by a research assistant rather than a clinician.173 To be

effective, safety counseling may have to be provided by the patient's own clinician, as suggested by

one descriptive study.174 A population-based nonrandomized controlled trial found little effect on

preventive behaviors of a brief nurse counseling intervention, but contamination of the

comparison group may have occurred because the same nurses saw study and control groups in

alternating weeks.175 The limited benefit from parent counseling reported in these studies may

therefore have been due to their methodologic limitations.

Some researchers have attempted to prevent childhood injuries through free distribution of

injury control devices during the clinic visit. When free smoke detectors were made available in

one program, 92% of the recipients installed the devices and 88% of these were found to be

operational 4-9 months later.176 Distributing a liquid-crystal thermometer along with office

counseling increased the likelihood of testing tap water temperature compared to counseling alone,

but both groups were equally likely to report lowering the thermostat.177 In another study, free

distribution of cabinet locks and electrical outlet covers resulted in increased use of outlet covers,

which are easy to apply, but no increase in the installation of cabinet locks, a more inconvenient

task requiring minimal carpentry skills.178 Similarly, providing a free slide-style cabinet lock

and telephone stickers significantly increased their use, while a discount coupon for syrup of

ipecac (which required a visit to a pharmacy to purchase) did not increase the likelihood of having

ipecac on hand.179

Adolescents and Adults.  Evidence on counseling to prevent household and recreational injuries to

adolescents and young or middle-aged adults is quite limited. Two randomized controlled trials

directed to young adolescents and their parents evaluated brief physician counseling addressing

awareness of bicycling injury risk and helmet efficacy and found only a slight, nonsignificant

increase in bicycle helmet purchases.180,181 The counseling intervention was designed

primarily to increase awareness and was probably inadequate to induce behavioral change (see

Chapter iv). A comprehensive review revealed no other studies specifically evaluating household

or recreational injury prevention counseling of adolescents or younger adults in the primary care

setting. Counseling middle-aged men who were heavy drinkers to reduce alcohol consumption

substantially reduced hospital days for accidents and injuries at 2-5-year follow-up of a

randomized controlled trial,182 although it is not clear whether this was due to a reduction in

injury events or in complications once an injury occurred. The effectiveness of identifying and

counseling persons with problem drinking is described in detail in Chapter 52.

Elderly Adults.  A number of trials have evaluated counseling elders to reduce the risk of household

and other unintentional injuries, although none involved counseling within the context of the

routine office visit. A randomized controlled trial enrolling public health clients 65 years

compared the effects of safety education (including falls prevention and fire safety) delivered

during a public health nurse home visit to control (influenza) education delivered in the same

manner.183 At 2-3-month follow-up, there were no differences between the two groups in the

proportion of subjects reporting they had made safety changes in the home (22% vs. 18%) or in

the mean number of safety changes made (0.35 vs. 0.26). Effects on injuries were not assessed.

Three randomized controlled trials have evaluated the effects of counseling interventions on falls

and fall injuries, one involving home visits and two conducted among elderly volunteers belonging

to health maintenance organizations (HMOs). A large trial conducted within a general practice

randomly assigned all households with patients aged 70 years and older to usual care or to receive

a home health visit at least once a year that included risk assessment for falls; counseling on diet,

medications, syncope, and environmental hazards; referrals as needed; and weekly fitness

classes.184 At 4-year follow-up, there were no differences between intervention and control

groups in the proportions who reported falls (28% vs. 20%) or fractures due to falls (5% vs.

4%) during the study period. One HMO trial evaluated the effects of four weekly, 90-minute group

counseling sessions led by a health behaviorist and a physical therapist and focused on exercise and

measures to reduce environmental hazards and behavioral risks, followed by quarterly

maintenance sessions; financial and technical assistance to make safety repairs was also

offered.185 The intervention reduced the odds of falling by 15%, but had little effect on the

probability or number of injury falls or of falls requirng medical treatment. Neither the odds of

falling nor number of falls was significantly related to the number of sessions attended by

intervention subjects, but analysis suggested that those with a higher underlying fall risk were

more likely to attend. The other HMO trial randomly assigned 1559 elderly volunteers to one of

three groups: usual care, a 60-90-minute visit with a nurse to discuss chronic disease

prevention, or a 60-90-minute visit with a nurse/educator who performed fall-related risk

assessment and screening, developed tailored recommendations for preventing falls (e.g.,

medication review, exercise, alcoholism treatment, home safety inspection), and made 1-2

follow-up calls.186 Compared to usual care, the intervention significantly reduced the percentage

of subjects reporting falls and injurious falls, with favorable trends for medically attended and

hospitalized falls, at 1-year follow-up, but differences disappeared by the end of 2 years. It is

unclear how much of the reduction in falls at 1-year follow-up can be attributed to the

intervention: similar reductions were seen in the control nurse visit group, and the intervention

had no effect on the prevalence of any fall-related behaviors except the receipt of a home safety

inspection. Whether the effects of home visits or of fairly intensive interventions in volunteers

who belong to HMOs can be extrapolated to routine clinician counseling in the office setting is

unclear. In all three of the trials assessing fall outcomes, falls were self-reported, possibly

leading to biased reporting of falls due to knowledge of intervention assignment.

Adverse Effects of Injury Prevention Counseling.  Injury prevention counseling has not been

associated with adverse effects in any trials. Concern has been raised that injury control

counseling may be harmful in some patients, such as adolescents.53 Several investigators have

hypothesized that adolescents who favor risk-taking behavior may respond to certain health

information (i.e., drug and sex education) by performing activities that increase risk,187-189

but no direct evidence to support this hypothesis, either for injury or other conditions, was found.

Recommendations of Other Groups

Specific recommendations for office-based counseling on household and recreational injury

prevention have been issued by the American Academy of Pediatrics,190 the American Academy of

Family Physicians,191 the Bright Futures project,192 the American Medical Association

Guidelines for Adolescent Preventive Services (GAPS),193 and the Public Health Service.193a

Clinicians are advised by these groups to provide age-specific injury prevention counseling,

which may include the following: install and maintain smoke detectors in the home, safely store

matches and lighters and avoid smoking near bedding or upholstery; set hot water temperatures to

120-130F; install window and stairway guards/gates and discourage use of infant walkers;

supervise young children in the bathtub and all children when swimming, install isolation fences

around swimming pools, learn CPR, learn how to swim, and avoid alcohol use during water-related

activities; avoid keeping guns or keep guns unloaded and stored in locked cabinets separate from

ammunition; purchase and use bicycle helmets; safely store medicines and household products and

acquire syrup of ipecac; correct home hazards related to falls; and follow other recommendations

on injury prevention. The American College of Obstetricians and Gynecologists recommends injury

prevention counseling on safety helmets, recreational hazards, and firearms for all women.193b

The Centers for Disease Control and Prevention recommends that all persons wear bicycle helmets

whenever and wherever they ride a bicycle.194 The Canadian Task Force on the Periodic Health

Examination recommends counseling parents to recognize home hazards, use smoke detectors and

nonflammable sleepwear, reduce hot water thermostat settings, keep ipecac on hand, and know the

poison control center telephone number, but it found insufficient evidence to recommend parent

counseling to prevent drowning or bicycling injuries.195 The Canadian Task Force found

insufficient evidence to recommend for or against counseling adults (other tan parents) to prevent

household and recreational injuries.

Discussion

There is good evidence from controlled trials that counseling the parents of young children can

increase safety-related behaviors (e.g., lowering hot water temperatures, reducing home hazards,

installing smoke detectors), and fair evidence from multiple observational studies that certain

safety behaviors are associated with reduced childhood injuries. A chain of evidence can thus be

constructed to support a recommendation that parents of children be counseled to prevent

household and recreational injuries, even though the evidence is less strong for a direct effect of

clinician safety counseling on injury rates. There is clearly room for substantial improvement in

the implementation of childhood injury prevention measures: in a national survey of households

with children, only 67% had functional smoke detectors, 50% knew the Poison Control Center

number, 26% had ipecac on hand, and 9% had hot water temperature known to be below 125

degrees F.196 The prevalence of all these measures decreased with decreasing level of education

and income. High cost and limited access to recommended protective devices,197 the need for

technical skills to install certain devices, and living in rental units should be recognized as

important barriers to implementing childhood injury prevention advice that particularly affect

low-income households.

No trials of counseling or other interventions in elderly adults have demonstrated significant

reductions in serious fall injuries, but there is strong observational evidence of the association

between falls and mortality and serious morbidity in the elderly, indicating that interventions that

reduce falls are likely to improve clinical outcomes. A meta-analysis of randomized controlled

trials indicates that exercise (especially balance training) can reduce the risk of falls in elderly

persons by about 10%. An intensive multifactorial intervention that directly addressed

physiologic and environmental risk factors during regular home visits also reduced the likelihood

of falling in high-risk community-dwelling elders, although substantial resources were required

that may not be available in all settings. Whether clinician advice to exercise or to address fall

risk factors will reduce falls or fall injuries is less clear. Weekly group counseling sessions or

detailed individualized counseling by health workers trained to address physiological, behavioral,

and environmental risk factors leads to modest short-term reductions in fall risk. These

interventions may not be generalizable to brief advice delivered in the office setting, however, and

direct evidence of a reduction in fall injuries with counseling is lacking. Periodic counseling of

elderly persons to exercise and to address environmental and behavioral risk factors for falls is

thus supported by fair evidence that these measures will reduce falls and thereby reduce

fall-related injuries, although the effectiveness of counseling patients to exercise and to address

these risk factors has not been established. There is fair evidence to 

recommend an intensive multifactorial fall prevention intervention for community-dwelling

elders at high risk for falls, in settings where adequate resources to deliver this intervention are

available.

In institutionalized elderly persons, there is evidence from one trial that the use of external hip

protectors reduces hip fracture rates. Confirmation of these results is needed, but the large

potential benefit and lack of adverse effects support their use. At present, such protectors are not

widely available nor have these devices been approved by the Food and Drug Administration.

Compliance with wearing the protectors was poor in institutionalized elderly. Whether

community-dwelling elders would comply with wearing similar protectors is questionable;

further research to address compliance is therefore necessary. Postfall assessment and

multifactorial intervention for institutionalized elderly does not appear to reduce falls, but can be

recommended on the basis of other significant health benefits unrelated to injuries.

Although there are few injury control measures for adolescents and younger adults for which there

is conclusive evidence of efficacy, and the effectiveness of injury control counseling of adults is

largely unstudied, counseling by physicians on these matters may be justified because of the

enormous burden of suffering associated with injuries. Thus, even minor reductions in their

incidence can have large public health benefits. The cost of physician time to deliver injury

prevention counseling may be kept to a minimum by conducting counseling during clinical

encounters and focusing attention on specific injuries for which the patient is at greatest risk and

on preventive strategies for which the strongest evidence of efficacy is available. For adolescents

and adults, intoxication by alcohol and other drugs appears to be most strongly associated with the

risk of unintentional injury or death, and there is fair evidence that counseling for problem

drinking is effective (see Chapter 52). Additional measures likely to prevent household and

recreational injuries to adolescents and adults include smoking cessation (see Chapter 54),

proper installation and testing of smoke detectors, and wearing bicycle and ATV safety helmets.

The solutions to many injury problems may require intervention both at the individual level (i.e.,

in the clinical setting) and at the community, state or national level. There are numerous

examples of public health education programs and legislation that have proved effective in

promoting safe behavior and preventing injuries.36,39,64,80,81,84,96,198,199 Measures

likely to be even more effective in preventing injuries involve re-engineering the household

environment or products (e.g., residential sprinkler systems, hot water heaters preset to 125

degrees at the factory32,34), because these measures do not depend on voluntary behavior

changes. Such re-engineering can also be achieved through legislation. In many communities,

physicians and other health professionals have provided leadership for effective community

programs and legislation to reduce injury morbidity and mortality.39,64,200,201 Clinicians

may wish to consider playing an advocacy role as a means of preventing household and recreational

injuries, while continuing to support behavior change with clinical interventions.

CLINICAL INTERVENTION

Counseling the parents of children on measures to reduce the risk of unintentional injuries from

residential fires and hot tap water, drowning, poisoning, bicycling, firearms, and falls is

recommended ("B" recommendation). Persons with alcohol or drug problems should be identified,

counseled, and monitored, and referred for treatment as appropriate (see Chapters 52 and 53);

all adolescents and adults who use alcohol or other drugs should be advised to avoid engaging in

potentially dangerous activities (e.g., swimming, boating, handling of firearms, smoking in bed,

hunting, bicycling) while intoxicated ("B" recommendation). Counseling regarding other

measures to prevent household and recreational injuries is recommended for adolescent and adult

(including elderly) patients based on fair evidence for the efficacy of risk reduction ("B"

recommendation), although the effectiveness of such counseling has not been adequately evaluated

("C" recommendation). The need to prevent household or recreational injuries should be

discussed regularly with patients, although the optimal frequency for such counseling has not been

determined and is left to clinical discretion. Clinicians should remain alert to the possibility of

abuse or neglect as the etiology of certain household and recreational injuries (see Chapter 51).

Illicit drug use, an important risk factor for adolescent and adult poisonings, is discussed in

Chapter 53. See also Chapter 50 (suicide), Chapter 57 (motor vehicle and pedestrian injuries),

and Chapter 59 (violent injuries).

Specific recommendations to prevent injuries to children include the following measures, many of

which are also likely to be effective in preventing injuries to adolescents and adults (including

elderly persons). Homeowners should be advised to install smoke detectors in appropriate

locations and to test the devices periodically to ensure proper operation. Infants and children

should wear flame-resistant nightwear during sleep. Smokers should be advised to cease or reduce

smoking (see Chapter 54). Hot water heaters should be set at 120-130 degrees F. Parents,

grandparents, or other patients with children in the home should be advised to keep a 1-ounce

bottle of syrup of ipecac, to display the telephone number of the local poison control center, and to

place all medications, toxic substances, and matches in child-resistant containers. Bicyclists and

parents of children who ride bicycles should be counseled about the importance of wearing

approved safety helmets194 and avoiding riding in motor vehicle traffic. Children and adolescents

who ride all-terrain vehicles, and their parents, should be advised to use approved safety helmets

and four-wheeled (rather than three-wheeled) machines with smaller engines. Families should be

encouraged to install 4-foot four-sided isolation fences with self-latching, self-closing gates

around swimming pools, and window guards on windows in buildings that pose high risk for falls.

Swimming pool owners and individuals living with or caring for young children or elderly persons

should be encouraged to learn cardiopulmonary resuscitation and maneuvers to manage choking

incidents. Although there is at present only limited evidence to support removing firearms from

the home or keeping them unloaded in a locked compartment for the prevention of unintentional

injuries, this intervention can be recommended based on its efficacy for the prevention of violent

injuries (see Chapters 50 and 59). Additional interventions likely to be effective but for which

there is currently limited evidence of benefitinclude: avoiding smoking near bedding or upholstery

and unsafe handling of smoking materials, installing collapsible gates or other barriers to

stairway entrances, observing safe boating practices and wearing personal flotation devices while

boating, and wearing orange fluorescent clothing while hunting. Poison-warning stickers intended

to deter children from playing with containers of medicine or other poisons (e.g., "Mr. Yuk"

stickers) have been found to be ineffective and are not recommended ("D" recommendation).

Counseling elderly patients on measures to reduce the risk of falling, including exercise

(particularly training to improve balance), safety-related skills and behaviors, and

environmental hazard reduction, along with monitoring and adjusting medications, is recommended

based on fair evidence that these measures reduce the likelihood of falling ("B" recommendation),

although the effectiveness of routinely counseling elders to prevent falls has not been adequately

evaluated ("C" recommendation). Recommendations for regular physical activity in elderly

patients without contraindications can also be made based on other proven benefits (see Chapter

55). Intensive individualized home-based multifactorial intervention to reduce the risk of falls is

recommended for high-risk elderly patients in settings where adequate resources are available to

deliver such services ("B" recommendation). Elderly persons at high risk for falls include those

aged 75 years and older; or aged 70-74 with one or more additional risk factors including: use of

certain psychoactive and cardiac medications (e.g., benzodiazepines, antihypertensives); use of 4

prescription medications; impaired cognition, strength, balance, or gait. There is insufficient

evidence to recommend for or against the routine use of external hip protectors to prevent fall

injuries ("C" recommendation). Once these devices become generally available, recommendations

for their use in institutionalized elderly may be made on other grounds, including the large

potential benefit and limited adverse effects. There is insufficient evidence to recommend for or

against postfall assessment and intervention in institutionalized elderly persons in order to

prevent falls ("C" recommendation), but recommendations for such interventions may be made on

the basis of other benefits, including reduced hospitalizations and hospital days unrelated to falls.

For other recommendations relevant to fall injuries in the elderly, see Chapter 33 (screening for

visual impairment), Chapter 46 (screenig for postmenopausal osteoporosis), Chapter 48

(screening for dementia), Chapter 55 (counseling to promote physical activity), and Chapter 68

(hormone replacement therapy).

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by

Carolyn DiGuiseppi, MD, MPH.

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