Injury Control Update

A PUBLICATION OF THE NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL

Vol.2, No.1 ▲ Winter/Spring 1997

CDC

CENTERS FOR DISEASE CONTROL

AND PREVENTION

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Smoking out barriers

to fire prevention

Sirens screamed and lights flashed

as fire trucks drove through the

streets of a low-income housing area

of Oklahoma City. Despite the

appearance, the trucks were not

rushing to a four-alarm fire. Instead,

they were out to promote fire

prevention. To bolster the effort,

volunteers walked alongside the fire

trucks and handed out free smoke

detectors to area residents.

In all, the Oklahoma City LifeSavers

project gave out 10,100 smoke

detectors to households that needed

them. As important, the program

emphasized maintaining the smoke

detectors to be sure they continued

working over months and years.

LifeSavers was the first program of

its type to use surveillance data to

evaluate its effectiveness, according

to Sue Mallonee, RN, MPH, of the

Injury Prevention Service at the

Oklahoma State Department of

Health. As a result, this NCIPCsponsored program has given concrete evidence of the value of smoke

detector programs. CONTINUED ON PAGE 5

IN THIS

ISSUE

▼

CDC’S DIRECTOR

SHARES VISION OF

SAFE AMERICA .......... 2

▼

UNIQUE PROGRAM

INVOLVES EDS IN

HELPING ABUSE

VICTIMS .................. 12

▼

NEW APPOINTMENTS

AT THE NATIONAL

CENTER ...................... 8

▼

RESOURCES YOU CAN

USE .......................... 14

▼

INJURY JOURNAL

CLUB ......................... 4

▼

CALENDAR ............... 16

Injury prevention enters the

emergency department

The gurney bursts through the

emergency department doors, and

EMS technicians race the bloodied

patient to the exam room, barking

out as they go: “Car crash—chest

wound—deep lacerations to the

head—BP 100 over 60!” Emergency

medicine doctors and nurses rush to

meet the arrival, responding to their

latest crisis with intensity and practiced professionalism.

Just another scene from “ER,” one of

network television’s hit shows,

which draws some 30 million

viewers every week. And just

another scene repeated daily at

hospital emergency departments

(EDs) across the country, where

crisis response is routine.

This frenetic environment, with its

emphasis on immediate treatment

of people in urgent need, may at

first seem an unlikely place for

injury surveillance and prevention

efforts. In fact, the ED is emerging

as an important nexus between

CONTINUED ON PAGE 9
2

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

CDC’s director shares his

vision of Safe America

Dr. David Satcher, MD, PhD, director of

the Centers for Disease Control and

Prevention, supports a comprehensive

approach to injury prevention and control

that is encompassed by the concept of a

safe America. He recently talked with

Injury Control Update editors to help

translate the concept into concrete ideas

and activities.

Q: NCIPC is proposing a new initiative

entitled “Safe America.” What is your vision

of a safe America?

A: I think of an America that has in place

all the systems necessary to keep people

safe. That includes being safe on the

highway; being safe in the home, from

fires, for example; being safe in communities from all kinds of violence, especially

that perpetrated with guns. What are the

systems we need to have in place? Environmental systems, trauma care systems

to reduce the impact of injuries, social

systems that give people hope for the

future, and individual support like training programs for parents.

If public health doesn’t work at the level

of the community, it doesn’t work. It can

be happening at CDC, but it will make no

difference unless it works in the community. Safe America means protecting

people in their homes, schools, communities, in all their interactions.

Q: Part of the Safe America proposal

involves initiating concrete interventions

at the community level. Do we have a

solid enough scientific base to be implementing these interventions?

A: Yes, we know a lot, especially in the area

of unintentional injury. We have good

information on keeping people safe in

automobiles, in homes, on playgrounds,

and at work. We are not adequately

utilizing the knowledge we have.

But even though we know a lot, we still

need to know more. The public health

approach is a continual process, a cycle.

Public health proceeds from surveillance.

We first ask questions in an attempt to

define the nature and magnitude of the

problem. We have been working hard to

implement surveillance for injury. Next

we try to identify risk factors—why some

people are more likely than others to be

victims of fires, suicide, homicide, and

other kinds of injuries. We go from there

to introduce interventions. We have

recently completed demonstration

projects in youth violence prevention in 15

cities. Once we know the outcomes of the

interventions, we will be able to say that

we know what things work and that we

should implement them more widely.

Then we go back and ask more questions.

Q: You mentioned that we know a lot in

the area of unintentional injuries: can you

mention a few interventions that you

believe really make a difference?

“If public health doesn’t work at the

level of the community, it doesn’t

work.”

— DAVID SATCHER, MD, PHD

DIRECTOR

CENTERS FOR DISEASE CONTROL

AND PREVENTION

▲
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

A: Bicycle helmets, for one. We know

they make a positive difference, but

people still ride bicycles without helmets.

Other obvious interventions that are not

being taken advantage of are automobile

safety seats for children and smoke

detectors. In1995, 26% of U.S. homes

were without functional smoke detectors;

the percentage is higher in some communities. So we know of many interventions

that work, and yet people are not adopting them.

We also know a good deal about what

puts people at risk for intentional injury,

even though some of these issues are

very sensitive politically. For example, we

know a lot about the relationship between guns and suicide and between

guns and homicide. We know that suicides have tripled among teenagers since

1950, and that at least 75% of that increase is associated with firearms. We

know that homicide among teenagers has

tripled since 1980, and that 90% of that

increase is associated with firearms.

We need to get firearms out of the hands

of children.

Q: What about the public’s awareness of

injuries as a serious public health problem?

Is there still a perception that injuries are

“accidents,” that they’re inevitable and

not preventable? What would you say to

people with that perception?

A: I believe many people have not gotten

to the point of thinking of injuries as

public health problems, and they don’t

necessarily see them as preventable. We

still have 200,000 traumatic brain injuries

and 80,000 spinal cord injuries in this

country every year; most of those are

preventable. The role of public health is

not only to define the magnitude of the

problem and to identify who is at risk, but

also to demonstrate that injuries can be

prevented and to show people how to

prevent them. We have found some

interventions that work, and where we’ve

done that, I think we need to communicate it better.

Q: How important are partners in CDC’s

vision of a safe America?

A: Partners are critical. The future of

public health depends on our ability to

develop new partnerships, especially at

the level of the community. The only way

we can get interventions to the people

who need them is to find natural partnerships within communities.

We also have to have partners at the

national level. The Department of Justice

and the National Highway Traffic Safety

Administration are important partnerships. So are the Consumer Product Safety

Commission and the Department of

Housing and Urban Development.

Q: In this era of belt-tightening and budgetcutting, why should injury be a priority?

A: In a time of downsizing and fiscal

constraints, it’s especially important to

make wise investments. I think injury

prevention represents a good investment

of public funds. When we can prevent

human pain and suffering, we’ve made a

good investment. It’s also a good financial

investment. This is a country in which

injuries cost us more than $150 billion a

year in direct and indirect costs. We can

prevent a lot of that cost if we invest in

injury prevention and control. The issue is

where to invest limited resources. I would

say it’s best to invest where you have the

greatest impact in terms of reducing pain

and suffering and in terms of reducing

costs in the health care system and beyond.

“Safe America means protecting

people in their homes, schools,

communitites, in all their

interactions.”

▲
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

Q: Children and older adults seem to be most

affected by injuries.

A: Yes. For example, the most recent

Surgeon General’s report noted that

physical activity can help prevent the

240,000 hip fractures we have in the

country every year by encouraging older

people to exercise and to improve their

strength and flexibility. NCIPC is also

looking at other interventions to reduce

hip fractures and falls among the elderly.

We spend a lot of money on medical care

to treat hip fractures and injuries resulting

from falls; we could save considerably if

we invested more in front-end research to

prevent these injuries from happening.

The elderly are often victims of fires and,

increasingly, of abuse. When we investigated all the deaths related to heat two

summers ago in Chicago, we found that

many elderly people had their windows

nailed shut for security reasons. In addition to the heat and the lack of air conditioning, fans didn’t even help because the

windows were closed.

Q: Do you have any final comments about

Safe America?

A: I’d like to stress the importance of

fostering a global perspective. We’re

dealing with so many issues at CDC that

have global implications. Injury is one of

these. As America becomes safer for

America’s people, it will also become safer

for other people. To the extent that we

teach children how to resolve conflicts in

their communities, they will grow up with

an orientation that helps them resolve

global conflicts. Without a safe America,

the United States cannot play its role in

making the world a safer place to live. ■

Injury Journal

Club

Schnitzer PG, Runyan CW. Injuries to

women in the United States: an overview. Women and Health 1995;23(1):9-27.

The heavy toll that injuries take on young

men is frequently in the news. What may

be less heralded is injury’s impact on

women. In fact, injuries are the leading

causes of death for women under the age

of 34 and are responsible for more years

of potential life lost before the age of 65

than any other cause of death. This article

summarizes gender-specific injury information, drawing on 1984-1988 mortality

statistics from CDC’s National Center for

Health Statistics and information from a

decade of studies. Overall, the most

significant injury problems for women are

motor vehicle-related injuries, falls, and

violence, especially domestic assault.

Malliaris AC, DeBlois JH, Digges, KH.

Light vehicle occupant ejections—a

comprehensive investigation. Accid Anal

and Prev 1996;28:1-14.

Being thrown, or ejected, from a vehicle as

a result of a crash is an infrequent incident

(about 1.5% of all occupant events), but a

very harmful one. This study examined a

range of variables relating to occupant

ejections from “light vehicles”—cars,

pickup trucks, vans, and utility vehicles. A

key finding was that people who used

some type of restraint, primarily safety

belts, had sharply lower rates of injury

than those who did not use safety belts.

However, there is an apparent disparity

between the substantial overall increase in

safety belt use over the past decade and

the absence of any reduction in occupant

ejections. This finding suggests that many

“high-risk” occupants involved in crashes

that lead to ejections are still not wearing

safety belts.
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

In the five years following the study, the

rate of injuries and deaths from fires in the

target area declined 73%. During the same

period, the rate for the rest of the city

increased 30%. A year after the giveaway

program, more than half of the smoke

detectors were still working, and four

years later, 45% were functional. Further,

the study showed that for every $1 spent

on the giveaway program, $20 was saved

in medical costs.

Concentrating on populations at

highest risk

In the rest of the United States, as in

Oklahoma City, the people at greatest risk

for fire-related injury and death are young

children and the elderly, both of whom

may be unable to move quickly if they

need to escape from smoke and flames.

For children under 5 years old, the risk of

dying in a house fire is twice as high as for

the rest of the population. Also, fatal

house fires are all too common in lowincome neighborhoods, where people are

unlikely to have smoke detectors.

A large number of the 12% of American

households without smoke detectors

installed have annual incomes below

$15,000. Yet smoke alarms are inexpensive, simple to install, and cost-effective.

Giveaway programs targeted at high-risk

areas—like the LifeSavers Program in the

inner city of Oklahoma City—should help

get smoke detectors into these homes.

Installing smoke detectors not enough

Programs to give away and install smoke

alarms provide only a partial solution,

however. An observational study by the

Consumer Product Safety Commission

(CPSC) found that 26% of households

with smoke detectors were not adequately

Tellez MG, Mackersie RC, Morabito D, SMOKING (continued) Shagoury C, Heye C. Risks, costs, and the

expected complication of re-injury. Am J

Surg 1995;170:660-4.

Violence tends not to be a one-time event.

Young people treated for violent injuries at a

San Francisco trauma center had a 16% rate

of prior injuries, virtually all of them within

the previous 5 years. The youths were

victims of gunshot wounds, assault, and

stab wounds, with gunshot wounds being

the major cause of injury (44%). The authors

note, “As surgeons, we would consider a

16% recurrence rate unacceptable in common operations and disease entities.”

Trauma registries can complement data

gathered by criminal justice agencies, to

give a fuller picture of how to reduce violence recidivism.

Massagli TL, Michaud LJ, Rivara, FP.

Association between injury indices and

outcome after severe traumatic brain

injury in children. Arch Phys Med Rehabil

1996;77:125-31.

Children who suffer a traumatic brain injury

(TBI) can benefit from a range of rehabilitation services. To identify the most appropriate services and to predict the likely outcomes for these children, health care professionals use various scales to assess the

child’s level of functioning after injury. This

study examined the outcomes of children 5

to 7 years after discharge from the hospital

to learn about any persisting disabilities and

to find out if the assessment instrument

(Glascow Outcome Scale) was accurate in

predicting their recovery. The study found

that it was difficult to measure future

outcomes at the time the children were

discharged from the hospital; almost half of

the children thought to have a good chance

of recovery later had moderate disability and

problems in a number of areas, including

education and jobs. Also, many of the

children in this study were not continuing

to receive important medical, neurological,

or social follow up. ■
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

protected because they did not have a

functional detector on every level. While

11 million U.S. households are without

smoke detectors altogether, an even

greater number—16 million—have nonworking detectors. These alarms have

dead, corroded, or missing batteries, or

they have been disconnected because of

nuisance alarms.

To examine the problem of nonworking

smoke detectors, CPSC initiated a task

force in 1989 that has grown into a publicprivate partnership of 200 organizations,

including manufacturers and safety

organizations. When they completed

deliberations in June 1996, the group

recommended to the Underwriters’

Laboratory Voluntary Standards (ULVS)

ten criteria for improving the reliability of

smoke detectors. One of these is a silencing

button that will allow people to turn off

a smoke alarm for 15 minutes, so they

won’t disable it in frustration when they

are cooking.

By identifying and then publicizing the

problem of nonworking smoke alarms,

the task force challenged industry to

develop solutions. Equipment that meets

safety and performance standards earns

ULVS approval, a certification highly

regarded throughout the industry, and

manufacturers have risen to the challenge.

One recently developed product is the 10-

year lithium battery, a major solution to

the problem of dead batteries and the

need to change them frequently.

James F. Hoebel, Chief Engineer for Fire

Safety at CPSC, credits the success of this

public-private effort to the dedication and

cooperative spirit within the task force.

“All involved parties were working

toward a common goal,” says Mr. Hoebel,

“and all of us thought the work was

worth doing.”

Federal partners fight

fire-related injuries

Fruitful collaboration is the essential

ingredient in another recent fire-injury

prevention effort, says Dr. Christine

Branche, Director of NCIPC’s Division of

Unintentional Injury Prevention.

Several of the federal partners in the

Healthy People 2000 Unintentional Injury

Work Group approach fire-injury prevention from different angles. The National

Fire Protection Association has developed

the Learn Not to BurnTM preschool curriculum to teach young children about fire

safety. The U.S. Fire Administration

(USFA) trains firefighters, makes fire

department personnel available to inspect

homes and install smoke alarms, and

sponsors awareness programs such as

Change Your Clock, Change Your Battery.

Working with USFA, the Indian Health

Service established the National Safe

Home Coalition, which concentrates on

reducing fire-related trauma in Native

American communities. The Administration

on Aging has developed Let’s Retire Fire:

A Fire Safety Program for Older Americans.

The National SAFE KIDS Campaign,

another of the working group partners,

worked with more than 200 state and local

coalitions to develop Project GET

ALARMED: A Residential Fire Detection

Strategy. The project focuses on educating

parents and raising public awareness 

about the importance of smoke detectors,

on advocating for strong state laws on

smoke detector use, and on installing and

maintaining alarms in homes of low-income

families with young children. SAFE KIDS

is targeting Mississippi and Missouri in

particular, because of the high residential

fire mortality rates in these states.

▲

“16 million American homes have

nonworking smoke detectors.”
7

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

In addition to fostering collaboration, the

Healthy People 2000 Unintentional Injury

Work Group recommends that states and

localities develop community-based

partnerships. According to Dr. Branche,

programs designed by the community

lead to better strategies for distributing

smoke alarms and give communities a

vested interest in the outcomes. The work

group encourages communities to direct

their programs to older adults as well as to

children, because people 65 and older are

a high-risk group often neglected by

residential fire prevention programs.

State programs benefit

children, elderly

NCIPC is now working with five states—

Arkansas, Kansas, Maryland, Minnesota,

and Oklahoma—to reduce fire-related

burn injuries and deaths among children

and adults. These states are establishing

surveillance systems to monitor the

prevalence of smoke detectors in homes

and are developing and evaluating interventions to increase the number of working

smoke detectors.

Arkansas’ program is an example of a

state-based intervention to provide smoke

detectors to the elderly and to low-income

families with young children. The program reached children through Head

Start, but Dr. David Bourne, Medical

Director of the Preventive Health Section

in the Arkansas Department of Health,

said that reaching the state’s elderly

residents presented a unique challenge.

After finding that many of the Arkansas

elderly were alone and unwilling to open

their doors, the department staff decided

to approach them through organized day

centers and volunteer fire departments.

Dr. Bourne adds that an advantage of

using fire department volunteers is that

once inside a home, they can look for

other obvious health risks. For instance,

many elderly people have inadequate

ventilation against the oppressive summer

heat because they nail their windows

shut, or they may have throw rugs scattered about, which increases the likelihood of falls.

With the graying of the U.S. population,

says Dr. Bourne, increasing attention and

resources must be devoted to the special

health and safety risks of older Americans. It is easy to underestimate their

potential isolation: surprisingly, not one

retiree who attended the health

department’s fire injury prevention

session at one senior center had ever seen

or even heard of a smoke detector. ■

Injury Control Update is a

publication of the Centers for Disease Control and

Prevention (CDC), National Center for Injury Prevention

and Control (NCIPC).

DIRECTOR, CDC

David Satcher, MD, PhD

DIRECTOR, NCIPC

Mark L. Rosenberg, MD, MPP

EDITOR

Gwen Ingraham

MANAGING EDITOR

Katie Baer, MPH

WRITER-EDITORS

Virginia Ross, PhD

Valerie Johnson

LAYOUT ARTIST

Leslie Parker

Direct editoral correspondence to:

Gwen Ingraham, Director, Office of

Communication Resources, NCIPC, CDC,

MS K-65

4770 Buford Hwy. NE • Atlanta, GA 30341-3724

Internet: gni@cipcod1.em.cdc.gov
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

CDC Staff photo

Dr. Christine Branche recently took over

leadership of NCIPC’s Division of

Unintentional Injury Prevention. The

division’s focus is on injuries related to

motor vehile crashes and home and

leisure activities.

CDC Staff photo

As the new director of NCIPC’s Division of Violence

Prevention, Dr. Rodney Hammond leads work in youth

violence, including suicide, and in family and intimate

violence.

▲

New appointments round out

NCIPC top management team

With the recent selection of two new

division directors, NCIPC has its top

management team in place, according to

Director Mark L. Rosenberg, MD, MPP.

Christine Branche,

PhD, now heads the

Division of Unintentional Injury Prevention (DUIP), and

Rodney Hammond,

PhD, is the new

director of the

Division of Violence

Prevention. Continuing as director

of the Division of

Acute Care, Rehabilitation Research,

and Disability

Prevention is Richard J. Waxweiler,

PhD.

Dr. Branche brings

extensive experience in the field of

injury prevention to her new position. She

became an Epidemic Intelligence Service

(EIS) officer in the Public Health Service in

1988, choosing injury epidemiology and

control as her area of focus. Her scientific

work in the field has included research on

drowning, spinal cord injuries from water

recreation, falls among the elderly, and

occupational injuries.

The new division director has worked

extensively with injury professionals, both

within CDC and nationally. Dr. Branche

has been team leader of DUIP’s Home and

Leisure Injury Prevention Team and also

headed the work group in that area in the

national agenda-setting process for injury

prevention and control. She currently

leads CDC’s working group to review

progress toward the Healthy People 2000

Objectives in reducing fire-related injuries.

Dr. Hammond brings to CDC a solid

grounding in academic research and

community-level programming in violence prevention. His work on prevention

of youth homicide and suicide has won

both professional awards and media

attention. Until his recent move to NCIPC,

he was director of the Center for Child

and Adolescent Violence Prevention in

Dayton, Ohio. He developed PACT

(Positive Adolescent Choices Training), a

school-based early intervention program,

and he is author of the series, Dealing with

Anger: A Violence Prevention Program for ▲ African-American Youth.
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

clinical care of injuries and the broader

quest for underlying risk factors for those

injuries and ways to prevent them.

Pushing the boundaries of the ED

“There’s no question that if you have 150

patients a day, your priority is treating

one patient and moving on to the next

crisis,” acknowledged Jeffrey H. Coben,

MD, director of the University of Pittsburgh Medical Center’s Center for Injury

Research and Control (CIRCL). “Making

the initial diagnosis and providing speedy

care are the core of emergency medicine,

and there are real constraints in terms of

time and the acuity of patients’ injuries

or illnesses.”

But people in the field who deal with

injuries day in and day out are interested

in doing more than just patching up the

wounded and moving along, he said.

“Nothing motivates you more to do

something about preventing the toll of

injuries than having to break the news to a

family about a relative’s death from a car

crash or gunshot wound.”

Most injuries that cause a significant

number of deaths are treated in EDs, and

from 25% to 40% of all hospital ED visits

INJURY (continued)

At Dayton, Dr. Hammond was associate

professor in the School of Professional

Psychology at Wright State University,

and he formerly was an assistant professor of psychiatry and director of children,

youth, and family services at Meharry

Medical College in Nashville, Tennessee.

He is a Fellow of the American Psychological Association and a member of the

Presidential Task Force on Violence and

the Family.

Dr. Waxweiler directed CDC’s 2-year

process to shape a national agenda on

injury prevention and control, which

culminated in recommendations published as Injury Control in the 1990s: A

National Plan for Action and a series of

professional publications. ■

are for care of injuries, ranging from the

minor to the life-threatening. Many of

these injuries are related to problems that

are recurrent and escalating in nature,

such as domestic abuse and alcoholrelated car crashes. Such a pattern of

injury, plus the fact that the ED is the only

place many people go to seek care, makes

it potentially an ideal point of intervention.

“The ED often is the only opportunity to

identify people with these problems and

to intervene,” said Rick Waxweiler, PhD,

director of NCIPC’s Division of Acute

Care, Rehabilitation Research, and Disability Prevention. He said that the ED is a

key element in the ideal trauma system’s

continuum of care, which begins with

prehospital care, such as response from

emergency medical services, and moves

on through ED care, inpatient hospital

care, and rehabilitation.

ED data—mining a valuable resource

Unfortunately, much of the information

that could make it possible to intervene is

not readily available. “In the traditional

paper-based information approach of

most clinical services, records get archived

and are virtually inaccessible,” said Dan

Pollock, MD, MPH, who leads the Acute

Care Team in the division.
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▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

As a result, we miss the opportunity of

mining ED data for insights into the

health care needs not only of people

treated in the ED, but also of the community. Most injuries are not fatal and may

not even require hospitalization, but the

data we have to work with are from death

certificates, medical examiner databases,

and trauma registries. “Focusing on this

incomplete and nonrepresentative set of

injuries,” say Dr. Herb Garrison and

colleagues in a 1994 issue of Annals of

Emergency Medicine, “reduces the validity

of the data and limits a full assessment of

preventive and therapeutic interventions.”

Standardized, easily accessible data also

have other advantages. Making ED data

more comparable and accessible will

increase its value for such applications as

quality assurance, research, and training.

Because the information will help define

ways to prevent injuries, there is also the

possibility of dramatic savings in health

care costs.

To put ED data in a form that will be most

useful both to ED staff and for defining

community patterns of injury and illness,

NCIPC has spearheaded efforts to standardize and consolidate all ED data—not

just injury-related data. Partners in this

surveillance initiative include the American College of Emergency Physicians

(ACEP), the Society of Academic Emergency Medicine (SAEM), the American

Trauma Society, the National Association

of State Emergency Medical Services

Directors, and other groups.

In January 1995, NCIPC convened a

meeting to develop recommendations for

standard data elements to be used in

coding information for an electronic data

base for EDs. A committee of ED physicians, nurses, and information specialists

revised the initial draft of Data Elements for

Emergency Department Systems (DEEDS).

NCIPC expects the report to be available

in summer 1997.

Barriers to change

Even though ED staff may appreciate the

potential of taking the longer view on ED

data, what about the pressure-cooker

environment that characterizes most EDs?

How can harried emergency medicine

professionals add one more

activity to their role?

Part of the solution is to bring in

other professionals whose expertise and focus on surveillance and

prevention activities can complement the core ED staff. For example, social workers and counselors in domestic violence help

identify and intervene with

patients’ problems (see accompanying article on page 12).

The goal in surveillance is to

make the information-gathering

task as easy as possible for the

time-pressured medical and

nursing staff. “We try to rely on

Photo courtesy of the Grady Health System

The words “emergency department” raise visions of frenetic activity, aimed at

treating people whose lives are in the balance. But the ED is also emerging as a

hub for injury surveillance and prevention efforts.

▲
11

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

data they are already collecting as part of

the clinical care of patients,” explained

CIRCL’s Dr. Coben. “We try not to be

intrusive about asking staff to fill out

additional forms or take extra steps. The

reality is, the ED is a busy place.”

Injury surveillance in today’s EDs

Despite the absence of a nationwide ED

information system, selected surveillance

efforts are underway in some areas. For

example, several hospital EDs are gathering information on nonfatal firearm

injuries. One site is Froedpert Memorial

Lutheran Hospital in Milwaukee, where

Steve Hargarten, MD, an associate professor of emergency medicine at the Medical

College of Wisconsin, directs surveillance.

“Emergency physicians see and treat

millions of injuries each year in the United

States,” said Dr. Hargarten. “One aspect of

managing these injuries from a public

health perspective is to take advantage of

surveillance in the ED.”

Interest in surveillance and prevention of

injury is rising, said Dr. Hargarten, who is

on SAEM’s task force on ED surveillance.

He points out that a decade ago, there was

virtually no interest in injury control, and

today, ACEP has an injury control section

with more than 100 members, SAEM has

been active in stimulating injury research,

and the Annals of Emergency Medicine regularly publishes articles on injury topics.

Pittsburgh’s CIRCL is also focusing on

ways to capture ED data. As part of a

wider surveillance effort to define the

extent of the injury problem in the state,

CIRCL is working with EMS providers to

gather population-based information on

injuries they record. Part of the research

center’s project emphasizes making these

injury data available to the public health

community. A natural language computer

program makes it easy for injury control

practitioners to access the EMS data base

to obtain information on which to plan

prevention strategies.

Opportunities for primary prevention

In its work, CIRCL also encourages EMS

responders to practice primary injury

prevention. “If a paramedic goes to the

home of an elderly person to transport

him to the hospital, there’s no reason why

the paramedic couldn’t do a quick home

assessment—check for risk factors for fire

or falls,” said Dr. Coben. “There’s a real

opportunity for paramedics to be an

extension of the emergency care providers

into the community.”

For emergency care nurses in the nation’s

hospitals, injury prevention has also

become a priority. The Emergency Nurses

Association (ENA), with a membership of

more than 25,000 registered nurses who

specialize in emergency care, has recently

established a national committee to look

at the issue of injury prevention.

Laurie Flaherty, RN,MS, CEN, project

coordinator of ENA’s injury prevention

grant, explained the emphasis on prevention in personal terms. After awhile, she

said, the adrenalin rush that often drives

emergency medicine professionals is

overcome by frustration at seeing one

preventable injury after another. Too

often, they see the consequences of kids

riding in cars without seat belts or kids

riding in the back of a truck.

“We all have stories of people who’ve

died or had their lives changed forever as

a result of injuries that were completely

preventable,” said Ms. Flaherty. “That’s

what ED staff can bring to the issue of

prevention in a way that others in the

field can’t: we can put a face on the tragedy of preventable injuries.” ■
12

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

Unique program involves EDs in

helping victims of domestic abuse

When an abused woman walks through

the doors of the emergency department

(ED) to seek treatment for physical injuries or medical symptoms, she may be

taking the first step in a journey to rebuild

her life.

Even women who come to the ED with

so-called “minor” injuries may be reaching out. A traditional response might be

to downplay the injuries, or even—in

response to managed care pressures—

chastise the patient for seeking an inappropriate level of care, without recognizing the signs of abuse or an indirect plea

for help.

However, an increasing number of hospitals throughout the country are beginning

to appreciate that EDs are ideal sites to

identify and help women who are in

abusive relationships. A pioneer in this

field is WomanKind, a hospitalwide

domestic abuse program, offering aroundthe-clock case management and advocacy

services at three Minneapolis-area hospitals,

including crisis intervention and ongoing

assistance to women who suffer from

physical, sexual, or emotional abuse.

The encounter between an abused woman

and an ED staff person represents an

important “teachable moment,” a type of

early intervention that can make a big

difference, according to Susan M. Hadley,

MPH, founder and director of

WomanKind. Started 11 years ago as a

nonprofit organization to provide domestic abuse counseling services in the ED on

a contract basis, WomanKind today is a

department of the Minnesota-based

Fairview Health System, serving an

average of more than 100 new clients each

month, including women in some inpatient units and numerous referrals from

medical offices in the community.

Building on the teachable moment

Although domestic abuse prevention

efforts are expanding to clinics and doctors’ offices, the ED remains the focal

point for reaching women with a violent

home life who are seeking help, even

indirectly. In the past, busy ED staff

haven’t always recognized the problem or

known how to respond. The warning

signs may be too subtle, the cause of the

injuries may masquerade as something

else (“I walked into a door”), and the

woman may be too ashamed or afraid to

acknowledge the real problem. If abuse

Photo courtesy of WomanKind

WomanKind founder and director Susan M. Hadley, MPH, and David

Justis, MD, counsel a woman at an emergency department in the Fairview

Health System.

▲
13

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

does become apparent, staff may react in a

judgmental manner or may counsel an

inappropriately precipitous action, such

as leaving the abuser immediately.

Enter WomanKind. If an ED clinician

identifies a potential abuse victim, she

offers to contact WomanKind on the

woman’s behalf. Within 30 minutes of

such a request from an ED physician or

nurse, a WomanKind volunteer arrives at

the hospital, provides support and information for the woman during her entire

stay, helps craft a safety plan if the patient

decides to return to her home, and sets up

a time for a WomanKind staff person to

make a follow-up call or visit. The

WomanKind staff maintain contact with

the woman and help her examine both

short- and long-term goals and options.

WomanKind training emphasizes that ED

counseling is, ideally, early intervention

and that many women are not ready to

take the major step of going to a battered

women’s shelter. “It’s a major life decision

for a woman to contemplate leaving an

abusive partner,” explained Ms. Hadley.

“And like all major life decisions, it’s a

process. It may take a woman weeks or

months or even years to work through

that process. The woman is the ‘expert’ on

what’s right for her, and health professionals need to respect her process and

decisions.”

Understandably, ED clinicians’ orientation

is to “fix” patients, but such expectations

may be unrealistic in the context of domestic abuse. “Often, ED staff feel that

they have failed if the abused woman

returns to her relationship. Our training

encourages staff to redefine ‘success’—

that is, the encounter has been successful

if the woman begins to feel a sense of

support and safety in the health care

setting, if she begins to talk about the

abuse, if she leaves the ED with a sense of

having choices. WomanKind’s counseling

aims to reduce the woman’s sense of

isolation and help her reorient her thinking so that she can break down what

seems like an insurmountable problem

into concrete steps.”

Working within the system

Staff training is an integral component of

WomanKind’s success. New nurses in all

departments in the Fairview System

hospitals and clinics get basic orientation

in domestic violence prevention, and

continuing in-service sessions reinforce

the message. Other key elements are

policies and protocols that aim to make

domestic violence assessment and intervention a routine part of patient care. For

example, the Fairview abuse prevention

plan is used to assess each patient for

possible abuse and specifies the actions

taken, including referral to WomanKind.

Being “in the loop” is critical, Ms. Hadley

said. “If you’re not part of the hospital’s

system, not part of the lines of referral and

communication, you may not get called

until the situation gets critical.” She

worked hard to win the hospital staffs’

trust, acknowledging that some clinical

staff initially resisted the idea of bringing

volunteers into a high-stress ED. “It was

not a turf issue,” she pointed out. “ED

doctors and nurses are wonderful—

intelligent, independent, activist—and

“The encounter between an abused

woman and an ED staff person is an

important “teachable moment,” an

early intervention that can make a

big difference.” – SUSAN M. HADLEY,

FOUNDER AND DIRECTOR,

WOMANKIND

▲
14

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

Resources You Can Use

they really care about their patients. We

had to prove ourselves to them, show that

we’d be there when we said we would

and that we could provide another facet

of care for their patients.”

For more information....

• Contact Susan M. Hadley (612/924-5775)

for information or samples of materials,

including the WomanKind reference card

series to help health professionals assess

women for abuse problems, the Fairview

abuse prevention plan, and a card summarizing an eight-step approach to supporting a woman who is being abused.

• A book by Ms. Hadley, The Health

Professional’s Guide to Domestic Abuse, will

be published soon by the Fairview Press. It

addresses signs and symptoms, assessment,

intervention, documentation, safety issues,

legal liability of health professionals, and

requirements of the Joint Commission on

Accreditation of Health Organizations.

• For a detailed description of the program, see “WomanKind: An Innovative

Model of Health Care Response to

Domestic Abuse,” in Women’s Health

Issues, Vol. 5, No. 4, winter 1995. ■

Several new publications are available

from the National Center for Injury

Prevention and Control. They can be

ordered through NCIPC’s Internet home

page: http://www.cdc.gov/ncipc/

ncipchm.htm or by writing to NCIPC,

Attention: Library Desk, MS K-65, 4770

Buford Highway, NE, Chamblee, GA

30341-3724.

Home and Leisure Injuries in the United

States assembles in one publication

articles that appeared in CDC’s Morbidity

and Mortality Weekly Report (MMWR)

between 1985 and 1995. The decade’s

collection includes reports on unintentional injury surveillance and the economic impact of unintentional injury as

well as cause-related information on

injuries from residential fires, sports and

leisure activities, and poisoning. This

compendium of articles underlines the

seriousness of unintentional injury as a

cause of morbidity, death, and significant

economic burden and also highlights

promising prevention strategies. The

Photo courtesy of WomanKind

WomanKind recommends these eight steps for supporting a

woman who is in an abusive situation.

▲
15

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

reports were compiled by Judy A. Stephens,

PhD, MS, MPH, and Christine Branche,

PhD, of NCIPC’s Division of Unintentional

Injury Prevention (DUIP).

Efforts to Increase Smoke Detector Use in

U.S. Households: an Inventory of Programs is another DUIP-prepared report.

Injury control practitioners throughout

the country are focusing on strategies to

reduce deaths and injuries from residential fires. Promoting the use of smoke

detectors in homes—assuring that people

obtain, install, and maintain smoke detectors—is a keystone of most strategies. This

report summarizes the approaches used in

49 programs in 33 states and 2 national

efforts and gives contacts for additional

information. Some of the summaries

describes comprehensive programs that

incorporate evaluation, and others report

on specific smoke detector giveaway

programs. This inventory is based on a 1994

DUIP survey and was compiled by Ruth

Shults, RN, MPH, and Pauline Harvey, MSPH.

Youth Violence Prevention: Descriptions

and Baseline Data from 13 Evaluation

Projects is a special supplement to the

American Journal of Preventive Medicine.

This publication assembles articles describing data and programmatic activities

of 13 youth violence prevention projects

throughout the country that were funded

under CDC cooperative agreements.

Overall, the projects reflect CDC’s dual

emphasis on scientific analysis and action

to stem the compelling problem of youth

violence. The demonstration projects use

varied strategies, but all have in common

strong theoretical foundations, active

collaboration with community partners,

and carefully planned evaluation. Each

article summarizes the project’s background, underlying scientific theory,

intervention activities, evaluation design,

and selected baseline data. Included are

overview chapters discussing the issue of

youth violence and public health approaches to its prevention. Guest editors for

this supplement are Kenneth E. Powell, MD,

MPH, and Darnell Hawkins, PhD.

Homicide and Suicide Among Native

Americans, 1979-1992, the second in the

Violence Surveillance Summaries published by NCIPC, underlines the serious

threat of violence to Native Americans.

During the 14-year period studied, 4,718

American Indians and Alaskan Natives

died from violence—about half from

homicide and half from suicide. The rates

of violence among Native Americans are

strikingly higher than the overall U.S.

rates: about double the homicide rate and

about 1.5 times the suicide rate. Rates of

suicide are disproportionately higher

among young people, especially males.

This report briefly addresses some of the

epidemiologic and social characteristics of

violence among Native Americans and

suggests prevention strategies. Authors of

this report are L. J. David Wallace, MSEH;

Alice D. Calhoun, MD, MPH; Kenneth E.

Powell, MD, MPH; Joann O’Neil, BS; and

Stephen P. James, BS.

Major Causes of Unintentional Injuries

Among Older Persons: an Annotated

Bibliography reviews 73 publications on

issues related to injuries that affect older

people. Gathered in one place are abstracts

of articles and books that address injury

epidemiology, the extent of unintentional

injuries, pedestrian and motor vehiclerelated injuries, falls, fires and burns, and

poisoning. This publication is a useful

resource for injury control practitioners

and others concerned with the overall

health care of older people. This bibliography was compiled by Judy A. Stephens, MS,

MPH, and Tracey A. Thomas. ■
16

▲INJURY CONTROL UPDATE ▲ Winter/Spring 1997

CALENDAR

November 19-21 Safe America: Fourth National Injury Control Conference ,

Washington, DC. Sponsored by CDC’s National Center for Injury

Prevention and Control, the meeting will highlight effective programs

linked to the science of injury control, strengthen partnerships among

organizations in the field, and foster communication about injury

prevention and control. Contact: Dr. George Roberts, NCIPC

(770/488-1441)

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

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Atlanta, GA 30333

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