A Descriptive Study of Childhood Injuries in Kingston, Ontario, Using Data from a Computerized Injury Surveillance System

Volume 17, No.1 -1997

[Table of Contents]

A Descriptive Study of Childhood Injuries in Kingston, Ontario, Using Data from a Computerized Injury Surveillance System
Monica Bienefeld, William Pickett and Pamela A Carr

Abstract

This report uses data from the Kingston and Region Injury Surveillance Program (KRISP), a subset of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), to describe rates and identify patterns of injury among children aged 0-19 years in Kingston and area. During 1994, there were 7572 reported injury events, resulting in an overall rate of 173.6 injuries per 1000 children per year (males: 202 per 1000; females: 143.7 per 1000). Four major patterns of injury were identified as priorities for intervention: 1) household injuries among children aged 0-4 years; 2) injuries occurring on playgrounds to children aged 5-14 years; 3) sports injuries among 10-19-year-old children and youth; and 4) bicycle-related injuries among children 5-14 years of age. Discussion focuses on the use of the surveillance system in prioritizing interventions and evaluating injury prevention programs for this population.

Key words: Child; Ontario; population surveillance; wounds and injuries

Introduction

Injuries are the leading cause of death and disability among children in Canada, and in much of the developed world.1-7 In 1993, 60% of the 2377 deaths that occurred among Canadian children and youth aged 1-19 years were attributable to injury.8 Data describing the occurrence of non-fatal childhood injuries on a population basis in Canada have, until recently, been limited. This lack of objective baseline data has been an important obstacle to the implementation and evaluation of injury prevention initiatives among Canadian populations.

In recent years there has been increasing recognition of the need for surveillance to guide the development and evaluation of childhood injury control programs. One national initiative in the area of injury surveillance is the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP). The mandate of CHIRPP includes the systematic collection and dissemination of data necessary for investigating the causes and nature of childhood injuries that present for emergency and in-hospital medical care.9

Two of the more recent sites to join the CHIRPP program are in Kingston, Ontario, and the data from these sites are compiled in what is known as the Kingston and Region Injury Surveillance Program (KRISP). The purpose of this paper is to provide one example of how data from KRISP are being actively used by public health professionals in Kingston and area to establish priorities for injury control. Two specific objectives are addressed.

To describe rates of injury among children and youth in Kingston and area, in order to identify subgroups of the study population who are at high risk for injury
To identify patterns of childhood injury that may be suited to the development and targeting of prevention programs

Setting

Demographic Characteristics of the Kingston Area
According to the 1991 census,10 the Kingston, Frontenac and Lennox & Addington (KFL&A) Health Unit covers a land area of 6660 square kilometres and serves a population of 166,330, of whom about 26% (43,000) are aged 0-19 years. Approximately 65% of the population resides in the urban core, consisting of the City of Kingston, Kingston Township and Pittsburgh Township. An additional 17% live in the townships immediately surrounding the core, and 18% reside in the rural areas to the north and west. The first language of 94% of the population is English.

In 1991, the average family income ranged from $47,779 for Lennox & Addington County, to $53,277 for Frontenac County, while unemployment was reported at 8%. The KFL&A area has a mixed economy, with strong representation in the manufacturing and service-based industries. Kingston is home to three post-secondary institutions (Queen's University, the Royal Military College, St Lawrence Community College) and is a major centre for the Canadian military and the federal corrections system.

The CHIRPP and KRISP Databases
CHIRPP is an emergency room-based computerized injury surveillance program that contains information on emergency room visits to ten pediatric hospitals and five general hospitals in Canada. The database is maintained in Ottawa at the Child Injury Section of the Bureau of Reproductive and Child Health at the Laboratory Centre for Disease Control (LCDC), a directorate of the Health Protection Branch of Health Canada. The Kingston General and Hotel Dieu hospitals, both general hospitals in Kingston, Ontario, joined CHIRPP in 1993.

KRISP is part of the CHIRPP surveillance system, but its scope is limited to data collected in the two hospitals in Kingston. Persons who seek medical attention for injury or poisoning at either of the two hospitals are entered onto the database. A nurse co-ordinator abstracts data from medical charts to provide information about the nature of the injury and treatment for all individuals (100%) presenting to the emergency department or admitted to hospital.

In addition, the patient or an accompanying adult is asked to provide a description of the circumstances of the injury, and this is obtained in approximately 85% of cases (R Brison, KRISP Director, unpublished data, 1995). All CHIRPP data rely on such unvalidated self-reports (we expect that this may be of particular concern with intentional and other injuries with legal implications). The information is then coded and entered into the main CHIRPP database in Ottawa, in accordance with the CHIRPP coding guidelines.11

The KRISP data are unique in that virtually all injuries in the local population requiring emergency or in-hospital patient care present at one of the two hospital emergency departments from which the information in the database is obtained. In particular, all serious injuries are likely to be brought to the regional trauma centre at the Kingston General Hospital. However, some less serious injuries involving residents of the KFL&A area may not be captured in this database, as persons with less serious injuries may report to other hospitals outside of the KFL&A area, particularly in the far northern and western areas of the region. Also, some individuals may not go to an emergency department at all. Therefore, the data may be considered population-based for severe (but non-fatal) trauma, and population-based in a limited way for less serious injuries. This allowed us to calculate rates of injury for children and youth, providing a basis for comparison with other communities.

Methods

Data Abstraction and Handling
Records of injuries to residents of the City of Kingston and of Frontenac and Lennox & Addington counties, aged 19 years or younger, were identified from the KRISP database by residential postal code for the one-year period ending December 31, 1994. These data were converted into a commercially available database manager 12 using a conversion program developed by John C LeBlanc (Epidemiologist, Izaak Walton Killam Hospital for Children, Halifax, Nova Scotia). The conversion transforms the data into a more usable format by aggregating information into defined categories and by assigning labels and titles to describe numerically coded data.

Counts of injury were calculated for the study population by age and sex. Rates of injury were calculated using the number of injuries as numerators and population counts from the 1991 census 10 as denominators.

Patterns of injury among all children were examined by time (month, day of week and time of day), location of occurrence of injury, circumstances of injury (activity being undertaken, mechanism of injury and breakdown event or "what went wrong"), nature of injury (injury type and anatomical site) and treatment.

The population under study was then divided into four age groups: young children (0-4), older children (5-9), adolescents (10-14) and youth (15-19). Rates of injury among males and females within each age group were evaluated by time, location, circumstance, nature and treatment.

Results

During 1994, there were a total of 7572 reported injury events involving children aged 0-19 living in Kingston and area, corresponding to an overall annual rate of childhood injury of 173.7 per 1000. Of these, 117 (1.5%) were admitted to hospital, 2744 (36.2%) received significant treatment (treatment with recommendation for follow-up treatment by an out-patient department, general practitioner or other health professional) and 4204 (55.5%) received minor treatment (treatment with no follow-up). Another 479 (6.3%) received advice only.

Distribution of Injuries by Age and Sex
Rates of injury were higher for males than females in all age groups (Table 1). Peak numbers and rates of injury occurred among 10-14-year-old females and 15-19-year-old males.

Time of Occurrence of Injury Events
Injuries happened more frequently in late spring and early fall among both males and females (Figure 1). There were no strong patterns either overall or by sex in the number of injuries observed by day of the week. Most of the injuries took place during the afternoon or early evening.

TABLEAU 1 Taux annuels de blessures pour 1 000 chez les enfants et les jeunes par âge et sexe, Kingston et sa région, 1994
Age(years)	TOTAL		Males		Females
Age(years)	Number of injuries	Rate	Number of injuries	Rate	Number of injuries	Rate
0-19	7572	173.7	4526	202.0	3046	143.7
0-4	1527	139.2	894	159.5	663	118.0
5-9	1434	129.9	843	149.9	591	109.1
10-14	2096	198.9	1173	217.8	923	179.0
15-19	2515	227.7	1616	279.3	899	170.8

Injury Contexts by Age and Sex
Table 2 provides rates of injury by age and sex for the eight most frequent contexts of injury, representing 85% of all recorded injuries.

Playing was the leading context of injury among both males and females aged 0-9 years, whereas sports injuries were the most common type among both sexes in the 10-19 age group. Informal sports accounted for over 50% of all sports injuries. The rate of injuries during organized sports was higher among older males than among other age groups; over the one-year study period, 35.8 injuries per 1000 males aged 15-19 occurred during an organized sporting event. The rate of sporting injuries in general was more than twice as high among males as among females, and the rate for organized sports injuries was five times higher among males.

Intentional injuries caused by fights or assaults represented less than 2% of injuries among children and youth. They were more common in males than in females, occurring at an annual rate of 15 per 1000 among males aged 15-19 years.

Characteristics of Injuries by Context
Counts of injuries by type (context) were cross-tabulated with various characteristics of the injury events. Injuries sustained while playing were mainly lacerations (28.6%) and inflammations (23.4%), whereas among sports injuries, inflammations (31.6%) and fractures (23.5%) were most common. Almost one half of all the sprains observed happened during a sporting activity. A higher proportion of abrasions were experienced while bicycling than in any other context (11.2% compared to 2.6% overall).

Injuries that occurred during play required significant treatment a greater proportion of the time (41.8%) when compared with all of the injuries reported (36.2%), while sports injuries required significant treatment less often (26.5%). Injuries from motor vehicle crashes required hospitalization 5.1% of the time.

Playing and walking/running injuries most often occurred as a result of a fall (40.6% and 62.4% respectively). Sports injuries were more likely to be caused by collisions (59.8%), whereas 76.8% of bicycling injuries were associated with a loss of control by the injured person. Very few injuries were reported due to improper use or malfunction of a product.

Breakdown Events by Age and Sex
The breakdown event is considered to be what went wrong and thereby caused the injury to occur. Rates of injury by age group and sex are listed in Table 3 for the most frequent breakdown events. Younger children were more likely to be injured by falls, while the older age groups experienced higher rates of injury due to collisions or loss of control. The rates of injuries caused by collisions and acts by persons were almost twice as high among males as females.

TABLE 2 Most frequent contexts of injury among children and youth by age and sex, Kingston and area, 1994
Context	Rates of injury per 1000 children per year
	0–4 years		5–9 years		10–14 years		15–19 years		0–19 years
	Males	Females	Males	Females	Males	Females	Males	Females	Males	Females
(N)	(894)	(633)	(843)	(591)	(1173)	(923)	(1616)	(899)	(4526)	(3046)
Playing	83.5	57.0	62.6	51.3	42.3	39.4	14.9	9.7	50.6	39.5
All sports	^a	^a	20.6	7.6	82.6	47.7	113.7	34.8	54.6	22.2
-informal	^a	^a	14.4	6.5	53.3	37.4	53.1	23.8	30.3	16.7
-organized	^a	^a	4.3	0.9	21.5	5.4	35.8	5.7	15.5	3.0
-not specified	^a	^a	2.0	^a	7.8	4.8	24.9	5.3	8.8	2.5
Walking/running	31.9	25.5	21.0	17.5	20.8	32.4	26.8	33.6	25.2	27.2
All recreation	3.9	3.2	10.5	9.6	21.2	21.1	17.5	21.5	13.2	13.7
Bicycling	0.9	^a	12.4	7.2	17.6	7.4	7.1	3.8	9.4	4.7
Sitting/standing	8.7	10.3	4.3	4.1	3.5	8.9	6.6	70	5.8	75
In car/van	4.3	3.5	3.2	3.1	3.0	2.1	12.1	13.9	5.8	5.8
At work	^a	^a	^a	^a	1.1	^a	17.5	12.0	4.8	3.2
Other/unknown	25.3	17.5	15.3	8.7	25.6	19.4	63.3	34.6	32.6	19.8
^aLess than five observations in this cell

TABLE 3 Breakdown events leading to injury among children and youth by age and sex, Kingston and area, 1994
Breakdown Event	Rates of injury per 1000 children per year
	0–4 years		5–9 years		10–14 years		15–19 years		0–19 years
	Males	Females	Males	Females	Males	Females	Males	Females	Males	Females
(N)	(894)	(633)	(843)	(591)	(1173)	(923)	(1616)	(899)	(4526)	(3046)
Falls	78.0	59.1	52.1	45.2	54.2	55.1	39.1	39.7	55.7	49.8
Collisions	16.6	9.3	31.6	16.6	66.7	45.0	94.2	42.9	52.5	28.2
Loss of control	14.1	14.5	21.5	20.3	50.0	41.7	70.9	44.4	39.2	30.0
Dangerous position	31.6	194	25.4	12.2	22.7	21.1	33.9	22.6	28.5	18.0
Acts by persons ^a	9.8	6.7	11.7	8.7	16.0	9.3	32.7	13.7	17.7	9.6
Other	9.3	8.9	7.5	6.1	8.4	6.8	8.3	7.4	8.5	7.3
^a Includes non-intentional, intentional and self-inflicted injuries

Nature and Sites of Injuries
The nature of injuries and anatomical sites involved varied by sex and age group. Overall, males experienced more cuts/lacerations and fractures, whereas injuries to females were more often inflammations and sprains.

The greatest percentage of injuries in children aged 0-4 years was to the head. These injuries were predominantly cuts and lacerations associated with falls against furniture and structural features (e.g. floors, walls, doors). Dislocations were also common among this age group (11.3 per 1000 per year among girls and 8.4 per 1000 among boys). Almost all of these dislocations involved the elbow (92%), with the remainder being of wrists and shoulders.

Among older children, inflammation was the most common type of injury. Sprains and strains occurred more frequently among adolescents and youth than in the younger age groups, particularly among females. Fractures were experienced more frequently by males than females.

Treatment of Injuries by Age and Sex
Table 4 describes injury treatments received by each age and sex group. Overall, males received significant treatment almost twice as often as females (82.5 per 1000 per year vs 42.2 per 1000). Rates of injuries requiring minor treatment were almost twice as high among the older age groups as among children aged 0-9 years, while nearly 10% of those aged 0-4 years received advice only-twice the proportion of any other age group.

Location of Occurrence of Injuries by Age and Sex
Seventy percent of all the injury events among young children (0-4 years) occurred in the home and yard, whereas less than half of the injuries in other age groups were reported in this location (Table 5). The rate of injuries in the home and yard generally decreased with increasing age, and it was lower for males than females in the two older age groups.

Children aged 5-14 experienced over one quarter of their injuries at playgrounds and at school, with rates as high as 44.4 per 1000 per year in males aged 10-14. The highest rate of injury (53.9 per 1000) among 15-19-year-old males took place at "organized sporting venues." The rates of injury occurring on roadways were twice as high among males (24.3 per 1000 per year) as females (11.5 per 1000), and these rates increased directly with age.

TABLE 4 Treatment of injuries by age and sex, Kingston and area, 1994
Treatment	Rates of injury per 1000 children per year
	0–4 years		5–9 years		10–14 years		15–19 years		0–19 years
	Males	Females	Males	Females	Males	Females	Males	Females	Males	Females
(N)	(894)	(633)	(843)	(591)	(1173)	(923)	(1616)	(899)	(4526)	(3046)
Advice Only	15.5	13.4	9.8	7.4	9.8	6.6	15.6	9.1	12.7	9.2
Minor	69.0	61.1	64.2	58.7	117.2	122.4	158.9	119.7	102.5	89.9
Significant^b	71.2	41.2	72.4	40.6	86.5	48.3	99.6	39.0	82.5	42.2
Observation	1.6	1.1	^a	^a	^a	^a	^a	^a	0.7	0.6
Admission	2.0	^a	3.2	1.8	3.7	1.7	5.4	2.3	3.5	1.7
Fatal Injuries	^a	^a	^a	^a	^a	^a	^a	^a	^a	^a
^a Includes non-intentional, intentional and self-inflicted injuries

TABLE 5 Location of occurrence of injuries among children and youth by age and sex, Kingston and area, 1994
Location	Rates of injury per 1000 children per year
	0–4 years		5–9 years		10–14 years		15–19 years		0–19 years
	Males	Females	Males	Females	Males	Females	Males	Females	Males	Females
(N)	(894)	(633)	(843)	(591)	(1173)	(923)	(1616)	(899)	(4526)	(3046)
Home	113.6	81.5	57.6	42.3	39.4	48.9	45.1	47.3	64.1	55.0
-living/sleeping area	63.0	48.7	19.6	14.8	10.6	18.6	20.2	21.3	28.5	25.9
-garage/yard	20.2	12.3	25.4	19.0	19.1	18.6	15.4	9.9	20.0	14.9
-kitchen	16.1	10.1	3.7	3.0	4.6	7.2	4.0	9.5	7.1	7.4
-basement	8.0	6.7	6.4	4.6	4.1	3.5	2.2	2.1	5.3	4.3
-bathroom	5.4	2.8	0.9	^a	^a	^a	1.0	2.9	1.8	1.7
-unspecified	1.1	0.9	1.6	^a	^a	^a	2.2	1.7	1.4	0.8
Playground^b	4.5	2.2	27.6	21.6	44.4	34.7	27.3	7.4	25.7	16.4
Roadway	9.6	8.8	20.1	12.2	28.6	17.5	38.5	32.1	24.3	17.5
-public	3.7	4.5	14.2	8.1	18.2	9.7	29.0	23.8	16.4	11.5
-private/driveway	5.9	4.3	5.9	4.1	10.4	7.8	9.5	8.4	7.9	6.1
Day care/school	2.7	3.4	10.7	6.1	31.9	34.3	31.8	24.7	19.2	16.9
Organized spor^c	^a	^a	6.2	3.3	27.9	9.9	53.9	11.0	22.4	6.1
Outdoor land recreation^d	6.2	5.0	11.2	10.7	21.0	15.3	14.7	9.9	13.3	10.2
Commerce/production^e	5.9	3.4	1.2	3.3	2.6	2.7	24.0	16.9	8.7	6.6
Water recreation	1.1	^a	1.8	0.9	4.6	3.1	3.5	2.9	2.6	1.8
Unknown/Other	15.0	12.9	13.5	8.7	17.5	12.6	40.6	18.6	21.6	13.2
^a Less than five observations in this cell ^b Includes those at day cares and schools ^c Sports arena, oval, court, pool ^d Camping areas, national parks, fields, beaches ^e Private enterprise area, government public utility/factory, warehouse, mine, quarry, construction site, farm, other industrial sites

Discussion

This paper provides new information from the Canadian Hospitals Injury Reporting and Prevention Program, describing patterns of injury among children and youth in the Kingston area on a population basis. Data from this injury surveillance system can be an important tool for public health professionals in the development of locally relevant injury control initiatives.

The magnitude of these observed annual rates of childhood injury in the study population ranges from a low of one injury for every 14 children under 1 year of age to a high of one injury for every 4-5 youths aged 15-19. Over one third of these injuries (37.4%) required significant treatment. In interpreting the magnitude of these rates, it is important to remember that they are conservative estimates, as they exclude childhood injuries treated in non-hospital medical settings (e.g. by family practitioners), those which received no medical intervention and fatal injuries never seen at hospitals.

The analysis indicates four patterns of childhood injury to be given priority for intervention, for two main reasons: they were especially common among some of the age groups, and effective interventions exist to reduce these types of injury at the community level. The patterns of interest were 1) household injuries among infants and preschoolers (0-4 years); 2) injuries occurring at playgrounds and schoolyards among children aged 5-14 years; 3) sports injuries among 10-19-year-old adolescents and youth; and 4) injuries related to loss of control by bicyclists aged 5-14 years.

The vast majority of injuries to children aged 0-4 were found to occur in the home and yard. This is consistent with studies of childhood injuries reported elsewhere.6,7,13 Examples of prevention programs focusing on household injuries among children that have been successfully implemented include passive measures such as standards for children's sleepwear and the introduction of childproof medicine containers.7 Education of parents is also effective in reducing hazards to children in the home, particularly when health professionals target individual families and focus upon specific hazards relevant to the developmental stage of the child.7,14,15

Injuries associated with playgrounds are a leading cause of morbidity among children and youth in Kingston and area, as is likely the case in other Canadian communities. These types of injuries are worthy of attention because of their amenability to prevention. In the KFL&A area, playground equipment was associated with 13% of playground injuries.16 Hazards associated with playground equipment can be reduced by ensuring that the equipment and the ground surfacing materials around it adhere to national safety guidelines.17 In response to this problem, a playground equipment survey has been conducted to identify hazards on public playgrounds and will be the basis for remedial action.

Sporting injuries represent a significant proportion of injuries among 10-19-year-old adolescents and youth in the Kingston area and elsewhere.7,18,19 Certain physical characteristics of the developing body place young athletes at high risk for fractures and overuse injuries.19-22 This problem is compounded by inappropriate training techniques and aggressive attitudes fostered by parental and coaching pressures.20,22 One method of addressing this area of concern is through coaching certification programs.19,22 Although more competitive levels of sports usually require coaching certification, recreational and educational sports environments for younger children often have no such requirement. Yet it is precisely in these areas where attitudes toward sports are developed. Coaches at all levels should be encouraged to take certification courses, and we intend to promote this practice in our community.

While bicycle injuries in Kingston and area constituted only 4% of all childhood injuries, over 75% of them involved children aged 5-14. In addition, more than three quarters of these injury events resulted from a loss of control on the part of the cyclist. Prior to this study, the Kingston Community Bicycling Safety Committee was formed to address this issue at a community level. Since then, school-based education programs have been offered in various schools in the area. The presence of KRISP will be an important tool in the evaluation and, if necessary, the modification of these programs.

Summary

Childhood injuries are an important public health problem in the Kingston area. Prior to this study there were few data available to health professionals and community groups describing the patterns of injuries. This analysis was intended to demonstrate how data from an existing injury surveillance system are being used in the development of locally relevant programs aimed specifically at important patterns of childhood injury. Ongoing monitoring of these patterns via the surveillance system will help to evaluate the effectiveness of interventions introduced to address these areas of concern.

Acknowledgements

We thank Dr Rob Brison and Ms Kathy Bowes of the Kingston and Region Injury Surveillance Program for their advice and assistance. This project was funded by the Advisory Research Committee Grants Program of Queen's University. Dr Pickett is a Career Scientist funded by the Ontario Ministry of Health.

References

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16. Carr P, Pickett W, Mowat DL, Chui A. Playground equipment injuries Kingston and area. Kingston: KFL&A Health Unit, 1995.

17. Canadian Standards Association. A guideline on children's playspaces and equipment: a national standard of Canada. Toronto: The Association, 1990.

18. Ellison LF, Mackenzie SG. Sports injuries in the database of the Canadian Hospitals Injury Reporting and Prevention Program-an overview. Chronic Dis Can 1993;14(3):96-104.

19. American College of Sports Medicine. Current comment: the prevention of sport injuries of children and adolescents. Med Sci Sports Exerc 1993;25(8 Suppl):1-7.

20. Micheli LJ, Klein JD. Sports injuries in children and adolescents. Br J Sports Med 1991;25(1):6-9.

21. Cook PC, Leit ME. Issues in the pediatric athlete. Orthop Clin N Am 1995;26(3):453-64.

22. Abraham E. Sports-related injuries in children and young adults. Comprehensive Therapy 1992;18(12):33-7.

Author References

Monica Bienefeld, William Pickett and Pamela A Carr, Department of Community Health and Epidemiology, Queen's University; and Centre for Injury Prevention and Research, Kingston, Frontenac and Lennox & Addington / Queen's University Teaching Health Unit, Kingston, Ontario
William Pickett, also affiliated with Kingston and Region Injury Surveillance Program, Kingston General Hospital, Queen's University; mailing address: KFL&A / Queen's University Teaching Health Unit, 221 Portsmouth Avenue, Kingston, Ontario K7M 1V5; E-mail: PICKETTW@QUCDN.QUEENSU.CA

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