WA CHILDHOOD INJURY SURVEILLANCE BULLETIN:

WA CHILDHOOD INJURY SURVEILLANCE BULLETIN: ANNUAL REPORT, 2012-2013 Prepared with the support of Princess Margaret Hospital Emergency Department Supported by

Kidsafe WA Suggested Citation: Richards J & Stepan, A (2013). WA Childhood Injury Surveillance Bulletin: Annual Report 2012-2013. Kidsafe WA: PMH. Produced for the Department of Health, Western Australia in consultation with Princess Margaret Hospital Emergency Department.

CONTENTS Table of Contents 1 List of Figures & Tables 2 Acknowledgements 3 EXECUTIVE SUMMARY 4 INTRODUCTION 5 1. Method of Data Collection 5 1.1 Data Accuracy and Completeness 5 1.2 Limitations 5 2. Demographic Data 6 2.1 Emergency Department Presentations 6 2.2 Age and Gender Distribution 7 2.3 Area of Residence 8 2.4 Ethnicity 8 3. Injury Data 9 3.1 Injury Intent 9 3.2 Main Cause of Injury 9 3.3 Place of Injury 10 3.4 Injury Factors 10 3.5 Use of Safety Equipment 11 3.6 Sports 11 4. Assessment & Treatment Data 12 4.1 Time Factors 12 4.2 Day of Attendance 13 4.3 Triage Category 13 4.4 Source of Referral 14 4.5 Outcome of Attendance 14 DISCUSSION 15 FUTURE (RECOMMENDATIONS) 16 1

LIST OF FIGURES & TABLES List of Figures Figure 1 Number of ED Presentations July 12 June 13 6 Figure 2 Highest & Lowest Injury Presentations as a % of Total Presentations 6 Figure 3 Gender Distribution July 12 June 13 7 Figure 4 Age Distribution July 12 June 13 7 Figure 5 Area of Residence 8 Figure 6 Ethnicity 8 Figure 7 Injury Presentations by Human Intent 9 Figure 8 Main Cause of Injury 9 Figure 9 Place of Injury 10 Figure 9a Place of Injury within the Home 10 Figure 10 Injury Factors 10 Figure 11 Safety Equipment 11 Figure 12 Top Ten Sport Injuries 11 Figure 13 Time of Presentation 12 Figure 14 Time of Injury 12 Figure 15 Day of Attendance 13 Figure 16 Triage Category 13 Figure 17 Source of Referral 14 Figure 18 Outcome of Attendance 14 List of Tables T a b l e 1 T r i a g e C a t e g o r y 13 2

ACKNOWLEDGEMENTS Injury Surveillance Data is collected by the Emergency Department at Princess Margaret Hospital for children and provided to Kidsafe WA on a quarterly basis for the preparation of the Biannual WA Childhood Injury Surveillance Bulletins. The following WA Childhood Injury Surveillance Bulletins were prepared by Kidsafe WA in conjunction with Princess Margaret Hospital for 2012 to 2013. Copies are available on the Kidsafe WA website www.kidsafewa.com.au. March 2013: Burns and Scalds (Bulletin 27) October 2013: Injuries to Aboriginal and Torres Strait Islander Children (Bulletin 28) OUR THANKS GO TO: The staff of Princess Margaret Hospital Emergency Department for their commitment to the collection of injury surveillance data. Dr Meredith Borland, Director of PMH Emergency Department for her continuing support of this data collection. Triage nurses who are responsible for entering the appropriate injury details into the Emergency Department Information System (EDIS). We also acknowledge the Department of Health for its ongoing financial support. This report was prepared by: Jessica Richards, Senior Project Officer Kidsafe WA Anita Stepan, Project Officer Kidsafe WA In conjunction with: Dmitry Skarin, Injury Surveillance Officer Princess Margaret Hospital 3

EXECUTIVE SUMMARY Being the only tertiary paediatric centre for Western Australia, Princess Margaret Hospital for Children remains a major referral centre for injured children. This is the seventh annual report using the revised Injury Surveillance coding system. The 2012-13 financial year saw 70,586 children present to the Princess Margaret Hospital Emergency Department (PMH ED). This represents a 1.4% decrease in total Emergency Department presentations when compared with the previous financial year (2011-12), in which 71,584 children presented to the Emergency Department. There were 19,252 injury presentations for the year, accounting for 27.3% of total PMH ED presentations. This is slightly above the long-term average of 25% of total presentations, however a decrease of 2.0% in injury numbers was seen when compared with the previous financial year (2011-12), which saw a total of 19,638 injury presentations. For the purpose of this report only children aged 0 to 15 years have been included. The male to female presentation ratio for injury of 3 to 2 respectively, remains constant. The preschool age group (children less than 5 years of age) continue to dominate injury presentations, representing 40.1% of total injury presentations to the PMH ED. The majority of injured children presenting to PMH reside within the metropolitan area of Perth (94.2%) and are not of Aboriginal/Torres Strait Islander descent (94.8%). The majority of injuries occur in or around the child s home (49.4%). The school/residential institution (24.2%) is the second most common location specified. It is important to note that Other Place now exceeds all location categories, accounting for 53.6% of reported locations. As a result this has been removed to calculate the specific injury location. Falls remain the dominant injury cause (38.3%), followed by Blunt Force (24.5%) and Other Cause (16.5%). The overall rate of admission following an injury was 16.9%, however rural children were 3 times more likely to be admitted to PMH following an injury presentation. In conclusion, the financial year 2012-13 saw a decrease in total emergency department and injury presentations. It is important that this trend continues so that the number of injury presentations are kept to a minimum. 4

INTRODUCTION Princess Margaret Hospital for Children is the only tertiary paediatric centre for Western Australia and is thus the reference centre for paediatric illness and injury for the state. Although the catchment zone may potentially be the entire state, it does not see all children requiring hospital treatment in any given year. Many will be treated at regional hospitals and medical centres. On average, approximately 70,000 children present to PMH seeking medical assistance at the hospital s Emergency Department each year. The majority of these children will be under 5 years of age. Paediatric Injury surveillance is the systematic collection of data related to all children presenting to the Emergency Department with an injury. A modified version of the International Classification of External Causes of Injury (ICECI), version 1.1a is currently used to code injury presentations. The ICECI is a member of the World Health Organisation s (WHO) Family of International Classifications. The five major data elements collected are: cause, human intent, location of injury, activity and injury factor. This report provides a summary of all the injury surveillance data collected during the 2012-13 financial year. The PMH Emergency Department uses the Emergency Department Information System (EDIS) version 9.31.000.01, a computer-based database to record and collate all details of children presenting to the hospital s Emergency Department. It is a real time electronic database used to record and manage patient data. The system has been in operation since January 1998 and is subject to quality assurance checking to ensure data accuracy and integrity. The EDIS database is accessible via the hospital s network at terminals within the Emergency Department. 1.0 METHODS OF DATA COLLECTION A triage nurse initially assesses the children presenting to the Emergency Department of PMH. All clinical information and basic demographic details are recorded together with the child s triage code, an indication of the level of emergency, based upon their reason for presentation. Those children presenting due to injury then have injury surveillance data collected, based on the following fields: date, time and cause of injury, intent of injury, place of injury, activity when injured and any appropriate injury factor. One full-time Injury Surveillance Officer is employed at PMH to monitor and analyse the injury data. 1.1 DATA ACCURACY AND COMPLETENESS PMH is committed to the provision of quality data for health professionals and other interested parties. Daily validation of injury data fields is undertaken by the Injury Surveillance Officer to ensure the accuracy of data. This involves the checking for null or missing data fields and identifying any misclassification of data. 1.2 LIMITATIONS The data contained in this report represents the paediatric population that presents to PMH and as such comparisons made on a state or other basis must be done with due care. The data used for this report is reliant on the accuracy of those entering data within EDIS and the effectiveness of quality validation by the Injury Surveillance Officer. As such, it may be subject to coding bias and associated skewing of injury data. Finally there is scope for inadequate or over reporting of injury data. 5

2.0 DEMOGRAPHIC DATA 2.1 EMERGENCY DEPARTMENT PRESENTATIONS The financial year saw a total of 70,586 presentations to the Emergency Department of PMH by children aged 0-15 years. This represents a decrease of 1.4% of total presentations seen during the previous financial year (70,763 in 2011-12). The yearly cycle experienced within total presentations to the Emergency Department is evident with the winter peak and summer trough, with Figure 1 showing monthly breakdowns Figure 1 Number of ED Presentations July 2012 June 2013 Injury presentations in 2012-13 by children aged 0-15 years (n=19,252) remained fairly constant since the previous financial year accounting for 27.3% of total presentations, but still remains slightly above the long-term average of 25%. Monthly injury presentations show no obvious seasonal cycle, however a cycle is noted when injury presentations are viewed as a percentage of total monthly presentations (Figure 2), with a peak in November (30.3%) and a July trough (20.7%). Figure 2 Lowest & Highest Injury Presentations as a Percentage of Total Presentations July 2012 & November 2012 6

Demographic Data 2.2 AGE AND GENDER DISTRIBUTION Male: Injuries accounted for 28.1% of All Male ED Presentations (n = 39,111) Female: Injuries accounted for 26.3% of All Female ED Presentations (n = 31,474) During this report period, males represented 57.0% of injury presentations (n = 10,978) and females 43.0% (n = 8,274). These percentages are consistent with the known gender injury ratio of 3:2. Figure 3 displays the monthly breakdown of presentations. The decreasing number of presentations this financial year does not appear to impact the gender ratio, and there is little variation seen throughout the year. October saw the highest percentage of female presentations (45%), with May being the highest for males (59%). Figure 3 Gender Distribution July 2012 June 2013 The pre-school age group, those under 5 years of age, remained the dominant group representing 40.1% (n = 7,711) of total injury presentations to PMH. Children under 10 years of age represented 66% of total injury presentations. Figure 4 shows the monthly breakdown by age groupings (excludes those where age is unknown). Males dominated injury presentations in all age groups, while teenagers (children aged 14+) only accounting for 11.5% of presentations due to the predictable trailing off to adult medical services. Figure 4 Age Distribution July 2012 June 2013 7

Demographic Data 2.3 AREA OF RESIDENCE Metro: (n = 18,142) Rural/Remote: (n = 853) Other (Interstate/Overseas/Unknown): (n = 257) Figure 5 Area of residence (Based on home postcode) 98 67 112 Perth Metro North = 11,682 South = 6,460 TOTAL = 18,142 280 86 South West 141 Great Southern 69 Children with a Perth Metropolitan residential postcode represent the majority (94.2%) of injured children seen by the emergency department, as shown in Figure 5. Males from outside the metropolitan region had a slightly higher proportion of presentations to PMH. Rural presentations recorded a 1.5% decrease from the previous financial year compared to a 1.5% increase in presentations from the Perth metropolitan area. Neither of which are significant. 2.4 ETHNICITY Children of Aboriginal or Torres Strait Islander decent represented 4.3% of children attending the emergency department during the financial year (Figure 6). There were no significant gender or age group differences between Aboriginal and non-aboriginal children, however 22.2% of presentations from rural regions were children of Aboriginal or Torres Strait Islander decent. A significant portion of the alleged assault (14.9%) and intentional injury presentations (5.3%) were children of Aboriginal or Torres Strait Islander descent. Figure 6 Ethnicity 8

3.0 INJURY DATA 3.1 INJURY INTENT The greatest proportion of injury presentations to Princess Margaret Hospital continues to be as a result of unintentional injuries. For 2012-13, unintentional injuries accounted for 96.2% of presentations, as shown in Figure 7. Children aged 12 years and older accounted for the highest proportion of Intentional injury presentations. In particular children aged 12 years and older accounted for 95.5% of Intentional Self- Harm and 56.1% of Alleged Assault. There is little difference between the proportion of children presenting from metropolitan and rural regions for intentional injury and alleged assault. Figure 7 Injury Presentation by Human Intent 3.2 MAIN CAUSE OF INJURY During the past financial year, Falls remained the leading cause of injury (Figure 8), although at a slightly higher percentage than the previous year. Blunt Force injuries have remained at second position, followed by Other Cause which has decreased by 3% since the previous year. This decrease could be due to improved detailed data collection as Other Cause includes injuries where a cause is not specified or does not fit into the existing categories. Overall, only slight increases or decreases in percentage were recorded for injury causes when compared to the previous year. Figure 8 Main Cause of Injury 9

Injury Data 3.3 PLACE OF INJURY Children presenting to PMH are most commonly injured in the home or its surrounds (n = 4,415), however this year 53.6% of injury presentations were coded as Other Place (n = 10,316). This includes those where a location is not specified or does not fit into the existing categories (Figure 9). When Other Place is excluded, the top three locations are: Home (22.9%); School/Residential Institution (11.2%) and Recreational/Cultural Areas (4.8%). Males were most commonly injured at each location. Evidence has shown that as children get older, injuries increasingly occur outside the home environment. Figure 9 Place of Injury Figure 9a Place of Injury within the Home Figure 9a shows where within the home injuries are most likely to occur. After Unspecified (48.0%) locations within the home environment, the most common place for children to be injured is Outdoors (18.8%) and Living/Dining Area (12.4%). Evidence has shown that within the home, the Outdoors and Living/Dining areas are consistently amongst the most common locations for injury to occur. 3.4 INJURY FACTORS When looking at factors involved in child injuries; (excluding Not Applicable code), Building Components (24.5%) was the most common injury factor recorded, followed by Furniture (15.3%). Poisoning Factors and Trampoline were the only factors that were higher for girls than boys. It must be noted that over half of all injury presentations (52.6%), did not have an associated injury factor recorded. Figure 10 shows the breakdown of recorded injury factors by gender. Figure 10 Injury Factors 10

Injury Data 3.5 USE OF SAFETY EQUIPMENT The use of safety equipment during activities can help reduce the risk and severity of an injury. Of the 19,252 injury presentations to PMH ED, only 24.8% recorded the use or non use of relevant safety equipment, with the remaining 75.2% of injury presentations coded as Not Applicable. Of the 24.8% that recorded under use of safety equipment, 91.6% were coded as Unknown or Inadequate Description, resulting in only 401 cases with a safety equipment coding. Of the 401 cases, a total of 34.7% were identified as No Safety Equipment being used. This represents cases where a piece of safety equipment should have been in place e.g. a helmet, seatbelt, child restraint or electrical safety switch. Figure 11 shows the breakdown of recorded safety equipment usage. Figure 11 Safety Equipment 3.6 SPORTS A total of 4,580 (23.8%) injury presentations to PMH ED were recorded as occurring during a sporting activity. With a possible 44 Sporting codes available, data has been grouped into the most common sports resulting in an injury presentation to PMH ED during 2012-13. Australian Rules Football was the most common sporting activity resulting in an injury presentation to PMH ED, followed by Trampolining and Cycling. The main concern with Cycling is that only 18.3% of Cycling injury presentations were recorded as wearing a helmet. A further 1.3% were identified as not using any safety equipment and 73.9% of the safety equipment usage was unknown or an inadequate description was provided. Figure 12 shows the top ten sports resulting in injuries that attended PMH ED in 2012-13. Figure 12 Top Ten Sport Injuries 11

4.0 ASSESSMENT & TREATMENT DATA 4.1 TIME FACTORS The majority of injured children (75.5%) present between midday and midnight each day (Figure 13). The peak period for presentations to PMH Emergency Department is between 11:00 and 21:00 (72.7%), with the highest number of children presenting between 18:00 and 18:59 (n = 1,708). Figure 13 Time of Presentation During 2012-13 a total of 7,273 presentations were recorded with an injury time occurring during the midnight to 5.59am period. Closer analysis found that 98.2% of the presentations occurring during this period were recorded as occurring at 0:01 (n=7,144) which is the time coded when injury time is unknown as identified in the Triage Description. For this reason the time of 0.01 has been renamed to Unknown to create five time periods in Figure 14. Figure 14 Time of Injury When excluding the unknown injury time, 47.5% of injuries were shown to have occurred between noon and 6pm with peak periods between 12 noon and 1pm and again between 4pm and 7pm. This correlates with the time periods of meal preparation, after school and before the evening meal. A comparison between the time of injury and time of presentation shows a time lag between time of injury and presentation. 12

Assessment & Treatment Data 4.2 DAY OF ATTENDANCE The weekend saw the highest presentations during the year (32.3%), with a peak on Sundays and a trough on Tuesday and Thursday (See Figure 15). Figure 15 Day of Attendance 4.3 TRIAGE CATEGORY The majority of children (95.5%) are given a triage category of either Semi-Urgent or Urgent, as shown in Figure 16. These are injuries deemed to require medical attention within 1 hour of being triaged. There were no major differences between the sexes or age grouping with reference to triage code. Figure 16 Triage Category The triage category (code) is a reflection on the urgency for medical intervention, as shown in Table 1. Table 1 Triage Category Category Resus (1) Seen within (mins) 0 (Immediately) Emergency (2) 10 Urgent (3) 30 Semi-Urgent (4) 60 Non-Urgent (5) 120 13

Assessment & Treatment Data 4.4 SOURCE OF REFERRAL The vast majority of children (82.4%), present without a referral from another medical source. A further 11.8% have been reviewed by either their local General Practitioner (GP) or another hospital. A significantly higher proportion of rural children present to PMH after medical review, as shown in Figure 17. These children are up to five times more likely to have been reviewed in their nearest hospital than children residing in the metropolitan area. Figure 17 Source of Referral 4.5 OUTCOME OF ATTENDANCE In the majority of cases (81.1%) children were able to depart the PMH ED with treatment completed. A further 16.9% were admitted to PMH, 1.2% did not wait for treatment and 0.1% were transferred to another hospital (Figure 18). Figure 18 Outcome of Attendance However there was a significant difference in admissions between children from rural and metropolitan regions. Rural children were three times more likely to be admitted to PMH following an injury presentation (with 53.2% of children from a rural postcode being admitted to PMH) and less likely to leave before treatment, than those from the metropolitan region. 14

DISCUSSION The collection of injury data plays a vital role in the development of strategies to prevent or minimise childhood injury. It relies on an efficient and reliable computer system and the co-operation of nursing, clerical and medical staff within the Emergency Department of PMH. Through the analysis of this collected data, injury trends and changes can be noted as well as the effects of injury prevention programs. The financial year 2012-2013 saw a 1.4% decrease in total PMH ED presentations compared to the previous year. There was an associated decrease in the number of injury presentations, however the percentage of injury presentation remains above the long term average of 25% of total presentations. Although the number of injury presentations to PMH has slightly decreased, proportionally there were no real obvious changes seen in the cause of the injury trauma recorded in 2012-13 when compared to the 2011-12 reporting period. Since the 2009-10 report there has been an increasing trend for either not utilising all existing codes available, coding items as Unknown or Not Applicable or missing a large share of coding options altogether. This was particularly an issue for location where injuries occurred which was more likely to be coded as Other Place than identifying the exact location. In 2012-13 however, there has been an decrease in the use of the codes Other place and Other Cause showing improvements in the use of coding categories. After preparing this report, it is clear that there is either; a great deal of data not being coded at time of presentation (resulting in limited data then being able to be accurately coded during data cleaning processes); a lack of time by staff to fill in the system (compounded by too many codes to choose from in each category); or possibly a lack of communication to staff of how the data is being used and the importance of each coding level. The solution may include ongoing education and support for the staff collecting and cleaning the data, and also a review of the data collection codes to enable code refinement and better code utilisation. This will hopefully lead to a more user friendly data set which provides a window to a greater understanding of how certain injuries occur and why they may be more severe than others. The decreasing numbers of child injury presentations to PMH ED also requires further investigation to determine whether there has been a real decrease in injury occurrence or a combination of other factors. Some of these other factors may include an overall decrease in population in WA; a low annual birth rate; a perceived increase in local services; or the ability to get an urgent appointment to see local GP s. With the proportion of injury presentations remaining slightly above the long term average of 25% and the number of injury presentations remaining consistently high, this highlights the need for the continued presence of organisations such as Kidsafe WA and a continuing focus on the prevention of childhood injuries, particularly unintentional injuries. Every day there is a new group of first time parents in WA who need information and education about child injury prevention. The prevention of childhood injuries needs to be adequately resourced to reduce the burden that childhood injuries place on the health system now and into the future. New approaches to promoting the preventability of major child injuries also need to be investigated in an attempt to engage new parents and halt the increasing number of children sustaining unintentional injuries. 15

RECOMMENDATIONS Injury data collection at PMH needs to continually evolve with changes made as appropriate. Following on from recent additions and alterations to the data collection process, coding changes have again been implemented. A review of the current set of Injury Surveillance Data codes should be undertaken in an attempt to alleviate the number of injuries coded as Other, Unknown or Not Applicable. The data code review should identify how codes could be condensed to enable detailed reporting within short time frames. Once the review is undertaken, a staff update should occur so that everyone is aware of the codes available and how they should be utilised. Although every care is taken to provide consistent data analysis, regular staff changes and individual interpretations may alter the way the data is coded and reported. Constant improvements to the EDIS system and education for the staff utilising the system will hopefully help make any future staff changes a more smooth transition. It is hoped that any future additions and amendments will provide greater access to injury data so that comparisons may be made with data collected and analysed in previous years. Since late 2010, Kidsafe WA has been invited to present on the Injury Surveillance Data at an Emergency Department staff development sessions. This provided a valuable opportunity to discuss with the nursing staff how they feel about the data collection system; what injuries they feel they see most regularly and why; and whether there were any particular injury prevention issues they required more information on. It is important for Kidsafe WA to seek out opportunities to share the way the data is being utilised when interacting with staff at PMH ED. This will ensure that the importance of correctly and comprehensively coding data is highlighted. The resulting strategies to reduce childhood injuries that result from this data should then be regularly presented to PMH ED staff. 16