Abstract Injuries are the leading cause of travel-related mortality worldwide and a significant reason for tourist hospital admissions. This study examined data on all admissions of overseas visitors to hospitals in Queensland, Australia (N=2598) over a fiveyear period. The main reasons for admission were motor vehicle crashes (21.8%) and water-related injuries (17.7%). Important, but less common were venomous bites (3.8%), horse riding accidents (3.0%), and overexertion (1.7%). Most admissions appear to be related to visitors being in an unfamiliar environment or participating in unfamiliar activities. The study confirms findings from other travel medicine investigations that overseas visitors are most likely to be injured on the roads and in the water. However, the frequency of adventure-related accidents and emerging areas of injury such as animal bites, highlight the importance of providing targeted health and safety messages for overseas visitors travelling to Australia. Professor Jeffrey Wilks is Director, Centre for Tourism and Risk Management, The University of Queensland, Ipswich, Australia. Dr Michael Coory is a Medical Epidemiologist with Queensland Health, Brisbane, Australia. Overseas Visitor Introduction Injuries in Queensland Hospitals: 1996-2000 Jeffrey Wilks and Michael Coory Injuries are the leading cause of travel-related mortality worldwide (Hargarten & Güler Gürsu, 1997), accounting for up to 25 times more deaths than infectious disease. Injuries to tourists are also a significant burden to hospitals and health care systems, both at the tourist destination (Colville, Burgess, Kermani, Touquet & Fothergill, 1996; Walker, Wilks, Ring Nicol, Oldenburg & Mutzelburg, 1995; Walters, Fraser & Alleyne, 1993) and in terms of continuing care when the patient returns home (Cossar, 1996). In order to reduce the number and severity of injuries experienced by tourists, it is important to first understand the number and type of injuries that currently occur. Travel medicine research shows that tourists are most likely to be injured while in unfamiliar surroundings and engaged in unfamiliar activities (Page & Meyer, 1997). For example, tourists are most often injured in motor vehicle crashes (Wilks, 1999) and in water-related recreation (Wilks & Atherton, 1994). Tourist injury profiles show that fractures, lacerations and open wounds are the main reasons for hospital presentation (Hartung, Goebert, Taniguchi & Okamoto, 1990; Nicol, Wilks & Wood, 1996; Walker et al., 1995). As international visitor numbers again increase post the 11 September 2001 terrorist attacks, it is important that health and 2 THE JOURNAL OF TOURISM STUDIES Vol. 13, No. 1, MAY 02
tourism authorities have accurate information on the types of injuries tourists experience, and also the health services they require. Some of these services may be specialised and relatively expensive. For example, recent studies have identified decompression illness, associated with scuba diving, as a significant cause of hospital admission for overseas visitors to Queensland (Nicol, Wilks & Wood, 1996; Wilks & Coory, 2000). Decompression illness requires treatment in a hyperbaric facility (Ramsay & Goble, 1993), and in many cases transfer to the hospital by aircraft carrying a portable chamber over considerable distance. Given the resources involved in such a medical retrieval and treatment, accurate information on visitor injury patterns is essential for health service planning. Monitoring of tourist injuries will also alert authorities to changes in tourist activity and their associated risks. For example, Bentley and his colleagues (Bentley, Meyer, Page & Chalmers, 2001) report that approximately 19% of all injuries to tourists in New Zealand involved recreational/adventure tourism activities, corresponding to 8.4 injuries per 100,000 overseas visitor arrivals. The main areas of injury identified by Bentley, Meyer et al. involved independent-unguided recreation, notably skiing, mountaineering and tramping. Among commercial adventure activities, horse riding and cycling were the cause of most tourist injuries. To date, there has been no national study of tourist health and safety in Australia, though the advantages of such investigation are well documented (Wilks & Grenfell, 1997; Wilks & Oldenburg, 1995). In the most comprehensive Australian study so far undertaken, Nicol and her colleagues (Nicol et al., 1996) analysed medical record data from seven regional hospitals in Queensland to determine the types of injury that resulted in overseas visitors being admitted to hospital. They found that motor vehicle crashes were the leading cause of injury admission, followed by decompression illness associated with scuba diving. A small number of transport accidents involving bicycles and animals being ridden were also identified. However, because the seven hospitals in the sample were all coastal facilities, it was not clear whether the injury profile obtained was representative of all overseas visitors in the State. The present study addressed this question by extending the work of Nicol et al. (1996) to an investigation of all hospital admissions for injury involving overseas visitors in Queensland over a five-year period. The main objective was to determine the number and causes of injuries, amount of time spent in hospital and the conditions treated. We were also interested in any emerging areas of injury associated with adventure tourism activities. Methods Data on admissions of overseas visitors to all 161 Queensland hospitals (12 regional, 22 Brisbane metropolitan and 76 rural public hospitals, and 51 private hospitals) were obtained from the Queensland Hospitals Admitted Patient Data Collection - QHAPDC (Queensland Health, 1998). The study period covered the five financial years 1995/96 to 1999/2000. QHAPDC collects data on the demographic characteristics of the patient, the diagnoses that influenced the current admission, the procedures that were performed and the event or accident leading to an injury (termed the external cause ). In July 1999 Queensland hospital coding changed from the International classification of diseases, version 9, clinical modification (ICD-9-CM) codes (National Coding Centre, 1996) to that of the ICD-10 (National Centre for Classification in Health, 2000). For injuries and external causes there is generally a straightforward concordance between ICD-9 and ICD-10 codes [ h t t p :// w w w. c c h s. u s y d. e d u. a u / n h c /, c accessed 10 July 2001], so that the change from ICD-9 to ICD-10 did not affect this study. We initially selected all records from QHAPDC where the principal diagnosis was an injury (ICD-9: 800 to 996, ICD-10: S00 to T79) and the patient s usual residence was overseas (3002 people). The principal diagnosis is the condition chiefly responsible for the patient s admission (Queensland Health, 1998). We then excluded those people who came to Queensland for treatment following an injury in their own country, specifically patients from Papua New Guinea (190, 6.3%) and the Pacific Islands (35, 1.2%). We also excluded those patients who gave their country-of-birth as Australia, but their curr ent address as overseas because it is probable that these patients were temporarily returning to Australia for treatment of an injury received while living overseas (179, 6.0%). This left 2598 overseas visitors; 1384 (53.3%) were male. The median age of the visitors was 27 years, with an inter-quartile range of 22 years to 47 years. Length-of-stay in hospital was calculated according to the national standard: date-ofdischarge minus date-ofadmission; a same-day patient is allocated a length-of-stay of one day (Australian Institute of Health and Welfare, 1999). Our analysis was based on people not admissions; the 2598 overseas visitors in our study accounted for 3083 admissions. We added the bed days for overseas visitors, who were admitted more than once, so that their lengths-of-stay reflected the combination of all their admissions to Queensland hospitals. This was mainly an issue for those overseas visitors with decompression illness who THE JOURNAL OF TOURISM STUDIES Vol. 13, No. 1, MAY 02 3
often had several shor t admissions. Results Table 1 shows the types of injuries for which overseas visitors were admitted to Queensland hospitals. Motor vehicle crashes were the most frequent cause of injury, followed by falls and diving accidents. Important, but less common were venomous bites, horse riding accidents and overexertion. The other category mostly included injuries where the cause was not stated. Table 2 shows the main conditions treated following an injury. Fractures were the most frequent conditions treated, followed by decompression illness, open wounds and minor head injury. The other category mainly included injuries of unspecified type. Table 3 shows the number of hospital bed days occupied by overseas visitors with injuries and their average length of stay, by hospital type. Regional hospitals recorded the largest number of admissions and the most occupied bed days. Together, the 12 regional hospitals in this study provided services to 1389 overseas visitors (53.5% of the admitted patients). The 22 Brisbane metropolitan hospitals treated 313 overseas visitors (12.1% of the admitted patients), but generally recorded longer stays (average, 7.6 days). An examination of specific injuries treated according to hospital type revealed that most motor vehicle injuries (46.9%), diving accidents (93.0%) and near drowning (82.7%) were treated in regional public hospitals, while most horse riding accidents (51.9%) were treated in rural hospitals. Regional and rural hospitals were similar in the proportion of dog and other nonvenemous animal bites they treated (41.5%) and injuries to Table 1: Type of Injury-Related Incident for Overseas Visitors Admitted to Queensland Hospitals, 1995/96 to 1999/2000 No. (%) Type of Injury-Related Incident Overseas Visitors Motor vehicle traffic accident 567(21.8) Fall on level ground, slip or stumble 408(15.7) Diving accidents 302(11.6) Fall from height, fall from one level to another 250 (9.6) Struck accidentally by object or person 121 (4.7) Bite from venomous spider, snake, marine animal 99 (3.8) Fight, rape, assault 94 (3.6) Accidental laceration 92 (3.5) Drowning, near drowning 81 (3.1) Water transport accident 79 (3.0) Horse riding accident 77 (3.0) Dog bite and other non-venomous animal bites 6 (2.5) Other transport accident 44 (1.7) Overexertion 43 (1.7) Fire, smoke or heat 37 (1.4) Suicide and intentional self harm 30 (1.2) Suffocation, inhalation of food or foreign body 2 (1.1) Accidental poisoning 28 (1.1) Other 153 (5.9) Total 2598(100.0) overseas visitors caused by fire or heat (32.4%). Discussion Tourist health and safety is now an important concern for travel destinations worldwide (World Tourism Organization, 1997; 2002). Tourists are actively turning away from places where they are likely to be at personal risk from crime, terrorism and infectious disease (Pizam & Mansfeld, 1996; Wilks, 2001). At the same time there is huge growth in adventure tourism activities, which by definition contain some element of risk, and also independent travel to Table 2: Main Conditions Treated Following an Injury-Related Incident for Overseas Visitors Admitted to Queensland Hospitals, 1995/96 to 1999/2000 No. (%) Main Condition Treated Overseas Visitors Fractures 962(37.0) Decompression illness 291(11.2) Open wound 291(11.2) Minor head injury 152 (5.9) Dislocation, ligament damage 141 (5.4) Venomous bites 99 (3.8) Drowning, near drowning 90 (3.5) Contusions, abrasions 86 (3.3) Major trauma at multiple sites 74 (2.8) Moderate or severe head injury 53 (2.0) Poisoning 46 (1.8) Injury to intra-thoracic, abdominal or pelvic organ 43 (1.7) Burns 40 (1.5) Spinal cord injury 22 (0.8) Foreign body 21 (0.8) Amputation 20 (0.8) Injury to peripheral nerve/s 15 (0.6) Injury to blood vessel/s 7 (0.3) Crush injury, single site 2 (0.1) Other 143 (5.5) Total 2598(100.0) 4 THE JOURNAL OF TOURISM STUDIES Vol. 13, No. 1, MAY 02
outback and remote locations. Queensland is a leading destination for adventure travel, so it is important that regular monitoring be undertaken to identify areas of potential risk for visitors. The present study confirms a now common international finding that overseas visitors are most likely to experience difficulties in unfamiliar environments and while participating in unfamiliar activities (Bentley, Meyer et al., 2001; Bentley, Page et al., 2001; Page & Meyer, 1997; Wilks, 2002; World Tourism Organization, 2002). Motor vehicle crashes were the leading cause of hospital injury admissions. Driving on the opposite side of the road to that which is familiar, fatigue and not wearing seatbelts have all been identified as key factors in overseas visitor crashes in Queensland (Wilks, Watson & Hansen, 2000). Decompression illness associated with scuba diving was the second major area for hospital injury admissions. In a previous report focusing on overseas visitors and water-related injuries we argued that scuba diving safety should be a continuing priority for tourism and health authorities in Queensland (Wilks & Coory, 2000). The present study confirms the significance of scuba diving accidents in comparison to all other injuries involving overseas visitors. While scuba diving is the most obvious adventure tourism activity identified among hospital injury admissions, horse riding also emerged as a substantial source of injury in Queensland, just as it has in New Zealand (Ben tley, Mey er et al., 2001). Other injuries that appear to be related to adventure activities include near drowning (81 cases) and accidents associated with watercraft (79 cases). Unfortunately, many of the hospital codes that capture adventure activities are very general (Queensland Health, 1998). To Table 3: Bed Days Occupied by Overseas Visitors Involved in Injury-Related Incidents and Average Length of Stay, by Hospital Type, 1995/96 to 1999/2000 No (%) Occupied Average Length Hospital Type Overseas Visitors Bed Days of Stay (days)* Public Regional 1389 (53.5) 5555 (52.1) 4.0 Brisbane 313 (12.1) 2373 (22.3) 7.6 Rural 534 (20.6) 995 (9.3) 1.9 Private 362 (13.9) 1744 (16.4) 4.8 Total** 2598(100.0) 10667(100.0) 4.1 * Average length of stay per overseas visitor; multiple admissions for the same overseas visitor were combined **Percentages rounded to 100 gain a more detailed understanding of injury causes for overseas visitors would require manual inspection of hospital charts, an approach that is labour intensive but has proven very valuable in previous research (Walker et al., 1995). Australia is acknowledged as having some of the most venomous animals and insects in the world (Sutherland & Nolch, 2000). The frequency of hospital admissions for bites from spiders, snakes and marine animals therefore requires attention by both tourism and health authorities. Most overseas visitor injuries in this study (74%) were treated in rural and regional public hospitals, reflecting the larger number of tourists moving about in rural and remote locations. Given the current interest in ecotourism worldwide (McKercher, 1998) and the gr eater accessibility to remote locations, it is essential that overseas visitors have some knowledge of local animals/ insects and also basic skills in first aid. Of the 99 venomous bites and stings recorded, 5 (5.1%) were by snakes, 5 (5.1%) by spiders, 5 (5.1%) were not specified and 84 (84.8%) were by m ar in e ani mals. T hi s aga in points to water-related activities as an area where overseas visitors are likely to experience difficulties. While the number of bites and stings reported here is small compared to general population reports of human injuries caused by animals in the United States (Conover, Pitt, Kessler, DuBow, & Sanborn, 1995) the present study provides only a single snapshot of all tourist injuries. Future studies might also examine the extent to which bites and stings are being treated by other health services (e.g., outpatient departments, clinics, general practitioners, ambulance and lifesaving groups), since hosp ital admissions only represent the most serious injuries (see Wilks, Walker, Wood, Nicol, & Oldenburg, 1995). Both overseas (Colville et al., 1996; Walters et al., 1993) and Australian studies (Nicol et al., 1996; Walker et al., 1995) show that the financial and resource costs to hospitals of treating international visitors can be substantial. In keeping with the movement of tourists along the Queensland coast, and the locations where most concentrated tourist activity occurs, regional public hospitals in this study accounted for 53.5% of overseas visitor admissions and 5,555 (52.1%) occupied bed days. Rural hospitals also provided substantial services, with 20.6% of all visitor admissions and 995 (9.3%) occupied bed days. In terms of predominant service, regional hospitals treated 46.9% of motor vehicle crashes and 82.0% of water-related injuries (diving, drowning and water THE JOURNAL OF TOURISM STUDIES Vol. 13, No. 1, MAY 02 5
transport combined); the two areas where overseas visitors are most likely to experience injuries. As highlighted in our earlier research (Nicol et al., 1996), many of these services are very resource-intensive and place a financial burden on the host hospital. In order to maintain high levels of care for nonresidents, some financial acknowledgement must be given to rural and regional hospitals with substantial visitor responsibilities. Finally, the profile of tourist injuries reported in this study is very similar to that obtained from an earlier investigation of seven Queensland coastal hospitals over a one-year period (Nicol et al., 1996). In both studies, fractures, decompression Monitoring of visitor injuries should be a central component of risk management and customer care everywhere. illness and open wounds were the main conditions treated. However, the present study provides the most comprehensive Australian coverage to date of the external causes for these treatments. As recommended by the World Tourism Organization (2002), regular hospital monitoring of visitor injuries and their causes should be a central component of risk management and customer care for all tourist destinations. In order to provide the most effec tive risk management responses, tourist destinations need to determine whether overseas visitors differ from domestic visitors and local residents in their reasons for hospital admission, and also whether there are sub-groups of overseas visitors (e.g., non- English speakers) who are experiencing particular types of difficulty. For example, previous Queensland hospital research has found significant differences between overseas visitors, interstate visitors and local residents in water-related injury rates. In particular, overseas visitor hospital admissions for dec ompression illness were significantly higher than those of the other groups (Wilks, 2002). In relation to non-english speaking visitors, hospital data is more limited since language spoken is not a variable routinely collec ted on admission. For reasons of patient confidentiality, even nationality is often not available for analysis. However, alternative sourc es of government information, such as official reports of tourist injuries or deaths, clearly indicate that some international tourist groups experience proportionally more problems than others. For example, the results of a recent study revealed that in two Australian jurisdictions German, English, American and Japanese tourists were more frequently involved in motor vehicle crashes than other nationalities (Wilks & Watson, 2000). Such findings assist tourism authorities to produce education and prevention materials in the correct language for the target groups, and to deliver the materials to visitors before they leave home on their journey (World Tourism Organization, 2002). Very specific information on tourist accidents and injuries is hard to obtain (Wilks, 2002). The main point of this paper, and the true value of hospital monitoring, is that patterns of injury affecting overseas visitors can be conveniently identified in all jurisdictions because most hospitals worldwide collect patient data in a standard format (ICD-9-CM or ICD-10). Hospital data can be used to identify particular areas and activities where overseas visitors experience problems (e.g., decompression illness associated with scuba diving), as well as providing a benchmark over time 6 THE JOURNAL OF TOURISM STUDIES Vol. 13, No. 1, MAY 02
to assess the effectiveness of government and industry programs aimed at inj ury prevention. Hospital data has some limitations due to issues of patient confidentiality and in terms of specifically identifying tourists and tourist-related activities. Nevertheless, it is a valuable tool to monitor trends in tourist health and safety. Conclusions By world standards, Queensland is a safe destination for overseas visitors. However, road and water safety must remain the State s two priorities. The emerging area of venomous bites, and general injuries associated with adventure activities, also highlight the importance of public health information being made available to visitors, especially those travelling to outback and remote locations (Peach & Bath, 2000). The recent agreement by the Tourism Ministers Council to develop a national program aimed at ensuring the safety of international visitors to Australia is a very positive step (Ministerial Press Release, 2001). Regional and rural hospitals continue to provide the majority of services to overseas visitors in Queensland. This fact must be considered in tourism and health authorities future planning and resource allocation. References Australian Institute of Health and Welfare. (1999). National health data dictionary, version 8. Canberra: AIHW (Catalogue No. HWI 18). Bentley, T., Meyer, D., Page, S., & Chalmers, D. (2001). Recreational tourism injuries among visitors to New Zealand: An exploratory analysis using hospital discharge data. Tourism Management, 22, 373-381. Bentley, T., Page, S., Meyer, D., Chalmers, D., & Laird, I. (2001). How safe is adventure tourism in New Zealand? An exploratory analysis. Applied Ergonomics, 32, 327-338. Colville, J., Burgess, A., & Kermani, C., Touquet, R., & Fothergill, J. (1996). The cost of overseas visitors to an inner city accident and emergency department. Journal of Accident and Emergency Medicine, 13, 16-17. Conover, M.R., Pitt, W.C., Kessler, K.K., DuBow, T.J., & Sanborn, W.A. (1995). Review of human injuries, illnesses, and economic losses caused by wildlife in the United States. Wildlife Society Bulletin, 23, 407-414. Cossar, J.H. (1996). Travellers health: A medical perspective. In S. Clift & S.J. Page (Eds), Health and the international tourist (pp. 23-43). London: Routledge. Hargarten, S.W., & Güler Gürsu, K. (1997). Travel-related injuries, epidemiology, and prevention. In H.L. DuPont & R. Steffen ( E d s ), Textbook of travel medicine and health (pp. 258-261). Hamilton, Ontario: BC Decker. Hartung, G., Goebert, D., Taniguchi, R., & Okamoto, G. (1990). Epidemiology of ocean sports-related injuries in Hawaii: Akahele O Ke Kai. Hawaii Medical Journal, 49, 52-56. McKercher, R.D. (1998). The business of nature-based tourism. Melbourne: Hospitality Press. Ministerial Press Release. (2001). Rose gets TMC tourist safety s u p p o r t. Press release from the Queensland Minister for Tourism, Racing and Fair Trading, Merri Rose, 26 July. National Centre for Classification in Health. (2000). I n t e r n a t i o n a l Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (2nd ed.). Sydney: University of Sydney. National Coding Centre. (1996). International Classification of Disease, 9th Revision, Australian Clinical Modification. Sydney: University of Sydney. Nicol, J., Wilks, J., & Wood, M. (1996). Tourists as inpatients in Queensland regional hospitals. Australian Health Review, 19, 55-72. Page, S.J., & Meyer, D. (1997). Injuries and accidents among international tourists in Australasia: Scale, causes and solutions. In S. Clift & P. Grabowski (Eds), Tourism and health: Risks, research and responses (pp. 61-79). London: Pinter. Peach, H.G., & Bath, N.E. (2000). Health and safety problems and lack of information among international visitors backpacking through North Queensland. Journal of Travel Medicine, 7, 234-238. Pizam, A., & Mansfeld, Y. (1996). Tourism, crime and international security issues. Chichester, England: John Wiley & Sons. Queensland Health. (1998). Manual for the Queensland hospital admitted patient data collection. Brisbane: Queensland Health. Ramsay, B., & Goble, S. (1993). Hyperbaric chambers. In J. Wilks, J. Knight & J. Lippmann (Eds), Scuba safety in Australia (pp. 29-41). Melbourne: JL Publications. Sutherland, S.K., & Nolch, G. (2000). Dangerous Australian animals. Melbourne: Hyland House. THE JOURNAL OF TOURISM STUDIES Vol. 13, No. 1, MAY 02 7
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