Disability in America Toward a National Agenda for Prevention (1991) / Chapter Skim
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5 Prevention of Injury-Related Disability
5 Prevention of Injury-Related Disability
Pages 147-183
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From page 147... ...
Consequently, gains in lives saved by advances in the care of injury victims have contributed to the prevalence of disabling conditions in the United States. Each year an estimated 2.3 million Americans are hospitalized as the 147
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From page 148... ...
The bulk of this loss is attributable to the high incidence of injury and injury-caused disabling conditions among people between the ages of 15 and 44, which encompasses the most productive period of the human life span. Injuries sustained by people in this age group in 1985 resulted in 2.7 million life years lost, or $44 billion in lost productivity.
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From page 149... ...
Nevertheless, these three categories account for a small percentage of the total economic costs of nonfatal injury relative to falls and motor vehicle injuries. Other common causes of injuries include stabbings and other assaults, injuries involving machinery, and sports-related injuries.
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From page 150... ...
Motor vehicle crashes are also a major source of costs due to nonfatal injuries, whereas firearm-related injuries account for about 2 percent of the total. The role of firearms in contributing to the population of people with disabling conditions needs to be carefully evaluated.
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From page 151... ...
The only national data available are from the National Head and Spinal Cord Injury Survey, which estimated a rate of 200 hospitalizations per year per 100,000 people (Kalsbeek et al., 1980~. Applying this annual rate to the projected 1990 U.S.
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From page 152... ...
The estimated 2,000 who sustain the most severe disabling conditions survive in a persistent vegetative state, a term referring to their lack of response to external stimuli (Rice et al., 1989~. Several studies have documented the sequelae of severe TBI, leading to the characterization of TBI as the "silent epidemic" because sequelae are primarily neurobehavioral.
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From page 153... ...
Intentional injuries also represent a major cause, although the contribution of assaults to the overall incidence of head injuries varies among populations according to socioeconomic composition. Studies of inner city Chicago and Bronx County, New York, for instance, indicate that motor vehicle crashes and violence contribute equally to the incidence of head injury (Cooper et al., 1983; Whitman et al., 1984~.
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From page 154... ...
and sports or recreational activity also contribute significantly to the incidence of SCI, each accounting for an estimated 5 percent to 20 percent of all SCIs. Diving is the major cause of sports-related SCI, being implicated in two-thirds of all sports-related SCI reported by the Model Spinal Cord Injury Systems Program.
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From page 155... ...
The National SCI Database has documented that while the proportion of all SCI patients who are quadriplegics remained fixed at about 50 percent between 1973 and 1983, the proportion with neurologically incomplete lesions increased from 38 percent to 54 percent. This increase is attributable, in large part, to improved emergency medical services, including better management of the patient at the scene of the injury and during transport to the hospital.
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From page 156... ...
Because these systems only track injuries of specific etiology, however, they do not provide complete enumeration of all head and spinal cord injuries. Surveys by the National Center for Health Statistics are another source of data on nonfatal injuries, although they are not designed specifically for the purpose of injury surveillance.
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From page 157... ...
The NHDS is an important source of national estimates of the incidence of neurological injuries severe enough to require hospitalization. It consists of hospital discharge abstracts uniformly collected for a probability sample of approximately 200,000 patients treated in nearly 600 short-stay, nonfederal hospitals.
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From page 158... ...
Underreporting of E-codes in hospital discharge abstracts has been recognized as a major obstacle in the use of this valuable source of data for monitoring the causes and trends of injuries (National Research Council, 1985; Sniezek et al., 1989; U.S. National Committee for Injury Prevention and Control, 1989; Rice et al., 1989~.
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From page 159... ...
Standard case definitions of TBI are needed and should be developed to facilitate this activity. PRIMARY PREVENTION: THE STRATEGY OF CHOICE An agenda for the prevention of disability associated with traumatic brain and spinal cord injury must place a priority on preventing the injury from occurring in the first place.
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From page 160... ...
were put in general practice, the result would be a dramatic saving in lives, health, and resources." A recent review of the literature on the evaluation of injury prevention programs estimated that, for those interventions for which adequate data are available, the potential cost savings, after the cost of the injury control programs, is in the billions of dollars (Rice et al., 1989~. For example, a promotional campaign developed in Australia to increase use of bicycle helmets has led to a documented 20 percent reduction in head injuries among bicyclists.
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From page 161... ...
. c nv~ng Raising state and federal alcohol excise taxes to reduce alcohol availability Server training programs directed at waiters, waitresses, and bartenders Educational programs to prevent impaired driving among youths and young adults Use of road edgelines and wrong-way signs Institute a lower BAC for teenage drivers Use of sobriety checkpoints Alcohol safety education schools for convicted drunk drivers Designated driver Ignition interlock systems Use of certain roadway countermeasures, including raised lane delineators, rumble strips, and herringbone patterns Improvement of safety belt systems to provide optimal protection and comfort for children under the age of l4 and the Requiring safety belt use by employees who drive in federal, state, municipal, or private fleet motor vehicles Local ordinances re quiring taxicabs to have accessible and usable safety belts Requiring rental car elderly companies to provide Development loaner child safety and use of safety seats for low birthweight infants seats Educational and behavioral change interventions for increasing safety belt and child safety seat use
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From page 162... ...
SOURCE: U.S. National Committee for Injury Prevention and Control, 1989.
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From page 163... ...
National Committee for Injury Prevention and Control, 1989~. It has been estimated that in 1985 nearly one-third of the costs associated with direct health care expenditures and 27 percent of transfer payments due to injury were paid by public sources (Rice et al., 1989~.
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From page 164... ...
Another conclusion that can be drawn from the literature is that comparatively little is known about the risk factors associated with falls; possible countermeasures are rarely researched (National Research Council, 19854. Falls rank highest among all nonfatal injuries in both incidence and cost, and constitute a leading cause of disabling conditions in the United States; nevertheless, there is limited information about the risk factors associated with falls (National Research Council, 1985~.
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From page 165... ...
In the hospital, definitive stabilization of the spine and measures to prevent such complications as deep vein thrombosis, pulmonary emboli, pneumonia, contractures, and decubiti must be performed by experienced personnel. Medical rehabilitation services should begin immediately in the acute phase to minimize physical deterioration and prevent further impairment and functional limitation due to loss of strength and range of motion, bladder and bowel incontinence, and inadequate or inappropriate training and provision of equipment.
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From page 166... ...
Therefore, skills learned in an inpatient acute care or rehabilitation facility may not be transferable to community living. Transitional living centers, day treatment programs, and outpatient services become important components of a coordinated approach to caring for TBI survivors.
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From page 167... ...
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From page 168... ...
Emergency Medical Services The nature of the trauma determines the initial severity of the injury to the central nervous system and to a substantial degree also determines the extent of the resulting impairment and functional limitation. Sufficient trauma to the brain may result in cardiopulmonary death, and direct injury to the upper cervical spinal cord may result in death due to paralysis of the muscles of respiration.
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From page 169... ...
Increased understanding of Evaluation is needed of current pathophysiology has been methods to stabilize the spine gained in animal studies, and their effects on neurologi as well as increased un- cat recovery in SCI. derstanding of the mecha- Evaluation is needed of the effec nisms and dynamics of tiveness of triage of patients spine and spinal cord with TBI and SCI to trauma injury in animal models.
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From page 170... ...
Increased long-term incidence of arthritis in the shoulders and progressive weak ness in the older SCI patient needs study. Cardiovas- Prevention of deep vein throm- Larger clinical trials are needed to cular/ basis in SCI has recently demonstrate the effectiveness of pulmo- been reported with use of deep vein thrombosis and pulmo nary electrical stimulation and nary embolus prevention.
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From page 171... ...
New devices and electrical stimulation for prevention of pressure sores need further investigation. Factors that contribute to pressure sores postdischarge need further study to identify effective interventions.
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From page 172... ...
Coma stimulation pro grams, day care, and transitional living pro grams have proliferated in recent years in re sponse to the needs of a large TBI population. Recent studies identify recovery from the persis tent vegetative state (PVS)
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From page 173... ...
Peer counseling through independent living centers has (perceived) value to individual adjustments.
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From page 174... ...
These associated injuries include fractures of long bones, skull, and spine; chest and abdominal injuries; and peripheral nerve damage (Stover and Fine, 1986~. The high incidence of associated injuries is related to the major role that motor vehicle crashes play in causing central nervous system trauma.
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From page 175... ...
Deep vein thrombosis is a very common medical complication and occurs in 80 percent to 100 percent of completely paralyzed SCI patients, leading to pulmonary embolism, one of the most frequent causes of early death. Recent studies provide evidence of effective methods of prevention, and these methods should be used more widely (Merli et al., 1988; Green et al., 1988~.
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From page 176... ...
In terms of the committee's disability model, it is important to establish the stage in the progression, the risk factors, and the relevant preventive interventions. Depending on the type of impairment, for example, different interventions can be used during rehabilitation to help prevent the development of functional limitations.
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From page 177... ...
has demonstrated that treatment with methylprednisolone within 8 hours of spinal cord injury significantly improved the recovery of motor and sensory function. Because most people with acute SCI are admitted to a hospital within the critical 8hour period, this intervention has great potential for reducing disabling conditions.
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From page 178... ...
With skillful training, more than 90 percent of SCI patients are capable of bladder and bowel continence. Training also includes education on how to avoid bladder infection and prevent other potentially disabling conditions.
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From page 179... ...
rehabilitation is an important component of the systems approach to acute care and rehabilitation. However, because impairments in strength, tone, coordination, and information transmission may be superimposed on cognitive and behavioral impairments, better indexes that integrate impairment, functional limitation, and disability need to be developed to determine the effectiveness of rehabilitation interventions.
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From page 180... ...
These centers are primarily staffed by individuals with disabling conditions and provide a supportive network for individuals who want to achieve an independent lifestyle. The importance of independent living centers to the welfare of people with disabling conditions cannot be overemphasized.
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From page 181... ...
Despite some questions about the efficacy of the increasing number of alternative strategies for rehabilitating people with SCI or TBI, it is clear that a wide range of community services are needed. It is also clear that many people who need these services do not receive them, and that quality psychosocial and vocational rehabilitation services aimed at reintegrating persons with disabling conditions into the community and back to work should be available to those who need them.
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From page 182... ...
Additional problems arise when the primary caregiver dies. Society must face the challenge of providing appropriate and adequate support to individuals with major physical and neurobehavioral disabling conditions.
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From page 183... ...
Although considerable progress has been made in accurately describing and establishing injury as a major public health concern, greater resources must be directed to the prevention of injuries by applying existing knowledge and by developing new intervention strategies. Available resources for injury prevention research and practice should reflect the importance of injury as one of the leading causes of disability.
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