Linda Quan

Characteristics of drowning by different age groups.

Context: While it is known that the risk of unintentional drowning varies with age, the manner in which drowning episode characteristics vary by age has not been well described. Such information might be useful for prevention. Objective: To describe characteristics of drowning by age group. Design: Retrospective review of the characteristics of drowning victims and their drowning incidents obtained from death certificates, medical examiner, pre-hospital, emergency department, and hospital records. Setting: Three counties in Western Washington state. Subjects: Residents who died (n=709) of unintentional drowning within the study region during 1980 through 1995. Outcomes: Age specific counts, proportions, and rates per million person years were estimated for and compared among six age groups. Results: Rates varied by age group: 0–4 (30.5), 5–14 (11.6), 15–19 (29.9), 20–34 (21.5), 35–64 (12.5), and 65 years or older (21.2). Among those 0–4 years, the proportions that drowned in pools, bathtubs, and open water were nearly equal. But from age 5–64 years, over 69% of deaths were in open water. Among those 65 years and older, the deaths were almost evenly divided between bathtub and open water; bathtub drowning rates were highest in this age group, 10.9. Pre-drowning activities were divided into boating, swimming, car passenger, bathing, and fell in while doing something else. Most (64/89, 76%) victims aged 0–4 years drowned while bathing or after falling in. Among those 15–19 years, most occurred while swimming (24/79, 34%) or boating (22/79, 31%). The drowning event was least often witnessed among those 0–4 years (10/36, 28%), and most often witnessed (44/58, 76%) among those 15–19 years. Medical care (pre-hospital, emergency department, or hospital) was most often involved in drownings of those 0–4 years (70/89, 79%) and least among those over 65 years (11/86, 13%). Conclusion: The characteristics of drowning episodes vary greatly by age. Different prevention strategies may be needed for different age groups.

Predicting outcome in pediatric submersion victims

STUDY OBJECTIVEnTo predict outcome in children after near-drowning.nnnDESIGNnRetrospective cohort study. Vegetative state and death were classified as unfavorable outcomes, whereas all other outcomes were classified as favorable. Demographic, episode-related, clinical, laboratory, and treatment variables available at the time of admission were evaluated for their usefulness in predicting outcome.nnnSETTINGnPediatric referral hospital.nnnPARTICIPANTSnChildren admitted after submersion injury in non-icy waters.nnnRESULTSnThe study cohort comprised 194 children (median age, 2.6 years; range, 5 months to 18 years); 131 were neurologically normal at the time of discharge, 10 had some degree of neurologic impairment, 15 were in a vegetative state at the time of discharge, and 38 died. We used a combination of partitioning and logistic regression to combine variables in a prediction rule that was always correct when unfavorable outcome was predicted. The final rule predicted favorable outcome for all children who were not comatose. Among comatose children, unfavorable outcome was predicted by a combination of absent pupillary light reflex, increased initial blood glucose concentration, and male sex. This rule had a specificity of 100%--children with favorable outcomes were always predicted to do well--and a sensitivity of 65%. Therefore the rule was overly optimistic for 35% of patients with unfavorable outcomes.nnnCONCLUSIONnPediatric submersion victims can be assigned to high or low likelihoods of unfavorable outcome with the use of four variables: comatose state, lack of pupillary light reflex, sex, and initial blood glucose concentration. This prediction rule may be useful if it can be validated in another cohort.

Evaluation of a drowning prevention campaign in King County, Washington

Objectives—A three year drowning prevention campaign focused on increasing the use of life vests among children 1–14 years old. An evaluation was conducted to determine campaign awareness, change in ownership and use of life vests by children, and predictors of life vest use. Setting—King County, Washington. Methods—Four telephone surveys were conducted with parents before, during, and after the campaign. Results—The campaign was recalled by 50% of families surveyed. From before to after the campaign, reported life vest use by children on docks, beaches, or at pools increased from 20% to 29% (p<0.01) and life vest ownership for children increased from 69% to 75% (p=0.06). Among parents aware of the campaign, reported child life vest use increased from 20% to 34% (p<0.001) and ownership increased from 69% to 80% (p<0.01). Among families unaware of the campaign, neither life vest use nor ownership changed significantly. Children were more often reported to wear life vests if a parent knew of the campaign, was confident fitting the vest, was younger than 40 years, felt the child could not swim well, and owned a life vest for the child. Conclusions—A community-wide drowning prevention campaign resulted in a significant, although modest, increase in reported life vest use and ownership among children.

Are life vests worn? A multiregional observational study of personal flotation device use in small boats

Objective—Although life vest use is thought to prevent drowning, their use by boaters has not been described. This study sought to determine the use of personal flotation devices (PFDs) in small boats. Methods—Boaters were observed between April and June 1995 in Washington and Oregon and classified by their age, gender, PFD use, and boat type. Results—Among 4181 boaters, 25% wore a PFD. Use was highest in <5 year olds (91%) and lowest in those over 14 years (13%). Those in kayaks were most likely (78%) and those in motor boats (19%) were least likely to wear a PFD. Females were more likely to wear a PFD than males (relative prevalence 1.5, 95% confidence interval 1.3 to 1.6). When a child less than 15 years was in a boat with an adult, PFD use was 65% if no adult wore a PFD and 95% if at least one accompanying adult wore a PFD (p=0.001). Conclusions—Generally, PFD use by boaters was low in the Northwestern US. Efforts to increase PFD use should target adolescents, adults and specific boating populations, especially those in motor boats.

Analysis of paediatric drowning deaths in Washington State using the child death review (CDR) for surveillance: what CDR does and does not tell us about lethal drowning injury

Background Drowning is second cause of paediatric injury death in Washington State. Child death review (CDR) data provide the unique opportunity to identify regional risk factors and opportunities for drowning prevention. Methods CDR teams data for drowning deaths of children <18u2005years between 1999 and 2003 were analysed for victim and event characteristics, and existing prevention/protective factors. A working group made data driven recommendations. Subsequent interventions were noted. Results Drowning death rates were significantly higher among Asian Pacific Islander children (3.3 per 100u2008000). Disproportionately, 32% of deaths involved families with prior child protective services (CPS) referrals. Most deaths (73%) occurred in open water; the proportion in open water increased from 42% of <5-year-olds, 83% of 5–9-year-olds, to 90% of 10–17-year-olds. Thirty per cent drowned at parks; 29% drowned in residential settings. Pre-drowning activity for 42% was swimming or playing in the water. Alcohol and drug use were low. Neglect/poor supervision was considered a factor in 68% (21/31) of the deaths of children <5u2005years of age. State CDR recommendations led to the development of a drowning prevention campaign targeted to an Asian American community, intra-agency changes resulting in reinstatement of lifeguard staffing and addition of lifejacket loaner programmes, collaboration with state commissions to enforce a state pool fencing ordinance, and model legislation prohibiting swimming in dangerous waterways. Conclusion CDR data collection and review process was an effective surveillance tool. It identified specific regional high risk groups and sites for drowning prevention and led to recommendations and implementation of effective local and state injury prevention interventions.

Outbreak of Escherichia coli 0157:H7 Hemorrhagic Colitis and Hemolytic Uremic Syndrome: Effect on Use of a Pediatric Emergency Department

STUDY OBJECTIVEnTo evaluate the effect of an outbreak of Escherichia coli O157:H7 colitis, and media coverage of the outbreak, on use of an emergency department.nnnDESIGNnReview of pediatric ED use and charges for gastrointestinal illness during the epidemic and during a control period.nnnSETTINGnPediatric ED in Seattle, Washington.nnnPARTICIPANTSnAll children seen in the ED with a gastrointestinal illness during the epidemic period (January and February 1993) and during a control period (January and February 1992).nnnRESULTSnDuring the epidemic, 31 patients with E coli O157:H7 infection had 45 visits to the ED. The number of visits for gastrointestinal illness not caused by E coli O157:H7 was 103% higher in the epidemic period than in the control period (653 in 1992, 1,327 in 1993). The number of visits was closely associated with the number of newspaper stories about E coli O157:H7 illness (correlation coefficient, .88; P = .002). The increased number of evaluations for gastrointestinal illness not caused by E coli O157:H7 infection during the epidemic period was associated with an additional

Impact of a statewide quality improvement initiative in improving the management of pediatric splenic injuries in washington state.

101,193 in charges per month compared with the control period. There were no important differences in the evaluation of gastrointestinal illness between 1992 and 1993 except for an increase in the proportion of patients with stool cultures (13.1% versus 26.4%, P < .001).nnnCONCLUSIONnFor every visit by a patient with E coli O157:H7 infection, there were 15 additional visits (above the baseline from the control period) by patients with other gastrointestinal illness. The true cost of this epidemic included not only the evaluation of patients with disease but also the evaluation of those who presented because they were worried they had the disease. The intensity of media coverage of a disaster may correlate with the number of visits to the ED, and understanding of this fact may help in disaster planning.

Association of hospital trauma designation with admission patterns of injured children.

BACKGROUNDnEvidence suggests that 90% of children with traumatic spleen injuries can be successfully managed nonoperatively. In Washington State, significant interhospital variation in pediatric spleen management led to the development and implementation of a statewide quality improvement initiative in 2002. We evaluated pediatric splenic injury management before and after the implementation of a statewide quality improvement initiative.nnnMETHODSnRetrospective cohort study using data from the Washington Trauma Registry for years 1999-2001 (preintervention) and 2003-2005 (postintervention). Children ages 0 to 14 years who were hospitalized with a traumatic (noniatrogenic) splenic injury were included. Multivariable regression was used to control for patient and hospital characteristics.nnnRESULTSnSplenectomies were more common, occurring in 13.6% of children, in the preintervention period, compared with 7.8% in the postintervention period (p = 0.027). After adjusting for patient, injury, and hospital characteristics, children remained less likely to receive a splenectomy in the postintervention period than in the preintervention period (odds ratio 0.39, 95% confidence interval 0.19-0.82). Children cared for at pediatric trauma hospitals were less likely to receive splenectomy in both the preintervention and postintervention periods, compared with children treated at general trauma hospitals (p < 0.001). Splenectomy remained less common among children treated at pediatric-designated hospitals (odds ratio, 0.21; 95% confidence interval, 0.08-0.58) than among children treated in general trauma hospitals after controlling for intervention period.nnnCONCLUSIONnThe statewide quality improvement initiative was associated with a reduction in the rate of splenectomy in both pediatric and general trauma hospitals. However, general trauma hospitals remained more likely to perform splenectomies than hospitals with pediatric trauma designation.

Evaluation of Resuscitation Skills in New Residents Before and After Pediatric Advanced Life Support Course

BACKGROUNDnLittle is known about the influence of regionalization of trauma care on pediatric trauma care delivery. The purpose of this study was to estimate whether formal adoption of a statewide trauma system was associated with hospital admission patterns of injured children.nnnMETHODSnA longitudinal study of children who were residents of Washington State during 1989 to 1999 was conducted. The main outcome measure was hospital admission for trauma.nnnRESULTSnDuring the 11-year period, there were 24,955 admissions. Admission rates of injured children to pediatric-designated trauma hospitals decreased by 20%, rates at adult-designated hospitals decreased by 60%, and rates at nondesignated hospitals decreased by 66%. Introduction of the trauma system in 1994 was associated with a 12% increase in admission rates to pediatric-designated hospitals, little change (+1%) in admission rates to adult-designated centers, and an 11% decrease in admissions at nondesignated hospitals.nnnCONCLUSIONnTrauma designation in Washington was associated with a shift in admissions from nondesignated hospitals to pediatric trauma hospitals.