Childhood Crash Injury Patterns Associated with Restraint Misuse: Implications for Field Triage

Adequacy of Emergency Department Documentation of Child Restraint Use After a Motor Vehicle Crash

OBJECTIVES

There are limited data on how often providers collect and document adequate restraint information in children seen in the emergency department (ED) after motor vehicle crashes (MVCs). The objectives of this study are to determine (1) how often adequate child restraint information to determine age-appropriate use is documented after MVC; (2) the frequency of incorrect use of the child restraint when adequate details are documented; and (3) for those discharged from the ED with identified incorrect use, the frequency of provision of information on child passenger safety (CPS).

METHODS

Retrospective chart review of visits of children younger than 13 years with an International Classification of Diseases, Tenth Revision code for MVC to an urban, academic, level 1 pediatric trauma center, from October 2015 to September 2018. Adequate documentation of child restraint use was defined as identification of location of the child in the car (front vs rear row), type of restraint used, and forward or rear facing for children 24 months or younger.

RESULTS

A total of 165 visits qualified for inclusion. There was adequate documentation in 46% of visits. Of those, incorrect child restraint use was identified in 49%. Of discharged patients with incorrect use, 10% had documentation of provision of CPS information.

CONCLUSIONS

Adequate details to determine proper age-appropriate restraint use are documented in only half of ED visits for MVC. Very few are given CPS instructions on discharge, even when incorrect use has been identified. Identification of incorrect restraint use in the ED is an opportunity for a teachable moment that is being underused.

An Adapted Child Safety Seat Hassles Score Is Associated With Suboptimal Child Passenger Safety Behaviors Among Parents

OBJECTIVE

We modified the Child Safety Seat (CSS) Hassles Scale to characterize CSS hassles in a diverse population and test for associations between hassles and caregiver-reported child passenger safety behaviors.

METHODS

Secondary analysis of a 2-site survey of caregivers seeking emergency care for their ≤10-year-old child in 2015. Caregivers answered questions regarding CSS hassles, child passenger safety behaviors, and demographics. Size-appropriate restraint use was defined by the American Academy of Pediatrics (AAP) 2011 Guidelines for Child Passenger Safety. We tested for associations between the number of hassles and adherence to AAP guidelines (including the consistent use of a size-appropriate CSS, travel in a back seat, and never traveling unrestrained).

RESULTS

There were 238 caregivers included in analyses. Overall, caregivers endorsed a median of 5 hassles (interquartile range 2, 8). Half (50.8%) of caregivers endorsed child passenger safety behaviors that were nonadherent to AAP guidelines. Compared with caregivers reporting no hassles, there was an increased odds of not adhering to AAP child passenger safety guidelines for each additional hassle reported (adjusted odds ratio [aOR] 1.11; 95% confidence interval [CI] 1.03, 1.19). In addition, a higher number of hassles was associated with the inconsistent use of a size-appropriate CSS (aOR 1.15; 95% CI 1.06, 1.25) and as sometimes traveling unrestrained (aOR 1.13; 95% CI 1.03, 1.23).

CONCLUSIONS

Caregivers who reported more CSS hassles were more likely to report behaviors that were not adherent to AAP guidelines. Addressing CSS hassles may provide solutions for nonadherence of AAP child passenger safety guidelines.

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair

Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

System providing automated feedback improves task learning outcomes during child restraint system (CRS) installations

OBJECTIVES

The objective was to build and test an automated, interactive educational system to teach adults how to install a child restraint system (CRS) into a vehicle seat.

METHODS

The automated feedback system (AFS) consisted of a mockup vehicle fixture, convertible CRS, and doll. Sensors were implemented into the equipment so that forward-facing (FF) CRS installation errors could be detected. An interactive display monitor guided users through the CRS installation process and alerted them when steps were done incorrectly. Sixty adult volunteers were recruited and randomized into either the treatment group or the control group. The treatment group used the AFS to guide them through a practice installation. The control group also completed a practice installation using the same equipment fixture without the feedback feature turned on; they only had standard printed instruction manuals to guide their tasks. Then, participants from both groups completed a second CRS installation in a real vehicle with standard instruction manuals only. The frequencies and types of errors in all the installations were evaluated by a Child Passenger Safety Technician (CPST). Error rates were compared between the treatment and control groups using lower-tailed t-tests and Pearson's chi-square tests. Error rates were evaluated considering minor and serious errors together and also considering serious errors alone.

RESULTS

Compared to the control group, participants who trained with the AFS exhibited fewer overall errors (minor and serious) in their fixture installations (p < 0.0001) as well as their follow-up vehicle installations (p < 0.0001). Specifically, participants in the treatment group had fewer errors in choosing an installation method, locking the seat belt (SB), tightening the SB or lower anchors (LA), and tightening the harness (p = 0.0002, p = 0.0003, p = 0.0084, and p = 0.0098, respectively, compared to control group during follow-up vehicle installations). The treatment group also performed significantly better than the control group when only serious errors were considered.

CONCLUSIONS

An automated feedback system is an effective way to teach basic CRS installation skills to users.

Cross-chest clips in child restraints: A crash testing study

Objective: Cross-chest clips are widely used in North American child restraints but are less common in other countries, partially due to concerns over anterior neck contacts in frontal crashes. They have recently been reported to be associated with lower odds of injury in real-world crashes, but there is a paucity of crash test performance information. This study aimed to compare the dynamic performance of a small child occupant in frontal crash tests with and without cross-chest clips in place. Methods: Frontal sled tests at 49 km/h were conducted to compare 2 cross-chest clip designs to nonuse of a chest clip. Tests using a P3/4 anthropomorphic test device (ATD) to represent the smallest occupant in a forward-facing child restraint were conducted with the chest clips in the recommended position and also in an incorrect lower position and with and without additional harness slack present. Results: Though contacts were observed between the chest clips and the base of the ATD's neck, there was little difference observed in head excursion or ATD sensor loads in the presence of the chest clips. No detectable change in the neck forces or moments was detected at the time of the neck contacts. The position of the clips did not affect the results. Harness slack increased head excursion, as expected, but this effect did not differ between the tests with and without the clips. Conclusions: Cross-chest clips do not appear to greatly influence the dynamic performance of a forward-facing child restraint in a simulated frontal crash. Taken together with recent research suggesting a potential benefit in injury reduction from the clips in the real world, possibly due to maintaining the harness straps in place on a child's shoulders, it may be appropriate to re-evaluate safety standards that prevent their use.

Factors Associated With Child Restraint Use in Motor Vehicle Crashes

Motor vehicle crashes (MVCs) are a leading cause of death among children. Multivariable analyses of age-appropriate child restraint system (CRS) use in the "booster-aged" population are needed. The current study identified factors associated with age-appropriate CRS use in fatal MVCs for children 4 to 7 years old, using 2011 to 2015 data from the Fatality Analysis Reporting System. Of 929 MVC fatalities, 32% of fatally injured children were in an age-appropriate restraint. While age-appropriate CRS use was higher for 4-, 5-, and 6-year-olds relative to 7-year-olds (adjusted relative risk [aRR] = 2.57, 2.51, and 2.18, respectively; p < .01 for each comparison), black children (aRR = 0.62; p < .01) relative to white children, and drivers who had not used a lap-shoulder belt (aRR = 0.40; p < .01) relative to belted drivers were associated with lower levels of age-appropriate CRS use. Our findings underscore the continued importance of communicating best practice guidelines on CRSs to caregivers of young children.

The effect of correct cross-chest clip use on injury outcomes in young children during motor vehicle crashes

OBJECTIVE

Traffic crashes have high mortality and morbidity for young children. Though many specialized child restraint systems improve injury outcomes, no large-scale studies have investigated the cross-chest clip's role during a crash, despite concerns in some jurisdictions about the potential for neck contact injuries from the clips. This study aimed to investigate the relationship between cross-chest clip use and injury outcomes in children between 0 and 4 years of age.

METHODS

Child passengers between 0 and 4 years of age were selected from the NASS-CDS data sets (2003-2014). Multiple regression analysis was used to model injury outcomes while controlling for age, crash severity, crash direction, and restraint type. The primary outcomes were overall Abbreviated Injury Score (AIS) 2+ injury, and the presence of any neck injury.

RESULTS

Across all children aged 0-4 years, correct chest clip use was associated with decreased Abbreviated Injury Scale (AIS) 2+ injury (odds ratio [OR] = 0.44, 95% confidence interval [CI], 0.21-0.91) and was not associated with neck injury. However, outcomes varied by age. In children <12 months old, chest clip use was associated with decreased AIS 2+ injury (OR = 0.09, 95% CI, 0.02-0.44). Neck injury (n = 7, all AIS 1) for this age group only occurred with correct cross-chest clip use. For 1- to 4-year-old children, cross-chest clip use had no association with AIS 2+ injury, and correct use significantly decreased the odds of neck injury (OR = 0.49; 95% CI, 0.27-0.87) compared to an incorrectly used or absent cross-chest clip. No serious injuries were directly caused by the chest clips.

CONCLUSIONS

Correct cross-chest clip use appeared to reduce injury in crashes, and there was no evidence of serious clip-induced injury in children in 5-point harness restraints.

The Impact of Child Safety Restraint Status and Age in Motor Vehicle Collisions in Predicting Type and Severity of Bone Fractures and Traumatic Injuries

BACKGROUND

Although morbidity and mortality in children increases in motor vehicle collisions (MVC) if child restraints are not used, no data exist correlating specific injuries with proper or improper use of safety restraints or age. The purpose of this study was to evaluate correlations between childhood MVC injuries, age, and restraint status.

METHODS

A medical record search for pediatric patients involved in a MVC was conducted at a pediatric hospital (level 1 trauma). Charts were reviewed for demographics and injury-specific information. Patients were grouped by age, restraint use, and injuries.

RESULTS

Nine hundred sixty-seven patients ≤12 years (average age 6.39 y) were identified. Being properly restrained was most common in all age groups except the 4- to 8-year age group in which being improperly restrained was most common. Unrestrained patients were most commonly found in the 9- to 12-year age group. A statistically significant difference was not observed for orthopaedic injuries among the restraint groups, but internal thoracic injuries, open head wound, and open upper extremity wounds were significantly more common in improperly or unrestrained patients. Improperly restrained infants had a significantly higher rate of intracranial bleeds and abrasions than those properly restrained. Unrestrained and improperly restrained 9- to 12-year olds had significantly more open head, open upper extremity, and vascular injuries. When comparing injury types with age groups, upper extremity fractures, femoral fractures, dislocations, and spinal fractures were found to be significantly higher in older children.

CONCLUSIONS

Preventing orthopaedic injuries in older children may be accomplished by changes in regulations or automotive safety equipment. Rear-facing child safety seats could possibly be improved to prevent head trauma in the youngest patients. There is a continued need to reinforce the importance of proper use of child safety devices to parents. Knowledge of the patient's age, along with restraint status, might aid in diagnosis of less obvious MCV injuries.

LEVEL OF EVIDENCE

Level III.

Child Passenger Safety Technician Consultation in the Pediatric Primary Care Setting

Correct use of a child safety seat (CSS) can reduce the risk of fatal motor vehicle crash-related injury by up to 71%; however, misuse rates for CSS are as high as 70%. We recruited 189 caregivers at 2 large suburban pediatric office practices; 94 in the intervention group and 95 in the control group. All participants completed a baseline survey and received a CSS safety brochure. Intervention participants had their CSS installation checked at enrollment by a certified child passenger safety (CPS) technician. Follow-up was conducted 4 months post enrollment. Intervention group participants had a 21.3% reduction in critical misuse at follow-up, whereas control participants critical misuse rate at follow-up was identical to the intervention group at baseline. A consult with a certified CPS technician, at the time of a routine visit to the pediatrician, resulted in a reduction in CSS misuse rates.

Comparison of the effectiveness of hands-on versus online education in child passenger safety

BACKGROUND

Community paediatricians' knowledge of appropriate child safety seat (CSS) use in vehicles may be inadequate. We compared the effectiveness of hands-on and online education in improving and retaining child passenger safety (CPS) knowledge and skills among paediatric trainees.

METHODS

Paediatric trainees were randomised to receive hands-on skills training versus a 1-hour online module in CPS. CSS knowledge and installation skills were assessed using a validated 10-item/point questionnaire and an assessment tool respectively at baseline and after 6 months. Preintervention and postintervention knowledge improvement and CSS installation skills between groups were assessed using paired t-tests and effect size (d).

RESULTS

Forty-eight students agreed to participate and were randomised. Thirty-nine completed training (hands-on: 23 and online: 15). At entry, no significant differences in learners' demographics and prior CPS education existed. Baseline CPS knowledge scores did not differ significantly between groups (p=0.26). Postintervention, both groups demonstrated a significant increase in knowledge scores (hands-on=3.1 (95% CI 2.4 to 3.7), p<0.0001; online=2.6 (95% CI 1.9 to 3.3), p<0.0001), though the pre-post gain in knowledge scores were not significantly different between groups (p=0.35). At follow-up, both groups demonstrated a significant increase in knowledge scores (hands-on=1.8 (95% CI 1.2 to 2.4), p<0.0001; online=1.1 (95% CI 0.7 to 1.6), p<0.0001) with the hands-on group scores significantly better than the online group (p<0.02). The long-term gain in knowledge scores was not significantly different between groups (p=0.12).Baseline CSS installation skill scores did not significantly differ between groups for forward-facing seats (p=0.16) and rear-facing seats (p=0.51). At follow-up, mean CSS installation skill scores significantly increased for the hands-on group (forward-facing seat: 0.8 (95% CI 0.16 to 1.44), p<0.02; rear-facing seat: 1.2 (95% CI 0.6 to 1.7), p<0.001) but not for the online group (forward-facing seat: 0.9 (95% CI -0.08 to 1.9), p=0.07); rear-facing seat: -0.2 (95% CI -1.1 to 0.7), p=0.6).

CONCLUSIONS

Among paediatric trainees, hands-on and online CPS education are both effective in improving long-term CPS knowledge. Long-term installation skills for forward-facing and rear-facing CSS persist for hands-on education but are inconclusive for online education.

Development of the major trauma case review tool

Background

As many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure.

Methods

Development of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool.

Results

The final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters.

Discussion

This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care.

Conclusions

This tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0353-5) contains supplementary material, which is available to authorized users.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review

BACKGROUND

Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear.

AIMS

This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury.

METHODS

Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories.

RESULTS

The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature.

CONCLUSIONS

Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.

Biofidelity Evaluation of a Prototype Hybrid III 6 Year-Old ATD Lower Extremity

Incomplete instrumentation and a lack of biofidelity in the extremities of the 6 year-old anthropomorphic test device (ATD) pose challenges when studying regions of the body known to interact with the vehicle interior. This study sought to compare a prototype Hybrid III 6 year-old ATD leg (ATD-LE), with a more biofidelic ankle and tibia load cell, to previously collected child volunteer data and to the current Hybrid III 6 year-old ATD (HIII). Anthropometry, range of motion (ROM), and stiffness measurements were taken, along with a dynamic evaluation of the ATD-LE using knee-bolster airbag (KBA) test scenarios. Anthropometry values were similar in eight of twelve measurements. Total ankle ROM was improved in the ATD-LE with no bumper compared to the HIII. The highest tibia moments and tibia index values were recorded in KBA scenarios when the toes were positioned in contact with the dashboard prior to airbag deployment, forcing the ankle into axial loading and dorsiflexion. While improvements in the biofidelity of the ATD-LE are still necessary, the results of this study are encouraging. Continued advancement of the 6 year-old ATD ankle is necessary to provide a tool to directly study the behavior of the leg during a motor vehicle crash.

Child Restraint Fitting Stations reduce incorrect restraint use among child occupants

This study evaluated the effectiveness of the NSW Restraint Fitting Station Network in preventing incorrect use of rearward facing and forward facing child restraints. The way children used restraints was observed randomly as they arrived at observation sites during a cross-sectional ecological study across New South Wales, Australia. Trained researchers examined restraint system installation once the child left the vehicle. A structured interview was also conducted with the driver. Logistic regression was used to examine the association between parental report of ever having the restraint checked at a Restraint Fitting Station and whether or not the restraint was used correctly, while controlling for potential confounders and accounting for the complex sample design. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The results demonstrated that children of respondents who did not use Restraint Fitting Stations were 1.8 times more likely to be incorrectly using their restraints (95% CI 1.1-2.8) than children of Restraint Fitting Station users. Regardless of whether or not a Restraint Fitting Station had been used, there was a trend towards a greater likelihood of incorrect restraint use as the length of restraint ownership increased (OR 1.3 95% CI 1.0-1.7). These results are important for developing strategies aimed at reducing child occupant casualties by reducing the rate of incorrect restraint use, and support programs encouraging the use of Restraint Fitting Stations and similar services as a countermeasure to incorrect use.

Child passenger safety

Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death for children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend inclusion of child passenger safety anticipatory guidance at every health-supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues that affect the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.

Population-level estimates of child restraint practices among children aged 0-12 years in NSW, Australia

This cross-sectional study provides population-referenced data on the restraints used and the extent of incorrect restraint use, among child vehicle passengers aged 0-12 years in NSW, Australia. A multistage stratified cluster sampling plan was used to randomly select vehicles from baby/child health clinics, pre-schools/day care centres, and primary schools across NSW to undergo detailed inspection of restraints used by child occupants within those vehicles. Overall, there were very high restraint usage rates (>99% of sampled children) but fewer than one quarter of children were using the correct size-appropriate restraints. Incorrect use (51.4%) was as common as inappropriate use (51.2%). Incorrect use was highest among users of dedicated child restraint systems (OR 16.0, 95% CI 6.9-36.0), and was more likely among those using size-appropriate restraints than those using inappropriate restraints (OR 1.8 95% CI 1.1-3.2); and among convertible restraints than those designed for a single mode of use (OR 1.5 95% CI 1.2-1.7). As incorrect use substantially reduces the protection from injury that is offered by child restraints, it is important that future strategies to reduce casualties among child occupants target both inappropriate and incorrect use.

The characteristics of incorrect restraint use among children traveling in cars in New South Wales, Australia

OBJECTIVE

This study aims to provide population estimates of incorrect restraint use among children aged 0-12 traveling in cars in New South Wales (NSW) and describe the errors occurring in different restraint types.

METHODS

Observations of randomly selected children and restraints were conducted in situ by trained researchers at sites statewide. Observation sites were randomly selected using a multistage stratified sample plan. Restraint use errors were recorded and analyzed by severity of error and restraint type using complex survey analysis techniques.

RESULTS

One in two children was incorrectly restrained, and 38 percent in a serious manner. Multiple errors were common (31% of children). Both installation and "securing" errors were common, with installation errors more common in convertible restraints (rearward-facing/forward-facing restraints and forward-facing restraints/booster seats) than single-mode restraints (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7-10.8). Multiple errors were more common in convertible restraints (OR 3.6; 95% CI 1.9-7.0). The most frequently observed errors were excessive seat belt slack (>25 mm), incorrect belt routing, nonengagement of the seat belt buckle, very loose harness (>25 mm slack), harness off the shoulder, nonuse of belt guides, sash belt worn under the arm, and very twisted harnesses and belts (>2 twists). For rearward- and forward-facing restraints the highest priorities in terms of frequency and degradation in crash protection are errors related to harness use. For booster seat users the most important are those related to correct seat belt and belt guide use. For seat belt users, errors related to correct positioning of the sash belt are key.

CONCLUSIONS

The results indicate that many errors are currently occurring in the way children are using restraints, as well as problems associated with the way child restraint systems are installed in vehicles. Incorrect use is particularly problematic in convertible restraints (rearward-facing/forward-facing restraints and forward-facing restraints/booster seats). Different priorities, in terms of the frequency and potential degradation in crash protection due to incorrect use for different restraint types, exist and these are important for those designing countermeasures to this problem.

Penetrating pediatric trauma owing to improper child safety seat use

We present a case of a 15-month-old child with a history of thoracic impalement after improper safety seat restraint. The foreign body was stabilized with bulky dressings in the field before transport. Imaging revealed possible pulmonary artery involvement; and consequently, a thoracotomy was done to obtain vascular control before removal. We use this case to highlight prehospital care and operative management of a patient with foreign body impalement.