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HAZARD 77 page 1VICTORIAN INJURY SURVEILLANCE UNIT

Hazard (Edition No. 77)

Winter 2014

Victorian Injury Surveillance Unit (VISU)

www.monash.edu/miri/visu

Monash Injury Research Institute (MIRI)

This, and the next, issue of Hazard is focused on child falls as this is the largest and most persistent cause of injury to children in Victoria. In this edition we provide an overview of all fall injury and then focus on playground equipment falls.

Preventing serious fall injury in children (1): Overview and playground equipment Erin Cassell and Angela Clapperton

SummaryAll injury

• Overthe3-yearperiod2010/11to2012/13there were 109,294 hospital-treated childfallinjurycasesinVictoria:17,534hospitaladmissions and 91,760 ED presentations(non-admissions). Onaveragetherewere~6,000 hospital admissions and ~31,000EDpresentationsperyear.

• Thefrequencyandrateofchildfallinjuryhospital admissions in 0-14 year oldsincreased significantly over the 14-yearperiod 1998/99-2011/12 (by 29% and21% respectively). The frequency andrate of child fall injury ED presentationsalsoincreasedsignificantlyoverthe8-yearperiod2004/05-2011/12(by26%and19%respectively).

• Maleswereover-representedoverall(56%)andespeciallyamonghospitaladmissions(61%).

• Therewasafairlyevenspreadofhospital-treatedinjurycasesacrossthethree5-yearagegroups(0-4,5-9,10-14).

• Theupperextremity(45%);head/face/neck(34%);andthelowerextremity(17%)werethemost frequently injuredbody regions.Bone fracture (33%), dislocation, sprain,strain(22%)andopenwound(18%)werethethreemostcommoninjurytypes.

• Fall injuriesweremore likely tooccur inthehome (at least41%of all cases) thaninotherlocationscommonlyfrequentedbychildren:schools,kindergartens,childcareandotherpublicbuildings(20%)andareasforsportandleisure(7%).

Serious injury: hospital admissions

• The major mechanisms of fall injuryadmissions were: falls from playgroundequipment (26%); falls on same levelfrom slipping, tripping and stumbling(11%); falls involving beds, chairs andother furniture (11%); and fall involvingice skates, skis, rollerskates, skateboards,scootersandotherpedestrianconveyances(10%).

• Hospital admissions for child fallsaccountedfor25,069hospitalbeddaysinall (~8,300 bed days per year). Hospitalcare for admissions cost $55.9 million in total($18.6millionperyear).

Priority issues: playground equipment falls, furniture related falls and skateboard and scooter falls

Three issues have been selected for specialfocus in this edition of Hazardbecauseofthemajor contribution theymake to serious fallinjury,andtheirpreventability:(1)playgroundequipment fall injury (26% of fall injuryhospital admissions), excluding trampolineinjury from the discussion as it was the focus of a recent Hazard (Issue 75, Autumn 2013);(2) furniture-related fall injury: chairs, beds,tablesandotherfurniture(11%);and(3)fallinjuryinvolvingiceskates,skis,rollerskates,skateboardsandscooters(10%)concentratingon the two largest problems, fall injuriesrelatedtoskateboardsandscooters.

ThiseditionofHazardprovidesanoverviewof all fall injury and a detailed examinationof the first of the three priority issues —playground equipment fall injury. The nextedition of Hazard will focus on furniture-related fall injury and fall injury involvingskateboardsandscooters.

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1. FALL INJURY IN CHILDREN AGED 0-14 YEARSFallsare themost significantcauseof injuryinVictorian children aged 0-14. Each yearinVictoria approximately 6,000 children arehospitalisedandclose to32,000childrenaretreated in the Emergency Department forinjuriescausedbyfalls.AnunknownnumberofchildrenaretreatedforfallinjurybyGPs,otherhealthprofessionals,firstaidersatsportsand recreation venues and their parents/carers.Fallsandhit/struck/crusharetheonlymajor causes of child injury where hospitaladmission rates have increased over the past14years(Figure1),signallinganurgentneedforactioninchildfallinjuryprevention.

Unintentional (accidental) child fall injury datafromhospitaldatasetswerelastanalysedinHazardEdition44publishedinSeptember2000, although later editions have provideddataandinformationonchildfallsinspecificsettings and on some of the major causesof falls: falls in the home encompassingfalls related to surfaces, furniture and playequipment (Hazard 65, 2007); playgroundequipment fall injury in all settings (Hazard65,2007);fallsinsnowandicesports–skiing,snowboarding and tobogganing (Hazard66, 2007); and falls from trampolines andbunkbeds(Hazard75,2013). It isthereforetimelytore-visit thisissueandtoreviewtheresearchevidencebasethatguidespreventionmeasures.

In the first section of this reportwe providean overview of the frequency and patternfor hospital-treated fall injury in children byanalysingthelatestthreeyearsofdata(2010/11to 2012/13) extracted from the VictorianAdmitted Episodes Dataset (VAED) andthe Victorian Emergency Minimum Dataset(VEMD).Theanalysisofthemechanismsofinjuryandlengthofhospitalstayisrestrictedto hospital admissions. We also investigatetheyearly trend in the frequencyand rateoffallinjuryhospitaladmissionsandEmergencyDepartment (ED) presentations over the 14yearsfrom1998/99to2011/12,overallandbyagegroupandmajorcausesoffallinjury.

The second section of this report will focuson the first of threemajor causes of seriousfall injury and includes recommendations for prevention based on research evidenceto date. For the purposes of this study theterm serious fall injury includes cases that required hospital admission, and excludes

cases that were treated and dischargedfrom the emergency department. The focusissue covered in this edition is playgroundequipment fall injury (26% of fall injuryhospital admissions), excluding trampolineinjury from the discussion as that topicwascovered in a recent Hazard. The other twoissues:furniture-relatedfallinjury(11%);andfallinjuryinvolvingskateboardsandscooters,willbecoveredinthenexteditionofHazard.

Data extraction and analysismethods for allsectionsaredescribedinBox1.

Overview: frequency and pattern of hospital-treated fall injuryFalls are the leading cause of hospital-treatedinjuryinchildrenaged0-14years,accountingfor44%ofchildinjuryhospitalisationsand38%ofchild injuryEDpresentations (non-admissions)overthe3-yearperiod2010/11to2012/13.

The frequency and pattern of hospital-treatedfall injury over this period are summarised in Table1:• In total, there were 109,294 hospital-treated fall injury cases: 17,534 hospitaladmissions and 91,760 ED presentations(non-admissions), an average of

approximately 6000 admissions and30,500EDpresentationsperyear.

• Maleswereover-representedinfallinjurycases(56%).

• Therewasafairlyevenspreadofhospital-treatedinjurycasesoverthe3agegroups(0-4,5-9,10-14).

• Themostfrequently injuredbodyregionsweretheupperextremity(45%ofallcasesand 53% of admissions); the head/face/neck (34% of all cases); and the lowerextremity(17%ofallcases).

• Bonefracturewasthemostcommoninjury,accounting for one-third of admissions.The other common injury types weredislocation,sprain,strain(22%)andopenwound(18%).

• The home was the setting where mosthospital-treated fall injuries occurred(41%), followed by schools, publicbuildings and administrative areas (20%)and areas for sports and recreation (7%).In 15%of all cases (41%of admissions)thelocationofinjurywasnotspecified.

Source: VAED (hospital admissions), admissions data includes same day admissions

Figure 1 Yearly trend in child injury hospital admission rates by major cause of injury, Victoria 1998/99 to 2011/12


Source: VAED (hospital admissions), VEMD (Hospital ED presentations, non-admissions)Note (1): In July 2012 the Victorian Hospital Admission Policy changed significantly so that episodes of care delivered entirely within a designated emergency department or urgent care centre could no longer be categorised as an admission regardless of the amount of time spent in the hospital. This has had the effect of reducing the number of admissions recorded on the VAED for the 2012/13 financial year. However, no change to the injury pattern was observed so 2012/13 was not excluded from the detailed analysis.

Table 1 Overview of unintentional fall injury in children 0-14 years by sex, age, body region injured, nature of injury and place of occurrence (location) of injury, Victoria 2010/11 to 2012/13 (3 years)

Hospital admissions ED presentations (non-admissions)

All hospital-treated injury cases

n % n % n % Year 2010/11 6,062 34.6 28,557 31.1 34,619 31.7 2011/12 6,566 37.4 31,254 34.1 37,820 34.6 2012/13 (1) 4,906 28.0 31,949 34.8 36,855 33.7 All years 17,534 100.0 91,760 100.0 109,294 100.0 Sex Male 10,650 60.7 50,563 55.1 61,213 56.0 Female 6,884 39.3 41,197 44.9 48,081 44.0 Age group 0-4 5,495 31.3 32,082 35.0 37,577 34.4 5-9 6,763 38.6 28,070 30.6 34,833 31.9 10-14 5,276 30.1 31,608 34.4 36,884 33.7 Body region injured Head/face/neck 5,836 33.3 31,790 34.6 37,626 34.4 Trunk 361 2.1 1,780 1.9 2,141 2.0 Upper extremity 9,357 53.4 39,608 43.2 48,965 44.8 Lower extremity 1,796 10.2 16,615 18.1 18,411 16.8 Multiple body regions * * 973 1.1 975 0.9 Unspecified 182 1.0 994 1.1 1,176 1.1 Nature of injury Fracture 10,578 60.3 25,722 28.0 36,300 33.2 Open wound 3,210 18.3 16,067 17.5 19,277 17.6 Intracranial injury 830 4.7 3,301 3.6 4,131 3.8 Superficial injury 480 2.7 11,823 12.9 12,303 11.3 Dislocation, sprain & strain 440 2.5 23,430 25.5 23,870 21.8 Injury to muscle & tendon 95 0.5 2,877 3.1 2,972 2.7 Injury to internal organs 50 0.3 204 0.2 254 0.2 Injury to nerves & spinal cord 36 0.2 26 0.0 62 0.1 Injury to blood vessels 22 0.1 120 0.1 142 0.1 Other and unspecified 1,793 10.2 8,190 8.9 9,983 9.1 Location School, public buildings 3,905 22.3 17,586 19.2 21,491 19.7 Home 3,737 21.3 40,742 44.4 44,479 40.7 Sports & athletic areas 1,371 7.8 6,658 7.3 8,029 7.3 Trade & service areas 248 1.4 651 0.7 899 0.8 Road, street & highway 196 1.1 2,747 3.0 2,943 2.7 Farm 17 0.1 284 0.3 301 0.3 Residential Institution 10 0.1 96 0.1 106 0.1 Industrial & construction areas 6 0.0 40 0.0 46 0.0 Other specified places 892 5.1 13,743 15.0 14,635 13.4 Unspecified places 7,152 40.8 9,213 10.0 16,365 15.0

Table 2 shows the causes (mechanisms),lengthofhospitalstayanddirecthospitalcostsforhospitaladmissionsonly

• Themajormechanismsoffallinjuryhos-pital admissions were: falls from play-ground equipment (26%); falls on samelevel from slipping/tripping and stum-bling(11%);fallsinvolvingbed,chairandother furniture (11%); and fall involvingiceskates,skis, rollerskates,skateboards,scootersandotherpedestrianconveyances(10%).

• Fallinjuryhospitaladmissionsaccountedfor25,069hospitalbeddays.Most(85%)ofpatientshadhospitalstaysoflessthan2 days (n=14,876) and a further 15%(n=2,589)stayed2-7days.Thelengthofstayof69patientswasfrom8to30daysor more. The most common diagnosesforthesepatientswere:fractureoffemur(n=13, 19%), intracranial injury (n=9,13%), superficial injury of head (n=6,9%),fractureoflowerleg,includingankle(n=5, 7%) and openwoundof lower leg(n=4,6%).

• The cost of hospital care for admissionswas $55,897,481 (mean cost: $2,908;range$194-$132,266).

Yearly trend in child fall injury cases

Hospital admissions

Therewasanupward trend in the frequencyand rate of child fall injury hospital admis-sionsoverallandinall5-yearagegroupsoverthe 14-year period1998/99 to 2011/12 (Fig-ures2&3).Thelatestavailableyearofdata(2012/13)hasbeenexcludedasthedefinitionofahospitaladmissionchangedinthatyear,foreshadowingatrendbreak. Trend in frequency

Thefrequencyofchildfallinjuryhospitalad-missions increased significantly from 4,863in 1998/99 to 6,566 in 2011/12, represent-inganestimatedannualchangeof1.8%andanoverall increase of 29% (95%CI22% to36%)(Figure2).Significantincreasesinad-missions were seen over the 14-year periodinallagegroups,withthelargestincreasein0-4yearolds(49%,95%CI37%to59%),fol-lowedby10-14yearolds(34%,95%CI26%to41%)then5-9yearolds(13%,95%CI5%to22%)(Figure2).


Table 2 Mechanisms and length of hospital stay for fall injury hospital admissions in children aged 0-14, Victoria 2010/11 to 2012-14 (3 years) (n=17,534)

Hospital admissions for fall injury n % Mechanism of injury Same level involving ice and snow * * Same level from slipping, tripping, stumbling 1,957 11.2 Involving iceskates, skis, rollerskates, skateboards, scooters & other pedestrian conveyances 1,739 9.9 Scooters 724 4.1 Skateboards 675 3.8 All other and unspecified pedestrian conveyances 340 1.9 On same level-collision with pushing by another person 673 3.8 While being carried or supported by other persons 248 1.4 Involving wheelchair 9 0.1 Involving bed, chair and other furniture 1,919 10.9 Involving playground equipment 4,472 25.5 On and from stairs and steps 422 2.4 On and from ladder 58 0.3 On and from scaffolding * * From, out of or through building or structure 460 2.6 From tree 322 1.8 From cliff 19 0.1 Diving or jumping into water - other injury not drowning 59 0.3 Other fall from one level to another 1,038 5.9 Other fall on same level 1,771 10.1 Unspecified fall 2,360 13.5 Length of hospital stay < 2 days 14,876 84.8 2-7 days 2,589 14.8 8-30 days 62 0.4 31+ days 7 0.0 Total hospital bed days 25,069 days Length of stay - mean Length of stay – range

1.3 days 1 day- 67 days

Direct hospital costs Total direct hospital costs $55,897,481 Direct hospital costs – mean Direct hospital costs – range

$2,908 $194 - $132,266


Trend in rate

The child fall injury hospital admis-sion rate also increased significantly from511.5/100,000 in 1998/99 to 650.3/100,000in2011/12, representinganestimatedannualchange of 1.4% and an overall increase of21%(95%CI15%to28%)(Figure3).Sig-nificantupwardtrendsinadmissionrateswereobserved inallagegroups,with increasesof28%(95%CI19% to37%)among0-4yearoldsand28%(95%CI20%to36%)among10-14yearolds,comparedwith14%(95%CI6%to21%)among5-9yearolds(Figure3).

ED presentations (non-admissions)

Complete data are only available fromfiscalyear2004/05forEDpresentationsbecausenotall of the major hospitals were contributinginjuryEDdatabeforethatyear.Inthisshorter8-year period there appears to be anupwardtrend in both the frequency and rate of EDpresentationsforfallinjury(Figures4&5).

Trend in frequency

The frequency of child fall injury EDpresentations in 0-14 year olds increasedsignificantlyfrom24,315in2004/05to31,254in2011/12, representinganestimatedannualchangeof2.9%andanoverallincreaseof26%(95%CI15%to36%)(Figure4).SignificantincreasesinEDpresentationswereseenoverthe8-yearperiod in all agegroups,with thelargest increase in 0-4 year olds (32%, 95%CI21%to43%),followedby10-14yearolds(26%,95%CI12%to40%)then5-9yearolds(18%,95%CI9%to27%)(Figure4).

Trend in rate

ThechildfallinjuryEDpresentationratealsoincreased significantly from 2,515.4/100,000in 2004/05 to 3,095.3/100,000 in 2011/12,representing an estimated annual change of2.2%andanoverallincreaseof19%(95%CI10%to29%)(Figure5).SignificantupwardtrendsinEDpresentationrateswereobservedinallagegroups,withincreasesof30%(95%CI 16% to 43%) among 10-14 year olds,compared with 16% (95% CI 8% to 24%)among5-9yearoldsand12%(95%CI2%to22%)among0-4yearolds(Figure5).

Causes of serious fall injury (hospitalisations)There is age variability in child injuryhospitalisations for falls (Table 3). Hospitaladmissions for falls in children aged lessthanonemostly involve furniture (40%)andfalls while being carried or supported byother persons (24%). Although furniture-related falls are also the most prominentcauseofadmission for falls inchildrenagedbetween1and4years(23%),fallsinvolvingplay equipment (18%) and from slipping,trippingand stumbling (12%)are substantialproblems.In5-9yearoldsthemostfrequentcauseoffallsadmissionsbyfarisplaygroundequipment falls (43%), followed by samelevel falls from slipping and tripping (10%).In the oldest age group (10-14 year olds)falls involving ice skates, skis, rollerskates,skateboardsandscootersaretheleadingcauseofadmissions(20%),followedbysameleveltripping, slipping, stumbling (14%) and fallsfrom playground equipment (13%, mostlytrampolines).


DiscussionFalls are the leading cause of child injuryadmissions and Emergency Departmentpresentations(non-admissions)inVictoriaandAustralia,yetthishealthissueisneglectedhereand inotherdevelopedcountries suchas theUS, Canada and European Union countries,wherefallinjuriesarealsoaprominentchildhealth problem. Morrongiello & Kiriakou(2004)studiedmothers’homesafetypracticesfor preventing six types of injuries (burns,poisoning, drowning, cuts, strangulation/suffocation/choking, and falls). They foundthat although mothers’ rated children’svulnerabilitytofallsashigherthanthatforallothertypesofinjuries,theyratedfallsaslessseverethanotherinjuries(allp<.05)andalsoratedthesocial-normpressurestopreventfallsassignificantlylowerthanthosetopreventallotherinjuries(allp<.05).

Anecdotally, the prevailing societal viewabout child falls and resultant broken bonesappearstobethattheyarea‘natural’partofgrowingupandpreventioneffortsarederidedas “wrapping kids in cotton wool/bubblewrap”. These oft expressed attitudes do notreflect the significance of the problem intermsofthephysical,emotionalandfinancialconsequences of serious fall injuries. Ourliteraturesearchfoundarelativelyhighnumberof studies describing the size and nature ofthe problem both here and in comparablecountries,butfewreportsofanalyticalstudiesto determine risk and protective factors toguide prevention efforts, and few evaluatedinterventions.

Risk factors for fall injury

Systematic reviewsA systematic review of risk factors for fallrelatedinjuriesinchildrenaged0-6foundfewcontrolled studies (Khambalia et al., 2006).The review covered the research literaturefrom1996to2005.Afteraninitialcull,only14ofthe336articlesretrievedinfullmetthestudy inclusion criteria of having a controlgroup of non-injured children to compareto thecasesof injuredchildren. Thequalityof the included studies varied. The authorsidentifieda smallnumberof established riskfactors for the incidence or severity of injuries due to falls. The demographic risk factorsincluded:ageandsex[infantboysforallfallinjury(onestudy);childrenaged<6forbunkbed falls (one study)]; socioeconomic status[low SES for bunk bed falls among fallersin newer beds that fell on uncarpeted floors(one study)]; and living in old stock rental

Figure 2 Yearly trend in the frequency of child fall injury hospital admissions by age groups, Victoria 1998/99 to 2011/12

Figure 3 Yearly trend in child fall injury hospital admission rates by age group, Victoria 1998/99 to 2011/12




Table 3 Mechanisms of fall injury hospital admissions among children aged 0-14, Victoria 2010/11 to 2012-14 (3 years)

Age group Mechanism Less than 1

year 1-4 years 5-9 years 10-14 years

n % n % n % n % Same level involving ice and snow 0 0.0 0 0.0 * * 5 0.1 Same level from slipping, tripping, stumbling 14 2.5 568 11.5 654 9.7 721 13.7 Involving iceskates, skis, rollerskates, skateboards, scooters & other pedestrian conveyances 39 6.9 192 3.9 464 6.9 1,044 19.8 On same level-collision with pushing by another person * * 42 0.9 149 2.2 480 9.1 While being carried or supported by other persons 134 23.8 59 1.2 31 0.5 24 0.5 Involving wheelchair 0 0.0 * * * * 6 0.1 Involving bed, chair and other furniture 225 40.0 1,152 23.4 423 6.3 119 2.3 Involving playground equipment * * 871 17.7 2,926 43.3 674 12.8 On and from stairs and steps 10 1.8 219 4.4 96 1.4 97 1.8 On and from ladder 0 0.0 23 0.5 24 0.4 11 0.2 On and from scaffolding 0 0.0 0 0.0 * * 0 0.0 From, out of or through building or structure * * 118 2.4 198 2.9 143 2.7 From tree 0 0.0 19 0.4 184 2.7 119 2.3 From cliff 0 0.0 * * 7 0.1 9 0.2 Diving or jumping into water - other injury not drowning 0 0.0 8 0.2 14 0.2 37 0.7 Other fall from one level to another 76 13.5 334 6.8 380 5.6 248 4.7 Other fall on same level 37 6.6 501 10.2 488 7.2 745 14.1 Unspecified fall 24 4.3 822 16.7 720 10.6 794 15.0 ALL 563 100.0 4,932 100.0 6,763 100.0 5,276 100.0


accommodation and living in a communitywith a high concentration of populations ofethnicminorities[forallfallinjuryinchildrenaged0-6(onestudy)].

The identified modifiable risk factors forfall injury included: (1) fall height [<5 feet(1.52m) not related to multiple and visceralinjuries in children (one study) and beingdroppedbyacaretakercomparedwithrollingoff a bed or furniture for severe injury (onestudy)]; (2)useofwalkers [increasedriskofstairwayfall injury(onestudy)and loweringof age at which a stairway fall occurs (onestudy)]; (3) height of equipment and natureofundersurfacing[forplaygroundfallinjuries(3studies)];and(4)theinjurysetting[higherrisk of fall injury among infants and youngchildreninhomecarecomparedwithdaycare(onestudy)].Theauthorsofthereviewcalledformore high quality population-based casecontrolstudiestoidentifytheriskfactorsforchildfallinjury(Khambaliaetal.,2006).

Many published systematic reviews thathave collated evidence from interventions that aimed to prevent childhood injury haveincluded studies focussed on preventingchildhood falls in the home setting. Younget al. (2013) recently published an overviewthat synthesised the evidence on home safety interventions targeting childhood falls from24studies included in13systematic reviewspublishedupto2009plus5additionalprimarystudiespublishedbetween2001and2010thatwerenotidentifiedfromtheincludedreviews.Most interventions promoted multiple homesafetyandfallspreventionmeasures.

In brief, the Young et al. (2013) overviewfound that: • Only three primary studies reported fallsor fall injuries as the outcome measure;onehadasignificanteffect.Theeffectivestudy, that targeted pregnant/parentingteen mothers in Baltimore (n=529), found that receipt of home safety information,most commonly provided by healthprofessionalsandtheinfant’sgrandmother,was associated with a reduction in injuries fromfalls(Jordanetal.,1993).

• Twenty-one primary studies reportedthe effect of interventions on possessionand use of various items of home safety equipment:

- Sixteen studies promoted the possession and use of safety gates. Three significantly increased use: oneprovidedsafetyadvicetopregnant women at home, a home safety inspection and fitted free safetygatestoungatedandaccessible

Figure 5 Yearly trend in the rate of child fall injury ED presentations by age group, Victoria 2004/05 to 2011/12

Figure 4 Yearly trend in the frequency of child fall injury ED presentations by age group, Victoria 2004/05 to 2011/12

Source: VEMD (hospital ED presentations, non-admissions only)

Source: VEMD (hospital ED presentations, non-admissions only)


stairways (Phelan et al., 2011); one provided safety advice by health visitors to families in deprived areas and supplied and fitted stair gates free to low income families (half ofstudyparticipants)andfreedelivery toothers(Watsonetal.,2005);andone provided safety advice only (no free safety gates) to pregnant women during home visits (Johnston et al., 2006). None of the 13 unsuccessful studiesincludedfittingofsafetygates, althoughtwoprovidedlowcostsafety gates and another provided discount vouchers.

- Five studies promoted the possession anduseofnon-slipbathmats,decals or rugs. One study that provided home safety counselling and free provision of non-slip bath decals by trained lay persons to caregivers of young children who had attended a hospital ED for home injury, reported a significant increase in the use of this item (Posner et al,2004).Oneofthefourunsuccessful interventions provided non-slip bath mats, all four provided safety counselling in the home and two providedhomesafetyinspections.

- Ten studies promoted the possession and use of window safety devices to prevent or limit the opening of windows,only twoofwhichreported a significant effect. One of the successful interventions provided safety advice and supplied and fitted windowlocksto lowincomefamilies with free delivery to other study participants (Watson et al., 2005) and the other provided safety advice onchildproofedwindowframesduring home visits by trained lay people (Chan, 2004). Five of the eight unsuccessful interventions provided free or low cost window safety devices.

- Four studiespromoted thepossession and use of furniture corner covers, two ofwhichfoundasignificanteffect.One ofthesuccessfulinterventionsprovided bothhomesafetycounsellingbyhealth professionalsandfreefurniturecovers in a home safety kit to socio economically disadvantaged families (Sznajder et al., 2003) and the other provided a home safety check and adviceonlocalretailerssellingcovers and access tomail order (Paul et al., 1994). One of the two unsuccessful studies provided furniture corner covers.

- Two studies promoted the possession and use of high chair harnesses,

neither successfully increased use. Highchairharnesseswerenotprovided in either intervention.

• Twenty-one studies reported theeffectivenessofinterventionsinpromotingother falls prevention interventionsincludingnineinterventionstoreducebabywalkeruse,sixtopromotestairwaysafety,four to reduce tripping hazards, three toprevent children being left unattendedon high surfaces, six to improve a rangeof falls prevention practices and five topromote other falls prevention practices(strategies to reduce accessibility toroofs, to rearrange furniture to avoidstaggering the layout, to improve lightingincorridors,toincreasebalconysafetyandreduce climbable fences and gates). Thesuccessful interventions were:

- Two studies reported a significant reduction in ownership and use of baby walkers (Tan et al., 2004; Kendricketal.,2005). Oneprovided counsellingofmothersatimmunisation sessions; in the other study health visitors or midwives delivered an educationalpackagetomothers.

- Onestudythatincludedahomesafety inspection reported a significant reduction in tripping hazards from loosefloor coverings (Schwarz et al., 1993).

- One study reported a significant improvement in participants’ scores onarangeoffallspreventionpractices, attributing this to the provision of a safety kit to intervention group families(Sznadjeretal.,2003).

- Three of the studies targeting other falls prevention practices were successful: one study demonstrated asignificantreductioninaccessibility ofroofs(Pauletal.,1994);onereported that significantly more intervention group families rearranged furniture to avoid staggering the layout (Chan, 2004)andanotherreportedsignificant improvement in lighting of corridors (Petridouetal.,1997).

Readers are advised to access the article in fullthroughPubMedasitprovidesadetailedupdate (including tables summarising thedesign and characteristics including thecontent of each included study) that enablesevidence based falls prevention policies andstrategies to be developed and implemented,buildingonpastsuccessesandfailures.

The Keeping Children Safe Study Group located in the UK recently announced thatit has made a start on three new case control studiestofillsomeoftheknowledgegapsto

underpinfallsprevention initiatives inyoungchildren(Kendricketal.,2012). Theaimofthese studies is to investigate themodifiablerisk and protective factors for falls in youngchildrenagedunder5years including safetybehaviours,safetyequipmentuseandhazards.Separate multicentre studies will investigateriskfactorsforthreecommonfallmechanisms:falls from furniture, falls down stairs and falls onthesamelevel. Recruitmentofcases(byclinicalstaffworkinginseveralUKhospitals)and controls (matched community controls and unmatchedhospitalcontrols)hascommenced.

Other intervention studies

Nauta et al. (2013) trialled an educationprogram in The Netherlands to improve fallskills designed to counteract the rising trendinfall-relatedarmfractureinchildren.Inthis8-week programme children learned basicmartialartsfallingtechniquesintheirphysicaleducation classes. A cluster randomisedcontrolled trial1wasconductedin33primaryschools.The intervention group received theeducational programme to improve fallingskills during their physical education (PE)classes whereas the control group receivedtheir regular PE curriculum. At baseline(October2009)andfollow-up(May2010),aquestionnairewascompletedby thechildrenabout their physical activity behavioursand fall-related injuries were registeredcontinuouslyduringanentireschoolyear.

A total of 36 incident injuries was reportedin the intervention group, equalling aninjury incidence density (IID) of 0.14 fall-related injuries per 1000 hours of physicalactivity(95%CI0.09to0.18).Incontrast,96injuries were reported by the control groupcorrespondingtoanIIDof0.26(95%CI0.21to 0.32). Because intra-cluster correlationwas high (ICC=0.46), differences in injuryincidence were not statistically significant.Whenactivitylevelwastakenintoaccount,atrendwasshownsuggestingthatthe‘fallingisasport’programmewaseffectiveindecreasingfalling-relatedinjuryrisk,butonlyinchildrenwithlowlevelsofhabitualphysicalactivity.

1A cluster randomised controlled trial is a type of randomised controlled trial in which groups of subjects (as opposed to individual subjects) are randomised. An advantage of cluster randomised controlled trials over individually randomised controlled trials is the ability to study interventions that cannot be directed toward selected individuals. Disadvantages include greater complexity in design and analysis, and a requirement for more participants to obtain the same statistical power.


Another ambitious falls preventionintervention trialled in physical educationclasses inTheNetherlands involvedchildrenaged 10-12 in primary schools (Collardet al., 2009). The iPlay 8-month injurypreventionprogramwasdeliveredinaclusterrandomised trial involving more than 2,200children from 40 primary schools. Theprogram aimed to improve attitudes, socialinfluences,self-efficacyandintentiontowardswearingappropriateprotectiveequipmentandfootwearduringorganisedphysicalactivities,leisure time activities and PE classes,and to reduce injuries. Published resultsshowed that the iPlay-program significantlyimproved behavioral determinants but theeffect on knowledge and attitudes was notstrong enough to improve injury preventingbehaviours(Collardetal.,2010a).Therewasasmallnon-significant interventioneffectontotal, sports club and leisure time injuries;the largest effect was observed in the lowactivegroup-theauthorsencouragedfurtherresearch(Collardetal.,2010b).

Other risk factor studies and preventioninterventions that pertain to the specificissues of focus in this Hazard edition (child hospitalisationsinvolvingfallsfromfurniture,playequipmentandscootersandskateboards)arecoveredinthenextsectionofthisreport.

Recommendations• Increase funding for research to better

understand serious fall injury and its consequencesinchildren.

• Conduct more high quality population-basedcasecontrolstudiesontheriskandprotectivefactorsforchildfallinjury.

• Develop a stand-aloneor integrated childfallinjurypreventionplantostimulatethedesign and evaluation of interventions toreduce fall injuries in age group 0-4, 5-9and10-14years.

ReferencesCollardDCM,ChinapawMJM,vanMechelenWetal.DesignoftheiPlay study: systematic development of a physical activity injuryprevention programme for primary schoolchildren. Sports Med.2009;39(11):889-901.

Collard DCM, Chinapaw MJM, VerhagenEALMetal.Effectivenessofaschool-basedphysical activity-related injury preventionprogram on risk behaviour and neuromotorfitness:aclusterrandomizedcontrolledtrial.Int J Behav Nutr Phys Act.2010;28;7:9.doi:10.1186/1479-5868-7-9.

Collard DCM, Verhagen EALM, ChinapawMJM et al. Effectiveness of a school basedphysicalactivityinjurypreventionprogram.Acluster randomised control trial. Arch Pediatr Adolesc Med2010;164(2)145-50.

Chan C. Promoting a safer householdenvironment: a volunteer based home visitprogram 7th World Conference on InjuryPrevention and Safety Promotion, Vienna,Austria(2004).

Johnston BD, Huebner CE, Anderson MLet al.Healthy steps in an integrateddeliverysystem: child and parent outcomes at 30months Arch. Pediatr. Adolesc. Med. 2006;160(8):793–800.

JordanEA,DugganAK,HardyJB.Injuriesinchildren of adolescent mothers: home safety education associated with decreased injury risk.Pediatrics.1993;91(2):481–487.

Kendrick D, Illingworth R,Woods A et al.Promoting child safety in primary care: acluster randomised controlled trial to reduce babywalkeruse.Br. J. Gen. Pract.2005;55(517):582–588.

KendrickD,MaulaA,StewartJetal.Keepingchildren safe at home: protocol for threematched case control studies of modifiablerisk factors for falls. Inj Prev 2012;18:e3.Doi:10.1136/injprev-2012-040394.

KhambaliaA,JoshiP,BrussoniMetal.Riskfactors for unintentional injuries due to falls in childrenaged0-6years:asystematicreview.Inj Prev2006;12:378-385.

MorrongielloBA,KiriakouS.Mothers’homesafety practices for preventing six types ofchildhood injuries: What do they do, and why? J Ped Psych2004;29(4):285-297.

Nauta J, Knol DL, Adriaensens L et al.Prevention of fall-related injuries in 7-year-old to 12-year-old children: a clusterrandomised controlled trial. Br J Sports Med. 2013;47(14):909-13. doi: 10.1136/bjsports-2012-091439.Epub2013Jan17.

PaulCL,Sanson-FisherRW,RedmanSetal.Preventingaccidentalinjurytoyoungchildreninthehomeusingvolunteers.Health Promot. Int. 1994;9(4):241–249.

Petridou E, Tolma E, Dessypris N et al.Acontrolled evaluation of a community injury preventionprojectintwoGreekIslands.Int. J. Epidemiol.1997;26(1):173–179.

Phelan KJ, Khoury J, Xu Y et al. Arandomized controlled trial of home injury hazard reduction: The HOME Injury StudyArch.Pediatr. Adolesc. Med. 2011; 165 (4):339–345.

Posner J, Hawkins L, Garcia-Espana F etal. A randomized, clinical trial of a homesafety intervention based in an emergencydepartmentsetting.Pediatrics.2004;113(6):1603–1608.

TanNC,LimNMLH,GuK.Effectivenessofnurse counselling in discouraging the use oftheinfantwalkersAsiaPac.J. Public Health. 2004;16(2):104–107.

Theurer WM, Bhavsar AK. Prevention ofunintentional childhood injury. Am Fam Physician 2013Apr1;87(7):502-509.http://www.aafp.org/afp/2013/0401/p502.html.Retrieved 7/5/2014

Schwarz DF, Grisso JA, Miles C et al. Aninjury prevention program in an urbanAfrican-American communityAm. J. Public Health.1993;83(5):675–680.

SznajderM,LeducS,JanvrinMPetal.HomedeliveryofaninjurypreventionkitforchildreninfourFrenchcities:acontrolledrandomizedtrial Inj. Prev.2003;9(1):261–265.

WatsonM, Kendrick D, Coupland C et al.Providing child safety equipment to preventinjuries: randomised controlled trial BMJ. 2005;330:178–181.

Young B, Persephone MW, He Z et al.Preventing childhood falls within the home:Overview of systematic reviews and asystematic review of primary studies. Accid Anal Prev2013;60:158–171.


2. SERIOUS FALL INJURY: PRIORITY ISSUES Three issues have been selected for specialfocusinthis,andthenext,editionofHazardbecauseof themajorcontribution theymaketo fall injury hospital admissions and theiramenability to prevention: (1) playgroundequipment fall injury (26% of fall injuryhospitaladmissions);(2)furniture-relatedfallinjury:chairs,bedsandotherfurniture(11%);and (3) fall injury involving skateboardsand scooters (10%). The following sectionprovidesadetailedexaminationofthefirstofthesepriorityissues—playgroundequipmentfall injury. The next edition ofHazardwillfocuson furniture-related fall injury and fallinjuryinvolvingskateboardsandscooters.

2.1 Preventing serious playground equipment fall injury Therewere4,472hospitaladmissionsforplayequipmentfallinjuriesoverthe3-yearperiod2010/11 to 2012/13 (Table 4), an averageof1,491peryear.Themajority(60%)involveditems of play equipment usually found inpublicplaygrounds(climbingframesincludingmonkeybarsandjunglegyms,swings,slides,flying foxes including track rides, see sawsetc.)butalsoinhomebackyards.Trampoline-related injury (25% of falls hospitalisations)was the focus of a recent Hazard edition (75, published in2013),so isgiven lessattentioninthisreport.

Yearly trend in frequency and admission rates (1998/99 to 2011/12)

Frequency of admissions

Thefrequencyofchildplaygroundequipmentfall injury hospital admissions increasedsignificantly from1,345 in1998/99 to1,692in2011/12, representinganestimatedannualincrease of 1.4% and an overall increase of21%(95%CI13%to29%).Figure6

Significantupwardtrendsinthefrequencyofadmissionswere observed in all age groups,withincreasesof41%(95%CI22%to62%)among0-4yearoldsand31%(95%CI14%to48%)among10-14yearolds,comparedwith14% (95% CI 6% to 22%) among 5-9 yearolds.Figure6

Figure 6 Trend in the frequency of hospital admissions for playground equipment fall injury by age groups, 1998/99 to 2011/12

Figure 7 Trend in the yearly hospital admission rates for playground equipment fall injury by age groups, 1998/99 to 2011/12

Figure 8 Trend in the yearly frequency of playground equipment fall injury hospital admissions by equipment type, 2002/03 to 2011/12





Admission rates

Yearly admission rates also increasedsignificantlyfrom141.5/100,000in1998/99to 167.6/100,000 in 2011/12, representinganestimatedannual increaseof0.9%andanoverallincreaseof14%(95%CI6%to22%).Figure7

Ratesincreasedsignificantlyinallagegroupswith the largest increase over the 14-yearperiodin10-14yearolds(25%,95%CI10%to41%),followedby0-4year-olds(22%,95%CI6%to41%)and5-9year-olds(14%,95%CI7%to22%).Figure7

Trend in frequency by equipment type

The introduction of Version 10 of theInternational Classification of Diseases-Australian Modification (ICD-10-AM), amajor revision of the hospital admissionscodingsystem,occurredin1998.Inthefirstfour years of ICD-10 the code W09.2 fallfrom playground equipment did not haveany sub-codes, meaning hospital admissionsfor injuries involving different types ofplay equipment could not be disaggregated.Seven specific sub-codes for different typesof equipment were introduced in 2002/03.Trendswere analysed for the10-year period2002/03-2011/12 for the four types ofequipmentthataccountedformorethanthree-quarters of playground equipment fall injuryhospital admissions over that period (Figure8).

Although therewas no significant change inthe frequencyof injuryadmissions foreitherclimbing apparatus or swing related falls,the frequency of child trampoline-relatedfall injury hospital admissions increasedsignificantly from 264 in 2002/03 to 421 in2011/12, representing an estimated annualincrease of 5.3% and an overall increaseof 68% (95% CI 43% to 92%). Over thesame time period, the frequency of childslide-related fall injury hospital admissionsdecreased significantly from 174 in 2002/03to153 in2011/12, representinganestimatedannual decrease of 2.5% and an overalldecreaseof23%(95%CI-33%to-11%).

Pattern of injury (2010/11 to 2012/13)

Age and sex

Two thirds of the 4,472 hospital admissionsfor play equipment fall injuries over theperiod 2010/11 to 2012/13 were aged 5-9years (65%, n=2,926). Males were slightly

over-represented overall (54%) and in thetwoyoungeragegroups(53%and52%),butcomprised61%ofadmissionsin10-14year-olds.Table4

Type of equipment

Fall injuries mostly occurred on climbingapparatus, that includes monkey bars andjunglegyms(40%), followedby trampolines(25%), slides (10%), swings (6%) andflying foxes (5%) (Table 4). This rankingis unchanged from 2003-5 (published inHazard65in2007),althoughthebroadVAEDcodingcategoriesmayhidesomechanges,forexample climbing walls have become morepopular but injury cases related to their usecannotbedisaggregated. Childrenaged0-4were more likely to be admitted to hospitalforinjuryrelatedtotrampolines(36%),slides(15%)andclimbingapparatus(14%),whereasmore than half of the hospital admissionsof 5-9 year-olds were for injuries relatedto climbing apparatus (51%) followed bytrampolines (17%) and slides (9%). Among10-14 year-olds, 41% of admissions werefor trampoline-related injury, followed byclimbingapparatus(27%)andswings(10%).Thesedifferentpatternsaremostlikelyrelatedtoexposure.

Setting (location) of injury event

Forty-five percent of admissions were notcodedforlocationsocareshouldbetakenininterpretingtheseresults(Table4).Analysisindicatedthat35%ofadmittedchildrenwereinjured in schools, other institutions that includeskindergartensandchildcaresettingsandotherpublicbuildings;10%wereinjuredin home backyards and 8% were injured in‘other specified places’ (the ‘other specified

places’ code includes parks). There is nospecific code for playground in the VAED;casesthatoccurredinplaygroundsshouldbecodedto‘otherspecifiedplace’.

Body site injured and type of injury

Among all playground fall admissions, theelbow and forearm was the most frequentlyinjured body site (54%), followed by theshoulder andupper arm (22%) and the head(12%)(Table4).Therewasadifferentpatternofinjuryinthethreeagegroups.Injurytotheelbow and forearm accounted for over half(59%)oftheadmissionsin5-9and10-14year-oldscomparedtoone-thirdoftheadmissionsin 0-4 year olds. By contrast, head injurieswere more common in 0-4 year olds (27%of admissions) than in the older age groupswhere they accounted for approximately 8%ofadmissions.Childrenaged0-4yearswere2-3 timesmore likely tobehospitalisedasaresult of injuries to the head than the two other age groups.Their greater headmass relativeto bodyweight ratiomakes them top-heavy.Shoulderandupperarminjurieswererelatedto around one-quarter of admissions in 0-4year-olds and 5-9 year-olds compared with8%in10-14yearolds.

Fracturewasthemostfrequentinjuryoverall(83%)andinallagegroups(71%-88%)(Table4).Openwoundwasthenextmostcommoninjury(6%),moreprominentin0-4yearolds(13%) compared with the two other groups(each4%). Injury severity (length of stay) and cost

Most admitted caseswere dischargedwithintwo days (84%), around fifteen percent(n=694) had a length of stay of 2-7 daysand 7 patients stayed in hospital 8-30 days(Table4).Amongthe701patientsstayinginhospitaltwodaysormore,themostcommondiagnoses were fracture of the upper limb,mainlysupracondylarfractureofthehumerus(n=148), fracture of the shafts of the radiusand ulna (n=110), fracture of the lower end of the radiuswithdorsalangulation (n=75)andfractureofthelowerendofboththeradiusandulna (n=49).

The total direct cost of hospital care forplayground equipment fall admissions overthe3-yearperiod2010/11-2012/13was$14.9million (mean cost: $2,970; range $508 -$39,859). Although5-9yearoldsaccountedfor the greatest proportion of direct hospitalcosts(65%),olderchildrenaged10-14yearshadthehighestmeancostpercase(meancost:$3,202;range$1,050-$39,859).


Pattern of injury by type of equipment

Table 5 summarises the pattern of injuryby type of equipment. The three types ofequipment that accounted for almost three-quarters (74%, n=3,305) of all hospitaladmissions for playground equipment fallsare shown separately: climbing apparatus,trampolinesandslides.

Age and sex

Children aged 5-9 years accounted for thehighest proportion of fall injury admissionsacross all types of equipment but theiroverrepresentation was most pronouncedfor climbing apparatus related falls wherethey accounted formore than 80%of injuryadmissions(n=1,488,83%).

While males were slightly over-representedoverall (54%) and among trampoline (56%)andslide(60%)fallinjuryadmissions,femalesaccounted for more climbing apparatus fallinjuryhospitaladmissionsthanmales(n=966,54%).

Setting (location) of injury event

Asmentionedpreviously,45%ofplaygroundequipmentfalladmissionswerenotcodedforlocationsocareshouldbetakenininterpretingtheseresults(Table4andTable5).Atleast56% of climbing apparatus and 29% ofslide injury admissions occurred in schools (that includes kindergartens and child caresettings). Althoughmost trampoline injurieswerecodedtounspecifiedlocation(67%),atleast31%occurredinprivatehomes.

Body site injured and type of injury

Fracture of the upper limb was the mostcommonspecific injury typeacrossall typesof equipment, but was most prominent inclimbing apparatus falls (87%) comparedwithfallsfromtrampolines(66%)andslides(74%). Around 10% of injury admissionsamong children injured on trampolines andslides were for fractures of the lower limb(11%and9%respectively).


Table 4 Frequency and pattern of playground equipment fall injury hospital admissions by age group, Victoria 2010/11 to 2012/13 (3 years)

0-4 years 5-9 years 10-14 years All admissions n % n % n % n % Sex Male 462 53.0 1,526 52.2 412 61.1 2,400 53.7 Female 410 47.0 1,400 47.8 262 38.9 2,072 46.3 All 872 100.0 2,926 100.0 674 100.0 4,472 100.0 Equipment Climbing apparatus 120 13.8 1,488 50.9 180 26.7 1,788 40.0 Trampoline 315 36.1 502 17.2 277 41.1 1,094 24.5 Slide 129 14.8 256 8.7 38 5.6 423 9.5 Swing 66 7.6 119 4.1 64 9.5 249 5.6 Flying fox 12 1.4 176 6.0 30 4.5 218 4.9 See saw 11 1.3 11 0.4 5 0.7 27 0.6 Tree house 12 1.4 14 0.5 0 0.0 26 0.6 Other 86 9.9 115 3.9 25 3.7 226 5.1 Unspecified 121 13.9 245 8.4 55 8.2 421 9.4 Location School, public buildings 125 14.3 1,242 42.4 194 28.8 1,561 34.9 School 104 11.9 1,213 41.5 187 27.7 1,504 33.6 other public buildings 21 2.4 29 1.0 7 1.0 57 1.3 Home 166 19.0 212 7.2 87 12.9 465 10.4 Sports & athletic areas 8 0.9 26 0.9 13 1.9 47 1.1 Trade & service area 21 2.4 20 0.7 * * 43 1.0 Other specified places 102 11.7 193 6.6 58 8.6 353 7.9 Unspecified places 450 51.6 1,233 42.1 320 47.5 2,003 44.8 Body region injured head 233 26.7 230 7.9 57 8.5 520 11.6 neck 10 1.1 37 1.3 29 4.3 76 1.7 thorax 0 0.0 6 0.2 13 1.9 19 0.4 abdomen, lowerback, lumbar spine & pelvis 5 0.6 33 1.1 17 2.5 55 1.2 shoulder & upper arm 200 22.9 745 25.5 56 8.3 1,001 22.4 elbow & forearm 289 33.1 1,724 58.9 399 59.2 2,412 53.9 wrist & hand * * 24 0.8 27 4.0 54 1.2 hip & thigh 39 4.5 29 1.0 5 0.7 73 1.6 knee & lower leg 86 9.9 85 2.9 58 8.6 229 5.1 ankle & foot * * 9 0.3 6 0.9 19 0.4 unspecified * * * * 7 1.0 14 0.3 Injury type fracture 618 70.9 2,580 88.2 528 78.3 3,726 83.3 open wound 114 13.1 121 4.1 27 4.0 262 5.9 intracranial injury 32 3.7 41 1.4 18 2.7 91 2.0 dislocation, sprain & strain 15 1.7 45 1.5 28 4.2 88 2.0 superficial injury 16 1.8 11 0.4 * * 30 0.7 other & unspecified 77 8.8 128 4.4 70 10.4 275 6.1 Length of stay < 2 days 740 84.9 2,494 85.2 537 79.7 3,771 84.3 2-7 days 130 14.9 428 14.6 136 20.2 694 15.5 8-30 days * * * * * * 7 0.2 Total bed-days 1,238 3,908 1,005 6,151 Mean bed-days 1.3 1.2 1.3 1.2 Direct hospital costs Total costs $2,716,685 $9,750,933 $2,427,213 $14,894,830 Mean costs $2,752 $2,982 $3,202 $2,970


DiscussionThere is increasing concern about childhoodinactivity and obesity; interesting andchallenging playgrounds are one wayof encouraging children to be active.Unfortunately, there has developed adisturbingtensionbetweenchildplayactivistsandinjurypreventionprofessionalsbasedonthefalsedichotomythatplayequipmentandplaygrounds that reduce the risk of injurynecessarily diminish the fun, challenge anddevelopmentalbenefitsofourplaygrounds.Amorecollaborativeandconstructiveevidence-basedapproach that encourages creative andthoughtful design of playgrounds and playequipment with the aim of achieving thetripleobjectivesof fun,challengeand injuryprevention, has more potential to optimisehealth and developmental outcomes forchildrenthan‘theblamegame’.


Table 5 Frequency and pattern of playground equipment fall injury hospital admissions by equipment type, Victoria 2010/11 to 2012/13 (3 years)

Climbing apparatus (n=1,788)

Trampolines (n=1,094)

Slides (n=423)

All other (n=1,167)

All (n=4,472)

n % n % n % n % n % Age group 0-4 120 6.7 315 28.8 129 30.5 308 26.4 872 19.5 5-9 1,488 83.2 502 45.9 256 60.5 680 58.3 2926 65.4 10-14 180 10.1 277 25.3 38 9.0 179 15.3 674 15.1 All 1,788 100 1,094 100 423 100 1,167 100 4,472 100 Sex Male 822 46.0 616 56.3 254 60.0 708 60.7 2,400 53.7 Female 966 54.0 478 43.7 169 40.0 459 39.3 2,072 46.3 Injury fracture - upper limb 1561 87.3 723 66.1 311 73.5 802 68.7 3397 76.0 fracture - lower limb 44 2.5 124 11.3 36 8.5 74 6.3 278 6.2 open wound – head/face/neck 47 2.6 49 4.5 19 4.5 105 9.0 220 4.9 intracranial injury 17 1.0 28 2.6 9 2.1 37 3.2 91 2.0 other & unspecified 119 6.7 170 15.5 48 11.3 149 12.8 486 10.9 Location School, public buildings 1,035 57.9 10 0.9 137 32.4 379 32.5 1,561 34.9 School 1,009 56.4 9 0.8 124 29.3 362 31.0 1,504 33.6 Other public buildings 26 1.5 * * 13 3.1 17 1.5 57 1.3 Home 22 1.2 335 30.6 34 8.0 74 6.3 465 10.4 Sports and athletics 13 0.7 15 1.4 * * 15 1.3 47 1.1 Trade and service * * 0 0.0 13 3.1 27 2.3 43 1.0 Other specified 103 5.8 17 1.6 62 14.7 171 14.7 353 7.9 Unspecified 612 34.2 717 65.5 173 40.9 501 42.9 2,003 44.8


Ourstudyshowsthatmorethan1,500Victorianchildrenareadmittedtohospitaleachyear(fouraday)asaresultoffallsfromplayequipment(including trampoline-related injury). Theincidence of hospitalisations increased from141.5/100,000 to 167.6/100,000 between1998/99 and 2011/12. Many more injuredchildren attend GPs or are treated by firstaiders and parents/carers. Among hospitaladmissions,thecurrentstudyfoundthataboutfour times as many children are injured in public settings (schools, kindergartens, childcarecentres,parksetc.)thanhomebackyards,butcareshouldbetakenininterpretingtheseresults as therewas substantialmissing dataon location of occurrence of injury.

Although it appears that play equipmentinjuries in public settings are much morecommon than in the home, there is some evidence that home play equipment injuriesare more severe. A recent Canadian casecontrol study involving young children aged3-11 compared the severity of playgroundequipment-relatedinjuriesfromjunglegyms,swings and slides in home backyards tothose occurring from the same equipment inpublicsettings(Keays&Skinner,2012).Thestudy found that children falling from homeplayground equipment had greater odds ofsevereinjury(OR=1.30;95%CI1.23to1.37)andfractures(OR=1.47;95%CI1.39to1.55)than those falling from public playgroundequipment (Keays & Skinner, 2012). Theauthors recommend that parents should bediligent in using proper landing surfaces, asinstalled in public playgrounds. Safe sitingofequipmentisprobablymoreproblematicintheconfinedspaceof thebackyard than inapublicspace.Thefollowingdiscussionofriskand protective factors and recommendationsforpreventionofinjurybelowdonotincludetrampoline injury, as this was covered in arecentissueofHazard(75,2013).

Free fall height from play equipment

Previous studies have demonstrated thatthe likelihood and severity of playgroundequipment fall injuries is directly associatedto the height of playground equipment, theheightofthefallandthecushioningpropertiesof undersurfacing (softfall material) belowthe equipment (Chalmers et al., 1996; Mottet al., 1997; Mowat et al., 1998; Macarthuret al., 2000, LaForest et al., 2001; Sherkeret al.,2005a). Theweightofevidence fromcase control studies demonstrates that a fall height greater than 1.5m significantlyincreases the likelihood of arm fracture, themostcommonseriousplayequipmentrelatedinjury(Chalmersetal.,1996;Macarthuretal.,2000).

In the 2004 revision of Standard for playground equipment (AS 4685.1-2004:Playground equipment – General Safetyrequirementsandtestmethods),themaximumfreefallheightwassetat2.5metres,asinthepreviousstandard. Thestandardisproducedspecificallytoaddresstheriskofseriousheadinjury rather than arm fracture. However, a reduced maximum of 2.2m for upper bodyequipment (such as monkey bars/horizontalladders) was included in the standard – aconcession that acknowledges both theresearch evidence of an association betweenfall height and injury risk and the highproportion of play equipment arm fracturesthatarerelatedtoplayonmonkeybars.

Themaximumallowablefallheightforupperbody equipment in the 2004 standard washigherthanthe1.8m.maximumrecommendedbytheauthorsofaQueenslandstudy(Nixonetal.,2004)thatexaminedthetypeofinjury,fallheights and measures of impact attenuationof surfaces on which children fell from horizontal ladders (monkey bars) and trackrides (fixed track flying foxes). All injuredchildren who presented to two children’shospitals and received medical attention forfallinjuryfromthesetwotypesofequipmentwereinterviewedandtheplaygroundvisited.

The study found that nearly three-quartersof injuries (mostly arm fractures) were from falls greater than 1.8m with the modal fallheight being 2.0m, and in 41% of cases thesurface was deficient in impact absorbingproperties for the height of the equipment.The authors recommended modifying theheightofmonkeybarsandtrackridesto1.8m(recognisingthathorizontalladdersandtrack

rideequipmentheightsneedtobegreaterthan1.5m for effective use) rather than removingthese popular pieces of equipment. Theyalso recommended that the impact testingthresholdsforundersurfacingintheAustralianstandard may need to be lowered, as whilethey appear adequate to reduce head injurytheyaretoohightoreducelongbonefracture.

The recently announced new playgroundequipment Australian standard (AS4684-2014)hasincreasedtheallowablefreeheightof fall fromplayequipment from2.5metresto3.0metres,harmonisingwiththeEuropeanstandard EN 1176-2008 (Eager, 2014;Standards Australia, 2014). The maximumfreeheightoffallfromupperbodyequipment(monkey bars and track rides) in the newAustralian standard, however, remains at2.2m. The main stimulus for adopting themore liberal 3.0m free fall height in theEuropean Standard is that it is a policy ofStandardsAustralia (SA) to alignAustralianstandards with international standards unless thereisevidenceofdetrimentalconsequencestothecommunity.AustraliaisasignatorytoThe World Trade Organizations Agreementon Technical Barriers to Trade. The morestringentheightoffallprovisioninour2004playgroundequipmentstandardwasassessedto be a barrier to trade because Europeanplayequipmentthatdidnotconformto2004StandardcouldnotbeimportedintoAustralia.

Apparentlytheinjurypreventionfielddidnotpresent any evidence to the SA Playgroundequipment standards committee for theretention of 2.5m as the maximum freeheight of fall from play equipment becausethe change could pose an increased risk ofchild injury(Personalcommunication,DavidEager, Chair, SA Playground EquipmentStandardCommittee,15/5/2014).Thecounterpositionthattheheightincreasewouldfosterchildren’s risk management learning andresult in the installationofmorechallengingand exciting play equipment in playgrounds(thus encouraging physical activity)without detriment to the health of children, was presented and accepted (Personalcommunication, David Eager, Chair SAPlaygroundEquipment StandardCommittee,15/5/2014;Eager,2014;StandardsAustralia,2014).

Thechange isa fait accompli; ifplaygroundequipment related injuries and their severityincreasesasaresultofthischangeitwilltakemany years to show up in hospital-treatedinjurytrenddataasthenewequipmentwillbeintroducedgraduallyintoourplaygrounds.ANewZealandcasecontrolstudyinvestigating


the effectiveness of the height and surfacingrequirements in the 1986 New Zealandstandard(NZS5828),thatrequiredamaximumfall height of 2.5 metres, found that fallingfromaheightexceeding2.5metresincreasedthe odds of injury threefold (Chalmers etal.1996).

The argument that height is a necessarycomponent of fun and challenge in play onplayground equipment was challenged byauthorsofarecentNewZealandstudy(Wakes&Beukes,2011). Themainobjectiveofthestudy—thatinvolved33playgroundusersandtheirparentsin4playgroundsand27primaryschool students and their parents from oneschool—was togainanunderstandingof therelationshipbetweenheightandfun.Childrenandparentswereobservedinplaygroundsandinterviewedandtheschoolchildrenundertookarangeoftasks,alltogaugetheirperceptionswithrespecttotheheightattractionsandrisksassociated with playground use. The studyfound that coordination is a greater sourceoffunandchallengethanheightforchildrenandchildrencreatefunatanyheightprovidedcoordination was involved. The authorssuggest that risk of injury can be reducedwhen the use of lower body strength andcoordinationarecombinedinplayequipmentwith lower free fall heights,which alsomayencouragebroaderrangeofchildrentoengageinphysicalactivity.

Given the strong evidence supporting theassociationbetweenheightofplayequipmentand forearm fracture, the effect of the increase of0.5minthemaximumfreeheightoffallinthenewStandardshouldbecloselymonitoredand the impact of this change should be thesubjectofresearch.IfadetrimentaleffectisfoundinfutureresearchthenitispossibletomakeapplicationtoSAforavariationtothestandard.

Cushioning of undersurfacing

Another important factor that may protectagainstinjuryinplaygroundsisthecushioningproperties of undersurfacing in and aroundplay equipment (and its maintenance).The Australian Standard permits loose fillundersurfacing, including sand and tanbark, and rubber-based bilaminate surfaceswhich are costlier to install. The Standardrecommends that loose fill should bemaintained to a minimum depth of 25cm,but playground operators are advised tofill to 30cm to allow for compaction andreplenish loose fill four times a year. Lackof compliance to the recommendeddepth of

undersurfacinghasmadeitdifficulttoevaluatethe contribution of compliant undersurfacingto injury risk reduction, independent of fallheight(Sherkeretal.,2005a;Chalmersetal.,1996;Macarthuretal.,2000).InaVictorianstudy on the risk factors for arm fracture inplayground equipment falls, Sherker et al(2005a) found only 4.7% of the 402 schoolplaygrounds inspected over the course ofthe study complied with the recommendeddepth of loose fill (tanbark) which madeit impossible to assess whether compliantundersurfacing protected against injury. Ina related study the same authors found that replenishment of tanbark should occur at3-month intervals to maintain compliance(Sherkeretal.,2005b).Inalaterstudy,Martin&Cooper(2005)auditedarandomsampleofplaygroundssituatedinSouthWesternSydneyforcompliancewiththe2004Australian/NewZealandStandard forplaygroundequipment.They reported that there was significantimprovementintheinstallationofappropriateundersurfacing materials (pinebark was themostpopularchoice)comparedtoa1995studybut poor compliance in relation to pinebarkundersurfacingdepth(18.5%compliance).

There is still debate around which of therecommended undersurfacing provides themostprotectionagainst injury. Asexplainedpreviously,researchontheprotectiveeffectoftanbark,popularinAustralianplaygrounds,hasbeenhamperedbypoormaintenance. Vidairetal. (2007)undertookastudy inCanada todetermine whether rubberised playgroundsurface made of recycled tyres compliedwith state-mandated standards for impactattenuation comparing their performancewith playgroundswithwood chip surfacing.Of 32 playgrounds with rubberised surfacestested (122 structures), 69% failed the headimpact criteria tests, probably due to failureto install rubberised surfacing at sufficientthickness. The wood chip surfaces in thefive comparisonplaygroundswere always incompliance with the standard. The authorsconcluded that the surfacing of wood chipsin Canadian playgrounds probably provideagreatermarginofsafetythanpourinplacerubberised surfacing as installed at the timeofthestudy,butthatimprovingtestingatthetime of installation of rubberised surfacingwould reverse this situation.

Howardetal(2009)hadauniqueopportunityto design a real world randomised trial ofschool playground surfaces because theywere given access to schools, run by TheToronto District School Board, that werepart of a program to retrofit and replaceunsafe playground equipment. Their clusterrandomised trial conducted in 37 schools

comparedthedifferencesinarmfractureratesand head injury rates in school playgroundsallocated to have wood fibre surfacingcompared to those allocated to have graniticsandsurfacing.

Among schools compliant with therandomisation there was a nearly five-fold higher risk of an arm fracture from afall off playground equipment in schoolswith wood fibre surfacing (9.4 per 100,000student-months, 95%CI 3.7-21.4) comparedwith schools with granitic sand playgroundsurfaces (1.9 per 100 student-months , 95%CI0.04-6.9).Therewasonlyonesignificantheadinjuryonanyoftheschoolplaygroundsin the study, and the child did not requirehospitalisation.Allequipmentintheschoolsin the study was new and complied withthe current Canadian standards and therewas a fairly high rate (70-75%) of ongoingmaintenanceofthesurfacingduringthestudyyearswhichtheauthorsinterpretedasfurtherevidence “that standardswork and surfacingworks” (Howard et al., 2009). The authors’explanation for the lower fracture rates onsand was because of lower surface friction.They recommended that safety standardsshould be updated to reflect the informationfrom their study.

Handhold diameter on playground equipment

Lossofhandgripisafrequentmechanismoffalls from climbers, monkey bars and trackrides. Handhold design recommendationsareusuallybasedongripstrengthbut recentresearchhasshownthatgripstrengthisnotareliablepredictorofthecapacitytoholdontorungs and rails and support the body withthe hands (Ehrlich et al., 2013). Therefore,the basis for the design of handholds onplayground equipment may be flawed. Ina biomechanical experiment, Ehrlich et al.(2013)measured the breakaway strength forschoolagechildrenoncylindricalhandholdsofdifferentsizesonseveraldependentvariables,including breakaway strength, grip strength,breakaway/grip and breakaway/bodyweight.Thestudyfoundthathandholdandindividualfactors (age, sex, hand dominance and handbreadth) influence breakaway strength. Theauthors suggested that the upper limit inrecommendations for playground rung/raildiametersormaximumcrosssectionsshouldbe revised downward as breakaway strengthon the 3.8cm handle was decreased for allagesofchildren(Ehrlichetal.,2013).Iftheexposure to falls from monkey bars, trackridesandclimbingframescanbereducedbyreducing the diameter of rung rails then this


intervention has good potential to preventinjury; more biomechanical studies and realworld trials are recommended.

Child behaviour and active supervision by parents/carers

Severalstudieshaveidentifiedchildbehaviour(inappropriate use of equipment, aggressiontowardplaymatesetc.)asacontributoryfactorfor injury on playground equipment (Pain,1992; Nixon et al., 2004). Morrongielloand colleagues have undertaken a numberof studieson thedeterminantsof risk takingbehaviour in children and have trialledbehavioural interventions to reduce riskybehavioursindifferentsettings.Twoofthesestudiesspecificallyaddress the issueofriskyplay behaviours of 6-11 year-olds related tofallsoffplaygroundequipment(Morrongiello& Matheis, 2007; Morrongiello & Mark,2008). The first study conducted in twoCanadianschoolswasarandomisedcontrolledtrial(interventiongroup191children,controlgroup67children)thatinvestigatedtheimpactof a cognitive intervention to induce fear toreduce risk taking behaviour, particularlytargetinghighsensationseekers(i.e.thosethatseek risk experiences that are novel, intenseand emotionally arousing) (Morrongiello &Matheis, 2007).

Itwasacomplexstudyandthisexplanationisasimplification. Childrencompletedpostersindicatingtheriskybehaviourstheywouldorwouldnotdousingstickersofphotographsofchildren engaged in moderate and high riskbehaviours based on previous observationsin local playgrounds. Childrenwere scoredon risk taking based on their choices andtheir scores on a questionnaire that includecompleting the Sensation Seeking Scalefor Children. Children in the interventiongroupwere thenexposed tovideoandaudiopresentations, using trainedchild actorswhoshowed the consequences of the risk takingbehaviours in a fear evoking way. Post-intervention (8-10 weeks later), the childrenin both the intervention and control groupswere asked to re-do their posters on thepretext that someof their stickers had fallenoff.Thechangesintheirassignationofwhatthey would and wouldn’t do were measured. The study found significant decreases inintention to risk take in the intervention butnot the control group, effectiveness did notvarybyageorsex,butwasgreaterforthosescoring high in sensation seeking. Childrenwerefullydebriefed,andthefunthatcouldbehadinplaygroundsifoneplayedcarefullywashighlightedinthedebriefing.

In the second study Morrongiello & Mark(2008) conducted another interventionaimedtomodifybehaviour throughreducingchildren’sintentiontorisktakeonplaygrounds.Two essential elements of the inducedhypocrisyparadigmdevelopedbyotherswereincorporated into this study. Children weremademindfuloftheirpastbehaviouronplayequipmentbybeingaskedtocompilealistofrisky playgroundbehaviours, then theywereaskedtoassumetheroleofadvocatesforsaferplaybysigningaposterpromotingsafeplayandcreatinganaudiotapedradiocommercialadvocating safe play. Effectiveness wasmeasured by changes in ‘before and after’interventionindicesofintentionstorisktake.In the pre-intervention session they wereaskedtomakepostersusingsuppliedstickersof colour photographs of low,moderate andhigh risk playground behaviours indicatingwhat they would and wouldn’t do and after the intervention theywere given the opportunityto change their posters. The interventionresulted in significant reductions in the risktakingbehaviourschildrenendorsed,bothfortargeted and non-targeted risky behaviours,withevidencetosupportthatthechangeswereattributabletochangesincognition.

Amajor limitation of both these studieswasthat there were no ‘real world’ observationsofthebehaviourofstudyparticipantsonplay

equipmentbeforeandaftertheinterventiontoconfirmthatchangesinintentionstorisktaketranslatedintoreducedrisktakingbehaviours.The authors recommend that this beincorporatedinfuturebehaviouralmodificationresearch.Theseprojects,however,havemadeapromisingstarttodevelopingapproachesthatcouldbeincorporatedinbroad-basedprogramsaimed at reducing risk taking behavioursassociatedwithfallinjuryinplaygroundsandothersettings.

TheStamp in Safetyprogramtookadifferentapproach. It is an intervention to promotebettersupervisionofchildrenusingchildcarecentreplaygroundsandtorewardchildrenforsafeplay(Schwebeletal.,2006;Chelvakumaretal.,2010).Therehavebeentwoevaluations:the first intervention and evaluation, using apre-postdesign,wasconductedinachildcarecentre in a relatively affluent centre with a less ethnically diverse clientele involving 12staffand44children(Schwebeletal.,2006);the second, using a non-equivalent controlgroup design, was conducted in five classesinvolving15 staff and71children inamoreethnically diverse and less affluent childcare centre(Chelvakumaretal.,2010).

Staff members supervising children in theplayareasreceivedatrainingsessioninactivesupervision techniques and children wererewarded by supervising staff throughoutplaysessionswithsmileystampsandpositiveverbal reinforcement if they played safely.Primaryoutcomemeasuresinbothevaluationswere supervisor verbalisations (warnings,explanations, redirects), supervisor location(core, outskirt, or fringe of playground) andthe number of injuries on the playground.In the second evaluation child risk takingbehaviourswerealsomeasured.Observationaldata were collected before, during and afterthe intervention and sixmonths later. Onlyone injury happened in the playground inthe pre-intervention phase of the first study.The small number of injuries in the secondtrialmade it toodifficult tocomparegroups.Analyses revealed that the interventionshad modest positive effects in changing thebehaviours of supervisors and children thatare likely to reduce the risk of child injuryontheplaygroundsofchildcarecentres.Thelessons learnt from these studies (the need to vary rewards offered to children and re-enforce desired behaviours of supervisorsand children with regular booster sessionsovertime)providethebasisfordevelopmentof low cost, easy to implement programs toimprovethequalityofsupervisionandreducerisktakingbehavioursofchildreninchildcaresettingsand,potentially,inkindergartensandthelowergradesofprimaryschools.


Recommendations

Injury surveillance and research

• Given the strong evidence supportingan association between height of playequipment (a proxy for free height offall) and forearm fracture, the effect of the increase of 0.5m in the maximumfree height of fall in the newAustralianStandardshouldbecloselymonitored.

• Further biomechanical and real worldstudiesshouldbeundertakentodeterminetheoptimaldiameterofrungrailstoreducefalls from monkey bars, track rides andclimbingframes.

• Further research should be undertaken todevelopsimpleandlowcostinterventionstargeting children, parents, child careworkersandteacherstomodifychildren’shigh risk behaviours in playgrounds andencourage more active supervision ofchildren’suseofplaygroundequipment.

Safety measures

• Councils, schools and parents shouldconsider granitic sand when selectingloose fill undersurfacing for playgroundequipment.

• AllplaygroundequipmentandplaygroundsshouldcomplywiththecurrentAustralianStandard. Australian designers andmanufacturers of playground equipmentare urged to maintain the maximum freeheight of fall of 1.5m or less. They areencouraged to use playground designelements to reduce the free height of fall(e.g., mounding), and use lower bodystrength and co-ordination challengesrather than height to provide fun andstimulation.

• Consumers are encouraged to carefullyconsider height of equipment and choosefun and challenging equipment with amaximumfreeheightoffallof1.5morlesswheneverpossibletoreducetheriskofarmfracture.

• Parents should be diligent in using andmaintaining recommended sand, loosefill or rubber undersurfacing under andin the fall area of playground equipmentin home backyards, as installed in publicplaygrounds. They should pay particularattentiontosafesitingofequipmentasitismoreproblematicintheconfinedspaceofthehomebackyardthaninapublicspace.

• Parents and care givers/teachers shouldreceiveeducation/trainingtoprovideactivesupervisioninplaygrounds.

• Parents should report injures to councils/playgroundoperators, takingphotographs

oftheequipmentandundersurfacingatthesceneifpossible.

• Parentsshouldcheckandreportplaygroundequipment hazards and noncompliantsurfacing, especially poorly maintainedloosefill,tocouncils/playgroundoperators.

• Children should be encouraged to reducetheir high risk taking behaviours inplaygroundswithreward-basedapproachesandbehaviourchangeinterventions.

• Children should wear closed shoes withslip resistant soleswhen playing on playequipment.Removeachild’shelmetbeforepermitting access to play equipment; achild should notwear a scarf or clothingwith drawstrings or cords, to preventstrangulation.

ReferencesChalmersDJ,MarshallSW,LangleyJD,etal.Heightandsurfacingasriskfactorsforinjuryin falls from playground equipment: a case-control study. Inj Prev1996;2:98–104.

ChelvakumarG,SheehanK,HillALetal.TheStamp-in-Safety programme, an interventionto promote better supervision of children onchildcare centre playgrounds: an evaluationinanurbansetting.Inj Prev.2010;16(5):352-354.

Eager D. New, internationally alignedplayground equipment standard. Instituteof Public Works Engineering Australasia(IPWEA) ASSET e-news blog postedMon March 10, 2014. http://www.ipwea.o rg / a s s e tmanag emen t / b l o g s / i pwea -australasia/2014/03/10/new-internationally-aligned-playground-equipment-standardAccessed1/5/2014

Ehrlich PF, Young JG, Ulin S et al. Theeffects of handhold diameter. Human Factors 2013;55(3):545-556

Howard AW, Macarthur C, Rothman L etal. School playground surfacing and armfractures in children: A cluster randomisedtrial comparing sand to wood chip surfaces.Plos Med 6(12):e1000195. Doi10.1371/journal.pmed.1000195

Keays G, Skinner R. Playground equipmentinjuries at home versus those in publicsettings: differences in severity. Inj Prev 2012;18(2):138-141.

Laforest S, Robitaille Y, Lesage D et al.Surface characteristics, equipment height,andtheoccurrenceandseverityofplaygroundinjuries. Inj Prev2001;7:35–40.

Macarthur C, Hu X, Wesson DE, ParkinPC (2000) Risk factors for severe injuries

associated with falls from playgroundequipment. Accid Anal Prev 2000; 32:377–382.

Martin J,CooperCD. Playground safety inSouth Western Sydney. J Paediatr Child Health. 2005;41(11):587-91.

MorrongielloBA,MarkA.Practicewhatyoupreach:Inducedhypocrisyasan interventionstrategytoreducechildren’s intentiontorisktake in playgrounds. J of Ped Psych. 2007 ;52(7)819-830

Morrongiello BA, Matheis S. Addressingthe issue of falls off playground equipment:an empirically based intervention to reducefall-riskbehaviorsonplaygrounds. J of Ped Psych.2008;33(10)1117-1128

Mott A, Rolfe K, James R et al. Safetyof surfaces and equipment for children inplaygrounds.Lancet1997;349:1874–1876.

Mowat DL, Wang F, Pickett W, Brison RJ(1998) A case-control study of risk factorsfor playground injuries among children inKingstonandarea.Inj Prev1998;4:39–43.

Nixon JW, Acton CHC, Wallis B et al.Preventing injuries on horizontal laddersand track rides. Inj Control Saf Promot 2004;11(4):219-224.

PaineD.Children’s playground and equipment injuries. Playground and RecreationAssociationofAustralia.Melbourne,1992.

SchwebelDC,SummerlinAL,BoundsMLetal.Safetyprogram:abehavioralinterventiontoreducebehaviorsthatcanleadtounintentionalplayground injury in a preschool setting. J Pediatr Psychol. 2006Mar;31(2):152-162.Epub2005Mar3.

Sherker S,Ozanne-Smith J,RechnitzerG etal.Outonalimb:riskfactorsforarmfracturein playground equipment falls. Inj Prev. 2005a;11(2):120-124.

Sherker S, Short A, Ozanne-Smith J.The in situ performance of playgroundundersurfacing:implicationsformaintenanceandinjuryprevention.Inj Control Saf Promot. 2005b;12(1):63-66.

Standards Australia. New playground standards. Standards Australia MediaRelease 16/4/2014 http://www.standards.org .au /Analy t icsRepor t s /140416%20Playground%20Standards%20AS%204685%20MR%20final.pdf.

WakesS,Beukes.Height,funandsafetyinthedesign of children’s playground equipment.Inj Control Saf Promot.2012;19(2):101-108


BOX 1: DATA SOURCES, CASE SELECTION AND ANALYSIS METHODS

Data Sources and Case Selection

Hospital admissions

HospitaladmissionsdatawereextractedfromtheVictorianAdmittedEpisodesDataset(VAED).TheVAEDrecordsallhospitaladmissionsinpublicandprivatehospitalsinthestateofVictoria.

Caseswereselectedifthepersonwasaged0-14yearsatthetimeofadmissionandhadafirstrecordedexternalcausecodeintherangeW00-W19-fall.Allfallssub-categoriesweredefinedusingexternalcausecodes.Formostanalysesreadmissionstothesamehospitalwithin30days,deathsinhospitalandtransferswithinandbetweenhospitalswereexcludedtoavoidovercounting.Allinjuryadmissionswereincludedwhenprovidingestimatesofdirecthospitalcostsandnumberofhospitalbeddaysastheirinclusionprovidesamoreaccurateestimateoftheburdenofinjury.

Foranalysisoftrendsdatamostlycoversthe14-yearperiodJuly1998-June2012.InJuly2012theVictorianHospitalAdmissionPolicychangedsignificantlysothatepisodesofcaredeliveredentirelywithinadesignatedemergencydepartmentorurgentcarecentrecouldnolongerbecategorisedasanadmissionregardlessoftheamountoftimespentinthehospital.Previously,thesetypesofepisodescouldbecategorisedasanadmissionifthelengthoftimeinthehospitalwas4hoursormore.ThishashadtheeffectofreducingthenumberofadmissionsrecordedontheVAEDforthe2012/13financialyear.Forthisreasonthe2012/13yearwasleftoutoftrendanalysisforthisreport.However,nochangetotheinjurypatternwasobservedso2012/13wasnotexcludedfromthedetailedanalysisthatcoversthemostrecentavailable3-yearperiodofdata(July2010-June2013).

Emergency Department (ED) presentations

EDpresentationsdatawereextractedfromtheVictorianEmergencyMinimumDataset(VEMD).TheVEMDrecordsallpresentationstoVictorianpublichospitalswith24-houremergencydepartments(currently39hospitals).EDpresentationswereselectedifthecausewascodedasafallandthepersonwasaged0-14years.Deaths,casessubsequentlyadmittedtohospitalandreturnvisitsforfollow-upcarewereexcludedtoavoidovercounting.

Analysis Methods

Trend analysis

Trends,analysedfortheperiod1998/99-2011/12forhospitaladmissionsand2004/05-2011/12forEDpresentations,weredeterminedusingalog-linearregressionmodeloftheratedataassumingaPoissondistributionofinjuries.Thestatisticsrelatingtothetrendcurves,slopeandintercept,estimatedannualpercentagechange,estimatedoverallchange,95%confidenceintervalsaroundtheseestimatedchangesandthep-valuewerecalculatedusingtheregressionmodelinSAS®9.3.Atrendwasconsideredtobestatisticallysignificantifthep-valueoftheslopeoftheregressionmodelwaslessthan0.05.

Rates

Injuryrateswerecalculatedper100,000Victorianresidents.

Hospital costs

TheNationalHospitalCostsDataCollection(NHCDC)isbasedontheprinciplesofCasemixcostinganalysiswhichisascientificapproachtotheclassificationofpatientcarewherebyeachhospitaladmissionisassignedanAustralianRefinedDiagnosisRelatedGroup(AR-DRG).AR-DRGsprovideaclinicallymeaningfulwayofrelatingthetypesofpatientstreatedinahospitaltotheresourcesrequiredbythehospital.TheNHCDCcontainscomponentcostsperDRGandenablesDRGCostWeightsandaveragecostsforDRGs(nationalandstate/territoryspecific)foracutein-patientstobeproduced.Thetypesofcomponentcostsincludedarewardmedical,wardnursing,non-clinicalsalaries,pathology,imaging,alliedhealth,pharmacy,criticalcare,operatingrooms,ED,wardsuppliesandotheroverheads,specialistproceduresuites,on-costs,prostheses,hotelanddepreciation.TheNHCDChaveceasedpublishingstate-specificcostsdatasoforthisHazardtheVictorianDepartmentofHealthsuppliedVISUwithVictorianaveragecostsperAR-DRGbyyear,5-yearagegroupandsexforthe3financialyears2009/10,2010/11and2011/12.ThesecostswereappliedtoeachadmissiontoestimatethedirecthospitalcostsassociatedwithinjuryadmissionsinVictoria.Costscalculatedherefor2012/13areprovisionalasthe2011/12valueswereused.


- INDEX -Subject.....................................................EditionAsphyxia..............................................................................................60Assaults...........................................................................................55,73Babywalkers,update.............................................................16,20,25,34Baseball................................................................................................30Boating-relatedrecreationalinjury.....................................................56Bunkbeds.......................................................................................11,75Button Batteries...................................................................................75Bicycles-Bicyclerelated..................................................6,31,34,44,65 -Cyclistheadinjurystudy......................................................2,7,8,10Burns-Scalds,Burnsprevention.................................................3,12,25 -Unintentionalburnsandscaldsinvulnerablepopulations...........57Childcaresettings...........................................................................16,76Clientsurveyresults.............................................................................28Cuttingandpiercing(unintentional)....................................................52Databaseuse,interpretation&exampleofform..................................2Deathsfrominjury(Victoria).....................................................11,38,76Dishwashermachinedetergents-Update............................................18DIYmaintenanceinjuries....................................................................41Dogbites,dogrelatedinjuries......................................3,12,25,26,34,69Domesticarchitecturalglass........................................................7,22,25DomesticViolence..........................................................................21,30Drowning/neardrowning,includingupdates....................2,5,7,30,34,55Elasticluggagestraps...........................................................................43Escalator...............................................................................................24Exercisebicycles,update....................................................................5,9Falls-Child,OlderPersons,Home,BunkBeds.........44,45,48,59,65,75Farm,Tractors..................................................................30,33,24,47,68Fingerjam(handentrapment)..........................................10,14,16,25,59Fireworks.............................................................................................47Geographicregionsofinjury...............................................................46Home...............................................................................14,32,59,65,76Horserelated.....................................................................................7,23Infants-injuriesinthefirstyearoflife.................................................8Injurysurveillancedevelopments,inc.ICD10coding....................30,43Intentional............................................................................................13LatrobeValley -First3months,Injurysurveillance&prevention ....................................................................9,March1992,Feb1994

Ladders.................................................................................................63Lawnmowers.......................................................................................22Marine animals.....................................................................................56Martial arts...........................................................................................11Mobilityscooters.................................................................................62Motorvehiclerelated,non-traffic,vehiclejackinjuires.................20,63Motorcycles.....................................................................................64,65Needlestickinjuries....................................................................11,17,25Nurseryfurniture.............................................................................37,44Olderpeople.........................................................................................19Off-streetparkingareas........................................................................20Pedestrians......................................................................................71,72Playgroundequipment...................................3,10,14,16,25,29,44,61,65Poisons-Domesticchemicalandplantpoisoning..............................28 -Drugsafetyandpoisonscontrol......................................................4 -Dishwasherdetergent,update.....................................................10,6 -EarlyChildhood,ChildResistantClosures...........................27,2,47 -Adultoverview...............................................................................39Powersaws,Chainsaws..................................................................22,28Roadinjury.................................................................................36,65,76RollerBlades,Skateboards..................................................2,5,25,31,44School..................................................................................................10Settingsforinjury.................................................................................76Shoppingtrolleys.......................................................................22,25,42Smoking-related....................................................................21,25,29,44Socio-economicstatusandinjury..................................................49,70Sports-childsports,adultsports,surfsports,snowsports.........................................................................8,9,44,15,51,56,66,74,76Suicide-motorvehicleexhaustgas......................................11,20,25,41Trailbikes............................................................................................31Trampolines...........................................................................13,42,61,75Vapouriserunits...................................................................................43Venomousbitesandstings...................................................................35VISS:Howitworks,progress,AdecadeofVictorianinjury surveillance..............................................................................1,26,40VISAR:CelebrationofVISAR’sachievements, VISARnamechangetoVISU....................................................50,61Work-related.........................................................................17,18,58,76

Injury severity: definition of ‘high threat-to-life’ (HTTL) injury ToexaminetheseverityofinjuryhospitalisationseachhospitalrecordwasgivenanInternationalClassificationofDisease(ICD)-basedInjurySeverityScore(ICISS)(Davieetal.,2008).TheICISSinvolvesestimatingprobabilityofdeathusingtheICDinjurydiagnosiscodesrecordedinaperson’shospitalrecord.Determiningwhichinjurieshaveahighthreat-to-life(HTTL)involvescalculatingasurvivalriskratio(SRR)foreachindividualinjury.AnSRRistheproportionofcaseswithacertaininjurydiagnosisinwhichthepatientdoesnotdie,orinotherwords,agivenSRRrepresentsthelikelihoodthatapatientwillsurviveaparticularinjury.Eachpatient’sfinalICISSistheproductoftheSRRsassociatedwithallthediagnoseslistedonthepatienthospitalrecord.Aninjuryisconsideredtohaveahighthreat-to-life(HTTL)iftheICISSislessthanorequalto0.941,thisisequivalenttoasurvivalprobabilityof94.1%orworse–meaningtheinjuredpersonhasaprobabilityofdeath(whenadmitted)ofatleast5.9%.

DavieG,CryerC,LangleyJ.ImprovingthepredictiveabilityoftheICD-basedInjurySeverityScore.Injury Prevention2008;14;250-255.


VISU Staff

Director: ProfessorLesleyDay

Manager Data Systems Data Requests & Reports: MsAngelaClapperton

Manager Data Quality Improvement and Consumer Product Safety: MsKarenAshby

Data Analyst: MrsTaraFernando

Research Officer: MsShannonGray

Statistical Advisor: MrAngeloD’Elia

Administration Officer: Mrs Samantha Bailey

Contact VISU at:MIRI–MonashInjuryResearchInstituteBuilding70Monash UniversityVictoria,3800

Phone:Enquiries (03)99051805Director (03)99051857Fax (03)99051809Email: [email protected]

All issues of Hazard and otherinformation and publications of theMonash Injury Research Institute can befoundonourinternethomepage:

www.monash.edu/miri/visu

Participating hospitalsFrom October 1995Austin&RepatriationMedicalCentreBallaratBaseHospitalTheBendigoHospitalCampusBoxHillHospitalEchucaBaseHospitalTheGeelongHospitalGoulburnValleyBaseHospitalMaroondahHospitalMilduraBaseHospitalTheNorthernHospitalRoyalChildren’sHospitalStVincentsPublicHospitalWangarattaBaseHospitalWarrnambool&DistrictBaseHospitalWesternHospital-FootscrayWesternHospital-SunshineWilliamstownHospitalWimmeraBaseHospital

From November 1995DandenongHospital

From December 1995RoyalVictorianEye&EarHospitalFrankstonHospital

From January 1996LatrobeRegionalHospital

From July 1996AlfredHospitalMonashMedicalCentre

From September 1996AnglissHospital

From January 1997RoyalMelbourneHospital

From January 1999WerribeeMercyHospital

From December 2000RosebudHospital

From January 2004BairnsdaleHospitalCentralGippslandHealthService(Sale)HamiltonBaseHospitalRoyalWomen’sHospitalSandringham&DistrictHospitalSwanHillHospitalWestGippslandHospital(Warragul)WodongaRegionalHealthGroup

From January 2005MercyHospitalforWomen

From April 2005CaseyHospital

From July 2011BassCoastRegionalHealth

How to access VISU data:VISU collects and analyses information on injury problems to underpin thedevelopmentofpreventionstrategiesandtheirimplementation.VISUanalysesarepublicly available for teaching, research and prevention purposes. Requests forinformationshouldbedirectedtotheVISUDataRequestManagerortheDirectorbycontactingthemattheVISUoffice.

VISU is a unit within Monash Injury Research Institute (MIRI) and is funded

by the Department of Health

Hazard was produced by the

Victorian Injury Surveillance Unit (VISU)

Illustrations by Debbie Mourtzios

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