Injury Control Research Centers (ICRCs)
Harborview Medical Center
Charles Mock, MD, PhD
University of Washington
Harborview Injury Prevention & Research
325 Ninth Avenue, Box 359960
Seattle, WA 98104
The Harborview Injury Prevention and Research Center (HIPRC) is a multidisciplinary effort which, through its research, education, and prevention programs, seeks to diminish the impact of trauma on people's lives and to broaden the effectiveness of the Northwest region's injury prevention and treatment programs. This Center develops, applies, and evaluates current and new interventions and strategies to decrease morbidity and mortality from trauma. This is accomplished by efforts within the four defined phases of injury control: prevention, acute care, rehabilitation, and biomechanics. We accomplish our aims by continuing to focus on priorities consistent with the aims of Healthy People 2010. We will continue our successful strategy of:
- Applying state-of-the-art tools of epidemiology to define risk factors and evaluate interventions;
- Developing and rigorously evaluating new injury prevention programs and disseminating these nationally and internationally;
- Evaluating traditional and new approaches to the treatment of acutely injured patients and disabled victims of trauma;
- Developing methods to prevent secondary disabilities among trauma victims;
- Using biomechanics to determine the physical cause of injury;
- Training investigators in the field of injury research; and
- Working with public and private organizations to provide technical assistance and consultation to enhance our mutual efforts to control injuries.
Project Title: Improving Firearm Storage: Improving Practices in Alaska Native Villages
Project Period: 08/01/04-07/31/07
Description: Rates of suicide among young Alaska Native males are more than 10 times higher than those among a similar age cohort in the rest of the United States. A high proportion of these deaths are associated with firearms. Firearms are an important part of the subsistence lifestyle of this population; however, restriction of access to guns by youth may be a promising strategy to reduce the risk of suicides in this population. Building on the foundation of a recently completed HIPRC series of studies, the aims of this research are to:
1. Estimate the prevalence of firearm ownership and of specific firearm storage practices among residents living in the Bristol Bay and Yukon-Kuskokwin regions of southwest Alaska.
2. Collaborate with the Bristol Bay Health Corporation, the Yukon-Kuskokwin Health Corporation, and the injury prevention program of the Alaska Native Tribal Health Consortium to plan and execute a randomized trial of an intervention to improve firearm storage practices among residents of selected villages.
Project Title: Barriers to PFD Use: Analysis of the Use of Personal Flotation Devices in Drowning from Boating Accidents and Evaluation of Key Factors for Intervention
Project Period: 08/01/07-07/31/09
Description: Almost all (95%) recreational boating deaths occur to adults or adolescents. The use of personal flotation devices (PFDs) in this group is low, with estimates ranging from 13% to 25% in recent observational studies. To date, drowning prevention programs have related to drowning in general or have focused on children. Little is known about why adult boaters do not use PFDs. This knowledge is important for designing interventions targeting this group. With a goal of identifying barriers to PFD use by adult boaters (specifically, those in small motorboats, where most boat related drowning events occur), this research will:
1. Analyze, using existing U.S. Coast Guard data, PFD efficacy. To date, this has not been demonstrated and would help answer one potential barrier to their use—a belief that they do not work.
2. Conduct focus groups with adult anglers and recreational boaters to identify barriers to PFD use and receptivity to possible future intervention approaches.
3. Conduct a cross-sectional survey to examine factors associated with PFD use among adult recreational boaters. The survey will be conducted concurrently with observations of PFD use to obtain more representative prevalence measures for adults.
Researchers will work closely with community partners currently involved in drowning prevention programs. It is hoped the work will establish a basis for future collaborative intervention studies.
Project Title: Inclusive vs. Exclusive Trauma Systems: Determining Optimal Configuration of Organized Systems of Trauma Care
Project Period: 08/01/07-07/31/09
Description: It is postulated that inclusive trauma systems provide better, more timely access to a higher standard of trauma care than exclusive trauma systems. The investigators will attempt to determine whether patients within an inclusive system are more likely to be cared for at designated centers with resources appropriate for their needs; whether the easier and more timely access to care reduces overall motor vehicle crash mortality within the region; and whether this improved access to designated centers reduces the rate of injury related complications. A population based interrupted time series analysis approach will be used to determine the effect of system implementation on motor vehicle crash mortality using data from the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System. Multistate inpatient discharge data derived from Harm’s Healthcare Cost and Utilization Project (HCUP) will be used to determine the effect of system configuration on the ultimate field triage and complication rate of the injured patient.
Many states are in the process of developing regional trauma care systems. Multistate In-patient discharge data will be critical in defining the optimal system configuration to provide optimal matching of individual hospital resources to patient needs and to provide the lowest risk of mortality and complications following injury. Taken together, the fulfillment of these specific aims will provide insight of the relative merits of inclusive versus exclusive trauma system configurations.
Project Title: Trauma System Audit Filters: Development and Validation of Audit Filters for Transfer Patients and Their Predictive Value for Mortality, Morbidity, Length of Stay, and Cost
Project Period: 08/01/04-07/31/06
Description: The rationale for any trauma system is to provide a coordinated, predictable, and multidisciplinary approach to managing the injured patient. To operate effectively and efficiently, a trauma system must undergo monitoring, evaluation, and improvement as defined by performance improvement (PI). A detailed PI framework with specific, well defined criteria measuring trauma system performance has not been established or validated. The American College of Surgeons' audit filters, developed as standards of care for trauma patients, have focused on PI in individual trauma centers. None of the filters was designed to monitor the trauma system as a whole. Thus, no systematic mechanism exists for evaluating other critical components of a system including pre-hospital care, inter-hospital transfers, and post acute care. It is hypothesized that a set of audit filters that evaluate the trauma system can be identified. These filters will be sensitive to identifying deviations in the integrated function of the trauma system and will optimize patient outcomes as defined by mortality, morbidity, and resource use. This project will use the Delphi method to obtain expert consensus on trauma system audit filters that are specific to the pre-hospital and inter-hospital transfer phases of the trauma system. After these filters are developed, 3 years of pre-hospital and trauma registry data from King County Washington will be linked. Logistic regression analysis will be performed to evaluate each audit filter's ability to predict adverse trauma outcomes such as morbidity, length of hospital stay, hospital costs, and mortality. The development and validation of these trauma filters will provide quality improvement measures by which to evaluate trauma systems and trauma care in the future.
Project Title: Substance Abuse and Injuries: Determining the Impact of Alcohol, Tobacco, and Illicit Drug Use on Functional Outcome After Injury
Project Period: 08/01/04-07/31/05
Description: This study tests two hypotheses:
1. After adjusting for important confounding variables, patients with pre injury substance abuse have worse functional outcomes at 3 and 12 months after trauma than do patients without prior substance abuse. Functional outcome will be measured by return to work, performance of activities of daily living, performance of instrumental activities of daily living, and health related quality of life.
2. Substance abuse is as an important predictor of adverse functional outcomes as injury severity.
It is anticipated that an estimate of the burden of disease associated with substance abuse in this context will set the stage for policies and interventions geared toward minimizing the adverse functional outcomes following injury in this population of patients.
Project Title: Airbags and Pregnancy
Project Period: 08/01/06-07/31/08
Description: Motor vehicle crashes (MVCs) are one of the leading causes of injury related maternal and fetal deaths and the most common cause of injury related hospitalizations during pregnancy. Although much research has focused on the effects of seat belts and airbags in MVCs, relatively little research has evaluated how these safety features affect pregnant women. To assess the effects of airbags in pregnancy, this study will use a retrospective cohort design to identify pregnant women involved in MVCs in Washington State by linking the Washington State Patrol crash data to Washington State birth and fetal death certificates. The exposures of interest will be airbag availability without deployment and airbag deployment. The outcomes of interest will be adverse maternal and infant outcomes including types of maternal injuries, pre-term labor and delivery, placental abruption, cesarean delivery, low birth weight, fetal distress, fetal injury, and fetal death. This study will also evaluate the effects of seat belt use on maternal and infant outcomes following MVCs. Knowledge about the effects of airbags on pregnancy outcomes is essential for health-care providers to adequately counsel women during prenatal care about motor vehicle safety.
Project Title: Raise the Alarms Sub-analyses: Improving Ownership, Smoke Detector Maintenance, and Safety Practices among Low- to Middle-income Families
Project Period: 08/01/04-07/31/06
Description: Residential fires are responsible for the majority of fire related deaths in the United States. Smoke detectors are recognized to be an economical and efficient injury intervention, capable of reducing risk of death by up to 70%. Currently it is estimated that the great majority (>90%) of U.S. homeowners report having at least one smoke detector. However, in homes where detectors are installed, 20% to 50% are nonoperational. These may also be installed in suboptimal locations, thereby decreasing the effectiveness in preventing injuries should a fire occur. This study will:
1. Identify family, home, and detector characteristics associated with whether or not smoke detectors are present and those installed in the home are operational and placed correctly.
2. Compare self reported information on smoke detector ownership and operational status with that obtained through direct observation.
3. Examine whether demographic, family, or home characteristics are associated with the presence of various other fire safety interventions in the homes, including extinguishers, escape ladders, and establishment of a family meeting place.
Results of this study will help identify possible barriers to ownership and maintenance of working smoke detectors, assess the accuracy of self reported smoke detector information, and help improve future fire related injury research and prevention efforts.
Project Title: Antilock Brakes: Estimation of the Association Between Antilock Brake Systems and the Risk of Traffic Crash Injury
Project Period: 08/01/04-07/31/06
Description: A few studies have tried to estimate the association between the presence of antilock brakes in a vehicle and either the risk of a crash or the risk of injury in a crash. To date, there is little evidence that antilock brakes are effective. This project consists of a case control study to estimate the association between the presence of an antilock brake system in a passenger vehicle and the risk of a traffic crash injury. It will use data from a large insurance carrier. Cases will be cars with a driver owner injured in a crash. Controls will be other cars matched to each case car on date of crash, and selected randomly from insured cars at the time of the crash. The analysis will adjust for potential confounding factors related to the car and to the driver owner. The final risk ratio estimates will be useful in understanding how antilock brakes may help reduce traffic crash injuries.
Project Title: Window Falls: Environmental Risks and Protective Factors for Falls of Children under 10 from Windows Resulting in Emergency Room Visits, Hospital Admissions, and Death
Project Period: 08/01/07-07/31/09
Description: Falls among children ages 0 to 5 years in the United States led to 64 deaths (2001), approximately 13,800 hospitalizations (2002), and 1.2 million emergency department visits (2001). A large proportion of hospitalizations result from falls from windows of buildings. Despite the magnitude and frequency of this problem, no controlled studies could be found to determine environmental risk factors for this type of fall in children. The only known strategy for preventing window falls is the installation of window bars. Other environmental approaches to prevention could be possible if more were known about risk factors for window falls. Factors such as window size, height, and opening mechanism; use of screens; and windowsill size could potentially affect the risk of a fall of a young child. Planning prevention strategies for these types of falls requires an enhanced understanding of risk and protective factors.
This pilot study has several aims:
1. Estimate the incidence of falls of children under 10 from windows resulting in emergency department visits, hospital admissions, and deaths.
2. Determine through medical record reviews the sensitivity and specificity of selected external cause of injury codes (E codes) to correctly identify window falls.
3. Pilot test subject identification and in home environmental assessment procedures for a future population based, case control study of modifiable environmental risk factors and window falls in children. The project would be conducted in collaboration with an existing community based injury prevention program, the Injury Free Coalition for Kids of Seattle.
4. Use the information from the pilot study to plan a population based, case control study to determine important risk factors for falls of children from windows.
Project Title: Alcohol Excise Taxes: Estimating the Association Between Amount of State Alcohol Excise Tax and Mortality from Intentional and Unintentional Injury
Project Period: 08/01/05-07/31/07
Description: A large body of literature demonstrates that alcohol consumption is related to the price of alcohol. This study will examine the impact of different levels of alcohol excise taxes on trauma deaths in the United States. Specifically, researchers will estimate the association between the amount of the state excise tax on alcohol and mortality from intentional and unintentional injury. It is hypothesized that higher alcohol excise taxes are associated with a lower rate of fatal injury, especially due to motor vehicle crashes and homicide.
This study will be a time series analysis in which the association between different levels of alcohol excise taxes and injury mortality in a state will be assessed. Researcher will examine all injury deaths with 800–949 ICD codes for the years 1979–2000. They will also review statutes of each state for 1979–2000 to obtain information about the date on which each law went into effect. In addition to changes in the age and sex distribution of the population, other potential confounders may include the cost of alcohol apart from taxes, the cost of living in a state, calendar year, and the poverty level in a state. In all states, the minimum legal age for purchase is 21. The cost of alcohol, apart from taxes, will be adjusted for in the analysis; this will allow the effect of the excise tax as an independent variable to be examined. The main analysis will use count data methods to estimate the change in mortality rates associated with changes in the alcohol excise tax. Negative binomial regression will be used, which may be thought of as a form of random effects Poisson regression.
This study will provide useful data to policy makers about the effectiveness of alcohol excise taxes, the size of the effect, and the amount of tax necessary to reduce injury mortality. This information can then be directly translated into policy changes at the state level.
Project Title: Side Impact Crashes and Pregnancy: Study of Mechanisms of Pelvic Fractures in Side Impact Collisions and Methods to Reduce Injuries to Pregnant Women
Project Period: 08/01/05-07/31/07
Description: Researchers on this project hypothesize that during side impact collisions, occupants may be trapped between the incoming door and the rigid center console that extends above the seat in some vehicles. Arm rest contact at the hip from the intruding door results in lateral compression and fracture of the pelvis, resulting in major trauma. A yielding or breakaway center console might reduce the potential for pelvic fracture during side impacts by eliminating the trapping effect. Researchers will first conduct epidemiological studies to determine demographics and risk factors for pelvic fractures to all occupants in side impacts, and specifically to the subpopulation of pregnant women involved in nearside impacts. The proposed mechanism of injury will be studied using an existing, pendulum-based, door punch, side impact test fixture, with a side impact test dummy, and by Mathematical Dynamical Models (MADYMO), mathematical modeling of the injury mechanism. This mechanism, while of concern for all occupants, may be particularly relevant to late-stage pregnant female occupants because of their enlarged abdominal regions. Based on the findings, a modification to the center console may be proposed that might reduce pelvic forces during side impact collisions.
Project Title: Rear-seat Side Airbags and Children
Project Period: 08/01/07-07/31/09
Description: There has been little survey of side air bag performance, especially for rear-seated child passengers. Children are common rear-seat passengers. While the optimal position for a child may be in the rear-center seat, out of the way of the side airbag, when more than one child is being transported, or in smaller vehicles, a child may occupy an outboard rear seat near the airbag. Only a few studies have addressed the risks side airbags pose for outboard rear-seated children. One researcher concluded that current side airbag designs may cause serious or fatal neck and chest injuries to out of position occupants. However, no studies have been conducted to model the dynamic door punch that occurs in a side impact. In this project, investigators will create a dynamic model of door/sidewall intrusion and airbag deployment resulting from a side impact collision. This research may provide a more realistic assessment of the interaction of the occupant with a rear-seat side airbag during a simulated side impact collision.
The study (scheduled for 2½ years) will consist first of an epidemiological review of NASS CDS data to determine demographics and risk factors for school-age children in side impacts in vehicles with side airbags. Next, modeling will be performed using MADYMO, and the model will be verified using a pendulum side impact apparatus, onto which a vehicle door with a side airbag has been mounted impacting a 6-year-old hybrid III impact dummy. Head and neck injury parameters will be determined for out of-position occupants, both in and out of a booster seat, on the nearside with a deployed airbag. Based on observation and measurements of head and neck injury mechanisms, seated positions for child occupants with the least risk of injury will be identified.
Project Title: Hospital-acquired Pneumonia in Persons with Spinal Cord Injury
Project Period: 08/01/06/-07/31/08
Description: Pneumonia is the leading cause of death in persons with spinal cord injury (SCI). Community-acquired pneumonia (CAP) in persons with SCI is caused by a different spectrum of bacterial pathogens than those seen in the general population, and the case fatality rate for CAP is significantly higher at hospitals without specialized SCI services than at those with these services. Hospital acquired pneumonia (HAP) in the general population has a case fatality rate of 36% and the risk factors and pathogens are different from CAP. HAP in persons with chronic SCI has not previously been investigated. This study will determine the incidence, crude and attributable mortality rates, risk factors, and etiologic pathogens for HAP in hospitalized patients with SCI. It will also characterize HAP management at specialized SCI centers. Researchers will conduct a retrospective, matched case control study using data abstracted from inpatient medical records from Veterans Affairs (VA) hospitals with SCI services. Additionally, a cohort study will be performed using national VA administrative data to compare mortality rates at VA hospitals with and without specialized SCI services. Characterization of the epidemiology, pathogenesis, and current treatment practices for HAP in persons with SCI may allow development of improved strategies for prevention and treatment.
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