n
School Injuries: What We Know, What We Need Rene R. Gratz,
.
PhD
Schools are the site of a substantial number of unintentional injuries each year. Current knowledge regarding the study of causes and implications of school injury is summarized in a review of the research literature. A discussion of future investigations and better management of school injuries focuses on research issues, practical management, and nursing concerns. Operational definitions and reporting mechanisms are emphasized as research needs. Practical management and nursing concerns include routine reporting, student supervision, treatment of injuries, communication with parents, and legal (liability) responsibilities. j PEDIATR HEALTH CARE. (1992). 6, 256-262.
U
nintentional (accidental) injuries are a grave threat to the health of our children, representing the leading cause of death during the first one half of the average U.S. lifespan (Guyer & Gallagher, 1985). Morbidity caused by unintentional injury also plays a large role in childhood health: injuries account for 20% of all hospitalizations among children, that is, 600,000 per year. Another 16 million children require emergency room visits (Division of Injury control, 1990). As the “primary workplace” of most children, schools represent the site of a substantial number of pediatric injuries and a logical site for injury research (Woodward, Feldman, Feldman, Hodgson & Milner, 1983). Various sources cited by Boyce, Sprunger, Sobolewski, & Schaefer (1984a) found that 70% of childhood injuries were sustained by school-aged children, 10% to 20% of these occurring in or on the way to or from school. Injuries are the condition most frequently cared for by school health personnel; over a 2-year period, 80% of elementary students see the school nurse for an injury-related complaint (Nader & Brink, 1981). Important as school injuries are, comparatively little research has been conducted. Most studies focus on school-based sports injuries; far fewer present analyses of all injuries found in school health records. Currently eight papers discuss five large-scale North American studies (Table 1). Other school-related studies have focused specifically on type of injury, that is, fractures (Johnson, Carter, Harlin, & Zoller, 1972) playground injuries (Boyce, Sobolewski, Sprunger, & Schaefer, 1984b), and on the relationship between injuries and various student characteristics, such as aggressive beRene R. Cratz, PhD, is an Associate Proiessor in the Department Sciences at the University of Wisconsin-Milwaukee, Wis. Reprint requests: Rene R. Gratz, PhD, Department Milwaukee, P.O. Box 413, Milwaukee, WI 53201. 25/l/33913
256
of Health
of Health Sciences,
UW-
havior (Johnson, Carter, Harlin, & Zoller, 1974) and locomotor skills (Angle, 1975). A review of this research presents a picture of what we currently know about school injuries. n
WHAT
WE KNOW
The five large-scale studies of school injury show remarkably comparable findings in many respects, though separated by vast geographic distances (Table 1). The McMaster School Injury Study, conducted in the Hamilton-Wentworth districts of Ontario, has been published most extensively, providing data regarding methods (Woodward et al., 1983), findings (Feldman et al., 1983), reporting issues (Woodward, Milner, Harsaryi, Feldman, & Hodgson, 1984), and parental perspectives (Hodgson, Yacura, Woodward, Feldman, & Feldman, 1984). Table 1 shows that definitions of reportable injuries and classifications of severity vary greatly. In the general population, overall injury incidence rates have been calculated as 20 per 100 for ages 6 to 12 years and 27 per 100 adolescents, aged 13 to 19 years (Gallagher, Finison, Guyer, & Goodenough, 1984). Table 2 shows school study incidence findings, with lower incidence rates of retrospective studies, as possible evidence of underreporting in the routine notation and/or filing of school injury records. Differences in definition and classification may also be reflected in the percentage of injuries reported as “serious”. Males account for significantly more injuries than females, a finding similar to the general injury reports (Division of Injury Control, 1990; Gallagher et al., 1984). The middle-school years, grades 6 through 8, show peaks in incidence, explained by some researchers to be caused by increased activity level and sports participation as well as puberty-associated body changes, for example, the “clumsy age” (Feldman et al., 1983). Variables such as day, month, and time of injury have not been analyzed consistently. JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health
n
TABLE
1
School
Care
Demographics
No. of schools Grades N Data collection Definition: reportable injury
Definition: severe injury:
*Information
Columbia,
257
and methodology
DALE ET Al. (19691
Years analyzed Site
Injuries
1967-B MO. * K-6 5,485
BOYCE ET AL. (19Wa)
1980-2 Tucson, Ariz. 96 K-l 2 55,000
SHEPS & EVANS (1987)
1981-3 Vancouver, B.C. 108 K-12 53,000
FELDMAN ET Al. (1983)
1981-2 Hamilton, Wentworth, Ont. 212 K-13 83,692
Retrospective
Prospective
Retrospective
Prospective
Not specifically stated, i.e. “An accident did not have to produce a detectable injury to be reported” (p. 294).
Must meet one of the following criteria: (1) required a physician’s care and/or major first aid; (2) resulted in an absence from school, or (3) resulted in restricted participation in competitive sports” (p. 343).
If a child sustains or requires: “all head injuries, suspected or definite fractures, an ambulance or inhaler, referral to a physician or dentist, sutures or a foreign body in the eye” (P. 69).
Decision as to reportability “made by school principal, consistent with his interpretation of the school board’s policy” (p. 277).
Amputations, third degree burns, concussions, crush wounds, fractures, multiple injuries
Fractures, loss of consciousness, burns, whiplash, open wounds, foreign body in eye
Fractures, loss consciousness, dislocations, sprains, torn ligaments & cartilage, chipped/ broken teeth, internal injury
*
TAKETA (1984)
1981-2 Hawaii 204 K-12 157,000 Retrospective “Any accident which happens at school, or at a school sponsored activity, on or off campus, which (1) interrupts the students’ normal or expected activity for that period to any significant degree, (2) causes any property damages or losses of more than $5 in estimated replacement cost and/or (3) can generate a litigation on behalf of the injured” (p. 208). “Most severe. . . . foreign bodies in the eye and fractures” (P.
208)
not given.
Playgrounds have been estimated to be the site of 72,000 childhood injuries each year (Bivara & Mueller, 1987) and are the localities of a substantial percentage of school injuries (Table 3). Boyce et al. (1984b) have presented a detailed analysis of playground injuries, which shows the following information: an incidence rate of 8.9 per 1,000 student-years, one-quarter of which are classified as severe; no significant sex differences exist; younger children are injured more frequently than older students; and climbing equipment was most frequently associated with injury.
The variety of activities listed in Table 4 highlights the difficulty of drawing comparisons and conclusions across studies. Falls, organized sports/athletics, and unorganized play are the most frequent injury-causing activities. Falls are also cited in the general injury literature as representing the highest rates for hospitalization and emergency room visits of all injury causes (Division of Injury Control, 1990; Guyer St ElIers, 1990) and as accounting for 59% of all playground injuries (Rivara & Mueller, 1987). Falls and unorganized play represent greater hazards
258
TABLE
n
Volume 6, Number 5, Part 1 September-October 1992
Gratz
2 Incidence
findings DALE
Overall incidence: (per 100 student years) Severe/serious injury By sex: Male
ET Al.
4.9
2.82
5.4
1.67
18%
35% Elementary 39% Secondary
28.6%
*
“Males significantly more#
68%
58%
AM
12-12:59
PM
By day of
24% Wednesday 23% Tuesday 20% Friday October
TABLE
TAKETA
7.45
lo-lo:59
n
ET AL.
wm4)
By time of day:
*Information
FELKMAN
f1983)
42% 2nd Grade (7 years) “highest frequency”
By month
SHEPS P EVANS
(1987)
25% (Moderate/severe)
ii!-2:59
ET Al.
(1984a)
Female By age/grade
Week
BOYCE
(1969)
*
67% 33% 8th Grade 19% all injuries
21% 34%
Grades 6-8 peak
82% school hours 18% before/after
*
*
*
*
*
PM 19%
32% Grades 6-8 highest incidence Frequency greater elementary grades (K-8) *
Grades 6-8 highest incidence Frequency higher elementary grades (K-8) lo-11 AM 17% 12-2 PM 31%
*
Evenly distributed *
September
not given.
3
Location
findings FELDMAN
ET At.
(1983) TAKETA
DALE ET AL. (1969) W)
Playground Gym/athletic field Classroom Bracket denotes combined *Category not used.
77 9 20
ROYCE ET AL. W384a~ (%)
SHEPS & EVANS
65
36 22
33 46
37 21
32 17
8
15
*
13
16
I
(1987)(%)
(% SERlouS INjURY)
(% MlNoR INRJRYf
WMW VW
categories.
to younger children; athletics and organized sports injuries are more common in the upper grades. The general injury literature on adolescents also has found physical education classesor interscholastic sports to encompass the largest group of school-related injuries (Bass, Gallagher, & Mehta, 1985). Other reports indicate that one of every 14 adolescents requires hospital treatment for a sports-related injury, most frequently associated with football and basketball (Gallagher et al., 1984; Guyer & Gallagher, 1985). When the body parts that are most frequently injured (Table 5) are analyzed by age group, elementary school students injure the head and face most frequently and secondary school students injure the upper extremities (Sheps & Evans, 1987). Minor injuries (such as con-
tusions, abrasions, and swellings) were more common in the elementary grades (Feldman et al., 1983; Sheps & Evans, 1987). On-site first aid was found to manage most injuries (Table 6). Fractures, classified by all studies as “serious” injuries, represent a small proportion of all the school-related injuries shown in Table 7. They are, however, the most commonly occurring type of severe injury. Johnson et al. (1972), who reviewed Seattle public school records focusing specifically on fractures, calculated a fracture incidence of 0.4 per 100 student years, with greater frequency in grades 7 through 9 and among males. The Johnson group (1972) found the most common injuries to be upper extremity fractures that is, finger (22%), wrist (16%), and arm (15%). More fractures
Journal of Pediatric Health Care
W TABLE
School Injuries
4 Injury-related
259
activities TAKETA DALE ET AL (19691 (X)
ACTIVITY
Unorganized play Falls Playground equip Collision other child Organized play Collision object Self caused Intentionally caused by other student Accidentally caused by another student Mechanical equipmerit/object Athletics-related Foreign body eye Playing or fighting Classroom activity Flying/thrown object Other Bracket denotes combined *Category not used.
BOYCE
ET AL
ww
(%I
SHEPS & EVANS (19871
*
(%I
FELDMAN
ET Al.
(1983)
(W
(1984) (96)
*
*
*
9
14 *
37 * 13
23 21 *
23 * * *
a
*
*
*
*
*
4 * *
* * *
35
1
74
8 * *
21 10
* * *
*
15
*
*
*
*
3
36
*
*
* * * * *
23 * * * *
7 2 * * *
35 * 16 6 4
20 * * * *
*
14
3
7
*
categories.
occurred on playgrounds for younger children (K-6) and in physical education-organized ball games, that is football, basketball, and soccer, for older students. Falls were an important cause of fractures for all age groups; however, malicious activities and horseplay are more frequent causes than falls in middle school and an equally common cause of fractures in high school. The Seattle Public School data cited were also studied with a focus on aggressive behavior as a cause of injury. Johnson, Carter, Harlin, & Zoller (1974) found that 13% of all accidents were caused by aggressive acts (such as, fighting, pushing, throwing objects), with the highest rates for aggression-related injuries in grades 7 to 9 and for males (4.7: 1). The locations of aggression-related injuries varied by age group: for grades K through 6, 74% of injuries occurred on the playground; 30% of the injuries occurred in the classroom for grades 7 through 9, and 32% of the injuries occurred in school corridors in grades 10 through 12. Angle (1975) investigated locomotor skills over a 3year period, correlating scores of motor abilities, such as balance and bilaterality of coordination; with reported school injuries. Injuries were associated with deficient locomotor skills in the 6 to 9-year-old group and with superior skills in grades 4 to 6. No sex differences in injuries were found for supervised sports and from nonagressive behavior. Aggressive behavior, however,
accounted for 49% of the male but only 17% of female injuries, as well as 58% of injuries in grades 1 through 3 and 70% in grades 4 through 6. n
WHAT WE NEED
Future investigations and better management of school injuries focus on two broad areas: (a) research methodology issues, and (b) practical management and nursing concerns. Operational definitions and reporting mechanisms represent methodologic needs. Practical management and nursing concerns include routine reporting, student supervision, treatment of injuries, communication with parents, and legal (liability) responsibilities. Research Methodology
Issues
A major problem in drawing conclusions from the current school injury literature centers on a lack of standardization in defining what is “reportable” injury and a consensus in categorizing “serious” injuries. Classifications for cause of injury (activity) also varies so greatly, making comparisons among studies difficult to impossible. As Evans and Sheps (1987) have discussed, minor injuries are usually defined by exclusion, that is anything not specifically noted as “severe” is apparently a minor injury. All seem to agree about the “seriousness” of
260
Volume 6, Number 5, Part 1 September-October 1992
Gratz
W TABLE
5 Body part injured* FELDMAN
BODY
PART
DALE ET Al. (1969) (%)
INVOLVED
I
Head Face Neck Eyes Upper extremity Hand/fingers Lower extremity Trunk
ET AL. (1983)
SHEPS & EVANS (1987)
TAKETA (% MINOR)
W
(% SERIOUS)
t
29
64
(1984) (94)
1
-