“Home” Environment

Data collection on domestic accidents at national level in Italy

Technical Report to the Italian Parliamentary Commission of inquiry on occupational accidents: the implementation of the National Information System on Home Accidents - SINIACA

Pilot Study

Edited by

Alessio Pitidis, Marco Giustini e Franco Taggi

November 22th 2005

© National Institute of Health The contents o this Report can be freely used referencing it in the following way: A. Pitidis et al., “La sorveglianza degli incidenti domestici in Italia”, paper ISS, 05/AMPP/AC/624, novembre 2005.

Data Collection on domestic accidents at national level in Italy

Pitidis A., Giustini M., Taggi F.

National Institute of Health, Rome 1. Introduction Accidents at home are in most of the industrialized countries a relevant problem area of public health, the quantitative evaluation of mortality and morbidity secondary to home injuries evidences it. The attention paid to that problem has increasingly grown in public health programs: since the last 20 years in many industrialized countries in the world and in the European Union many research projects, surveillance initiatives and prevention programs have been activated on the matter. The growing interest is related to the social burden of home injuries in terms of human lives, inpatient and outpatient care, permanent and temporary disabilities, correspondent to the commitment of a large amount of resources i.e. in the public health care sector. In Italy too the aforesaid problem seems particularly relevant, but the available data are still incomplete and sometimes fragmented. Let us take a rapid overview on the available data sources (1). The Italian National Institute of Statistics (ISTAT) conducts a periodical survey on the family life habits (2), a sample of around 53,000 subjects, representative of 23,000 Italian families, are interviewed. By mean of that sample it can inferred that in Italy during 2001 there have been 2,848,000 persons injured at home, the 5,0 percent of the population with an incidence of 50 cases per 1,000 inhabitants per year. Population groups that spend longer time at home were involved: women (incidence 68.0 / 1,000 inhab. x year vs. 30.4 for men), the elders (incidence 97.2 over age 75 and 66.0 age 65-74) and children in pre-scholar age (incidence 62.4 / 1,000). The most frequent cases regard elderly women (28.2 percent over age 65), adult women (15.9 percent age 25-64) and elderly men (9.6 percent over age 65). With regard to the causes of the events the most common are falls (28.4 percent of accidents), kitchen utensils or activities carried out in kitchen (33 percent); among the kitchen utensils the most dangerous are knifes which determines 12,8 percent of the whole accidents. What is lacking in this survey is the injury and the necessity of health care that accident caused: in a late sense the severity of the accident. By considering that aspect the proportions change considerably; i.e. observing the accesses to hospital Emergency Departments (ED) registered in the newly instituted National Information System on Accidents at Civilian Residences (SINIACA), that will be described more thoroughly in the next pages, we note that, during 2004, the proportion of falls causing injury raise up to the 56 percent of cases while the events occurred in kitchen descend to 19 percent, still being the kitchen on of the most dangerous places in the house; the whole domestic appliances also do not cause more than the 7 per cent of accidents. The last public health oriented information we have on domestic accident in Italy comes from the 1995 Italian Study on Accidents (SISI by Italian National Institute of Health), a sample study (3) on three Italian Regions (Liguria in northern Italy, Marche in the center and Molise in the south) based on 60.000 injury attendances in hospital emergency departments (ED). On the basis of that survey we could calculate, at that time, the health burden of injury in around 1.800.000 cases visited at hospital ED and 250.000 inpatients. In order to have an up to date surveillance system on domestic accidents the Italian Parliament instituted with law n. 493 December 3rd 1999, article 4 the National Information System on Accidents at Civilian Residences (SINIACA), within the Italian National Institute of Health (ISS). The principal aims of the system (4) were the home injuries monitoring and the evaluation of the effectiveness of prevention actions. It is at first a general information system supporting the decision making process of policy-makers rather than an epidemiological surveillance based on the public health experts perspective.

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As aforesaid what is actually lacking is a complete information on injury and related health care. Consequently in setting up the system we had to start from an home injury scenario based on our estimates of the real incidence of home injuries in Italy and its discrepancy with current available statistics (see table 1).

There is substantial difference between the mortality data officially registered in the death certificates and the ones that can be reasonably calculated, the same situation for Hospital Discharge Register (HDR) data (the estimate criteria will be explained in the following pages). The ED attendance recorded at hospital level are not currently collected at national level. That is a key information given the organization of health care in Italy. The Italian National Health Service (SSN) is a totally public one, free care is guaranteed to every citizen. The hospital service plays a major role in the SSN and have not been fully developed first level outpatient territorial services that can provide first-aid care, general practitioners also do not guarantee always first-aid services. Because of those reasons injured people generally prefer going directly to the hospital for first-aid assistance even in case of very low severity trauma. ED is a very good point of observation for injuries because all the events having at least a minimum severity pass trough it and information on the cause and mechanism of the accident are normally registered in the ED forms in most of the hospitals. Finally it is worth to have an overview of the definitions of home accidents adopted internationally. The World Health Organization (WHO) considers accident a sudden, undesired, and unforeseen event resulting in acute physical injury, for which medical assistance is sought at an Accident and Emergency department or other indoor/outdoor patients hospital department. There is not a specific definition of home accident by the WHO, but one can refer generally to the authors who treated the matter and indicated as domestic accidents those occurred within the residence and its dependencies such as outdoor staircase, garden, cellar, garage, balcony, etc.

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The European Home and Leisure Accident Surveillance System (EHLASS) considers home and leisure accident as an accident which is not a traffic accident, an occupational accident, an injury due to violence or a self inflicted injury. The residential areas in the EHLASS system are defined as private residences including protected home, pensioners´ home, weekend cottage, residential caravan park. Residential and public institutions are excluded by this definition (e.g. nursing home and home for the sick, day-and-night centre, prison, hotel, motel). The law n. 493/99 (Rules for the health protection at home and institution of the national insurance for home injuries) at the article 6 has fixed for Italy this definition of domestic environment: the whole of residential real estates and their dependencies where the people usually live, if the real estate consists in a joint ownership block of flats the domestic environment includes the common spaces.

2. Information System Structure

2.1 Information levels

Despite the absolutely relevant impact of home accidents on the population health status, that we indicated above, it is still an underestimated problem which does not have adequate consideration in the health policy priority settings. In the population perception even the risk of trauma is generally associated to working activities or road traffic, whilst the domestic environment is perceived as safe; it is so only if its spaces and objects are used properly. A good indicator of that undervaluation of risk is the fact that till the IX revision of the WHO international classification of diseases (ICD-9), which is still adopted by many countries Italy included (5), the home accident was not explicitly listed within causes of trauma . That fact possibly may be deemed as one of the main problems. The absence even of basic data produces lack of both the risk consciousness in the population, that does not induce changing in non appropriate behaviours, and the possibility of designing effective prevention strategies by observing the evolution and the trend of home injuries. Having those two objectives in mind (the home injuries evolution monitoring and the formulation of prevention programs) we designed a 3-level information system:

1) Surveillance of home accident ED attendance on a large sample of hospitals. Extraction of domestic trauma hospital discharge records from the national HDR. Extraction of home injury death cases from the national mortality register. This first level is focused on codified descriptions of the events and will produce categorical information which is aimed to the estimate of the phenomenon dimension and to its trend monitoring.

2) Surveillance of home accident ED attendance on a small sample of mastering centres. Those hospitals already acquired experience on domestic accidents surveying within the EHLASS system. It will be adopted for them the European Home and Leisure Accidents classification (HLA), but this second level is focused on the open description of the events, by mean of a structured response procedure. Products, installations and equipments involved in the accident will also be registered.

3) Once identified specific groups at risk or event typologies of particular social relevance, by mean of the precedent levels of information, analytical studies will be applied on small samples, representative of the aforesaid groups, aimed to investigate the accident determinants.

The three sources of data chosen for the first two information levels of the system (ED attendance forms, HDR, mortality register) indirectly reflects three different levels of trauma severity and complexity of health care procedures. The last two type of morbidity and mortality data (HDR, deaths) may be selected from existing current databases, whilst the ED attendance national surveillance system will be set up within the SINIACA frame.

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2.2 Morbidity surveillance: ED attendance Following those three severity/complexity trauma degrees the data collection can start from the ED care records either for data comparability and availability reasons or in order to select only those accidents that determined at least minimal health care consequences; taken into account that as aforesaid the most of injured people is not filtered by any territorial service and arrive directly to hospital ED. For the national estimate purposes, therefore, we define as morbid events those traumas caused by domestic accident determining at least an ED attendance or consequent hospital admission. Once defined the aims and the statistical units of the surveillance systems we must examine the samples dimension and the real availability of current data sources. The system continuity is assumed as given. Concerning the ED attendance data there is not deductive reason for ex-ante expecting a significant distortion in the events frequency distribution and typology due to the fact that for ED surveillance we do not use a mathematical sample, but a natural one which in brief time will be extended to as many territories as to be representative of Italy (see the SINIACA operative description paragraph). On the contrary precedent studies (6) indicate that home injury cases are distributed on the territory in direct proportion to the population with similar age-sex frequency distributions. Consequently we started the SINIACA setting up with a census of the hospital ED potentially participating in SINIACA either already included in a local emergency information system (EIS) or simply having a computerized registration (CR) of ED attendance. Table 2 reports the results of that census.

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A pilot test of SINIACA ED surveillance has been conducted in the hospitals of the territories indicated in purple colour in figure 1.

All the EDs have received an application module, developed by ISS, integrable in their EIS or directly applicable to a single Personal Computers (PC). That software was made of multiple modules for data entry, query, and export on electronic terminal (i.e. see application developed in VBA, MS-Access environment: fig. 2 – 3 - 4). The data-entry form includes demographic information, modality of arrive to ED, treatment and follow-up, etc. In particular mechanism, activity and place of accident are described analytically. Those classification items are compatible with the upper levels of the European HLA coding system (7), but the SINIACA one is a simplified system where all the data entry items must be included in a one page form and each item has not to exceed 20 possible codes. That in order to make feasible a large sample survey in ordinary hospitals without stressing excessively ED operators tasks with to much additional bureaucratic activity. Type of injury and body area are codified according to the Abbreviated Injury Scale (AIS) general structure (8).

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Software applications and upgrades have been transmitted to the EDs via internet, by mean of FTP (File Transfer Protocol) transmission. In the same way collected data have been automatically sent by the EDs directly to the SINIACA central computer servers. Actually the ED attendance data from SINIACA pilot test centres for the year 2004 have been sent to the central system. That sample consists in 11 hospital ED centres throughout Italy (3 in the north, 2 in centre, 5 in south) plus two Regions widely covered, respectively 10 EDs in Basilicata and 39 EDs in Latium (see fig. 1). In those last Regions the minimum data set used for the SINIACA ED surveillance has been integrated in the regional emergency information system. At the same time ISS has assumed the maintenance of the European HLA surveillance in Italy as national database administrator (NDA). The Italian HLA sample consists in 7 hospital ED (3 in north, 3 in centre, 3 in south) evidenced with green dots in figure 1. For those centres have been developed transmission procedures and software applications similar to those above described, but integrally based on European HLA V2000 coding system (translated in an Italian edition, see fig. 5-6-7-8-9-10).

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Those centres operate at the second level of the SINIACA structure producing more detailed information on the accidental event and providing the record of products involved or causing the accident. Nevertheless their main role in SINIACA is related to the open description of the event. The mastering centres ED operators will record in natural language the description of accident and its circumstances, but adopting a structured response procedure. In describing in natural words the accidents they shall respond to the following questions (see fig. 11):

1) What was the person doing at the moment of accident? 2) In which room (or home dependency) was the person? 3) How injury occurred (Describe mechanism)? 4) Which products (or structure, equipment) were involved in the accident? 5) In case of products involved, if known, please indicate model, brand, and country or

geographical area of production.

It will be developed and trained an expert software for the automatic recognition of products and circumstances of accident (activity, place, mechanism) directly from natural language description. That expert system can be the basis for the setting up of a rapid alert system (SAR) that by mean of a real time automatic interpretation of ED open responses signals unexpected or excessively frequent events. Hospital caption area have been calculated for the mastering centres. The whole 7 EDs concern a population of 517,000 people (about 1 percent of the Italian population. Their age-sex distribution does not significantly differ from the Italian general population one (Female/Male ratio = 1.06 in both populations; age distributions concordance: Kendall w = 0.967, p = 0.021; see fig. 12) (9),

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therefore that sample area population is representative of Italy. All the Italian HLA data for the period 1986-2003 have been included in the SINIACA databases.

The need of activating rapidly a national information system on domestic accidents has led us to immediately integrate the SINIACA ED pilot test surveillance with the existing data collection networks such as HLA and the regional EISs, in order to have a system fitting geographical representativeness criteria. Depending on the need of fulfilling statistical representative sampling criteria for the SINIACA ED surveillance operative phase 98 hospital EDs all over the nation have been contacted, they will get into the system progressively during year 2005. There should be at least 5 EDs in each Region (3 in minor Regions). In total the 98 EDs (see fig. 13) will correspond to 90 hospitals (12,0 percent of the total) in 57 local health district units (29,2 percent) or 42 Provinces (40,7 percent) with a potential caption area of about 19 million people: 1/3 of the Italian population.

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2.3 Morbidity : inpatient care In Italy each inpatient case is registered in a national standard nosological form (SDO: hospital discharge form) summarizing all the clinical papers information. It is an exhaustive survey because every patient in any hospital is recorded and since 1997 more than 95 per cent of the hospitals partially or totally financed by the national health service (almost all) are covered by this hospital discharge register. In theory the HDR information is quite complete, but the data quality for the external cause of trauma (type of accident) is very poor: i.e. during year 2000 in 50 percent of cases it was not reported and in 20 percent was indicated as “other”. In the end we know the accident causing trauma only in the 30 percent of patients. It depends on the fact that SDO is filled in the last hospital unit where patient stayed at discharge time, at that moment the information on accident that could be still recorded at ED is lost. In any case the HDR accident classification is very compact consisting just in wide categories such as occupational, road traffic, home, etc. On the contrary traumatological information quality is pretty good including up to 6 diagnoses and 6 surgical or medical procedures descriptions codified in ICD-9-CM clinical classification system (10). HDR data will be included in SINIACA databases, we defined a minimum data set that is used for selecting hospital discharge trauma records from regional health information systems. An other source of data for hospital admission cases is the SINIACA and HLA ED surveillance: in both classifications it is indicated the eventual hospitalization within the treatment and follow-up items. In the pilot test samples we observed similar rates of hospitalization with respect to ED attendances: 9.3 percent in pilot test centres (Basilicata region included), 8.0 percent in Latium. All those ED data collections are focused on the accident circumstances description providing a quite rich information on the external cause of trauma, while as above mentioned hospital discharge data have a more detailed description of the nosological aspects of trauma. Consequently one of the

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scopes of SINIACA is linking ED information systems with HDR and it will be achieved by recording on the ED data entry form the progressive number of hospital discharge form for the admitted patient. Actually six Regions a three Provinces (see fig. 14) have transmitted their HDR data representing 38,5 percent of the Italian population and around 1/3 of Italian public hospitals.

2.4 Mortality In Italian death certificates trauma is codified according to ICD-9 classification of death causes, so that the codes for external cause of injury (E codes) do not explicitly indicate home accident, but since year 1998 the National Institute of Statistics (ISTAT) has added to those certificates an item concerning the place of accident. If you analyze those data you face out a systematic underestimation of home accident fatalities, i.e. 1,713 deaths were recorded during year 2001. Now during the same year there were 10,575 trauma fatalities without indication of the place of accident, 79.9 percent of them where caused by accidental fall regarding in 7,586 cases people older than the age of 75. In a study on elders accidental falls Simoncini evidenced (11) the most of those events for elderly people occurs at home. One can assume, in a conservative hypothesis, that 50 percent at least of fatal falls for the elders (age greater than 75) occurs at home. Therefore he can calculate a number of 3,800 domestic deaths that summed up with the fatalities of younger people (age lesser than 75) raises the statistic of home accident fatalities up to 4,500 cases per year with an incidence rate of 7.8 deaths per 100,000 inhabitants/year. In comparing that rate with international correspondent figures (12) we observe similar values in Switzerland (7.8), U.S.A (9.0), and lower but comparable rates in Spain (5.3) and UK (6.6). Thus the recalculated Italian rate seems better assessing the real dimension of home accident mortality in Italy. In conclusion we do not have

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information for about 60 percent of mortality, but it has to be underlined that ISTAT definition of home does not include residential institutions such as protected home, pensioner’s home, private day-care home, etc. In our opinion many accidental fatalities (mainly falls) concerning old people occur in those places which even if are not private home in a strict sense, in fact are the elders domicile. The domestic accident mortality data are included in SINIACA databases in collaboration with ISTAT and next year will be adopted a new model of death certificate including the modality “residential institution” within the place of accident variable. 2.5 Information System From a technical view-point SINIACA information flow and data processing procedures are illustrated in figure 15.

That scheme corresponds to the way illustrated above the data will be selected directly from local, regional and national existing information systems or manually entered for ED attendances of some hospitals. At the central level it will be developed a data bank, made of many related databases, by mean of a RDBMS (Relational Database Management System) such as MS-SQL Server. Manipulation and data extraction procedures are developed by non procedural or object oriented programming languages such as SQL (Structured Query Language) or Visual Basic. Data are stored on a dedicated server (O.S. Windows 2.x Server) situated in the National Institute of Health Environment and Primary Prevention Department. They are allocated in specific mass memory space, on multiple RAID-5 (Redundant Array of Independent Disks) configured hot-swap hard

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disks. The logical protection of mass memory areas is guaranteed by authentication policies for working groups and usernames. Specific services are active for databases mirroring on external removable high capacity hard disks and periodical automatic backup processes on high capacity magnetic tapes. Data transmission may be performed by regional local workstations terminals connected through internet network via FTP (File Transfer Protocol) to an FTP internet site of the National Institute of Health (ISS) based on a server (O.S. Linux) located in the Data Processing Office of the ISS (see fig. 16).

The user interface is a Web-browser or WYSWYG (What You See is What You Get) FTP-client shaped module with archives graphical visualization of hierarchical type (i.e. see fig. 17). Security is guaranteed by mean of an authentication site access procedure based on userid and password keys and accessing IP address control. Every region has a dedicated mass memory area on the site server protected by the authentication process (see fig. 18). Regional access consents only data upload/download in the dedicated area.

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With regard to transmission capacity required to the accessing systems we assessed that the whole national dataset to be transmitted will have a maximum dimension of 2 GigaByte per year for ED data files and 1 GigaByte for hospitalization data files. Those dimensions can be managed even by a single workstation with a low capacity telephonic connection line determining a maximum network transmission load of 7 hours per month (see table 3). Each workstation with a normal telephonic connection to internet will be capable to perform the complete upload of the entire national datasets.

3. Preliminary results In the SINIACA pilot test phase during year 2004 home accident data have been collected by hospital EDs of the pilot centres (11 hospitals throughout Italy and 10 hospitals in the Basilicata Region ), Latium Region EDs (39 hospitals), which partially integrated the SINIACA module in their EISs. Mastering centres HLA (7 hospitals) data were included in the system databases since year 1986 up to 2003. Moreover the year 2002 hospital discharge records have been transmitted to SINIACA by the Regions and Provinces listed in figure 14 (242 hospitals). Mortality data are also provided to the system by the Italian National Institute of Statistics (ISTAT). The following paragraphs will briefly illustrate the results of preliminary analysis of those records, the most of which are recently being gathered into the central system.

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3.1 The ED samples We will consider hereinafter the 3 ED attendance samples: in the pilot centres around 15,000 cases were observed, about 25,000 in Latium and approximately 12,000 in the mastering centres, in total about 52,000 ED patients recorded in the whole SINIACA pilot phase. The 3 samples are collected in different geographical areas: pilot centres more represented in southern Italy, mastering centres concentrated in northern and central Regions, Latium hospitals representing their Region. Nevertheless the demographical information is very similar in the three datasets (i.e. age distributions concordance: Kendall w = 0.91; p=0.0007). We observe three frequency peaks for the domestic injuries (see fig. 19): the first is one for pre-scholar ages, the second concerns 30-39 adult ages and the third one regards people older than 80 years.

Splitting the age distribution by sex in pilot and mastering centres we observe different trends in males and females (see fig. 20).

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Males have systematically higher frequencies than females till the age of 50, for elderly ages the proportion is inverted and women are represented much more than men. Apart the similar peak in pre-scholar ages the difference in trend in the other ages is implied by different activities and ages of population between the sexes. Young adult males (age 20-39) are more interested in do-it-yourself and repairing activities, whilst adult women are more concerned with domestic work activities and tend to manifest problems in the elderly ages. Among the elders females show higher figures for injuries because of their greater presence in elderly population due to their higher life expectancy. Time of attendance was recorded in both pilot and mastering centres; its frequency distribution shows higher values in the morning within 9 and 11 o’clock and in the late afternoon among 16 and 19 (see fig. 21), both periods of greater domestic activity (domestic or repairing work) and presence of family members at home.

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The domestic place in which accidents occur more frequently is kitchen (see table 4).

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It is followed by bedroom and living room that are the places were people stay longer at home . Stairs appear particularly dangerous having high figures for accidents while exposition to risk is lesser than in other rooms because normally people spend few time on the stairs; bathroom has a similar condition of risk. The samples differ for injuries occurred in garden and other residence outdoors; those are pretty common in mastering centres and in Latium were they are coded as happened in courtyard that is the common outdoor space in an Italian block of flats. That typology of residence is very common in Latium Region whose most population is included in the metropolitan area of Rome. In the pilot centres, instead, practically there are no accidents in residence outdoors whilst parking areas and store-rooms account for a relatively high number of injured people.

Mechanism of injury distribution is quite similar in the samples so that it will be shown in an aggregated way (see fig.22).

Falls cause about half of the accidents and struck/hit/crushing by contacts with object/person/animal or cutting/piercing determines around one third of them. Splitting this last category we observe that contacts represent around 20 per cent of all injuries and cutting/piercing wounds the 10 per cent of them. Struck and hit by fall or contact altogether are causing more than 65 per cent of the accidental events and we will see later they are associable with structural elements of the house and furniture, while cutting/piercing wound can be associated with the use of appliances and tools for domestic work or handicraft and hobby activities. An other accident quite common is that related to foreign body (about 1/20 of ED attendances). It can be very dangerous for children in early ages. Frequent cases list is completed with thermal effects mechanisms, due to hot objects and materials (i.e. stove, boiling beverages), or chemical reaction (i.e. corrosion by acids). The importance of it,

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despite of the 3 per cent of cases represented lays in the fact that the potential consequences of those events may be on average very severe. There is not appreciable difference in mechanism of injury between men and women excepted the falls for females that are in a highest proportion than males (around 60 vs. 40 percent) depending on the older mean age of women. The most of home injuries have minor severity consisting in superficial traumas such as contusion or laceration: 57 percent of ED attendances concerns superficial injury in pilot and mastering centres samples (see table 5). Table 5

Home Injury type ED Attendance % Distribution, Pilot (n=10,257) and Mastering HLA Centres (n=11,871)

Pilot Mastering Type of Injury % % Contusion/abrasion/strain 36.1 31.5 Laceration/ Open Wound/ Flaying 23.2 24.4 Fracture (closed and open) 14.8 10.7 Dislocation/Sprain 10.7 7.3 Other 15.3 26.0

Potentially moderate or serious traumas in the observed home accidents are fractures and dislocations that cause a significant proportion (21,0 percent) of ED attendances. A more detailed perspective is obtained by considering i.e. the pilot centres data (see fig. 23).

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You see that substantially the fractures are closed and potentially dangerous injuries for instance foreign body, penetrating wound and burns show figures around 3-4 percent of cases each, while poisoning and intracranial or internal injuries each account respectively for about 1,5 percent. Those injuries are more severe on average than the other more common ones, because even if fortunately they are rare at ED then determine a relevant proportion of mortality. The body parts involved reflect type, severity and mechanism of injury as it is shown in table 6, notice once again the good concordance of the two samples:

Table 6

Home Injury ED Attendance % Distribution by Body Part, Pilot (n=10,772) and Mastering HLA Centres (n=10,555)

Pilot Mastering Body Part % % Head, face 21.7 28.4 Neck, throat, cervical spine 1.4 0.9 Thorax, thoracic spine 6.5 5.1 Abdomen, pelvis, lumbar spine 6.1 3.5 Upper limbs 36.0 40.0 Lower limbs 27.6 21.6 Other/Unspecified 0.2 0.5

The most of the above described superficial injuries and fractures/dislocations concerns the extremities (about the 63 percent of accidents), lower limbs injuries in particular are linked with falls, upper limbs instead are involved even in hit by contacts and cutting/piercing mechanisms which explain their higher figures. Around one fourth of the events regards head and face and it is caused by falls mainly, but even by hits. To be noticed that in pilot centres we observed specifically a relevant number of injuries to spine with a proportion (4,4 percent) comparable to the abdomen/pelvis one. That delicate body area also is involved mainly bay falls. We talked about the potential severity of different types of injury: a first measure of trauma severity are the day of prognosis and the selection procedures of patients for the ED care waiting list, both those variables are recorded in pilot centres sample. Those emergency selection procedures are based on a method called “triage” which consists in assigning the patients codes of priority rights for care. Those procedures are essential to a proper functioning of the Italian hospital ED, because as above discussed normally patients are not previously filtered by their general practitioner nor by an outpatient first-aid service. The codes are:

1) White – less severe case; patient could have contacted his general practitioner or an outpatient first-aid service, he is included in waiting list with very low priority and will be assisted only when all emergencies are treated.

2) Green – deferrable care case, low priority. 3) Yellow – severe case with evolving risk for life, relative priority reducing at minimum

possible waiting time. 4) Red – very severe case, real threat for life high priority with immediate intervention of the

emergency team.

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Table 7 Home Injury ED Care Priority % Distribution, Latium (n=25,140) and Pilot Centres (n=9,818)

Priority Code Latium Pilot

Centres

non treated 0.21 0.00White 12.20 24.37Green 82.89 64.20Yellow 4.63 11.00Red 0.04 0.43Dead 0.02 0.00

In both samples more than 85 percent of attendances regards non-severe injuries, that observation is confirmed by the days of prognosis which in pilot centres are not over one week for about 50 percent of patients, within two weeks for at least 70 percent of them and not longer than three weeks for more than 80 percent of injured people. Domestic accidents involve a large number of people, but for the most have minor health consequences for the individuals, although a wide number of injured people, even if at low severity, requires a big organizational effort and resource consumption by the health services.

Table 8 Home Injury Days of Prognosis % Distribution,

Pilot Centres (n=7,887)

Days % 1 1.02-4 14.35-7 34.28-13 21.014-20 12.321-30 13.530 + 3.7

What is interesting is how severe cases interest different patient groups and the pilot centres data (see fig 19 and 24) show that severe cases are significantly concentrated within children and elderly groups, for instance age groups 1-4 and over 80 respectively represents about 19 and 28 percent of severe cases (yellow codes), while they account respectively just for 7 and 12 percent of the whole ED attendances; similarly pre-scholar age children concentrate the 21 percent of very severe injuries (red codes). We can state therefore the elders and children are at higher risk of severe trauma than all other age groups.

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In conclusion of this preliminary analysis of ED data we observe the products involved in the domestic accident. Mastering centres as aforesaid collect information even on products causing or simply involved in the accident. The structural elements of the house (indoors or outdoors) such as stairs, floors, walls, pavements, etc. are the main causes of accident (see table 9) for both women and men.

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Those accidents are associable with struck and hit by fall or contact mechanisms of injury that we already observed as the most frequent dynamics of accident. Furniture, which is the second cause of injury for both sexes, is also associable to struck or hit by contact. Typically frequent for males are injuries caused by do-it-yourself, repairing or handicraft tools, those accidents linkable with the raw material and elements (i.e. Glass, brick, chip, pipe, nail, screw, etc.) caused ones. Women, instead, are more frequently injured by domestic work appliances (i.e. cleaning tools, cutlery, kitchen utensils, etc.). 3.2 Inpatients: ED and hospital discharge samples We can calculate the incidence of hospitalizations because of domestic accidents by mean of the hospital discharge record already gathered into SINIACA central system (see fig. 14). It leads to an estimate of 113,000 admissions to hospital secondary to home injury in Italy during year 2002, with an incidence rate of 200 cases per year for each 100,000 inhabitants. Nevertheless we know this calculation is affected by underestimation depending on the already discussed data quality problems. An alternative method for assessing incidence is considering those ED patients destined to hospital staying. In this way if we select from SINIACA ED samples those centres that present best quality data and of which we know exactly the caption area. We arrive then, in a conservative hypothesis to an estimated incidence rate of at least 230 hospitalizations per 100,000 inhabitants/year equivalent to 130,000 admissions. In calculating the sex-age specific groups incidences we will use the admitted to hospital patients data of three samples: pilot and mastering centres, hospital discharge registers records (HDR). Their demographical structure is very similar with a proportion of women positioned around a 60 percent figure among them. The age distributions also are highly concordant (concordance: Kendall w = 0.95, p = 0.000; see fig. 25 ).

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That similitude is maintained if the age distributions are split by males (concordance: Kendall w = 0.86, p = 0.001) and females (concordance: Kendall w = 0.92, p = 0,000). We do not see significant differences in the samples so that hereinafter the HDR one will be used being the larger one and covering the entire territory and hospitals of the six Regions and three Provinces that already transmitted their hospital discharge records to the central system. In incidence and hospital resources consumption calculations HDR data will be parametrically corrected as above exemplified in order to avoid the afore-cited under estimation bias. The home accidents hospitalization incidence distribution by specific sex-age group assumes the typical “U” (or system failure) curve (see fig. 26): if one overcomes the risk of being hospitalized in early ages then that risk diminishes progressively and stabilizes till raising up again after long time.

It is the combined effect of the greater exposition to domestic accident for children and the elders, who spend more time at home than the other age groups, and their physical fragility toward trauma. In children plays an effect the admission procedure even, because they tend to be admitted to hospital more easily than other age groups. Talking about risk comparisons is more correct to refer to appropriate risk indicators and in figure 27 is reported the relative risk of the different sex-age groups versus the base group which is female age group 15-19.

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The diagram as the same U shape so that major risk groups are children in neonatal or pre-scholar age and elderly people. Females risk since the age of 60 systematically grows faster than the males one, consequently the group at highest risk is females over the age of 80. We mentioned the fragility of children and elderly people, but it implies a more severe trauma for them than the other ages and we effectively observed it in the ED priority care procedures, a gross indirect measure of it can be the hospitalization rate for ED attendances. That value is similar, as aforesaid, for Latium and pilot centres, considering those last data the severity hypotheses are indirectly confirmed and we see higher rates for children and elderly people (see fig. 28). Among them elderly women have systematically higher rates than men. Nevertheless the children figures may be influenced even by a different style of admission because more attention is paid by the clinicians to them. We have analyzed hospitalizations till now in terms of individual risk and care needs let us see how those needs are traduced in healthcare services workload.

30

If you go back to figure 25 you observe that number of admissions increases more than proportionally with age. The most of patients (60 percent) have more than 60 years and among them females are 70 percent of cases, depending it on risk conditions (greater exposition: women are more present at home than men), demographical reasons (there are more elderly women than men in the general population, because of their greater life expectancy), and severity of trauma effects indirectly evidenced by elderly women high rates of hospital admission. The result of those combined effects is shown in figure 29 where women having initially a weight on total number of inpatients similar to men then diverge from them after the age of 60. The patient workload on services depends also on hospital length of stay. The analysis of domestic injury patients average length of stay in hospital (AVLOS) demonstrates that length of stay strictly depends on age (R2=0,96) and increases proportionally to it (fig. 30). That relation is similar in both sexes.

31

32

Those observations confirm what reported in literature (13): age can be used as a proxy for the general health conditions of the patient which influence the magnitude of damage suffered (trauma severity), the course of disease, and the body capacity of reaction to treatment. The HDR records prove i.e. that a very old person, over the age of 80, has on average necessity of hospital care for a period four time longer than a child in pre-scholar age. The average length of stay for domestic injury patients is 8.4 days a period similar to the one of the whole trauma, but longer for instance then the road traffic accidents one which involves generally younger people. If we combine both effects: specific sex-age group weight (see fig. 25) and AVLOS (see fig. 30) we obtain that unit cost per patient (UCP) grows exponentially with age similarly in men and women (see fig. 31). As a result for instance a 70-74 age old patient costs five times more than a baby of some months of age. Children are at high risk of hospitalization by domestic injuries, but they determine a minor workload on hospital services because they are less in general population, stay less in hospital depending on their body good capacity of reaction to treatments and in conclusion cost less.

Hospital inpatient unit cost have been calculated with an incidence approach per pathology (14) using the Diagnosis Related Groups method (15): the average cost per home injury patient is equal to 3,014.63 Euros in year 2002 hospital discharge cases recorded in the HDRs of the Regions and Provinces that already sent their hospital data to SINIACA (see fig. 14). There is a certain variability at territorial level (Coefficient of Variation = 47,8 percent), but in general the cost is slightly higher in northern regions (+6,7 percent), which have a population on average older than the other regions one, and in almost all territories women average cost is significantly higher than males one (on average +28,2 percent: UCP in Euros females = 3,296.59; males = 2,572.30), in all the territories they represent a larger and older case-mix of hospital admissions.

33

By mean of the incidence values of hospitalization above indicated we can asses the national total cost for home injuries admissions to hospital in year 2002 at 395.310.081,33 Euros. This is a minimal value calculated in the conservative hypothesis that Italian incidence is at least 130,000 inpatients by domestic injury per year. In consequence of the above discussed factors (weight on total admissions number and length of stay trends by age and sex) total cost increases exponentially with age (see fig. 32) and as expected females cost diverges from the males one and since the age of 60 rapidly increases (see fig. 33). What is maybe more interesting from a financial point of view is that 69 percent of total cost depends on over 70 age patients (see fig. 34), over 70 years old females only determine 54 percent of total cost. Correspondently patients younger than 60 years of age represent not more than 20 percent of total cost.

34

35

That phenomenon descends from three fundamental factors: prevalence of elderly people in the general population, domestic trauma incidence in the elders and their unit cost of inpatient care. The first factor is not controllable: the number of elders is fortunately destined to grow because of life expectancy increasing. Thus, coeteris paribus, unless a radical changing in health care system organization there will be inevitably an increment in health care assistance demand by the elderly population which is now already representing the most of that demand in domestic accidents. In order to confirm this hypothesis is sufficient considering i.e. the relative weight of the elders on domestic injury inpatients number in Lombardy Region during the period 1997-2002. That figure raised up for both sexes in the period (see fig. 35), for that reason we assume as given the demographical shift factor not considering it explicitly in the model synthesizing the variables determining the home injury share of inpatients total cost due to elderly people:

ββααββαα

αα ciciCTIDcici

ci..7,0

...

≥⇐⋅≥+

(1)

where

)70( >== ageincidenceelderlyiα )70(cos >== agetunitelderlycα

)70( <= ageincidenceelderlynoniβ )70(cos <= agetunitelderlynoncβ

with α

α i

ic j

j∑=

⋅=

120

70p

e β

β i

ic k

k∑=

⋅=

69

0p

;

where ij = incidence in each single elderly age year (ages >=70) ik = incidence in each single non elderly age year (ages <70)

∑=

120

70jji = elderly ages inpatients case-mix

∑=

69

0kki = non elderly ages inpatients case-mix

p = production factors prices vector The unit cost component even is difficultly controllable because health care production factors are under strict control in Italy since many years. An indirect prove of it can be observed in the above mentioned HDR data of Lombardy: given that real prices (net of inflation) of health goods and services are substantially stable since 1997 the unit cost increased essentially because of the shifting of home injury inpatients case-mix toward older ages, in fact you can see (fig. 36) that the costs significantly diverge through the years in older age groups whilst tend to remain stable the younger ones in the same period.

36

37

Therefore the component on which is possible to act remains the incidence of home injuries in the elders. We observed that for the most it is caused by falls. In conclusion then is opportune targeting the action on prevention of falls in the elders on one side trying to maintain them in good general health conditions and on the other one focusing the action on the elimination or reduction of causes of fall in the home environment and on implementation of contrivances for reducing the effects of fall once it has unfortunately occurred. The admission to hospital represents in itself a first raw selection of ED attendance cases by the potential severity of trauma. It is of some interest then the comparison of the ED attendance frequencies by mechanisms of accident with those observed in hospitalized cases. Using the admissions recorded in Latium Region we see for instance (see figure 37) that poisoning and intoxication, which is very rarely observed at ED, is the second cause of hospitalization, on the contrary struck and hit by contacts is the second cause of ED attendances, but represents less than 1 percent of admissions. Therefore we individuate 2 typologies of accidental events: a) rare event, but potentially severe, b) frequent event, but not potentially severe. The falls are contemporary frequent and potentially severe being the first cause of both ED attendances and hospitalizations.

With regard to the place of accident the proportions of hospitalized cases by type of home place are substantially similar to those observed at ED (see figure 38 and table 4) not indicating a specific place causing injuries more severe than the other places ones.

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The activities causing accident are for the most unspecific such as everyday life activities (eating, personal hygiene, etc) or other generic activities (walking, sitting, etc.), but from the about 54 percent observed at Latium hospital EDs they raise up to 67 in hospitalization. The opposite situation for specific activities such as domestic work, do-it-yourself work, play and sporting activities that altogether are the 37 percent of ED attendances and for inpatients descend to 23 percent. There is an implicit effect of falls (in the elders) as prevalent cause of domestic accident. 3.3 Mortality data We already discussed the underestimation bias in home accidents mortality data and recalculated its incidence. The recorded data come at 75 percent from 11 Regions (in northern and central Italy) that represent the 55 percent of Italian population, a first possible bias then is the territorial one. Although the data sex-age distributions do not differ considerably (sex variation coefficient = 30 percent; age group variation coefficient < 35 percent age group) at detailed (Provincial) territorial level so that we can use them, which represent around 40 percent of the expected fatalities, as a general sample of home accidents mortality in Italy. The analysis of the external causes of domestic mortality confirms accidental fall as highly frequent and severe cause of trauma with a proportion of 68 percent of fatalities, greater even than the correspondent one observed in hospitalizations (see table 10). The other leading causes of death are fire, poisoning (with a proportion similar to the hospital inpatients one) and drowning/suffocation/foreign body. Poisoning (or intoxication) is frequently observed in

39

hospitalizations and mortality data evidencing its potential lethality rate, the other two last causes instead are respectively less frequently or rarely present in hospital cases even within inpatients so that they are characterized by an implicitly high lethality rate. Those leading causes altogether determine 89 percent of mortality. Tab. 10 Home Injury Mortality Percentage Distribution by External Cause – Italy years 2000 and 2001

E Cause N. % Transport 2 0.06 Poisoning by pharmaceutical product 105 3.00 Intoxication by other substance 169 4.83 Complication of medical or surgical procedure 4 0.11 Accidental fall 2,384 68.06 Fire and burning 293 8.37 Natural elements 17 0.49 Drowning, suffocation and foreign body 155 4.43 Other accidents 265 7.57 Adverse effect of medicines 5 0.14 Unspecified 103 2.94 Total 3,502 100.00

Consequently to the above indicated mechanisms of injury the most frequent causes of traumatic death are listed in table 11, the first seven in the list altogether determine the 93 percent of domestic mortality. Their association with the mechanism of injury is reported in table 12.

Tab. 11 Home Injury Mortality Percentage Distribution by Nosological Cause – Italy years 2000 and 2001

E Cause N. % Head Trauma 1,219 34.81 Lower limbs fracture 881 25.16 Internal trauma of thorax, abdomen, pelvis 335 9.57 Burnings 324 9.25 Poisoning, intoxication 282 8.05 Neck and trunk fracture 146 4.17 Foreign body 76 2.17 Other 104 2.97 Unspecified 135 3.85 Total 3,502 100.00

It shows that head trauma, neck and trunk fracture, limbs fracture are essentially caused by accidental fall. Internal trauma of thorax, abdomen and pelvis are also determined for 2/3 by fall. Altogether those fall depending traumas are the 67 percent of all domestic injury deaths. For the rest home related mortality depends substantially on poisoning, burns and suffocation representing on the whole 21 percent of deaths.

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Tab. 12

Domestic Death Type of Injury Percentage Distribution by Mechanism of Injury E Cause

Pois

onin

g,

into

xica

tion

Fall

Fire

, bu

rnin

g

Suffo

catio

n

Oth

er

Tota

l

Head trauma 0.0 89.1 0.0 0.0 10.9 100.0Neck and trunk fracture 0.0 95.9 0.0 0.0 4.1 100.0Limbs fracture 0.0 98.8 0.0 0.0 1.2 100.0Internal trauma of thorax, abdomen, pelvis 0.0 66.0 0.0 0.0 34.0 100.0Burning 0.0 0.0 90.1 0.0 9.9 100.0Poisoning by pharmaceutical products 94.5 0.0 0.0 0.0 5.5 100.0Intoxication by other substances 97.7 0.0 0.0 0.0 2.3 100.0Other 0.7 9.8 0.4 56.4 32.7 100.0

N C

ause

Total 7.8 68.1 8.4 4.4 11.3 100.0 Once calculated how the different mechanisms of injury determine trauma let us see in which way they affect different age groups, in the analysis of data the situation resulted similar for both sexes, therefore only the total figures (males + females) will be showed. In observing external causes of domestic trauma relative weight within each age group three characteristic trends by cause (see figure 39) emerge: First of all there is a peak of mortality by falls in paediatric ages, i.e. fall is the

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first cause of domestic mortality for the 10-14 age youngsters (almost 50 percent of deaths), then the figure descends in teen-agers and young adults starting again to increase with age after the age of 25. Over the age of 80 fall cause more than 80 percent of deaths. The trend is opposite for burnings and suffocation (foreign body): they affect more kids for whom are the first cause of home related mortality till the age of 9 years old, but after that age fatalities descend by age. Poisoning and intoxication effect is particularly worrying because it grows through adolescence becoming the leading cause of domestic accident death in young adults (50 per cent of mortality in 20-24 age group), then it decreases with age. Those home related mortality patterns identify different modality of fatal accidents for different groups of people who should be targeted by prevention actions.

Conclusions The data flow from Regions and territorial local health care units toward the central structure of the National Information System on Accidents in Civilian Residences Environment (SINIACA), during the pilot phase of the system, has permitted to obtain some important results:

a) testing the feasibility of the system in integrating the information coming from different data sources, currently existing registers and newly set up surveillances;

b) identifying the critical points in information already available; c) assessing the different dimensions of the home accidents phenomenon producing a first

estimate of domestic environment related trauma incidence; d) identifying specific groups at risk and patterns of accident ; e) evaluating the impact of home accidents on health care services identifying its

determinants; f) assessing the hospital inpatient costs of domestic trauma defining its factors; g) indicate some priority objectives of prevention aimed to the promotion of health and the

health care costs control; h) producing first information on home accidents typology and mechanism.

As far as the data flow gradually increases becoming systematic and uniform at territorial level, in compliance with the technical specification for data collection and transmission indicated to territorial surveillance units, it will be possible producing information more and more complete, detailed and affordable. The next objective of the information system, once we succeed in linking hospital ED information with the hospital discharge records one, is the analysis of the trauma aetiology in relation with the type and severity of injury, assessing even its effect on patient outcome. All is aimed to the identification of those types and mechanisms of accident that primarily affect the population health status causing the most frequent and/or severe injuries.

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