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Maximizing the continuum of care through prevention.

Injury is the leading cause of death for Americans under the age of 44. Each year, traumatic injuries result in approximately 150,000 deants in the United States. Not only is traumatic injury a leading cause of death, it is a leading cause of disability as well.

Injury is now recognized as a major public health problem in the United States. However, for decades, injuries simply were dismissed as "accidents" that just "happen." The study of injury has given us a new perspective: Injuries are not accidents. Accidents are defined as random, upredictable acts of fate. Further study of injury has shown that there are patterns of common variables and risk factors assciated with injury. Thus, most injuries are predictable and preventable.

Traumatic brain injury (TBI) is one of the most serious and costly of all injuries. It is estimated that each year 1 to 2 million Americans sustain TBI, with 70,000 to 90,000 brain injuries severe enough to require the patient to have long-term rehabilitation. Approximately 10 percent of all head injuries are fatal.

The leading causes of TBI are motor vehicle collisions, violence, falls, and sports and recreational activities. Alcohol and other drug use is a contributing factor in the occurrence of brain injury because it increases one's risk for injury and can exacerbate its consequences.

The Cost of Injury

Though the severity of brain injury may vary by degree, the consequences are always significant to the individual experiencing the injury. Nonfatal brain injuries may result in limitations of physical, cognitive, and emotional functioning. These impairments may last a lifetime and prevent a person from resuming his or her previous roles in life.

While the costs of injury are often thought of in terms of the human suffering associated with death and disability, there are also grave economic costs. Society absorbs the cost in lost productivity when a person is unable to return to his or her job as a factory worker, accountant, homemaker, or student. Lost productivity is an indirect cost, while medical care and services are direct costs to the individual, family, and society. The long-term cost of care for one person with a severe traumatic brain injury has been estimated at $4.1 to $9 million by the National Head Injury Foundation (NHIF). It is not uncommon for a person with a severe TBI to require 5-10 years of rehabilitation and followup services.

Meeting the Challenge

Recognizing the serious consequences of traumatic brain injury and the spefic and sometimes life-long needs of the people who sustain them, the Rehabilitation Services Administration (RSA) and the National Institute of Disability Rehabilitation and Research (NIDRR) of the U.S. Department of Education are supporting Head Injury Centers demonstrating model systems of care for people with TBI and their families. Model systems of care provide comprehensive services on a continuum which begins with prevention of TBI and extends to emergency medical services, acute medical care, rehabilitation, community and vocational reintegration, and followup services. Six regional head injury centers have been designated by RSA since 1990 and five centers have been designated by NIDRR to meet the growing and changing needs of people who sustain TBI (also referred to in this article as consumers).

Control of Injury

Although prevention and rehabilitation may seem to be two distinctly different concepts, they both seek to promote healthy life choices and maximize quality of life. Thus, they are critical components of injury control efforts. Consistent with an interdisciplinary approach to rehabilitation, researchers have found that effective prevention programs should also take a broad approach. Prevention programs should be comprehensive, in that they involve multiple strategies and many segments of any community.

Traumatic brain injury control encompasses several phases of prevention:

* Primary prevention focuses on preventing the occurrence of an injury-producing event. The goal is to prevent the event (crash, fall, gunshot) from happening, thus it is often referred to as the "pre-injury phase." Examples of primary prevention include promoting safe driving habits, preventing substance use and abuse, providing safe roadways for motor vehicles and bicycles, and using stair gates in homes to prevent children from falling.

* Secondary prevention focuses on minimizing the debilitating consequences of injury or reducing the extent of injury if the event does happen. This is often accomplished by placing a barrier between the human body and the energy transferred during the injury-producing event. Examples of secondary prevention of TBI includes use of occupant restraint systems, bicycle and motorcycle helmets, and soft surfaces under playground equipment. Because a person will fare better if he is not intoxicated at the time of brain injury, substance abuse prevention is another example of secondary prevention. Providing the best care at the scene of injury, including first responder and emergency transport, is a critical factor in reducing the immediate consequences of injury.

* Tertiary prevention attempts to minimize the secondary complications ofd the injury once it has occurred. Providing medical services and rehabilitation to maximize functional outcomes and reduce the consequences of injury are examples of tertiary prevention. Substance abuse prevention for people with brain injury and their families focus on reducing the risk of additional injury and maximize rehabilitation outcome.

Injury Classification

The six RSA Regional Head Injury Centers are implementing various combinations of primary, secondary, and tertiary prevention interventions. However, understanding an injury problem is necessary before identifying which prevention strategy (or combination) might be most effective. To better understand injuries, it is helpful to classify them into several categories by analyzing different characteristics.

Brain injures and other traumatic injuries can be classified as "unintentional" or "intentional" injuries. Motor vehicle collisions (including pedestrian injuries), falls (home, job, playground), sports and recreational activities (bicycling) are among the most common ways that unintentional brain injuries are sustained. Interntional injuries--many of which involve firearms--include domestic violence, child abuse, assault and battery, suicide and homicide.

Dr. William Haddon Jr. introduced a widely used classification mechanism so that injuries can be examined and studied the way infectious diseases have been studied. The host is the person(s) involved (infant, child, adolescent, adult, or elderly person). The agent is the mechanism of energy transfer, whether it's a firearm, a motor vehicle, or stairs in the home. The environment can be analyzed in terms of socio-economic factors, cultural factors, and environment and/or physical factors.

Recognizing that the environment surrounding an injury often involves the use of alcohol and/or drugs, substance abuse prevention is a vital component of several of the RSA Regional Head Injury Centers' prevention activities. The Midwest Regional Head Injurt Center of Rehabilitation and Prevention at the Rehabilitation Institute of Chicago (MRHICRP) and the Comprehensive Regional Traumatic Brain Injury Rehabilitation and Prevention Center (TBI--NET) at Mount Sinai have a specific focus in substance abuse prevention for people with TBI. The Midwest Center has developed a resource manual and training module for rehabilitation professionals for use with brain injured patients and their families. The two newly designated RSA Centers--Ohio Valley Center for Injury Prevention and Rehabilitation (OVCHIPR) at Ohio State University/Columbus and the Southeastern Comprehensive Head Injury Center (SCHIC) at the University of Alabama/Birmingham--will also include substance abuse prevention for consumers and families.

Strategies to Prevent Injury

Generally, the RSA Regional Head Injury Centers' prevention initiatives can be groupes into three recognized injury prevention strategies: educational, legal, and technical. The educational approach provides information to people to persuade them to change current behaviors or adopt behaviors which reduce the risk for injury.

Many innovative prevention programs are being developed at the RSA Regional Head Injury Centers. One educational approach to preventing TBI is the use of an instructional guide and video, entitled All The Kings Horses and All the Kings Men, developed by (TBI-NET) and Norwalk Hospital. The video, which is narrated by TV Sports Commentator Frank Gifford (and is also available in Spanish), was honored with the Globe Award in the Public Health Category at the Houston International Film Festival. The video and prevention manual are available to interested groups for implementation in Region II (New York, New Jersey, Connecticut, and Puerto Rico). All the King's Horses aims to educate teachers, parents, and others wsho supervise children so that they recognize the serious consequences of brain injury and implement strategies to prevent them.

Another educational effort to raise public awareness of the magnitude of injury is a recently published article, There Are No Accidents, which was a collaborative project of The Institute for Rehabilitation and Research (TIRR), its Southwest Regional Brain Injury Rehabilitation and Prevention Center (SWRBIRC), and the Chronic Disease and Injury Prevention Program of the Houston Department of Health and Human Services (HDHHS). The publication featured the testimonals of many people who sustained traumatic injury sharing the impact that injury had on their lives. Further information about the consequences and economic costs of traumatic injury were included to help raise the public's awareness of injury-related issues. This population had a distribution of nearly 700,000 and a readership of 1.2 million. An additional 2 million copies of the article were mailed directly to health professionals and organizations involved in injury prevention and rehabilitation.

Obviously, public information campaigns and educational programs are targeted toward people. However, behavioral change is difficult to achieve through education only. In fact, education is more effective when it is reinforced with other approaches, particularly with legal or technological interventions.

The legal approach is directed at requiring behavior change by law or mandate. This is most often seen in public policy and laws that govern behavior (i.e., motorcycle helmet laws, safety belt laws, and impaired driving laws). Model centers provide an excellent way of sharing legislative and regulatory efforts which have been successful in one state and supporting their replication in other states. Colorado and Illinois are two of three states without a motorcycle helmet law. The Midwest Regional Head Injury Center and the Rocky Mountain Regional Brain Injury Center (RMRBIC) provide information to organizations in support of such vital public policy directed toward reducing brain injuries. Of course, many states are involved in strengthening existing laws and supporting the enforcement of existing laws.

The technological strategies attempt to eliminate human control by providing automatic or passive intervention through environmental design and/or engineering. As one might guess, this is a very effective strategy to reduce injury, as it leaves little or no room for human decision/choice. Air bags and automatic safety belts are examples of technological approaches to reduce injury.

It is vital to examine all prevention strategies to determine their effectiveness. Through evaluation efforts, it is known that a combination of the above-mentioned strategies are most effective. Evaluation has not shown that education alone effectively changes behavior, though there are many situations that demonstrate the necessity of education in injury control. For example, over 50 percent of all child safety seats are used incorrectly. Thus, the technological advances in child occupant restraint systems and the laws in all 50 states do not protect our children unless education is provided about the need to use child safety seats and how to use them properly.

In efforts to reduce brain injuries to children in motor vehicle collisions (a leading cause of death), the Eastern Regional Center at Mount Sinai Medical Center is implementing a program specifically aimed at promoting infant and child passenger safety, called Kids are Riding Safe/Special Kids are Riding Safe (KARS/SPKARS). KARS/SPKARS is a child passenger safety program developed by the National Easter Seal Society and funded by the National Highway Traffic Safety Administration (NHTSA). This program promotes hospital involvement to ensure that each discharged infant/child is properly restrained while riding in a motor vehicle. This model also addresses special needs of children who may have cerebral, palsy, spina bifida, orthopedic needs, or have been born prematurely. In order to ensure child passenger safety, it is critical to train parents and hospital staff, develop hospital discharge policies, and provide safety seats to the users. Collaboration with local and state departments of health, transportation, and other health promotion groups has been critical to the success of this program.

Developing an Injury Prevention Program

One widely used model for developing an injury prevention program or initiative involves a series of 10 steps. Because each community is different, the model may need modification to be meaningful for a specific locality. It is not unusual to be working on some steps at a local level while supporting other activities on a regional and national level as well.

Step 1. Gather and Analyze Data. Access to data about traumatic brain injury varies from state to state. Currently, 14 states have legislation making TBI a reportable condition. Within the last decade, several states have developed TBI registries or surveillance systems.

Registries may be intended to identify patients eligible for clinical or other services, evaluate treatment methods, and monitor patient outcomes. Individual states may also have surveillance systems with a public health emphasis on injury prevention. These systems collect information used to assess the magnitude of an injury problem, drive and monitor prevention programs, support public policy, and may also identify individuals who need services.

A major limitation in documenting the true incidence of traumatic brain injury is the lack of a standardized definition. This limitation is currently being addressed by the Centers for Disease Control and Prevention through the development of standardized definitions and data sets for spinal cord injury and traumatic brain injury.

Baseline data are needed to evaluate injury interventions. Model TBI centers support traumatic brain injury data collection efforts and are using other state data collection systems.

The Rocky Mountain Regional Brain Injury Center at the Colorado Rehabilitation Services has developed a TBI surveillance system to serve as a model to other states in Region VIII. Data from this system will drive the prevention activities. A contract with the Colorado Department of Health has provided for the development of this TBI surveillance system. Materials are being disseminated by the Rocky Mountain Center through its Prevention Advisory Committee which has representation from the six states in Region VIII (Colorado, Montana, New Mexico, North Dakota, Utah, and Wyoming).

Step 2. Select Target Injuries and Population. Injury data are used to determine how to utilize time and money most effectively to prevent brain injuries. Analysis of data defines a target population and mechanism of injury to be addressed. If one community's leading cause of brain injuries as falls, the age group and the physical environment must be determined as well. Prevention TBI's secondary to falls of elderly people in their homes is quite different than preventing TBI's of children who fall off of their bicycles. Thus, prevention programs must be age and cultural specific. Interventions which target young children, adolescents, and young adults are most common because of the high incidence of TBI's in these age groups.

The Rocky Mountain Center has produced and distributed posters throughout the region to encourage children to wear bicycle helmets. Recognizing that today's youth are influenced by athletes, the posters feature Olympic medal recipients and a player from the Denver Broncos.

Step 3. Determine Intervention Strategies. because it has been determined that a combination of educational, legislative, and technological interventions can prevent injuries most effectively, all model head injury centers are involved in a combination of the three strategies.

All of the RSA Regional Head Injury Centers are affiliated with THINK FIRST, the National Head and Spinal Cord Injury Prevention Program which aims to reduce the incidence of traumatic brain injury and spinal cord injury. The THINK FIRST model is an initiative of the American Association of Neurological Surgeons and Congress of Neurosurgeons (AANS/CNS) which has been developed to address the injury problem using four components:

1. Basic Education: Presentation in schools

2. Reinforcement: Followup activities

3. General Public Education: Communitywide safety programming and

4. Public Policy Initiatives: Addressing injury prevention issues.

THINK FIRST is a program which fosters a multifaceted approach and can easily be modified to address the injury problems in various localities.

The educational curriculum of THINK FIRST is a strong component of the program and is designed for adolescents--the age group at high risk for traumatic injury. THINK FIRST curriculum addresses the consequences of risk-taking behaviors while encouraging students to examine their own vulnerability. Key to this program is a young adult or adolescent who shares with students his/her personnel experiences about dramatic life changes and disability caused by injury.

Additionally, all Regional Head Injury Centers participate and facilitate participation in the National SAFE KIDS Campaign. National SAFE KIDS Campaign is a national model of a multidisciplinary approach to prevent all unintentional childhood injuries. The five leading causes of unintentional childhood injury are motor vehicle collisions (passenger, pedestrian, and bicyclist) drowning, burns, falls, and choking/poisoning. Motor vehicle collisions and falls are also leading causes of traumatic brain injury for children. Local and state coalitions of SAFE KIDS are working to raise awareness of childhood injury, educate adults about injury prevention, and support public policy that regulates consumer products and the environment.

Step 4. Develop an Implementation Plan. While model head injury centers develop plans for program implementation in their region, it is imperative that model centers facilitate collaboration with states that have already developed plans and activities. They can assist in developing methodologies to accomplish goals and objectives and identify resources needed to carry out the plans. The Southwest Regional Brain Injury Rehabilitation and Prevention Center established at TIRR provides technical advice and facilitates prevention activities throughout Region VI (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas). Resources are also provided through Instructional Institute courses offered by Southwest Center.

Step 5. Identify, Select, and Commit Community Agencies and Individuals to Implement Plans. Multidisciplinary approaches to injury control have proven to be necessary and successful. Model head injury centers collaborate and contract with agencies and organizations that can effectively implement interventions to reduce brain injuries. While model centers are able to provide technical assistance with projects, they benefit from collaborating with various agencies which offer additional expertise which can enhance their efforts. Such disciplines include public health, departments of transportation, safety advocates, civic organizations, businesses, retailers, engineers, legislative groups, state chapters of the National Head Injury Foundation, public officials, the media, consumer groups, and healthcare professionals. The Ohio Valley Center designated at Ohio State University/Columbus will promote NHIF state the chapters' involvement in the "Partners in Prevention" model project in Indiana, Virginia, and West Virginia. This collaborative approach ensures state-of-the-art interventions, and prevents duplicaation of efforts, or "reinventing the wheel."

Another benefit to a multiagency approach to injury control can be the institutionalization of programs. This insures that programs maintain themselves after initial "seed funds" expire. For example, the Head Strong Coalition and the Colorado Department of Health are working with area school districts to encourage integration of head injury prevention into standard health education curriculum.

Step 6. Develop Protocols and Materials. New materials are being developed by model head injury centers in addition to replicating and disseminating already established curriculums and written materials.

In addition to videos, manuals, and posters already mentioned, the Southwestern Center is developing a step-by-step guide for regional bicycle helmet promotion and developing coalitions around bicycle clubs. Also, they are developing a driving while intoxicated (DWI) awareness program which will include a curriculum to be delivered by emegency medical technicians regarding alcohol and driving. The curriculum will include audiovisual materials and will be targeted toward high school students.

Step 7. Orient and Train Agencies/Individuals Implementing the Intervention Plan. Model head injury centers collaborated with and/or train staff from appropriate agencies to implement various types of interventions. For example, the Rocky Mountain Regional Brain Injury Center has trained peace officers (the umbrella term for all law enforcement officers). Peace officers are often the first responders at car, bicycle, and motorcycle crashes and on domestic calls where child abuse or a battering incident has occurred. Since they are responsible for law enforcement of drunk driving, car safety restraint, and motorcycle helmet laws, the curriculum stresses aggressive enforcement of laws which could ultimately prevent brain injuries. The importance of reducing the period of time between the onset of an injury and the commencement of definitive medical care is stressed. Peace officers from all seven states are being trained about the importance of prevention of TBI for themselves and the general public. Dave Roberts, a medically retired Denver Police Officer who received a penetration brain injury while making an arrest is the co-facilitator for all law enforcement training in the region.

Another training focus of the Midwest Regional Head Injury Center for Rehabilitation and Prevention is to train staff from other organizations wishing to become affiliate members of THINK FIRST, the National Head and Spinal Cord Injury Prevention Program. Training staff of other organizations enables them to replicate THINK FIRST in their own communities, thus increasing the number of THINK FIRST programs available to Region V (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin). The Midwest Center works closely with the National THINK FIRST Foundation to identify and refer organizations from all states for a THINK FIRST training session at any one of several designated model training sites.

Step 8. Implement the Program. It is imperative to have a strong implementation plan for each community intervention. Feedback from all the programs should be used to further refine the intervention.

Step 9. Monitor and Support the Program. Model centers are not only involved in starting up injury prevention projects, but they are involved in monitoring and supporting programs that are active in their region. Model centers strive to stay a breast of TBI injury prevention initiatives being implemented throughout the region. Frequent communication with states and other agencies is critical.

The Midwest Regional Head Injury Center for Rehabilitation and Prevention has conducted an inventory of existing brain injury prevention programs and initiatives in Region V. A survey was distributed to target organizations in the six-state area. The goal is to publish and disseminate a directory of brain injury prevention programs to serve as a tool for organizations desiring to get involved in injury prevention activities and also for established prevention programs who wish to collaborate with other active organizations.

Additionally, the Southwestern Center at TIRR has drafted a regional directory of brain injury prevention programs and resources. The newly designated Southeastern Center at the University of Alabama-Birmingham plans to make regional brain injury prevention program information available on a computer-based electronic directory. Pathways for publicizing the Southeastern directory regionwide will be explored with the Centers for Disease Control (CDC) and representatives of other federal and state agencies. The Southeast Region IV includes Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee.

Another innovative approach to supporting brain injury prevention is the Rocky Mountain Center's letter-writing campaign. Positive letters of reinforcement are sent to companies which have promoted the importance of safety belts, helmets, and child safety seats. Similarly, missed opportunities to promote positive and safe behaviors are noted with a letter to the retailer or media to help them recognize opportunities to promote safe behaviors in future and advertising.

Step 10. Evaluate and Revise the Program. It is critical to evaluate injury prevention initiatives to determine their effectiveness. Model centers are concerned with outcome evaluation and process evaluation. Outcome evaluation measures the final outcome which is hopefully a reduction in brain injury. Unfortunately, outcomes may not be immediately apparent or measurable secondary to limited data on the incidence of brain injury. However, because data is limited, outcome evaluations, need to be generated in terms of measuring changes in knowledge, attitudes, and behavior of the targeted population.

Evaluative research, such as using scientific methods and designs to confirm an experimental model and measure the effectiveness of injury prevention programs, is quite meaningful, though not all organizations have the resources to do such research. Model centers can be used as resources to link prevention programs with a university or regional injury prevention center.

One such effort involves the collaboration between the Midwest Center, the Southwest Center, and the National THINK FIRST Foundation. Building upon previous works of several THINK FIRST programs, an evaluation tool for THINK FIRST will be piloted during 1993. The evaluation tool is a written survey that adolescents will complete before and after the THINK FIRST presentation to measure knowledge, attitude, and behavior changes. The survey toll will be refined and disseminated by the THINK FIRST Foundation to local THINK FIRST programs allowing broad collection and analysis of evaluation data. This effort endeavors to further document the quality and effectiveness of the THINK FIRST program.

All model centers conduct process evaluation to track methods and activities and examine whether objectives and goals are being met. Process evaluation may be as simple as documenting the number of programs conducted, the numbers of persons reached, the numbers of helmets distributed, etc. These data can be used to measure a program's progress and modify its activities.

Striving Together

Recognizing the unique needs of each region, the RSA Regional Head Injury Centers have developed plans and prioritized their activities of facilitate reduction of brain injuries effectively in their own regions. While each region, state, and locality reflects different resources, it is a combination of these resources which have led to successful initiatives, some of which have been described in this article.

It is important to remember that the injury prevention model is a systems approach. Collaboration and flexibility are key. By following a solid theoretical base to control injury, the serious consequences of TBI can be reduced, saving lives and saving dollars.


[1.] Bernard, B. (1986). Characteristic of effective prevention programs; Prevention Forum.

[2.] Committee on Trauma Research, Commission of Life Sciences, National Research Council and the Institute of Medicine. (1985). Injury in America: A continuing public health problem. Washington D.C.: National Academy Press.

[3.] Frankowski, R.F., Annegers, J.F., & Whiteman, S. (1985). The descriptive epidemiology of head injury in the United States.

[4.] Harborview Injury Prevention Research Center. (1991). Injury prevention: You can do it. A community guide for injury prevention.

[5.] National Committee for Injury Prevention and Control. (1989). Injury prevention: Meeting the challenge. Washington D.C.: National Academy of Science.

[6.] Rice, D.P., MacKenzie, E.J., & Associates. (1989). Cost of injury in the United States: A report to Congress. San Francisco, CA: Institute for Health and Aging, University of California, and Injury Prevention Center, The Johns Hopkins University.
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Article Details
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Title Annotation:care of traumatic brain injury
Author:Sells, Julie A.
Publication:American Rehabilitation
Date:Jun 22, 1993
Previous Article:Introduction to the RSA regional brain injury centers.
Next Article:Traumatic brain injury: a public policy analysis from a state perspective.

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