Injury Surveillance Course Draft Outline

Contents

General Comments 2

Course Introduction – 1 hour 3

Objective I: Understand the Conceptual Model of Injury Prevention – 1 hour 4

Objective 2: Identify and Assess Existing Data Sources – 4 hours 9

Objective 3: Build a Coalition or Committee to Support the Injury Surveillance System – 1 hour 16

Objective 4: Determine the Appropriate Methodology for the SS – 3.5 hours 19

Objective 5: Define and Develop and Analysis Plan for Sureillance Data – 4 hours 28

Objective 6: Use Surveillance Data to Inform Injury Prevention – 5.5 hours 36

Objective 7: Define an Evaluation Plan for the SS and Monitor Prevention Activities – 1.5 hour 40

Injury Surveillance Course -- Draft Outline

General Comments

1. This is an outline for a course manual. All the other materials – presentation, handouts, exercises – will be based on this.

2. The Objective for each section you are reviewing can be found in the header

3. These outlines have been edited to reflect the changes suggested in the previous review by each of the smaller workgroups

4. Please review this outline for the following

Flow of each objective
Flow of the course in general
Any content that is missing
Any content that is repetitive

5. It was suggested that the San Carlos Apache Motor Vehicle Injury Prevention Program could serve as an example of a successful surveillance system and could be woven throughout the course to illustrate many of the points made in the course. I have tried to weave information from the program into various spots in the outline, but please feel free to suggest a more appropriate spot for the information if you feel it is misplaced or to suggest other places where information from the program would serve as an example. Another approach would be to detail the entire SC program in the appendix and make reference to it as appropriate. Below are links to information about the program.

PowerPoint presentation about the San Carlos Apache Motor Vehicle Prevention Program

Using Evidence Based Strategies to Reduce Motor Vehicle Related Injuries on San Carlos

Economic Costs of Motor Vehicle Crashes and Economic Benefit of Prevention for San Carlos

MADD Nomination Letter

6. The time estimates for each objective are based on the time allotted for each objective plus in the CDC course plus extra time for exercises. They do not reflect the fact that additional material has been added to the course from IHS Level 2, but in some cases that material was used to replace materials in the manual. Please feel free to suggest changes to the timeframe based on your experience with teaching or taking the Level 2 Course. Total time for the course, based on the estimates here is 21.5 hours. A 3-day course, based on 6 hours of teaching time each day, would be 18 hours.

7. We will review the outline on January 10, 2013, 1-2:30 p.m. EST via WebEx.

MEETING REVIEW OUTLINE: January 10, 2013 is

Injury Surveillance Course -- Draft Outline

Course Introduction

Course Introduction – 1 hour

1. What is a surveillance system

Gather thoughts from participants as part of an ice-breaker
Define surveillance system

c. Show examples of surveillance systems used in Indian Country, including the San Carlos Apache surveillance system, which should be woven throughout the course when appropriate.

2. Explain the purpose of the course

3. Explain the process for creating the course

4. General outline for the course – list of objectives

5. Agenda including timeframe for covering each objective

6. Other information …

Instructor’s guide will include a list of materials within the manual or other course materials that need to be updated
Instructor’s guide will a guide to time frame for each exercise so he or she can decide whether it should be included or not
Instructor’s guide will include a list of any additional materials or equipment that may be needed, such as AV, paper, post-its, flip charts, etc.
Other information that will be helpful for instructors …

Injury Surveillance Course -- Draft Outline

Objective 1-Understand the Conceptual Model of Injury Prevention

Objective I – 1 hour

Understand the conceptual model of injury prevention

· Understand the concepts, definitions, and classification of injuries

· Know the differences between violence related injury and unintentional injury

· Describe the burden and cost of injuries

· Know the conceptual models for understanding and preventing injuries

· Know the steps to develop an injury surveillance system

· Review the ethical considerations

Introduction
Description of what the section covers
Review of key concepts
Definition of injury
Magnitude of injury problem in Indian Country
Conceptual Model for understanding and preventing injury
Steps to develop and maintain an injury surveillance system
Ethical considerations
Injury definition
Damage inflicted on the body by an external force. Uncontrolled release of mechanical energy
About three fourths of all injuries, including motor vehicle crashes, are caused by uncontrolled release of mechanical energy
Injury vs. Disease
Some experts think that an injury is distinguished by immediate damage to the body from an external force.
Others think that the interval between the exposure and the damage can be relatively long, such as in poisoning from carbon monoxide, alcohol abuse or lead poisoning.
Chart – Injury vs. Disease modified to include Indian Country examples
Injury vs. Accident
Experts believe the widespread use of the word “accident” in place of injury has caused confusion and inhibits efforts to reduce injuries. Injuries are not accidents.
They do not happen by chance. For many people, an accident is something unpredictable. Actually events that injure people are not random and have identifiable risk factors.
Injuries are caused by events that involve people, equipment, vehicles, processes, and the physical and social environment. Avoid the use of the word “accident” when referring to injuries.
NOTE: 1 and 2 can be pared down.
Injury Classification
Unintentional injuries
Physical damage to the body
Occur without the intent of anyone involved, it’s not deliberate
Can be caused by excessive force to the body, as in an auto accident or a fall or when the body is deprived of something essential, such as air, as in drowning or smoke inhalation.
Mechanisms of unintentional injury – the source of the energy that causes an injury
An impact with a moving or stationary object (mechanical)
Ultraviolet radiation (Radiant)
Air or water that is too hot or too cold (Thermal)
Electrical
Chemical
Unintentional Injuries Chart
Draw comparisons based on ethnicity using WISCARS data
The Mechanism of Unintentional Injury
Place of Occurrence
Intentional Injuries/Violence-related
Occur because of a person’s deliberate actions to harm another person, oneself or a group of people
Can be divided into categories based on the person who commits the violence and the nature of the violence
Specific types of violence based on person who commits the violence
Self-directed – suicidal behavior, self-abuse
Interpersonal violence inflicted by one person or a small group on another
Collective violence is committed by governments or organized groups
The nature of violent acts
Physical
Sexual
Psychological
Deprivation or neglect
Paragraph on impact of violence in Indian Country
Injury Pyramid from IHS (Burden of Injury: United States 2002, NCHS)
Deaths: 161,269
Hospital Discharges: 1,835,713
Emergency Department Visits: 32,981,000
Outpatient and Physician Office Visits: 82,343,000
The Cost of Injuries
Physical
Unintentional injuries are the leading cause of death for AI/AN ages 1-44 (47.1%)
Much higher than those of the general population, in some cases, 2 to 3 times higher
Financial
Nationally injuries cost $224 Billion annually, including direct medical care, rehabilitation costs, and the cost of lost wages and productivity (Source: CDC, National Center for Injury Prevention)
Who Pays
Private Sources, such as insurance pay about 72% of cost ($161 Billion)
Public Sources, such as state, local and federal government pay about 28% ($63 Billion)
The federal share of the $63 Billion is about $12.6 Billion annually in medical costs and $18.4 Billion in disability and death benefits
Injury Costs for American Indian and Alaska Native Communities for year 200 was $2.1 Billion. Each year more than $2 billion is withdrawn from health care and economic development resources that would have been available had the injury not occurred.
Chart –Lifetime Costs of AI/AN Injuries according to 2000 data ($ millions) other statistical information. From: Piland, Neil F. and Lawrence R. Burger. “The Economic Burden of Injuries Involving American Indians and Alaska Natives: A Critical Need for Prevention.” IHS Primary Care Provider 32.9 (September 2007) 269-271.
Emotional

d. Example: Economic impact of motor vehicle crashes for the San Carlos Apache Tribe

Financial Benefits of Injury Prevention
Brief introduction to benefits of injury prevention
Interventions that Save Money Bulleted list to include the following
DUI Laws
Personal Floatation Devices
Smoke Detectors
Gun Locks
Bike Helmets
Seat Belts
Livestock Control
Others

c. How Intervention benefited the San Carlos Apache

Cost Outcome Analysis of Interventions – information to be taken from Cost/Outcomes Analysis of Intervention updated in 2010
Conceptual Models for Understanding and Preventing Injury
The Public Health Approach to Injury Prevention using the Medicine Wheel as a Model, pictured above.
Define the Problem through surveillance
Identify the Risk Factors – who and/or what
Find out what works to prevent the problem
Implement and Evaluate Prevention Programs
Brief Review of the Epidemiological Triad in the development of disease – host, agent, and environment and how William Haddon applied it to unintentional injuries. The Haddon Matrix and Haddon Counter Measures

c. Brief review of the Ecological Model to address the violence prevention using graph below

Figure 5. Ecological Model for Understanding Violence

Societal Community Relationship Individual

Source: Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World Report on Violence and Health. Geneva: World

Health Organization; 2002.

Development of a Surveillance System
Brief introduction
Introduce the 7-step plan which incorporates the IHS 10-step plan from level 2 and models the flow of the course .
Understand the conceptual model of injury prevention
Identify existing data sources, determine the strengths and weaknesses of those data sources, consider linkage with other data sources, describe injury problem with preliminary data analysis.
Build a coalition or committee to support the injury surveillance system, data collection and prevention activities
Determine the appropriate methodology for the surveillance system, define objectives, perform validation studies, re-evaluate objectives as needed.
Define and develop an analysis plan for the surveillance data, develop a plan for disseminating analysis results
Use injury surveillance data to inform injury prevention, tie surveillance to action and funding
Define an evaluation plan for the surveillance system and monitor prevention activities. Reevaluate objectives/system.
Mention that each step will be addressed in detail later in the course/manual
Ethical considerations
Confidentiality
Privacy – small communities make it possible to identify people even when precautions have been taken.
Brief mention of HIPAA, which will be covered later
Process of obtaining data and procedures for using data from tribes may be different from other governments or organizations. May differ from tribe to tribe.
Summary: Now that you’ve completed this objective you should:
Understand the concepts, definitions, and classification of injuries
Know the differences between violence related injury and unintentional injury
Describe the burden and cost of injuries
Know the conceptual models for understanding and preventing injuries
Know the steps to develop an injury surveillance system
Review the ethical consideration

Injury Surveillance Course -- Draft Outline

Objective 2 – Identify and assess data sources, consider linkage and describe injury problem

Objective 2 – 4 hours

Identify and assess existing data sources, consider linkage with other data sources, and describe injury problem with preliminary data analysis.

· Identify the injury data sources strength and weaknesses

· Identify the available data sources that can provide information to the surveillance system

· Describe the size of the injury problem

· Compare the frequency of injuries calculated with data from different sources

Introduction
Overview of data sources in an injury surveillance system
Death certificates
Police reports
Reports on occupational injuries
Local newspaper accounts
Linked Databases
Useful, but difficult to do. It would be ideal if you could validate the data, but just getting data in the first place is hard enough. This is a case where you have to let the ideal give way to the reality
May be Costly
May have Limited access
Technical difficulties
Determining the Strengths and Weaknesses of a Database
Judging Strengths and weaknesses
Usefulness for injury surveillance, research and practice
Estimate the accuracy, completeness and representativeness
Timeliness
Resource and Requirements
Simplicity
Data Collection Strategy Exercise – 15 minutes
Imagine you have recently learned the state health department has an injury hospitalization database. You have a meeting with the lead epidemiologist to learn more about this database and whether or not it might help you in your surveillance effort. What questions would you ask to determine the strengths or weaknesses of this database? Keep the above considerations in mind. Debrief by writing the questions down and discussing.
Questions to Consider – possible answers for exercise above. This will be in the appendix
What is the quality of data?
Are the data computerized or must they be manipulated manually?
What period of time do the records span?
How often are data collected: annually, monthly, continuously, periodically?
Are the data disseminated regularly?
How are data disseminated?
Are the data available on the internet or CD-ROM?
What is the most recent year of available data?
Is there a report available with the latest results?
Is reporting of data voluntary?
How complete is the data?
How much time is there between the date of the injury and its availability for surveillance purpose?
Is there a code book that defines variables and coding of variables?
Are analyses available on request?
Can custom tabulation be done?
Is access to original documents possible?
Are there any restrictions on access to records?
Is a memorandum of understanding required for access?
Is there a fee for the data?
To what level of geographic specificity are the data available: national, regional, state, county, city, census tract, zip code?
What type of data is obtained: mortality, morbidity, incidence, prevalence, nature of injury, severity of injury, body region affected, treatment, length of hospitalization, level of impairment or disability, expected source of payment, cost/charge information, surgical and medical procedures performed?
What demographic information is available: age (actual years or group categories), date of birth, sex, race, ethnicity, marital status, occupation, industry, education, income, place of residence? When is information collected?
What data are available on the circumstances surrounding the injury event: date of injury, time of injury, place of occurrence (home, school, work), intent, product involved, type of weapon involved, and external cause of injury code?
What activities were associated with the injury: sports, work, day care, boating, home, recreation, farm, domestic violence, child neglect or abuse?
Is a narrative description available?
Area data included on contributing behaviors: seatbelt use, airbag installation, smoke detector installation, drug and alcohol involvement, riding with a drinking driver, bicycle helmet use, motorcycle helmet use, protective equipment for sports, unsupervised swimming, swimming pool fencing, swimming ability, firearm storage, weapons carrying, physical fighting, mental health treatment, previous suicide attempt?
What other barriers are there to the use of these data?
What is the quality of the data
Graphic of common data sources for a fatal injury surveillance system in Indian Country
Forensic Medicine
Transportation office
BIA Law Enforcement
Transportation Office
EMS
District Attorney
Police
Tribal Resources: registry, burial fund registry, enrollment records
Describe Data Collection Method and Data Flow
Data Collection Methods
Record Abstraction
Surveys
Personal Interviews
Focus Groups
General information to include
General description of data flow when a death occurs every state different
Three types of death certificate data
Death Certificate may be available within 30 days
Preliminary electronic data
Final death certificate data – clean and fully coded may take up to a year or more
Process for investigating an injury death in IC. Open it up to the class for discussion because every tribe is different. Include a paragraph or two about some general investigative practices.
Identify Data Sources to Include in a Surveillance System
Take advantage of existing data sources. There may be some limitations depending on the intent of the data collection, but almost all data sources have limitations. Existing data sources can save you time and resources.
Injury events determine which data sources are necessary to provide information.
Table: Possible Data Sources in an Injury Surveillance System – these entities may have data at the national, state or local level.
National data provides the big picture in the US and may be in the states. Generally not sufficient for community program development.
State and local data more likely to reflect a local injury problem. Problems: not always computerized, lag time, race not always specified.
WISQARS a source of data, allows mapping, etc. – more explanation needed, sum this up in a paragraph or two. Fully explain what WISQARS is, what information is available, and mention new features and tutorial that is being developed.
Data Source Matrix for IC – needs to be developed