American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Characteristics of intentional fall injuries in the ED☆ Jae Hoon Choi, MD a, Sun Hyu Kim, MD a,⁎, Sun Pyo Kim, MD b, Koo Young Jung, MD c, Ji Yeong Ryu, MD d, Sang Cheon Choi, MD e, In Cheol Park, MD f a
Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan 682-714, Republic of Korea Department of Emergency Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea Department of Emergency Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea d Department of Emergency Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea e Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea f Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea b c
a r t i c l e
i n f o
Article history: Received 18 December 2013 Received in revised form 27 January 2014 Accepted 28 January 2014 Available online xxxx
a b s t r a c t Introduction: This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis. Methods: The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups. Results: The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height. Conclusion: The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury. © 2014 Elsevier Inc. All rights reserved.
1. Introduction The death rate from injury per 100 000 people in South Korea was 64.7 in 2011. Injury-related deaths were the third most common cause of death followed by cancer and circulatory disease. Suiciderelated death was 31.7, approximately half of the total injury-related deaths [1]. The suicide rate in South Korea was 33.3 per 100 000 persons in 2011 according to statistics from the Organization for Economic Cooperation and Development Social in 2011; this was the highest among Organization for Economic Cooperation and Development countries [2]. The government has been interested in preventing injury-related deaths and suicide because injury-related deaths, including suicide, are the most frequent cause of death among people younger than 40 years. Falls from a height were the main cause of injury-related deaths, followed by traffic accidents excluding suicide attempts; the ☆ Conflict of interest statement: All the authors declare no conflict of interest with this study and are only responsible for this manuscript. ⁎ Corresponding author. Tel.: +82 52 250 8405; fax: +82 52 250 8071. E-mail address: [email protected] (S.H. Kim).
leading methods of suicide in South Korea are falls from a height, suffocation, and poisoning [3]. Traffic accident–related deaths have been on the decline in South Korea; however, deaths due to falls from a height have been increasing regardless of whether the falls were unintentional or intentional [3]. Although falls from a height occurred at lower frequency compared with the other mechanisms of injury, the risk of death was higher for falls from a height than for any other mechanism. Therefore, this injury mechanism, which has been on the rise and has a high risk of accidental or suicide-related death, requires consistent attention. Several studies have discussed about general injury–related deaths, general unintentional injury–related deaths, and intentional injury–related deaths [3-6]. In addition, some studies have investigated patients with intentional or unintentional injuries from a fall from a height, at a single-institute research [7,8]. However, there has been no study that included all the patients presented to an emergency department (ED) with intentional or unintentional fallrelated injuries. This study was undertaken to examine the characteristics of intentional fall injuries compared with unintentional fall injures and to determine the factors associated with the prognosis of intentional
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2014.01.053
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
2
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
fall injuries at an ED with the goal of promoting the prevention, intervention, and treatment of intentional fall injuries.
2. Materials and methods Data from an in-depth surveillance study of injuries in the ED conducted by the Korea Center for Disease Control and Prevention (KCDC) were retrospectively reviewed from January 2007 to December 2010. The ED injury study by the KCDC started at 5 hospitals in 2006 and was extended to 20 hospitals in 2010. All the hospitals that participated in the surveillance program gathered general information for all types of injuries, and each collected indepth injury information for 1 of the following 4 categories: (1) traffic accidents; (2) head and neck injury; (3) injury involving preschoolaged children; and (4) suicide, poisoning, falls (including falls from height), and injuries due to slipping. These categories were surveyed at individual hospitals. In-depth surveillance for falls from a height and suicide began at 2 hospitals in 2007 and was extended to 6 hospitals in 2010. A total of 9136 subjects who were admitted to the ED after a fall from a height were included; 57 patients were excluded because their intent at the time of the injury was not known. There were 8992 patients admitted after an unintentional fall from a height (called the nonintentional group) and 144 who were admitted after an intentional fall from a height patients (called the intentional group) (Fig.). Approximately 30 000 to 90 000 ED patients were admitted annually to the study hospitals, and injured patients made up approximately 20% of all ED patients. Fall from a height made up approximately 5% of all injuries. This study was approved by the relevant institutional review boards. General characteristics of the subjects, including age, sex, season of injury occurrence, time of injury occurrence, place of injury occurrence, height of fall, activities during the injury occurrence, alcohol ingestion, means of transit to the ED, educational state, and occupation were investigated. Ages were classified using the following groups: 0 to 14, 15 to 29, 30 to 44, 45 to 59, 60 to 74, and 75 years or older, and injury dates were divided into 4 seasons: spring (March to May), summer (June to August), autumn (September to November), and winter (December to February). Time was classified into 4 groups 6 hours in length, and height of the fall was divided into 3 groups: less than 1, 1 to 4, and 4 m or higher. Activities in progress during injury occurrence, including work, unpaid work, educational activities, sports activities, leisure activities, daily activities (such as showering, shaving, and other activities), were noted. Work was defined as economic activities or activities related to occupation as well as unpaid work, including activities at home such as cooking and cleaning. For patients older than 20 years, educational level was classified into 4 groups: elementary school education or less, junior high school, high school, and college or more. Education and occupation were investigated for inpatients only, and some of the
Fig. Selection of study subjects.
data acquired at the ED were also included. Initial blood pressure at the ED (except for deceased patients) was analyzed, and mental state was also investigated and categorized as alert, verbal response, pain response, or unresponsive. The results after ED treatment were noted, including discharge, transfer to another hospital, admission to the general ward, admission to the intensive care unit, death at or before the ED, and emergency operation. Injury severity was classified into 2 groups: severe injury (severe group) and nonsevere injury (nonsevere group). Patients were considered to have a severe injury was if they required emergency surgery, were admitted to the intensive care unit, were transferred to another hospital for specialized care, or were dead on arrival or died within 3 days of being admitted to the hospital [5]. General and clinical characteristics of falls from a height were compared between the intentional and nonintentional groups. Further examination was carried out for the intentional group to determine specific causes of the fall from a height, whether the patient had a previous history of a suicide attempt, whether the patient received psychiatric consultation after a previous suicide attempt, the previous method of suicide attempt, whether the patient had a history of a double suicide attempt (a suicide attempt involving 2 people), whether the place of the fall was familiar to the patient, and the exact height of the fall. We examined the factors associated with severe injury in the intentional group by comparing the severe and nonsevere groups. Age, sex, season, time, place, height of fall, activities during the injury occurrence, alcohol ingestion, means of transit to the ED, education, occupation, previous suicide history, and whether the place was familiar to the patients were compared by univariate analysis. Missing or unknown data were excluded from analysis. We compared the intentional and nonintentional groups for all injuries involving a fall from a height as well as the severe and nonsevere groups in the intentional group, using the χ 2 test, Fisher exact test, and Student t test. Bivariate logistic regression analysis was performed to investigate the factors related to severe injury in the intentional group using the significant factors with P b .05 from the univariate analysis. All statistical analyses were performed using SPSS 19.0 (SPSS, Chicago, IL), and statistical significance was defined as P b .05. 3. Results The mean age was 18 years old in the nonintentional group and 45 years old in the intentional group. Patients younger than 14 years were the most common in the nonintentional group, and most patients in the intentional group were between 30 and 44 years old. Males made up 65% of the nonintentional group and 48% of the intentional group (P = .000). Falls from a height were less common in winter among the nonintentional group and less common in autumn and winter in the intentional group. The time of injury occurrence was more common between 12 and 24 than between 0 and 12 in the nonintentional group; however, all time groups had a similar frequency of more than 20% in the intentional group (P = .000). Residential areas were the most common place of injury occurrence in both groups (60% in the nonintentional group, 80% in the intentional group). A fall height of less than 1 m was most frequent in the unintentional group, making up 62% of unintentional falls; however, a fall height of more than 4 m was most common in the intentional group, making up 83% of the intentional falls (P = .000). Falls occurred most often during daily activities than other activity type in both groups. Work was the other common activity type, involved in 13% of falls in the nonintentional group. Alcohol intake was involved at the time of injury occurrence for 4.1% of patients in the nonintentional group; however, 23% of patients in the intentional group had consumed alcohol (P = .000). Individual transportation to the ED was common means of transit in the nonintentional group, but
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
patients in the intentional group were most commonly transported to the hospital either by a public ambulance (65.5% of patients) or from another hospital (30.6% of patients) (P = .000). High school was the most common educational level for patients 20 years or older in both groups. Employed people made up 69.1% of the nonintentional group, whereas “housewife” and “unemployed” were the most common occupations in the intentional group (Table 1). Alert mental state upon ED arrival was found in 96.9% of patients in the nonintentional group. An unresponsive mental state was the most common in the intentional group, making up 45.4% of the patients. Discharge was the most common result in the nonintentional group; Table 1 General characteristics of intentional and nonintentional fall injuries
Average age, y Age group, years old (%) 0-14 15-29 30-44 45-59 60-74 N75 Sex, male (%) Season of injury occurrence (%) Spring (March-May) Summer (June-August) Autumn (September-November) Winter (December-February) Time of injury occurrence (%) 0-6 o'clock 6-12 o'clock 12-18 o'clock 18-24 o'clock Location of injury occurrence (%) Residential facility Commercial facility Sports facility Transportation area Construction, factory area Educational facility Other outdoor area Height of fall (%) b1 m ≤1 to b4 m ≥4 m Activity during injury occurrence (%) Paid work Unpaid work Education Sports Leisure activity Daily activity Others Alcohol ingestion, n/total n (%) Transportation to ED Public ambulance Individual transportation Other medical facility Others Education (if age ≥20 years old) (%) Uneducated or elementary school Junior high school High school ≥College Occupation (%) Total employed Engineer Office worker Service job Soldier Others Student Housewife Unemployed
Nonintention (n = 8992)
Intention (n = 144)
P
18.1 ± 23.4
44.6 ± 20.0
.000 .000
5902 (65.6) 576 (6.4) 790 (8.8) 1015 (11.3) 511 (5.7) 198 (2.2) 5821 (64.7)
5 (3.5) 32 (22.2) 41 (28.5) 28 (19.4) 24 (16.7) 14 (9.7) 69 (47.9)
2390 (26.6) 2428 (27.0) 2401 (26.7) 1773 (19.7)
49 47 26 22
827 (9.2) 1372 (15.3) 2966 (33.0) 3827 (42.6) n = 8968 5353 (59.7) 708 (7.9) 350 (3.9) 650 (7.2) 855 (9.5) 396 (4.4) 656 (7.3)
40 (27.8) 36 (25.0) 29 (20.1) 39 (27.4) n = 144 115 (79.9) 12 (8.3) 0 (0) 8 (5.6) 0 (0) 1 (0.7) 8 (5.6)
5595 (62.2) 2928 (32.6) 469 (5.2) n = 8939 1135 (12.7) 165 (1.8) 97 (1.1) 220 (2.5) 1401 (15.7) 5731 (64.1) 190 (2.1) 354/8687 (4.1) n = 8990 1352 (15.0) 6020 (67.0) 857 (9.5) 761 (8.5) n = 2045 245 (12.0) 351 (17.2) 1021 (49.9) 428 (20.9) n = 2032 1404 (69.1) 241 (11.9) 182 (9.0) 125 (6.2) 11 (0.5) 845 (41.6) 91 (4.5) 171 (8.4) 366 (18.0)
5 (3.5) 20 (13.9) 119 (82.6) n = 140 0 (0) 2 (1.4) 0 (0) 0 (0) 2 (1.4) 82 (58.6) 54 (38.6) 28/123 (22.8) n = 144 94 (65.3) 4 (2.8) 44 (30.6) 2 (1.4) n = 63 7 (11.1) 12 (19.0) 34 (54.0) 10 (15.9) n = 68 12 (17.6) 3 (4.4) 3 (4.4) 5 (7.4) 1 (1.5) 0 (0) 4 (5.9) 26 (38.2) 26 (38.2)
.000 .018
(34.0) (32.6) (18.1) (15.3) .000
.010
.000
.000
.000 .000
.773
.000
3
77.1% of these patients were discharged. Death before arrival at the ED or during ED treatment, however, occurred for 54.9% of the patients in the intentional group. Emergency operations were performed more often in the intentional group, at 9.0%, than in the nonintentional group, at 2.7% (P = .000). Severe injury occurred in 7.2% and 79.2% of the patients in the nonintentional and intentional groups, respectively (P = .000) (Table 2). The most common reason for intentional fall from a height was depression at 30.6%, and this was followed by conflict with a spouse, other psychiatric problems, medical illness, and conflict with parents. Among patients in the intentional group, 7.4% had a previous history of a suicide attempt, and 44.4 of these patients had received psychiatric treatment after their first suicide attempt. In addition, 2.4% (3/126) of patients in the intentional group had a history of a double suicide attempt. The fall from a height occurred at a place that was familiar to the patient in 85.2% of intentional fall cases. The mean height of intentional falls from a height was 18.4 m (Table 3). Patients were older and the height of the fall was higher in the severe group for the intentional fall patients. The injury occurred in residential facility for 83.2% of patients in the severe group and 66.7% in the nonsevere group. Patients were brought to the ED by public ambulance or from another hospital in 97.4% of cases in the severe group and 90% of cases in the nonsevere group. Of patients in the severe group, 6.4% were college graduates, but 43.8%, in the nonsevere group. A history of a previous suicide attempt was present in 4.1% of patients in the severe group and 26.3% of patients in the nonsevere group (Table 4). Educational status (with high school graduates more likely to sustain a severe injury than college graduates) and greater fall height were factors associated with severe injury in the intentional group (Table 5). 4. Discussion Information collected at the ED is important to the identification of the general characteristics of injuries due to falls from a height because many patients present to the ED after an injury of this type. Therefore, the system of in-depth surveillance of injuries at the ED conducted by the KCDC plays an important role in identifying the characteristics of injuries from falls from a height and provides a significant source of data for the intervention and prevention of fallrelated injury. This study is meaningful because it is the first study conducted at multiple EDs in Korea to distinguish the characteristics of intentional and nonintentional injuries due to falls from a height and to include further analysis of intentional injury due to falls from a height.
Table 2 Clinical characteristics and outcomes of intentional and nonintentional fall injuries
Blood pressure, mm Hg (dead patients excluded) Systolic blood pressure Diastolic blood pressure Consciousness at ED (%) Alert Verbal response Pain response Unresponsive Result of ED treatment (%) Discharge Transfer to other facility Admission to general ward Admission to intensive care unit Death at ED Emergency operation (%) Severe patients (%)
Nonintention (n = 8992)
Intention (n = 144)
n = 3527
n = 58
122.6 ± 23.9 74.1 ± 14.9 n = 6804 6591 (96.9) 86 (1.3) 73 (1.1) 54 (0.8)
112.6 ± 31.1 67.6 ± 21.1 n = 119 43 (36.1) 12 (10.1) 10 (8.4) 54 (45.4)
6933 (77.1) 233 (2.6) 1392 (15.5) 366 (4.1) 68 (0.8) 246 (2.7) 644 (7.2)
15 (10.4) 3 (2.1) 17 (11.8) 30 (20.8) 79 (54.9) 13 (9.0) 114 (79.2)
P
.002 .022 .000
.000
.000 .000
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
4
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Table 3 Details of the intentional fall group
Table 4 General characteristics of intentional fall injuries by injury severity n = 144
Reasons for intentional fall, n (%) Interpersonal conflict Conflict with spouse Conflict with parents Conflict with offspring Conflict with other family members Conflict with friends Conflict with lover Death of parents Medical illness Psychiatric disease Depression Drug intoxication Other psychiatric problem Sexual abuse Work-related stress Financial problems Unemployed Other financial problems Others History of previous suicide attempt, n/total n (%) Intoxication Fall Cut Self-burning Received psychiatric consultation after a previous suicide attempt, n/total n (%) Double suicide with, n/total n (%) Offspring Other people Place of fall Familiar with patients, n/total n (%) Mean height of fall, m
n = 98 36 (36.7) 22 (22.4) 6 (6.1) 3 (3.1) 2 (2.0) 2 (2.0) 1 (1.0) 1 (1.0) 8 (8.2) 40 (40.8) 30 (30.6) 1 (1.0) 9 (9.2) 1 (1.0) 4 (4.1) 5 (5.1) 3 (3.1) 2 (2.0) 3 (3.1) 9/121 (7.4) 3 2 2 2 4/9 (44.4) 3/126 (2.4) 1/126 (0.8) 2/126 (1.6) 109/128 (85.2) 18.4 ± 14.8 (n = 122)
Conflict with family was found to be the most common cause of suicide in previous studies [5,9], and this study showed a similar result, in that conflict with family was involved in 33.7% of intentional fall from a height cases. As in another study, we found that depression was the other major cause; it was involved in 30.6% of cases of intentional fall from a height [10]. Some previous studies have reported that men sustained more severe injuries from suicide attempts by falls from a height than women [11,12]. Multiple studies have also reported that men were at higher risk for death due to nonintentional injury from falls from a height [6,13,14]; however, other studies reported the opposite [3,15]. The severity of injuries due to intentional falls from a height was not found to be different between the sexes in this study. Alcohol consumption has been found to be a potential risk factor for suicide attempts [16]; however, a previous study found that alcohol intake resulted in a less severe outcome in patients attempting suicide [5]. Alcohol intake was more common in the intentional group than the nonintentional group in this study. Within the intentional group, however, alcohol intake was not significantly different between the severe and nonsevere injury groups; in the severe group, 20% of patients had consumed alcohol, and in the nonsevere group, 31% had. A lower educational level had been found to be associated with a higher suicide rate in a previous study [17]. In the intentional group in the present study, 15.9% of the patients had educational levels of college graduation or above, whereas 54.0% were high school graduates only. High school graduates were also at higher risk for severe injury compared with college graduates in the intentional group in this study. The outcomes of cases falls from a height were influenced by several factors including fall height, age, impact area of the body, and the material of the impact floor. Old age has been reported as a risk factor associated with a poor prognosis in patients who attempted suicide [5,18-21] and as a factor associated with mortality after injury from a fall from a height [22,23]. The average patient age was older in
Age, y Group of age, years old, (%) 0-14 15-29 30-44 45-59 60-74 N75 Sex, male (%) Season of injury occurrence (%) Spring (March-May) Summer (June-August) Fall (September-November) Winter (December-February) Time of injury occurrence (%) 0-6 o'clock 6-12 o'clock 12-18 o'clock 18-24 o'clock Location of injury occurrence (%) Residential facility Commercial facility Transportation area Education facility Other outdoor area Height of fall, m Height of fall (%) b1 m ≤1 to b4 m ≥4 m Activity during injury occurrence (%) Unpaid work Leisure activity Daily activity Others Alcohol ingestion, n/total n (%) Transportation to ED Public ambulance Other medical facility Individual transportation Others Education (if age ≥20 years old) (%) Uneducated or elementary school Junior high school High school ≥College Occupation (%) Workers Student Housewife Unemployed Previous suicide attempt, n/total n (%) Place of fall Familiar with patients, n/total n (%)
Severe (n = 114)
Nonsevere (n = 30)
P
46.5 ± 21.0
37.4 ± 14.2
.007 .083
4 (3.5) 25 (21.9) 29 (25.4) 20 (17.5) 22 (19.3) 14 (12.3) 58 (50.9)
1 (3.3) 7 (23.3) 12 (40.0) 8 (26.7) 2 (6.7) 0 (0) 11 (36.7)
44 35 20 15
(38.6) (30.7) (17.5) (13.2)
5 (16.7) 12 (40.0) 6 (20.0) 7 (23.3)
29 32 23 30
(25.4) (28.1) (20.2) (26.3)
11 (36.7) 4 (13.3) 6 (20.0) 9 (30.0)
95 (83.2) 10 (8.8) 6 (5.3) 0 (0) 3 (7.3) n = 100 20.7 ± 14.2
20 (66.7) 2 (6.7) 2 (6.7) 1 (3.3) 8 (5.6) n = 22 8.0 ± 10.0
1 (0.9) 10 (8.8) 103 (90.4) n = 110 2 (1.8) 1 (0.9) 64 (58.2) 43 (39.1) 19/94 (20.2)
4 (13.3) 10 (33.3) 16 (53.3) n = 30 0 (0) 1 (3.3) 18 (60.0) 11 (36.7) 9/29 (31.0)
71 (62.3) 40 (35.1) 2 (1.8) 1 (0.9) n = 47 6 (12.8) 11 (23.4) 27 (57.4) 3 (6.4) n = 62 10 (16.1) 14 (22.6) 16 (25.8) 22 (35.5) 4/97 (4.1)
23 (76.7) 4 (13.3) 2 (6.7) 1 (3.3) n = 16 1 (6.3) 1 (6.3) 7 (43.8) 7 (43.8) n = 21 2 (9.5) 5 (23.8) 10 (47.6) 4 (19.0) 5/19 (26.3)
91/105 (86.7)
18/23 (78.3)
.218 .102
.336
.000
.000 .000
.733
.310 .026
.007
.268
.006 .334
the severe group within the intentional group in this study. Previous studies have found that prognosis was poorer when the height of the fall was higher [23,24] and that the pattern of injury depended on the height of the fall [25]. However, it was also found to be possible for low falls to lead to severe outcomes [26]. In our study, the height of the fall was higher, and the prognosis was poorer in the intentional Table 5 Factors associated with severe injury for intentional falls
High school, education vs college or above Height of fall
Odds ratio
95% confidence interval
P
8.829
1.196-65.182
.033
1.240
1.019-1.508
.032
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
group than in the nonintentional group. In the intentional group, the average height of the fall was 20.7 m in the severe group and 8 m in the nonsevere group. The height of the fall was found to be related to the chance of severe injury in the regression analysis. A previous study found that the prognosis of a fall from a greater height was poor regardless of age [27]. Although injury-related deaths as a whole have decreased in Korea, nonintentional fall injuries in elderly people and intentional fall injuries in adolescents are increasing [3]. The observation that the occurrence of fall-related injuries increases with age was confirmed in another study [28]. Preventive efforts, such as enforcement of legislation and the introduction of effective safety equipment and safety programs, have decreased traffic accident–related deaths [13], but preventive activities targeted toward deaths related to falls from a height have been less effective. Deaths by suicide have been decreasing in some countries [29,30] and increasing in others [31]. The suicide rate in Korea has more than tripled over the last 2 decades [1]. The most common method of suicide varies by country and may involve firearms, hanging, suffocation, poisoning, charcoal burning, or falling from a height according to the characteristics of the country [32-35]. The leading methods of suicide in Korea in 2011 were suffocation, poisoning, and falling from a height [3,36]. Injury related to a fall from a height has a poorer prognosis than all other injury mechanisms, and the prognosis of intentional injury was poorer than that of nonintentional injury because intentional injury has a higher proportion of injuries related to falls from a height [22]. The combined rate of patients reported dead on arrival and of death at the ED was only 0.8% in the nonintentional group, but it was 54.9% in the intentional group in this study. The major limitation of this study was that the number of intentional fall cases might be underestimated because patients or their guardians tend to claim that injuries were accidental rather than intentional. Patients or their guardians may hide intentional injury because, in principle, the medical costs of an intentional injury are not covered by the national health insurance scheme in Korea, and patients with an intentional injury must, therefore, pay the hospital bill themselves. Moreover, the occurrence of a previous history of a suicide attempt and psychiatric consultation after a suicide attempt in the intentional group surveyed in this study might be underestimated because many patients tend to refuse to talk about their mental health history and to hide previous psychiatric symptoms. Another limitation was that, in intentional fall group, the relation between the reason for attempting suicide by patient age and severity of injury could not be sufficiently evaluated due to the small size of the group.
5. Conclusion The number of females, height of the fall, and occurrence of alcohol consumption were all higher in the intentional group than in the nonintentional group, and prognosis was poorer in the intentional group. The average age was older, and the height of the fall was higher in the severe group than the nonsevere group among intentional fall injuries. In the intentional group, the risk of severe injury increased with higher height, and patients with a high school level of education sustained more severe injuries compared with college graduates. Because intentional fall injuries have a high risk for a severe outcome, considerable effort should be devoted to preventing that type of injury. Preventative efforts including telephone counseling and installing signs advising against suicide in risky areas for intentional falls (such as bridges) have been undertaken. More importantly, the government is supporting efforts to improve the social environment to reduce intentional fall with the help of the community, the workplace, educational facilities, and the family.
5
Acknowledgments The authors are grateful to the KCDC for supporting the registry financially and providing data. References [1] Korea National Statistical Office. National statistics report 2011. Daejeon: Korea National Statistical Office; 2012. [2] OECD. OECD health data 2011: statistics and indicators for 34 countries. Paris: Organization for Economic Cooperation and Development; 2012. [3] Hong J, Lee WK, Park H. Change in causes of injury-related deaths in South Korea, 1996-2006. J Epidemiol 2011;21:500–6. [4] Im JS, Choi SH, Hong D, Seo HJ, Park S, Hong JP. Proximal risk factors and suicide methods among suicide completers from national suicide mortality data 20042006 in Korea. Compr Psychiatry 2011;52:231–7. [5] Lee CA, Choi SC, Jung KY, et al. Characteristics of patients who visit the emergency department with self-inflicted injury. J Korean Med Sci 2012;27: 307–12. [6] Rockett IR, Regier MD, Kapusta ND, et al. Leading causes of unintentional and intentional injury mortality: United States, 2000-2009. Am J Public Health 2012;102:e84–92. [7] Richter D, Hahn MP, Ostermann PA, Ekkernkamp A, Muhr G. Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional high falls. Injury 1996;27:655–9. [8] Teh J, Firth M, Sharma A, Wilson A, Reznek R, Chan O. Jumpers and fallers: a comparison of the distribution of skeletal injury. Clin Radiol 2003;58: 482–6. [9] Jeon HJ, Lee JY, Lee YM, et al. Unplanned versus planned suicide attempters, precipitants, methods, and an association with mental disorders in a Korea-based community sample. J Affect Disord 2010;127:274–80. [10] Jeon HJ, Lee JY, Lee YM, et al. Lifetime prevalence and correlates of suicidal ideation, plan, and single and multiple attempts in a Korean nationwide study. J Nerv Ment Dis 2010;198:643–6. [11] Bradvik L, Mattisson C, Bogren M, Nettelbladt P. Long-term suicide risk of depression in the Lundby cohort 1947-1997—severity and gender. Acta Psychiatr Scand 2008;117:185–91. [12] Skogman K, Alsen M, Ojehagen A. Sex differences in risk factors for suicide after attempted suicide—a follow-up study of 1052 suicide attempters. Soc Psychiatry Psychiatr Epidemiol 2004;39:113–20. [13] Kannus P, Niemi S, Palvanen M, Parkkari J, Jarvinen M. Secular trends in rates of unintentional injury deaths among adult Finns. Injury 2005;36:1273–6. [14] Stevens JA, Dellinger AM. Motor vehicle and fall related deaths among older Americans 1990-98: sex, race, and ethnic disparities. Inj Prev 2002;8:272–5. [15] Paulozzi LJ, Ballesteros MF, Stevens JA. Recent trends in mortality from unintentional injury in the United States. J Safety Res 2006;37:277–83. [16] Conner KR, Duberstein PR. Predisposing and precipitating factors for suicide among alcoholics: empirical review and conceptual integration. Alcohol Clin Exp Res 2004;28:6S–17S. [17] Kim MH, Jung-Choi K, Jun HJ, Kawachi I. Socioeconomic inequalities in suicidal ideation, parasuicides, and completed suicides in South Korea. Soc Sci Med 2010;70:1254–61. [18] Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry 2002;52:193–204. [19] Harwood DM, Hawton K, Hope T, Harriss L, Jacoby R. Life problems and physical illness as risk factors for suicide in older people: a descriptive and case-control study. Psychol Med 2006;36:1265–74. [20] Juurlink DN, Herrmann N, Szalai JP, Kopp A, Redelmeier DA. Medical illness and the risk of suicide in the elderly. Arch Intern Med 2004;164:1179–84. [21] Powell J, Geddes J, Deeks J, Goldacre M, Hawton K. Suicide in psychiatric hospital in-patients. Risk factors and their predictive power. Br J Psychiatry 2000;176: 266–72. [22] David JS, Gelas-Dore B, Inaba K, et al. Are patients with self-inflicted injuries more likely to die? J Trauma 2007;62:1495–500. [23] Lapostolle F, Gere C, Borron SW, et al. Prognostic factors in victims of falls from height. Crit Care Med 2005;33:1239–42. [24] Goodacre S, Than M, Goyder EC, Joseph AP. Can the distance fallen predict serious injury after a fall from a height? J Trauma 1999;46:1055–8. [25] Petaros A, Slaus M, Coklo M, Sosa I, Cengija M, Bosnar A. Retrospective analysis of free-fall fractures with regard to height and cause of fall. Forensic Sci Int 2013;226: 290–5. [26] Helling TS, Watkins M, Evans LL, Nelson PW, Shook JW, Van Way CW. Low falls: an underappreciated mechanism of injury. J Trauma 1999;46:453–6. [27] Liu CC, Wang CY, Shih HC, et al. Prognostic factors for mortality following falls from height. Injury 2009;40:595–7. [28] Stevens JA. Falls among older adults—risk factors and prevention strategies. J Safety Res 2005;36:409–11. [29] Morrell S, Page AN, Taylor RJ. The decline in Australian young male suicide. Soc Sci Med 2007;64:747–54. [30] Tamosiunas A, Reklaitiene R, Virviciute D, Sopagiene D. Trends in suicide in a Lithuanian urban population over the period 1984-2003. BMC Public Health 2006;6:184. [31] Chang SS, Gunnell D, Sterne JA, Lu TH, Cheng AT. Was the economic crisis 19971998 responsible for rising suicide rates in East/Southeast Asia? A time-trend
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
6
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med 2009;68:1322–31. [32] Centers for Disease Control Prevention (CDC). Increases in age-group-specific injury mortality—United States, 1999-2004. MMWR Morb Mortal Wkly Rep 2007;56:1281–4. [33] Lin JJ, Lu TH. Suicide mortality trends by sex, age and method in Taiwan, 19712005. BMC Public Health 2008;8:6.
[34] Meel B. Epidemiology of suicide by hanging in Transkei, South Africa. Am J Forensic Med Pathol 2006;27:75–8. [35] Yip PS, Liu KY. The ecological fallacy and the gender ratio of suicide in China. Br J Psychiatry 2006;189:465–6. [36] Kim SY, Kim MH, Kawachi I, Cho Y. Comparative epidemiology of suicide in South Korea and Japan: effects of age, gender and suicide methods. Crisis 2011;32: 5–14.
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Characteristics of intentional fall injuries in the ED☆ Jae Hoon Choi, MD a, Sun Hyu Kim, MD a,⁎, Sun Pyo Kim, MD b, Koo Young Jung, MD c, Ji Yeong Ryu, MD d, Sang Cheon Choi, MD e, In Cheol Park, MD f a
Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan 682-714, Republic of Korea Department of Emergency Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea Department of Emergency Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea d Department of Emergency Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea e Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea f Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea b c
a r t i c l e
i n f o
Article history: Received 18 December 2013 Received in revised form 27 January 2014 Accepted 28 January 2014 Available online xxxx
a b s t r a c t Introduction: This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis. Methods: The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups. Results: The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height. Conclusion: The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury. © 2014 Elsevier Inc. All rights reserved.
1. Introduction The death rate from injury per 100 000 people in South Korea was 64.7 in 2011. Injury-related deaths were the third most common cause of death followed by cancer and circulatory disease. Suiciderelated death was 31.7, approximately half of the total injury-related deaths [1]. The suicide rate in South Korea was 33.3 per 100 000 persons in 2011 according to statistics from the Organization for Economic Cooperation and Development Social in 2011; this was the highest among Organization for Economic Cooperation and Development countries [2]. The government has been interested in preventing injury-related deaths and suicide because injury-related deaths, including suicide, are the most frequent cause of death among people younger than 40 years. Falls from a height were the main cause of injury-related deaths, followed by traffic accidents excluding suicide attempts; the ☆ Conflict of interest statement: All the authors declare no conflict of interest with this study and are only responsible for this manuscript. ⁎ Corresponding author. Tel.: +82 52 250 8405; fax: +82 52 250 8071. E-mail address: [email protected] (S.H. Kim).
leading methods of suicide in South Korea are falls from a height, suffocation, and poisoning [3]. Traffic accident–related deaths have been on the decline in South Korea; however, deaths due to falls from a height have been increasing regardless of whether the falls were unintentional or intentional [3]. Although falls from a height occurred at lower frequency compared with the other mechanisms of injury, the risk of death was higher for falls from a height than for any other mechanism. Therefore, this injury mechanism, which has been on the rise and has a high risk of accidental or suicide-related death, requires consistent attention. Several studies have discussed about general injury–related deaths, general unintentional injury–related deaths, and intentional injury–related deaths [3-6]. In addition, some studies have investigated patients with intentional or unintentional injuries from a fall from a height, at a single-institute research [7,8]. However, there has been no study that included all the patients presented to an emergency department (ED) with intentional or unintentional fallrelated injuries. This study was undertaken to examine the characteristics of intentional fall injuries compared with unintentional fall injures and to determine the factors associated with the prognosis of intentional
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2014.01.053
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
2
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
fall injuries at an ED with the goal of promoting the prevention, intervention, and treatment of intentional fall injuries.
2. Materials and methods Data from an in-depth surveillance study of injuries in the ED conducted by the Korea Center for Disease Control and Prevention (KCDC) were retrospectively reviewed from January 2007 to December 2010. The ED injury study by the KCDC started at 5 hospitals in 2006 and was extended to 20 hospitals in 2010. All the hospitals that participated in the surveillance program gathered general information for all types of injuries, and each collected indepth injury information for 1 of the following 4 categories: (1) traffic accidents; (2) head and neck injury; (3) injury involving preschoolaged children; and (4) suicide, poisoning, falls (including falls from height), and injuries due to slipping. These categories were surveyed at individual hospitals. In-depth surveillance for falls from a height and suicide began at 2 hospitals in 2007 and was extended to 6 hospitals in 2010. A total of 9136 subjects who were admitted to the ED after a fall from a height were included; 57 patients were excluded because their intent at the time of the injury was not known. There were 8992 patients admitted after an unintentional fall from a height (called the nonintentional group) and 144 who were admitted after an intentional fall from a height patients (called the intentional group) (Fig.). Approximately 30 000 to 90 000 ED patients were admitted annually to the study hospitals, and injured patients made up approximately 20% of all ED patients. Fall from a height made up approximately 5% of all injuries. This study was approved by the relevant institutional review boards. General characteristics of the subjects, including age, sex, season of injury occurrence, time of injury occurrence, place of injury occurrence, height of fall, activities during the injury occurrence, alcohol ingestion, means of transit to the ED, educational state, and occupation were investigated. Ages were classified using the following groups: 0 to 14, 15 to 29, 30 to 44, 45 to 59, 60 to 74, and 75 years or older, and injury dates were divided into 4 seasons: spring (March to May), summer (June to August), autumn (September to November), and winter (December to February). Time was classified into 4 groups 6 hours in length, and height of the fall was divided into 3 groups: less than 1, 1 to 4, and 4 m or higher. Activities in progress during injury occurrence, including work, unpaid work, educational activities, sports activities, leisure activities, daily activities (such as showering, shaving, and other activities), were noted. Work was defined as economic activities or activities related to occupation as well as unpaid work, including activities at home such as cooking and cleaning. For patients older than 20 years, educational level was classified into 4 groups: elementary school education or less, junior high school, high school, and college or more. Education and occupation were investigated for inpatients only, and some of the
Fig. Selection of study subjects.
data acquired at the ED were also included. Initial blood pressure at the ED (except for deceased patients) was analyzed, and mental state was also investigated and categorized as alert, verbal response, pain response, or unresponsive. The results after ED treatment were noted, including discharge, transfer to another hospital, admission to the general ward, admission to the intensive care unit, death at or before the ED, and emergency operation. Injury severity was classified into 2 groups: severe injury (severe group) and nonsevere injury (nonsevere group). Patients were considered to have a severe injury was if they required emergency surgery, were admitted to the intensive care unit, were transferred to another hospital for specialized care, or were dead on arrival or died within 3 days of being admitted to the hospital [5]. General and clinical characteristics of falls from a height were compared between the intentional and nonintentional groups. Further examination was carried out for the intentional group to determine specific causes of the fall from a height, whether the patient had a previous history of a suicide attempt, whether the patient received psychiatric consultation after a previous suicide attempt, the previous method of suicide attempt, whether the patient had a history of a double suicide attempt (a suicide attempt involving 2 people), whether the place of the fall was familiar to the patient, and the exact height of the fall. We examined the factors associated with severe injury in the intentional group by comparing the severe and nonsevere groups. Age, sex, season, time, place, height of fall, activities during the injury occurrence, alcohol ingestion, means of transit to the ED, education, occupation, previous suicide history, and whether the place was familiar to the patients were compared by univariate analysis. Missing or unknown data were excluded from analysis. We compared the intentional and nonintentional groups for all injuries involving a fall from a height as well as the severe and nonsevere groups in the intentional group, using the χ 2 test, Fisher exact test, and Student t test. Bivariate logistic regression analysis was performed to investigate the factors related to severe injury in the intentional group using the significant factors with P b .05 from the univariate analysis. All statistical analyses were performed using SPSS 19.0 (SPSS, Chicago, IL), and statistical significance was defined as P b .05. 3. Results The mean age was 18 years old in the nonintentional group and 45 years old in the intentional group. Patients younger than 14 years were the most common in the nonintentional group, and most patients in the intentional group were between 30 and 44 years old. Males made up 65% of the nonintentional group and 48% of the intentional group (P = .000). Falls from a height were less common in winter among the nonintentional group and less common in autumn and winter in the intentional group. The time of injury occurrence was more common between 12 and 24 than between 0 and 12 in the nonintentional group; however, all time groups had a similar frequency of more than 20% in the intentional group (P = .000). Residential areas were the most common place of injury occurrence in both groups (60% in the nonintentional group, 80% in the intentional group). A fall height of less than 1 m was most frequent in the unintentional group, making up 62% of unintentional falls; however, a fall height of more than 4 m was most common in the intentional group, making up 83% of the intentional falls (P = .000). Falls occurred most often during daily activities than other activity type in both groups. Work was the other common activity type, involved in 13% of falls in the nonintentional group. Alcohol intake was involved at the time of injury occurrence for 4.1% of patients in the nonintentional group; however, 23% of patients in the intentional group had consumed alcohol (P = .000). Individual transportation to the ED was common means of transit in the nonintentional group, but
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
patients in the intentional group were most commonly transported to the hospital either by a public ambulance (65.5% of patients) or from another hospital (30.6% of patients) (P = .000). High school was the most common educational level for patients 20 years or older in both groups. Employed people made up 69.1% of the nonintentional group, whereas “housewife” and “unemployed” were the most common occupations in the intentional group (Table 1). Alert mental state upon ED arrival was found in 96.9% of patients in the nonintentional group. An unresponsive mental state was the most common in the intentional group, making up 45.4% of the patients. Discharge was the most common result in the nonintentional group; Table 1 General characteristics of intentional and nonintentional fall injuries
Average age, y Age group, years old (%) 0-14 15-29 30-44 45-59 60-74 N75 Sex, male (%) Season of injury occurrence (%) Spring (March-May) Summer (June-August) Autumn (September-November) Winter (December-February) Time of injury occurrence (%) 0-6 o'clock 6-12 o'clock 12-18 o'clock 18-24 o'clock Location of injury occurrence (%) Residential facility Commercial facility Sports facility Transportation area Construction, factory area Educational facility Other outdoor area Height of fall (%) b1 m ≤1 to b4 m ≥4 m Activity during injury occurrence (%) Paid work Unpaid work Education Sports Leisure activity Daily activity Others Alcohol ingestion, n/total n (%) Transportation to ED Public ambulance Individual transportation Other medical facility Others Education (if age ≥20 years old) (%) Uneducated or elementary school Junior high school High school ≥College Occupation (%) Total employed Engineer Office worker Service job Soldier Others Student Housewife Unemployed
Nonintention (n = 8992)
Intention (n = 144)
P
18.1 ± 23.4
44.6 ± 20.0
.000 .000
5902 (65.6) 576 (6.4) 790 (8.8) 1015 (11.3) 511 (5.7) 198 (2.2) 5821 (64.7)
5 (3.5) 32 (22.2) 41 (28.5) 28 (19.4) 24 (16.7) 14 (9.7) 69 (47.9)
2390 (26.6) 2428 (27.0) 2401 (26.7) 1773 (19.7)
49 47 26 22
827 (9.2) 1372 (15.3) 2966 (33.0) 3827 (42.6) n = 8968 5353 (59.7) 708 (7.9) 350 (3.9) 650 (7.2) 855 (9.5) 396 (4.4) 656 (7.3)
40 (27.8) 36 (25.0) 29 (20.1) 39 (27.4) n = 144 115 (79.9) 12 (8.3) 0 (0) 8 (5.6) 0 (0) 1 (0.7) 8 (5.6)
5595 (62.2) 2928 (32.6) 469 (5.2) n = 8939 1135 (12.7) 165 (1.8) 97 (1.1) 220 (2.5) 1401 (15.7) 5731 (64.1) 190 (2.1) 354/8687 (4.1) n = 8990 1352 (15.0) 6020 (67.0) 857 (9.5) 761 (8.5) n = 2045 245 (12.0) 351 (17.2) 1021 (49.9) 428 (20.9) n = 2032 1404 (69.1) 241 (11.9) 182 (9.0) 125 (6.2) 11 (0.5) 845 (41.6) 91 (4.5) 171 (8.4) 366 (18.0)
5 (3.5) 20 (13.9) 119 (82.6) n = 140 0 (0) 2 (1.4) 0 (0) 0 (0) 2 (1.4) 82 (58.6) 54 (38.6) 28/123 (22.8) n = 144 94 (65.3) 4 (2.8) 44 (30.6) 2 (1.4) n = 63 7 (11.1) 12 (19.0) 34 (54.0) 10 (15.9) n = 68 12 (17.6) 3 (4.4) 3 (4.4) 5 (7.4) 1 (1.5) 0 (0) 4 (5.9) 26 (38.2) 26 (38.2)
.000 .018
(34.0) (32.6) (18.1) (15.3) .000
.010
.000
.000
.000 .000
.773
.000
3
77.1% of these patients were discharged. Death before arrival at the ED or during ED treatment, however, occurred for 54.9% of the patients in the intentional group. Emergency operations were performed more often in the intentional group, at 9.0%, than in the nonintentional group, at 2.7% (P = .000). Severe injury occurred in 7.2% and 79.2% of the patients in the nonintentional and intentional groups, respectively (P = .000) (Table 2). The most common reason for intentional fall from a height was depression at 30.6%, and this was followed by conflict with a spouse, other psychiatric problems, medical illness, and conflict with parents. Among patients in the intentional group, 7.4% had a previous history of a suicide attempt, and 44.4 of these patients had received psychiatric treatment after their first suicide attempt. In addition, 2.4% (3/126) of patients in the intentional group had a history of a double suicide attempt. The fall from a height occurred at a place that was familiar to the patient in 85.2% of intentional fall cases. The mean height of intentional falls from a height was 18.4 m (Table 3). Patients were older and the height of the fall was higher in the severe group for the intentional fall patients. The injury occurred in residential facility for 83.2% of patients in the severe group and 66.7% in the nonsevere group. Patients were brought to the ED by public ambulance or from another hospital in 97.4% of cases in the severe group and 90% of cases in the nonsevere group. Of patients in the severe group, 6.4% were college graduates, but 43.8%, in the nonsevere group. A history of a previous suicide attempt was present in 4.1% of patients in the severe group and 26.3% of patients in the nonsevere group (Table 4). Educational status (with high school graduates more likely to sustain a severe injury than college graduates) and greater fall height were factors associated with severe injury in the intentional group (Table 5). 4. Discussion Information collected at the ED is important to the identification of the general characteristics of injuries due to falls from a height because many patients present to the ED after an injury of this type. Therefore, the system of in-depth surveillance of injuries at the ED conducted by the KCDC plays an important role in identifying the characteristics of injuries from falls from a height and provides a significant source of data for the intervention and prevention of fallrelated injury. This study is meaningful because it is the first study conducted at multiple EDs in Korea to distinguish the characteristics of intentional and nonintentional injuries due to falls from a height and to include further analysis of intentional injury due to falls from a height.
Table 2 Clinical characteristics and outcomes of intentional and nonintentional fall injuries
Blood pressure, mm Hg (dead patients excluded) Systolic blood pressure Diastolic blood pressure Consciousness at ED (%) Alert Verbal response Pain response Unresponsive Result of ED treatment (%) Discharge Transfer to other facility Admission to general ward Admission to intensive care unit Death at ED Emergency operation (%) Severe patients (%)
Nonintention (n = 8992)
Intention (n = 144)
n = 3527
n = 58
122.6 ± 23.9 74.1 ± 14.9 n = 6804 6591 (96.9) 86 (1.3) 73 (1.1) 54 (0.8)
112.6 ± 31.1 67.6 ± 21.1 n = 119 43 (36.1) 12 (10.1) 10 (8.4) 54 (45.4)
6933 (77.1) 233 (2.6) 1392 (15.5) 366 (4.1) 68 (0.8) 246 (2.7) 644 (7.2)
15 (10.4) 3 (2.1) 17 (11.8) 30 (20.8) 79 (54.9) 13 (9.0) 114 (79.2)
P
.002 .022 .000
.000
.000 .000
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
4
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Table 3 Details of the intentional fall group
Table 4 General characteristics of intentional fall injuries by injury severity n = 144
Reasons for intentional fall, n (%) Interpersonal conflict Conflict with spouse Conflict with parents Conflict with offspring Conflict with other family members Conflict with friends Conflict with lover Death of parents Medical illness Psychiatric disease Depression Drug intoxication Other psychiatric problem Sexual abuse Work-related stress Financial problems Unemployed Other financial problems Others History of previous suicide attempt, n/total n (%) Intoxication Fall Cut Self-burning Received psychiatric consultation after a previous suicide attempt, n/total n (%) Double suicide with, n/total n (%) Offspring Other people Place of fall Familiar with patients, n/total n (%) Mean height of fall, m
n = 98 36 (36.7) 22 (22.4) 6 (6.1) 3 (3.1) 2 (2.0) 2 (2.0) 1 (1.0) 1 (1.0) 8 (8.2) 40 (40.8) 30 (30.6) 1 (1.0) 9 (9.2) 1 (1.0) 4 (4.1) 5 (5.1) 3 (3.1) 2 (2.0) 3 (3.1) 9/121 (7.4) 3 2 2 2 4/9 (44.4) 3/126 (2.4) 1/126 (0.8) 2/126 (1.6) 109/128 (85.2) 18.4 ± 14.8 (n = 122)
Conflict with family was found to be the most common cause of suicide in previous studies [5,9], and this study showed a similar result, in that conflict with family was involved in 33.7% of intentional fall from a height cases. As in another study, we found that depression was the other major cause; it was involved in 30.6% of cases of intentional fall from a height [10]. Some previous studies have reported that men sustained more severe injuries from suicide attempts by falls from a height than women [11,12]. Multiple studies have also reported that men were at higher risk for death due to nonintentional injury from falls from a height [6,13,14]; however, other studies reported the opposite [3,15]. The severity of injuries due to intentional falls from a height was not found to be different between the sexes in this study. Alcohol consumption has been found to be a potential risk factor for suicide attempts [16]; however, a previous study found that alcohol intake resulted in a less severe outcome in patients attempting suicide [5]. Alcohol intake was more common in the intentional group than the nonintentional group in this study. Within the intentional group, however, alcohol intake was not significantly different between the severe and nonsevere injury groups; in the severe group, 20% of patients had consumed alcohol, and in the nonsevere group, 31% had. A lower educational level had been found to be associated with a higher suicide rate in a previous study [17]. In the intentional group in the present study, 15.9% of the patients had educational levels of college graduation or above, whereas 54.0% were high school graduates only. High school graduates were also at higher risk for severe injury compared with college graduates in the intentional group in this study. The outcomes of cases falls from a height were influenced by several factors including fall height, age, impact area of the body, and the material of the impact floor. Old age has been reported as a risk factor associated with a poor prognosis in patients who attempted suicide [5,18-21] and as a factor associated with mortality after injury from a fall from a height [22,23]. The average patient age was older in
Age, y Group of age, years old, (%) 0-14 15-29 30-44 45-59 60-74 N75 Sex, male (%) Season of injury occurrence (%) Spring (March-May) Summer (June-August) Fall (September-November) Winter (December-February) Time of injury occurrence (%) 0-6 o'clock 6-12 o'clock 12-18 o'clock 18-24 o'clock Location of injury occurrence (%) Residential facility Commercial facility Transportation area Education facility Other outdoor area Height of fall, m Height of fall (%) b1 m ≤1 to b4 m ≥4 m Activity during injury occurrence (%) Unpaid work Leisure activity Daily activity Others Alcohol ingestion, n/total n (%) Transportation to ED Public ambulance Other medical facility Individual transportation Others Education (if age ≥20 years old) (%) Uneducated or elementary school Junior high school High school ≥College Occupation (%) Workers Student Housewife Unemployed Previous suicide attempt, n/total n (%) Place of fall Familiar with patients, n/total n (%)
Severe (n = 114)
Nonsevere (n = 30)
P
46.5 ± 21.0
37.4 ± 14.2
.007 .083
4 (3.5) 25 (21.9) 29 (25.4) 20 (17.5) 22 (19.3) 14 (12.3) 58 (50.9)
1 (3.3) 7 (23.3) 12 (40.0) 8 (26.7) 2 (6.7) 0 (0) 11 (36.7)
44 35 20 15
(38.6) (30.7) (17.5) (13.2)
5 (16.7) 12 (40.0) 6 (20.0) 7 (23.3)
29 32 23 30
(25.4) (28.1) (20.2) (26.3)
11 (36.7) 4 (13.3) 6 (20.0) 9 (30.0)
95 (83.2) 10 (8.8) 6 (5.3) 0 (0) 3 (7.3) n = 100 20.7 ± 14.2
20 (66.7) 2 (6.7) 2 (6.7) 1 (3.3) 8 (5.6) n = 22 8.0 ± 10.0
1 (0.9) 10 (8.8) 103 (90.4) n = 110 2 (1.8) 1 (0.9) 64 (58.2) 43 (39.1) 19/94 (20.2)
4 (13.3) 10 (33.3) 16 (53.3) n = 30 0 (0) 1 (3.3) 18 (60.0) 11 (36.7) 9/29 (31.0)
71 (62.3) 40 (35.1) 2 (1.8) 1 (0.9) n = 47 6 (12.8) 11 (23.4) 27 (57.4) 3 (6.4) n = 62 10 (16.1) 14 (22.6) 16 (25.8) 22 (35.5) 4/97 (4.1)
23 (76.7) 4 (13.3) 2 (6.7) 1 (3.3) n = 16 1 (6.3) 1 (6.3) 7 (43.8) 7 (43.8) n = 21 2 (9.5) 5 (23.8) 10 (47.6) 4 (19.0) 5/19 (26.3)
91/105 (86.7)
18/23 (78.3)
.218 .102
.336
.000
.000 .000
.733
.310 .026
.007
.268
.006 .334
the severe group within the intentional group in this study. Previous studies have found that prognosis was poorer when the height of the fall was higher [23,24] and that the pattern of injury depended on the height of the fall [25]. However, it was also found to be possible for low falls to lead to severe outcomes [26]. In our study, the height of the fall was higher, and the prognosis was poorer in the intentional Table 5 Factors associated with severe injury for intentional falls
High school, education vs college or above Height of fall
Odds ratio
95% confidence interval
P
8.829
1.196-65.182
.033
1.240
1.019-1.508
.032
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
group than in the nonintentional group. In the intentional group, the average height of the fall was 20.7 m in the severe group and 8 m in the nonsevere group. The height of the fall was found to be related to the chance of severe injury in the regression analysis. A previous study found that the prognosis of a fall from a greater height was poor regardless of age [27]. Although injury-related deaths as a whole have decreased in Korea, nonintentional fall injuries in elderly people and intentional fall injuries in adolescents are increasing [3]. The observation that the occurrence of fall-related injuries increases with age was confirmed in another study [28]. Preventive efforts, such as enforcement of legislation and the introduction of effective safety equipment and safety programs, have decreased traffic accident–related deaths [13], but preventive activities targeted toward deaths related to falls from a height have been less effective. Deaths by suicide have been decreasing in some countries [29,30] and increasing in others [31]. The suicide rate in Korea has more than tripled over the last 2 decades [1]. The most common method of suicide varies by country and may involve firearms, hanging, suffocation, poisoning, charcoal burning, or falling from a height according to the characteristics of the country [32-35]. The leading methods of suicide in Korea in 2011 were suffocation, poisoning, and falling from a height [3,36]. Injury related to a fall from a height has a poorer prognosis than all other injury mechanisms, and the prognosis of intentional injury was poorer than that of nonintentional injury because intentional injury has a higher proportion of injuries related to falls from a height [22]. The combined rate of patients reported dead on arrival and of death at the ED was only 0.8% in the nonintentional group, but it was 54.9% in the intentional group in this study. The major limitation of this study was that the number of intentional fall cases might be underestimated because patients or their guardians tend to claim that injuries were accidental rather than intentional. Patients or their guardians may hide intentional injury because, in principle, the medical costs of an intentional injury are not covered by the national health insurance scheme in Korea, and patients with an intentional injury must, therefore, pay the hospital bill themselves. Moreover, the occurrence of a previous history of a suicide attempt and psychiatric consultation after a suicide attempt in the intentional group surveyed in this study might be underestimated because many patients tend to refuse to talk about their mental health history and to hide previous psychiatric symptoms. Another limitation was that, in intentional fall group, the relation between the reason for attempting suicide by patient age and severity of injury could not be sufficiently evaluated due to the small size of the group.
5. Conclusion The number of females, height of the fall, and occurrence of alcohol consumption were all higher in the intentional group than in the nonintentional group, and prognosis was poorer in the intentional group. The average age was older, and the height of the fall was higher in the severe group than the nonsevere group among intentional fall injuries. In the intentional group, the risk of severe injury increased with higher height, and patients with a high school level of education sustained more severe injuries compared with college graduates. Because intentional fall injuries have a high risk for a severe outcome, considerable effort should be devoted to preventing that type of injury. Preventative efforts including telephone counseling and installing signs advising against suicide in risky areas for intentional falls (such as bridges) have been undertaken. More importantly, the government is supporting efforts to improve the social environment to reduce intentional fall with the help of the community, the workplace, educational facilities, and the family.
5
Acknowledgments The authors are grateful to the KCDC for supporting the registry financially and providing data. References [1] Korea National Statistical Office. National statistics report 2011. Daejeon: Korea National Statistical Office; 2012. [2] OECD. OECD health data 2011: statistics and indicators for 34 countries. Paris: Organization for Economic Cooperation and Development; 2012. [3] Hong J, Lee WK, Park H. Change in causes of injury-related deaths in South Korea, 1996-2006. J Epidemiol 2011;21:500–6. [4] Im JS, Choi SH, Hong D, Seo HJ, Park S, Hong JP. Proximal risk factors and suicide methods among suicide completers from national suicide mortality data 20042006 in Korea. Compr Psychiatry 2011;52:231–7. [5] Lee CA, Choi SC, Jung KY, et al. Characteristics of patients who visit the emergency department with self-inflicted injury. J Korean Med Sci 2012;27: 307–12. [6] Rockett IR, Regier MD, Kapusta ND, et al. Leading causes of unintentional and intentional injury mortality: United States, 2000-2009. Am J Public Health 2012;102:e84–92. [7] Richter D, Hahn MP, Ostermann PA, Ekkernkamp A, Muhr G. Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional high falls. Injury 1996;27:655–9. [8] Teh J, Firth M, Sharma A, Wilson A, Reznek R, Chan O. Jumpers and fallers: a comparison of the distribution of skeletal injury. Clin Radiol 2003;58: 482–6. [9] Jeon HJ, Lee JY, Lee YM, et al. Unplanned versus planned suicide attempters, precipitants, methods, and an association with mental disorders in a Korea-based community sample. J Affect Disord 2010;127:274–80. [10] Jeon HJ, Lee JY, Lee YM, et al. Lifetime prevalence and correlates of suicidal ideation, plan, and single and multiple attempts in a Korean nationwide study. J Nerv Ment Dis 2010;198:643–6. [11] Bradvik L, Mattisson C, Bogren M, Nettelbladt P. Long-term suicide risk of depression in the Lundby cohort 1947-1997—severity and gender. Acta Psychiatr Scand 2008;117:185–91. [12] Skogman K, Alsen M, Ojehagen A. Sex differences in risk factors for suicide after attempted suicide—a follow-up study of 1052 suicide attempters. Soc Psychiatry Psychiatr Epidemiol 2004;39:113–20. [13] Kannus P, Niemi S, Palvanen M, Parkkari J, Jarvinen M. Secular trends in rates of unintentional injury deaths among adult Finns. Injury 2005;36:1273–6. [14] Stevens JA, Dellinger AM. Motor vehicle and fall related deaths among older Americans 1990-98: sex, race, and ethnic disparities. Inj Prev 2002;8:272–5. [15] Paulozzi LJ, Ballesteros MF, Stevens JA. Recent trends in mortality from unintentional injury in the United States. J Safety Res 2006;37:277–83. [16] Conner KR, Duberstein PR. Predisposing and precipitating factors for suicide among alcoholics: empirical review and conceptual integration. Alcohol Clin Exp Res 2004;28:6S–17S. [17] Kim MH, Jung-Choi K, Jun HJ, Kawachi I. Socioeconomic inequalities in suicidal ideation, parasuicides, and completed suicides in South Korea. Soc Sci Med 2010;70:1254–61. [18] Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry 2002;52:193–204. [19] Harwood DM, Hawton K, Hope T, Harriss L, Jacoby R. Life problems and physical illness as risk factors for suicide in older people: a descriptive and case-control study. Psychol Med 2006;36:1265–74. [20] Juurlink DN, Herrmann N, Szalai JP, Kopp A, Redelmeier DA. Medical illness and the risk of suicide in the elderly. Arch Intern Med 2004;164:1179–84. [21] Powell J, Geddes J, Deeks J, Goldacre M, Hawton K. Suicide in psychiatric hospital in-patients. Risk factors and their predictive power. Br J Psychiatry 2000;176: 266–72. [22] David JS, Gelas-Dore B, Inaba K, et al. Are patients with self-inflicted injuries more likely to die? J Trauma 2007;62:1495–500. [23] Lapostolle F, Gere C, Borron SW, et al. Prognostic factors in victims of falls from height. Crit Care Med 2005;33:1239–42. [24] Goodacre S, Than M, Goyder EC, Joseph AP. Can the distance fallen predict serious injury after a fall from a height? J Trauma 1999;46:1055–8. [25] Petaros A, Slaus M, Coklo M, Sosa I, Cengija M, Bosnar A. Retrospective analysis of free-fall fractures with regard to height and cause of fall. Forensic Sci Int 2013;226: 290–5. [26] Helling TS, Watkins M, Evans LL, Nelson PW, Shook JW, Van Way CW. Low falls: an underappreciated mechanism of injury. J Trauma 1999;46:453–6. [27] Liu CC, Wang CY, Shih HC, et al. Prognostic factors for mortality following falls from height. Injury 2009;40:595–7. [28] Stevens JA. Falls among older adults—risk factors and prevention strategies. J Safety Res 2005;36:409–11. [29] Morrell S, Page AN, Taylor RJ. The decline in Australian young male suicide. Soc Sci Med 2007;64:747–54. [30] Tamosiunas A, Reklaitiene R, Virviciute D, Sopagiene D. Trends in suicide in a Lithuanian urban population over the period 1984-2003. BMC Public Health 2006;6:184. [31] Chang SS, Gunnell D, Sterne JA, Lu TH, Cheng AT. Was the economic crisis 19971998 responsible for rising suicide rates in East/Southeast Asia? A time-trend
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
6
J.H. Choi et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med 2009;68:1322–31. [32] Centers for Disease Control Prevention (CDC). Increases in age-group-specific injury mortality—United States, 1999-2004. MMWR Morb Mortal Wkly Rep 2007;56:1281–4. [33] Lin JJ, Lu TH. Suicide mortality trends by sex, age and method in Taiwan, 19712005. BMC Public Health 2008;8:6.
[34] Meel B. Epidemiology of suicide by hanging in Transkei, South Africa. Am J Forensic Med Pathol 2006;27:75–8. [35] Yip PS, Liu KY. The ecological fallacy and the gender ratio of suicide in China. Br J Psychiatry 2006;189:465–6. [36] Kim SY, Kim MH, Kawachi I, Cho Y. Comparative epidemiology of suicide in South Korea and Japan: effects of age, gender and suicide methods. Crisis 2011;32: 5–14.
Please cite this article as: Choi JH, et al, Characteristics of intentional fall injuries in the ED, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.01.053
