PEDIATRICS Vol. 108 No. 3 September 2001, pp. 631-635
A Population-Based Assessment of Pediatric All-Terrain Vehicle Injuries
,,, and
From the Intermountain Injury Control Research Center,
* Division of Critical Care, Objective. To describe the types of
injuries sustained by children who ride all-terrain vehicles (ATVs), to
estimate the hospital charges associated with these injuries, and to
determine adherence to existing rules and regulations governing ATV
use.
Methods. Analysis of statewide hospital admissions
(1992-1996) and emergency department (ED) visits (1996) in Utah. All
patients who were younger than 16 years and had an external cause of
injury code for ATV use were included.
Results. In 1996, 268 ED visits by children involved an
ATV. Boys were twice as commonly injured as girls (male:female ratio:
2.1:1), and skin and orthopedic injuries were most frequent. The median ED charge was $368, and ED charges for these patients totaled $138 000. From 1992 to 1996, 130 children were hospitalized as a
result of injuries sustained during ATV use, with median charges of
$4240 per admission. Male to female ratio was 2.7:1, and the average
age was 11.2 ± 3.6 years. Mean injury severity score was 8.0 ± 6.0, and median length of stay was 2 days (range: 0-43 days). Orthopedic injuries were most frequent, but 25% (n = 32) of children sustained head or spinal cord injury. Most children
(94%) were discharged from the hospital, but 8 children died as a
result of their injuries. Utah regulations prohibit children who are younger than 8 years from driving an ATV and advise against carrying passengers on ATVs. However, 25% (n = 15) of all
injured children who were younger than 8 were driving the ATV when
injured, and 15% (n = 60) of injured children were
passengers on ATVs. Four of the 8 fatally injured children were younger
than 8, and all were driving the ATV at the time of the crash. Finally,
the estimated injury rate per 100 registered ATVs is significantly
higher for children than for adults (3.41 vs 1.71).
Conclusions. ATV use results in significant injuries to
children. Efforts to educate parents regarding the risks of ATV use,
proper supervision, and use of safety equipment are warranted.
Manufacturers of ATVs should continue to improve the safety profile of
these inherently unstable vehicles.
Department of Pediatrics, University of
Utah School of Medicine, Salt Lake City, Utah.
ABSTRACT
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Most injuries are preventable, yet they are the leading
cause of death among people 1 to 44 years of age.1 Many
injuries are sustained during recreational activities. One form of
recreation that can be particularly dangerous and has received an
increasing amount of attention is the use of all-terrain vehicles
(ATVs). ATVs are 3- or 4-wheeled motorized vehicles with large,
low-pressure tires designed to be ridden in off-road conditions. They
initially were sold in the early 1980s as "toys," suitable for use
by the whole family.2 However, it soon became evident that
ATVs were a significant public health hazard, resulting in an estimated 106 000 emergency department (ED)-treated injuries and 347 deaths in
1986; approximately 40% of these deaths and injuries involved children
who were younger than 16 years.3
Because of these findings, the US Consumer Product Safety Commission
(CPSC) and the major ATV manufacturers signed a consent decree that
took effect in 1988. This decree included agreements to stop
manufacturing 3-wheel ATVs, to develop nationwide training and safety
education programs, and to make ATVs safer. In addition, distributors
agreed to prohibit use of ATVs with engines larger than 90 mL to
children who are younger than 16 years and to prohibit use of ATVs with
engines larger than 70 mL to children who are younger than 12 years.4,5 The American Academy of Pediatrics (AAP)
Committee on Accident and Poison Prevention also issued a consensus
statement reiterating the recommendations of the consent
decree.6 Follow-up analysis of the decree has revealed no
decrease in the proportion of children who are injured in ATV-related
crashes; children who are younger than 16 years still sustain 40% to
50% of all ATV-related injuries7,8 and account for more
than 35% of all ATV-related deaths.5 Since then, the AAP
has issued an updated consensus statement recommending more stringent
restrictions and design modifications.9
Although the consent decrees were sponsored by the federal government
and signed by national manufacturers of ATVs, each state legislates ATV
use and thus may not necessarily implement age restrictions or
passenger limitations as specified in the decrees. In Utah, for
example, the legislature has determined that children TABLE 1
8 years of age
may operate an ATV on public land with no restriction on engine size.
Also, in Utah, helmets are required only for ATV riders who are younger
than 18 years, and passengers are not allowed on single-use vehicles,
which are the majority of ATVs (Table 1).
Utah ATV Rules and Regulations
Several recent studies have reported on ATV injuries that were sustained by children treated at regional trauma centers.7,10,11 To delineate further the magnitude of the problem of pediatric ATV injuries, we performed a population-based, statewide assessment of all ATV injuries that required an ED visit or hospitalization over a 5-year period in Utah. The objective of this study was to determine the epidemiology of ATV injuries in Utah, especially among children who are younger than 16 years. We sought to describe the types of injuries sustained by children who ride ATVs and attempted to determine adherence to existing Utah ATV rules and regulations in regard to age limitations and passenger restrictions. Finally, we attempted to estimate the cost savings in terms of injuries, deaths, and hospital charges that might have occurred had existing passenger recommendations been followed and had state-specific driving age limitations been in agreement with those of the consent decree and the AAP.
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METHODS |
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Databases
Three data sets were used in this analysis: 1) the Utah Hospital Discharge Database, 2) the Utah Emergency Department Database, and 3) the Utah Death Certificate Database. The 1992 to 1996 Hospital Discharge Database was acquired from the Utah Health Data Committee/Office of Health Data Analysis, Utah Department of Health. The Utah Department of Health mandates that all Utah-licensed hospitals, both general acute and specialty care, report all inpatient discharges. The Hospital Discharge Database includes demographic information (gender, date of birth, admission date) and up to 9 International Classification of Diseases-Ninth Revision codes, 5 procedure codes, an external cause of injury code (E code), discharge status, length of stay, and hospital charges. Injury severity scores, which provide a measure of injury severity by summing the most severe injuries sustained in each of 3 predefined body regions (range: 1-75),12,13 were calculated using ICDMAP-90 (Tri-analytics, Inc, Bel Air, MD).
ED records for a single year (1996) were acquired from the Utah Department of Health. Since 1996, the Department of Health has mandated that all Utah-licensed hospitals report information on ED patient encounters. The ED database includes similar data fields to those found in the Utah Hospital Discharge Database. This database includes only those patients who are treated and released from the ED. Patients who are admitted to the inpatient service of the same facility are not included in this database. To identify patients who were transferred to other hospitals from an ED, we probabilistically linked the ED and hospital data sets, using the methods described by Jaro.14 Patients who were present in both databases were eliminated from the ED database, and charges incurred in the referring ED were added to the hospital charges.
The Death Certificate Database from 1992 to 1996 was obtained from the Bureau of Vital Statistics through the University of Utah Resource for Genetic and Epidemiologic Research. This database includes demographic information (gender, date of birth, date of death, and place of death), up to 4 International Classification of Diseases-Ninth Revision codes, and an E code. The Institutional Review Board of the University of Utah approved use of these databases for this study.
Study Population
All injury records that contained an E code for ATV injury were extracted for analysis. The patient population was limited to children who were younger than 16 years.
Analysis
We developed a general estimate of the injury rate among young ATV drivers by combining information on yearly statewide ATV registration obtained from the Utah Department of Parks and Recreation with national estimates of the number of ATV drivers who are younger than 16 years (14%), available from the CPSC Exposure Survey.5 The total number of ATVs registered in Utah in 1998 was multiplied by 14% to obtain an approximation of the number of ATVs driven primarily by children in Utah in 1998. We then used this information and the number of injuries in 1 year to estimate injury rates per 100 ATVs driven by children versus adults. Descriptive statistics were performed using Microsoft Excel (Seattle, WA) and SAS (SAS Institute, Cary, NC). A test of proportions was used to compare crude injury rates for adults versus children.
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RESULTS |
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In 1996, there were 788 ATV-related ED visits in Utah. Thirty-four percent (n = 268) of these visits were associated with patients who were younger than 16 years. These patients all were treated and released as a condition of being in the database. Demographics associated with this injury group are described in Table 2. No children died of ATV-related injuries in the ED in 1996.
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From 1992 to 1996, 406 patients were hospitalized as a result of injuries sustained in an ATV-related incident. Thirty-two percent of patients (n = 130) were younger than 16 years. Among these hospitalized children, the average injury severity score was 8.0 ± 6.0, and the median length of stay was 2 days (range: 0-43 days). One child died in the presenting hospital, 6 additional children were transferred to other hospitals, and 1 child was discharged to a skilled nursing facility. Finally, using the Utah Death Certificate Database, we identified 7 additional children who died as a result of ATV-related injuries in the 5-year study period. Three of these children died at the scene; the other 4 children died in hospitals. Because of the nature of the database, we were unable to determine whether these children died in the ED (in which case, they would not have appeared in our ED database if death occurred before 1996) or whether these children had E codes in their hospital record that were too general to identify them as having sustained ATV-related injuries.
Figure 1 indicates an increase in pediatric ATV-related injuries with increasing age of the child. Figure 2 shows the distribution of injury types for children who are injured in ATV crashes and are treated and released from the ED and for those who are admitted to the hospital. Each injury was classified separately, ie, a multiply injured child would be counted more than once if he or she sustained more than 1 type of injury. Orthopedic injuries were common among both ED patients and hospitalized patients, although skin injuries such as abrasions and lacerations were the most common injury type among the ED patients. Twenty-five percent (n = 32) of the hospitalized children sustained injuries to the central nervous system, defined as intracranial or spinal cord injury. The fatally injured child identified in the hospital database sustained a head injury. Cause of death other than E code was not consistently available for children who were identified in the death certificate database.
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The consent decree specifies that ATVs with engine sizes >90 mL be sold only for use by those who are 16 years or older and that ATVs with engine sizes of 70 mL be sold only for use by those who are at least 12 years of age.4 However, Utah state regulations allow children who are as young as 8 years to drive an ATV. Figure 3 shows the riding position of ATV-injured children by 3 age groupings. In violation of the Utah age limit, 25% (n = 15) of all injured children who were younger than 8 years were driving the ATV at the time of their injury. Thirty-eight percent (n = 74) of children who were younger than 12 years were driving the ATV at the time of their injury, against the recommendations of the federal consent decree. All of the children who died were driving the ATV at the time of the crash, and 4 of 8 fatally injured children were younger than 8 years. The Utah Division of Parks and Recreation advises against allowing passengers on single-use ATVs, yet 15% (n = 61) of injured children were passengers on ATVs.
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By adhering to existing state regulations and recommendations governing ATVs, 61 children would not have been injured as passengers on ATVs, 15 children would not have been injured while driving ATVs, and 4 children would not have died. Injuries sustained by children who were younger than 8 years and driving ATVs resulted in $48 187 in hospital charges, and injuries sustained by all children who were riding as passengers on ATVs resulted in $159 917 in hospital charges. Assuming 100% compliance with regulations, if Utah had raised the age limit for driving ATVs to 12 years, as specified in the consent decree, and had continued restricting passengers, then 120 injuries to children may have been prevented and $483 923 in hospital charges may have been avoided; five children may not have died.
In the CPSC National Exposure Survey,15 Rodgers found that 14% of ATV drivers were younger than 16 years. Using this figure, we estimated that children who were younger than 16 years drove 14% of ATVs registered in Utah. Using the number of ATVs registered in Utah in 1998 (the only year for which registration data were available) as a proxy for the number of ATV drivers, we estimated crude injury rates for adults and children on ATVs. The results are shown in Table 3. The estimated injury rate for children who were younger than 16 years is significantly higher than that for adults (3.41 vs 1.71; P < .001).
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DISCUSSION |
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ATVs are a significant cause of morbidity and mortality nationwide. To our knowledge, this is the first population-based study of ATV injuries that includes patients who were treated and released from EDs as well as those who required hospitalization. In Utah, in the 5-year study period, there were an estimated 1340 ED visits (extrapolated from 1996 ED data) and 130 hospitalizations of children who were younger than 16 years. There were >$1.6 million in hospital charges, and 8 children died as a result of ATV-related injuries. If recommendations of the consent decree had been adhered to, then 120 children would not have been injured and nearly $500 000 in hospital charges would have been saved, resulting in a 30% reduction in both injuries and hospital charges. Fatalities would have been reduced by >60%.
Despite the signing of the consent decree >10 years ago, ATV-related injuries have not decreased nationwide, nor has the proportion of injured children.7 One reason for the failure of the consent decree to reduce pediatric injuries may be that state-specific regulations do not support the age and passenger limitations. In Utah, the legislature has determined that an 8-year-old may drive an ATV on public land. There is no engine size specification for ATVs used by children, and helmets are required only for those who are younger than 18 years (Table 2). As our data show, however, not even the existing regulations governing drivers in Utah are effective: 25% of injured children who were younger than 8 years were driving the ATV at the time of their injury. Passengers are prohibited on the majority of ATV types, yet 15% of injured children were passengers on ATVs.
Our overall injury rate of 1.95 per 100 ATVs registered per year is slightly higher than that found nationwide. In the 1997 CPSC Injury Survey, the rate of injury was 1.5 injuries per 100 ATVs in use.8 This national estimate, however, was not stratified by age. In our study, we found that children had significantly higher injury rates than adults, indicating that operating or riding on ATVs carries a particularly high risk of injury to children.
There are several limitations of our study. First, the number of children injured in ATV-related incidents likely is underestimated. This may be a result of both inaccurate or nonspecific E coding, as well as of our inability to capture injuries that are treated in a nonhospital setting (eg, an urgent care clinic, a doctor's office). We also were unable to determine mechanism of injury (eg, rollover, collision), ATV size or type, helmet use, or alcohol involvement.
It is difficult to determine actual exposure rates for children who drive or ride on ATVs. In fact, no estimates of pediatric injury rates exist in the literature. Using national estimates from the CPSC Exposure Survey indicating that 14% of ATV drivers are younger than 16 years,15 we estimated that children are at significantly increased risk of injury when operating or riding on ATVs (Table 3). One should note that the number of ATVs registered in 1998 (the earliest year for which data were available from the Utah Division of Motor Vehicles) is likely to be different from registration rates in 1996, the year for which outcome data were available. ATV usage has increased steadily since their introduction to the market; thus, our injury rates may be slight underestimates. However, the discrepancy between adult and child injury rates is unlikely to be affected by a change in usage rates. It also is possible that some ATVs in use are unregistered, resulting in an underestimate of exposure. Nevertheless, our injury rates are intended to be only a rough estimate of actual injury rates.
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CONCLUSION |
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ATVs are an important public health problem for children in Utah and in the rest of the United States. As advocates for the safety and well-being of children, we have a responsibility to address the dangers of ATV use by children both as drivers and as passengers by lobbying legislators for more stringent regulations of ATV use; encouraging ATV manufacturers to continue efforts to design safer, more stable vehicles; and educating parents regarding the risks of allowing children to operate or ride on ATVs. Difficulties with enforcement of regulations will continue, but perhaps by raising the level of awareness of both parents and law enforcement officials regarding the dangers of ATV use by children, we can make progress in alleviating this problem. Studies to determine the effectiveness of existing ATV safety education courses and parents' awareness of and adherence to state ATV rules and regulations and to AAP, CPSC, and manufacturer recommendations are warranted.
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FOOTNOTES |
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Dr Cvijanovich is currently with the Division of Critical Care, Children's Hospital Oakland, Oakland, California.
Received for publication Jun 2, 2000; accepted Jan 9, 2001.
Address correspondence to Natalie Z. Cvijanovich, MD, Division of Critical Care, Children's Hospital Oakland, 747 52nd St, Oakland, CA 94609.
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ABBREVIATIONS |
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ATV, all-terrain vehicle; CPSC, Consumer Product Safety Commission; AAP, American Academy of Pediatrics; E code, external cause of injury code.
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REFERENCES |
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Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics
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