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ARTICLE |
a Department of Pediatrics, The Ohio State University College of Medicine and Public Health, and Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, Columbus, Ohio
b Division of Epidemiology and Biostatistics, School of Public Health, The Ohio State University, Columbus, Ohio
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. We conducted a retrospective analysis of data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission. Reported cases were used to project national estimates and rates of escalator-related injuries in the United States. The analysis included all patients who were 0 to 19 years of age in the National Electronic Injury Surveillance System database and were seen in an emergency department for an escalator-related injury during the 13-year period 1990–2002.
RESULTS. There were an estimated 26000 escalator-related injuries among children who were 0 to 19 years of age in the United States during 1990–2002, yielding an average of 2000 of these injuries annually (rate = 2.6 per 100000 population per year). The mean age was 6.5 years at the time of injury, and 53.4% of the patients were male. When comparing cases by 5-year age groups, children who were younger than 5 years had the highest estimated number of injuries (12000), as well as the highest annual escalator-related injury rate (4.8 per 100000). The most common mechanism of injury for all age groups was a fall, accounting for 13000 (51.0%) injuries. Entrapment accounted for 29.3% of all injuries and 36.5% of injuries among children who were younger than 5 years. Six percent (723) of injuries to children who were younger than 5 years involved a stroller, with most injuries occurring when a child fell out of the stroller while on the escalator. The most common body part injured for all ages was the leg, accounting for 27.7% of all injuries. Among children who were younger than 5 years, the hand was the most common injury site (40.6%), with hand injuries frequently occurring as a result of entrapment (72.4%). A laceration was the most common type of injury, accounting for 47.4% of escalator-related injuries. Amputations and avulsions were uncommon; however, 71.4% (595 of 833) occurred among children who were younger than 5 years.
CONCLUSIONS. There was a disproportionate number of escalator-related injuries among children who were younger than 5 years. Entrapment occurred more frequently among children who were younger than 5 years than in any other age group, which may explain the increased number of hand injuries in this age group. Escalator designs that reduce the gap between the steps and sidewall or shield against access to the gap may decrease entrapment risk. Young children should be supervised properly and should not be transported in a stroller while riding on an escalator. All passengers should use caution and remain alert when riding an escalator to avoid injuries related to falls or entrapment. Additional research is needed to determine the relationship among passenger behavior, escalator design, and escalator-related injury.
Key Words: child • escalator • injury
Abbreviations: CPSC—Consumer Product Safety Commission • NEISS—National Electronic Injury Surveillance System • ED—emergency department • CI—confidence interval
The US Consumer Product Safety Commission (CPSC) estimates that >7300 escalator-related injuries occur in the United States each year. Most of these injuries are attributed to falls; however, injuries also occur when clothing or body parts become entrapped in the escalator.1 The CPSC has published safety recommendations for use of escalators, directed especially toward children.1 The American Society of Mechanical Engineers/American National Standards Institute has established a voluntary standard for escalators.2
There are 
33000 escalators operating in the United States.3 This is a relatively small number compared with the number of other vertical transport systems, such as the 660000 elevators in operation. However, there are differences in the frequency of injuries per operating unit. There are an estimated 9800 elevator-related injuries annually, yielding 15 (9800 of 660000) injuries per 1000 elevator units. By comparison, there are an estimated 221 (7300 of 33000) injuries per 1000 escalator units annually, a nearly 15-fold difference in magnitude.3
There have been no large-scale epidemiologic studies regarding escalator-related injuries. There are case reports dating back several decades that describe escalator-related injuries.4–7 Most of these reports concern incidents that occurred in countries other than the United States. Almost all reports involved young children, who were injured when a body part, usually the foot or the hand, became lodged between the escalator step and the sidewall. Murphy and Moore8 conducted a prospective survey of patients who were treated for escalator-related injuries at University College Hospital of London. Unlike previous case reports, the study population was only 6% children, and a number of injuries involved the use of alcohol (28%).
Platt et al9 conducted a retrospective chart review of children with escalator-related injuries during a 5-year period. The average age at the time of injury was 6 years, although half of study participants were 2 to 4 years. Half of the 26 children in that study sustained injuries that were serious enough to require surgical intervention, 4 children had injuries that resulted in functional loss of an extremity, and 12 injuries resulted in permanent disfigurement.9 To our knowledge, the study by Platt et al is the only study that attempted to describe the epidemiology of escalator-related injuries; however, the sample size was small and originated from only 1 hospital.
This study is the first to describe the epidemiology of escalator-related injuries among children using a national sample. We present the results of a descriptive analysis of escalator-related injuries that were reported through the National Electronic Injury Surveillance System (NEISS) during the 13-year period 1990–2002. Particular attention is given to the age-related differences in the mechanism of injury and the type of injury, especially among children who were younger than 5 years.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Escalator-related injuries were identified using the consumer product code for escalators (product code 1890). The narrative descriptions that were given for each case also were examined to determine further whether the case should be included in the analysis. Any cases that did not involve an escalator were removed. Most of these cases were injuries related to elevators or moving walkways and were miscoded as escalator-related. The narrative description of each case also was used to generate a new variable that described the mechanism of injury. The injury mechanism categories included fall, entrapment, combination of fall and entrapment, injury caused by stroller involvement, and other/not stated.
Data were analyzed by using SPSS 12.011 and Stata 8.0.12 National estimates were calculated using sample weights provided by the NEISS. The CPSC considers an estimate to be unstable and possibly unreliable when the estimate is <1200 or the number of sample observations is <20.12
The NEISS data set included information on patient age, gender, race, body region injured, type of injury, location of injury, and ED disposition. Estimates of the number of injuries were rounded to the nearest 100 when reported in the text of this article. Average annual injury rates for the 13-year period were calculated for the overall injury rate, by age group, and by gender. Population data that were used to estimate injury rates were obtained from the US Bureau of the Census.13,14 The denominators for all injury rates were calculated by averaging data for the 13-year period. For example, the escalator-related injury rate for 5- to 9-year-olds was calculated by dividing the estimated number of escalator-related injuries in the NEISS by the total number of 5- to 9-year-olds in the United States during 1990–2002 and then dividing the quotient by 13. Proportions with 95% confidence intervals (CIs) were calculated by age group for injury mechanism, injured body region, and injury type.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Injury Mechanism
Table 2 presents the age group–specific distribution of escalator-related injuries for injury mechanism, injured body region, and type of injury. The most frequent mechanism of injury was a fall, accounting for 13300 (51.0%) injuries. There was a consistent increase by age group in the proportion of injuries that were attributed to a fall (Fig 2). Conversely, there was a consistent decrease in the proportion of injuries that were attributed to entrapment by age group. Entrapment accounted for 36.5% (4373 of 11985) of injuries among children who were younger than 5 years, and the proportions of these injuries decreased with increasing age group.
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800 (2.9%) injuries. These injuries occurred almost exclusively among children who were younger than 5 years and most often were attributed to the child's falling out of the stroller while on the escalator. Six percent (723 of 11985) of injuries to children who were younger than 5 years involved a stroller. In addition, admittance to the hospital was required for 5.8% of injuries that involved a stroller compared with 2.1% of simple falls and 3.2% of entrapment injuries.
Body Region
The leg was the most frequently injured body region overall (27.7%) and for all age groups, with the exception of children who were younger than 5 years (Table 2). Injuries to the head accounted for 24.2% of injuries overall and 39.1% of injuries among children who were younger than 5 years. Twenty-three percent of all injuries were to the hand region (including the fingers); however, these injuries occurred most frequently among children who were younger than 5 years, accounting for 40.6% of injuries in this age group. Hand injuries among children who were younger than 5 years frequently occurred as a result of entrapment (72.4% [3531 of 4877]). There was an increase in the proportion of leg injuries by increasing age group, whereas there was a decreasing trend observed for head and hand injuries (Fig 3).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The highest escalator-related injury estimates and rates occurred among children who were younger than 5 years and decreased with increasing age group. Falls were a significant mechanism of injury for all ages, although falls occurred more frequently among older children. Falls among children who were younger than 5 years may be attributable to lack of coordination, strength, judgment, and experience with riding escalators. Supervision also may play a role in preventing escalator-related falls among children, particularly among children who are younger than 5 years. Chiaviello et al15 found that 71% of stairway falls among children who were younger than 5 years occurred when no supervision was present. These authors also showed that 90% of stairway-related injuries to children involved the head and that 82% of head or face injuries among children who were younger than 5 years were caused by falls. The findings in our study are consistent with their observations. In our study, the proportion of injuries to the head/face region was highest among children who were younger than 5 years (39%) compared with all other age groups. Young children are more likely to sustain head injuries than older children and adults because their heads are large relative to the rest of their body and their center of gravity is higher, causing them to topple head first. Young children also have not fully developed their upper extremity strength and coordination to help protect their head in a fall.
On the basis of our findings, children who are younger than 5 years may be at higher risk for escalator-related entrapment injuries. The proportion of entrapment decreased with increasing age, and nearly 60% of entrapment injuries occurred to children who were younger than 5 years. Among children who were younger than 5 years, the body region that most frequently was injured was the hand (41%). This is consistent with previous case reports of escalator-related injuries to children.5,6,9 Seventy-two percent of hand injuries among children who were younger than 5 years were caused by entrapment. Children's small hands and feet make it easier for them to become entrapped in the space between the escalator step and the sidewall, especially when there is a wide gap. Children may place their hands or feet in the side gap without realizing the danger, which underscores the importance of parental supervision when children ride an escalator. Holding a young child's hand or carrying the child while on an escalator will help to prevent him or her from putting hands or fingers between the escalator step and the sidewall or getting close enough to the sides to allow entrapment of loose clothing, shoelaces, or drawstrings. Escalator designs that reduce the gap between the steps and the sidewall or shield against access to the gap could decrease entrapment risk by removing the potential hazard from the environment. This redesign approach provides automatic, or "passive," protection that is most likely to prevent entrapment injuries in all age groups. Entrapment injuries among older children are less common but still a concern.
Strollers were involved in a significant proportion of escalator-related injury events among children who were younger than 5 years. The narrative section in the NEISS data set provided information regarding how some of these injuries occurred. Most injuries occurred to children as a result of falling out of the stroller. The CPSC recommends that children not be transported in a stroller on an escalator.1 Parents should find an alternative way, such as an elevator, of transporting their child from floor to floor if they want the child to remain in a stroller. If an escalator is used, then parents should remove their child from the stroller and carry him or her while on the escalator, making sure that they have 1 hand free to hold the escalator railing for balance.1 In addition, there were a small number of stroller-related injuries among older children who were 15 to 19 years of age. We hypothesize that these injuries occurred to older children perhaps while caring for a younger sibling, when they were maneuvering a stroller while riding the escalator.
Although the leg was the most frequent anatomic region injured for all ages combined, accounting for nearly 30% of injuries, leg injuries were less frequent among children who were younger than 5 years. Developmental differences between older and younger children likely account for the observation that older children primarily injure their lower extremities, whereas young children most frequently injure their hands and heads.
Lacerations were common among all children, especially children who were younger than 5 years. The hand or the fingers were the site of the laceration in 43% of cases involving children who were younger than 5 years. Children who were younger than 5 years accounted for >70% of all amputations and avulsions. More than 90% of amputations and avulsions in this age group were to the hand. These injury patterns are attributed to the frequency of entrapment injuries in children who are younger than 5 years. These findings are consistent with previously published reports of children with lacerations, amputations, and degloving injuries as a result of limb entrapment between the escalator step and the sidewall.4–7,9
The CPSC has issued recommendations to help prevent escalator-related injuries. These include removal of drawstrings from children's clothing; supervision of young children while using an escalator and holding the child's hand or picking up the child when riding on the escalator; not transporting children on the escalator in a stroller or cart; facing forward and holding onto handrails to avoid falls; and avoiding the sides of escalator steps to prevent entrapment between the escalator step and the sidewall.3 In addition, the American Society of Mechanical Engineers/American National Standards Institute has established a voluntary standard for escalators that stipulates clearance width between the edges of the steps and the skirt (3/16"), warning signs, and emergency shutoff buttons at the top and the bottom of escalators.2,10
Although there was not enough information in the NEISS data set to identify specific behavioral risk factors that lead to escalator-related injury, this still is important to address. Platt et al9 found that 31% of children who were injured on escalators in their study were riding the escalator improperly (eg, walking, running, playing, sitting on the escalator), and most of these children were older than 4 years. This may explain the higher frequency of falls among older children compared with younger children seen in our study, particularly if older children are more likely to engage in horseplay while riding the escalator.
In 1997, the CPSC was petitioned by the parents of a child who was injured on an escalator to develop mandatory safety standards for escalators, including (1) closing the gap between the escalator step and the sidewall, (2) informing the general public about the specific dangers of escalators, and (3) better warning signs posted at escalators. The CPSC denied the petition, citing that compliance with the voluntary standard would reduce the injury risk adequately.16
Limitations of this study include missing data and inconsistent documentation, particularly in the comments section of the NEISS data set. There was no uniform data collection protocol for the comments section, so estimates that were calculated from information that was provided in the narrative text (eg, mechanism of injury) may be underestimated if specific information was not given or overestimated if incorrect information was documented. Reporting of some injuries may be underestimated because there is documentation given for only 1 body region and 1 injury type per case in the NEISS data set. For example, if an individual sustains injuries to both the head and the hand, then only 1 of those injuries is included in the NEISS data set. Error also may result from incorrect documentation in ED medical charts or incorrect data entry into the NEISS database. Audits by the CPSC reduce error that is caused by the latter source. The relatively small number of cases in some subgroups prevented additional stratified analyses as a result of potential unreliability of calculated estimates.
Although this data set was weighted to be representative of all EDs in the United States, it does not include information on patients who had escalator-related injuries and were treated in other health care settings or who did not seek medical treatment. Therefore, the findings of this study may not be generalizable to all escalator-related injuries to children.
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CONCLUSIONS |
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FOOTNOTES |
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Address correspondence to Jennifer McGeehan, MPH, Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, 700 Children's Dr, Columbus, OH 43205-2664. E-mail: mcgeehaj{at}ccri.net
The authors have indicated they have no financial relationships relevant to this article to disclose.
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This article has been cited by other articles:
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  J. O'Neil, G. K. Steele, C. Huisingh, and G. A. Smith Elevator-Related Injuries to Children in the United States, 1990 Through 2004 Clinical Pediatrics, September 1, 2007; 46(7): 619 - 625. [Abstract] [PDF]
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