Inova Regional Trauma Center - NHTSAHonda Inova Fairfax Hospital CIREN Center Payer for Pedestrian...

1Inova Fairfax Hospital

Falls Church, VA

Inova Regional Trauma CenterInova Regional Trauma Center

2

University of Virginia

INOVA REGIONAL TRAUMA CENTER

Honda Inova Fairfax Honda Inova Fairfax Hospital CIREN Hospital CIREN

TeamTeam

3

Honda Inova Fairfax Hospital CIREN Center

• Samir M. Fakhry, MD, Principal Investigator

• Anne Rizzo, MD, Co-Principal Investigator

• Refaat Hanna, M.D., M.A., Epidemiologist

• Christine Burke, CIREN Study Coordinator

• Greg Stadter, Crash Reconstructionist

• Rodney W. Rudd, Ph.D. CIREN Study Consultant

• Christopher Sherwood, Auto Safety Lab, University of VA

• Capt. Christine Woodard, Fairfax County Fire and Rescue

• Detective J.J. Banachoski, Fairfax County Police CRU

• Lt. Scott McLean, Prince William County Fire and Rescue

Team Members:

4Honda Inova Fairfax Hospital CIREN Center

Pedestrian Injuries: Analysis of the

Burden with Case Illustrations

5

• Address the unmet needs of the “walking” population

• Identify patterns of injuries among pedestrians to better understand mechanism of injury and develop efficient prevention methods

• Identify vehicle features that cause or mitigate injuries

• Educate pre-hospital healthcare providers to conduct on-scene triage based on specific crash criteria and injury criteria


CIREN Pedestrian Study Objectives

6

• Each year in the United States, there are 8,000 pedestrians killed and another 100,000 injured in traffic crashes.

• This accounts for 13% of the nation’s total traffic fatalities and 5% of injuries (FARS, NASS, GES).

• On average, a pedestrian injury occurs every six minutes and a pedestrian fatality occurs every 107 minutes in the United States (1).

• The proportion of pedestrian fatalities is a greater concern in many other countries, such as Japan, where pedestrians account for nearly 27% of total traffic fatalities, and in Europe, where the percentage reaches nearly 30% in the United Kingdom (2)

(1) 1. U.S. Department of Transportation, National Highway Traffic Safety Administration, 2000.2. Jason A. Stammen Roger A. Saul, National Highway Traffic Safety Administration


Burden of Pedestrian Injuries


Pedestrian Injuriesin the

Washington DC MetropolitanRegion

(DCMR)

8

For the purposes of this study, the DC Metro Region (DCMR)

is defined as the counties and municipalities of:

– Virginia (Northern Virginia)– District of Columbia (DC)– Maryland (Central Maryland)

The following data sets were available and analyzed for the years 1999-2004:

– Police car crash data– Injury related hospital discharge data – Injury mortality data – The rates are calculated using 2000 population data obtained

from US Census Bureau.


9

Summary• Approximately 3000 pedestrians are involved in

crashes with motor vehicles every year in the DC Metro region.

• The vast majority (92%) sustained one or more injuries.

• A significant percentage of these (17%) required hospitalization of 24 hours or longer.

• Average hospital charges of $17,000 to $30,000 per patient depending on the region.

• Approximately 80 pedestrians die each year. Honda Inova Fairfax Hospital CIREN Center

10

Vehicle Type and Maneuver

Pedestrian Crashes by Vehicle Type

2 1

13

78

5 2

13

93

2 2 3

83

0

10

20

30

40

50

60

70

80

90

100

Passenger car Trucks Bus Other/Not Stated

Northern Virginia

DC

Central Maryland


Pedestrian Crashes by Passenger Vehicle Maneuver

61

24

5

53

25

9

54

126

-

10

20

30

40

50

60

70

Straight Left/Right Turn Backing

Per

cen

t (%

)

Northern Virginia

DC

Central Maryland

Pedestrian Crashes by Trucks Maneuver

32

23

15

44

26

10

42

9

18

-

510152025303540

4550

Straight ahead Left/Right Turn Backing

Per

cent

(%

)

Northern Virginia

DC

Central Maryland

Pedestrian Crashes by Buses Maneuver

51

22

105

0

46

38

6

0

8

31

46

1 0 0-

10

20

30

40

50

60

Left/Right turn Straight ahead Backing Ran off road –right

Side Swiped

Per

cent

(%

)

Northern Virginia

DC

Central Maryland

Making left or right turn was the most common maneuver prior to pedestrian crashes by buses in both Northern Virginia and DC

11

Pedestrian crashes involving trucks and buses resulted in 11% and 10% mortality in both Northern Virginia and DC respectively


Mortality by Vehicle Type

Mortality by Vehicle Type

4

3

4

11

10

2

11 11

7

0

2

4

6

8

10

12

Northern Virginia DC Central Maryland

Per

cen

t (%

)

Passenger Vehicle

Trucks

Bus

12

Pedestrian Crashes by Day of Week Pedestrian Crashes by Day of the Week

-

2

4

6

8

10

12

14

16

18

20

Monday Wednesday Friday Sunday

Per

cen

t (%

)

Northern Virginia

DC

Central Maryland

Pedestrian crashes are higher during weekdays with the peak on Friday (Northern Virginia and Central Maryland)


13

Pedestrian Crashes by Time of Day DC 2000 to 2004

-

2

4

6

8

10

12

Midnight

1:00 AM2:00 AM

3:00 AM4:00 AM

5:00 AM6:00 AM

7:00 AM8:00 AM

9:00 AM10:00 AM

11:00 AM

12:00 PM

1:00 PM2:00 PM

3:00 PM4:00 PM

5:00 PM6:00 PM

7:00 PM8:00 PM

9:00 PM10:00 PM

11:00 PM

Per

cent

(%

)

Pedestrian Crashes by Time of Day Central Maryland 2000 to 2003

-123456789

10

Midnight

1:00 AM2:00 AM

3:00 AM4:00 AM

5:00 AM6:00 AM

7:00 AM

8:00 AM9:00 AM

10:00 AM

11:00 AM

12:00 PM

1:00 PM2:00 PM

3:00 PM4:00 PM

5:00 PM6:00 PM

7:00 PM

8:00 PM9:00 PM

10:00 PM

11:00 PM

Per

cen

t (%

)

Pedestrian Crash by Time of Day Northern Virginia Police Crash Data 1999 to 2003

0

2

4

6

8

10

12

Midnight

1:00 AM

2:00 AM3:00 AM

4:00 AM

5:00 AM

6:00 AM

7:00 AM

8:00 AM

9:00 AM10:00 AM

11:00 AM

12:00 PM

1:00 PM2:00 PM

3:00 PM

4:00 PM

5:00 PM

6:00 PM

7:00 PM8:00 PM

9:00 PM10:00 PM

11:00 PM

Per

cen

t (%

)


Time of the Crash

14

Pedestrian Injury Hospitalization by State of Residence in DC

Pedestrian Injury Hospitalizations by State of Residence DC 2001 - 2002

50

39

83

-

10

20

30

40

50

60

Washington DC Maryland Virginia Other/Unknown

Per

cent

(%)

Fifty-percent of the pedestrian injured in Washington DC are non-residents of the city


15

Pedestrian Age

Pedestrian Crashes by Age

0

5

10

15

20

25

0 to 4 5 to 9 10 to14

15 to19

20 to24

25 to34

35 to44

45 to54

55 to64

65 +

Per

cen

t (%

)

Northern Virginia

DC

Central Maryland

Children in DC aged 5 to 9 years were more than twice as likely as the same age group in both Northern Virginia and Central Maryland to be involved in a pedestrian crash


Pedestrian Injury Hospitalizations by Age

0

5

10

15

20

25

0 to 4 5 to 9 10 to14

15 to19

20 to24

25 to34

35 to44

45 to54

55 to64

65 +

Per

cent

(%)

Northern Virginia

DC

Central Maryland

In Washington DC, pedestrian hospitalizations are significantly higher among children aged 0 to 9,

compared to the same age group in both Northern Virginia and Central MarylandPedestrian Deaths by Age

0

5

10

15

20

25

0 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 &above

Perc

ent (

%)

Northern Virginia

DC

Central Maryland

In Washington DC, pedestrian deaths are significantly higher among children aged 0 to 9,

compared to the same age group in both Northern VA and Central MD

Average Hospital Charges by Age

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

0 to 4 5 to 9 10 to14

15 to19

20 to24

25 to34

35 to44

45 to54

55 to64

65 +

Northern Virginia

DC

Central Maryland

In Washington DC, hospital charges are significantly higher for children aged 5 to 14 years

16

Pedestrian Injury Hospitalizations by Race Northern Virginia 1999 to 2003

8

6

43 2

0

2

4

6

8

10

Hispanic Black Other White Asian

Rat

e/10

0,00

0

Pedestrian Injury Hospitalizations by Race DC Residents Only 2001 to 2002

33

21

10

1-

5

10

15

20

25

30

35

Other Black White Asian

Rat

e/10

0,00

0Pedestrian Injury Hospitalizations by RaceCentral Maryland 2000 - 2003

14

11

7

0

2

4

68

1012

14

16

Other Black White

Rat

e/10

0,00

0

“Other” Races refers to: Hispanics, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, Middle Eastern and Asians (in Central Maryland)


Pedestrian Injury By Race

17

Driver age and Gender in Pedestrian Crashes

Age of Drivers Northern Virginia 1999 to 2003

10

2119

14

8

6

13

8

-

5

10

15

20

25

15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 + Unknown

Per

cent

(%

)

Young drivers aged 15 to 24 were the third highest age group to be involved in pedestrian crashes


Gender of Drivers Northern Virginia 1999 to 2003

Female33%

Unknown13%

Male54%

18

Driver Violation Prior to Pedestrian Crash

Drivers Violation Prior to Pedestrian Crash Northern Virginia 1999 to 2003

48

13 118 9

53 1

-

10

20

30

40

50

60

None Driverinattention

Hit and run Did not haveright-of-way

Otherviolations

Not stated Improperbacking

Exceededspeed limit

Per

cen

t (%

)


19

Pedestrian Hospital Charges and Payments

Average Hospital Charges for Different Types of Injuries Northern Virginia 1999 to 2003

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

Firea

rm

Pede

strian

MV traff

ic

Suffoc

ation

Machine

ry Fall

Transp

ort oth

er

Fire fla

me burn

Struck

by

Pedal

cyclis

t other

Ave

rage

Cha

rges

($)

Pedestrian Injuries are the second most costly injuries after firearms


Payer for Pedestrian Hospital Charges

-10203040506070

Commercial

Medicare

Medicaid

Indigent/Charity

Self Pay

Other

Per

cent

(%)

Northern Virginia DC

Central Maryland

Medicaid and Self-Pay accounted for about 50% of payers in both Washington DC and Central Maryland

20

Maps of DC by Pedestrian Injury, Population Density, Race and

Poverty

D.C. PovertyD.C. Poverty

7.4-12%19-22%25%36%

nn Poverty rate 16.9% Poverty rate 16.9% nn National Avg.: 12.5 %National Avg.: 12.5 %

nn Unemployment 7.7 % Unemployment 7.7 % nn National Avg.: 5.8 %National Avg.: 5.8 %

D.C. African American PopulationD.C. African American Population

6%20%46%64-71%88-97%

Source: Center for Social Justice Research, Teaching and Service. 2000. DC Maps.

Source: Inova Regional Trauma Center

4 0 4 8 Miles

N

EW

S

Population Density Washington DC 2001

Frequency0 - 18911892 - 44714472 - 1730417305 - 3383033831 - 58216

21

Methodology• Case Selection Criteria

– Admitted to the trauma center – MAIS 2+ injury – Struck by the front of the vehicle– Upright when struck– Hit by a passenger car, SUV, minivan or small

pickup truck– Pedestrians struck by a large vehicle such as a

bus or tractor trailer, were run over or were sitting/lying down when they were struck are excluded from the study


22

Methodology• Enrollment & Consent

– Eligible patients and families are approached by hospital personnel to obtain “Informed Consent”

– Police contacted to obtain a crash report to identify vehicle owner/driver

– Vehicle owner is visited to obtain “Informed Consent”

– Medical information and vehicle information is required to complete case


23

Methodology• Data Collection

– Medical• Pre-crash data from EMS reports and interviews• Full hospital medical records• Patient interview• Photographs of injuries• Anthropometric measurements• 6 & 12 month follow-up health survey• Injuries & procedures are reviewed and coded

– AIS, ICD-9, CPT codes


24

Methodology• Data Collection

– Vehicle & Crash• Data is collected along Pedestrian Crash Data

Study (PCDS) protocols• Police report (vehicle & owner information,

scene diagram & photos)• Impact speed estimation (skid mark analysis,

throw distance calculation)• Vehicle inspection (damage/deformation profile,

contact marks)


25

Methodology• Reconstruction & Simulation

– MADYMO multi-body modeling• Pedestrian Model (anthropomorphicmeasurements)

• Vehicle Model (facet or ellipsoid model, UVA database)

– Simulation Matrix• Multiple orientations & speeds to match witness marks and injury

outcome

168

132

84

44

Broken/bent

ShoulderLeft side folding mirror

BrokenHeadWindshield

ScratchedShoulderA pillar

Bent HipHood edge

EvidenceBody Region

Component Contacted

26

Challenges• Case Enrollment

– 47 Cases Investigated– Socioeconomic challenges

– Homelessness– Physiological and dependency issues

• Legal concerns & other repercussions• Inability to consent

– Vehicle owner consent is very difficult• Concerned about legal issues• Guilt over the event• Vehicles are often repaired soon after the event• Necessary to inspect the vehicle

– Currently necessary vehicle data and photos are obtained from police when inspection is not possible



Case Illustrations


• Male age 17 attempting to cross at an intersection against the light at 22:40. Clear & dry condition on a Saturday evening in the fall.

• Driver of 2003 Chrysler Town & Country van did not observe pedestrian until impact.

• The pedestrian was struck on his left side.

Case #1


Pedestrian Wrap Measurements

162cm

134 cm

90 cm

47 cm

45 cm

55 cm

80 cm93 cm

165 cm

275 cm

237 cm


DentedShoulderFront fender top surface

Broken/bent

ShoulderLeft side folding mirror

BrokenHeadWindshield

ScratchedShoulderA pillar

ScratchedHipFront fender top surface

BentHipFront fender top surface

Bent HipHood edge

CrackedHipHeadlight

CrackedLegFront bumper

EvidenceBody Region

Component Contacted

Vehicle


Case Summary:è On scene: pedestrian unconscious, fixed and dilated pupils, è Transported by air to the trauma center - intubated by flight crewè In trauma bay: pupils sluggishly reactive but equal, GCS 3Tè Physical examination notable for:è positive for alcohol consumption, contusions lower extremities

è Radiological examination significant for:è left frontoparietal and temporal subdural hematomaè right subdural and frontotemporal contusionè left lateral superior and inferior pubic rami & acetabulum fractures

èTo OR for: è right-sided hemicraniectomyè evacuation of subdural hematomaè debridement of contused brain

Case Summary

32

Case Summary Continued


Case Summary (continued):è Admitted to TICU, remained intubated & sedated on TBI protocolè HD # 5 underwent tracheostomy and PEGè Slowly improved, sedation weaned down, to IMC on HD # 7èNeurological status slowly improving, to floor on HD # 10 è Received cognitive evaluation along with PT and OTè Returned to OR on HD # 58 for cranioplasty - reimplant bone flapè Due to financial issues could not be transferred to rehabilitation è Discharged home with family on HD # 62è RLAS at discharge was VI; able to communicate in his native language, following some commands, able to ambulate with some assistance, able to eat a regular dietè Hospital Charges: $151,736


Injuries (ICD) AIS

Severity

Info

Source

Aspect

(R,L,bilat,etc)

Contact Area

(door, seat,etc)

Subdural hematoma

(852.25)

140654.5 CT Right

Left

A-Pillar &

contra coup

injury

Temporoparietal

contusion (851.05)

14608.4 CT Right A-pillar – contra

coup injury

Injuries

34

Injuries Continued


Injuries (ICD) AIS

Severity

Info

Source

Aspect

(R,L,bilat,etc)

Contact Area

(door, seat,etc)

Hip contusion

(924.01)

890402.1 Exam Left Fender

Pubic rami fracture

(808.2)

852602.2 CT Left – superior

& inferior

Fender

Acetabulum fracture

(808.0)

852602.2 CT Left Fender

35

Injuries Continued


Injuries (ICD) AIS

Severity

Info

Source

Aspect

(R,L,bilat,etc)

Contact Area

(door, seat,etc)

Knee abrasion

(916.0)

890202.1 Exam Right Ground


• Male age 35 attempting to cross a 7-lane roadway at 19:00. Clear & dry conditions, on a Sunday evening in the winter.

• Driver of 1997 Honda Accord did not observe pedestrian until impact.

• Pedestrian was struck on his right side

Case #2


Pedestrian Wrap Measurements

172 cm

148 cm

100cm

48 cm

40cm

50 cm

71 cm78cm

180 cm

270cm


Vehicle 1

39

Case Summary


Case Summary:èOn Scene: pedestrian found conscious and alert, deformities to the left arm & right lower extremity as well as laceration to the left scalpèImmobilized and transported to the Trauma Center by airèPhysical examination notable for:è left temporal scalp laceration, swelling of right shoulder, deformed right lower extremity, positive for alcohol consumption

èRadiological examination identified:è right comminuted tibia and fibula fracturesè right comminuted proximal humerus fractureè CT scan of head negative for intracranial injury

èRight lower extremity splinted, right arm placed in slingèAdmitted to IMCèTo the OR on HD # 2 for:èfour-compartment fasciotomyèexternal fixator to the right lower extremity

40

Case Summary Continued


Case Summary (continued):

èRemained stable, transfer to the ward on HD # 3èReturned to the OR on HD # 4 for:èORIF of the right proximal humerus fractureèdebridement and irrigation of the right lower extremity

è Returned to the OR on HD # 10 for:è removal of external fixatorè plating of the right fibula with wound closure

è PM&R evaluation diagnosed cerebral concussion - RLAS of VIIè Discharged home with home health services on HD # 15è Hospital Charges: $78,965

41

Injuries


Injuries (ICD) AIS

Severity

Info

Source

Aspect

(R,L,bilat,etc)

Contact Area

(door, seat,etc)

Cerebral concussion

(850.0)

161000.2 Exam Whole Windshield

Scalp laceration

(873.0)

190602.1 Exam Left Windshield

42

Injuries Continued


Injuries (ICD) AIS

Severity

Info

Source

Aspect

(R,L,bilat,etc)

Contact Area

(door, seat,etc)

Humerus fracture

(812.0)

752604.3 X-ray Right Cowl/base of

windshield

43

Injuries Continued


Injuries (ICD) AIS

Severity

Info

Source

Aspect

(R,L,bilat,etc)

Contact Area

(door, seat,etc)

Thigh abrasion

(916.0)

890202.1 Exam Right Leading edge of

hood

Tibia fracture

Fibula fracture

(823.2)

853422.3

851606.2

X-ray Right Bumper

Heel contusion

(928.20)

890402.1 Exam Right Unknown

44

1. Head Injuries

Ø Comparison of PCDS and CIREN data

Ø Risk of head injury significantly decreases when the head strikes the center of the windshield

Ø Risk of head injury (AIS > 2) is two (2) times more likely when the head strikes around the edge of the windshield

2. Humerus Fractures

• Comparison of PCDS and CIREN data could not be done for humerus fractures based on selection criteria

• CIREN pedestrians are at an increased risk for humerusfractures; 23% of CIREN pedestrian cases involve a humerus fracture compared with 7% of PCDS cases


Examples of Lessons Learned


We would like to thank the following agencies for making this project a success:

Honda R&D Co. Ltd

The Fairfax County Police Crash Reconstruction Unit

Fairfax County EMS

Prince William County EMS

Conclusion

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