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Ladders Revisited RESEARCH Ladders revisited Biswadev Mitra, Peter A Cameron and Belinda J Gabbe he first major report of falls from ABSTRACT ladders as a significant cause of mor- Objective: To describe the epidemiology of falls from ladders in a state-wide tality and morbidity was published in T1 2,3 population. 1981. Single-centre studies in Australia and overseas studies4-7 have all concluded Design and setting: Retrospective review of data from the the Victorian State Trauma that falls from ladders result in significant Registry and the Victorian Emergency Minimum Dataset on patients presenting to mortality and morbidity, demanding public hospital emergency departments (EDs) with injuries due to a fall while climbing a focused injury prevention efforts. Under- ladder, from 1 July 2001 to 30 June 2005. standing the epidemiology of falls from lad- Main outcome measures: Overall trends in the incidence of ladder-related ED ders is crucial for developing targeted presentations, and in cases of major trauma, trends according to age, and trends The Medical Journal of Australia ISSN: according to activity at the time of the fall. prevention0025-729X1 strategies 1 January with 2007 the 186 greatest 1 31-34 Results: 4553 patients presented to EDs after falls from ladders in Victoria during the potential©The for Medical reducing Journal incidence. of Australia 2007 Ourwww.mja.com.au aims were to describe the epidemiol- study period; 160 patients had injuries classified as major trauma. There has been a ogy ofResearch falls from ladders resulting in serious significant rise in the number of presentations to EDs following falls from ladders in injury across a state-wide population (Vic- Victoria, with a marked increase in the number of cases involving patients aged over 50 toria, total population about 5 million), and years and those climbing ladders outside of paid working conditions. Deaths occurred to identify priority groups for future target- predominantly in the elderly after falls from heights above 1 metre. ing of prevention strategies. Conclusions: Despite knowledge of the dangers of falls from ladders, there has been a significant increase in the number of patients presenting to hospitals after ladder falls. METHODS Middle-aged to elderly patients undertaking unpaid work account for this increase. A targeted public health initiative is required to curb this trend. Over the 4 years from 1 July 2001 to 30 June 2005, we performed a retrospective MJA 2007; 186: 31–34 review of all Victorian patients who had an injury after falling from a ladder that was serious enough to warrant presentation at an Demographic, injury and outcome data The incidence rate ratio (IRR) and 95% CIs emergency department (ED) or classification for all patients were obtained from the data- were calculated; a P value < 0.05 was con- as major trauma. sets for analysis. Summary data provided by sidered significant. Data on all patients who presented to the the VEMD included demographic informa- ED of a Victorian public hospital after a fall tion, activity at the time of injury, cause of RESULTS from a ladder during the study period were injury, and disposition from the ED. Data obtained from the Victorian Emergency extracted from VSTORM included patient During the study period, 4553 patients pre- Minimum Dataset (VEMD). It is estimated demographic information, activity at the sented to Victorian public hospital EDs with that more than 80% of ED presentations time of injury, cause of injury, injury details injuries from falling from a ladder. Of these, are included in this dataset.8 Data on and in-hospital mortality. An injury was 160 patients were classified as major trauma injured patients classified as major trauma classified as work-related if the activity at cases on the basis of VSTORM inclusion were obtained from the Victorian State the time of injury was recorded as doing criteria. Box 1 shows the profile of ladder- Trauma Outcome Registry and Monitoring paid work for salary, bonus or other types of related falls presentations to EDs and cases (VSTORM) Group database. Inclusion cri- income, but excluded voluntary work. A classified as major trauma. The vast majority teria for the VSTORM database have been low fall was classified as a fall from a height of patients presenting to EDs and sustaining previously described,9 and include any of of 0 to 1 metre above the ground. major trauma from ladder falls were men. the following: death due to injury; an Stata (StataCorp, College Station, Tex, Presentations to the ED for ladder falls Injury Severity Score > 15; urgent surgery; USA) was used for all analyses. Population were most common in the 50–59-years age or an intensive care unit stay of more than estimates for Victoria were obtained from group (Box 1). Forty per cent of ED presen- 24 hours requiring mechanical ventilation. the Australian Bureau of Statistics.10 tations, and 70% of major trauma cases VSTORM collects data on all major trauma Descriptive statistics were used to summ- involved people aged 50 years or more. A cases for Victoria, and data quality checks arise the profiles of ED presentations and fall from a height greater than 1 metre was are performed against other databases major trauma cases. Population-based inci- the most common mechanism of injury, including Victorian Admitted Episode dence rates (95% CIs) were calculated for accounting for 59% of ED presentations and Data, Death Registry and Hospital data- each 12-month period based on the total 91% of major trauma cases. About 20% of bases. All VSTORM cases were admitted population at the end of June 2002, 2003, ladder-related falls resulting in ED presenta- through the ED. In both datasets, ladder- 2004 and 2005. A Poisson regression model tions and major trauma occurred while peo- related falls were identified by the inclu- was used to test for a dose–response effect of ple were working for income. Over a quarter sion of the word “ladder” in the text narra- increasing incidence over the 4 years by of people presenting to EDs after ladder- tive of the injury event and “fall” as the assuming a linear increase in the logarithm related falls (1191; 26.1%) were admitted to recorded cause of injury. of the rate with increasing calendar years. hospital (this excludes ED short-stay admis- MJA • Volume 186 Number 1 • 1 January 2007 31 RESEARCH sions). Overall, there were 16 deaths publication11) for categorising the 1 Profile of presentations to emergency (0.3% of people falling from ladders) causes of falls from ladders. Each factor departments and major trauma cases and all were related to a fall from a in Box 5 can be used to direct strategies resulting from ladder falls in Victoria height of over a metre (Box 1). for preventing falls. Various programs (2001–2005) Box 2 shows the population-based aimed at reducing falls at home exist, rates for ED presentations and major Emergency and a similar approach could be used to trauma from ladder-related falls over department target falls from ladders. the 4 years to 30 June 2005. Since Variable presentations* Major trauma Climbing ladders at home is a risk 2001, there has been a significant Total number 4553 160 behaviour that requires targeted modi- increase in the incidence of falls fication. Home visits by occupational Sex resulting in major trauma therapists have been used successfully (P < 0.001; IRR, 1.33; 95% CI, Male 3689 (81.4%) 152 (95.0%) to reduce low falls after hospital dis- 1.15–1.54) and emergency depart- Female 843 (18.6%) 8 (5.0%) charge.12 Home environment assess- ment presentations (P < 0.001; IRR, Age (years) ments, installation of safety devices 1.05; 95% CI, 1.02–1.08). < 20 316 (6.9%) 1 (0.6%) and educational programs have also The incidence of ED presentations been used to significantly reduce falls 20–29 404 (8.9%) 4 (2.5%) and major trauma in patients aged less among the elderly.13,14 than 50 years and 50 years or more is 30–39 685 (15.1%) 9 (5.6%) Risk assessment through interviews shown in Box 3. Since July 2001, there 40–49 875 (19.2%) 23 (14.4%) combined with feedback and counsel- had been a significant increase in the 50–59 943 (20.7%) 35 (21.9%) ling sessions have been successful 15 incidence of ED presentations 60–69 764 (6.8%) 40 (25.0%) strategies. Education in small groups (P<0.001; IRR, 1.10; 95% CI, 1.06–1.14) 70–79 442 (9.7%) 37 (23.1%) results in more behavioural changes and major trauma cases (P < 0.001; IRR, than individual education.16 A recent у 80 120 (2.7%) 11 (6.9%) 1.41; 95% CI, 1.19–1.67) related to report on the “Stepping On” program, ladder falls in those aged 50 years or Mechanism which included home environmental more. The rate of ladder-related falls Fall from р 1 m 1954 (42.9%) 14 (8.7%) safety assessments and education in leading to ED presentations and major Fall from > 1 m 2599 (57.1%) 146 (91.3%) small groups to reduce the risk of falls trauma for those less than 50 years has Activity at time of injury in the elderly, showed a 31% reduction not changed. in falls in the intervention group.17 Working for income 851 (18.7%) 33 (20.6%) The incidence of ladder-related ED † Ladder falls differ from low falls in that presentations and major trauma cases Unpaid work 657 (14.4%) 77 (48.1%) most of the successful interventions for grouped by whether or not patients Other‡ 3045 (66.9%) 50 (31.3%) prevention of repeated low falls occur were working for income at the time of Disposition after an initial fall, which allows tar- their fall over the period of the study is Discharge 3220 (70.7%)§ 99 (61.9%)¶ geted education messages.
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