Photo: E ric Cote/Sh utterstock

CONCUSSION AMONG CHILDREN & YOUTH: COASTAL HEALTH AUTHORITY The Injury Research and Prevention Unit (BCIRPU) was established by the Ministry of Health and the Minister’s Injury Prevention Advisory Committee in August 1997. BCIRPU is housed in the Evidence to Innovation theme within the Child and Family Research Institute (CFRI) and supported by the Provincial Health Services Authority (PHSA) and the University of British Columbia (UBC). BCIRPU’s vision is “to be a leader in the production and transfer of injury prevention knowledge and the integration of evidence-based injury prevention practices into the daily lives of those at risk, those who care for them, and those with a mandate for public health and safety in British Columbia”. Acknowledgements: The BC Injury Research and Prevention Unit (BCIRPU) would like to acknowledge the contributions of Child Health BC in the development of this report. In particular, BCIRPU would like to acknowledge Jennifer Scarr, Provincial Lead, Health Promotion, Prevention and Primary Care, Child Health BC, who assisted in obtaining the National Ambulatory Care Reporting System data and provided the maps. Child Health BC is a network of BC health authorities, BC government ministries, health professionals, and provincial partners dedicated to improve the health status and health outcomes of BC’s children and youth by working collaboratively to build an integrated and accessible system of health services. One of the focus areas of Child Health BC is injury prevention.

Authors: Fahra Rajabali, Rachel Ramsden, Marina Wada, Kate Turcotte, Shelina Babul

Reproduction, in its original form, is permitted for background use for private study, education instruction and research, provided appropriate credit is given to the BC Injury Research and Prevention Unit. Citation in editorial copy, for newsprint, radio and television is permitted. The material may not be reproduced for commercial use or profit, promotion, resale, or publication in whole or in part without written permission from the BC Injury Research and Prevention Unit.

For any questions regarding this report, contact:

BC Injury Research and Prevention Unit F508-4480 Oak Street Vancouver, BC V6H 3V4 Email: [email protected] Phone: (604) 875-3776 Fax: (604) 875-3569 Web page: www.injuryresearch.bc.ca

Suggested Citation: Rajabali F, Ramsden R, Wada M, Turcotte K, Babul S. Concussion in Children and Youth: Vancouver Coastal Health Authority. Vancouver, BC: BC Injury Research and Prevention Unit; 2015.

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KEY HIGHLIGHTS The purpose of this report is to provide details on the  Male children and youth had twice the rates of burden of concussion hospitalizations among children concussion hospitalizations as females and youth in Vancouver Coastal Health Authority. This (14.8/100,000 vs. 7.4/100,000). report is targeted to health care providers and com-  The leading causes of child and youth concussion munity stakeholders in the health authority to be used hospitalizations were due to falls (52%) and to facilitate discussion of the need for standardized transport-related events (31%). concussion prevention, diagnosis and management  Among children and youth aged 0 to 19 years in specific to children and youth. Vancouver Coastal Health, those aged 1 to 4 years Evidence suggests that children and youth are at had the highest rates of fall-related concussion greater risk of concussion and more serious head hospitalizations (10.4/100,000) and those aged 10 injury than the general population, take longer than to 19 years had the highest rates for transport- adults to recover following a concussion, and that related concussions (6.2/100,000). concussions can permanently change the way a child  Older children in Vancouver Coastal Health or youth talks, walks, learns, works and interacts with experienced a larger proportion of sports-related others. concussion hospitalizations as compared to younger children, with a greater rate of occurrence among Concussion management and appropriate return to males rather than females. activity is crucial, particularly in the paediatric and  Cycling (36.1%), playground (12.9%), and ski and adolescent populations. Active and timely rehabilita- snowboard (11.6%) activities were the greatest tion is essential for concussion patients who remain contributors for sport and recreation-related symptomatic longer than a six-week period. This may concussion hospitalizations in Vancouver Coastal include physiotherapy, occupational therapy, educa- Health among children and youth 0 to 19 years old. tional support, neuropsychology and in some cases,  Child and youth residents within North Shore/Coast neuropsychiatry. Garibaldi had the highest rates of concussion It is important to note that an individual is 3-times hospitalizations (22.3/100,000), with 70.1 percent more likely to sustain a second concussion while admitted to Vancouver Coastal Health hospitals. recovering from the primary concussion. Further-  Leading causes of child and youth fall-related more, while a rare occurrence, a condition known as concussion hospitalizations in Vancouver Coastal second-impact syndrome (SIS) may occur if a second Health were ‘fall involving skates, skis and skate- injury to the brain is sustained within a day or two boards’ (19.0%) and ‘fall on the same level’ (16.8%). after the first concussive event. This leads to swelling  Leading causes of child and youth transport-related of the brain that can result in brain damage, causing concussion hospitalizations in Vancouver Coastal severe disability and in a few cases even death. Health were ‘pedal cyclist’ (56%) and ‘motor vehicle Concussions are the most common form of head occupant’ (19.3%). injury, yet this significant health issue is under-  Rates of emergency department visits within reported due to a lack of education and awareness Vancouver Coastal Health were highest among among the general public and inconsistent and males and among children aged 0 to 4 years. limited availability of data around the burden of this  Lions Gate Hospital reported the highest number of injury. The data presented in this report represent concussion emergency department visits (710 visits) only a fraction of the children and youth that may within Vancouver Coastal Health from 2013/14 to have sustained a concussion, as this report does not 2014/15. capture concussions treated at physicians’ offices, Concussions remain a significant health issue for walk-in clinics, or those not recognized and treated children and youth in Vancouver Coastal Health, and at all. require further attention given the potential for long- Highlights include but are not limited to the following: lasting effects. This may include concussion prevention, education and awareness, standardizing  From 2001/02 to 2013/14 there were 354 care, and ensuring correct treatment protocols are concussion hospitalizations among children and adhered to and appropriate concussion management youth aged 0 to 19 years. is employed. ii

TABLE OF CONTENTS

KEY HIGHLIGHTS ...... ii INTRODUCTION ...... 1 Purpose ...... 1 METHODOLOGY ...... 1 Data Sources ...... 2 Analysis ...... 2 Data Limitations ...... 3 CONCUSSION HOSPITALIZATION...... 2 Fall-related Concussion Hospitalization ...... 6 Transport-related Concussion Hospitalization ...... 9 Sport and Recreation-related Concussion Hospitalization ...... 11 Concussion Hospitalization between Health Service Delivery Areas ...... 13 Concussion Hospitalization by Health Service Delivery Area: Vancouver Coastal South ...... 16 Concussion Hospitalization by Health Service Delivery Area: Vancouver Coastal East ...... 17 Concussion Hospitalization by Health Service Delivery Area: Vancouver Coastal North ...... 20 CONCUSSION EMERGENCY DEPARTMENT VISIT RATES ...... 23 CONCLUSION ...... 28 REFERENCES ...... 30

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INTRODUCTION Children and youth are at greater risk of concus- Active and timely rehabilitation is essential for sion and more serious head injury than the concussion patients who remain symptomatic general population. Concussions are the most longer than a six-week period. This may include common form of head injury, yet it is believed physiotherapy, occupational therapy, educational that they are under-reported owing to both a lack support, neuropsychology and in some cases of consensus in the definition of a concussion and neuropsychiatry. It is important to note that an the presence of misconceptions among the individual is 3-times more likely to sustain a general public on the symptoms of concussion second concussion while in recovery from a [1]. The rate of concussion hospitalization in the concussion [7]. Also, while rare, a condition adult at-risk population has been measured at 1 known as second-impact syndrome (SIS) may to 3 per 1,000 in the United States, but it is occur if a second injury to the brain is sustained estimated that the true concussion rate could be within a day or two of the first concussion event, as high as 6 per 1,000 [2]. Nonetheless, where swelling of the brain that can result in concussions reportedly account for 3 to 8 percent brain damage causing severe disability or even of all sports-related injuries among youth death [8]. presenting to urban emergency departments in Purpose Canada, which is expected to increase as public The purpose of this report is to provide details awareness rises [1, 3]. Furthermore, studies using on the burden of unintentional concussion national injury reporting databases in the United hospitalizations and emergency department States indicate that sports-related injuries are visits among children and youth living within or responsible for 46 to 58 percent of all attending any of the hospitals in the Vancouver concussions suffered by youth between the ages Coastal Health Authority. This report will be of 8 and 19 years [1, 4]. Comparable Canadian used to facilitate discussion of the need for data are not available. standardized concussion prevention, diagnosis Concussion, also known as mild traumatic brain and management specific to children and youth. injury (mTBI), occurs as a result of an impact to or Concussion as a health event is recognized to be forceful motion of the head, resulting in a jarring under-reported and inconsistently coded. of the brain. This may lead to a brief alteration of Concussion may also be labelled as a minor mental status, which may include: confusion, loss traumatic brain injury (mTBI), or sometimes as a of memory directly preceding the event, sensiti- ‘head injury’, which may include other injuries vity to light, slurred speech, dizziness, emotional not involving the brain. changes, and may or may not be accompanied by loss of consciousness or seizures [1, 5, 6]. Evidence exists that children and youth take longer than adults to recover following a concussion [1], and that concussion can permanently change the way a child or youth talks, walks, learns, works and interacts with others. Therefore, concussion management and appropriate return to activity protocol are crucial, particularly in the paediatric and adolescent populations.

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METHODOLOGY Data Sources extracted using postal code information that Hospitalization Data: The Discharge Abstract represented the residence of the patient. Data Database (DAD) obtained from the BC Ministry of for BC Children’s hospital was available from April Health was used to provide information on 1, 2012 to May 21, 2015. concussion hospitalizations for the fiscal years 2001/02 to 2013/14. The data include external Analysis causes of injury classified according to Hospitalization rates were calculated per International Classification of Disease (ICD)-10 100,000 population for age, sex, year and CA. In 2001, injury hospitalization data coding leading cause of injury. Age-specific and crude switched from ICD-9 to ICD-10 CA. By 2002, all rates are used in the report to describe actual hospitals in BC reported using ICD-10 CA for their burden rather than comparative rates across Discharge Abstract Data. Differences in numbers time and regions (where age-standardized rates between 2001 and 2002 may be attributed to would normally be used). The age-specific rates some hospitals still converting to the new coding were calculated by dividing the number of cases structure. Unintentional concussion hospitaliza- in each age group by the population of that tions were also extracted separately using ICD-10 specific age group within Vancouver Coastal CA code S06. The hospitalization data include all Health. Rates presented by region are based on acute, rehab and day surgery cases. The data are the patients’ residence and not the location of based on hospital separations rather than on injury occurrence. patient, therefore multiple admissions of the Emergency department rates for Vancouver same patient for the same injury would be Coastal Health residents were calculated per counted as separate cases. 100,000 population for the region and rates for Emergency Department Visit Data: Emergency each hospital were calculated per 100,000 department visit data are reported in two emergency department visits for all diagnoses. segments. The first is using all emergency Population data were obtained from BC Vital department visits from hospitals within Statistics Agency. Vancouver Coastal Health, and the second is emergency department visits to the BC Children’s Trend analyses were conducted using a linear Hospital by residents of Vancouver Coastal regression model to test the statistical signi- Health. Data were obtained from Decision ficance of the association between injuries over Support Services, Provincial Health Services time. This test appraises the linear component Authority (PHSA). The emergency department of the relationship between injury rates and data are part of the National Ambulatory Care scores allocated to the categories of time (cal- Reporting System (NACRS). Data were available endar years). In addition, Z tests for proportions for fiscal years 2012/13 to 2013/14 by age, sex were conducted to test significance between and type of injury. Unintentional concussion age groups and region. emergency department visits were extracted Definitions for leading causes of concussion: separately using ICD-10 CA code S06. External  Transport-related events include: crashes codes for injury were not available and data by involving cars, trucks, motorcycles, bicycles, cause of injury are therefore not presented for pedestrians, etc. emergency department visits. Data for emer-  Falls include: fall on the same level, fall from gency department visits to BC Children’s Hospital a height, falls on stairs or steps, fall from a by residents of Vancouver Coastal Health were building or other structure, etc. 2

 Struck by/against an object includes: forceful contact with a falling object, striking against or struck accidentally by objects or persons, and caught between objects, depending on the coding system, struck by/against an object involving sport may be captured by sports and recreation activities. This category does not include assault.  Sports and recreational activities include: falls on same level from collision, pushing or shoving by or with other person in sports; striking against or struck accidentally by objects or persons in sports; and object in sports with subsequent fall.

Data Limitations Concussion as a health event is recognized to be under-reported and inconsistently coded. Concussion is often not clearly defined and may also be labelled as a minor traumatic brain injury (mTBI), or sometimes as a ‘head injury’ that may include other injuries not involving the brain. The data presented in this report represent only a fraction of the children and youth that may have sustained a concussion. This report does not capture concussions treated at physician offices, medical clinics, or not treated at all. Hospitalization data can vary over time and be- tween areas for factors not related to health, such as accessibility of treatment, and medical or administrative decisions that may affect the number of hospitalizations and lengths of hospital stay [9, 10].

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CONCUSSION HOSPITALIZATION There were 354 hospitalizations among children Concussion hospitalization rates were lowest and youth aged 0 to 19 years resulting from among infants less than one year of age concussion within Vancouver Coastal Health over (5.5/100,000), and highest among 10 to 14 year the 13-year period from 2001/02 to 2013/14. olds (16.6/100,000), followed by teens 15 to 19 years of age (10.7/100,000) (Figure 1).

Figure 1: Concussion hospitalization counts and rates by age group, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

120 20.0

16.0 80 12.0

8.0 40

4.0 NumberofHospitalizations 0 0.0 Rate per 100,000 Population <1 1-4 5-9 10-14 15-19 Number of 7 57 91 113 86 Hospitalizations Rate per 100,000 5.5 11.8 14.7 16.6 10.7 Population Age Group

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Concussion hospitalization rates among children 100,000, and were lowest in 2012/13 at 8.4 per and youth were seen to vary from 2001/02 to 100,000 (Figure 2). Rates peaked for females in 2013/14 (Figure 2). Rates peaked in 2006/07 at 2001/02 at 15.6 per 100,000 and were lowest in 20.6 per 100,000 and were lowest in 2010/11 at 2008/09 at 2.0 per 100,000. 6.3 per 100,000. Concussion hospitalization rates Males accounted for 72.3 percent (n=256) of all were consistently higher among males than concussion hospitalizations among children and females from 2001/02 to 2013/14. youth. Rates for males were higher than for Concussion hospitalization rates peaked for females among all age groups, except among males aged 0 to 19 years in 2006/07 at 31.5 per infants less than one year of age (Figure 3).

Figure 2: Concussion hospitalization rates by year and sex, ages 0-19 years, Vancouver Coastal Health, 2001/02 - 2013/14. 40.0

30.0

20.0

10.0

0.0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Rate per 100,000 Population /02 /03 /04 /05 /06 /07 /08 /09 /10 /11 /12 /13 /14 Males 18.4 24.7 20.2 16.6 24.9 31.5 12.1 15.0 19.6 9.3 15.9 8.4 20.3 Females 15.6 8.7 11.7 9.8 6.9 8.9 6.0 2.0 5.1 3.0 6.1 6.0 7.0 Total 17.0 16.9 16.1 13.3 16.2 20.6 9.2 8.8 12.6 6.3 11.2 7.2 13.9 Year

Figure 3: Concussion hospitalization rates by age group and sex, ages 0-19 years, Vancouver Coastal Health, 2001/02 - 2013/14.

50.0 40.0 30.0 20.0 10.0 0.0

<1 1-4 5-9 10-14 15-19 Rate per 100,000 Population Males * 16.1 22.3 21.5 16.1 Females 8.2 7.3 6.7 11.3 4.9 Total 5.5 11.8 14.7 16.6 10.7 Age Group

Note: * Represents fewer than 5 cases 5

Leading causes of concussion hospitalization Leading causes varied by age group, with falls among children and youth included falls, being the leading cause for 0 to 14 year olds, transport-related events and struck by/against an while transport-related events were the leading object (Figure 4). Fall-related concussion hospital- cause of concussion hospitalizations for 15 to 19 ization was the leading cause for both males and year olds (Figure 5). Concussion hospitalization females at 9.3 per 100,000 and 4.1 per 100,000, rates for falls were highest among 1 to 4 year olds respectively. Of those concussions caused by (10.4/100,000), while transport-related struck by/against an object, 62.7 percent concussion rates were highest among both 10 to occurred during sport and recreation activities. 14 and 15 to 19 year olds (both at 5.4/100,000) (Figure 5).

Figure 4: Concussion hospitalization rates by cause and sex, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

12.0

8.0

4.0

0.0 Falls Transport Struck by Object Males 9.3 5.2 3.6

Rate per 100,000 Population Females 4.1 2.8 0.7 Total 6.8 4.0 2.2 Cause of Injury

Note: Total also includes other causes of concussion hospitalizations which are not shown as there are no or fewer than 5 cases.

Figure 5: Concussion hospitalization rates by cause and age group, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14. 24.0

16.0

8.0

0.0 <1 1-4 5-9 10-14 15-19 Transport 0.0 * 4.2 5.4 5.4 Falls 5.5 10.4 8.4 6.7 3.6

Rate per 100,000 Population Struck by Object 0.0 * 2.1 4.4 1.5 Total 5.5 11.8 14.7 16.6 10.7 Age Group

Note: * Represents fewer than 5 cases; Total also includes other causes of concussion hospitalizations that are not shown as there are fewer than 5 cases. 6

Fall-related Concussion Hospitalization Concussion hospitalizations among children and Among young children aged 1 to 4 years, falls from youth resulting from a fall were primarily the result furniture and falls from stairs, steps, ladder and of a fall involving skates, skis and skateboards scaffolding were the leading causes of fall-related (19.0%, n=35) and falls on the same level (16.8%, concussion (both at 2.1/100,000) (Figure 7). Falls n=31) (Figure 6). Over a quarter of cases were involving skates, skis and skateboards resulting in a classified as “other and unspecified” falls (26.6%, concussion were more common among older n=49). youth ages 10 to 14 years (2.3/100,000) and 15 to 19 years (1.7/100,000).

Figure 6: Proportion of fall-related concussion hospitalizations by type of fall, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

Fall involving skates, skis, skateboards 19.0

Fall on same level 16.8 Fall involving bed, chair and other 11.4 furniture Fall on and from 10.9 stairs/steps/ladder/scaffolding

Typeof Fall Fall involving playground equipment 10.3

Fall from high level 4.9

Other and unspecified fall 26.6

0.0 5.0 10.0 15.0 20.0 25.0 30.0 Percent of Falls

Note: ‘Other and unspecified falls’ includes fall involving ice and snow and fall involving wheelchair.

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Figure 7: Fall-related concussion hospitalization rates by type of fall and age group, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

3.5

3.0

2.5

2.0

1.5

1.0

Rate per 100,000 Population 0.5

0.0 Fall Fall on and Fall Fall involving from Other and Fall on involving involving Fall from bed, chair stairs/steps unspecified same level skates, skis, playground high level and other /ladder/ Fall skateboards equipment furniture scaffolding <1 * 0.0 * 0.0 * 0.0 * 1-4 1.5 * 2.1 1.2 2.1 * 3.1 5-9 1.9 * 0.8 1.6 * * 1.9 10-14 0.7 2.3 * * * * 2.3 15-19 0.6 1.7 * 0.0 * * 0.5 0-19 1.1 1.3 0.8 0.7 0.7 0.3 1.8 Type of Fall

Note: *Represents fewer than 5 cases; ‘Other and unspecified falls’ includes fall involving ice and snow and fall involving wheelchair.

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Transport-related Concussion Hospitalization Concussion hospitalization rates from transport- Rates for both males and females were highest for related injuries among children and youth were pedal cyclist-related injuries (3.5/100,000 and generally higher among males than females, except 0.9/100,000, respectively). Rates were the same for pedestrian-related (Figure 8). among males and females for motor vehicle occupant-related injuries (0.8/100,000) (Figure 8).

Figure 8: Transport-related concussion hospitalization rates by type of transport and sex, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

3.5 Pedal cyclist 0.9

0.8 Motor vehicle occupant 0.8 Males 0.6 Females Pedestrian

0.8 Typeof Transport

0.4 Other and unspecified transport 0.3

0.0 1.0 2.0 3.0 4.0 Rate per 100,000 Population

Note: 'Other transport' includes concussion hospitalizations due to off-road vehicle, motorcyclist, other land transport, and unspecified.

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Across all age groups, highest rates were observed Rates of motor vehicle occupant-related for pedal cyclist concussion hospitalizations concussion hospitalization were highest among compared to any other transport type, with highest youth aged 15 to 19 years (1.9/100,000). Rates of rates among 5 to 9 year olds (3.1/100,000) (Figure pedestrian-related concussion hospitalization were 9). highest among 10 to 14 year olds (1.5/100,000) (Figure 9).

Figure 9: Transport-related concussion hospitalization rates by type of transport and age group, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14. 4.0

2.0 Rate per 100,000 Population

0.0 Other and Motor vehicle Motorcyclist Pedal cyclist Pedestrian unspecified occupant transport <1 0.0 0.0 0.0 0.0 0.0 1-4 * 0.0 * * 0.0 5-9 * 0.0 3.1 * * 10-14 * * 2.8 1.5 0.7 15-19 1.9 * 2.7 * * 0-19 0.8 * 2.3 0.7 0.3 Type of Transport *

Note: * Represents fewer than 5 cases; 'Other transport' includes concussion hospitalizations due to off-road vehicle, other land transport, and water transport.

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Sport and Recreation-related Concussion Hospitalization Sport and recreation-related concussion hospitali- Cycling was the sport and recreation activity with zation rates for children and youth were generally the highest proportion of concussion hospitaliza- higher among males than females, with the highest tions among children and youth, at 36.1 percent rates being among males aged 10 to 14 years (n=53) (Figure 11). Other leading types included (13.3/100,000) and 5 to 9 years (9.4/ 100,000) playground (12.9%) and, skis and snowboards (Figure 10). Rates for females were highest for ages (11.6%). 10 to 14 years at 4.6 per 100,000.

Figure 10: Sport and recreation-related concussion hospitalization rates by age group and sex, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0

Rate per 100,000 Rateper 100,000 Population <1 1-4 5-9 10-14 15-19 Male 0.0 2.4 9.4 13.3 8.6 Female 0.0 * 1.7 4.6 1.6 Total 0.0 1.7 5.7 9.1 5.2 Age Group

Figure 11: Sport and recreation-related concussion hospitalization rates by type of sport/recreation, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

Cycling 36.1 Playground 12.9 Ski/Snowboard 11.6 Skateboard 6.8 Hockey 6.1 Football/Rugby 5.4 Soccer 4.1 Scooter 3.4

Typeof Sport/Recreation Ice Skates 3.4 Other Sports 10.2

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Percentage

Note: 'Other sports' includes concussion hospitalizations due to all-terrain vehicle, hit by ball, baseball and tobogganing. 11

The rate of cycling-related concussion hospitali- Rates of cycling-related concussion hospitalizations zations for males was 3.1 per 100,000, followed by were highest among children aged 10 to 14 years ski and snowboard (1.0/100,000) and playground (2.8/ 100,000) and 5 to 9 years (2.4/100,000) (0.9/ 100,000) (Figure 12). For females, highest (Figure 13). Playground concussion rates were rates were seen for cycling (0.7/100,000) and play- higher among younger children aged 0 to 9 years, ground (0.5/ 100,000). while generally sport concussion rates were highest among the older children and youth.

Figure 12: Sport and recreation-related concussion hospitalization rates by leading type of sport/recreation and sex, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

Male Female

Cycling 3.1 Cycling 0.7 Ski/Snowboard 1.0 Playground 0.5 Playground 0.9 Ski/Snowboard * Skateboard 0.6 Skateboard * Hockey 0.6 Football/Rugby 0.0 Football/Rugby 0.6 Hockey 0.0 Other Sports Typeof Sport/Recreation 1.6 Other Sports 0.7

0.0 2.0 4.0 0.0 0.5 1.0 Rate per 100,000 Population Note: * Represents fewer than 5 cases

Figure 13: Sport and recreation-related concussion hospitalization rates by leading type of sport/recreation and age group, ages 0-19 years, Vancouver Coastal Health, 2001/02 – 2013/14.

3.0 2.5 2.0 1.5 1.0 0.5 0.0 Football/ Ski/ Other Cycling Hockey Playground Skateboard Rugby Snowboard Sports Rate per 100,000 Population <1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1-4 * 0.0 0.0 1.2 0.0 0.0 * 5-9 2.4 0.0 * 1.6 * * * 10-14 2.8 0.9 0.7 * 1.2 0.9 2.2 15-19 2.2 * * 0.0 * 0.9 1.5 0-19 2.0 0.3 0.3 0.7 0.4 0.6 1.1 Type of Sport/Recreation

Note: * Represents fewer than 5 cases 12

Concussion Hospitalization between Health Service Delivery Areas Vancouver Coastal Health consists of three Richmond (6.4/100,000) (Figure 14). The Health Service Delivery Areas (HSDAs): highest number of concussion hospitalization Richmond, Vancouver and North Shore/Coast cases was within North Shore/Coast Garibaldi Garibaldi. The majority of Vancouver Coastal (177 cases). Statistical testing yielded significant Health child and youth residents who were differences between North Shore/Coast hospitalized for concussion sought treatment Garibaldi and Vancouver, between North Shore/ within the Vancouver Coastal Health Authority Coast Garibaldi and Richmond, and between and Provincial Health Services Authority (PHSA) Richmond and Vancouver (p-value <0.05). (Table 1). About 70 percent of North Shore/ Concussion hospitalization rates were highest in Coast Garibaldi residents were admitted to North Shore/Coast Garibaldi among all age hospitals within Vancouver Coastal Health for groups (Figure 15). Highest rates for concussion concussion; this is a higher proportion than for hospitalization in Richmond were among 1 to 4 residents of both Richmond and Vancouver year olds (13.6/100,000). In both Vancouver (47.1% and 9.8% respectively). Over three- and North Shore/Coast Garibaldi, highest quarters of residents of Vancouver received concussion rates were observed among children hospital care from BC Children’s Hospital. aged 10 to 14 years (14.4/100,000 and Concussion hospitalization rates were highest 26.8/100,000, respectively). among residents of North Shore/Coast Garibaldi (22.3/100,000) and lowest among residents of

Table 1: Concussion hospitalization counts by health service delivery area of patient’s residence and health authority in which treatment sought, ages 0-19 years, Vancouver Coastal Health, 2001/02-2013/14.

Health Service Delivery Area of patient’s residence North Shore/Coast Richmond Vancouver Health Authority Garibaldi in which treatment sought Vancouver Coastal Health 16 (47.1%) 14 (9.8%) 124 (70.1%) * 10 6 * * * 0 * * * * 0 Provincial Health Services Authority+ 14 (41.2%) 113 (79.0%) 40 (22.6%) Out-of-province * 0 * Grand Total 34 143 177

Note: * Represents fewer than 5 cases; +Provincial Health Services Authority refers to BC Children’s Hospital.

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Figure 14: Concussion hospitalization counts and rates by Health Service Delivery Area, ages 0-19 years, Vancouver Coastal Health, 2001/02-2013/14. 200 40.0

160 30.0

120 20.0 80

Number of Hospitalizations of Number 10.0

40 Rate per 100,000 Population 0 0.0 North Richmond Vancouver Shore/Coast Garibaldi Number of 34 143 177 Hospitalizations Rate per 100,000 6.4 10.3 22.3 Population Health Service Delivery Area

Figure 15: Concussion hospitalization rates by Health Service Delivery Area and age group, ages 0-19 years, Vancouver Coastal Health, 2001/02-2013/14. 30.0

20.0

10.0 Rate per 100,000 Population

0.0 <1 1-4 5-9 10-14 15-19 Richmond * 13.6 5.0 5.9 4.2 Vancouver * 9.5 12.1 14.4 7.0 North Shore/Coast Garibaldi * 15.3 25.5 26.8 21.8 Total 5.5 11.8 14.7 16.6 10.7 Age Group

Note: * Represents fewer than 5 cases

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The number of child and youth concussion The number of concussion inpatients was inpatients was highest among residents in Howe highest at Lions Gate Hospital (18 cases) in the Sound, followed by North Vancouver in 2013/14 2013/14 year (Figure 16). (Figure 16).

Figure 16: Pediatric concussion Inpatients by local health area and hospital, Vancouver Coastal Health, 2013/14.

Note: * Represents fewer than 5 cases Note: 38: Richmond, 44: North Vancouver, 45: West Vancouver-Bowen Island, 46: Sunshine Coast, 47: Powell River, 48: Howe Sound, 49: Bella Coola Valley, 83: Central Coast, 161: City Centre, 162: Downtown Eastside, 163: North East, 164: Westside, 165: Midtown, 166: South Vancouver

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*

* Concussion Hospitalization by Health Service Delivery Area: Richmond

A total of 34 concussion hospitalizations were Richmond did not exhibit total number of cases reported for Richmond between 2001/02 and high enough to further investigate age and sex 2013/14. Concussion hospitalization rates in differences. Richmond were higher among males

(8.7/100,000) than females (3.9/100,000) (Figure 17). Rates of fall-related child and youth concussion hospitalization in Richmond were highest among children aged 1 to 4 years (11.3/ 100,000, n=10) (chart not shown).

Figure 17: Concussion hospitalization rates by sex, ages 0-19 years, Vancouver Coastal Health: Richmond, 2001/02-2013/14.

Total

Male

Female

0.0 2.0 4.0 6.0 8.0 10.0 Female Male Total Richmond 3.9 8.7 6.4

Rate per 100,000 Population

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Concussion Hospitalization by Health Service Delivery Area: Vancouver

A total of 143 concussion hospitalizations were Concussion hospitalization rates were higher reported for Vancouver between 2001/02 and among males than females within all Vancouver 2013/14. Among all age groups, 10 to 14 year LHAs except in City Centre. The highest rates olds had the highest rate of concussion, most of among males were in Westside (16.6/100,000) which comprised of fall-related cases. while the highest rates among females were in City Centre (14.7/ 100,000) (Figure 20). Rates of child and youth fall-related concussion hospitalizations in Vancouver were highest Concussion hospitalization rates were among children aged 1 to 4 years (8.0/100,000), particularly high among 10 to 14 year olds in while transport-related concussion City Centre (28.9/100,000) (Figure 21). All LHAs hospitalization rates were highest among within Vancouver reported low rates of children aged 5 to 9 years (5.1/100,000) (Figure concussion hospitalization among infants less 18). than one year of age, with fewer than five cases reported (Figure 21). Vancouver is split into six LHAs: City Centre, Downtown Eastside, Midtown, North East, South Vancouver and Westside. The concussion hospitalization rate was highest in Westside (12.2/100,000) and lowest in North East (8.0/100,000). The total numbers of hospitaliza- tion cases within Vancouver Coastal were lowest in Downtown Eastside and City Centre and highest in South Vancouver (Figure 19).

Figure 18: Concussion hospitalization rates by cause and age group, ages 0-19 years, Vancouver Coastal Health: Vancouver, 2001/02-2013/14. 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Rate per 100,000 Rateper 100,000 Population <1 1-4 5-9 10-14 15-19 Transport 0.0 * 5.1 4.5 3.2 Falls * 8.0 5.4 6.0 2.2 Struck by Object 0.0 * 1.6 3.9 1.2 Total * 9.5 12.1 14.4 7.0 Age Group

Note: * Represents fewer than 5 cases; Total also includes other causes of concussion hospitalizations which are not shown as there are no or fewer than 5 cases. 17

Figure 19: Concussion hospitalization counts and rates by local health area, ages 0-19 years, Vancouver Coastal Health: Vancouver, 2001/02-2013/14. 50 14.0 43 40 12.0 40 10.0

30 8.0 21 22 6.0 20

4.0 NumberofHospitalizations 9 8

10 Rate per 100,000 Population 2.0

0 0.0 City Centre Downtown Midtown North East South Westside Eastside Vancouver Local Health Area

Figure 20: Concussion hospitalization rates by local health area and sex, ages 0-19 years, Vancouver Coastal Health: Vancouver, 2001/02-2013/14. 18.0 16.0 14.0 12.0 10.0 8.0 6.0

Rate per 100,000 Population 4.0 2.0 0.0 Downtown South City Centre Midtown North East Westside Eastside Vancouver Male * 14.2 14.2 9.8 15.5 16.6 Female 14.7 * 6.0 6.0 7.3 7.6 Total 8.2 8.4 10.3 8.0 11.6 12.2 Local Health Area

Note: * Represents fewer than 5 cases

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Figure 21: Concussion hospitalization rates by local health area and age group, ages 0-19 years, Vancouver Coastal Health: Vancouver, 2001/02-2013/14.

35.0 30.0 25.0 20.0 15.0 10.0

Rate per 100,000 Population 5.0 0.0 Downtown South City Centre Midtown North East Westside Eastside Vancouver <1 * 0.0 0.0 * * * 1-4 * * * * 16.2 12.8 5-9 * * 12.0 10.8 17.0 9.7 10-14 28.9 * 12.6 7.3 13.5 18.1 15-19 0.0 * 11.8 7.7 4.3 9.6 0-19 8.2 8.4 10.3 8.0 11.6 12.2 Local Health Area

Note: * Represents fewer than 5 cases

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Concussion Hospitalization by Health Service Delivery Area: North Shore/Coast Garibaldi highest in North Vancouver (73 cases) and A total of 177 concussion hospitalizations were lowest in Central Coast and Bella Coola, each reported for North Shore/Coast Garibaldi with fewer than 5 cases (Figure 23). between 2001/02 and 2013/14. Among all age Concussion hospitalization rates were higher groups, 10 to 14 year olds had the highest rate among males than females for all LHAs of North of concussion, most of which comprised of fall- Shore/Coast Garibaldi. High rates among males related cases. and females were found in Howe Sound (48.7/ Child and youth fall-related concussion 100,000 and 25.0/100,000, respectively) (Figure hospitalization rates in North Shore/Coast 24). Garibaldi were highest among children aged 5 Concussion hospitalization rates among infants to 9 years (16.2/100,000), while transport- less than one year of age were lowest across all related concussion hospitalization rates were LHAs in North Shore/ Coast Garibaldi, with highest among youth aged 15 to 19 years fewer than five cases reported. Howe Sound (11.6/100,000) (Figure 22). had high rates of concussion hospitalizations North Shore/Coast Garibaldi is split into seven among children aged 10 to 14 years and among LHAs: Bella Coola Valley, Central Coast, Howe youth 15 to 19 years (56.8/100,000 and Sound, North Vancouver, Powell River, Sunshine 51.1/100,000, respectively) (Figure 25). Coast and West Vancouver-Bowen Island. The number of concussion hospitalizations was

Figure 22: Concussion hospitalization rates by cause and age group, ages 0-19 years, Vancouver Coastal Health: North Shore/Coast Garibaldi, 2001/02-2013/14.

30.0

25.0

20.0

15.0

10.0

Rate per 100,000 Population 5.0

0.0 <1 1-4 5-9 10-14 15-19 Transport 0.0 * 5.4 8.9 11.6 Falls * 14.5 16.2 11.3 7.3 Struck by Object 0.0 0.0 3.8 6.6 2.6 Total * 15.3 25.5 26.8 21.8 Age Group

Note: * Represents fewer than 5 cases; Total also includes other causes of concussion hospitalizations that are not shown as there are no or fewer than 5 cases.

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Figure 23: Concussion hospitalization counts and rates by local health area, ages 0-19 years, Vancouver Coastal Health: North Shore/Coast Garibaldi, 2001/02-2013/14. 80 73 50.0

40.0 60 38 30.0 40 34 20.0 17 20 10 10.0 * *

0 0.0

NumberofHospitalizations

Rate per 100,000 Population

PowellRiver

HoweSound

CentralCoast

Island

SunshineCoast

NorthVancouver

Bella Coola Valley West Vancouver-Bowen Local Health Area

Note: * Represents fewer than 5 cases

Figure 24: Concussion hospitalization rates by local health area and sex, ages 0-19 years, Vancouver Coastal Health: North Shore/Coast Garibaldi, 2001/02-2013/14.

60 50 40 30 20 10 0 West Bella Rate per 100,000 Population Central Howe North Powell Sunshine Vancouver Coola Coast Sound Vancouver River Coast -Bowen Valley Island Male * * 48.7 28.0 28.6 29.8 38.8 Female 0.0 0.0 25.0 7.1 * 16.3 8.8 Total * * 37.5 17.9 18.7 23.1 24.2 Local Health Area

Note: * Represents fewer than 5 cases

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Figure 25: Concussion hospitalization rates by local health area and age group, ages 0-19 years, Vancouver Coastal Health: North Shore/Coast Garibaldi, 2001/02-2013/14. 60.0 50.0 40.0 30.0 20.0 10.0 0.0

West Rate per 100,000 Population Bella Coola Central Howe North Powell Sunshine Vancouver- Valley Coast Sound Vancouver River Coast Bowen Island <1 0.0 0.0 * * 0.0 0.0 * 1-4 0.0 * * 16.0 * 0.0 * 5-9 0.0 0.0 24.3 28.2 * * 32.2 10-14 * 0.0 56.8 19.5 * 24.0 34.5 15-19 * 0.0 51.1 11.0 31.2 45.2 14.7 0-19 * * 37.5 17.9 18.7 23.1 24.2 Local Health Area

Note: * Represents fewer than 5 cases

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CONCUSSION EMERGENCY DEPARTMENT VISIT RATES There were a total of 3,994 concussion (Figure 26). Lowest rates of concussion emergency department visits by child and youth emergency department visits were seen in residents of Vancouver Coastal Health for the 2- North Shore/Coast Garibaldi (657.5/100,000) year period of 2013/14 and 2014/15. Emer- (Figure 26). Concussion emergency department gency department visit rates for Vancouver visits within Vancouver Coastal Health were Coastal Health residents were calculated per highest among children under the age of five 100,000 population for the region. Rates of years. Rates within Richmond, Vancouver and emergency department visits for concussion North Shore/Coast Garibaldi were highest were highest in Vancouver (1,152.2/100,000), among infants less than one year (2,157.4/ which also had the highest rates for both males 100,000, 3,352.2/100,000 and 1,447.9/100,000, (1,358.5/ 100,000) and females (931.2/100,000) respectively) (Figure 27).

Figure 26: Concussion emergency department visit rates by health service delivery area and sex, ages 0-19 years, residents of Vancouver Coastal Health, NACRS, April 1, 2013 – March 31, 2015

1,400.0 1,200.0 1,000.0 800.0 600.0 400.0 200.0 0.0

Rate per 100,000 Population North Shore/ Richmond Vancouver Coast Garibaldi Male 984.7 1,358.5 779.5 Female 778.4 931.2 525.9 Total 885.3 1,152.2 657.5

Health Service Delivery Area

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Figure 27: Concussion emergency department visit rates by health service delivery area residence and age group, ages 0-19 years, residents of Vancouver Coastal Health, NACRS, April 1, 2013 – March 31, 2015

4,000.0 3,500.0 3,000.0 2,500.0 2,000.0 1,500.0

1,000.0 Rate per 100,000 Population 500.0 0.0 <1 1-4 5-9 10-14 15-19 Richmond 2,157.4 1,564.0 746.4 638.2 634.2 Vancouver 3,352.2 1,956.7 925.5 839.5 649.4 North Shore/ 1,447.9 843.6 465.9 659.7 597.1 Coast Garibaldi Age Group

Vancouver Coastal Health has six principal males (4,997.3/100,000) and Lions Gate hospitals with recorded concussion emergency Hospital reported the highest rates among department visits: Lions Gate Hospital, Mount females (3,122.8/100,000). Males exhibited Saint Joseph Hospital, St. Paul’s Hospital, higher rates than females among all Vancouver Richmond Hospital, UBC Hospital and Coastal Health hospitals. Lowest rates among Vancouver General Hospital. Rates for each males were reported at UBC Hospital, and hospital were calculated per 100,000 lowest rates among females were reported at emergency department visits for all diagnoses. Vancouver General Hospital (2,712.1/100,000 and 1,664.8/100,000, respectively) (Figure 28). There were a total of 1,833 child and youth concussion emergency department visits to When looking at emergency department visits these hospitals during the 2-year period of from concussions by month between April 1, 2013/14 and 2014/15 (Table 2). During this 2013 and March 31, 2015, the number of cases period, Mount Saint Joseph Hospital saw the presented was highest during the months of highest rate of concussion emergency November (182 visits), March (172 visits) and department visits per 100,000 visits among all May (170 visits). Rates of concussion emergency hospitals in Vancouver Coastal Health (4,054.9/ department visits per 100,000 visits peaked 100,000) (Figure 28). Lowest rates of emergency during November (4,113.9/ 100,000). The department visits due to concussion within the number of concussion emergency department Vancouver Coastal Health region were seen at visits was lowest during August (118 visits), UBC Hospital (2,389.0/100,000). Mount Saint December (131 visits) and July (136 visits). Joseph Hospital reported the highest rates of Lowest rates were reported during December concussion emergency department visits among (2,688.8/100,000) (Figure 29).

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Figure 28: Concussion emergency department visit rates by hospital and sex, ages 0-19 years, Vancouver Coastal Health, NACRS, April 1, 2013 – March 31, 2015

6,000.0 5,000.0 4,000.0 3,000.0 2,000.0 1,000.0 0.0

Rate per 100,000 Visits Mount Saint Vancouver Lions Gate St. Paul’s Richmond Joseph UBC Hospital General Hospital Hospital Hospital Hospital Hospital Male 4,204.2 4,997.3 3,524.2 3,820.5 2,712.1 3,452.4 Female 3,122.8 2,937.3 2,385.9 3,072.3 2,014.7 1,664.8 Total 3,719.8 4,054.9 2,960.3 3,483.4 2,389.0 2,527.3 Hospital

Figure 29: Concussion emergency department visit rates and number of cases by month, ages 0-19 years, Vancouver Coastal Health Hospitals, NACRS, April 1, 2013 – March 31, 2015

250 4500.0

4000.0

200 3500.0

3000.0 150 2500.0

2000.0 100

NumberofVisits 1500.0 Rate per 100,000 Visits 50 1000.0 500.0

0 0.0 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Number of Visits 157 170 159 136 118 133 162 182 131 156 157 172 Rate per 3,432.4 3,487.2 3,565.0 3,235.8 2,912.1 2,985.4 3,455.6 4,113.9 2,688.8 3,117.5 3,336.9 3,715.7 100,000 Visits

Month

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The total number of child and youth emergency During the 2013/14 year alone, emergency department visits for concussion at Vancouver department visits occurring at hospitals located Coastal Health treating hospital facilities was within the region of Vancouver Coastal Health highest for Lions Gate Hospital during 2013/14 were highest at BC Children’s Hospital (PHSA) and 2014/15 (710 cases). The highest propor- with 1,431 reported cases (Figure 30). Lions Gate tions of emergency department visits attributed Hospital saw 410 concussion emergency visits to child and youth concussion were seen at during the same year. The lowest numbers of Mount Saint Joseph and Lions Gate Hospitals child and youth emergency visits recorded in (4.1% and 3.7%, respectively). Low numbers of 2013/14 were seen at Mount Saint Joseph visits were seen at Mount Saint Joseph Hospital Hospital (62 visits) and Vancouver General (136 cases) and Vancouver General Hospital (132 Hospital (82 visits) (Figure 30). cases). Vancouver General Hospital also reported the second lowest proportion of concussion emergency visits as a proportion of overall emergency department visits (2.5%) and UBC Hospital reported the lowest (2.4%). Across all treating hospitals, Vancouver Coastal Health saw an average 3.3% of all child and youth emergency departments visits attributed to concussion- related injury (Table 2).

Table 2: Concussion emergency department visit rates by hospital, ages 0-19 years, Vancouver Coastal Health, NACRS, April 1, 2013 – March 31, 2015

Number of ER % of concussion ER Total ER visits concussion visits visits

Mount Saint Joseph Hospital 136 3,354 4.05 Lions Gate Hospital 710 19,087 3.72 Richmond Hospital 541 15,531 3.48 St. Paul’s Hospital 173 5,844 2.96 Vancouver General Hospital 132 5,223 2.53 UBC Hospital 141 5,902 2.39 Grand Total 1,833 54,941 3.34

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Figure 30: Pediatric concussion emergency visits by local health area and hospital, Vancouver Coastal Health Authority, NACRS, 2013/14

Note: 31: Richmond, 32: Vancouver, 33: North Shore/Coast Garibaldi

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EMERGENCY DEPARTMENT VISITS AT BC CHILDREN’S HOSPITAL

Among child and youth residents of Vancouver respectively). Overall concussion emergency Coastal Health, rates of emergency department department visit rates at BC Children’s Hospital visits to BC Children’s Hospital for concussion among children residing in Vancouver Coastal were highest among males and females less Health were highest for infants less than one than one year of age (Figure 31). Rates were year of age (1,831.2/100,000) and children 1 to lowest among males and females 15 to 19 years 4 years old (878.9/100,000) (Figure 31). of age (118.1/100,000 and 42.8/100,000,

Figure 31: Concussion emergency department visit rates at BC Children’s Hospital by age group and sex, ages 0-19 years, residents of Vancouver Coastal Health, NACRS, April 1, 2012 – May 21, 2015

2,000.0

1,600.0

1,200.0

800.0

400.0 Rate per 100,000 Population 0.0 <1 1-4 5-9 10-14 15-19 Male 1,876.8 982.2 583.5 529.1 118.1 Female 1,782.8 768.9 157.9 118.0 42.8 Total 1,831.2 878.9 459.9 390.4 104.5

Age Group

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CONCLUSION Vancouver Coastal Health exhibited low overall There was a large discrepancy in rates among rates of child and youth concussion LHAs. Bella Coola Valley, Howe Sound and West hospitalization. The highest rates of concussion Vancouver-Bowen Island exhibited much higher hospitalizations were seen among 10 to 14 year rates of concussion hospitalizations than most olds, largely due to transport-related causes. regions in Vancouver Coastal Health, while The majority of these hospitalizations were due Richmond, North East and City Centre reported to the involvement of pedal-cyclists and motor low rates of child and youth concussion vehicle occupants. Falls were the leading cause hospitalizations. of concussion hospitalization among children Concussion emergency department visits rates under the age of 14 years, where the leading were higher among males than females residing cause of falls involved skates, skis and within Vancouver Coastal Health. Rates were also skateboards. higher among children less than 5 years of age. Males within Vancouver Coastal Health exhibited Overall, concussion emergency department visit higher rates of concussion hospitalizations than rates among 0 to 19 year olds were highest females across all ages between 0 to 19 years. among Vancouver residents. Sport and recreation-related concussion hospital- Between April 1, 2013 and March 31, 2015, izations were mostly observed among males Mount Saint Joseph Hospital had the highest rate between the ages of 5 and 19 years. of child and youth concussion emergency Of all the HSDAs in Vancouver Coastal Health, department visits per 100,000 visits among all North Shore/Coast Garibaldi displayed the hospitals within Vancouver Coastal Health, while highest rates of transport-related concussion UBC Hospital had the lowest rate. hospitalization across all age groups, while The months of November and March reported Richmond displayed the lowest rates. the highest rates per 100,000 visits and Fall-related concussion hospitalization rates numbers of concussion emergency department varied with age within each HSDA. Children visits, while the months of August and Decem- aged 1 to 4 years displayed the highest rates of ber recorded the lowest rates and numbers of fall-related concussion hospitalization in concussion emergency department visits. Richmond and Vancouver, while in North Shore/ This report provides a comprehensive glance at Coast Garibaldi, rates were highest among the burden of concussion among children and children aged 5 to 9 years. Richmond had the youth within Vancouver Coastal Health, both at a highest rate of fall-related concussion hospital- regional and hospital level. With this information, ization for the 1 to 4 years age category. Vancouver Coastal Health can work towards Fewer than five cases of fall-related concussion reducing the occurrence and burden of hospitalization among infants less than one year concussions among children and youth in BC. of age were experienced in all three HSDAs.

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