Intracranial Injuries and Concussions – Emergency Department visits, Niagara Region, 2008-2012
Dr Sinéad McElhone
Niagara Public Health
2201 St David’s Road
Thorald
Ontario
L2V 4T7
1
Emergency Department Visits for Intracranial Injuries (ICD10-CA code S06)
Niagara
2
Percentage of Intracranial Injuries* that are Concussions, Niagara Region 2008-2012
2008 2009 2010 2011 2012 Total Concussions 414 508 474 533 602 2531 ICI 571 676 633 795 827 3502 % 75% 75% 75% 67% 73% 72%
*Emergency visits for intracranial injuries are defined by an ICD-10 code of S06 which includes the ICD-10 codes for concussions (S06.0)
3
Number of ED visits for Intracranial injury in the Niagara region in 2010 - 2012 450
400
350
300
250
200
150
100
50
0 10 - 15 - 20 - 25 - 30 - 35 - 40 - 45 - 50 - 55 - 60 - 65 - 70- 75 - 80 - 85 - 0 - 4y 5 - 9y 90+y 14y 19y 24y 29y 34y 39y 44y 49y 54y 59y 64y 69y 74y 79y 84y 89y Total Intracranial 2010/11/12 66 78 301 424 207 132 93 80 98 108 100 74 69 65 66 64 98 69 63 Intracranial Female 31 21 86 159 86 48 39 34 52 50 37 29 35 27 28 34 48 39 44 Intracranial Male 35 57 215 265 121 84 54 46 46 58 63 45 34 38 38 30 50 30 19
4
Rate of ED visits for Intracranial injury in the Niagara region in 2010 - 2012 700.0
600.0
500.0
400.0
300.0
200.0
100.0
0.0 10 - 15 - 20 - 25 - 30 - 35 - 40 - 45 - 50 - 55 - 60 - 65 - 70- 75 - 80 - 85 - All 0 - 4y 5 - 9y 90+y 14y 19y 24y 29y 34y 39y 44y 49y 54y 59y 64y 69y 74y 79y 84y 89y ages Rate per 100,000 (Total) 107.0 118.4 418.4 481.6 221.1 164.2 124.5 102.5 112.8 102.0 96.7 77.7 79.5 92.3 119.6 138.7 262.8 291.5 539.8 168.7 Rate per 100,000 (Female) 103.0 65.6 241.0 367.3 192.0 120.6 105.3 85.7 118.6 93.8 70.5 58.8 77.9 74.8 94.6 132.4 223.0 257.7 511.3 135.7 Rate per 100,000 (Male) 110.9 168.2 593.1 592.0 247.8 207.1 143.4 119.7 107.0 110.3 123.7 98.0 81.2 110.7 148.6 146.6 317.3 351.3 619.7 203.1
5
Age-standardized rate of emergency department visits for Intracranial injury, Niagara and Ontario, 2008 - 2012 250.0
200.0
150.0
100.0 ED ED visit rate per100000
50.0
0.0 2008 2009 2010 2011 2012 Total Niagara 133.8 156.9 147.6 179.2 190.0 Total Ontario 123.0 140.7 146.6 175.6 197.0
6
Age standardized rate of ED visits for intracranial injury by sex, Niagara and Ontario, 2008 - 2012 250.0
200.0
150.0
100.0 ED ED rateper 100000
50.0
0.0 2008 2009 2010 2011 2012 Males Niagara 164.2 182.6 180.9 220.9 229.9 Females Niagara 103.6 132.0 115.1 137.8 151.9 Males Ontario 153.8 171.2 178.0 211.5 230.8 Females Ontario 92.7 110.7 116.0 139.9 163.2
7
Reasons for ED intracranial Injury visits in Niagara and Ontario in 2010 - 2012 combined 50
45
40
35
30
25
20
15
10
5
0 Pedestrian/Cyclist Injured in Transport - Motor Inanimate Animate Transport vehicle (V20 - Falls (W00 - W19) mechanical forces mechanical forces Assult (X85 - Y09) Other Accident (V01 - V99) (W20 - W49) (W50 - W64) V19) Total Niagara 4.88 8.9 46.12 18.71 12.55 5.85 2.97 Total Ontario 4.4 10.09 41.57 21.37 12.86 5.6 4.07
8
Reasons (n) for ED Intracranial Injury visits in Niagara by age ranges from 0 - 24, 25 - 49, 50 - 74 and 75 + years in 2010 - 12 1200
1000
800
600 75+ y 50 - 74 y 25 - 49 y 400 0 - 24 y
200
0 Pedestrian/Cyclist Transport - Motor Falls (W00 - W19) Inanimate Animate Assult (X85 - Y09) Other Injured in vehicle (V20 - V99) mechanical forces mechanical forces Transport Accident (W20 - W49) (W50 - W64) (V01 - V19)
* ED visits for concussion caused by Animate and Inanimate mechanical forces for the 50 – 74y AND ED visits for all categories with the exception of Falls in the 75y+ age group were not reported due to low numbers.
9
Reasons (%) for ED Intracranial Injury visits in Niagara by ages ranges 0 - 24, 25 - 49, 50 - 74 and 75+ years in 2010 - 2012 100%
90%
80%
70%
60%
50% 75+ y 50 - 74 y 40% 25 - 49 y 0 - 24 y 30%
20%
10%
0% Pedestrian/Cyclist Transport - Motor Falls (W00 - W19) Inanimate Animate Assult (X85 - Y09) Other Injured in vehicle (V20 - V99) mechanical forces mechanical forces Transport Accident (W20 - W49) (W50 - W64) (V01 - V19)
10
Reasons (n) for ED intracranial visits in Niagara by age ranges from 10 - 14, 15 - 19 and 20 - 24 years in 2010 - 12 combined 140
120
100
80
10 - 14y
60 15 - 19y 20 - 24y
40
20
0 Pedestrian/Cyclist Transport - Motor Falls (W00 - W19) Inanimate Animate mechanical Assult (X85 - Y09) Other Injured in Transport vehicle (V20 - V99) mechanical forces forces (W50 - W64) Accident (V01 - V19) (W20 - W49)
11
No. of ED visits for Intracranial Injury by sport/recreation specific external cause (2010,11,12 combined)
Hockey
Cycling
Football/Rugby
Other sports related injuries
Hit by ball
Ski/snowboard
Soccer
Ice-skates
ATV snowmobiles
Fall involving rollerblades/scooter/skateboard
Playground equipment
Tobogganing
0 50 100 150 200 250
In 2010 - 12, there were 603/2255 ED visits for Intracranial injury with an external cause linked to sports/recreation. Hockey was the sport category with the highest number of visits accounting for n = 199 (33%) of all sport/recreation visits followed by cycling (13%) and football (10%).
12
Number of ED visits for concussions by sport recreation specific external cause (2010 - 2012) % Tobogganing 11 2 Playground equipment 14 2 Fall involving rollerblades/scooter/skateboard 14 2 ATV snowmobiles 15 2 Ice-skates 27 4 Soccer 29 5 Ski/snowboard 33 5 Hit by ball 41 7 Other sports related injuries (including struck by bat/pool and water/recreational boating/baseball) 61 10 Football/Rugby 63 10 Cycling 81 13 Hockey 199 33 603
13
ED visits for Intracranial Injury linked to falls, inanimate and animate mechanical forces in the Niagara region in 2010/11/12.
For ED Intracranial Injury visits within the Falls category (W00 - W19 n = 1040) in 2010-12, 20% (n = 203) were coded as a 'Fall at the same level from slip, trip or stumble’. 8% (n = 84) of ED intracranial Injury visits within the Falls category were related to sport/activity related incidents. Therefore, the majority of intracranial Injuries categorized as ‘Falls’ were not linked to sport/activity and were mainly from falling on the same level or from steps/ladders/stairs/off furniture (n = 548; 53%).
For ED intracranial Injury visits within the Inanimate mechanical forces category (W20 - W49 n = 1422); 170 (40%) of ED intracranial Injury visits were linked to sport/activity with the majority being linked to Hockey. The majority of ED concussion visits related to this category were coded as exposure to non-specific non-sports objects (60%).
283 ED intracranial Injury visits were as a result of exposure to animate mechanical forces (W50 – W64). 80% (n = 227) were as a result of playing a sport/activity and the majority of these (39%) were related to playing hockey, while 20% were related to playing football/rugby.
14
Emergency Department visits for Intracranial Injury in Niagara: Place of occurrence (2010 - 2012)
59% of all visits in 2010 - 2012 did not have a place of occurrence specified making it difficult to draw strong interpretations from the data. Sports/athletics and the home were the most common places of occurrence.
Place of occurrence description (ICD10-CA Code) Count % of Total
NOT ASSIGNED 362 16 OTHER SPECIFIED PLACE OF OCCURRENCE 75 3 PLACE OF OCCURRENCE, FARM * * PLACE OF OCCURRENCE, HOME 309 14 PLACE OF OCCURRENCE, INDUSTRIAL AND CONSTRUCTION AREA 24 1 PLACE OF OCCURRENCE, RESIDENTIAL INSTITUTION 68 3 PLACE OF OCCURRENCE, SCHOOL OTHER INSTITUTION AND PUBLIC AREA 95 4 PLACE OF OCCURRENCE, SPORTS AND ATHLETICS AREA 319 14 PLACE OF OCCURRENCE, STREET AND HIGHWAY 42 2 PLACE OF OCCURRENCE, TRADE AND SERVICE AREA 97 4 UNSPECIFIED PLACE OF OCCURRENCE 903 40 Total 2255
15
Emergency Department Visits for Concussions (ICD10- CA code S06.0
Niagara
16
Percentage of Intracranial Injuries* that are Concussions, Niagara Region 2008-2012
2008 2009 2010 2011 2012 Total Concussions 414 508 474 533 602 2531 ICI 571 676 633 795 827 3502 % 75% 75% 75% 67% 73% 72%
*Emergency visits for intracranial injuries are defined by an ICD-10 code of S06 which includes the ICD-10 codes for concussions (S06.0)
17
No. of ED visits for concussions by age group and sex for the Niagara Region in 2010 - 2012 450
400
350
300
250
200
150
100
50
0 10 - 15 - 20 - 25 - 30 - 35 - 40 - 45 - 50 - 55 - 60 - 65 - 70- 75 - 80 - 85 - 0 - 4y 5 - 9y 90+y 14y 19y 24y 29y 34y 39y 44y 49y 54y 59y 64y 69y 74y 79y 84y 89y Total Concussions 2010/11/12 55 71 291 387 173 107 71 62 79 73 63 40 31 31 20 21 16 8 10 Concussions Female 27 20 84 146 75 42 35 27 43 40 32 19 15 17 7 12 9 0 7 Concussions Male 28 51 207 241 98 65 36 35 36 33 31 21 16 14 13 9 7 6 0
18
Rate of ED visits for concussion, by age-group and sex, Niagara, 2010 - 2012
600
500
400
300
200
100
0 10 - 15 - 20 - 25 - 30 - 35 - 40 - 45 - 50 - 55 - 60 - 65 - 75 - 80 - 85 - All 0 - 4y 5 - 9y 70-74y 90+y 14y 19y 24y 29y 34y 39y 44y 49y 54y 59y 64y 69y 79y 84y 89y ages Rate (Total) 89.19 107.74 404.53 439.53 184.79 133.12 95.06 79.40 90.97 68.93 60.95 42.02 35.71 44.01 36.24 45.51 42.91 33.80 85.68 120.36 Rate (Female) 89.71 62.47 235.41 337.31 167.44 105.49 94.47 68.07 98.05 75.05 61.00 38.55 33.38 47.07 23.64 46.71 41.81 0.00 81.34 96.50 Rate (Male) 88.71 150.51 571.00 538.36 200.72 160.25 95.63 91.10 83.74 62.73 60.89 45.75 38.21 40.79 50.82 43.99 44.42 70.27 0.00 145.28
19
Age standardized rate of ED visits for concussions for Niagara and Ontario 2008 - 2012. 180.0
160.0
140.0
120.0
100.0
80.0 ED ED visit rate per100000x 60.0
40.0
20.0
0.0 2008 2009 2010 2011 2012 Total Niagara 104.5 114.7 118.4 135.2 150.9 Total Ontario 94.4 111.8 117.5 144.7 163.9
20
Age standardized rate of ED visits for concussions for Niagara and Ontario males and females 2008 - 2012. 200.0
180.0
160.0
140.0
120.0
100.0 Males Niagara
80.0 Females Niagara
ED ED visit rate per100000 Males Ontario 60.0 Females Ontario
40.0
20.0
0.0 2008 2009 2010 2011 2012 Males Niagara 123.1 128.3 141.4 164.9 184.9 Females Niagara 86.2 101.6 95.9 106.1 117.9 Males Ontario 116.6 133.3 140.3 172.5 189.4 Females Ontario 72.8 90.8 95.1 117.1 138.5
21
Reasons (%) for ED Concussion visits in Niagara (n = 1609) and Ontario 2010 - 2012 combined 40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00 Pedestrian/Cyclist Injured in Transport - Motor Inanimate Animate Transport vehicle (V20 - Falls (W00 - W19) mechanical forces mechanical forces Assult (X85 - Y09) Other Accident (V01 - V99) (W20 - W49) (W50 - W64) V19) Total Niagara 4.10 8.57 37.39 23.68 16.46 5.63 4.16 Total Ontario 3.67 9.99 35.65 25.89 16.01 5.57 3.21
22
Reasons (n) for ED Concussions in Niagara by age ranges in 2010 - 2012 combined 700
600
500
400 75+ y
300 50 - 74 y 25 - 49 y 0 - 24 y 200
100
0 Pedestrian/Cyclist Transport - Motor Falls (W00 - W19) Inanimate Animate Assult (X85 - Y09) Other Injured in vehicle (V20 - V99) mechanical forces mechanical forces Transport Accident (W20 - W49) (W50 - W64) (V01 - V19)
* ED visits for concussion caused by Animate and Inanimate mechanical forces for the 50 – 74y AND ED visits for all categories with the exception of Falls in the 75y+ age group were not reported due to low numbers.
23
Reasons (%) for ED Concussions in Niagara by age ranges in 2010 - 2012 100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% Pedestrian/Cyclist Inanimate Animate Injured in Transport - Motor Falls (W00 - W19) mechanical forces mechanical forces Assult (X85 - Y09) Other Transport Accident vehicle (V20 - V99) (W20 - W49) (W50 - W64) (V01 - V19) 75+ y 0 0 83.93 0.00 0.00 0.00 0.00 50 - 74 y 5.32 7.45 64.36 15.96 0.00 0.00 3.72 25 - 49 y 3.80 15.95 35.70 23.29 6.08 10.63 4.56 0 - 24 y 4.12 6.03 30.35 26.33 24.02 4.92 4.22
0 - 24 y 25 - 49 y 50 - 74 y 75+ y
* ED visits for concussion caused by Animate and Inanimate mechanical forces for the 50 – 74y AND ED visits for all categories with the exception of Falls in the 75y+ age group were not reported due to low numbers.
24
Reasons (n) for ED Concussions in Niagara by for those aged between 10 - 24 years in 2010 - 2012 combined 120
100
80
60 10 - 14y 15 - 19y 20 - 24y 40
20
0 Pedestrian/Cyclist Transport - Motor Falls (W00 - W19) Inanimate Animate Assult (X85 - Y09) Injured in vehicle (V20 - V99) mechanical forces mechanical forces Transport Accident (W20 - W49) (W50 - W64) (V01 - V19)
25
ED visits for concussion linked to falls, inanimate and animate mechanical forces in the Niagara region in 2010 - 2012.
For ED Concussion visits within the Falls category (W00 - W19 n = 612) in 2010 - 2012, 37% (n = 229) were coded as a 'Fall at the same level from slip, trip or stumble/fall at the same level’. 13% (n = 80) of ED concussion visits within the Falls category were related to sport/activity related incidents. Therefore, the majority of concussions categorized as ‘Falls’ were not linked to sport/activity and were mainly from falling at the same level (37%) or falling from steps/ladders/stairs/furniture (n = 132; 22%). For ED concussion visits within the Inanimate mechanical forces category (W20 - W49 n = 388); two fifths (n = 181; 47%) of ED concussion visits were linked to sport/activity. All of these were coded as ‘struck by/struck against’ a sport related inanimate object ( – e.g. bat/ball/stick/other) and 84 of these (i.e. 84/181 = 46%) were related to hockey. 335 ED concussion visits were as a result of exposure to animate mechanical forces (W50 – W64). 217 (65%) were as a result of playing a sport/activity. All of these were coded as ‘struck against/bumped into’ when playing sports and of these 109/207 (50%) were related to hockey. Therefore, of all concussions in Niagara 2010 – 2012 combined (taking into account, pedestrian/cyclist/transport/falls etc etc), approximately a quarter (n = 398/1609) were as a result of being struck by/struck against/bumped into during a sport (13.5 % animate (217) and 11.2% (181) inanimate). The sport most frequently cited is Hockey.
26
% of Concussions caused by Transport, Falls, Struck by and against, Other unintentional and Assult in Niagara 2010 - 2012
6% 13% 4%
Transport Falls Struck by/against Other unintentional Assult 40% 37%
* Niagara numbers too small to break into meaningful age categories. Of the ‘struck by/struck against’ category 398 (24%) of ED concussions are as a result of sports (and of that 193 (48%) are as a result of Hockey)
27
Sport/Recreation Specific Cause of ED visit for concussion, Niagara 2010 - 2012 Count % of Total Tobogganing 8 1.55
ATV/snowmobile 10 1.93 Playground equipment 12 2.32 Rollerblades/scooter/skateboard 17 3.29
Ice-skates 24 4.64 Soccer 26 5.03
Ski/snowboard 34 6.58
Hit by a ball 36 6.96
Cycling 54 10.44
Football/Rugby 61 11.80 Other sports related injuries 68 13.15
Hockey 193 37.33
543
28
Sport/recreation specific cause of ED visits for concussion, Niagara, 2010 - 2012
Hockey
Other sports related injuries
Football/Rugby
Cycling
Hit by a ball
Ski/snowboard
Soccer
Ice-skates
Rollerblades/scooter/skateboard
Playground equipment
ATV/snowmobile
Tobogganing
0 50 100 150 200 250 In 2010 - 2012, there were 543 ED visits for concussion with an external cause linked to sport/recreation. Hockey was the sport category with the highest number of visits accounting for n =193 (37%) of all sport/recreation visits. Cycling and Football were the next two highest categories. The ‘other’ sports related injuries category comprised of swim, hit by a bat, other sports equipment, other sport and recreation, baseball and bumped into sports and recreation equipment.
29
Emergency Department visits for concussions in Niagara: Place of occurrence (2010 – 2012 combined)
61% of all visits in 2010 - 2012 did not have a place of occurrence specified making it difficult to draw strong interpretations from the data. Sports/athletics areas followed by home were the next most common places of occurrence i.e. a fifth of ED visits for concussion occurred in sports or athletics areas.
Place of occurrence description (ICD10-CA Code) Count % of Total Not assigned 246 15 Home (U980) 118 7 Residential Institution (U981) 17 1 School/Institution and public area (U982) 81 5 Sport and Athletics Area (U983) 305 19 Street Highway (U984) 22 1 Trade/Service Area (U985) 74 4 Industrial/Construction area (U985) 15 1 Farm (U987) * * Other (U988) 55 3 Unspecified (U989) 701 43 Total 1637
Of the concussions caused by falls, 14% were in the home and 10% were in sports/athletics areas.
Of the concussions caused by inanimate mechanical forces a fifth (24%) occurred in a sports/athletic area.
30
Of the concussions caused by animate mechanical forces, 54% occurred in a sports/athletic area.
Data Source, Definitions, Methods, and Limitations
Data on emergency department visits for concussions was extracted from IntelliHEALTH ONTARIO using the ICD 10 Main Problem Diagnosis code of S06.0 for residents of the geographical area specified (Niagara Region or Ontario) and only for unscheduled emergency visits. Inclusions: - Unscheduled emergency visits: AM case type = EMG - Ontario (Province of patient residence = ON) or Niagara Region (PHU = Niagara 2246) residents - Intracranial Injury: ICD-10-CA MPDx code = S06 - Concussion: ICD-10-CA MPDx code for the visit begins with S06.0 - Age standardization is a method of adjusting rates to minimize the effects of different age distributions between two or more populations (in this case, Niagara Region and Ontario). Where indicated, rates were age standardized to the 1991 Canadian Standard population using the direct method. The rates refer to the number of emergency department visits per 100,000 population. Limitations: - Not all visits for concussion have an external cause of injury reported for the visits and a visit could have more than one external cause of injury reported - ICD-10 external cause of injury blocks V01-V89 (transport accidents) are not assigned a place of occurrence as they are assumed to occur in the specified transport-related location - Emergency department visit data reflects the number of visits to an emergency room by individuals residing in the designated area based on place of residence and does not represent the number of emergency department visits occurring in institutions in the designated area. - Emergency visit data does not capture those who did not seek treatment for an injury in a hospital setting and therefore will underestimate burden of injury.
31
Sports and Recreation Specific External Cause ICD10-CA Codes
Description ICD10-CA Code Baseball W2205, W5105 Hit by Bat W2101 Hit by Ball W2200 Cycling V10-V19 Rollerblade/Skateboard W0202, W0203 Football/Rugby W2203, W5103 Hockey W2102, W2103, W2202, W5102 Ice Skates W0200 Playground equipment W09-W0909 Skiing/Snowboarding W0201, W0204, W2200, W5100 Soccer W2204, W5104 Water sports V90-V94 ATV/Snowmobile V86 Other sports injury W2108, W2207, W5107 Tobogganing W2201, W5101 Swimming/Diving W16, W67-W74
Data Citations:
Ambulatory ALL Visit Main Table (NACRS, CIHI), 2008-2012, MOHLTC, IntelliHEALTH ONTARIO, Date Extracted: January 2014
Ambulatory Emergency External Cause (Chapter 20) (NACRS, CIHI), MOHLTC, IntelliHEALTH ONTARIO, Date Extracted: January 2014
Population Estimates (Statistics Canada), MOHLTC, IntelliHEALTH ONTARIO, data extracted January 2014
32
33