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Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
Address correspondence and reprint requests to: Lara B. Trifiletti, PhD, Columbus Children’s Research Institute, Center for Injury Research and Policy, Assistant Professor, Department of Pediatrics, The Ohio State University College of Medicine, 700 Children’s Drive, Columbus OH 43205.
Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
Ladder use is involved in many occupational and non-occupational activities. Falls from ladders can result in serious injury and affect people of all ages. The purpose of this study was to comprehensively examine nonfatal ladder-related injuries on a national level.
Methods
Using the National Electronic Injury Surveillance System (NEISS) database, cases of nonfatal ladder-related injuries treated in U.S. emergency departments (EDs) from 1990 through 2005 were selected using NEISS ladder product codes. Analysis was conducted from June 2006 to August 2006.
Results
An estimated 2,177,888 (95% confidence interval [CI]=1,885,311–2,470,466) individuals ranging in age from 1 month to 101 years were treated in U.S. EDs for ladder-related injuries during the 16-year study period, yielding an average of 136,118 cases annually, an average of 49.5 per 100,000 people. Males predominated in ladder-related injuries (76.5%, 95% CI=75.8–77.2). Fractures were the most common type of injury (31.5%, 95% CI=30.5–32.6). The body parts most frequently injured were the legs and feet (30.4%, 95% CI=29.5–31.2). Nearly 10% of injuries resulted in hospitalization (8.5%, 95% CI=7.4–9.6) or transfer to another hospital (1.4%, 95% CI=1.1–1.8), approximately twice that of consumer product–related injuries overall. The number of ladder-related injuries increased by more than 50% from 1990 to 2005. Ladder-related injuries per 100,000 people rose almost 27% during the 16-year study period. Of the cases for which locale of injury was recorded, 97.3% occurred in non-occupational settings, such as homes and farms.
Conclusions
Given the 50% increase in ladder-related injuries during the study period, the relatively high likelihood of hospital admission, and the predominance of injuries in non-occupational settings, increased efforts are needed to prevent ladder-related injuries.
Introduction
In the United States, falls are the leading cause of unintentional nonfatal injury for all children and adults except for the 15- to 24-year-old cohort, for whom falls from heights are the third leading cause of unintentional nonfatal injury.
Non-occupational ladder-related injuries account for one half to two thirds of injuries from ladder-related falls, even though ladders may not always be necessary for the tasks being performed.
Data from seven studies show that common types of ladder-related injuries were strains/sprains, bruises/contusions, and fractures to the upper and lower extremities.
The majority of published studies have assessed ladder-related injuries in small sample populations of fewer than 300. The results vary as to the most common location and type of injury.
Lost productivity from work and school is important as well, especially because the majority of those injured are men and women who represent a cross-section of the U.S. labor force, that is, individuals aged 16 and older.
Due to the prevalence, cost, and severity of ladder-related injuries, the objective of this research was to determine national patterns of ladder-related injuries for people of all ages treated in emergency departments (EDs) between January 1, 1990 and December 31, 2005. To our knowledge, this is the first U.S. study to use national data to comprehensively examine nonfatal ladder-related injuries by demographics, type of injury, body part affected, and disposition from the ED.
Methods
Data were obtained through the National Electronic Injury Surveillance System (NEISS), which is operated by the U.S. Consumer Product Safety Commission (CPSC). The CPSC provides data on consumer product–related and sports activity-related injuries treated in U.S. EDs. The NEISS receives data from a network of 98 hospitals, representing a stratified probability sample of 6100 hospitals in the U.S. and its territories with at least six or more beds and a 24-hour ED.
The NEISS sample (design and implementation), 1997 to present. U.S. Consumer Product Safety Commission, Division of Hazard and Injury Data Systems,
Washington DC2001
Data incorporated into NEISS are weighted to produce national estimates for consumer product–related injuries to specific products treated in individual hospitals.
The NEISS sample (design and implementation), 1997 to present. U.S. Consumer Product Safety Commission, Division of Hazard and Injury Data Systems,
Washington DC2001
Established in 1972, the NEISS sampling frame was revised in 1978, 1990, and 1997. At all 98 hospitals, ED medical records are viewed by professional NEISS coders, and data regarding patient age, gender, race, injury diagnosis, body part injured, product(s) involved, treatment received, and a brief narrative describing the incident are recorded. Analysis was conducted from June 2006 to August 2006.
After reviewing all NEISS data narratives identified by ladder codes for straight or extension, step, and other/not specified ladders (product codes 4077, 0618, and 4078, respectively), cases describing patients treated for “carrying,” “hitting,” “bumping,” “tripping over,” or “being hit by” ladders were excluded. The estimates for this study were based on weighted data for 55,077 patients treated for injuries in EDs between January 1, 1990 and December 31, 2005 from “climbing on,” “slipping on,” “jumping off,” “stepping off,” or “falling off” ladders.
Data were analyzed using SPSS, version 14.0 (SPSS Inc., Chicago IL, 2003). The sample weight assigned to each case was based on the inverse probability of selection. Computation of relative risks (RRs) with 95% confidence intervals (CIs) was performed. All data reported in this article are national estimates unless otherwise specified.
Results
From 1990 to 2005, an estimated 2,177,888 people (95% CI=1,885,311–2,470,466) were treated in EDs for unintentional ladder-related injuries, 76.5% of which were men (1,666,311 cases, 95% CI=1,443,303–1,889,317) (Table 1). Age range was 1 month to 101 years with a mean age of 45.6 years and a median age of 44.0 years. Injury rates were highest for the 36- to 45-year-old group (493,358 cases, 95% CI=425,021–561,693) (Figure 1). The estimated number of patients treated for ladder-related injuries showed an overall increase from 107,477 (95% CI=80,425–134,530) in 1990 to 161,940 (95% CI=123,028–200,852) in 2005, representing a 50.7% increase during the 16-year study period. Of the 1,457,723 cases (66.9% of the total) for which location was recorded, 97.3% of ladder-related injuries occurred at home (1,418,250 cases, 95% CI=1,188,103–1,648,397).
Table 1Nonfatal unintentional ladder-related injuries treated in U.S. emergency departments, 1990–2005
Fractures were the most common injury type for all age groups except the 18-to-25 and 26-to-35 age groups (686,595 cases [31.5%], 95% CI=593,923–779,265), among which sprains and strains were the most common. Fractures were the most common injury to the arms/hands (52.9%, 250,380 of 473,343 cases) and the arms/hands were the most commonly fractured body parts (36.5%, 250,380 of 686,594 cases). Of all leg injuries, strains and sprains were the most common (37.6%, 248,561 of 661,346 cases). Of all strains and sprains, injuries to the legs/feet were the most common (49.0%, 248,561 of 506,923 cases). The legs/feet sustained the highest percentage of total injuries (661,346 cases [30.4%], 95% CI=570,683–752,009). Strains and sprains were the most common injury to the lower trunk (35.5%, 117,646 of 331,180 cases). Contusions/abrasions were the most common injury to the upper trunk (including shoulders and neck) (36.2%, 156,876 of 433,654 cases, RR=1.83, 95% CI=1.74–1.92). Lacerations/avulsions were 6.48 times more likely to occur (95% CI=5.95–7.05) if an injury was to the head/face.
Most injured patients (1,946,861 cases [89.4%], 95% CI=1,678,704–2,215,018) were treated and released from the ED. Patients who were hospitalized or transferred to another hospital comprised 9.9% of cases (217,088 cases, 95% CI=177,532–256,643). Hospitalization rates showed an overall increase with increasing age. Patients in the ≥76 age group were 2.69 times more likely (95% CI=2.40–3.01) to be admitted for hospitalization than patients in all other age groups. The highest percentages of hospitalization were for the legs/feet (28.2%, 52,469 of 185,885 cases) and lower trunk (23.4%, 43,495 of 185,885 cases). Admission rates were highest for fractures (RR=5.73, 95% CI=5.01–6.56), concussions (RR=2.24, 95% CI=1.80–2.77), and lower-trunk injuries (RR=1.70, 95% CI=1.51–1.93).
When NEISS data narratives included information about the height of fall or the height of the ladder, that height was recorded and used to calculate an association between hospital admission and fall height. Although much of the data concerning the height of fall was missing (76.8%), the available data show that hospital admission rates increase with increasing fall height. Admission rates are 2.3 times higher (95% CI=1.92–2.82) when patients fall from heights ≥6.10 m compared with patients who fall from heights less than 6.10 m above the ground. Similarly, admission rates increase for patients who fall from heights ≥7.62 m and higher compared with those who fall from heights <7.62 m (RR=2.97, 95% CI=2.15–4.09). Fractures are the leading type of injury resulting from a fall, slip, or jump from any height from a ladder. However, there is higher risk associated with increased height. There is no increased risk associated with patients who fall from heights ≥1.52 m as compared with patients who fall from heights <1.52 m.
Discussion
This study is the first to examine ladder-related injuries treated in U.S. EDs on a national level. Consistent with other studies, injuries due to falls from ladders most often occur to men. The low proportion of injuries among women (23.5%, CI=22.7–24.2) was unexpected, because do-it-yourself home renovations are popular among women.
Two possible explanations follow: (1) men are involved in more ladder-related activities than women, and (2) men may be more susceptible to ladder-related injuries given similar exposure to ladder use as women.
Most ladder injuries result from improper ladder positioning or support, overextension by the user causing imbalance, or slipping of the base of the ladder on the ground.
Many patients (65.1%, 95% CI=59.8–70.4) in this study were injured in non-occupational settings. Workers may have the benefit of protection and training from organizations like the Occupational Safety and Health Administration (OSHA),
although the extent to which safety training is followed or enforced is unknown.
Men and women aged 36 to 45 sustained the greatest numbers of ladder injuries in this study with a mean age of 45.6 years. Previous studies that assessed both non-occupational and occupational ladder-related injuries showed that the mean age range was significantly higher for non-occupational injuries (46.5 to 59.0 years)
In this study, almost 10% of ladder injuries resulted in hospitalization (8.5%) and transfer to another hospital (1.4%). The admission rate is approximately twice that of consumer product–related injuries overall, indicating the relatively high severity of these injuries. Ladder-related injury severity has been shown to increase with age.
In this study, the 36-to-45 age group received the greatest number of injuries, but hospital admission rates were highest for adults aged 56 and older (RR=2.57, 95% CI=2.37–2.79). These results agree with those of Diggs et al.,
who found marked increases in hospitalization rates among patients aged 56 and older, who fell off ladders.
Consistent with other published studies, fractures, strains/sprains, and contusions/abrasions were the three most common types of ladder-related injury.
Not only were fractures the most common injury in this study, but they were 5.7 times more likely to result in hospital admission (95% CI=5.01–6.56). Hospital admission and fracture injuries increase with increasing age. Fracture cases generally result in higher medical costs and more disability days than other ladder-related injury cases.
Strains/sprains were twice as likely to be injuries to the legs/feet (95% CI=2.05–2.38), while fractures were twice as likely to be injuries to the arms/hands (95% CI=1.98–2.16). Many of the ladder-related injuries to the legs/feet were most likely caused by jumping from ladders or by stepping off incorrectly or slipping off rungs. Attempts to break a fall with outstretched arms probably account for fractures to the arms/hands.
Although more than three fourths of data concerning the height of fall was missing, the available data show that hospital admission rates increase with increasing height. These results disagree with those from another U.S. study that found no association between height of fall and outcome of fracture injury or hospital admission, but concur with findings of studies from Australia and Sweden.
This study did not find any seasonal injury patterns. However, ladder injuries increased by more than 50% during the 16-year study period. According to U.S. Census Bureau statistics, the U.S. population increased by almost 20% from 1990 to 2005.
U.S. Census Bureau. National and state population estimates. Annual population estimates 2000 to 2005. annual estimates of the population for the United States and States, and for Puerto Rico: April 1, 2000 to July 1, 2005 (NST-EST2005-01). Available at: www.census.gov/popest/states/NST-ann-est.html.
Ladder-related injuries per 100,000 people rose almost 27% during the 16-year study period. With one exception, previous studies have not examined secular trends in ladder-related injuries because sample sizes were small or the study was limited to a short period of time (i.e., 1 year). An Australian study showed that ladder-related injuries, especially ladder-associated falls at home, increased from 2000 to 2003.
The reason for the increasing annual number of injuries is unknown. It may be due to increased ladder use reflected by growing interest in home improvement and do-it-yourself television shows, changes in ladder characteristics, changes in how and where ladders are used, or changes in the characteristics of those who use ladders.
This study has several limitations. It is likely that the number of injuries was underestimated; the actual number of ladder-related injuries may be greater than the number reported in this study, because only injuries treated in EDs are included.
The findings of this study may not be representative of those for ladder-related injuries treated in other healthcare facilities, or those that did not receive medical treatment. Data reported to the NEISS are limited by the detail provided in the ED medical record. Missing data and inconsistent documentation in the medical record may also occur. The narrative portion of the NEISS database frequently lacks detail about the height of the fall, the surface on which the patient landed, the type of work/activity being performed, the type of ladder being used, other factors that may have contributed to the injury event, and injury severity. This level of detail, if included, might be useful for prevention efforts. Despite these limitations, the strength of this study is its large, nationally representative sample size over a 16-year study period.
Increased public health initiatives that target men and women, especially of working age, could help reduce the number of ladder-related injuries. Currently, the U.S. CPSC and the National Ag Safety Database website, sponsored by the National Institute of Occupational Safety and Health and OSHA, publish tips for safe ladder use. In an educational pamphlet that specifies ladder safety techniques, OSHA recommendations include that ladders be used only on level surfaces, that objects under and around ladders be removed, that ladders should not be moved while in use, and that heavy loads should not be carried while on ladders.
Having another person secure the ladder by holding it may also prevent injuries. The September 2006 issue of Consumer Reports magazine rated ladders based on strength, ease of use, tipping/swaying, and walking with the ladder.
Consumer Reports recommends that users test ladders before buying, and that they consider the material of the ladder (e.g., do not use a metal ladder near sources of electricity) before use.
The authors wish to thank The Samuel J. Roessler Memorial Medical Scholarship Fund for financial stipend support for ALD while conducting this study. The authors appreciate the helpful comments and suggestions from Brenda Shields, MS, Center for Injury Research and Policy, and Sarah K. Fields, JD, PhD, School of Physical Activity and Educational Services, The Ohio State University.
No financial conflict of interest was reported by the authors of this paper.
References
Office of Statistics and Programming, National Center for Injury Prevention and Control
10 leading causes of nonfatal injury by age group, United States—. 2004 (Available at: www.cdc.gov/ncipc/wisqars/nonfatal/quickpicks/quickpicks_2004/unintall/htm.)
The National Electronic Injury Surveillance System: a tool for researchers. U.S. Consumer Product Safety Commission,
Washington DC2000 (Available at: www.cpsc.gov/neiss/2000d015pdf.)
The NEISS sample (design and implementation), 1997 to present. U.S. Consumer Product Safety Commission, Division of Hazard and Injury Data Systems,
Washington DC2001
U.S. Census Bureau. National and state population estimates. Annual population estimates 2000 to 2005. annual estimates of the population for the United States and States, and for Puerto Rico: April 1, 2000 to July 1, 2005 (NST-EST2005-01). Available at: www.census.gov/popest/states/NST-ann-est.html.
U.S. Occupational Safety and Health Administration
Stairways and ladders: a guide to OSHA rules. U.S. Department of Labor,
Washington DC2003(3124–12R). Available at: www.osha.gov/Publications/osha3124.pdf.
The following paper won the 2006 competition for the Best Paper in Preventive Medicine by a Medical Student. Since its inception in 1992, this award has been co-sponsored by the American College of Preventive Medicine, the Association for Prevention Teaching and Research, the Association of American Medical Colleges, the American Journal of Preventive Medicine, and the Ulrich and Ruth Frank Foundation for International Health. The monetary prize for the best paper is $1000; 2006 was the last year of the competition.
The full text of this article is available via AJPM Online at www.ajpm-online.net; 1 unit of Category-1 CME credit is also available, with details on the website.
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