Article, Pediatrics

Characterization of pediatric golf cart injuries to guide injury prevention efforts

a b s t r a c t

Background: Golf cart injuries represent an increasing source of morbidity and mortality in the United States. Characterization of the circumstances of these injuries can inform Injury prevention efforts.

Methods: This study retrospectively reviews a prospective trauma registry at a level-one pediatric trauma center for golf cart-related injuries in patients under 18 years of age admitted to the hospital between 2008 and 2016. Results: The 40 identified crashes were associated with 82 hospital days, 17 ICU days, and more than $1 million in hospital charges over the study period. The median hospital stay was 1.5 days, and the median hospital charge was $20,489. Severe injuries with an Injury Severity Score of N15 were identified in 25% of patients, and moderate injuries with scores between nine and 15 were identified in an additional 30%. The most common injures were head and neck (60%) and external injuries to the body surface (52.5%). Only a single child was wearing a seatbelt, and the vast majority was not using any safety equipment. Children as young as nine years old were driving golf carts, and child drivers were associated with the cart overturning (p = 0.007).

Conclusions: Golf cart crashes were a source of substantial morbidity at a level-one trauma center. Increased Safety measures, such as higher hip restraints, seatbelts, and front-wheel breaks could substantially increase the safety of golf carts. Increased regulation of driving age as well as driver education may also reduce these injuries.

(C) 2018

Introduction

Golf cart injuries represent a significant and increasing source of morbidity and mortality in the United States. There were an estimated 147,696 injuries treated in the United States between 1990 and 2006 with a N100% rate increase over this period [1]. Injuries are more com- mon among children and the elderly [2] with an estimated 31.2% of in- juries involving children under 16 years of age [1]. Golf cart injuries are a common cause of neurologic injury in children [3,4] and are a known cause of craniofacial trauma [5,6]. Additionally, golf cart injuries are generally more severe among children than adults [6].

Most Public health measures have targeted All-terrain vehicles , but the risk of other non-automobile vehicles is evident [7]. At one Tertiary medical center, central Neurologic injuries were the most

* Corresponding author.

E-mail addresses: [email protected] (J.R. Starnes), [email protected] (P. Unni), [email protected] (C.A. Fathy), [email protected] (K.A. Harms), [email protected] (S.R. Payne), [email protected] (D.H. Chung).

common injury type observed in pediatric golf cart injuries, and the me- dian hospital charge was $23,677 [8]. This same study found that more than half of patients spent time in the intensive care unit. Consensus guidelines from professional organizations–including the American Academy of Pediatrics (AAP) [9] and the American Pediatric Surgical Association [10]–recommend that children under 16 not operate ATVs or similar unlicensed vehicles and that children wear seatbelts while riding as passengers. The AAP has informally extended these recommendations to golf carts specifically [11]. Despite these recom- mendations, use of seatbelts and other safety measures is rare [4,8].

In response to increasing on-road use and higher top-speeds, a fed- eral regulation was created that requires seat belts in golf carts with top speeds between 20 and 25 miles per hour [12]. However, many golf carts do not meet this speed requirement and are only subject to state and local laws that vary widely [12]. For example, in Tennessee, slower carts are not allowed on city streets but also do not require seat belts or a valid license [13]. Because laws vary by state, it is likely that types of crashes and injuries vary by state as well.

This study aims to expand the geographic reach of existing local studies [8] and add insights into additional variables not available in

https://doi.org/10.1016/j.ajem.2018.03.002

0735-6757/(C) 2018

1050 J.R. Starnes et al. / American Journal of Emergency Medicine 36 (2018) 10491052

national studies [1,2], such as use of safety equipment and location of chil- dren in the cart at the time of the crash. These analyses will inform injury prevention efforts. We reviewed the trauma registry records at a level-one pediatric trauma center to characterize golf cart-related injuries between 2008 and 2016 and identify potential injury prevention interventions.

Methods

The Institutional Review Board at the authors’ home institution approved this study.

Data collection

A retrospective review of a prospective trauma registry at a level- one pediatric trauma center was conducted to identify patients under 18 years of age admitted to the hospital for golf cart-related injuries between 2008 and 2016. Patient demographics, injury locations, Injury Severity Score (ISS), Abbreviated Injury Scale , referral status, hospital stay, and hospital charge data were reviewed from the registry. Location in the golf cart, direct cause of injury, and use of safety mea- sures were collected by chart review. Prior to May 2015, there was no golf cart field available in the database. Golf cart crashes prior to this date were identified by manual review of all traumas in the database. County and state median incomes were taken from the Small Area In- come and Poverty Estimates program of the US Census Bureau [14].

Data analysis

Descriptive statistics were used to describe the results. Chi-squared tests were used for categorical variables where the expected values exceeded five in each cell, and Fisher’s exact test was used otherwise. Logistic regressions were used to examine associations between some variables. All statistical analyses were conducted using Stata version

14.2 (StataCorp LP, College Station, TX).

Results

During the nine-year study period (2008-2016) there were 40 golf cart-related crashes found in the database. Children between 5 and 14 years of age accounted for 85% of crashes with relatively few cases among those younger than 5. The majority of children were white and male. Basic demographics and crash information are presented in Table 1.

Injury severity

Injury Severity Score (ISS) was used as a measure of injury severity. About 25% of children had severe injuries (ISS N15), and an additional 30% had moderate injuries (ISS 9-15). Major trauma is generally defined as an ISS N15. ISS generally increased with age (median ISS [0-4 years], 5; [5-9 years], 10; [10-14 years], 10; [15-18 years], 13), but this difference was not statistically significant. More than a quarter (27.5%) of children spent time in the intensive care unit (ICU). Children

Table 1

Characteristics of golf cart crashes

Age 10.855 (7.68, 13.06)

Gender

Female 37.5%

Male 62.5%

Race

African American 2.5%

White 95.0%

Other/unknown 2.5%

ISS score 10 (5, 13)

Hospital days 1.5 (1, 2)

Continuous variables are presented as median (IQR), and categorical variables are presented as percentages. N = 40 for all variables.

with higher ISS were more likely to go to the ICU when adjusted for age and gender (OR 1.23 per point; 95% CI [1.06-1.43]; p = 0.007).

Fig. 1 shows Abbreviated Injury Score by body region. More than half of children (52.5%) had a serious injury to at least one body re- gion (AIS >= 3). An AIS score of two is considered moderate while a score of 3 is considered serious. The most overall injuries were seen in the head and neck followed by external injuries to the body surface. The highest proportions of Serious injuries (AIS >= 3) were seen in head and neck and extremity injuries.

Injury mechanism

Being thrown off the cart was the most common cause of injury in both age categories. The cart overturning was more common in older children (29%) than Younger children (11%) while being thrown off was more common in younger children (63%) than older children (43%). These differences were not statistically significant (Table 2).

The most common sites of injury were home (22.5%) and recrea-

tional areas, including golf courses (17.5%). Just one child (2.5%) was in- jured while the cart was being driven on the street. Injury locations for other children were listed as “other” or “unspecified” and could not be determined from manual chart review.

Safety measures

Only one child (2.5%) was using a seatbelt at the time of the crash. Nearly all (90%) of children did not use any safety equipment, including seatbelts or helmets. Use of safety equipment in the remaining cases could not be determined from chart review.

Children were most commonly seated passengers (58%) or drivers (22%) during the crash (Table 3). Driving was relatively rare among children under nine years of age but was the most common location in the cart for children aged 10-14. The youngest drivers were 9 years old, and only one child driver was over 16 years of age. When the child was driving, the most common cause of the crash was the cart overturning (55.6%). When the child was a passenger, the most common cause was falling or jumping from the cart (69.6%). Being the driver was associated with the cart overturning compared to other in- jury mechanisms (OR 11.67; 95% CI [1.98-68.75]; p = 0.007).

Hospital course

The median hospital stay was 1.5 days, and 97.5% of children spent at least one day in the hospital. 27.5% of children spent at least one day in the ICU. The median hospital charge was $20,489, and a total of

$1,225,393.60 charges were generated across all children. Nearly all

Abbreviated Injury Scale by Body Site

30

25

20

15

10

5

0

24

21

15

17

9

10

2

4

6

1

3

4 4

0

2 2

0

4

Head/Neck Thorax Extemities Face

Abdomen

Total

External

AIS score < 3

AIS score >= 3

No. of Children

Fig. 1. Abbreviated Injury Scale by body region. Injuries to the head and neck (60%) and external injuries (52.5%) were the most common. Severe injuries with an AIS of greater than or equal to three were most common in the head and neck and extremities.

J.R. Starnes et al. / American Journal of Emergency Medicine 36 (2018) 10491052 1051

Table 2

Injury mechanism

Age

Cart overturned

Thrown off

Collision

Struck/run over

Entering/exiting

Total

0-9, n (%)

2 (11)

12 (63)

2 (11)

2 (11)

1 (5)

19 (100)

10-18, n (%)

6 (29)

9 (43)

4 (19)

2 (10)

0 (0)

21 (100)

Total, n (%)

8 (20)

21 (52)

6 (15)

4 (10)

1 (2)

40 (100)

children (85%) had Commercial insurance while 15% had Medicaid. The majority (77.5%) came from referring hospitals with the remainder coming from the scene of the crash.

Injury location

Home zip codes and counties were available for all children. Nine counties had more than one incident and accounted for 57.5% of all crashes. Nearly two-thirds (62.5%) of children were residents of Tennes- see, and 32.5% were residents of Kentucky. The median income for the counties of residence was $46,788, which is similar to the median in- come for the state of Tennessee of $47,243.

Discussion

Similar to national and local studies, we find that golf cart injuries are a significant source of both medical and economic costs. These crashes were associated with a total of 82 hospital days, 17 ICU days, and more than $1 million in hospital charges over the study period.

While national studies have indicated golf cart injuries are a signifi- cant source of morbidity [1,2], few local studies have been conducted. While these national studies established the problem, they did not in- clude details about the use of safety equipment or position in the cart that could inform safety interventions. At our level-one trauma center we found that use of safety equipment, including seat belts, was essen- tially nonexistent among pediatric golf cart crashes. This is consistent with results from a study conducted in Arizona [8] and suggests a wide- spread lack of adoption of these safety measures.

The majority of patients were passengers at the time of the crash, but driving was common among children over 10 years of age. Almost one- fourth of crashes occurred when the child was driving. Only one patient was old enough to have a valid drivers’ license, and children as young as 9 were driving golf carts. Interestingly, driving was associated with a greater risk of the cart overturning. This may be because children drivers are more risky or less aware of the potential dangers of reckless driving due to lack of experience.

Injuries to the head and neck were the most common. This is consis- tent with prior research. Head injuries could be the result of difference in terrain with a fall onto asphalt or concrete being more severe than onto grass [6]. It is likely that many of these head injuries occurred when children were thrown from the cart or the cart overturned. Stud- ies have shown that most golf carts only have rear wheel breaking and that this leads to directional instability and rollover when breaking until skidding occurs [15]. This is especially true at high speeds and on slop- ing paths [16]. Compounding this problem is the fact that most golf carts do not include seatbelts. Instead, they have hip restraints located on the sides of bench seating. These are of insufficient height to prevent ejection and can even act as a fulcrum to tip the passenger prior to ejec- tion causing them to fall headfirst [17]. Golf cart manufacturers could

reduce the number of these injuries by increasing the height of these hip restraints, adding seatbelts and central handles [17], and adding front-wheel breaks [15].

In contrast, some national studies [1] found that extremity injuries were much more common than head and neck injuries. This is likely a product of multiple factors. First, national studies based on the National Electronic Injury surveillance System (NEISS) include patients that were treated and released while local trauma registry studies generally do not. Patients with head and neurologic injuries are more likely to be admitted and enter these local registries. Additionally, NEISS studies in- clude both children and adults. It is possible that children are more likely to experience head and neurologic injuries compared to adults. This is corroborated by the fact that NEISS studies restricted to children show a high prevalence of head and neck injury and that these injuries were significantly more common among children [6].

In addition to characterizing burden, local studies can identify spe-

cific geographic areas and populations to best target interventions [18,19]. Just nine counties accounted for nearly 60% of incidents, making these potential targets for educational initiatives. Because non-modified golf carts are not allowed on public roads in Tennessee, most golf cart usage is confined to golf courses and specific communities. These recreational areas represent potential community partners where a high proportion of children using golf carts could be reached. Addition- ally, many golf carts on golf courses are owned by the course and rented by patrons. This would make installation and regulation of safety measures–such as seat belts and higher hip restraints–centralized and relatively simple. Golf cart manufacturers and sellers should be re- quired to provide safety education materials, especially to families where children will be riding in the cart [2]. It is also important that golf cart owners, especially parents, ensure that their children have adequate driving abilities prior to allowing them to drive carts. A standardized cutoff would be to only allow those with motor vehicle licenses to operate golf carts. In our sample, just one child who was in- jured while driving was over 16 years of age. Younger drivers should at least be supervised by a licensed driver. Increased enforcement of existing regulations about driver age and safety measures may also con- tribute to reducing injuries from these crashes. Current Tennessee laws do not require a license to drive a golf cart [13], but current regulations do require a license to operate a golf cart within state parks [20].

Our study has several limitations. First, the sample is limited to golf cart crashes admitted to a level-one trauma center. This likely biases injuries to be more severe because the majority of patients come from referring hospitals. Additionally, it is not known what proportion of injuries in the region are captured by the hospital system. This makes the calculation of crash rates impossible. The sample is also limited geo- graphically, which makes it difficult to generalize these results to other regions and states. This is especially true because of the varying nature of local and state laws surrounding golf carts and golf cart safety. Finally, the study is limited by the small sample size. Although the number of

Table 3

Location in cart

Age

Driver

Passenger

Backseat passenger

Standing on back

Other/NS

Total

0-4, n (%)

0 (0)

1 (50)

0 (0)

0 (0)

1 (50)

2 (100)

5-9, n (%)

2 (12)

12 (71)

1 (6)

1 (6)

1 (6)

17 (100)

10-14, n (%)

6 (35)

5 (29)

2 (12)

2 (12)

2 (12)

17 (100)

15-18, n (%)

1 (25)

1 (25)

1 (25)

1 (25)

0 (0)

4 (100)

Total

9 (22)

19 (48)

4 (10)

4 (10)

4 (10)

40 (100)

Declaration of interest“>1052 J.R. Starnes et al. / American Journal of Emergency Medicine 36 (2018) 10491052

crashes is similar to or larger than other studies [4,8], the small sample size limits the statistical conclusions that can be drawn.

Conclusions

Golf cart injuries were a significant source of injury in the Pediatric trauma registry at a level-one trauma center. These results suggest a po- tential role for public health officials to reduce the medical and eco- nomic costs of these injuries by improving educational efforts for families on the risks of golf cart use.

Acknowledgements

None.

Data statement

Data will be supplied by the corresponding author on reasonable request.

Declaration of interest

None.

Funding source

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

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