a b s t r a c t

Objective: Proper use of automobile seat belt in a motor vehicle crash is associated with reduced morbidity and mortality, shorter hospital stays, reducED resource utilization, and fewer missed work days. Seatbelt compliance nationwide is 86%. This study was undertaken to identify factors associated with noncompliance with seatbelt use among admitted patients following a motor vehicle crash.

Methods: This study was a retrospective analysis of motor vehicle crashes at an Urban Level 1 Trauma Center. El- igible subjects included patients age 18 and over, who were admitted by the Trauma Service following a motor vehicle crash from January to December 2017.

Results: Among 766 participants, the overall rate of seatbelt noncompliance was 32% (N = 245). Some partici- pants met the legal limit of intoxication (80 mg/dl) (N = 119 patients; 22%). Drug use was high among this pop- ulation, including THC (30%), opiates (29%), benzodiazepines (24%), cocaine (10%), and methamphetamine (10%). Patients who did not wear seat belts were more likely to be male (62.4% no seat belt vs. 51.8% seat belt), intoxicated (30.5% vs. 17.0%), screen positive for cocaine (18.2% vs. 4.7%), THC (37.7% vs. 24.2%), and meth- amphetamine (15.6% vs. 5.9%). We did not detect significant differences by seat belt use with respect to ethnicity, mode of arrival, day of week, opiate use, or benzodiazepine use.

Conclusions: In this study, 32% of patients in motor vehicle crashes were not compliant with seat belt use. Non- compliance with seat belt use was higher among patients who were male, younger age, intoxicated, or who had positive screens for cocaine, THC, or methamphetamine.

(C) 2019

1. Introduction

Motor vehicle collisions (MVC) are one of the leading causes of mor- tality in the first thirty years of life. Proper use of automobile seat belts in a motor vehicle crash is associated with reduced morbidity and mortal- ity, shorter hospital stays, and reduced resource utilization, and fewer missed work days [1-9].

The Centers for Disease Control reports that seatbelt compliance na- tionwide is 86% for drivers and front-seat passengers [10]. Previous studies have identified higher rates of seat belt compliance in states with primary seatbelt laws, or laws that allow law enforcement officers to apprehend drivers for lack of wearing a seatbelt. Factors previously reported as being associated with non-compliance include alcohol use, young age, lack of medical insurance, high rate of speed, older vehicles, single vehicle crashes, male sex, passenger status, smoking, secondary

* Corresponding author at: Department of Emergency Medicine, 3525 Southern Boulevard, Kettering, OH 45429, United States of America.

E-mail address: [email protected] (C.A. Marco).

roads, rural residence, low level of education, no dependents, previous driving record history, unemployment, teenage passengers, illicit and prescription drug use, and trip distance [11-25]. Compliance with seat belt use varies by region, state, and population [2].

This study was undertaken to identify factors associated with non- compliance with seatbelt use among admitted patients following a motor vehicle crash.

1. Methods

This study was a retrospective analysis of motor vehicle crashes at Miami Valley Hospital, an Urban Level 1 Trauma Center. The study was approved by the Wright State University Institutional Review Board.

Eligible subjects included patients age 18 and over, who were admit- ted by the Trauma Service following a motor vehicle crash from January to December 2017.

Data collected included: age, sex, ethnicity, use of seat belt, mode of arrival, day of the week, serum alcohol, urine toxicology results

https://doi.org/10.1016/j.ajem.2019.158367

0735-6757/(C) 2019

1070 C.A. Marco et al. / American Journal of Emergency Medicine 38 (2020) 1069-1071

(benzodiazepines, opiates, THC, cocaine, and methamphetamines), di- agnoses, and final disposition (discharge to home, discharge to rehabil- itation, or expired). Data were previously entered in the Trauma Registry by trained trauma registrars, based on EMS reports and medical records.

Sample size was determined a priori to be a minimum of 84 subjects, based on a goal to detect a medium effect size (rho = 0.3 or more) with a two-tailed test, 5% type I error and 80% power. Age was described with mean and standard deviation. Student’s t-test was used to compare age between patients with and without seat belt use. Factors associated with seat belt use were tested with Chi-square tests. Statistical signifi- cance was determined a priori at p b 0.05. Data were analyzed using SAS Version 9.4, (Statistical Analysis Software, Copyright

Table 2

Patient characteristics by restraint use.

No Restraint N (95% CI)

No. patients	245 (32.0%)	521 (68.0%)	-
Age in years (mean +- SD)	37.8 +- 15.2, 35.9-39.7	48.0 +- 20.8, 46.2-49.8	b0.001a
Male	153 (62.4%), 56.4%-68.5%	270 (51.8%), 47.5%-56.1%	0.006
Ethnicity African	56 (23.0%), 17.8-28.3	103 (20.0%),	0.61
American	179 (73.7%),	16.5-23.4 395 (76.4%),
	68.1-79.2	72.7-80.1

Restraint N (95% CI)

p-Value*

(c) 2002-2017 by SAS Institute, Inc., Cary NC, USA).

1. Results

Among 766 eligible participants, the mean patient age was 45 years old and 55% of participants were male (Table 1).

The overall rate of seatbelt noncompliance was 32% (N = 245). The majority of patients arrived to the ED via ambulance (74%), followed by helicopter (23%), and walk-in (3%). Most participants were tested for al- cohol (70%; N = 539) and drugs of abuse (51%; N = 392), based on the orders by the treating physician. Some participants met the Ohio legal limit of driving under the influence (80 mg/dl) (N = 119 patients; 22%). Drug use was high among this population, including THC (30%), opiates (29%), benzodiazepines (24%), cocaine (10%), and methamphet- amine (10%). Patients who did not wear seat belts were more likely to be male (62.4% no seat belt vs. 51.8% seat belt), intoxicated (30.5% vs. 17.0%), screen positive for cocaine (18.2% vs. 4.7%), THC (37.7% vs.

24.2%), and methamphetamine (15.6% vs. 5.9%). (Table 2). We found

Table 1

Patient characteristics.

White 8 (3.3%), 1.0-5.5 19 (3.7%), 2.1-5.3

Other

0.47

Mode of Arrival in ED Walk-in	8 (3.3%), 1.0-5.5	12 (2.3%), 1.0-3.6
Ambulance Helicopter	176 (71.8%), 66.2-77.5 61 (24.9%), 19.5-30.3	394 (75.6%), 71.9-79.3 115 (22.1%), 18.5-25.6
Day of week of injury Mon	33 (13.5%), 9.2-17.7	82 (15.7%), 12.6-18.9
Tue	34 (13.9%), 9.5-18.2	62 (11.9%), 9.1-14.7
Wed	28 (11.4%), 7.4-15.4	79 (15.2%), 12.1-18.2
Thr	38 (15.5%), 11.0-20.0	83 (15.9%), 12.8-19.1
Fri	33 (13.5%), 9.2-17.7	71 (13.6%), 10.7-16.6
Sat	41 (16.7%), 12.1-21.4	74 (14.2%), 11.2-17.2
Sun	38 (15.5%), 11.0-20.0	70 (13.4%), 10.5-16.4
Intoxicated (N80)	62 (30.5%), 24.2-36.9	57 (17.0%), 13.0-21.0
Opiate	43 (27.9%), 20.8-35.0	69 (29.2%), 23.4-35.0
Cocaine	28 (18.2%), 12.1-24.3	11 (4.7%), 2.0-7.4
THC	58 (37.7%), 30.0-45.3	57 (24.2%), 18.7-29.6
Meth	24 (15.6%), 10.0-21.3	14 (5.9%), 2.9-8.9
Benzo	41 (26.6%), 20.0-33.6	51 (21.4%), 16.2-26.6
Disposition Discharged home	151 (71.2%),	322 (73.2%),
	65.1-77.3	69.0-77.3

0.68

b0.001 0.78 b0.001 0.004

0.002

0.24

0.32

	All Patients		Rehab, other facil.	51 (24.2%), 18.3-29.8	107 (24.3%),
Patients Gender	N = 766		Expired	10 (4.7%), 1.9-7.6	20.3-28.3 11 (2.5%), 1.0-4.0
Male	423 (55.2%)
Female	343 (44.8%)

no significant differences by seat belt use with respect to ethnicity, mode of arrival, day of week, opiate use, or benzodiazepine use.

Ethnicity (N = 760) African American	159 (20.9%)
White	574 (75.5%)
Other	27 (3.6%)
Mode of arrival in ED
Walk-in	20 (2.6%)

1. Discussion

Ambulance	570 (74.4%)	Since the inclusion of three-point seat belts in motor vehicles in
Helicopter	176 (23.0%)	1959, their implementation has saved more lives than all other vehicle
Day of week of injury Mon	115 (15.0%)	Safety measures combined [26]. Their value was apparent in initial re- ports examining the effects of seat belt use that showed the efficacy of
Tues	96 (12.5%)	the three-point system over the two-point lap belt, the fact that three-
Wed	107 (14.0%)	point belts do not cause severe injury, and that seat belt use reduces

Thr	121 (15.8%)
Fri	104 (13.6%)
Sat	115 (15.0%)
Sun	108 (14.1%)
Intoxicated (N = 539) Yes (N80)	119 (22.1%)
Positive toxicology screen (N = 389) Opiate	112 (28.7%)
Cocaine	39 (10.0%)

THC 115 (29.5%)

Meth 38 (9.7%)

Benzo	92 (23.5%)
Disposition (N = 652) Discharged home	473 (72.6%)
To rehab or other facility	158 (24.2%)
Expired	21 (3.2%)

the risk for severe and fatal injuries [27].

Analysis of drivers and front seat passenger results released by the NHSTA in 2010 found that seat belts decreased the risk of death by 45% and the risk of injury by 50%. Since their implementation, current estimates calculate the numbers of lives saved by seat belts to be ap- proximately 300,000 since 1960 [28-30].

Primary enforcement laws allow law enforcement officials to pull over and penalize non-compliant persons, whereas secondary enforcement laws only allow repercussions if the non-compliant person has already been stopped for another reason. Primary enforcement laws are strongly recommended by the Community Preventative services Task Force [31]. Currently, Ohio currently has only a secondary enforcement law [32].

According to the Centers for Disease Control and Prevention (CDC), seat belt use rates are 86% nationwide and 82% in the state of Ohio as of the most recent data collected in 2017 [33,34]. The improvement of

C.A. Marco et al. / American Journal of Emergency Medicine 38 (2020) 1069-1071 1071

seat belt compliance over time is in part due to legislation at the state level allowing for more education and enforcement of fines and cita- tions for those not compliant with primary and secondary enforcement seat belt laws [35].

This study found a lower seat belt compliance rate (68%) than re- ported nationwide (86%) and in the State of Ohio (82%). This may reflect the population at our Level 1 Trauma Center, or it may be related to a higher incidence of injuries, and thus admissions related to trauma, than the general population that certain drugs are associated with non- compliance with seat belt use, including alcohol, THC, cocaine, and meth- amphetamine. This study validates findings of previous studies which have associated substances like alcohol, marijuana, opioids, cocaine and methamphetamine with an increased risk of motor vehicle crashes [14- 16,18,36]. These substances are associated with increased risk behavior for numerous proposed mechanisms. Alcohol and other illicit drugs are associated with poor driving habits as well as a predictor for lack of seat belt use [11]. A recent study reported that the lack of seat belt use was as- sociated with a higher chance of a positive drug screen, however there was no relationship between drug class and the lack of seatbelt use [20]. Many studies have demonstrated deleterious cognitive effects of alcohol intoxication [37-40]. Patients that are given alcohol under experimental conditions demonstrate a failure to adequately evaluate outcomes, both good and bad, when the decisions are based previous outcomes [41]. One experimental study, while small, demonstrated that drivers under controlled conditions repeatedly selected the more risky conditions even when coupled with the highest penalties for failure [42].

It is unclear why certain drugs were associated with noncompliance with seat belt use (i.e. alcohol, cocaine, THC, and methamphetamine), while others were not (opiates, benzodiazepines). One possible expla- nation may be that some patients screen positive for opiates and benzo- diazepines for legitimate prescribed therapeutic indications, while the other three drugs are considered drugs of abuse.

1. Limitations

These data were collected from a single institution and may not be generalizable to other settings. This study examined only patients ad- mitted, and it is possible that patients discharged from the ED may have different characteristics. Not all patients had toxicologic testing and this may have introduced bias. This study is based on retrospective data and is dependent on the accuracy of these data. Missing data may have affected the accuracy of results.

1. Conclusions

In this study, 32% of patients in motor vehicle crashes who were ad- mitted to a Level 1 Trauma Center were not compliant with seat belt use. Noncompliance with seat belt use was higher among patients who were male, younger age, intoxicated, or who had positive screens for cocaine, THC, or methamphetamine use.

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