CAN WE ELIMINATE SERIOUS INJURIES THROUGH LEGISLATION? The Next Step – The Path of Action Must be Based on Universal Terms and Definitions to Reasonably Reduce Playground Injuries.

CAN WE ELIMINATE SERIOUS INJURIES THROUGH LEGISLATION? The Next Step – The Path of Action Must be Based on Universal Terms and Definitions to Reasonably Reduce Playground Injuries.
By Kenneth S Kutska, CPSI
Executive Director
International Playground Safety Institute, LLC
July 4, 2014

Several months ago I ended my column with the following statement: “Assuming the ISO TC 83 terminology paper “Injury and Safety Definitions and Thresholds” is approved and published, I will discuss the terms and definitions for different types of injuries and break down each type into various levels of severity.” This document has been approved by the International Organization for Standards Technical Committee Technical Committee ISO/TC 83 for Sports and other recreational facilities and equipment, Subcommittee. I believe it is at their editor for printing where it will be given some sort of identification number similar to what ASTM does. I will share my thoughts on some of the terms and definitions within this document. I will try to relate how they may impact international standards related to child injury prevention in the future. My comments will primarily focus on fall related injuries and their relationship to the current international playground industry impact attenuating surface standards.

I begin with my perspective on how playground related injuries, and the different levels of injury severity, relate to a currently compliant playground surface systems. The question which needs to be answered is, “Do the current fall impact thresholds within these standards address the level of injury, specifically life-threatening and debilitating, these international performance standards (ASTM F1487, ASTM F1292, EN1176, EN1177, CSA Z614) and the CPSC Handbook recommendations are attempting to address. Each standard introduction and scope defines the objective of injury reduction while each one continues to admit there will continue to be many injuries sustained by children at play. Play environments are not, and should not, be inspected as if the inspector were an OSHA inspector in a workplace. Children are expected to challenge themselves beyond their current level of proficiency. This is all part of child development. We must find balance between safety versus risk versus hazard.

Some of these terms have been used synonymously and maybe after going this article you may change your mind on a few things. Let us first define an “injury,” but more importantly define the levels of injury severity we are most concerned with and want to address in our international playground related standards. Nobody wants a child to suffer a serious injury. What is a serious injury? It is easier to define than to accept when it is your child or grandchild on the receiving end of the pain and suffering.

Based on the new ISO TC 83 document; the terminology used to separate the severity of injury classes are defined as follows;

“Life-Threatening Injury: an injury to any part of the human body which are serious or resulting in permanent impairment, that would be categorized as AIS (abbreviated injury scale) of 4 (severe with survival probable) or greater.

Debilitating Injury: an injury that diminishes or weakens the human body and has a legacy of greater than 1 month and that could be categorized as AIS (abbreviated injury scale) of 3 (serious, but not life-threatening).
Note; debilitating injuries would include requiring surgery, concussions that require removal from play to medical attention.

Serious Injury: an acute physical injury requiring medical or surgical treatment or under the supervision of a qualified doctor or nurse, provided in a hospital or clinic and includes injuries such as burns, factures, lacerations, internal injury, injury to organ, concussion, internal bleeding, etc.”

While these definitions may give us some frame of reference, we still need more information to help guide the lay person and the medical profession. What does “removal from play to medical attention” mean? What constitutes “medical attention?” Are we talking about a physician or a school nurse? Both have a level of medical training. When we mention fractures under serious injuries, are we talking about any fracture or one that requires reduction through surgery? You will notice the categories, “life-threatening injury” and “debilitating injury” as it relates to the Abbreviated Injury Scale (AIS). The AIS system is a medical diagnostic and prognosis system. I foresee issues with the definition of serious injury and how it relates to the AIS. Additionally, there is some confusion between minor and moderate injuries AIS 1 and 2 and how the level of AIS defines the level of severity of a burn (as an example.) For burns the medical profession considers a 2nd and 3rd degree burn and then factors in the body part and the percentage of the body or part that is impacted. I see some subjectivity involved here, but the medical training of the evaluator, should address my concerns. This scale originated in the automotive industry, where the current surfacing thresholds come from, and has become recognized within the international medical profession and should serve us well as we move forward with the debate on what level of injury society is willing to accept. The risk of a fatality for each AIS is minor 0%, moderate 0.5%, serious 2.1%, severe 10.6%, critical 58.4%. This AIS diagnostic and prognosis system is defined as follows;

“The writing of standards and the elimination of hazards must have an evaluation system based on injuries. To this end a universal injury evaluation system both for injury reporting and scoping in standards will benefit all involved. The risk evaluation is based on scoring systems, which may vary by country. It may be considered whether those tools should be part of the Standards written by ISO TC 83. This threshold for injury would be acceptable in the scoping of national standards to ensure universality for elimination of hazards and risk evaluation. They may be mentioned in an informative annex or listed as reference.

Medical Thresholds and Diagnostic Tools
Abbreviated Injury Scale (AIS):
A numerical rating for quantifying the severity of injury to a human based on body region, anatomic structure, level of injury and injury severity that must be used in the scope of standards intended for safety or injury prevention. The range of severity is from 1-9.

Injury Severity Abbreviated Injury Score

Minor injury 1
Moderate injury 2
Serious, but not life-threatening 3
Severe Potentially life-threatening, survival likely 4
Critical with uncertain survival 5
Un-survivable injury (maximum possible) 6

The AIS system also considers
• different parts of the body
• the type of anatomic structure

Summary:
Injury Prevention Thresholds for Scope of Standards
The scope of TC/83 calls for both product safety and promotion of trade and to this end the user of the products in the standards should be able to rely on credible standards to ensure them that claims of compliance to a standard will effectively protect them from hazards and harm within the context of acceptable risk. The scopes of standards must clearly state the harm and risk to which the consumer and user of a product is exposed.

The provision of definitions and thresholds are only valuable if they are used in the development of standards and used, particularly in the scope of standards intended to prevent injury. The prevention statement of the scope shall assist the manufacturers, test houses and legislators in understanding the intent of the standards writers and specify the limitations related to prevention of injury.

The definitions and a carefully defined scope must by extension focus the standards writers in their deliberations and development of those performance standards.

It must be noted that using thresholds, terms and definitions is not intended to reduce the challenge or enjoyment of a sport or recreation activity, but to raise the awareness of the need to accept risk, while working to avoid and limit risks in the context of reasonably foreseeable misuse.

This has and will continue to be a collaborative effort and should assist the sub-committees under ISO TC/83 and hopefully National and European Standard Bodies with similar scope as of ISO TC/83 to consider the need to harmonize terms and standards to assist ISO TC/83 in promoting international trade within the context of injury and risk prevention.”

Designers, manufacturers, owners and operators should not be in the business of eliminating risk but rather managing elimination of hazards and injury prevention to allow children to be children. There will always be some residual risk of harm in anything a child is doing within their immediate environment as they undertake the graduated challenge opportunities within the play environment.

How does this impact ASTM F1487 and ASTM F1292 standards now and in the future?

I am responsible for facilitating the discussion which determines the direction and content of ASTM F1487. I am also a voting member on the ASTM F1292 standard. F1487 requires compliance to ASTM F1292. The international standards industry has been using the maximum impact attenuating threshold of 1000 HIC (Head Injury Criteria) as the gold standard for a compliant playground surface system. Previously, I have discussed what this threshold means in terms of AIS in my previous column. Also, I have discussed what our standard scoping statements suggest we shall address. I am starting to believe that 1000 HIC does not address the level of injury we profess to address in our standard. We may be addressing the level of injury with regards to equipment performance, but the surfacing within our use zones is probably missing the mark, as the scope or the CPSIA are currently worded. It is time to say what we mean and mean what we say.

The obstacles to meeting or current scoping statements are;
• the need to reconcile the difference between the definitions for a “serious injury” according to the AIS System and the Consumer Product Safety Improvement Act and what our standard’s scope says.
• the playground industry’s agreement on the risk assessment process based on the possibility, probability, and level of injury likely from a fall to a surface just under 1000 HIC, which is a 16% risk of AIS >4.
• the need to accept the residual risk or harm after a risk assessment, which includes risk analysis and evaluation, has been conducted by the designer, manufacturer and owner and reasonable risk reduction or protective measures have been taken based on the intended use and reasonable foreseeable misuse of the equipment.

I believe we can make progress in providing more graduated challenge opportunities within the play environment while minimizing the liability exposure to designers, manufacturers and owners of public play areas if we can address these issues. Without some clarification to our playground standards scoping statements and performance objectives, the dark cloud of uncertainty will continue to inhibit our ability and desire to provide the types of age appropriate challenging and risky play opportunities for our children, the intended users, need and deserve. I will continue to work towards a solution and I urge everyone to get involved. You all have a dog in the hunt.

I leave you with this question. Can you define what tolerable or acceptable risk or to put it another way, injury threshold, is when it comes to your child? Are you willing to except a child’s accident resulting in a mild concussion or even momentary unconsciousness? Are you willing to accept a leg or arm fracture? If your answer is yes, are you also willing to accept the same consequences if the accident involves your child?

NOTE: You may have noticed some of the words were underlined. These words are just some of the terms defined in this new ISO Document.

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