AORN JOURNAL AUGUST 1989. VOL. SO. NO 2

Legislation

Nationwide mandatory seat belt, motorcycle helmet legislation proposed

n 1988, approximately 47,000 people were I killed on US highways, according to statistics from the National Highway Traffic Safety Administration (NHTSA), Washington, DC.

“That motor vehicle crashes are the leading cause of death for people age 1 to 45 is a national tragedy that must end,” said Sen John H. Chafee (R-RI). “Road trauma produces more paraplegics and quadriplegics each year in the United States than all other causes combined.”

In May, Senator Chafee introduced the National Highway Fatality and Injury Reduction Act of 1989, which would require all states to enact legislation requiring seat belt use and motorcycle helmets (S 1007). He stated that his bill would save lives, reduce the number of injuries, and decrease health care costs.

The bill will give states three years to enact such laws. States that do not meet the deadline in the first year will lose 5% of their highway construction funds and 10% for each year of noncompliance thereafter.

Senator Chafee modeled the proposed legisla- tion after the successful federal legislation used to encourage states to reduce the speed limit to 55 and to raise the minimum drinking age to 21.

As incentives, the bill will provide $95 million in grants to states, which already have seat belt and motorcycle helmet legislation, to develop education and enforcement programs. An additional $5 million will be available to the Highway Traffic Safety Administration to assist states in these activities.

In drafting the legislation, Senator Chafee obtained input from the medical community. The

bill has the support of many physician and nursing organizations including AORN and the American Nurses’ Association (ANA). The bill has been assigned to the Senate Environment and Public Works Committee, of which Senator Chafee is a member.

Results of Legislation

eat belt legislation has been attributed to saving S lives and reducing injuries. Officials from NHTSA estimate that between 1983 and 1988, 10,300 of the 15,200 lives saved by safety belts were due to laws requiring safety belts. A study of front seat passengers showed that safety belts prevented 48,000 moderate to critical injuries in 1987; of those, 37,000 were in states with seat belt laws.

To measure national seat belt use, NHTSA officials conduct surveys each year in 19 cities. Thirteen of the cities are in states that have safety belt use laws. Use in those cities was 51.1% compared to 36.3 % in the six cities without such laws. If all motorists in these cities had used safety belts, NHTSA officials estimate that more than 10,000 additional lives could have been saved in 1988. Also, they found that use in the 19 cities increased from 11% in 1982 to 42% in 1987.

The United States is the only developed country in the world that does not have mandatory seat belt legislation. State legislators first started discussing safety belt legislation in the early 1970s, but it was not until 1985 that the first state- New York-enacted legislation.

Since then, 32 other states and the District of

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NO BELT-USE LAW ENACTED

BELT-USE LAWS PASSED

Fig I. Status of safety belt legislation in the United States as of April 1989. (Il!ustrafion courtesy of TrafJc Safety Now, Inc, Detroir)

Columbia have enacted safety belt legislation (Fig 1). The three states that have repealed the legislation are Massachusetts, Nebraska, and Oregon. Legislation is pending in several states that would amend their laws.

In 1985, a final rule was issued on Federal Motor Vehicle Safety Standard (FMVSS) 208, Occupant Crash Protection. Under this rule, automobile manufacturers are required to install automatic restraints such as air bags or automatic seat belts in all new cars by the 1990 model year. If states comprising two thirds of the nation’s population passed seat belt use laws by 1989, this rule will be rescinded.

In April 1989, Secretary of Transportation Samuel K. Skinner said that the two-thirds population limit had been met; however, he issued another ruling that continues to hold automobile manufacturers responsible for installing automatic restraints, according to Mike Witter, highway safety specialist, NHTSA. With the 1990 model

year, the three-year phase-in process should be complete, and all new cars should have air bags or automatic seat belts.

As part of its Federal Motor Vehicle Safety Standard 208, NHTSA is requiring that a three- point belt system be installed in the rear seats of all new vehicles by the model year 199 1.

The laws in every state vary. Data from the National Conference of State Legislatures, Denver, shows that the laws require seat belts for the driver in all states that enacted seat belt legislation; however, they include the front seat passenger in 27 of the states and all passengers (both front and back seats) in five states. In two states, back seat passengers under certain ages are required to wear seat belts.

The laws also vary in the types of vehicles covered by belt laws: vans (29 states), pickup trucks (28 states), mediumlheavy duty trucks (12 states), and multipurpose vehicles (27 states). State laws also allow different exemptions-all states

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Injury Frequency

Head injury. . . . . . . . . . 8.5 times higher Fracture. . . . . . . . . . . . 2.7 times higher Laceration. . . . . . . . . . . 2.8 times higher Injury severity score.. . . 2.2 times higher Hospital bills. . . . . . . . . 3.3 times higher Hospitalization. . . . . . . . 3.0 times higher Length of stay. . . . . . . . 2.4 times higher Permanent disability.. . . 7.4 times higher Death. . . . . . . . . . . . . .14.8 times higher

without seat belts

,

allow medical exemptions, most allow exemptions for mail carriers and others who make deliveries, and a few states exempt people in farm and emergency vehicles.

Penalties for driving without a safety belt range from a low of $5 in Idaho to a maximum of $50 in New York, Texas, and New Mexico. Seventeen states charge between $20 and $25 for a first offense. In a few states, the safety belt law is a primary law, which means that the police can stop a driver for not wearing a belt; however, in most states the law is a secondary law and citations for not wearing a seat belt can only be issued when the driver is stopped for another offense. Studies have shown that compliance is highest in states that consider not wearing seat belts a primary offense.

The majority of states enacted legislation in 1985- 1986, according to Witter. The most recent states to enact legislation were North Dakota and Wyoming (1989).

Nationally, the safety belt use rate is about 47%. Use ranges from 65% in North Carolina to 22% in Utah. Studies in various states have shown that usage is high when the legislation is first enacted, but after a few months, it drops.’

Injuries

he greatest sources of injuries for motor vehicle T occupants without safety belts are the steering wheel, the windshield frame and windshield, and the instrument panel. The largest number of fatalities are caused by head injuries and injuries of the chest, abdomen, and pelvis.2

Studies have shown the following when people who wore seat belts were admitted to a hospital: ( 1 ) the number of deaths before amval in a hospital is reduced; (2) the admission rate is much lower; (?’ the number of internal organs injured is reduced; (4) the injury rate per person is decreased; and (5) fractures, wounds, and closed injuries of soft tissue are decreased for all sites, except for the chest and neck areas.3

In 1988, a study in Iowa showed that the average person has a one in three chance of suffering a disabling injury as a result of a motor vehicle crash during his or her lifetime. People

Table 1 Vehicle Injuries

using seat belts have a 54.4% reduction in their severity of injury, a 66.3% reduction in the need for hospital admission, and a 69.5% decrease in hospital charges!

For people not wearing seat belts, the average hospital cost including emergency room treatment was more than three times higher ($2,462) than for people wearing seat belts ($753).5 The average length of hospital stay is more than twice as long- 17 days for patients not wearing seat belts and seven days for those wearing seat belts.

On the average, data showed that people not wearing safety belts were likely to incur severe injuries or die in vehicle accidents (Table 1). Of those victims not wearing seat belts, 1 out of 24 died or were permanently disabled; of those who were wearing seat belts, only 1 out of 232 died or were permanently disabled.

The study, called the Iowa Safety Restraint Assessment, was conducted by the Governor’s Traffic Safety Bureau and the Iowa Traffic Safety Now coalition. Of the 1,454 people studied, 48% wore seat belts.

Similarly, a 1986 Chicago study showed that 54 (6.8%) of 791 people wearing safety belts required hospitalization compared to 110 (19.2%) of 573 people not wearing safety belts? Overall, there was a 60% reduction in severity of injury, a 67% decrease in hospital admissions, and a 66% decline in hospital charges for seat belt wearers. Costs also were higher in front-end collisions, when

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In Elmira, NY, seat belt use increased considerably because of an

enforcement/publicity program.

the accidents occurred between 35 and 45 mph, and increased with the age of the patient.

Injuries also can occur when safety belts are worn improperly. To prevent injuries, the lap portion of the safety belt should be worn across the bony part of the pelvis, below the abdomen. The shoulder portion should be worn over the shoulder so that it rests on the clavicle, the top part of the shoulder, and the front of the chest. When worn correctly, the forces from a crash are transferred to the bones rather than the soft organs of the abdomen.

If the shoulder belt is worn too high, the soft tissue in the neck can be injured, and if the lap belt is placed over a person’s stomach, soft tissue damage can occur in the abdomen area, according to Eunice Tokatloglou, RN, EMT, director of the EMS department at Humana Aurora (Colo) Hospital.

Tokatloglou sees the results that occur when people do not wear safety belts. Since Colorado has enacted safety belt legislation, she says that she has “not seen as many people biting the windshields.”

Effect of Education/ Legislation on Belt Use

ince enacting legislation, several states have S conducted studies comparing seat belt use rates before legislation and after legislation.

A 1985 study conducted in Elmira, NY, showed the success of using an enforcement and publicity program. The purpose of the study was to determine how well such programs would work in the United States and to demonstrate that they are needed to strengthen the effectiveness of seat belt laws.

The campaign consisted of three phases: publicity (first week); publicity plus police warnings (second week); and publicity plus traffic tickets (third week). The publicity included

television and radio spots, newspaper coverage, posters, and printed materials. The focus of the campaign was summarized in a television spot, “But, even with that law, people are forgetting to buckle up. So, in case anyone needs another reason to wear a seat belt . . . we’ll give you a ticket if you don’t.”’

During the second week of the campaign, police issued 500 warning notices, which showed a facsimile of a ticket on one side and information about the program on the other. During the third week, police ticketed 189 motorists who violated the seat belt law.

Seat belt use increased considerably because of the enforcement and publicity program. In Elmira, NY, the rates were 49% before the program, 77% immediately after the program was initiated, and 66% two months later. In Glen Falls, NY, a comparison city that did not have an enforcement/publicity program, belt use declined from 43% to 37% during this same period.8

In a study of the first eight states to adopt seat belt legislation, results showed a decline of 8.7% in the rate of front seat fatalities; the fatality rate was higher in states with primary enforcement laws (9.9%) than in states with secondary enforcement only (6.8%). This data was taken from monthly data on crash fatalities between January 1976 and June 1986.9 The states participating in the study were New York, New Jersey, Michigan, Illinois, Texas, Nebraska, Missouri, and North Carolina. (Nebraska has since repealed its legislation.)

Lack of education about seat belt use in reducing severe injuries and deaths was a factor in causing Massachusetts to repeal its seat belt legislation in late 1986, according to Pat Brigham, RN, associate director of the Massachusetts Nurses Association.

Brigham says that the bill had the support of state legislators when it was first enacted Jan 1, 1986, but it did not have grass-roots support. Subsequently, a radio talk show host, Jerry

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A O R h JOURNAL AUGUST 1989, VOL 50. NO 2 ~ ~~ _ _ _ ~

Trauma Gains National Attention Trauma is fast becoming a national issue. The interest in trauma care is becoming evident on all fronts: prevention, health care delivery, and research. A lobbyist with the American Trauma Society said that both the public and members of Congress want to “save lives and save money.”

Prevention. Sen John Chafee (R-RI) introduced federal legislation (S 1007) that would require states to enact mandatory seat belt use and motorcycle helmet use or lose a portion of their federal highway funds.

Heulth cure delivery. Sen Alan Cranston (D-Calif) and Rep Jim Bates (D-Calif) intro- duced legislation that would establish a com- prehensive, standardized means of providing trauma services throughout the country. Changes have been made in the House ver- sion since it originally was introduced in Jan-

uary. Now called HR 1602, the major change includes removing a provision in which emer- gency personnel would be informed about patients’ infectious diseases.

The House has passed HR 1602, but its companion bill (S 15) has not moved in the Senate. During the last legislative session, the bill passed the House, but not the Senate.

Research. During the last legislative ses- sion, funding for an infant injury prevention and control research program at the Centers for Disease Control, Atlanta, was increased by almost $23 million. For fiscal year 1989, the Department of Health and Human Ser- vices increased its funding to $20 million for the infant injury prevention and control research program. In addition, the program is receiving an additional $2.7 million from the Department of Transportation.

Williams, was able to develop public support to repeal the legislation. A referendum was placed on the November 1986 ballot, and it passed 53% to 47‘;.‘0

Since the bill was repealed, legislation has been introduced in the state legislature each year to reenact the seat belt law. Those attempts have failed. Brigham emphasizes that legislation and education must be used together. “Education without legislation will not be effective in changing people’s opinions.” she says.

A coalition of national groups is spearheading a campaign to increase the seat belt use. The “70 by 90’ campaign i5 an effort to achieve a 70% safety belt and correct child safety seat use by the year 1990. (See “Trauma Gains National Attention.”)

Its goals are to achieve the following: all states shall enact safety belt laws by 1990; all states with safety belt laws shall implement education and enforcement programs to achieve a minimum 707 compliance rate by 1990; and all states shall achieve a minimum 70% correct child safety seat use by 1990.

By raising and maintaining safety belt use to 70%, 3,500 additional lives could be saved and 59,000 fewer disabling injuries could result on an annual basis, according to the National Safety Council.

The coalition includes the insurance industry, safety associations, automobile manufacturers and dealers, governors, mayors, and law enforcement officials.

The ANA also is involved in publicizing seat belt use. With grants from NHTSA, state nurses associations in 11 states have demonstrated the role of nurses in motor vehicle occupant protection. Jackie Witt, RN, coordinator of ANA’s Department of Transportation Project, says the association is trying to obtain 1989 grants from NHTSA to study ways of increasing seat belt use in rural populations and in increasing the use of child passenger restraints.

Personal Freedom vs Cost to Society

pposition to seat belt legislation is rooted 0 in the belief that the federal government

AUGUST 1989, VOL. 50, NO 2 AORN J O U R N A L

should not interfere with a person’s personal freedom. In Massachusetts, Williams based his grass-roots campaign on the fact that the law was an intrusion on personal freedom.

Dawn James, president of the Colorado EMT-I Society, says that the consensus of people living in rural, eastern Colorado, is that, “It’s my life, and I don’t like people telling me what to do with it.” As administrative assistant of Kit Carson Ambulance SeMce, James would like to change that attitude because she sees the results of motor vehicle crashes. She says that rural areas see more fatalities because the respnse time is longer and it takes longer to get the victim to a trauma center.

In introducing his legislation, Senator Chafee said that the cost of motor vehicle accidents is becoming prohibitive for taxpayers. The overall cost of motor vehicle injuries and fatalities in 1986 resulted in $16.4 billion for lost productivity, $4.1 billion for medical costs, and $9 billion for insurance administration, legal, and other costs. The $29.5 billion total does not include $27.4 billion in property damage.”

“There is a growing body of evidence that many of the costs of motor vehicle injuries are being borne by the public,” he said. “This is not an individual liberty issue. Driving on our highways is a privilege, not a right.”

SUSAN SCHLEPP ASSISTANT EDITOR

Notes 1. A F Williams, A K Lund, “Results of a seat

belt use law enforcement and publicity campaign in Elmira, New York,” Accident, Analysis & Prevention

2. J A Holden, “Why do safety belts work?” Tra#ic Sajety (January/February) 1989 1 1 .

3. M J Allen, M R Barnes, G G Bodiwala, “The effect of seat belt legislation on injuries sustained by car occupants,’’ Injury: The British Journal of Accident Surgery 16 No. 2 (1985) 475.

4. Iowa Sajety Restrain Assessment (Des Moines: Governor’s Traffic Safety BureauAowa Traffic Safety

19 NO. 4 (1987) 243-249.

NOW, 1988) 46-52. 5. Ibid 6. E M Orsay et al, “Prospective study of the effect

of safety belts on morbidity and health care costs in motor-vehicle accidents,” Journal of the American Medical Association 260 (Dec 23/30, 1988) 3598- 3603.

7. Williams, Lund, “Results of a seat belt use law enforcement and publicity campaign in Elmira, New York,” 243-249.

8. Ibid 9. A C Wagenaar, R G Maybee, K P Sullivan,

“Mandatory seat belt laws in eight states: A time-series evaluation,” Journal of Safev Research 19 (Summer

10. R Hingson et al, “Repeal of the Massachusetts seat belt law,” American Journal of Public Health 78 (May 1988) 548-552.

1 1. Congressional Record, Congressional Session: 101-1 (May 16, 1989) S 6397.

1988) 51-70.

Domino-Donor Procedure Raises Questions A fairly new procedure, called domino-donor heart and lung transplantation, is seen as a way to help increase the availability of vital donor organs. In a domino-donor transplantation, a patient who is about to receive a donor heart and lungs donates his or her heart to another patient, according to the June 2, 1989, issue of the Jour- nal of the American Medical Association.

Refinements in transplantation techniques have made dominodonor transplantation pos- sible. These include improved donor organic preservation methods, new immunosuppressive medications, advances in technical capabilities, and increased surgical experience.

The procedure was first conducted at The Johns Hopkins Medical Institutions, Baltimore, in May 1987. The case involved a 28-year-old man with cystic fibrosis and a 38-year-old man with ischemic cardiomyopathy. A year after receiving the heart-lung combination, the younger man died of apparent rejection. The older patient, who received the younger patient’s heart, is alive and doing well.

Since then, five other domino-donor proce- dures have been performed. Three deaths have been attributed to postoperative infection, but not to the procedure itself.

In the article, the authors address the ethical question of whether the surgery puts either patient at increased risk, and if so, whether that risk is greater than with other transplant options.

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