TIPP Usage

TIPP

Usage

Leonard Krassner, MD

Fran t! D3artinent o( iatrics, Yale (Jniveslty School of Medicine, N Haven, CI

ABSTRACT. In recent years, physicians have become more concerned about the prevention of childhood sod-dents. Developed to help physicians teach parents how

to avoid unintentional injury, The Injury Prevention Program (TIPP) is significant because anticipatory

guid-ance has now been recognized as being as much a part of

routine health supervision as the history and physical

eaminatjon. The American Academy of Pediatrics’

pol-icy statement enclosed with each TIPP package states

five goals that deal with major causes of childhood

mor-tality; three can be achieved with a single purchase or

action-buying a smoke alarm, buying a bottle of ipecac,

and turning down hot water temperathre. TIPP com-prises three elements A parent questionnaire (the Fram-ingbam safety survey) is used to identify at-risk behavior.

Safety sheets to be handed out at the next visit reinforce

the information provided by the physician in his or her discussion of the questionnaire results. A model

counsel-ing schedule suggests how to incorporate the

question-naire and safety sheets into an effective office program.

By gradually phasing TIPP into an office practice,

phy-sicians can become familiar with TIPP materials and

integrate it in a controlled manner. The AAP COmmittee

on Accident and Poison Prevention is studying measures

to increase the usefulness of TIPP. Pediatrics

l9M;74(suppl):976-980 patient education, The Injury

Prevention Program (TIPP), anticipatory guidance, Frwningham safety survey.

In the past several years, there has been a

sig-nificant change in the medical profession’s attitude

toward the prevention ofchildhood accidents.

Prac-titioners who previously focused their attention

almost exclusively on the consequences of

trau-matic events have broadened their concern to

en-compass causative elements that can lead to serious injury and death.

Led by such diverse groups as the American

Read before the Symposium on Pediatric Patient Education:

Challenge for the SOs, Dallas, Nov 29-30, 1983.

Reprint requests to (LK.) 116 Sherman Aye, New Haven, CT

06511.

PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the

American Academy ofPediatrics.

Academy of Pediatrics and its Committee on

Acci-dent and Poison Prevention, the Physicians for

Automotive Safety, National Safety Council, and

various agencies of the federal government, a loose

coalition has evolved to deal with the tragic problem

of accidental injury and death.

It would seem reasonable to expect that the

mag-nitude ofthe unintentional injury problem, whether

measured in terms of morbidity and mortality,

eco-nomic costs, or human suffering, would lead to a

vigorous national response. For reasons stifi

diffi-cult to understand, however, no coordinated

re-sponse has evolved to end this needless loss of life.

One possible explanation for the medical

profes-sion’s lack of interest in the problem is the almost

complete absence of accident prevention in the

curricula of the vast majority of the nation’s

medi-cal schools. Students receive their degrees without

ever seeing academicians, their most important role

models, recognize the importance of anticipatory

guidance for the prevention of injury by giving it a

permanent place in the curriculum. It was a

“logi-cal” assumption, therefore, that “real doctors”

corn-mitted their professional efforts to treating disease

and that prevention was the province of health

educators, the media, and the National Safety Council.

Another cultural factor has been our society’s

inclination to label unintentional death and injury

as “accidents.” And because accidents are the result

of “bad luck” or an “act of God,” it would be both

presumptuous and a waste of effort to attempt to

study them.

A more recent view, however, has been that it is

difficult to study a so-called accident and not be

able to identify a number of factors that could have

significantly modified or eliminated the uninten-tional trauma that resulted.

BACKGROUND

One of the first indications that organized

SUPPLEMENT 977

prevention came with the AAP’s national program,

“First Ride/A Safe Ride.” The goal of this effort

was to have, by 1983, 75% of newborns born in the

United States going home from the hospital in

approved infant seat restraints.

At the same time that the Academy was dealing

with automobile safety, the DHHS was working on

a program called the “Injury Prevention Project.”

Its purpose was to conceive and develop a variety

of approaches that could be used by both

govern-mental agencies and private practitioners in injury

prevention. During the fmal phases of this project,

it was decided to invite the AAP Committee on

Accident and Poison Prevention to discuss whether

any of the Injury Prevention Project’s efforts might

be suitable for incorporation into an already

estab-lished or anticipated program.

During this meeting, three items were determined

to be applicable to pediatric practice: a set of three

age-appropriate questionnaires (the Framngham

safety survey); a set of four developmentally

ori-ented handouts dealing with the major causes of

childhood injury; and a model counseling schedule

for incorporating the sheets and questionnaire into

an organized, reproducible, and effective office

pro-gram.

The joint meeting then produced a policy

state-ment (Table 1) that was presented to and approved

by the Academy’s Executive Board. Thus, The

In-jury Prevention Program (“TIPP”) was conceived.

TIPP

The significance of the Executive Board’s

state-ment was not that it introduced new concepts in

the management of unintentional injury. The

sig-nificance was that anticipatory guidance for injury

prevention was now as much a part of routine

TABLE 1. Policy Statement on Injury Prevention

Ap-proved by the Executive Board of the American Academy of Pediatrics

All children should grow up in a safe environment

Anticipatory guidance for injury prevention should be

an integral part of the medical care provided for all

infants and children

All physicians caring for children should advise parents

to acquire for their children’s safety: 1. Currently approved child car restraints

2. Smoke detectors in the home that would protect the

child’s sleeping area

3. Safe hot water temperatures at the tap

4. Window and stairway guards/gates to prevent falls

5. A 30-mL (1-oz) bottle of syrup of ipecac.

In addition, all physicians caring for children should counsel parents in age-appropriate, season-appropriate,

and locality-appropriate prevention strategies that

re-duce common serious injuries. Medical records should

reflect this counsel.

health supervision as the history and physical

ex-amination. Physicians were now mandated to teach,

and patients not only could expect but were entitled

to learn from their pediatrician what they should

do to avoid unintentional injury.

The five goals stated in the policy statement were

highlighted because all deal with major causes of

morbidity and mortality and three of the five goals

can be achieved by a single purchase or action.

Purchasing a smoke alarm, purchasing a bottle of

ipecac, and turning down hot water temperatures

are all maneuvers that effectively reduce the chance

of injury.

Designing the first stage of the program to focus

on the first 4 years of life makes use of the unique

relationship physicians share with parents of young

children. Capitalizing on the pediatrician’s ability

to modify parental behavior, the program aims to

establish patterns early in life that will carry over

as the child grows older.

The most important step in incorporating TJPP

into a practice is to acknowledge that anticipatory

guidance is an essential part of pediatric practice

and that you want to make it part of your office

routine. The next step, and this is essential to a

successful effort, is to educate your office staff as

to why it is important that parents be made aware

of their responsibility in accident prevention. Once

this is done, you can deal with the mechanics of

incorporating TIPP into your health supervision

routine with minimal disruption to your usual office

format.

FRAMINGHAM SAFETY SURVEY

The Framingham safety survey consists of three

sheets of questions that concentrate on the major

causes of morbidity and mortality during the first

4 years of life. Attached to each color-coded sheet

is a specially treated second sheet which transfers

from the top sheet only those responses that

mdi-cate some at-risk behavior (Figure).

The three questionnaires, colored blue, yellow,

and green, are designed to cover a broad range of

safety-related topics and are oriented for ages, 2,

15, and 24 months. The appropriate form is

pre-sented to the parent once the infant is in the

examining room and before the physician arrives.

The nurse explains to the parent that the survey is

not a test but rather a new program to promote

injury prevention.

Use of the questionnaire offers an interesting

variation to the “active doctor-passive patient” type

of teaching. Here the patient (parent) must take a

more active role and is asked to think about

poten-tial problem situations and how to deal with them.

Experience during development of the

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PARENT COPY AND PHYSICIANS

SCREENING COPY OF

ThE FRAMINGHAM SAFETY SURVEYS

FIRST

PAGE-FOR PARENTAL RESPONSES

FRAMIPIGHAM SAFETY SURVEY

TFflt wLi

b

-, , 2 I97’ , , Appropriate responses are not

transferred

\

‘

“At risk” responses are

transferred

‘ %

require discussion.

S

SECOND PAGE- \

FOR PHYSICIAN SCREENING \

k .‘

:

i!c!/

- ‘4 s,’s$

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2 ,

Figure. Framingham safety survey.

naires has shown that it takes a parent about three

minutes to fill out the form and the physician (once

he is familiar with the materials) about the same

length of time to go over the at-risk answers.

Al-though most pediatricians will already have the

necessary body of knowledge to discuss the areas

covered by the survey, it has become apparent that

some expository material covering all the elements

of the program is needed. To fill this need, a short

brochure discussing the components of the program

is being prepared. It will accompany each order of

TIPP materials and will also be available on request

from the Academy.

During the discussion in the office, points will

arise that can be most effectively communicated by

the use of appropriate written material. Some of

these, such as the management of choking, can be

copied from the Academy’s first-aid chart.

Single-sheet discussions on safe bicycling, fire

emergen-cies, babysitting tips, etc, are also available from

the Academy’s publication office.

At the close of the discussion, a helpful way to

reinforce what has been discussed is to circle the

at-risk answers on the top sheet and allow the

parent to take the top sheet home for review. The

second sheet is filed in the patient’s chart as a

record of the discussion.

An appropriate notation on the immunization

sheet or some similar place on the patient’s chart

makes it easy for the office staff to determine which

patients have received the appropriate material.

When first starting to use the TIPP materials, it

is important that the nursing staff integrate it in a

controlled manner. In the early stages, the focus

should be on the older children who don’t come

into the office often. Because the frequency of

routine visits decreases progressively after the first

birthday, the focus should be on reaching as many

2- to 3-year-old childre and 15-month-old infants

as possible during the period that the program is

being introduced into the practice. This phasing-in

process smoothes that short period necessary to

become familiar with the TIPP materials.

Once the physician is assured that the presence

of a questionnaire attached to the chart of the next

TABLE 2. Tips on Incorporating The Injury

Preven-tion Program (TIPP) into Office Practice

1. The use of a clipboard with a pen attached makes it

easier for the parent to fill out the questionnaire.

2. Have your nurse emphasize to parents that they

must cross out their answers. If a circle is used, the

special paper may read all answers and not just those at risk.

3. Instruct parents to write only on the top sheet

(some look at the second sheet and think the carbon

is not working).

4. Incorporate with the questionnaire any handouts

that you have previously used for home review.

5. From such sources as the AAP first-aid chart, copy

pertinent sections such as what to do for choking. Distribute these items when an at-risk situation is

present.

6. Periodic reminders to your nursing staff will

under-score your aim to incorporate TIPP as a permanent

addition to your practice.

7. Don’t just hand out a TIPP safety sheet. Discuss

why the child is different at a particular age level

and why the parents must rethink protective

mea-sures. Demonstrate your concern.

8. During the initial use of TIPP and until you are familiar with the questionnaire, it is suggested that

you not try to incorporate it into the entire practice

at once. Space “TIPP patients” out.

9. When introducing the program, give first priority to

the 2-to 4-year-olds who come for health

supervi-sion visits less frequently.

10. Decide on a method of recording on the chart folder

sheet the parts of the program that have been given

TABLE 3. Early Childhood Safety Counseling Schedule for Well-Child Visits

Age Minimal Safety COunseling

Introduce Reinforce Materials

2 mo

4

6 mo

9mo

lyr

15 mo

18 mo

2yr

3yr

4yr Specific to need

SUPPLEMENT 979

patient will not disrupt the schedule, he or she is

ready to introduce TIPP to all appropriate age

groups. Depending on the make-up of the practice,

it may take more than 6 months to introduce the

age-appropriate materials to each patient.

SAFETY SHEETS

TIPP’s second component is a series of four

sheets on child safety. Three of these sheets are

color-coded to correspond to the questionnaires:

blue for the visit at age 2 months, yellow for the

visit at age 15 months, and green for the visit at

age 24 months. The fourth sheet, not matching a

survey sheet, is colored tan and is directed toward

the 6- to 12-month age group. The material covered

in these sheets is confined to the six leading causes

of morbidity and mortality in the early years of life:

motor vehicle accidents, choking, falls, drowning,

fires, and poisonings.

Most educators are convinced that the simple act

of distributing an information sheet will not

effec-tively change human behavior. Experience with

TIPP has done nothing to modify this concept. A

handout with no professional input is, in all

prob-ability, a waste of effort. Patients being treated by

physicians in private practice generally respond to

advice that they feel reflects the significant

con-cerns of their doctor. Thus, age-specific, seasonally

oriented, economically appropriate advice

pre-sented verbally and reinforced by the use of

effec-tive written material has proven an effective

method of patient teaching.

The safety sheets, although they may be used

alone, are intended as boosters to the “primary

sensitization” of the questionnaires. At the health

supervision visit following the use of the

question-naire, the safety sheet ofthe matching color is given

to the parent. At this time, emphasis should be

Prenatal/ Infant car seat

newborn Smoke detector

Crib safety 2to4wk Falls

Burns-hot liquids

Choking

Poison

Burns-hot surface

Water safety Toddler car seat

Specific to

need-Optional

Falls-play equipment,

tricycles

Automobile-pedestrian

Infant car seat Infant car seat Falls

Infant car seat Falls

Burns-hot liquids

Falls

Burns-hot liquids

Poison Falls Burns

Poison

Falls Burns

Poison

Falls

Burns

Automobile-retraints Poison

Burns

Automobile-restraints, pedestrain Falls Burns

Automobile-restraints,

pedestrian

Falls-play equipment Burns

Questionnaire 1

Safety sheet 0-6 mo

Safety sheet 0-6 mo

Safety sheet 7-12 mo

Ipecac syrup Poison center sticker

Safety sheet 1-2 yr

Safety sheet 1-2 yr

Questionnaire 2

Safety sheet 1-2 yr

Questionnaire 3

Safety sheet 2-4 yr

Safety sheet 2-4 yr

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placed on the concept that a child will often be able to perform some motor function tomorrow that is

impossible today. In many cases, accidents can be

prevented, but parents must anticipate normal

de-velopmental progression and take appropriate pre-ventive action.

Each safety sheet deals, from different

develop-mental levels, focusing on the six major causes of

childhood mortality. The sheets emphasize how the

child’s improving motor abilities, from rolling over

to riding a tricycle, mean that parents must be alert

to the changing potential for injury that can take

place in the home. Objects that can be a positive

factor in the environment at one developmental

level, can become a significant hazard with the

development of basic locomotive abilities.

Through actual office experience, there has

evolved a series of practical points that facilitate

incorporation of TIPP into an office practice (Table 2).

COUNSELING SCHEDULE

The third part of the TIPP program is the

sug-gested counseling schedule (Table 3). Starting at

the prenatal visit, the physician can help parents

prepare for the baby’s arrival by advising purchase

of an approved child safety seat and installation of

smoke detectors as well as discussing crib safety.

During subsequent visits, various topics are

dis-cussed so that they are brought to the fore before

their developmental need. Thus, a discussion of

falls is scheduled before the baby rolls over, choking

is discussed before the baby can grasp and place

things in its mouth, and a forward-facing

automo-bile safety seat is discussed before the infant mode

is outgrown.

Like all parts of the program, the use of the

schedule will require modification to suit the needs

of each individual practice and practitioner. The

parts of the program that are used and/or

empha-sized will depend on the particular interests and

concerns of the physician involved.

PLANS FOR ThE FUTURE

In reviewing the factors that would increase the

usefulness of TIPP, the AAP Committee on

Acci-dent and Poison Prevention has determined several

areas to be developed. They include construction of

a teaching package that can be used as an

introduc-tion to accident prevention in medical student and

house staff teaching-, production of a videotape that

could teach effective usage of TIPP and could be

shown at national, state, and local meetings; and

translation of the TIPP materials into Spanish.

These additions to the program will facilitate the

introduction of TIPP to the three basic levels of

medicine: students, house staff, and practitioners.

Observers of the national medical scene have

noted that the next great increase in life expectancy

will result not from major medical breakthroughs,

but rather from changes in life-style. Because

pre-ventable injuries are the major factor in number of

productive years and lives lost, it is appropriate

that pediatricians focus their attention on

institut-ing these changes in life-style at a critical time of

1984;74;976

Pediatrics

Leonard Krassner

TIPP Usage

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1984;74;976

Pediatrics

Leonard Krassner

TIPP Usage

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