Running head: INTEGRATED REVIEW 1

Integrative Review of Literature

Savannah Turnage

Bon Secours Memorial College of Nursing

NUR 4122

November 8, 2017

“I pledge”
INTEGRATED REVIEW 2

Abstract

The purpose of this integrated review is to determine if children who wear helmets while riding

bicycles are less likely to suffer from traumatic brain injuries (TBIs), than children who do not

wear helmets. An estimated 33 million children ride bicycles annually in the United States,

resulting in over 450,000 emergency department visits and 384 deaths, most resulting from

traumatic brain injuries. Databases such as OVID and PubMed were utilized to locate research

articles. The searches yielded 114 articles, which were then narrowed down by specific criteria

set by the author. This resulted in one qualitative article and four quantitative articles. The results

of the five articles clearly show a correlation between children that wear helmets suffering less

TBIs than children who do not wear helmets while riding bicycles. This confirms that helmets

reduce the risk of TBIs in children. There are limitations in this review due to the researcher’s

inexperience in writing integrative reviews and limited use of journal articles. The results of

these studies implicate that screenings need to be done at every healthcare pediatric visit and

more education on wearing a helmet implemented. Future research needs to be done after these

implications have taken place in a certain region. After these interventions have been given time

to work, repeat research needs to be done in order to see if more children are wearing their

helmets and suffering less TBIs.

INTEGRATED REVIEW 3

Integrative Review of Literature

The purpose of this integrated review is to determine if children who wear helmets while

riding bicycles are less likely to suffer from traumatic brain injuries (TBIs), than children who do

not wear helmets. Riding bicycles has been a common pleasurable activity for children for many

years. Bicycles provide recreation, good aerobic activity, and transportation for many children.

However, apart from automobiles, bicycles are tied to more childhood injuries than any other

consumer product (Kaushik, Krisch, Schroeder, Flick, & Nemergut, 2015).

An estimated 33 million children ride bicycles annually in the United States, resulting in

over 450,000 emergency department visits and 384 deaths, most resulting from traumatic brain

injuries (Phillips, Overton, Campbell-Furtick, Nolen, Gandhi, & Shaf, 2016). Studies found that

the greatest risk of death and disability to bicyclists are head injuries (Jewett, Beck, Taylor, &

Baldwin, 2016). Kauchik, Krisch, Schroeder, Flick, & Nemergut (2015) found that 85% of

deaths attributed to riding bicycles can be prevented by simply wearing a helmet.

While bicycle helmet use reduces bicycle-related head injuries, few children wear them

regularly (Sullins, Yaghoubian, Nguyen, Kaji, & Lee, 2014). These are staggering statistics and

make this integrative review that much more important to find answers in order to prevent

children from suffering TBIs. The aim of this literature review is to collect appropriate

information regarding the researcher’s PICOT question, “For children who ride bicycles does the

use of helmets reduce the risk of traumatic brain injuries compared with no helmet use?”

Design/Search Methods

This integrative review focuses on five research articles. Two databases, OVID, and

PubMed, were utilized to search for articles that fit specific criteria set by the researcher. Key
INTEGRATED REVIEW 4

terms used in the searches included: ‘pediatrics’, ‘bicycle riding’, ‘helmet use’, ‘traumatic brain

injures’, and ‘head injuries’. Ovid yielded 36 articles and PubMed yielded 78 articles.

In order to obtain recent articles, the search was limited to articles from 2012 to 2017. To

further narrow down the search, filters were implemented to locate only peer reviewed English

articles that were published in academic journals with full text. Any articles that did not meet the

inclusion criteria were excluded from the integrative review. The researcher then located and

examined five articles that met all the specified criteria. The review includes one qualitative

study and four quantitative studies that directly relate to the selected PICOT question, “For

children who ride bicycles does the use of helmets reduce the risk of traumatic brain injuries

compared with no helmet use?”

Findings/Results

The results and findings of the research clearly show a correlation between children that

wear helmets suffering less TBIs than children who do not wear helmets while riding bicycles

(Phillips et al., 2016; Kauchik at al., 2015; Sullins at al., 2014; Davison at al., 2013; Jewett,

Beck, Taylor, & Baldwin, 2016). Another major theme identified was that children who came

from lower income families, uninsured, African American, Hispanic, male, and above the age of

10 years old were more likely to not wear a helmet and suffered more TBIs (Phillips et al. 2015;

Sullins at al., 2014). Lastly, another major similarity between articles was that less than half of

all children reported that they wore helmets the majority of the time, while riding their bicycles

(Davison, Torunian, Walsh, Thompson, Mcfaull, & Pickett, 2013; Jewett, Beck, Taylor, &

Baldwin, 2016). A summary of the research articles is located at the end of the integrative

review.
INTEGRATED REVIEW 5

In the study by Phillips, Overton, Campbell-Furtick, Nolen, Gandhi, & Shaf (2016), the

authors evaluated helmet use trends and determine risk of in-hospital mortality and TBI among

the national pediatric trauma population. The authors retrospectively analyzed the data collected

from the National Trauma Data Bank National Sample Program. Their sample was comprised of

children under the age of 17 who were admitted to any of the 405 selected trauma centers that

were riding a bicycle at the time of injury.

Phillips, Overton, Campbell-Furtick, Nolen, Gandhi, & Shaf (2016) found out of the

16,681 patients, helmet use was reported for 3,537 (21%) and no helmet use was reported for

13,144 (79%). The proportion of patients with life threatening injuries was higher among non-

helmeted patients. It was also found that helmeted patients suffered fewer TBIs. The authors

discovered that the odds of wearing a helmet was significantly lower among patients aged 10-12

and 13-17, Hispanics and AA, and in patients with public insurance or no insurance. The writers

determined the odds of suffering a TBI were greatest for uninsured children and less likely for

helmeted children.

Davison, Torunian, Walsh, Thompson, Mcfaull, & Pickett (2013) investigated health

equity interventions by profiling stratified analytic methods and identifying potential inequities

associated with bicycle-related injury and the use of bicycle helmets among Canadian youth. The

design method was based upon an equity analysis and completion of a voluntary survey given to

children. Data for this study was obtained from the 6th cycle of the Health Behavior in School-

ages Children study, which was a general health survey that was completed by 26,078 students in

grades 6-10 from 436 Canadian schools.

Davison, Torunian, Walsh, Thompson, Mcfaull, & Pickett (2013) discovered that among

bicycle riders, 43% reported never wearing a helmet and 32% reported inconsistently wearing a
INTEGRATED REVIEW 6

helmet. They also found that only 26% reported always wearing a bicycle helmet. More children

that did not wear helmets reported having to go to the hospital TBIs than those children who did

wear helmets. Based on the survey responses, the authors determined point prevalence for

bicycle ridership, bicycle helmet use, and relative risks for bicycling-related injury. The authors

stated that troubling disparities exist in bicycle use, bicycle helmet use, and bicycling-related

injuries across specific population subgroups.

In the study by Sullins, Yaghoubian, Nguyen, Kaji, & Lee (2014) the authors aimed to

describe racial/ethnic and socioeconomic differences in pediatric helmet use in Los Angeles

County (LAC) to help target groups for injury prevention programs. A retrospective review of all

pediatric patients involved in bicycle-related accidents in LAC between 2006 and 2011 was

performed by gathering information from public LAC records. The primary analysis examined

the association between helmet use, age, gender, insurance status, and race/ethnicity. The authors

also evaluated the association between helmet use and the need for emergency surgery,

mortality, and length of hospital stay (LOH), after adjusting for injury severity score (ISS), age,

insurance status, and race/ethnicity.

Sullins, Yaghoubian, Nguyen, Kaji, & Lee (2014) discovered out of the 1248 patients,

11.3% wore helmets, with decreased use among children 12 years and older, minorities, and

those without private insurance. Nearly 90% of children involved in bicycle-related accidents

were not wearing helmets. Helmet use was lower among children, minorities, and those from a

low socioeconomic status. The authors believe injury prevention programs targeting low-income

middle and high schools and minority communities may help increase helmet use in children in

LAC.
INTEGRATED REVIEW 7

A survey study by Jewett, Beck, Taylor, & Baldwin, (2016) intended to provide estimates

of prevalence and associated factors of bicycle riding and helmet use among children and adults

in the United States. The researchers analyzed self-reported data from the 2012 Summer

ConsumerStyles survey. Adult respondents (18+) were asked about bicycle riding and helmet use

on the last 30 days for themselves and their children (5 to 17 years). The researchers estimated

the prevalence of helmet use and conducted multivariable regression analyses to identify factors

associated with helmet use. The sample size consisted of 1220 children aged 5 to 17 years.

Respondents reported that, of the 61% of children who ride bicycles within the past 30 days,

42% always wore helmets.

Jewett, Beck, Taylor, & Baldwin, (2016) found that children were more likely to always

wear helmets (90%) when their adult respondents always wore helmets then when their adult

respondents did not always wear their helmets (38%). Children who lived in states with a child

bicycle helmet law were more likely to always wear helmets (47%) than those in states without a

law (39%). The authors found even though bicycle helmets are highly effective at reducing the

risk for TBIs, less than half of children and adults always wore bicycle helmets while riding. The

authors believe communities and states should consider interventions that improve the safety of

riding such as: policies to promote helmet use, modeling of helmet wearing by adults, and

focusing of high risk groups, including Hispanic cyclists, occasional riders, adults, and children

ages 10 to 14. The authors concluded that in the event of a crash, bicycle helmets are effective

for the prevention of traumatic brain injuries and deaths.

A study conducted by Kauchik et al. (2015) sought to estimate the incidence of pediatric

bicycle-related injuries in Olmstead County and assess differences in injuries between these

wearing helmets vs. not. The data was pulled from the Rochester Epidemiology Project (REP)
INTEGRATED REVIEW 8

database, which each of the three medical centers in Olmstead County submit medical records.

Olmstead County, Minnesota residents 5 to 18 years of age with a diagnostic code consistent

with an injury associated with the use of a bicycle between January 1, 2002, and December 31,

2011, were identified. Incidence rates were calculated and standardized to the age and sex

distribution of the 2000 US white population. Type of injuries, the percentage requiring head CT

or X-ray, and hospitalization were compared using a chi-square test. Pediatric intensive care

(PICU) admission, permanent neurologic injury, seizure, need for mechanical ventilation, and

mortality were compared using Fisher’s exact test. A total of 104 females and 225 injuries for

males were identified.

Kauchik et al. (2015) found of the patients with head injuries, 17.4% were documented to

have been wearing a helmet, 44.8% were documented as not wearing a helmet, and 37.8% had

no helmet use documentation. Patients with a head injury that were reported not wearing a

helmet were significantly more likely to undergo imaging of the head due to experiencing a

traumatic brain injury. Children and adolescents continue to ride bicycles without wearing

helmets, resulting in traumatic brain injuries, facial injuries, and mortality. The authors also

inferred that educational campaigns and mandatory helmet legislation might encourage helmet

use and reduce bicycle-related traumatic brain injuries.

Discussion/Implications

After review of all five articles, there is a positive correlation of a decreased risk of

suffering a TBI in children by using a helmet while riding a bicycle (Phillips et al., 2015;

Davison et al., 2013; Sullins at al., 2014; Jewett, Beck, Taylor, & Baldwin, 2016; Kauchik et al.

2015). These results support the PICOT question selected by the researcher. Kauchick et al.

(2015) stated TBIs are the leading cause of death among cyclists, 85% of which can be prevented
INTEGRATED REVIEW 9

by wearing a bicycle helmet. Knowing that helmets reduce the risk of children from suffering

TBIs and that the majority of children do not wear helmets all of the time, it is clear that there

needs to be interventions put in place to resolve this dilemma.

The results of these studies implicate that screenings need to be done at every healthcare

pediatric visit. There also needs to be more education in schools and out in the community. Both

implications would allow for more children to wear helmets, thus preventing them from suffering

TBIs if they were to fall. Future research needs to be done after these implications have taken

place in a certain region. After these interventions have been given time to work, repeat research

needs to be done in order to see if more children are wearing their helmets. Once those results

come back, they can then be compared to the number of children that suffered from TBIs. Then

once that research came back, it would hopefully show an increase in the number of children

wearing their helmets and a decrease in the amount of TBIs.

Limitations

While there were several limitations throughout the integrative review, the biggest

limitation would be the lack of inexperience that the researcher had in conducting an integrative

review prior to this one. The researcher is also technically not qualified to write or publish an

integrative review. Additionally, the search criterion of articles having to be within 10 years was

a limitation. Many articles the researcher found were from the early 2000’s. The subject matter

of trying to find information dealing specifically with TBIs was another limitation. Many articles

dealt with basic head injuries or did not say what type of head injuries the child suffered. The

fact that the researcher was restricted to five articles could also be considered a limitation.

Another limitation would be that each of the articles selected also had their own

limitations, which affected the overall integrity of the literature review. The study done by
INTEGRATED REVIEW 10

Kauchik et al. (2015) had a vast amount of information on head injuries in children, however,

34% of the gathered data had no documentation if a helmet was used or not. Another major study

limitation in the studies of Sullins et al. (2014) and Kauchik et al. (2015) was that both of their

research was restricted to one county. Another major study limitation throughout each of the

articles was that they did not all use the same age ranges in their studies. Davison at al. (2013)

used ages 11 to 16, while Jewett, Beck, Taylor, & Baldwin (2016) used ages 5 to 17.

Conclusion

Findings discussed in this integrative review highlight the importance of children wearing

helmets while riding bicycles. Helmets significantly reduce the number of TBIs and prevent

children from other serious head injuries. Children who came from lower income families,

uninsured, African American, Hispanic, male, and above the age of 10 years old were identified

as more likely to not wear a helmet and suffered more TBIs (Phillips et al. 2015; Sullins at al.,

2014). It was also confirmed that less than half of all children included in the survey studies

reported that they wore helmets the majority of the time while riding their bicycles (Davison et

al., 2013; Jewett, Beck, Taylor, & Baldwin, 2016). After reviewing all the research, it is evident

that actions must be taken to get children to wear their helmets to reduce the risk of suffering

from TBIs. This all relates back to the selected PICOT question, “For children who ride bicycles

does the use of helmets reduce the risk of traumatic brain injuries compared with no helmet

use?”
INTEGRATED REVIEW 11

Reference

Cronin, P., Ryan, F., & Coughlan, M. (2008). Undertaking a literature review: a step-by-step

approach. British Journal of Nursing, 17(1), 38-43. doi:10.12968/bjon.2008.17.1.28059

Davison, C. M., Torunian, M., Walsh, P., Thompson, W., Mcfaull, S., & Pickett, W. (2013).

Bicycle helmet use and bicycling-related injury among young Canadians: an equity

analysis. International Journal for Equity in Health, 12(1), 48. doi:10.1186/1475-9276-

12-48

Jewett, A., Beck, L. F., Taylor, C., & Baldwin, G. (2016). Bicycle helmet use among persons

5years and older in the United States, 2012. Journal of Safety Research, 59, 1-7.

doi:10.1016/j.jsr.2016.09.001

Kaushik, R., Krisch, I. M., Schroeder, D. R., Flick, R., & Nemergut, M. E. (2015). Pediatric

bicycle-related head injuries: a population-based study in a county without a helmet law.

Injury Epidemiology, 2(1). doi:10.1186/s40621-015-0048-1

Phillips, J. L., Overton, T.L., Campbell-Furtick, M., Nolen, H., Gandhi, T., & Shaf, S. (2016).

Bicycle helmet use trends and related risk of mortality and traumatic brain

injury among pediatric trauma. Journal of Epidemiology and Public Health Reviews (

ISSN 2471-8211 ), 1(1). doi:10.16966/2471-8211.103

Sullins, V. F., Yaghoubian, A., Nguyen, J., Kaji, A. H., & Lee, S. L. (2014). Racial/ethnic and

socioeconomic disparities in the use of helmets in children involved in bicycle accidents.

Journal of Pediatric Surgery, 49(6), 1000-1003. doi:10.1016/j.jpedsurg.2014.01.038

INTEGRATED REVIEW
First Author Phillips (2016) MS, MPH, CPH, JPS Health Network, Fort Worth
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
12
 An estimated 33 million children ride bicycles annually in the United States, resulting in
~450,000 emergency department visits and 384 deaths--most resulting from traumatic brain
injury (TBI).
 Bicycle helmet use among children is low despite educational and injury prevention efforts.
 The study aims to evaluate helmet use trends and determine risk of in-hospital mortality and
TBI among the national pediatric trauma population.
 The theoretical framework was used and adequately described as helmet use, traumatic brain
injuries, and in-hospital mortality.
 Retrospectively analyzed the data collected from the National Trauma Data Bank National
Sample Program.
 The sample size consisted of a total of 16,681 patients.
 The subjects were not informed of the purpose of the study, because the information was
simply pulled from a database that the researchers were approved access.
 The autonomy and confidentiality of the subjects were maintained and protected form harm
because no names were used in the study. It does not clearly state that the overall study was
approved, but it is stated that the sampling program approved that researchers to use their
data.
 The major variables studied were helmet use, traumatic brain injuries, and In-hospital
mortality.
 Data was obtained from the National Trauma Data Bank National Sample Program.
 The sample was comprised of children under the age of 17 who were admitted to any of the
405 selected trauma centers that were riding a bicycle at the time of injury.
 Out of the 16,681 patients, helmet use was reported for 3,537 (21%) and no helmet use was
INTEGRATED REVIEW
Findings/Discussion
Appraisal/Worth to
practice
First Author Davison (2013) MPH, PhD, Department of Public Heath Sciences, Queen’s University
(Year)/Qualifications
Background/Problem
Statement
13
reported for 13,144 (79%).
 The proportion of patients with life threatening injuries was higher among non-helmeted
patients.
 Helmeted patients suffered fewer TBIs.
 The odds of wearing a helmet was significantly lower among patients aged 10-12 and 13-17,
Hispanics and AA, and in patients with public insurance or no insurance.
 The odds of suffering a TBI were greatest for uninsured children and less likely for helmeted
children.
 Children who do not wear their helmets while riding bicycles are more likely to suffer from
traumatic brain injuries and death.
 Helmet use among the pediatric population admitted for bicycle-related injuries is a
nationwide problem and use did not improve over an eight-year period.
 Knowledge dissemination of helmet use trends and related risks of injury and mortality from
non-compliance could improve prevention efforts aimed at increasing helmet compliance
among pediatric bicycle riders.
 While helmet use is protective against TBI and lowers risk of death following bicycle-
related injury, certain age and racial/ethnic groups are at increased risk of mortality and have
higher odds of suffering a TBI following bicycle-related injury
 This article would be a great asset to writing a paper and provides vast information on key
concepts of the selected PICOT question.
 Cycling is a major activity in Canada and potential differences exist in bicycling-related risk
and experience of injury by population subgroup.
 The overall aim of this study was to inform health equity interventions by profiling stratified
analytic methods and identifying potential inequities associated with bicycle-related injury
INTEGRATED REVIEW 14

and the use of bicycle helmets among Canadian youth.

Conceptual/theoretical  The objectives of this study were: (1) to examine national patterns in bicycle ridership and
Framework also bicycle helmet use among Canadian youth in a stratified analysis by potentially
vulnerable population subgroups, and (2) To examine bicycling-related injury in the same
population subgroups of Canadian youth in order to identify possible health inequities.
Design/  The design method was completion of a voluntary survey given to children.
Method/Philosophical  The study was based on an equity analysis.
Underpinnings

Sample/ Setting/Ethical  The sample size consisted of 26,078 students that completed the survey.
Considerations  The autonomy of the children was kept.

Major Variables Studied  The major variables studied were bicycle and bicycle helmet use, youth sub-groups, and
(and their definition), if injury.
appropriate

Measurement Tool/Data  Data for this study was obtained from the 6th cycle of the Health Behavior in School-ages
Collection Method Children study, which was a general health survey that was completed by 26,078 students in
grades 6-10 from 436 Canadian schools.

Data Analysis  Among bicycle riders, 43% reported never wearing a helmet and 32% reported
inconsistently wearing a helmet.
 Only 26% reported always wearing a bicycle helmet.
 More children that did not wear helmets reported having to go to the hospital for head-
related injures than those children who did wear helmets.

Findings/Discussion  Based on the survey responses, the authors determined point prevalence for bicycle
ridership, bicycle helmet use, and relative risks for bicycling-related injury.
 The authors stated that troubling disparities exist in bicycle use, bicycle helmet use, and
bicycling-related injuries across specific population subgroups.

Appraisal/Worth to  This article provides vast information relating to the PICOT question.
INTEGRATED REVIEW
practice
First Author Sullins (2014) – PhD, Department of Surgery, Harbor-UCLA Medical Center
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
15
 While bicycle helmet use reduces bicycle-related head injury, few children wear them
regularly.
 The purpose of this study was aimed to describe racial/ethnic and socioeconomic differences
in pediatric helmet use in Los Angeles County (LAC) to help target groups for injury
prevention programs.
 The primary analysis examined the association between helmet use, age, gender, insurance
status, and race/ethnicity.
 The authors also evaluated the association between helmet use and the need for emergency
surgery, mortality, and length of hospital stay (LOH), after adjusting for injury severity score
(ISS), age, insurance status, and race/ethnicity.
 A retrospective review of all pediatric patients involved in bicycle-related accidents in LAC
between 2006 and 2011 was performed.
 The sample size consisted of 1248 patients.
 The autonomy of the patients was kept because the study did not use the names of the
children.
 The major variables studied were between helmet use, age, gender, insurance status, and
race/ethnicity.
 The data for this study was pulled from public records from LAC.
INTEGRATED REVIEW
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
First Author Jewett (2016) – MPH, Transportation Safety Team, Division of Unintentional Injury
(Year)/Qualifications Prevention
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
16
 Out of the 1248 patients, 11.3% wore helmets, with decreased use among children 12 years
and older, minorities, and those without private insurance.
 Overall, 5.9% required an emergency operation, 31.4% returned to their pre-injury capacity,
and mortality was 0.7%.
 Nearly 90% of children involved in bicycle-related accidents were not wearing helmets.
Helmet use was lower among children, minorities, and those from a low socioeconomic
status.
 Injury prevention programs targeting low-income middle and high schools and minority
communities may help increase helmet use in children in LAC.
 This is a valuable article for the PICOT question.
 The greatest risk of death and disability to bicyclists is head injuries.
 The objective of this study was to provide estimates of prevalence and associated factors of
bicycle riding and helmet use among children and adults in the United States.
 The theoretical framework for this study was based upon the major variables of finding the
factors associated with wearing a helmet.
 The CDC analyzed self-reported data from the 2012 Summer ConsumerStyles survey.
 Adult respondents (18+) were asked about bicycle riding and helmet use on the last 30 days
for themselves and their children (5 to 17 years).
 For bicycle riders, the CDC estimated the prevalence of helmet use and conducted
multivariable regression analyses to identify factors associated with helmet use.
 The sample size consisted of 1220 children aged 5 to 17 years.
 The surveys were anonymous, so the childrens’ identities were kept safe.
INTEGRATED REVIEW 17

Major Variables Studied  The major variables studied for children (5 to 17 years) included the adult respondents’
(and their definition), if annual household income, education, employment, marital status, helmet use race/ethnicity,
appropriate gender, age group, child’s age group, ride frequency, and presence of state laws requiring
helmet use for children.

Measurement Tool/Data  The CDC analyzed self-reported data from the 2012 Summer ConsumerStyles survey.
Collection Method  A multivariable analysis was conducted to determine the factors associated with always
wearing a helmet among adults and children.

Data Analysis  Respondents reported that, of the 61% of children who ride bicycles within the past 30 days,
42% always wore helmets.
 Children were more likely to always wear helmets (90%) when their adult respondents
always wore helmets then when their adult respondents did not always wear their helmets
(38%).
 Children who lived in states with a child bicycle helmet law were more likely to always wear
helmets (47%) than those in states without a law (39%).

Findings/Discussion  The authors found that despite the fact that bicycle helmets are highly effective at reducing
the risk for head injuries, including traumatic brain injuries, lass than half of children and
adults always wore bicycle helmets while riding.
 States and communities should consider interventions that improve the safety of riding such
as policies to promote helmet use, modeling of helmet wearing by adults, and focusing of
high risk groups, including Hispanic cyclists, occasional riders, adults, and children ages 10
to 14.
 In the event of a crash, bicycle helmets are effective for the prevention of traumatic brain
injuries and deaths.

Appraisal/Worth to  The article provides vast information on the selected PICOT question.
practice
INTEGRATED REVIEW
First Author Kaushik (2015) – MD, Mayo Clinic Children’s Center
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
18
 Head injuries are the leading cause of death among cyclists, 85% of which can be prevented
by wearing a bicycle helmet.
 Bicycle riding is common among children and adolescents in the USA, providing recreation,
transportation, and a pleasurable form of aerobic activity.
 Apart from automobiles, bicycles are tied to more childhood injuries than any other
consumer product.
 In 2010, 112 children and adolescents died and over 200,000 children 5 to 14 years of age
visited the emergency department for bicycle related injuries.
 This study aims to estimate the incidence of pediatric bicycle-related injuries in Olmstead
County and assess differences in injuries between these wearing helmets vs. not.
 The theoretical framework was based upon children who were suffered from a traumatic
brain injury or severe head injury while riding a bicycle and whether or not they were
wearing a helmet at the time of the incident.
 Olmstead County, Minnesota residents 5 to 18 years of age with a diagnostic code consistent
with an injury associated with the use of a bicycle between January 1, 2002, and December
31, 2011, were identified.
 Incidence rates were calculated and standardized to the age and sex distribution of the 2000
US white population.
 Type of injuries, the percentage requiring head CT or X-ray, and hospitalization were
compared using a chi-square test.
 A total of 104 females and 225 injuries for males were identified.
 The researchers were granted access to the medical records and all of the patients’ identities
were kept anonymous.
 Pediatric intensive care (PICU) admission, permanent neurologic injury, seizure, need for
mechanical ventilation, and mortality were compared using Fisher’s exact test.
INTEGRATED REVIEW 19

Measurement Tool/Data  The data was pulled from the Rochester Epidemiology Project (REP) database, which each
Collection Method of the three medical centers in Olmstead County submit medical records to.

Data Analysis  Of the patients with head injuries, 17.4% were documented to have been wearing a helmet,
44.8% were documented as not wearing a helmet, and 37.8% had no helmet use
documentation.
 Patients with a head injury that were reported not wearing a helmet were significantly more
likely to undergo imaging of the head and experience a traumatic brain injury.

Findings/Discussion  Children and adolescents continue to ride bicycles without wearing helmets, resulting in
traumatic brain injuries, facial injuries, and mortality.
 Educational campaigns, provider counseling, and mandatory helmet legislation may
encourage helmet use and reduce bicycle-related traumatic brain injuries.

Appraisal/Worth to  This article provides immense data on the selected PICOT question.
practice