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Firework injuries remain high in years after legalisation: its impact on children
  1. Colette Galet1,
  2. Isaac Slagel1,
  3. Adam Froehlich2,
  4. Morgan Bobb3,
  5. Michele Lilienthal1,
  6. Elizabeth Fuchsen4,
  7. Karisa K Harland2,5,
  8. Carlos A Pelaez4,
  9. Dionne A Skeete1,
  10. Michael E Takacs5
  1. 1Department of Surgery, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
  2. 2Injury Prevention Research Center, The University of Iowa, Iowa City, Iowa, USA
  3. 3The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
  4. 4Department of Surgery, UnityPoint Health, Des Moines, Iowa, USA
  5. 5Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
  1. Correspondence to Dr Colette Galet, Department of Surgery, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA; colette-galet{at}uiowa.edu

Abstract

Purpose We evaluated the impact of Senate Bill 489 passed in May 2017, allowing the sale and use of fireworks in Iowa 1 June to 8 July and 10 December to 3 January, on hospital presentations for firework injuries in the state. To identify the public health implications of this law, we conducted a detailed subanalysis of hospital presentations to the two level I trauma centres.

Methods Hospital presentations for firework injuries from 1 June 2014 to 31 July 2019 were identified using the Iowa Hospital Admission database and registries and medical records of Iowa’s two level 1 trauma centres. Trauma centres’ data were reviewed to obtain demographics, injury information and hospital course. Prefirework and postfirework legalisation state data were compared using negative binomial regression analysis. Trauma centre data detailing injuries were compared using χ2 and Mann-Whitney U tests as appropriate.

Results Emergency department (ED) visits and hospital admissions for firework injuries increased in Iowa post-legalisation (B-estimate=0.598±0.073, p<0.001 and B-estimate=0.612±0.322, p=0.058, respectively). ED visits increased postlegalisation in July (73.6% vs 64.5%; p=0.008), reflecting an increase in paediatric admissions (81.8% vs 62.5%; p=0.006). Trauma centres’ data showed similar trends. The most common injury site across both study periods was the hands (48.5%), followed by the eyes (34.3%) and face (28.3%). Amputations increased from 0 prelegalisation to 16.2% postlegalisation.

Conclusion Firework legalisation led to an increase in the number of admissions and more severe injuries.

  • Injury Diagnosis
  • Burn
  • Hand Injury
  • Child

Data availability statement

Data are available on reasonable request. Data are available on reasonable requests.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • While demand for display fireworks such as those purchased by professionals declined, consumer firework consumption has increased between 2000 and 2020. Alongside, emergency department (ED)-treated, fireworks-related injuries significantly increased from 2005 to 2020 in the USA.

WHAT THIS STUDY ADDS

  • State data showed that legalisation of the sale and use of fireworks in Iowa led to a significant increase in paediatric ED visits and hospital admissions for fireworks-related injuries. Legalisation also resulted in a significant increase in amputations from 0 to 19, with 18 adults and 1 child requiring upper extremity digit(s)’amputation.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE AND/OR POLICY

  • These results will be used to inform public safety campaigns and/or legislation to control the use of fireworks by minors.

Introduction

Fireworks are explosive pyrotechnic compositions designed to provide visual and audible effects.1 Commonly used for celebratory and recreational uses, these explosives pose a danger, particularly to consumers using them without proper precautions.2 According to the American Pyrotechnics Association, total US firework consumption has increased by a factor of 2.66 between 2000 and 2020, driven by non-professional demand.3 While demand for display fireworks such as those purchased by professionals declined from 50.6 million lbs. to 18.7 million lbs., consumer firework consumption increased by 283.8 million lbs.3

Based on the Consumer Product Safety Commission’s 2020 Fireworks Annual Reports, emergency department (ED)-treated, fireworks-related injuries significantly increased from 2005 to 2020.4 Similarly, using the National Emergency Department Sample, Bitter et al showed an increase in fireworks-related injuries in the USA from 2008 to 2017.5

Common injuries from fireworks include ocular and hand trauma, burns and traumatic amputations. These injuries can result in lifelong deformity and disability.6 Wisse et al found that one in six ocular injuries due to fireworks resulted in severe vision loss.7 Hand injuries due to fireworks are associated with long hospital stays and increased healthcare utilisation.8 Harris et al found that blast-related traumatic digit amputations rise significantly in the summer months, implying their relation to the seasonal use of fireworks.9 Bitter et al showed that the burden of firework injuries rested predominately on paediatric and young adult patients, 74.6% of whom were male.5

Consumer fireworks are legal in 47 states and Washington DC, USA.10 In many states, legalisation of consumer fireworks has coincided with increases in fireworks-related injuries. The Michigan Fireworks Safety Act (Act 256), which allows the sale of consumer fireworks, led to a significant increase in the annual incidence of fireworks-related injuries, including a significant increase in traumatic amputations postlegalisation.11 In West Virginia, the law increasing access to class C fireworks led to a 39% increase in the rate of fireworks-related injuries.12

On 9 May 2017, the Iowa legislature approved SB489, which, for the first time since 1938, allowed the sale of fireworks in Iowa from 1 June to 8 July and 10 December to 3 January. Although sales during these periods are legal statewide, counties and municipalities can restrict sales locally. We hypothesised that the legalisation of fireworks would result in an increase in firework-related injuries leading to an increase in ED visits and hospital admissions for fireworks-related injuries across the state and specifically at the two level I trauma centres. Here, we examine ED visits and hospital admissions across the state of Iowa using the Iowa Hospital Admission (IHA) database. We then focused on ED visits and hospital admissions in Iowa’s two level I trauma centres before and after firework legalisation to identify the public health implications of the new law.

Methods

Deidentified state data were obtained from the IHA database.

Patient and public involvement

Patients or public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Study design

Deidentified state data from 1 January 2014 to 31 December 2019 were obtained from the IHA database. Both ED visits and hospital admission databases were queried to identify all patients who presented to hospitals for firework injuries using the following International Classification of Diseases (ICD)-9 and ICD-10 codes: E9230, W39XXXA, W39XXXD and W39XXXS.

The University of Iowa Hospitals and Clinics (UIHC) and Iowa Methodist Medical Center are the only two American College of Surgeons verified level 1 trauma centres in the state of Iowa. The two level 1 Trauma Registries were queried to identify all patients admitted for firework injury from 1 January 2014 to 31 December 2019. Additional patients were identified by querying all electronic health records (EHR’s) held by UIHC and Iowa Methodist Medical Center using a search algorithm to locate the word ‘firework’ in any part of a patient’s EHR for the years 2014–2019. Patients transferred from Iowa Methodist Medical Center to UIHC were counted only once. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines for cross-sectional studies.13 14

Data collection

Data obtained from the IHA included presentation date, hospitals’ and patients’ county information, and patient age. We also collected the overall population per county for each year using the Iowa government website (https://data.iowa.gov/Community-Demographics/County-Population-in-Iowa-by-Year/qtnr-zsrc).

Patient data collected from the two level I trauma centres included demographics (sex, age, race, home zip code), transfer status, inpatient or outpatient status, admission department, alcohol and drug screen data. Collected injury information included injury zip code, firework display type, firework type, whether the patient was a bystander or a handler of the fireworks, body location injured and type of injury based on ICD-9 and ICD-10 codes. In case of a burn injury, the percentage of total body surface area involved and the degree of burn (first, second or third) were collected. Medical care information such as hospital length of stay (LOS), the need for surgery, surgery type, surgical service and any other treatment received was also noted. We also collected data on complications such as infection, amputation, graft loss, vision loss, disability when available, discharge disposition and if the patient died from the firework injury. Data were collected in a REDCap database.

Statistical analysis

IHA data were used to create maps of hospital presentations (outpatients and inpatients) prelegalisation and postlegalisation based on hospital county using R packages ggplot2 (V.3.3.5) and maps (V.3.4.0). Univariate analyses were performed to identify differences between the prelegalisation and postlegalisation groups. Normality was assessed using the Kolmogorov-Smirnov test for all continuous variables. All non-normally distributed continuous variables are presented as median and IQR. χ2 and Fisher’s exact test were used for categorical variables as appropriate, while Mann-Whitney U test was used for continuous variables. Negative binomial regression analysis was used to assess the impact of firework legalisation on hospital presentation in the State of Iowa using the IHA data. The average population per county prelegalisation and postlegalisation was used as the offset variable in our analysis. The impact of firework legalisation on injury type and severity, hospital LOS and complications was analysed using the two level I trauma centres’ data from the months of June and July as those were the months during which we had most of hospital presentations for firework injuries. IHA data were analysed using R V.4.1.1. For data from the two level I trauma centres, analyses were performed using SPSS (V.28.0 IBM). A p<0.05 was considered significant. Bar graphs were prepared using GraphPrism (GraphPad, San Diego, California, USA).

Results

Hospital presentations have increased postlegalisation of fireworks in Iowa

Presentations to hospitals across Iowa increased postlegalisation of fireworks according to the IHA data (ED visits: 765 (post) vs 307 (pre); hospital admissions: 65 vs 23). Patients were mainly male regardless of legalisation (ED visits: 76.9% vs 80.8%; hospital admissions: 93.8% vs 91.3%). While the median age of patients presenting to ED was not significantly different between the prelegalisation and postlegalisation period (27 (17–37) vs 24 (16.3–48.50), p=0.960), patients admitted for firework injuries were significantly younger postlegalisation (28 (20–38.5) vs 52 (45–52), p=0.038). While not significant, the proportion of paediatric cases admitted for firework injury increased (18.5% vs 13%).

As shown in figure 1, Iowa has 99 counties, 90 of which have hospitals.

Figure 1

Map of the trauma facilities in Iowa.

Hospitals (based on the hospitals’ counties) observed significant increase in ED visits (B-estimate: 0.598±0.073, p<0.001) and hospital admissions tended to increase (B-estimate: 0.612±0.322, p=0.057) postapproval (figure 2). We observed a significant increase in the number of paediatric ED visits postlegalisation of fireworks (B-estimate: 0.486±0.100; p<0.001) (figure 3A) and paediatric admissions tended to increase as well (B-estimate: 0.649±0.382; p=0.089, map not shown) Similarly, the number of adult patients seen in the ED significantly increased postlegalisation (B-estimate: 0.641±0.074; p<0.001) (figure 3B) and adult admissions tended to increase as well (B-estimate: 0.606±0.313; p=0.053, map not shown)

Figure 2

Heatmaps of emergency department visits (Left Column) and hospital admissions (Right Column) for firework injuries based on hospitals’ county across Iowa. White shaded counties are those who do not have hospitals. Grey shaded counties are counties with hospitals that did not see firework injury. Graded shading of yellow to red indicates counties where hospitals saw fireworks injuries.

Figure 3

Heatmaps of paediatric and adult emergency department visits for firework injuries based on hospitals’ county across Iowa. (Left Column) Paediatrics; (Right Column) adults. White shaded counties are those who do not have hospitals. Grey shaded counties are counties with hospitals that did not see firework injury. Graded shading of yellow to red indicates counties where hospitals saw fireworks injuries.

Firework-related ED visits significantly increased postlegalisation especially during the month of July (73.6% vs 64.5%; p=0.008), which reflected an increase in overall paediatric ED visits postlegalisation during the month of July (81.8% vs 62.5%; p=0.006). No significant increase in overall adult ED visits was observed postlegalisation in July (70.7% vs 65.3%; p=0.317). Overall, hospital admissions significantly increased especially during the month of July (67.4% vs 43.5%, p=0.046).

Iowa trauma level I centres’ data

As observed with the IHA data, the two Iowa level I trauma centres saw an increase in the number of hospital presentations associated with firework injuries postlegalisation of fireworks (figure 4A). This increase was mostly associated with an increase in the number of ED visits and admissions during the month of July followed by the month of June, reflective of 1 June to 8 July legal use period in Iowa (figure 4B).

Figure 4

Firework-related admissions to the two Iowa level I trauma centres prelegalisation and postlegalisation of fireworks. (A) Per year; (B) per month.

Patient characteristics

Baseline characteristics of patients admitted to the two Iowa level I trauma centres during the months of June and July are presented in table 1. Postlegalisation of fireworks, patients admitted to the two Iowa level I trauma centre tended to be younger. The number of adult patients with a positive drug screen on admission was significantly higher than prelegalisation. One paediatric case screened positive for drugs on admission postlegalisation, none did prelegalisation. Alcohol use screening was performed more often on adult patients’ postlegalisation and the number of patients screening positive for alcohol use increased. Severity of injury was calculated for all but one patient postlegalisation when, prelegalisation, it could not be calculated for nine patients. Injury severity scores were not significantly different prelegalisation and postlegalisation. Although not significant, the number of paediatric cases increased from eight to 33 postlegalisation of fireworks. Of those 33 cases, 9 required hospital admission while there was no paediatric hospital admission prior to legalisation. The number of paediatric cases seen or admitted for burn injuries increased from 6 to 27 postlegalisation.

Table 1

Patient characteristics

Firework characteristics

As shown in table 2, there was no difference in the type of fireworks used by patients admitted prelegalisation and postlegalisation. Postlegalisation, firework displays that led to injuries tended to be private as compared with prelegalisation. Postlegalisation, four cases presented for injuries incurred at a professional display. One was a professional who was injured while handling the fireworks, three were bystanders. The professional sustained an eye injury. Two of the bystanders suffered burns on their legs and one had a wound with foreign material, likely debris from fireworks, scattered bruises and abrasions on buttocks. There was no difference in the role (handler or bystander) of the patients between the prelegalisation and postlegalisation periods. Although not significant, we saw a shift in the number of paediatric cases who were handling the fireworks when they got injured from 2 (25%) to 18 (54.5%) post legalisation, while the proportion of paediatric cases who were bystander decreased from 50% to 33.3%. Whether paediatric cases were handlers or bystanders was unknown for two and four cases prelegalisation and postlegalisation, respectively.

Table 2

Firework characteristics

Outcomes

As shown in table 3, there was no significant difference in term of overall complications, disability, death and discharge disposition to home. Postlegalisation, we observed a significant increase in the proportion of amputations from 0 to 18%, with 15 adults and 1 child requiring amputation. All the amputations involved upper extremity digits. Seven cases underwent full digit(s)’ amputations, five underwent partial amputations and seven had distal amputations.

Table 3

Patient outcomes

Discussion

Following the passage of SB489 in 2017 in the state of Iowa, the number of firework injuries resulting in ED visits and hospital admissions increased significantly, particularly for paediatric patients. Our findings corroborate previous studies that have shown increases in firework injuries following firework legalisation in Washington, West Virginia, Minnesota, North Carolina, Michigan and Georgia.11 12 15–18 State legislators should consider all consequences of firework legalisations, especially the costs levied on paediatric patients who face disproportionate risks of injury.

In addition to the increase in the total number of firework-related injuries, we also observed greater geographic spread. A higher percentage of Iowa counties saw patients with firework injuries following legalisation. Of these counties, a higher proportion saw more than five residents suffering fireworks-related injuries postlegalisation. Moreover, the number of paediatric ED visits significantly increased postlegalisation of fireworks. This higher strain on healthcare resources could negatively impact the care of patients with fireworks-related injuries, especially in the state’s many rural regions. Others have shown that rural critical access hospitals (CAHs) may not all be equipped and staffed to provide adequate care for trauma patients.19 20 Jiang et al assessed trauma resources in rural northern Alberta, a regional trauma system and identified deficiencies in trauma-specific personnel training and equipment availability.19 Pilkey et al assessed paediatric readiness of CAHs and noted several challenges affecting low-volume to medium-volume CAHs when it comes to paediatric readiness, including the lack of policies for paediatric emergency care and the cost of training personnel.20

Many of the specific types of fireworks causing injury were unknown in our sample. However, when firework type was recorded, most injuries were caused by firecrackers and mortars. Sandvall et al showed that these types of fireworks, with a characteristically higher explosive power, are the cause of most severe injuries.21

Both before and after legalisation, most patients presented with injuries to the hands, face, and eyes. The number of patients suffering amputations due to firework injury went from 0 to 18%. This increase in severity of injury is associated with higher levels of healthcare utilisation and cost, in addition to disability associated with the injury.22 Although not significant, we observed that firework handlers were injured at a higher rate postlegalisation, particularly in the paediatric population. Notably, about one-third of firework injuries affected bystanders, both prelegalisation and postlegalisation. Firework safety initiatives and intervention should consider how bystander choices, like watching from a safe distance, can play a role in preventing injury.

Research has shown that severe firework injuries can be prevented without enacting total firework bans.23 Instead, the number and severity of injuries can be reduced by limiting access to fireworks with greater explosive energy, like mortars and limiting use to those over 18 years old.23 Stakeholders in healthcare, parents and state legislators should advocate for laws to limit the types of fireworks allowed or limiting firework use by minors.

Our findings should be interpreted with a complete understanding of certain strengths and limitations. First, certain municipalities could restrict the use of fireworks more than others, which may account for differences observed in this study. The use of the IHA database provided us with the numbers of patients that presented to EDs and/or were admitted to hospitals statewide. However, individuals who were injured may have opted not to present to a hospital or may have received care at a hospital in a bordering state. The decision to present for medical care could depend on a patient’s particular situation and level of injury, factoring in proximity to a healthcare centre and health insurance status. Thus, the reported number of injuries could underestimate the total number of firework injuries statewide in a skewed manner. The data from the two Iowa level I trauma centres were collected retrospectively, which introduces a risk of selection bias and incomplete data capture from poor documentation or missing data. In fact, unless the term firework was used in the ED note or anywhere in the medical records, patients were not included in the dataset analysed in this study. In some cases, we could not decipher from chart review the type of firework, display and/or whether the injured person was a firework handler or bystander. Future improvement in refining the information collected during an ED visit or on hospital admission for patients presenting with fireworks-related injuries are warranted. Finally, the sample size from the two Level I trauma centre was small, limiting our statistical power. Developing a statewide fireworks-related injury registry would allow us to have a better understanding of the type of fireworks-related injuries treated in EDs and hospitals across the state of Iowa.

Conclusions

Legalisation of fireworks in Iowa through SB489 was followed by an increase in firework injuries statewide. Increases in firework injuries in the paediatric population were particularly profound following legalisation. Further work is warranted to establish whether public safety campaigns or policy changes could be effective in preventing these injuries.

Data availability statement

Data are available on reasonable request. Data are available on reasonable requests.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by University of Iowa Institutional Review Board IRB # 201707719. Retrospective review of the medical records of patients admitted to the two Iowa level I trauma centres was approved by the University of Iowa Institutional Review Board (IRB # 201707719). A waiver of consent for all subjects was approved by the University of Iowa Institutional Review Board.

References

Footnotes

  • Twitter @ColetteGalet, @Iowa_EM

  • Contributors Conceptualisation: KKH, CG, MET, AF and DAS; methodology: CG, KKH and MB; formal analysis: CG, KKH, MB and IS; data collection: AF, EF, CAP, CG and ML; data curation: CG, MB and KKH; writing—original draft: CG, AF and IS; writing—review and editing: AF, MB, IS, ML, EF, CAP, KKH, DAS, MET and CG; visualisation: IS and CG; supervision: CG, KKH, DAS and MET.

    Drs Takacs, Harland and Galet are the authors responsible for the overall content as guarantors

  • Funding This research was funded by the Iowa Department of Public Safety, State Fire Marshal (project #1227892). Research reported in this publication was partially supported by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002537.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.