The volume of EMS responses for injurious falls on streets and sidewalks was substantially greater than for pedestrians injured by motor vehicles. Similarly, the overall number of injured pedestrians with Emergent or Critical acuity rated by EMS was much higher for pedestrians with injurious fall than for pedestrians struck by motor vehicles. This is particularly true for individuals ≥ 50 years old, where the number of pedestrian injuries coded as Emergent or Critical acuity was 4.3-fold for falls than for pedestrians struck by motor vehicles. Although fewer in numbers, a larger proportion of pedestrians struck by motor vehicles were rated as Emergent or Critical acuity and had a higher probability of being dead on scene compared to pedestrians with an injurious fall on streets or sidewalks. The vast majority of both types of injury occur in urban spaces, suggesting that urban design, policy and built environment interventions are important tools for reducing morbidity and mortality.
The overall number of older pedestrians who fell and required EMS responses is alarming, especially the number coded as Emergent or Critical on scene by EMS.23 Unintentional injuries rank as the 8th cause of death, and fall-related injuries account for 80% of all trauma admissions among older persons in the U.S.24 Even falls without significant injuries increase the risk of declines in mobility and social participation.25 Falls without injuries are also associated with the fear of falling, a well-described phenomenon among older persons with no clear modifiable risk factor,26 but compounds the detrimental effects of falls by restricting healthy activities27 and increasing the incidence of disability.28
Despite the high incidence of pedestrians experiencing injurious falls, there has been much less policy attention given to this public health issue than to preventing pedestrian injuries from motor vehicles. We argue that this likely arises from differences in who is responsible for, and who pays for, sidewalk and road maintenance.29 In many cities landowners are responsible for the maintenance of sidewalks that are along the perimeter of the land parcel, both for snow and ice removal and for repairing damage to the sidewalk surface.29 Thus, a single city block can vary tremendously in terms of the cleanliness and maintenance of the physical surface of the sidewalk. Roadways, however, are maintained by city, county and state agencies, organizations likely to have better access to human and material resources to maintain infrastructure than individual property owners. Moreover, maintenance of roadbed surfaces tends to focus on larger scale damage (e.g. potholes) that might interfere with driving, rather than smaller hazards that might pose a risk to pedestrians crossing the street. Some cities provide financial incentives to homeowners to fix physical damage to sidewalks and/or provide hotlines to report damaged sidewalks so that cities can serve notice or fines to landowners.13 It seems possible that when municipal work crews are dispatched to repair roadways, install curb extensions, plant street trees, or maintain medians, these same crews can also repair sidewalks along that roadway.
Many cities have robust surveillance programs for motor vehicle crashes and injuries to pedestrians and cyclists from motor vehicles. They also have an arsenal of policy, design, and built environment interventions to increase motor vehicle related road safety, with much of the work to develop these interventions having been done by the NHTSA, the Vision Zero program and the Safe Routes to School program.30, 31 However, there is a lack of robust surveillance systems for monitoring pedestrian falls occurring on sidewalks and roadbeds.32 Without such systems it is difficult to understand the burden of falls and motivate the development of prevention programs or prioritize interventions programs to high-risk areas. We have argued that the NEMSIS system of reporting EMS activations presents an opportunity for states or cities to develop such a surveillance system based on standardized EMS data.13
Creating urban environments that support the health and engagement of older persons is becoming increasingly important as populations age. Multiple characteristics can contribute to making a pedestrian environment “age-friendly” including walkable design, ambient temperature, lighting, signage, appropriate street crossing design or crossing speeds and provision of seating.33 But pedestrian safety is also critical and requires proper maintenance of sidewalks.33 Designing an age-friendly street environment is therefore not a straightforward task and involves many trade-offs. For example, street trees create welcoming and shadier environments that encourage people to leave their homes and be physically active. The shade they provide reduces ambient temperatures on streets and two recent studies suggest that lower outdoor temperatures are associated with lower risk for pedestrian falls among older adults.34, 35 However, the roots of poorly chosen, inappropriately placed or poorly maintained trees can disrupt pavements, and fallen leaves or branches can create trip hazards that increase the risk of falls.36 An appropriate policy response is further complicated by the disjointed responsibility for road and sidewalk maintenance. The burden of injurious falls among older pedestrians highlighted by this paper suggests new approaches are required that span all aspects of age-friendly design. It is likely that, rather than relying on individual property owners, more centralized mechanisms for sidewalk maintenance are required.29
The NEMSIS data recorded fewer pedestrian injuries and fatalities from motor vehicle collisions than reported by the NHTSA or the CDC WISQARS. The differences in the totals across the three systems may reflect the differences in data gathering: Administrative reports of EMS activations with fatalities counted only for those dead at the scene (NEMSIS); a sample of police reports for injuries and all fatalities within 30 days of a collision (NHTSA); and a probability sample of hospitals (CDC). It is also possible that not all police-reported collisions or ED visits involve an EMS response. For instance, among the 15,221 pedestrians injured by motor vehicles recorded in NY State Department of Motor Vehicles data for 2019, 60% of the pedestrians were described as having minor injuries and thus perhaps EMS activations for these collisions did not involve treatment or transport.37 Another weakness of the NEMSIS data is that injury acuity data were missing for 27% of the fall injuries and 31% of the motor vehicle injuries. However, even if all of the pedestrians injured by motor vehicles with missing acuity ratings had the three worse acuity ratings (Emergent, Critical or Dead without Resuscitation Efforts), there would still be fewer pedestrians injured by motor vehicles than pedestrians injured by falls whose acuity was classified into these categories. Lastly, the NEMSIS data does not differentiate between events occurring on streets versus sidewalks, but we can logically assume, for events coded as occurring on streets or sidewalks, that the pedestrians struck by motor vehicles were more likely to be struck in the street than on the sidewalk. Analyses of 1997–2010 NHIS data showed that 38.4% of pedestrian falls occurred on sidewalks, 21.4% at the curb and 40.2% on streets. However, it is unclear whether these percentages for falls requiring any medical attention can be applied to falls that EMS responded to. The strengths of NEMSIS are that it covers both pedestrian falls and injuries from motor vehicles in a single data set with a single system for gathering data and provides consistent coding for the location of the event, disposition of the patient and patient acuity allowing for head-to-head comparisons.