Illnesses and Injuries at a Remote American Residential Summer Camp Over 3 Seasons

Introduction

Residential and wilderness excursion summer camps are safe, but outdoor activities can lead to injuries. The frequency of various illnesses and injuries at summer camps has been incompletely described. The treatments provided and the need for escalation to higher levels of care are variable.

Methods

A retrospective cohort analysis was conducted for all visits to a camp infirmary over 3 seasons at a residential summer camp in Minnesota. Seventeen descriptive categories of chief complaints and 13 categories of treatment disposition were created for all 695 eligible infirmary visits. The frequency and illness type for which escalation to a higher level of care beyond the camp infirmary was needed were reviewed.

Results

Four hundred one campers sought medical care 695 times over 3 seasons. The most common chief complaints were related to skin (35%), musculoskeletal injury (17%), and upper-respiratory symptoms (15%). The most common treatment and dispositions were over-the-counter medications (43%) and simple bandage or dressing (19%). Escalation of care to a clinic or emergency room was uncommon, with 35 (5%) infirmary visits requiring escalation. Musculoskeletal injuries were the most common reason for escalations of care. While overall less common than musculoskeletal injury, dental injury almost always resulted in escalation of care.

Conclusions

An analysis of 3 y of visits to a summer camp infirmary was used by camp medical staff to update protocols and obtain new supplies for diagnosis and treatments. A more complete understanding of the prevalence of injuries and illnesses has the potential to allow better preparation for camp medical staff.

KeywordsIntroductionAttending summer camp is a common activity for American children from childhood through adolescence. Before the COVID-19 pandemic in 2018, >14 million children per year attended summer camp in the United States.Franzidis A. Seaman A.N. Donaldson J. A toponymy of American summer camps: onscreen stereotypes or symbols ripe for change?. At residential summer camps, campers stay overnight. Wilderness excursion summer camps combine residential activities with overnight camping off site. While residential and wilderness excursion summer camps are generally safe and developmentally appropriate activities for children and adolescents, activities in the outdoors can lead to injuries. A 2006 convenience sample of summer camps found that 68% of reported events were illnesses, and of 32% of injury events, cut, scratch, or scrape was the most common.Yard E.E. Scanlin M.M. Erceg L.E. Powell G.M. Wilkins J.R. Knox C.L. et al.Illness and injury among children attending summer camp in the United States, 2005. The duration of camps has previously been shown to be associated with an increased risk of injuries; however, residential summer camps have lower rates of injury than most common high school sports.Goldlust E. Walton E. Stanley R. Yard E. Garst B. Comstock R.D. et al.Injury patterns at US and Canadian overnight summer camps: first year of the healthy camp study. A 2013 review of 5 y of illnesses and injuries at day and overnight or residential summer camps reported that sprains and strains topped the list of injuries, while respiratory and gastrointestinal illnesses were the most common communicable illnesses spread at camps.Garst B.A. Erceg L.E. Walton E. Injury and illness benchmarking and prevention for children and staff attending U.S. camps: promising practices and policy implications.

Camp Kooch-i-Ching opened in 1925 as a residential summer camp for boys and is located in International Falls, Minnesota. The associated girls’ camp Ogichi Daa Kwe was founded in 2004 and is located a half mile south of the boys’ camp. Campers from both the camps range in age from 8 to 18 y and are divided into 4 groups based on their year in school. Both the camps maintain an in-camp program and a wilderness excursion program. The in-camp program offers >20 land- and water-based activities, while the wilderness excursions involve multiday canoeing or backpacking trips across North America. All campers attend the in-camp program, followed by a wilderness excursion that varies in duration from 2 to 21 d. The camp duration varies from 10 d to 8 wk. The staff-to-camper ratio is 3:1.

Over the 3 y of data collection, the staff members of the camp infirmary included a volunteer family medicine physician (author JS), 2 first-year medical students from the University of Cincinnati College of Medicine (authors KJM and EG), and 2 licensed and practicing emergency medical technicians at the boys’ camp. The infirmary staff at the girls’ camp included 2 registered nurses. When injuries or illnesses could not be handled by the infirmary staff, transportation was made to urgent care at a nearby community health clinic or to a local emergency department. Both the locations are approximately 16 km (10 mi) from the camp.

Methods

Our retrospective observational cohort study was designed to illustrate data on the prevalence and frequency of various ailments and treatments for infirmary visits during 3 consecutive years at a residential summer camp. Injuries and illnesses occurring during wilderness excursions were not logged in the electronic health record (EHR) and, thus, not included in this analysis. We also reported the frequency and illness type for which escalation of care to an outside provider was needed.

In 2017, both the infirmaries transitioned to the use of CampMinder (CampMinder LLC; Boulder, CO, 2019), an EHR and data management software, to track the medications, background health needs, and allergies of the campers. This EHR system allowed the infirmary staff to record visits more effectively. The presence of EHR also allowed for retrospective sampling of past visits for illnesses and injuries to the infirmary.Kaufman L. Holland J. Weinberg S. Rosenbloom S.T. Medical record keeping in the summer camp setting.

The EHR system was retrospectively queried for all encounters during these 3 seasons. Visits to the infirmary did not include encounters while the camper was on a wilderness excursion. Demographic information was deidentified. A retrospective cohort analysis was then conducted using EHRs. Visit entries were reviewed, and a database was created using the Excel program (Microsoft, 2017). Upon arrival at the camp and following all overnight wilderness excursions, a screening visit was conducted for all campers, and these visits did not generate an entry into the EHR unless an injury or illness was identified. Additionally, information regarding daily medication administration for chronic conditions was not included in the database. After a review of 695 eligible encounters, authors JS and KJM met and created 17 descriptive categories to describe chief complaints and 13 categories to describe treatment and disposition. The categories were then internally validated by each author based on a consensus. Each of the unique infirmary encounters was coded according to both chief complaints and treatment or disposition by the authors of this study (AP, AMW, and KJM). The University of Cincinnati institutional review board deemed this research study to be not human subject research and, thus, did not require review.

ResultsThere were 1259 campers between 2017 and 2019. Four hundred one (32%) campers sought medical care between 1 and 9 times during the summer for a total of 695 unique infirmary visits over 3 seasons from 2017 to 2019. The most common chief complaints were related to skin (35% of all visits), musculoskeletal injury (17%), and upper-respiratory symptoms (15%) (Table 1). Headache and gastrointestinal issues resulted in 60 (9%) and 54 (8%) infirmary visits, respectively. Head injury was an uncommon complaint, contributing only 20 (3%) chief complaints. Only 5 (0.7%) complaints of a burn resulted in an infirmary visit. The most common treatment and dispositions were over-the-counter (OTC) medications (43% of all treatments) and simple bandage or dressing (19%) (Table 2).

Table 1Frequency of chief complaints presented to the camp infirmary

Table 2Rates of treatments and dispositions for all infirmary encounters

Of the 695 total visits over 3 y, 35 (5% of all visits) required escalation of care (Figure 1). Over 3 y, 116 musculoskeletal injuries were logged in the system, representing 17% of the total encounters. Of these 116 musculoskeletal injuries, 12 (10%) musculoskeletal injuries required escalation, most frequently for x-rays. Musculoskeletal injuries were the most common reason for escalation of care, contributing 12 out of the 35 escalations. When their high incidence rate overall (17% of all encounters) was accounted for, musculoskeletal injury was the most frequent chief complaint that required care escalation.Figure thumbnail gr1

Figure 1Relative rate of escalation to a higher level of care based on the chief complaint. MSK, musculoskeletal.

While only 8 dental injuries were identified over 3 y, 5 of those 8 injuries (63%) required escalation to a higher level of care. Therefore, while they represented a much lower absolute number of injuries, dental injuries led to a much higher rate of escalation than musculoskeletal injuries. Five patients presented with tick bites and potential Lyme disease exposure, and 3 instances required escalation to obtain recommended antibiotic treatment.

DiscussionThe most prevalent ailment presenting to the infirmary over 3 seasons was skin disruption. The rate of overall escalation to a higher level of care was 5% of all infirmary visits. This is a rate similar to an escalation rate of 7% at a boy scout camp in Missouri.Health supply utilization at a boy scout summer camp: an evaluation for improvement and preparedness.

While dental injuries were relatively uncommon in all 3 y of visits, 5 of 8 dental injuries required escalation. This high rate of escalation could prompt residential summer camps to have a defined procedure for urgent dental referral. A revised protocol and staff education on dental injury was added to staff training, and the phone number for a local dentist providing urgent referrals was posted in the infirmary. Asthma is a common condition during childhood, but there were only 2 chief complaints of shortness of breath or asthma at the infirmary in 3 y, and there were no escalations required for acute asthma exacerbation. The baseline incidence of asthma in the camper population at Camp Kooch-I-Ching and Ogichi Daa Kwe is unknown but potentially low given the selection bias of remote wilderness camps.

Tracking infirmary visits presented several opportunities for process improvement of the summer camp infirmary, including evaluation of tick bites and upper-respiratory infections. Minnesota has the sixth highest prevalence of Lyme disease in the United States, and thus, it must be frequently considered by the infirmary staff. When tick bite was the chief complaint (n=5), it resulted in escalations for antibiotics 60% of the time, only slightly trailing dental injuries in escalation rate. In 2019, the infirmary began stocking doxycycline and created a standard algorithm based on Centers for Disease Control guidelines for Lyme disease prophylaxis in the event of tick exposure.Centers for Disease Control and Prevention
Lyme disease prophylaxis after tick bite.,Nadelman R.B. Nowakovski J. Fish D. Falco R.C. Freeman K. McKenna D. et al.Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. This allowed for campers with tick exposure to avoid needing to be transported to urgent care for recommended antibiotic prophylaxis.

All 3 escalations for upper-respiratory infections (n=3) were because of suspicion of strep throat infection and the need for additional diagnostic testing. In 2019, a rapid strep A antigen throat swab test kit was purchased. This availability decreased the need for escalation of care to obtain diagnostic testing. A greater understanding of any camp’s ailment and treatment records can better improve infirmary efficiency and improve delivery of care to campers; when injury and illness are able to be appropriately handled on site, campers avoid the expense and time away from the camp for travel to an emergency room. It is possible that a less disrupted camp experience could potentially lead to higher camper retention, decreased parental anxiety, and decreased additional costs through minimization of transportation to emergency departments.

Limitations

There are several limitations to our study. Our data are based on 1 organization and 2 summer camps in northern Minnesota, limiting generalizability. The wilderness excursion elements of the camps could likely lead to selection bias of healthier campers, who are less likely to experience exacerbation of a chronic disease such as asthma. The wilderness excursions could also lead to a higher incidence of skin-related and musculoskeletal injuries. A retrospective review could not differentiate a scheduled follow-up visit from a visit to the infirmary for a similar but new condition. With a retrospective analysis of all 695 infirmary visits, it became clear that specific conditions required follow-up more often, leading to potential overrepresentation. For example, wound check of an abrasion and a second abrasion on a different extremity could not be differentiated if they both occurred in the same camper. While we have decided to present data from each year, the variations in the reporting of illnesses and injuries between years are not known. Finally, because some visits for extremely minor complaints might not have warranted creation of a note in the EHR, the true number of visits to the infirmary and the true number of treatments categorized as “no treatment/reassurance,” are not known. Unknown total visits precluded the ability to know total injury or illness rates.

Conclusions

Our study described infirmary visits during 3 seasons of a residential summer camp in northern Minnesota. A better understanding of the prevalence of both common and rare injuries and illnesses allowed better preparation for camp medical staff. A review of infirmary visits also presented several opportunities for process improvement of the summer camp infirmary. A review of conditions that were most likely to require escalation of care to a clinic or emergency room enabled better preparation for future illnesses and emergencies at the summer camp. Other camps could improve protocols for common injuries through an understanding of their most common reasons for a visit to the infirmary. While one third of campers visited the infirmary over 3 y, serious injury was uncommon, most illnesses and injuries were treated with OTC treatments, and few campers required escalation to a higher level of care. Our findings support the general safety of residential summer camps for children and adolescents.

Presented by Glankler E, Milligan K, Cohn W, Schlaudecker J as “A Descriptive Evaluation of Two Years of Injury and Illness Patterns at Two Remote Residential American Summer Camps” at the North American Primary Care Research Group (NAPCRG) 47th Annual Meeting, November 19, 2019, Toronto, Ontario.

Acknowledgment: The authors wish to thank the dedicated staff of the Camping and Education Foundation for their support of this endeavor.

Author Contributions: study concept and design (JS, KM, WC, EG); data acquisition (JS, KM, WC, EG); data analysis (JS, AW, AJ, KM); drafting and critical revision of the manuscript (JS, KM, AW, AJ, WC); approval of final manuscript (all authors approved the final manuscript).

Financial/Material Support: None

Disclosures: None

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Injury and illness benchmarking and prevention for children and staff attending U.S. camps: promising practices and policy implications.

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N Engl J Med. 345: 79-84Article infoPublication history

Published online: April 29, 2023

Accepted: March 1, 2023

Received: September 7, 2022

Publication stageIn Press Corrected ProofIdentification

DOI: https://doi.org/10.1016/j.wem.2023.03.003

Copyright

© 2023 Wilderness Medical Society. Published by Elsevier Inc.

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