home safety for public health professionals supporting evidence-informed practice wrha injury...

Home Safety for Public Health Professionals

Supporting evidence-informed practice

WRHA Injury Prevention Program (IMPACT)Dr. Lynne WardaMedical Consultant, Injury Prevention and Child Health

Injury Prevention Champion Meeting

September 30, 2015

Objective

Consider evidence and strategies for home safety in public health practice

• WHAT GUIDES PRACTICE?• Burden• Evidence• IMPACT activities• Resources

What Guides Practice?

1. Policy context: legislation, standards, policies, guidelines2. Priorities: vs. other tasks/topics

• Severity of the hazard? (fire/drowning)• Likelihood of the injury occurring? (suffocation)• Time, resources required? (smoke alarm)

3. Evidence for effectiveness of interventions4. Ability to implement effective interventions

Standards, Policies, Guidelines

1. Legislation: SAFT assessment – home/property hazards2. National Standards: Accreditation Canada Required

Organizational Practices (ROP)– Fall prevention, Home safety

3. Regional guidance (safety topics): Clinical Practice Guidelines, Care maps, Home Visitor Log (CHEERS), Service Delivery Standards, Healthy Beginnings Manual, etc.

Home Safety ROP

• The team conducts a safety risk assessment for clients receiving services in the home.

Home Safety Assessment ToolsKey safety issues can be identified using structured assessment tools:•Occupational/Personal Safety: SAFT•Home safety assessment (staff): WRHA Safety Teleform•Home safety checklist (parent): Give Your Child a Safe Start •Documentation: care map safety section•Policy guidance: CPG, operational guidelines, service delivery standards, Healthy Beginnings safety section

Home Safety Approach?

• Integrated in daily practice (SAFT, care map, checklist, parent handout)

• Practical, reasonable– One visit vs. ongoing relationship– Appropriate for degree/nature of hazards– Focus on serious injury (fire, suffocation, falls)

• Supports families – safer homes/practices• Documented, feedback loop (client, system)

• What guides practice?• BURDEN• Evidence• IMPACT activities• Resources

Burden-injury death

Children under 1 year of age: sudden infant death, suffocation, assault, burns, drowningCauses: over-heating, soft bedding, unsafe sleep surfaces, adult beds, bedsharing

Burden-injury death

Children 1-4 years of age: strangulation/choking and suffocation, drowning, MVC, assaultCauses of suffocation: food, coins, batteries, balloons, gel candies and certain types of foods like whole hot dogs and whole grapes

Burden-adult fatal injury

The leading causes of injury death occurring in the home are falls, poisonings, fire and burn injuries

•Combined = 78.6%

Burden-injury and hospitalization

Children under 1 year of age: falls (81 cases), assault (48 cases) and burns (26 cases)

Children 1-4 year of age: falls (247 cases), burns (92 cases) and poisoning (85 cases)

Burden-injury and hospitalization

FALLS:•Leading cause of injury and more than half of all injury hospitalization•From furniture, down stairs, windows and one level to another•Half of injuries are to the head and face

Burden-injury and hospitalization

BURNS:•Caused by hot liquids and tap water •Lengthy hospital stays (average 13 days)•Recurrent hospitalizations and lifelong treatment•Intense pain and suffering, disfigurement, permanent physical disability, emotional adjustments and family disruption

Burden-injury and hospitalization

POISONING:Toxic symptomatic ingestions: •Cardiovascular agents (e.g. clonidine)•Oral hypoglycemics (e.g. glyburide)•Sedative/hypnotics (e.g. benzodiazepines)•Hydrocarbons (e.g. paint thinner, lamp oil) •Anticonvulsants (e.g. carbamazepine)

Burden- Emergency Department Data

• 5 years and younger: majority of injury visits result from injuries occurring in the home (80%)

• Most severe causes being scalds, poisoning, animal bites, electrical burns and ingesting or choking on small objects

Burden-adult hospitalizations

The leading causes of injury hospitalization occurring among older adults are falls (61.6%), and struck by/against, or motor vehicle crash (15%)

•Combined = 76.6%

Burden-ED

In a study conducted by Runyan and colleagues, falls were the leading cause of injury occurring within the home:

•Falls (46%)

Being struck by or against an object or cuts and piercing injuries within the home occurred frequently

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CHIRPP Case Studies

• What patterns of injury do we see?• Winnipeg CHIRPP data 2004-2008 • Age < 5 years• Home injuries• Variables: child characteristics, injury circumstances, nature

of injury, disposition• Ranking by severity (using disposition)• Analysis by safety teleform category

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CHIRPP Injuries: Age < 5

YearNumber of Injuries (%)

Total Injuries Home Injuries(%)

2004 1,683 (17.4) 6,113 1,285 (17.2)

2005 1,838 (19.0) 5,602 1,426 (19.1)

2006 1,817 (18.7) 5,754 1,383 (18.5)

2007 2,117 (21.8) 6,085 1,663 (22.3)

2008 2,234 (23.1) 6,097 1,707 (22.9)

Total 9,689 (100) 29,651 (100) 7,464 (100)

(X2=112.67, p<.0001).

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CHIRPP: study results

• Children in this age group account for 36% of CHIRPP injuries• Home injuries: 77% in this age group• Age: mean age 2.0 years• Gender: 57% of injuries were to boys• Body Part: 53% to head and face• Nature of Injury: 31% were open wounds, 17% minor head

injury, 11% fractures

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CHIRPP: disposition after injury

Disposition Number (%) Severity

Left without being seen 23 (0.2) Unknown

Short stay observation in ED 59 (0.6) Minor

Advice only 2,822 (29.1) Minor

Treated, follow-up as needed 3,659 (37.8) **Minor**

Treated, follow-up required 2,884 (29.8) Moderate

Admitted to hospital 239 (2.5) Severe

Direct admission to ICU 2 (0.02) Severe

Total 9,688 (100)

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CHIRPP: results

• Context: 45% playing, climbing or dancing; 25% walking, running or crawling

• Mechanism: 1/3 were falls• Location: 77% in own/other house/apartment, 5% at

daycare or preschool• Months: August, July, April, May • Time: 4-8pm (34%), 12-4pm (27%)

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CHIRPP: top 5 severe injuries

Injury N Mean Age (years)

ModerateSeverity

Severe

Hot Liquids 159 1.2 81% 10%

Poisoning 202 1.9 1% 5%

Pets 110 2.6 44% 4%

Small Objects 114 2.5 14% 3.5%

ElevatedFurniture

755 1.7 26% 2.4%

See complete list of teleform-coded injury, mean age and severity in the CHIRPP report.

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CHIRPP: top 5 moderately severe

N Mean Age (years)

Moderate Severity

Electrical Cords 6 2.2 83%

Hot Liquids 159 1.2 81%

Meal Preparation 9 Injury 56%

Bathing 56 1.8 54%

Electrical Sockets 4 2.0 50%

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CHIRPP: hot liquids

• 159 cases, mean age 1.2 years• 9% minor severity, 81% moderate, 10% admitted to

hospital• 33% of hot tap water cases were admitted• “Pulled bowl of hot soup onto herself while eating”

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CHIRPP: toxic substances

• 202 cases, mean age 1.9 years• 93% minor severity, 1% moderate, 5% admitted to hospital

(1% left unseen)• “Playing with 2 y.o. sister, sister fed her ‘extra strength

Tylenol’, Tylenol overdose”

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CHIRPP: pets

• 110 cases, mean age 2.6 years• 52% minor severity, 44% moderate, 4% admitted to

hospital• “Playing with cat, bit and scratched by cat”

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CHIRPP: small objects

• 114 cases, mean age 2.5 years• 83% minor severity, 14% moderate, 3.5% admitted to

hospital• “Playing with marbles, put marble in mouth and swallowed

it”

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CHIRPP: elevated furniture

• 755 cases, mean age 1.7 years• 72% minor severity, 26% moderate, 2.4% admitted to

hospital• “Fell from change table onto floor while being changed”

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CHIRPP Cases: summary

• Injuries in preschool children and home injuries in this age group increased

• There were 2884 moderate and 241 severe injuries captured by the CHIRPP system

• Injury severity ranking by teleform topic can validate and identify priority topics to target for prevention efforts (scalds, poisoning, pets, electrical cords/sockets, small objects)

• What guides practice?• Burden• EVIDENCE• IMPACT activities• Resources

Comprehensive injury prevention projects employ strategies that include :

•Environment •Education •Enforcement •Economics

Evidence-strategies

Home-based interventions and low cost/free safety devices can improve home safety and reduce injuries involving:

•Infant sleep practices•Home hazards•Lack of caregiver supervision

Evidence: home based interventions

Evidence: effective interventions

Injury Prevention strategies

Fires Smoke alarm distribution, installation

Child-resistant lighters

No smoking in the home

Fire escape planning

Burns Hot tap water temperature reduction

Anti-scald devices

Electrical outlet covers

Fireplace guards

Evidence: effective interventions

Injury Prevention Strategies

Suffocation Safe sleep locations

Back to sleep/supine positioning

Firm sleep surface

No soft objects/loose bedding

Choking Food safety/preparation

Small parts, balloons, plastic bags, button batteries out of reach

Poisoning Safe medication storage

Medication packaging-child resistant-bubble packs

Evidence: effective interventions

Injury Prevention Strategies

Falls Stair gates

Window guards

Use straps/harnesses/restraints on baby equipment

No baby walkers

Avoid putting child on elevated surfaces

Evidence: compliance and uptake

• Many prevention strategies are effective• BUT most require action by the parent

– One time action: install stair gate, smoke alarm– Frequent action: close the gate– Occasional action: test alarm/change battery

• How can we assist in changing behaviour– Use passive strategies whenever possible– Develop routine habits, designate safe spaces

Evidence- passive strategies

• Require one-time action• Smoke alarms (long-life battery, hardwired)• Reducing hot tap water temperature• Install window guards• Install stair gate at top of stairs• Purchase a crib or playpen for newborn• Purchase nontoxic cleaning products• Disposal of medications not in use

Evidence-active strategies

• Supervise: proximity, attention, continuity• Safe storage of small parts, choking hazards• Hot liquids: carrying, accessible to child• Medications: close and store after using• Solutions? Designate one child-safe area and keep it “tidy”,

baby-gate a safe room, use playpen or high chair as safe place during meal preparation

Research Evidence

Many studies have documented improvements in home safety using:•Education (individual/group/public)•Home visiting•Pediatric office-based interventions•Free/low-cost safety devices•Standards/legislationLimitations: study design, injury outcomes

Cochrane Systematic Review

• 98 studies (2.6 million people), 35 RCTs• home safety education with or without the provision of

safety equipmentInjury reductions for interventions:• delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), with

no safety equipment (IRR 0.78, 95% CI 0.66 to 0.92)

Home safety education and provision of safety equipment for injury prevention. Cochrane Database of Systematic Reviews 2012, Issue 9.

Cochrane - Results

Safety behaviours/safety equipment:•safe hot tap water temperatures (OR 1.41, 95% CI 1.07-1.86), functional smoke alarms (OR 1.81, 95% CI 1.30-2.52), fire escape plan (OR 2.01, 95% CI 1.45-2.77)•storing medicines (OR 1.53, 95% CI 1.27-1.84) •storing cleaning products (OR 1.55, 95% CI 1.22 -1.96), having syrup of ipecac (OR 3.34, 95% CI 1.50-7.44), poison control numbers accessible (OR 3.30, 95% CI 1.70-6.39)•having fitted stair gates (OR 1.61, 95% CI 1.19-2.17)•having socket covers on unused sockets (OR 2.69, 95% CI 1.46-4.96)

Evidence: HOME Study

• Prospective RCT• Enrolled expectant mothers, followed at 12 and 24 months• 355 families randomized• Baseline hazard assessment• Installation of safety devices• Outcomes: medically attended injuries, modifiable injuries,

hazards

Evidence: HOME Study

• Hazards: number and density of hazards 15% less than controls at 12 months (p<0.005), mean number of hazards lower than controls at 24 months

• Safety devices: Table 3 (at 12 /24 months)– Stair guards: OR 9.26/8.68– Smoke alarm OR 3.02/1.85– CO detector: OR 6.5/3.23– Hot water less than 49 degrees: OR 1.7/1.3

Evidence: HOME Study

• Injuries: all medically attended injuries reduced by 31% during 24 month follow-up, compared to controls (NS)

• Modifiable injuries: 70% reduction in modifiable medically attended injuries in the intervention group over 24 months of follow-up (p=.03)

Evidence: HOME Study

• What guides practice?• Burden• Evidence• IMPACT ACTIVITIES• Resources

IMPACT Activities

• Injury Surveillance and Data• Leadership and Collaboration• Communication• Strengthening Capacity• Policy and Advocacy• Health Equity Promotion• Applied Injury Prevention Research

• What guides practice?• Burden• Evidence• Impact activities• RESOURCES

IMPACT Resources Resources for the public, community, and professionals

IMPACT Resources

NEW! Parent home safety illustrated handout and checklist

Home Safety Assessment?

• Occupational/Personal Safety: SAFT• Home safety assessment (staff): WRHA Safety Teleform• Home safety checklist (parent): Give Your Child a Safe Start • Home safety checklist (client): handout, online• Documentation: care map safety section• Policy guidance: CPG, operational guidelines, service delivery

standards, Healthy Beginnings safety section

IMPACT References1. Flavin, M. P., Dostaler, S. M., Simpson, K., Brison, R. J., & Pickett, W. (2006). Stages of development

and injury patterns in the early years: a population-based analysis. BMC public health, 6(1), 187. 2. Home safety education and provision of safety equipment for injury prevention. Cochrane Database of

Systematic Reviews 2012, Issue 9. 3. IMPACT, Injury Prevention Program, Winnipeg Regional Health Authority. (2011). Injuries to Children

Less Than Five Years of Age: Using the Winnipeg CHIRPP Database to Inform Public Health Practice, 1-24. Retrieved from http://www.wrha.mb.ca/extranet/publichealth/services-injury-prevention.php

4. Kendrick, D., Young, B., Mason-Jones, A. J., Ilyas, N., Achana, F. A., Cooper, N. J., Hubbard, S. J., Sutton, A. J., Smith, S., Wynn, P., Mulvaney, C., Watson, M. C., & Coupland, C. (2012). Home safety education and provision of safety equipment for injury prevention. Cochrane Database Systematic Reviews. 12(9). doi: 10.1002/14651858.CD005014.pub3.

5. Manitoba Health. Injuries in Manitoba: A 10-Year Review. Winnipeg, Manitoba, 2004. 6. Phelan, K. J., Khoury, J., Xu, Y., Liddy, S., Hornung, R., & Lanphear, B. P. (2011). A Randomized,

Controlled Trial of Home Injury Hazard Reduction: The HOME Injury Study. Archives of Pediatrics & Adolescent Medicine, 165(4), 339–345. doi:10.1001/archpediatrics.2011.29

Questions?