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?