Home Safety for Public Health Professionals Supporting evidence-informed

Home Safety for Public Health Professionals Supporting evidence-informed practice WRHA Injury Prevention Program (IMPACT) Dr. Lynne Warda Medical 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, guidelines 2. 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 interventions 4. Ability to implement effective interventions

Standards, Policies, Guidelines 1. Legislation: SAFT assessment – home/property hazards 2. 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 Tools Key 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, drowning Causes: 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, assault Causes 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

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 • • • 20

CHIRPP Injuries: Age < 5 Year Number 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) (X 2=112. 67, p<. 0001). 21

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 22

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) 23

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 -8 pm (34%), 12 -4 pm (27%) 24

CHIRPP: top 5 severe injuries Injury N Mean Age (years) Moderate Severity 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% Elevated Furniture 755 1. 7 26% 2. 4% See complete list of teleform-coded injury, mean age and severity in the CHIRPP report. 25

CHIRPP: top 5 moderately severe N Mean Age (years) Moderate Severity 6 2. 2 83% 159 1. 2 81% Meal Preparation 9 Injury 56% Bathing 56 1. 8 54% Electrical Sockets 4 2. 0 50% Electrical Cords Hot Liquids 26

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” 27

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” 28

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” 29

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” 30

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” 31

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) 32

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

Evidence-strategies Comprehensive injury prevention projects employ strategies that include : • • Environment Education Enforcement Economics

Evidence: home based interventions 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: 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/legislation Limitations: 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 equipment Injury 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. 071. 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 for the public, community, and professionals • • Give Your Child a Safe Start (parent home safety illustrated handout and checklist) • • Quick Reference Guide (key injury • messages by ages/stages for public • health staff) • • Keeping You and Your Family Safe In • and Around the Home Checklist • Home Safety Services and Programs • • Safe Sleep Easy Read • • Home Safety Teleform • • Soothing a Crying Baby • Staying Calm with Baby is Crying • • Keeping Baby Comfortable (temperature control) • • How to Prevent Playground Injuries (Poster and Pamphlet) • Safe Sleeping for Baby and A Baby’s Safe Sleep Environment hang tags and brochure (Health Canada) Crying Banner stand Safe Sleep banner stand Safe Swaddling Choosing Safe Sleep Sacks Home Safety and Falls Prevention Online Checklist (www. preventfalls. ca) Hot Water Burns like Fire pamphlet Hot Water test cards Hot Water Burns Like Fire flipchart for group presentations Stay Water Safe COMING SOON…Home Safety Speaker’s Kit

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 References

Questions?