Health and Safety in the Home Care Environment

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Strategies............................................... 24 3.2 Worker Strategies................................................. 26 Module 4 Communicable Disease Prevention................. 29 4.1 Employer Strategies............................................... 30 4.2 Worker Precautions............................................... 31 Module 5 Musculoskeletal Injury Prevention ................. 37 5.1 Employer Strategies............................................... 39 5.2 Worker Strategies................................................. 40 5.3 On-The-Job Exercises............................................. 43 Standing Extension (Back Bends)........................ 44 Flexion in Sitting .......................................... 45 Retraction in Sitting ...................................... 46 5.4 At Home Exercises ................................................ 47 Lumbar Extension (Sloppy Push-Up).................... 47 Hamstring Stretch......................................... 50 Upper Abdominal .......................................... 51 Lower Abdominal.......................................... 52 Upper Back Extensors (Chest Raise).................... 53 ii Table of Contents Lower Back Extensors..................................... 54 Module 6 Motor Vehicle Safety.................................. 55 6.1 Employer Strategies............................................... 55 6.2 Worker Strategies.................................................. 56 Module 7 Wellness Promotion ................................... 61 7.1 Employer Strategies............................................... 62 7.2 Worker Strategies.................................................. 63 Module 8 Emergency Preparedness Procedures............. 65 8.1 Employer Strategies............................................... 65 8.2 Worker Strategies.................................................. 66 Appendix A Assessment of Unsafe Conditions in the Home En- vironment 69 Examples of Hazards 71 Entrance to Building/ Home............................ 71 Chemical/Biological/Environmental Hazards ....... 71 Personal Safety Hazards ................................ 72 Fall Hazards ............................................... 73 Fire Hazards............................................... 74 Physical/Psychological/Ergonomic Hazards......... 75 Hazards Impeding Emergency Response............. 75 References .......................................................... 77 Resources............................................................ 81 Video Resources 82 Notes.................................................................. 83 Index.................................................................. 85 Introduction 1 Introduction A number of workers are involved in the deliv- ery of home care: case managers, nurses, health care aides, ther- apy specialists, social workers, home support workers, physicians, laboratory technicians, dieticians, transporta- tion providers, and so on. This handbook is designed for these workers and the organi- zations that employ them or coordinate their services. It provides information on ways to reduce risk, prevent injury and promote worker safety in the home care environment and emphasize the importance of Internal Responsibility Systems (IRS). It is consistent with the standards for home care organi- zations developed by the Canadian Council on Health Services Accreditation. According to the Canadian Home Care Association (1998), over 300,000 clients receive home care serv- ices in Ontario every year and the number of clients continues to grow. Demand for home care services has increased as a result of earlier discharges from hospital, increased outpatient surgeries, reduced hos- pitalization, as well as technological advances and pharmaceutical developments that have lengthened the survival of severely and chronically ill clients. Cli- ents receiving home care services include clients with AIDS, those on dialysis, chemotherapy and ventila- tors, as well as clients with mental illness and physical "In the home environment, safety is a more complex issue than it is in a controlled setting. There's more for you to think about and watch out for, and there may be more dangers facing you personally. Even in safe homes, you'll need to maintain a level of watchfulness that's typically unnecessary in dedicated health care settings" (Cray et al., 1998:71). 2 Introduction disabilities. Medical technology in the home is increasingly complex. Home health care workers are now managing intravenous therapy, tracheostomy care, wound irrigations, etc., in addition to managing the risks inherent in home environments, where pre- dictability and controls may be lacking. Chapter Set-up This handbook consolidates information available from a variety of sources. It is organized under eight sections: 1. Legislative Requirements 2. Personal Safety 3. Home Hazard Assessment 4. Communicable Disease Prevention 5. Musculoskeletal Injury Prevention 6. Motor Vehicle Safety 7. Wellness Promotion 8. Emergency Preparedness Procedures Information for both employers and workers is pro- vided under each topic. The term "responsibilities" is used to denote legislative requirements. The terms "strategies" and "precautions" are used to denote sug- gested ways that employers and workers can enhance health and safety. Each of these topics is interrelated. It is recom- mended that all the information be reviewed before developing policies and procedures regarding occu- pational health and safety. cAssessment of Unsafe Conditions in the Home Envi- ronment d on page 69 contains information on helping employers and workers identify hazards in a home environment. Home care agencies are encouraged to use or tailor this form so that it fits within their health and safety programs as well as their client demo- graphics. Health and Safety in the Home Care Environment Introduction 3 The creation of this document was made possible by a partnership of the Health Care Health & Safety Association (HCHSA), the Workplace Safety & Insur- ance Board (WSIB) and the Ontario Ministry of Labour. These partners would like to acknowledge the contributions of the following groups to the contents of the document: the former Community Workplace Safety Program (a collaborative project of 23 Toronto- area agencies), the Community Care Access Centres throughout Ontario and the HCHSA Community Care Workplace Specific Hazard Certification Advisory Committee. 4 Introduction Legislative Requirements 5 Module 1 Legislative Requirements What is the Occupational Health and Safety Act (OHSA)? The OHSA is legislation enforced by the Ontario Ministry of Labour to make sure that work- places are healthy and safe for workers. There are also regulations made under the Act that apply to spe- cific types of workplaces and workplace hazards. The OHSA applies to owners, employers, supervisors and workers. Each person in the workplace is responsible for health and safety and must comply with the requirements of the Act. Does the OHSA apply to a home health care agency? Yes. An agency that employs workers to provide care to clients in the clients' homes is an "employer" under the Act, with specific obligations to protect workers' health and safety. Does the OHSA apply in a client's home? It may. While the agency's worker is in a client's home providing services to the client, the client's home is a workplace under the Act. However, the OHSA does not apply to work performed by the client in his or her home. While in the client's home, a worker must comply with the Act and work in a safe manner, according to the employer's established work practices. 6 Legislative Requirements What are some of the potential hazards to a home care worker that could exist in clients' homes? Hazards in the home might include the following: " potential violence from clients or others " exposure to communicable diseases " ergonomic issues (e.g., lifting of clients, etc.) " physical conditions (e.g., poor lighting, cold temperatures, broken stairs, snow/ice on walkways, etc.) " hazardous chemicals " environmental tobacco smoke " pets " oxygen equipment/tanks What kind of responsibilities does a home care agency have under the OHSA? A home care agency is an employer. As an employer, the agency must take every reasonable precaution to protect the health and safety of all its workers, including office staff and those providing services in clients' homes. The employer must develop a health and safety policy and programs that address the requirements of the Act including: " establishing joint health and safety committees or designating worker representatives " conducting assessments of workplace hazards " establishing safe operating procedures for the workplace " training workers " obtaining and providing workers with health and safety information " providing appropriate personal protective equipment " ensuring equipment is inspected and maintained " reporting accidents and fatalities Health and Safety in the Home Care Environment Legislative Requirements 7 Does a health care agency need to set up a Joint Health and Safety Committee (JHSC)? An agency that has 20 or more workers (full-time or part-time) must set up a JHSC. The committee must have at least two mem- bers for workplaces with 20 to 49 workers, and four or more members for workplaces with 50 or more work- ers. At least half of the JHSC members must be non- management and selected by the workers or the unions they represent. At least one of the manage- ment and one of the worker representatives must be certified by training administered by the Workplace Safety & Insurance Board (WSIB). The primary purpose of a JHSC is to provide a forum for all workers to participate in the health and safety of their workplace, including those who work outside the agency office (e.g., in clients' homes). The JHSC has the power to identify hazards found in the workplace, including hazards that workers are likely to encounter in clients' homes. A JHSC also investigates accidents and makes rec- ommendations to the employer to improve workers' health and safety. The JHSC has the authority to inspect the workplace, but does not have the authority to inspect a client's home. The employer is required to respond to the recommendations made by the JHSC. If an agency has six to 19 staff, no JHSC is needed, but the workers or union must select a worker repre- sentative with rights similar to those of the worker members on a committee. No committee or worker representative is needed if there are fewer than six staff. If an agency has many branches and those branches all have more than 20 workers, is a JHSC needed at each branch or is a central committee with representatives from each branch acceptable? Note that each sepa- rately located branch of a head office is a separate workplace. A JHSC is required if a branch office has 20 or more workers regularly employed. Employers may seek permission from the Regional Director of the Ministry of Labour to establish a multi- workplace JHSC. A multi-workplace JHSC is a JHSC established and maintained for more than one work- place or parts thereof. For further information, consult 8 Legislative Requirements the Ontario Ministry of Labour document, Multi-Work- place Joint Health and Safety Committees (July 2001). This document can be obtained by phoning the local Ministry of Labour office. Can a home care worker refuse to do unsafe work under the OHSA in a client's home? Yes. All workers have the right to refuse to do unsafe work, including home care workers. Section 43 of the Act sets out restrictions on the right to refuse unsafe work for workers who are employed in specific types of health care facilities (e.g., hospitals and nursing homes), but these restric- tions do not extend to workers providing health care services in a client's own home. The OHSA sets out a general procedure to follow dur- ing a work refusal. Home health care agencies should build on this procedure and develop a detailed plan on how the employer/supervisor and worker would pro- ceed with a work refusal while in a client's home. As the Smoking in the Workplace Act does not apply to private residences, employers should address workers' concern about residents smoking in their homes as part of their health and safety policy, which is required under the OHSA . Are home care service providers required to perform inspections in the homes where their clients live? Employers are required under the OHSA [Sec. 25(2)(h)] to take every reasonable precaution in the circumstances for the protection of the worker. Employers should try to obtain as much information as possible about the client and his or her home through pre-placement inspection of the residence, questionnaires and/or interviews with the client or referral agency. Inspections of a private residence can only occur with the permission of the occupier of a private residence. The authority of a JHSC or health and safety repre- sentative is to conduct inspections at the employer's workplace, but this does not include a private resi- dence. The employer is required to address health and safety concerns associated with the client's resi- dence, which are brought to his or her attention by the home care worker, JHSC or health and safety repre- sentative. Health and Safety in the Home Care Environment Legislative Requirements 9 In order to conduct an investigation in the event of an accident involving a home care worker, the employer must have permission from the occupier to enter the private residence. It would be a good idea to inform the client and obtain permission at the beginning of the service provision and then again if there is an inci- dent. What is the role of the Ministry of Labour inspectors and what powers do they have? Health and safety inspec- tors respond to work refusals, complaints and acci- dents. They conduct investigations and, when they find a contravention of the Act or any health and safety regulations made under the Act, they can issue orders to remove or reduce the hazard. Although an inspector has the power to enter most workplaces without prior notification, she or he may enter a dwelling that is being used as a workplace only with the consent of the occupier. This extends to situations where there is a critical injury. Which requirements apply to the handling of hazardous chemicals in the home? Ontario Regulation 833 as amended, applies to the control of exposure to biolog- ical or chemical agents in a workplace. Employers must train workers in the safe use and handling of hazardous substances in the workplace. The OHSA includes the Workplace Hazardous Materi- als Information System (WHMIS), which is "right-to- know" legislation for workers. Under WHMIS, employ- ers must ensure that hazardous products in the work- place are properly labelled and that workers have access to material safety data sheets and training for the handling and use of these products. Ontario Regulation 860 (WHMIS Regulation) as amended sets out the details regarding labels, mate- rial safety data sheets and worker training. If agencies purchase industrial supply controlled prod- ucts for use in clients' homes, WHMIS applies. How- ever, it does not apply to consumer products that have been purchased by the agency or the client for use in the client's home. Employers are required to provide training in the use of consumer products and to 10 Legislative Requirements ensure that all decanted products are properly identi- fied. When workers are working alone in a private residence, what first aid requirements apply? All employers cov- ered under the Workplace Safety and Insurance Act must meet the first aid requirements of Regulation 1101. However, it is recognized that workers working alone cannot treat themselves, even though the requirement for first aid training is enforced. In prac- tice, it is suggested that workers who drive vehicles to and from a client's home have small first aid kits avail- able in their vehicles. Personal Safety 11 Module 2 Personal Safety There is growing recognition of the problem of work- place violence. For home care workers, the potential threats to personal safety are amplified. Compared to workers in institutional settings, they often work alone in environments where there are limited controls and greater unpredictability. Travelling to and from clients' homes also poses security risks. For workers operat- ing in rural areas, there are obvious obstacles to accessing prompt help in crisis situations. While the Mental Health Act exists to regulate how much information an employer is allowed to give workers about a client's history, protection of client confidentiality does not exempt employers from warn- ing workers of anticipated dangers related to a client's behaviour. The duty to warn a worker of a dangerous situation relating to a client's behaviour supersedes client confidentiality. 2.1 Employer Strategies To reduce threats to workers' personal safety, employ- ers should: " Have a written policy that commits the organization to promoting worker safety. The purpose is to protect workers in situations that could result in injury or health problems, or expose them to possible criminal violence or other adverse conditions. This policy should prevent visits to homes where there is a likelihood of violent or dangerous behaviour, as assessed by the worker, and promote zero tolerance for violence (physical, sexual or verbal abuse) against workers. Employer Strategies 12 Personal Safety " Consult with the JHSC or worker health and safety representative, as well as the workers directly involved, to develop work processes that will ensure, as far as possible, workers' safety. " Ensure there is an adequate assessment of the home environment prior to undertaking home visits. Use a letter of agreement or service contract with the client so that all parties understand their roles and responsibilities, as well as the zero tolerance policy for violence, the requirements for no alcohol or illegal drug use during the visit, etc. " Gather appropriate information that includes identification of the possible risks in the home environment, control measures that will minimize each risk and details of how workers can get help in the event that they are injured or encounter situations that could endanger their safety. " Choose appropriate control measures. These could include: a "buddy system;" directions on when to involve police; generic business cards/name tags that provide only the first name, professional title and organization name; permission for taxi use where entry and exit of a neighbourhood could be a safety issue; notification of police about nighttime services; a computerized client database that flags higher risk environments; scheduling, which takes into consideration the neighbourhood and other risk indicators; etc. " Ensure workers are familiar with the organization's control measures. Be alert to the unique dangers that exist for workers servicing remote, high-risk areas. Special controls may be needed in these circumstances. " Ensure that there is good communication flow between the organization and the workers. Workers should know about policy changes or administrative problems like cancelled appointments, which may upset clients and elicit aggravated responses. Health and Safety in the Home Care Environment Personal Safety 13 " Ensure workers are aware of cultural interpretation and translation services that can be accessed. The aim is to facilitate an understanding of the client's needs and appropriate violence prevention strategies. " Provide workers with training that includes: the employers' and workers' responsibilities for the prevention of violence; how to determine the risk of specific situations; how to leave a risky situation safely; and how to identify, prevent and manage aggressive behaviours. It needs to be emphasized to all workers that their safety comes first. Where workers will be involved in transporting a potentially violent person, ensure they are trained on appropriate procedures. " Ensure that all incidents are reported promptly and that accurate record keeping exists. Continual analysis of incidents and injury trends will assist to evaluate and revise the organization's safety program - an important component of a continuous quality improvement approach to identified risks. " Institute policies and procedures whereby supervisors must approve all work completed after routine business hours and must be informed of the location, time, contact or client name and phone number. A good strategy is to have workers leave a voice mail message for supervisors at a prearranged time when their after-hours work assignments are completed. If a worker does not call, the supervisor initiates the following to locate the worker: (1) calls the worker's home; (2) calls the client; (3) calls the identified emergency contact person; (4) calls the police. " Develop appropriate policies and procedures on how to re-establish worker-client relationships after a client has acted out verbally or physically. " When problems have occurred, provide the necessary counselling or other help that the workers need. Investigate the incident thoroughly to identify ways to prevent future problems. Worker Strategies 14 Personal Safety " Provide a comprehensive program of counselling, debriefing, etc. for workers who have experienced or witnessed violent incidents. " Provide workers with cellular phones/pagers, personal safety alarms, car spotlights, CALL POLICE signs, etc. In rural areas, satellite phones may be required. Note: In Canada, pepper sprays and mace are illegal. " Ensure any mechanical safety devices are routinely tested for effectiveness and maintained on a schedule based on the manufacturers' recommendations. 2.2 Worker Strategies Workers can use the following strategies to minimize risks to their personal safety. Pre-Visit " Get to know the area, particularly the safe areas in the district. Sources of danger can only be anticipated if workers are constantly in tune with the community and its changes. Tenant associations, local clubs, the police, etc. may have knowledge that could be helpful. " Plan the safest route to and from the client's home, even if it isn't the most direct. Make a note of the locations of nearby police stations, public telephones and other public buildings like hospitals as well as restaurants or stores that are open late. " Know the numbers of police, emergency services and well-known, reliable taxi services. " Know the bus, streetcar or subway route and schedule. " Do not give clients personal phone numbers. When placing calls to clients from home, be aware of the potential "call display" feature. To block call display, press "*67" prior to making the call. Health and Safety in the Home Care Environment Personal Safety 15 " Schedule and set up visits based on the knowledge of the area and the client (e.g., visiting early in the day, with another person, meeting the family outside the dwelling). " Ensure head office is apprised of the location of all visits, estimated arrival times and duration of visits. En Route to Client's Home " Dress conservatively. Wear religious symbols discreetly. Clothing should not restrict your movements. Wear comfortable shoes with nonskid soles that allow you to move quickly and safely. Avoid wearing earrings or other accessories that could be grasped or pulled by another person. " Wear light-coloured clothing during evening visits to ensure visibility. " Inform the client if you are going to be late for an appointment. " Sit near the bus driver or streetcar operator or in the Designated Waiting Area section of the subway. " Stand away from the edge of the subway platform and use the alarms in the subway, bus, streetcar as necessary. " If taking a taxi, ensure the driver's identification and photo are clearly displayed and match the driver. Sit behind the front passenger seat. State the route you prefer, sticking to main streets. If you become uneasy with the driver, request that he or she pull over and let you out. " Make sure your headlights have been turned off to avoid draining the battery during the visit. " Avoid parking in underground parking lots, in isolated areas or in deserted alleyways. " Don't park beside a van or other large vehicle where there is the possibility of being wedged in. " Don't park too far from the client's home unless it is safer to do so. " Roll up windows and lock the car. Worker Strategies 16 Personal Safety " Don't leave personal or nursing items visible in the car. Visible medications can be a target. Purses should be left at home and not locked in the car or trunk. Required identification and money should be placed in front pockets. Some groups recommend posting a sign on the dashboard, which states that there are no drugs or equipment in the car. " Be alert to any passengers sitting in parked cars and, where possible, avoid these cars. " Try to keep arms free, where possible. " Do not wear headphones. " Stick to well-travelled streets and avoid shortcuts through parks or other wooded areas, lots or alleys. Stay alert and mindful of the surroundings. " Walk briskly and with purpose. Stand tall and make quick eye contact with the people around you. Walk against the flow of traffic so you can see approaching vehicles. " Do not participate in lengthy conversations with people in the street. " Where possible, do not walk through a crowd. " If someone harasses you, stay calm and say loudly, "I don't know you. Leave me alone." Leaving a Client's Home " Notify the office that the visit is completed. " Have car keys in hand before leaving to avoid delays in entering the car. Car keys should be kept on your person at all times. You may want to carry a second set of keys as backup. " If the neighbourhood seems dangerous, ask one of the client's family members to escort you to your car. " Check the outside as well as the front and back seats before getting into your car. " Lock the doors as soon as you are in the car. " Obtain a CALL POLICE sign. Use this sign to request help in the event of a car breakdown. " Do not use pay phones in potentially dangerous areas unless it is an emergency. Health and Safety in the Home Care Environment Personal Safety 17 " Avoid using automated bank machines in the evenings. " If you think someone is following you, switch direction or cross the street. Walk toward an open store, restaurant, or lighted house. If you're scared, yell for help. " If you think you are being followed in your car, drive to the nearest police, fire station or gas station or an open business. Do not head home. " Never hitchhike or pick up hitchhikers. " If someone tries to rob you, don't resist. Give up your property, not your life. Shout FIRE to attract attention from bystanders. Report the crime to the police. " If someone attempts to assault you near your car and you fear serious injury, roll under the car if possible and yell for help. " If someone tries to force you into a vehicle, fight back (yell, kick) even if they have a weapon. You are at significantly greater risk if you are forced into the vehicle. " Report broken street lights, etc. Lobby local government for better lighting in public places. Client Visits " Never enter a home that is not scheduled for a visit. " Where appropriate, inform the superintendent or security personnel of your whereabouts in an apartment building. " Exercise care in hallways, elevators and stairwells. In elevators, stand close to the control panel with your back to the wall. Be aware of the location of the alarm. If anyone bothers you, press the buttons on the floor closest to the one you are on and press the alarm - do not push stop. Get off as soon as elevator stops. Knock on the first available apartment door. If avoiding an assault, yell FIRE and kick the walls. Do not get on an elevator where you feel uneasy about anyone waiting with you to enter the elevator. Use the excuse "Go ahead. I'm waiting for a friend." Worker Strategies 18 Personal Safety " Stick to the centre of the hallway, avoiding alcoves and hidden corners. In a hallway emergency, knock on as many doors as possible and yell FIRE. If you fear serious injury to yourself or others, pull the fire alarm. " If you must use stairwells, keep a count of the number of floors you are ascending or descending as some buildings may not have the floor doors numbered. " Do not enter a home if there is a visible threat to safety (e.g., drugs, alcohol, weapons, animals, pornographic posters, etc.) or where your instinct tells you not to. According to Canada's Firearms Act , all firearms are to be unloaded, locked or in a secure container and in a place where ammunition is not readily accessible. " Pause for a few seconds when entering someone's home to assess the situation and plan a response. Observe the environment for signs of used syringes, odours, clutter, other people, household items that could be used as weapons, etc. Make a sweep with eyes in the first 30 seconds to note the location of the phone and any obstacles to a quick exit. " Do not remain at a visit where a client, a client's visitors or family members are intoxicated, abusive, inappropriately dressed or where sexual comments and innuendoes are made or pornography is viewed in your presence. " Leave if you are told to leave. " Let the client lead the way down corridors, up staircases, etc. " Sit where you have a good view of the bedrooms or the hall to the bedrooms. Listen for anyone coming in from an outside door. " Always leave an exit route or situate yourself between the exit and the client. Do not allow yourself to be cornered. Use your judgement as to whether a door should be left open and unlocked. Health and Safety in the Home Care Environment Personal Safety 19 " Carry a lightweight briefcase for an interview. Place necessary valuables, equipment, etc. in your briefcase. If you need to carry valuables outside your briefcase, wear a jogger's pouch. Try to turn it so it is not visible. " For an interview, stay in the living room or dining room. You may want to avoid having conversations in the kitchen, where potential weapons (e.g., knives) may be readily available. " Never promise what you cannot deliver. " Record any notes with discretion. If a client or family member seems protective and hostile about having a stranger in the home or perceives that your assessment questions are intrusive, avoid lengthy explanations or justifications for your presence. " Adopt a defensive sitting position. Sit with your strong leg back and your other leg forward. This will allow you to get out of your seat quickly without using your hands. " Sit in a hard-backed chair. You can get up faster from a firm chair than a soft sofa. " Leave your shoes on. If a confrontation arises, you need to be able to leave in a hurry. If you do have to leave your outdoor footwear at the door, carry a pair of shoes for indoor use. If the client doesn't want you wearing shoes inside, mention that you have to wear them because of your employer's health and safety policy. " Recognize the first signs of a change in your client's behaviour or the behaviour of others in the home. Assess the client's appearance, routines of daily living, how he or she spends the day, and any other outstanding characteristics. Watch for subtle changes and danger signals (e.g., explosive anger, pacing, destruction of property) that might indicate the need for immediate safety interventions. " Report any unusual incidents to your supervisor as soon as possible. Worker Strategies 20 Personal Safety When Someone is Venting Hunter (1997) suggests that a proactive prevention approach to violence involves collecting information prior to doing the first home visit. Information from the referring agency as well as the client and his/her fam- ily can be gathered. Specifically, potentially violent conditions need to be determined. From the referring agency, Hunter recommends asking questions about history of physical or verbal abuse, known triggers, existence of restraining orders, recent divorce/separa- tion, frequent requests for changes in providers, the presence of mental illness and impaired cognitive function. From clients and their families, the existence of weapons or lethal items (e.g., bows and arrows, acids, etc.), vicious pets, volatile relationships with others (e.g., neighbours) should be determined as well as their plans for reducing these threats during the worker's visit. If clients are delusional and believe that they are being threatened, workers should attempt to increase their feelings of safety. For example, workers could reassure clients that they will be safe talking to them. It is important that workers allow about four times the personal space between themselves and the client and refrain from touching the client. While firm and consistent direction is needed, workers should not argue or try to convince delusional clients that their thinking is irrational. If clients have dementia , workers should aim to anticipate their needs and avoid unfamiliar situations. A family member who knows their routine can help to determine the best time for home visits (e.g., when the client isn't too tired or hungry). Every time workers visit, they should ensure that the family member introduces them and explains the reason for the visit. If the client is getting frustrated by requests, the assessment process, etc., workers should stop making demands and try changing the conversation or invite the client to sit quietly, take a walk, etc. Workers should not touch the client as it might startle him or her. Health and Safety in the Home Care Environment Personal Safety 21 With potentially aggressive clients, "no harm" con- tracts can be used as a measure of protection 1 . That is, clients can be asked to agree to and sign a written statement that they will not hurt themselves or others "no matter how bad things get" and will use an alter- native strategy such as talking to someone, using relaxation techniques, etc. Workers who are trained in anger management and relaxation techniques can discuss these methods with clients. If a client or a family member is angry and begins to vent, it is important that workers stand up so that this person does not dominated them. It is also advised that workers: " Stay calm. " Stand facing the aggressive person with their feet slightly apart. They should keep their arms at their sides with palms up (never clench fists). This is less threatening and the individual can see that the workers do not have a weapon. " Keep their voices down. Don't argue with the aggressor. Speak slowly using simple, precise words. Be polite, calm and positive (e.g., "You seem upset. Can we sit down and talk about your concerns?" "What can we do to increase your comfort with this situation?"). " Identify the issues leading up to the escalating behaviour to reassure the client that the worker is concerned. " Use culturally-appropriate eye contact. Some people find eye contact a threat or challenge; for others, direct eye contact conveys a sense of concern and support. " Let the person know they are being listened to, by using appropriate communication signals (e.g., paraphrasing, head nodding, etc.). Reassure clients that their specific concerns will be addressed as soon as it is feasible and safe to do so. 1. Hunter, 1997 Worker Strategies 22 Personal Safety " Advise clients of the organization's complaint procedures when they disagree with something or believe that something is unfair. " Communicate to clients, in verbal and nonverbal ways, that they are expected to maintain control over their behaviour. Issue behaviour limits and inform clients of the positive consequences that will result from compliance. " If possible, move away from the person, leaving a distance of about six feet. At this distance, it will be more difficult for the worker to be hit. " Watch the person's body language, including shaking or clenching fists, or a change in posture. He/she may be ready to do something physical. " If the client is quietly looking off into space after a period of venting, he/she may be considering taking action against the worker. The worker should say something out of the ordinary to get the client's attention or try to divert him/her by giving him/her something to do in another room (e.g., ask for a glass of water). " If possible, phone the office to alert them to a problem. A prearranged code can be used to alert them to a crisis (e.g., "I need to speak to Dr. Black."). " Leave the house if it is suspected that the person is going to lose control. If a worker cannot leave, he/she should call the police. " Leave immediately if the client brandishes any kind of weapon. The worker should call police from a safe distance or from his/her car. If a worker needs to get out fast, he or she should not be concerned about gathering possessions. " In the event of family violence, workers should leave the premises and call police when they are a safe distance from the residence or in their car. Home Hazard Assessment 23 Module 3 Home Hazard Assessment There are four ways that hazards are controlled, reduced and elimi- nated. These are: 1. Engineering con- trols: modifica- tions to the environment to reduce exposure to hazards (e.g., substitution of less hazardous prod- ucts, provision of lifting device). 2. Administrative controls: policies and procedures determined by employers (e.g., work assign- ment, training in specific work practices). 3. Work and hygiene practices: worker practices (e.g., hand washing, proper body mechanics, use of Standard Precautions). 4. Personal protective equipment (PPE): clothing or equipment designed to protect the worker (e.g., gloves, eye protection). Implementing engineering controls in the home environment can be problematic. More reliance is typically given to administrative controls, work and hygiene practices and PPE. It is particularly important that workers hone their observation and analytical skills so they can assess home environments for hazards. "The first contact with a client should be used to negotiate the joint responsibilities of home service delivery. The worker's responsibility is to deliver the right service to the right person at the right time. One of the client's responsibilities is to ensure a safe work environment. This means a work area that is free of pets, alcohol, illegal drugs and abusive behaviour" (Leiterman, 1999). Employer Strategies 24 Home Hazard Assessment 3.1 Employer Strategies Employers should: " Have in place control measures and policies aimed at the prevention, recognition and control of potential exposures. These documents should address areas such as risk communication, notification of pregnancy or planning for pregnancy, job reassignment (when necessary) and medical surveillance. All workers should have the right to ask clients and their family members to refrain from smoking and remove pets during the home visit. A letter of agreement between the CCAC and the client may be used to clearly identify the roles and responsibilities of the client, workers and members of the team. " Adopt a hazard identification system and train workers to use it. For example, the Grey-Bruce CCAC uses a colour coding system to alert providers to potential risks (i.e., purple = violence/abuse; orange = weapons; red = fire; green = environment; blue = substance abuse; black = other). The name of the colour is written on the assessment sheet beside "Current History" and underlined to alert providers upon referral. " Have in place policies related to preparation, administration, transportation and disposal of antineoplastic agents, other drugs and specimens. Arrange working relationships and written agreements with pharmacies regarding the type and amount of supplies, timing of delivery and pickup, emergency response plan and pertinent client education. " Train workers on procedures and techniques for administering and disposing of antineoplastic agents and equipment with an aseptic technique. Include information on how to protect family members, visitors and pets. Health and Safety in the Home Care Environment Home Hazard Assessment 25 " Ensure a formal documented inventory is conducted, listing chemicals and other hazards to which workers, clients and their family members could be exposed. " Provide training to workers on how to read consumer product labels, recognize consumer product symbols, properly use, handle, store and dispose of consumer products and respond in the event of an emergency. Where controlled products (as defined in the Hazardous Products Act ) are also present, the requirements under WHMIS with respect to labels, MSDSs and training must also be met. " Ensure workers know how to use public equipment like emergency exits, fire alarms and fire extinguishers. " Provide workers with appropriate PPE (Personal Protective Equipment - gloves, gowns, eye wear, face protection, respirators, PPE disposal products) and ensure they know how to correctly use this equipment. " Ensure home health care workers assess, document and evaluate a client's technique for self-administering medication and performing clean-up to ensure proper safety precautions are taken for the worker's own protection. " Develop methods for reporting accidental exposures and hazardous effects. " Provide an appropriate monitoring, record- keeping and a hazard communication program, which addresses methods for spill management and disposal of bodily fluids. " Consult with the JHSC or worker health and safety representative about work-related accidents and problems and appropriate preventative measures. " Use team conferencing as a means of effectively communicating concerns about clients and transferring knowledge of problem-solving techniques. Worker Strategies 26 Home Hazard Assessment " Have an intervention procedure in place for dealing with workers at risk of psychiatric emergencies (e.g., suicidal behaviour). " Establish an Employee Assistance Program (EAP) so that workers can receive counselling for problems both on and off the job. 3.2 Worker Strategies In addition to addressing the problems identified in an assessment of the home environment, workers should: " Report any health and safety concerns that the client does not address. The employer should have a policy on this. " Take along a snake light for a makeshift source of light. " Carry as little as possible into the home until insect or rodent infestations are handled. Place any belongings in a clean area. Inspect it discreetly before leaving so that insects or eggs are not carried out. " Ensure spills are promptly cleaned. " Conduct a formal documented inventory of chemicals and other hazards to which the worker, the clients and their family members could be exposed. This should include any hazardous material that the worker brings into the home to provide client services. Conducting an inventory will help to identify hazardous substances. " Where necessary, educate clients in the safe use, handling and storage of consumer products and other hazardous materials and emphasize the importance of maintaining a hazardous material inventory. " Always read the label before using a household cleaning product or other consumer product used in the home. " Ensure grab bars and bath stools are made available. Educate the client on how to use aids and prevent falls. Falls prevention for clients means less opportunity for musculoskeletal injury in workers. Health and Safety in the Home Care Environment Home Hazard Assessment 27 " Ensure client and family members never smoke around oxygen delivery equipment and that such equipment is never used around an open flame. Remind clients that oxygen will saturate their clothing, towels and sheets, increasing the risk of a rapidly spreading fire. Workers should leave if clients refuse to exercise caution around oxygen delivery equipment. " Never lubricate an oxygen gauge with a petroleum-based product. Never use petroleum-based adhesive tape to label an oxygen cylinder. " Ask that pets be kept restrained or kept out of the room on initial visits. If it is determined that the pet has attacked any visitor in the past or if the worker is uncomfortable around a pet, have the pet restrained or put in a separate room for every visit. " Do not assume that animals will react the same way on every visit. It is important that workers proceed with caution - they are the intruders in the animal's home. Even a normally calm animal may grow protective during unfamiliar nursing procedures. " Never offer an outstretched palm or look at a dog or cat straight in the eye. Look down or to the side. Do not approach a dog or cat that has its hair raised, teeth bared, tail raised or between its legs - these are signals that the animal feels threatened. " Maintain a distance of at least ten feet from the pet. If a pet approaches, slowly back toward an exit or safe area. " Acknowledge the importance of pets in the home environment and show interest in the relationship that clients have with their animals. " If required to handle or clean up after pets, including reptiles, fish or birds, wash hands thoroughly with soap and water. Because of the risk of a fetal illness called toxoplasmosis, pregnant women must not clean up cat litter or cat feces. Worker Strategies 28 Home Hazard Assessment " Keep a flea spray bottle in your car, especially during the fall season. Spray lower legs and feet when you suspect you have been in contact with fleas. " If bitten by a dog and there is a puncture/ laceration, wash wound thoroughly with soap and water at the client's home and go immediately to the nearest treatment facility. A worker may need to undergo rabies prophylaxis if the animal has rabies. " If scratched or bitten by a cat, wash lesion carefully with soap and water at the client's home and seek medical attention after the visit. (Cat bites and scratches may result in hemorrhagic septicemia or cat scratch fever.) Any animal bite that occurs must be reported to the local public health unit for follow up to determine if there is any risk of rabies transmission. Clients can be advised that the bite will be reported and that such a report is routine and not intended to get anyone "in trouble." " Call animal control authorities as soon as possible when sick animals are noticed in a client's home or neighbourhood. Communicable Disease Prevention 29 Module 4 Communicable Disease Prevention Understanding how the specified communicable dis- eases are transmitted is important in terms of their prevention and control. Workers should have knowl- edge of the following: " the agents (i.e., bacteria, fungi, viruses) that cause communicable diseases " where the agents are commonly found (e.g., blood) " objects or surfaces in the environment that can play a role in the spread of the specified disease " how the agents can be spread " how long it takes to develop signs or symptoms of the disease (incubation period) " when people are most likely to be infectious (i.e., when the disease is communicable or the stage in the disease when it is most easily spread) " whether the worker is susceptible (likely to get the disease) or has a natural or acquired resistance to the disease Immunization is a key strategy in preventing transmis- sion and spread of certain communicable diseases. In addition, precautions, safe work procedures, barriers and equipment should all be used to reduce the risk of exposure. Employer Strategies 30 Communicable Disease Prevention Health Canada's revised infection control guidelines, Routine Practices and Additional Precautions for Pre- venting the Transmission of Infection in Health Care (1999), should be consulted for further details. 4.1 Employer Strategies Employers should provide: " A comprehensive control program in collaboration with local public health departments and infection control practitioners. HCHSA offers a document titled "Developing Infection Control Policies" available on the HCHSA web site and CD- ROM. " An ongoing risk assessment program that includes information about tuberculosis (TB) in the community, data interpretation and follow-up for exposures in co-ordination with the local health department. " Participate and encourage participation in TB control programs for staff and clients. " An annual influenza vaccination campaign for workers providing direct care to susceptible individuals. " A written TB infection control program. The Employment Agencies Act requires that new workers have a skin test or x-ray within the 12-month period prior to beginning employment. " Engineering, administrative and work practice recommendations and requirements for PPE (e.g., respiratory protection). " A blood borne pathogen exposure control plan that is evaluated and reviewed annually. " A hepatitis B vaccine program including policy, procedures, a consent/refusal form and an employee information sheet. " A policy and procedure for the safe disposal of used needles and other sharps, which defines whether it is the client's or agency's responsibility. " A process whereby workers are trained, observed and evaluated in the performance of infection control measures in the home Health and Safety in the Home Care Environment Communicable Disease Prevention 31 environment. This process should occur at the time of orientation, and at least annually when there are changes in client status. " Education and training that will give workers the skills to apply Standard Practices and additional precautions appropriately in all situations. A training program called "Developing Infection Control Policies & Procedures: Infection Education Program in 10 Modules" is available on the HCSHA web site or in CD-ROM. " Sharps containers for all clients who are receiving infusion therapy or injections. " Non-latex barrier protection for workers. (Although less than 1% of the general public has allergic reactions to latex, more than 10% of health care professionals do.) Workers who have a latex allergy should be encouraged to wear a medical alert bracelet. " Procedures relating to antibiotic resistant organisms (AROs), which include direct communication with workers regarding the ARO status of clients to ensure proper precautions are followed. 4.2 Worker Precautions Workers should: " Use proper food handling techniques to protect workers and clients. This means ensuring raw meats are separated from cooked or ready-to-eat foods, cleaning and sanitizing all surfaces contaminated by raw meat, thorough hand washing after handling raw foods and before preparing any foods, thoroughly cooking hazardous foods such as meats or eggs (i.e., ground meats and chicken must be cooked so that there is no pink in the middle), ensuring that all foods are from a reputable source and storing foods at refrigeration temperatures below 5°C. " Avoid handling dog treats as some may be contaminated with salmonella. " Teach sound infection control techniques to clients and their families. Worker Precautions 32 Communicable Disease Prevention " Keep immunizations up-to-date using the following guidelines: " Tetanus/diphtheria should be administered once every 10 years. If a person sustains a puncture wound, other than a clean minor one, and it is 5 years or more since the last inoculation, then a booster dose of vaccine should be given. " Polio routine immunization is not considered necessary for adults living in Canada. Most adults are already immune and have a very low risk of exposure to wild polioviruses in North America. However, immunization is recommended for health care workers who are in close contact with people who may be excreting wild or vaccine strains of polioviruses, and some employing agencies may require polio vaccinations. " Rubella (German measles) vaccine should be administered to female workers who have no documented history of vaccination or who test negative for the rubella antibody. Female workers should be advised to avoid pregnancy for three months after vaccination. " Measles vaccine should be administered to people born after 1956 and who have no documented record of immunization or who are known to be seronegative. " Hepatitis B vaccine should be administered to workers who are at risk of potential exposures such as blood or sharps injuries. A series of three inoculations should be administered over a six-month period. " Use Standard Precautions and additional precautions with all procedures where there is risk of exposure. Standard Precautions give workers the knowledge and skills to assess personal risk in emergency situations and to take precautions to protect themselves. Health and Safety in the Home Care Environment Communicable Disease Prevention 33 " Wash their hands using the seven steps listed below, after any contact with a client, as well as before and after each home visit, even if gloves have been worn: 1. Remove all rings. 2. Wet hands with fresh, running water. 3. Place a small amount (1-3 mL) of liquid soap from a single-use dispenser on the palm of one hand. 4. Rub hands together for 10 seconds so a lather is produced. Provide friction to all surfaces, getting in between fingers and under finger- nails. 5. Rinse hands thoroughly with clean, running water. Try not to handle the faucets once hands are clean. Use a paper towel, if avail- able. 6. Pat hands with paper towels. 7. Use hand lotion from a single-use dispenser, to put moisture back into the skin. " Encourage clients to purchase soap and paper towels. Do not use the client's towels for drying hands. " Carry antimicrobial hand wipes or hand gels in the event that access to water is limited. " Handle any clothing splattered with blood or other body fluids as little as possible. This clothing can be washed in a normal laundry cycle. " Treat the nursing bag as a piece of clean equipment and handle it in such a way as to prevent contamination from hands or used equipment. Hands should be washed before handling equipment inside the nursing bag. " Clean and disinfect any equipment as instructed by the manufacturer prior to placing it back in the nursing bag. Worker Precautions 34 Communicable Disease Prevention " Wear clean, non-sterile gloves when in contact with blood, body fluids, secretions and excretions, mucous membranes, draining wounds or non-intact skin; when handling items visibly soiled with blood, body fluids, secretions and excretions; and when the worker has open skin lesions on his/her hands. " Wear disposable gloves when cleaning blood or body fluid spills on floors or other surfaces and wipe up the fluid using disposable towels. The area must then be decontaminated with an appropriate germicide or a fresh 1:10 solution of bleach and water. Let the area air dry. Remove gloves before touching clean surfaces. Wash hands after removing gloves. " Change gloves as soon as they become torn or soiled and also between handling different people. If latex gloves are chosen, low protein and unpowdered gloves should be selected. Dispose of gloves in the proper manner and wash hands as soon as possible after removing gloves. " Wear masks and protective eye wear when there is a risk that the worker may be splashed with blood or body fluids. " If artificial respiration needs to be given to a client, use a resuscitation mask with a one- way valve to limit exposure to the client's saliva. " Handle soiled dressings and other medical supplies carefully, using protective gloves. Try to keep the materials away from clothing. Wash hands thoroughly with soap and water after removing gloves and immediately after exposure to infectious waste. Place disposable materials in plastic bags and close them securely. Put the garbage bag out for regular garbage pickup. " Avoid contact with any sharp object or instrument, including needles. If workers accidentally punctured or cut themselves with a used sharp, they should treat the wound using first-aid measures and then seek medical attention within two hours. Health and Safety in the Home Care Environment Communicable Disease Prevention 35 " Dispose of sharps in properly designed puncture-resistant containers. Do not re-cap needles. A sharps disposal container should be made of puncture-resistant material and should not be stored near food supplies or where children can reach it. Sharps containers should be clearly labelled as hazardous materials. " At the end of the workday, remove clothes upon arriving home and store them in a safe, contained area until they can be washed. TABLE 1. Worker Precautions by Transmission Route a Transmission Diseases Precautions AIRBORNE Carried in airborne or dust particles and inhaled Suspected and active tuberculosis (TB), measles, varicella, herpes zoster and Lassa fever, Ebola, Marburg, other hemorrhagic fevers with pneumonia All workers should be immune to measles and varicella. Workers' susceptibility should be assessed prior to caring for clients with varicella or herpes zoster. Workers not immune should be restricted from visiting infected clients. Workers should wear an appropriate mask (NIOSH Certified N-95) at all times while in the home of a client who has infectious TB. Worker Precautions 36 Communicable Disease Prevention DROPLET Transmitted via client coughing or sneezing and procedures like bronchoscopy Diphtheria, H. influenzae type B invasive infections, mumps, N. meningitis, parovirus B19, pertussis, plague, rubella, streptococcus Group A invasive disease and streptococcus Group A pharyngitis, pneumonia, scarlet fever, viral respiratory tract infections, influenza, Lassa fever, Ebola, Marburg, other hemorrhagic fevers with pneumonia. Workers not immune to rubella or mumps should not conduct visits to infected clients unless essential and equipped with a mask. Workers should wear a surgical mask if within one metre of the client who is coughing or is likely to cough. (It is not necessary to wear a mask if the worker is immune.) Workers should wear eye protection as per Standard Precautions. CONTACT Direct (body surface to body surface) or indirect via hands not being washed between clients, contaminated equipment, other inanimate objects in the client's immediate environment Diarrhea due to campylobacter, pathogenic strains of E. coli, giardia, rotavirus, salmonella, shigella, yersinia, C. difficile infections with diarrhea, enteroviral infections, hepatitis A and B, herpes simplex virus, scabies, varicella, herpes zoster, congenital rubella, certain viral respiratory tract infections, hemorrhagic fever, antimicrobial resistant organisms Workers should wear gowns and gloves if there will be substantial contact with the client or environmental surfaces. Equipment should be cleaned and disinfected before it is transported and used with another client. The need for dedicated equipment should be assessed. Workers should take all precautions to minimize the risk of transmission. a. Source: Health Canada. (1999). Routine Practices and Additional Precautions for Preventing th e Transm ission of Infection in Health Care: Revision of Isolation and Precaution Techniques. CCDR Supplem ent, Volum e 25S4. TABLE 1. Worker Precautions by Transmission Route a Transmission Diseases Precautions Musculoskeletal Injury Prevention 37 Module 5 Musculoskeletal Injury Prevention The home environment poses many risks in terms of musculoskeletal injury. For example, traditional, non- adjustable beds in the home can be ergonomically ill- suited to allow the worker to perform a proper lift or transfer and workers must often perform transfers and lifts without assistance. A study conducted in Sweden found that the annual incidence of injury from overex- ertion accidents and musculoskeletal diseases was found to be higher in home care workers than all employed women in the country 2 . Lifting other people was the most frequently reported cause of overexer- tion accidents. A more recent study conducted in the U.S. found that injuries among home health care workers, while less frequent than among workers from nursing homes, resulted in greater lost time from work 3 . This indicates greater severity of injury. Muscu- loskeletal injuries are usually caused by awkward or static/prolonged postures, repetition and forceful exer- tions. Awkward postures result when the body is forced into a position that deviates from the neutral position of a joint. When the body is forced into awkward pos- tures, the ligaments and muscles with their tendons cannot protect the underlying joints. There is a danger of injury to all these structures. Client handling tasks may involve awkward postures of the back, neck, shoulders, elbows, wrists and lower extremities. In addition, space limitations in the home environment often result in awkward postures being used. 2. Ono et al., 1995 3. Meyer and Muntaner, 1999 38 Musculoskeletal Injury Prevention With static/prolonged postures , the body is held in the same position for a long period of time. The mus- cles are in a constant state of static contraction. Pro- longed standing puts stress on the legs and back. Tasks, such as making beds, transferring and lifting, bathing, feeding and dressing clients cause prolonged trunk and neck flexion. Repetitive lifting and bending, squatting and stooping also occur during the provision of home care services. When the musculoskeletal tissues are used too quickly, too often and for too long, they become dam- aged. Forceful exertions result from pushing, pulling, low- ering, grasping, carrying and lifting excessive loads or sudden/unexpected shifts in loads (e.g., when a client moves unexpectedly during a transfer). A Swedish study undertaken to investigate physical work load, physical capacity, physical strain and per- ceived health among elderly aides in home care serv- ice found that home care work was characterized by long periods of standing and walking. In addition, pos- tures potentially harmful for the low back and shoul- ders occurred frequently. It was concluded that elderly aides in home care service are probably exposed to high risks of overexertion and impaired health as a result of high postural loads in combination with the stress created by time pressures and lack of equip- ment.

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