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Hazardous conditions in the home health-care setting may put frail and elderly at risk

March 05, 2009

A large-scale study conducted at Columbia University's Mailman School of Public Health has identified the type and frequency of hazardous conditions found in the home healthcare (HHC) setting. An anonymous survey of over 700 home healthcare RNs employed in New York City provided the most complete assessment of homecare hazardous household conditions to date. The most common hazardous conditions found in households were environmental and physical hazards, including animal hair, cigarette smoke, excessive dust, and mold/dampness. Physical hazards, such as loose rugs, were also common. The paper, "Household-Related Hazardous Conditions with Implications for Patient Safety in the Home Health Care Sector," was published in the December 2008 issue of the Journal of Patient Safety.

"Although HHC is the fastest growing sector in the health care industry, data are particularly sparse with respect to patient and provider safety in this setting," says Robyn Gershon, DrPH, professor of clinical Sociomedical Sciences at the Mailman School of Public Health and principal investigator. "Of special concern is the fact that nearly 70% of homecare patients in the U.S. are 65 years or older. Frail and elderly HHC patients may be particularly vulnerable to unsafe conditions." Environmental and physical hazards were three times more likely to be associated with households located in inner-city urban communities compared with other types of communities. The research team also collected extensive data on violence and the threat of violence in the household. Nearly 40% of RNs reported feeling threatened by their clients' neighborhoods and 9% reported the presence of guns in their clients' homes.

"Another important finding from this study was the observation of unsanitary conditions in the household, which could increase the risk of infectious disease," noted Dr. Gershon. Vermin (predominantly rodents, cockroaches, and bedbugs) were noted in over 40% of households. "Poor housekeeping was not uncommon," Dr. Gershon stated, "and may be related to the fact that increasing numbers of elderly patients live alone, and are too frail to perform routine household cleaning."

Importantly, the findings suggest that unsafe conditions in the households of homecare patients could present a risk of injury and illness in both homecare patients as well as the homecare workers who provide them with necessary care.

More than 735 RNs responded to a 96-item questionnaire. Information was also based on qualitative data collected during in-depth interviews, focus groups and cognitive interviews, to assess safety hazards found by RNs in their patients' households. Roughly 44% of RNs' patients resided in urban areas, generally in single-family homes or apartments.

Dr. Gershon believes that organizational characteristics of the RN's agency could increase the risk of adverse events in the HHC setting. While a large majority of RNs (91%) did report receiving infection control training, few RNs reported that they were provided with sharps containers (14%), safety needles and syringes (9%), safety butterfly needles (23%), or safety lancets (26%). Reports of understaffing (37%) were also relatively common.

Dr. Gershon commented, "Some of the household hazards identified in our study might be remedied with relatively simple interventions; for example, HHC workers may use hand gels and creams between treating patients because of the unsanitary conditions of patients' sinks. Other hazards, such as the presence of mice and other vermin, might be more difficult to address, as they generally require the assistance of building managers, contractors, or other outside assistance to remedy. However, because RNs frequently provide patient/family education, they could similarly provide information on achieving and maintaining a clean and safe household."

"Given that 20% of the U.S. population will be over 65 years old by the year 2030, keeping our older population healthy and free from injury is critical," says Linda Fried, MD, MPH, dean of the Mailman School of Public Health. "Research such as Dr. Gershon's is key to help us assess the prevalence of risk factors in the home healthcare setting and the interventions necessary to promote the health, safety, and well-being of older adults - especially frail older adults," added Dr. Fried, an epidemiologist and geriatrician whose career has been dedicated to the science of healthy aging.

Columbia University's Mailman School of Public Health