Department of Developmental Services
Office of Quality Management

Living Well
SPRING/SUMMER 2013

Welcome to the Spring/Summer 2013 issue of "Living Well", a publication of the Department of Developmental Services, Office of Quality Management.  "Living Well" is published on a semi-annual basis and features important information for individuals and their supporters.  

In this edition, you will find helpful information to assist people you support to enjoy spring and summer activities in a safe and healthy manner.

"Living Well” represents one component of DDS's continuing commitment to share information which will safeguard and improve individuals’ quality of life.  Information and knowledge is a powerful tool.  We hope that this and future editions of "Living Well" will be used effectively to enhance the health and well-being of individuals we support.

   We'd welcome your feedback and suggestions regarding content areas for future editions of the publication.  Please submit your suggestions to Sharon.Oxx@state.ma.us.  Thank you!

Elin Howe
Commissioner Department of Developmental Services

DDS Treadmill Use Safety Guidelines

Use of treadmills with individuals with intellectual or developmental disability (I/DD) have become fairly common place. There are a lot of great reasons for this:
•	Provides good, weight bearing and aerobic exercise for individuals who may have limited access to walking outside
•	Great alternative to walking outside when weather is bad or it is unsafe to do so.
•	Improves balance, strength, bone density, digestion, constipation, cardiac health 

But treadmills can also cause serious injuries for all. Some common injuries are:
•	Severe friction burns to skin when in contact with moving belt 
•	Sprained or broken wrists, ankles and knee injuries from wearing improper footwear or moving at too rapid a pace for the individual
•	Head or back injuries from tripping or falling off treadmill or being propelled off treadmill when speed is accelerated or decelerated too quickly or when stepping on or off a moving belt.  

Some key areas of concern that place individuals with I/DD at risk for injury include:
•	Balance and gait problems. Individuals with I/DD suffer more falls for their age when compared to the general population. They are more reliant on the use of handrails throughout the exercise session not just for getting on and off the belt.
•	Reflexes: Individuals may not be able to problem solve as quickly and react in time. May also have problems with gross and fine motor coordination that can delay their response. 
•	Their understanding of the risks of treadmill use may be limited or they may be unable to retain safety information or training.  They may be more easily distracted.

So what can you do to prevent or limit the severity of injuries sustained by individuals you support while using a treadmill?
All staff and individuals should be trained in the safe use and operation of the treadmill they will be using. This training should include minimally:
•	Where the emergency stop switch (red button) is located on the machine
•	How to attach the safety cord/operating key device to the individual using the treadmill. This device is designed to completely stop all moving parts of the treadmill if the person falls or steps away when the key becomes disconnected from the machine and automatically cuts off all power to the machine, thus preventing or minimizing injury. This device is essential and must be used every time someone uses the treadmill!  
•	How the individual will get on or off the machine
•	Pace of belt for the individual and length of time they are to use it.
•	How to check all safety features before each use.
•	How to maintain the machine in good working order.
•	How to unplug the machine when not in use. May be necessary to also remove the key. 

Important!!
•	At least one staff person should be nearby while the treadmill is in use. This does not mean that a staff person needs to be standing beside the treadmill while it is in use, especially in the case of an individual who can use it independently. But rather, based on the identified needs of the individual, provide an appropriate level of support. For example. if someone is fully independent on the treadmill, ask the individual to inform staff when they will be using it so that the staff  can be assured that the safety cord is attached and in working order, they can keep other individuals out of the area who may be at risk for injury, and remain in an area of the house where they could hear if there was a problem and react quickly. 

WATER  SAFETY
Enjoying the water can be a special way to enjoy warm, summer days.  DDS updated their water safety safeguards on 5/10/13. With these precautions and planning, these activities can be the basis of happy memories of a fun summer.  Some key parts of the safeguards are:
•	Environmental safeguards (e.g. locked access when not in use) must be in place.
•	An assessment of each individual's water safety skills must be made. This includes evaluating each individual’s capabilities and needs when using different water venues, such as a pool, the ocean, or boating. 
•	Ensure staff is knowledgeable of people’s capabilities and are able to meet those support and supervision needs. 
•	Staff supervising individuals must be knowledgeable about water safety. (See bottom of page for resources on water safety.)  Remember, in sight supervision must be provided at all times to fully ensure safety.  
•	There must be at least one staff certified in CPR supervising individuals when there is no lifeguard present. 
•	Policies and procedures outlining supervision and use of a body of water need to be in place, and staff needs to be knowledgeable in the policies and procedures.
•	Whenever possible utilize sites that provide lifeguard over sight of the beach or pool
•	Before use, identify any potential hazards and unique safeguards required for the specific water environments individuals will be using.  Potential hazards, for example, could include finding out about surf conditions to determine whether swimming in the ocean is safe, or knowing the depth of the water or possible underwater hazards when swimming at a lake or river. Safeguards would include the use of life jackets when boating
•	Watch out for the “dangerous too’s”—too tired, too cold, too far from safety, too much sun, too much strenuous activity
•	Pay attention to the weather and stop swimming at the first indication of bad weather.  Know what to do in an electrical storm.  Upon the first sign of thunder or lightning, leave the water, and do not re-enter the water until at least twenty minutes after the last indication that a storm is present. 
•	Even wading pools can pose a danger. Make sure the surfaces are not slippery as people step into the pool. Apply nonskid bathtub decals to reduce this risk. Ensure that individuals are well-supervised when using the pool, and empty the wading pools when not in use.
Additional resources:
The DDS Water Safety Safeguards document can be found at: http://www.mass.gov/eohhs/docs/dmr/awp/hcpi-risk-watersafety.rtf
Water safety skills: Go to: poolsafely.gov and www.mass.gov/dph.  Search “water safety
BE SAFE OUT THERE

Summer is a time for fun and leisure activities.  As we all take advantage of warm weather and extended daylight hours, many recreational day trips are planned. Drivers, especially those transporting individuals with disabilities should make an extra effort to keep vehicles in good repair and gas tanks at least ½ full at all times to avoid emergencies. 

Here are some helpful tips when out on the road: 
 
“The breakdown lane may be a safer place than the travel lane of a road”, “but it is not a safe place to be”, so writes Massachusetts State Police Major Kevin Kelly in a recent American Automobile Association newsletter. In the event that the unexpected happens, Major Kelly recommends:

•	Pulling over as far to the right as possible, away from the travel lane
•	If possible, pick a spot highly visible to oncoming traffic, NOT just over the crest of a hill, or on a blind curve.  It may be safer to pull on to the grass.
•	Park in a spot which allows room to get out, not on an overpass or bridge.
•	 If the breakdown is at night, stay in the vehicle under a streetlight
•	Put on your hazard lights and only if it is safe to do so, put up your hood. This signals to others your distress
•	Use your cell phone and call 911 for any roadside emergency. 
•	One driver and one individual could probably safely exit the vehicle and stay behind a guardrail or on the grass away from the vehicle
•	When one driver is transporting more than one individual it is usually safer to stay in the vehicle with seatbelts buckled, hazard lights on and  hood elevated
•	On any road or highway, know when a “breakdown” lane is an active travel lane. In the Boston area, during the morning and evening commuter rush  Routes 3, 93 , 95 and 128, allow breakdown travel.  Posted signs show the hours

      If it is hot sunny day, remember to open the windows. If the windows do not open, open the doors on the side of the vehicle away from the traffic (usually the right side)

IMPORTANT!
Never, never leave an individual attended or unattended in a vehicle in hot weather

DEHYDRATION
(The lack of sufficient fluid in the body)

Because many people are on certain medications requiring a stable blood level to maintain effectiveness (like seizure and psychotropic medications), even mild dehydration can cause those blood levels to rise to dangerous levels, even toxic levels. This can create serious health consequences for the individual. Increasing fluid intake on hot days and offering them frequently can help prevent such an event.

Some signs of dehydration include:
•	Decreased amount of urine                                              
•	Less frequent urination
•	Dry skin or cracked lips
•	Sunken eyes
•	Less elasticity to the skin
•	Fever
•	Sleepiness
•	Headache
•	Increased heart rate
•	Strong, dark urine
•	Weakness
•	Confusion or agitation

REMEMBER:  

Popsicles, watermelon, cantaloupe, fruit salad and jello all contain a lot of water and summertime is the perfect time to indulge in such treats.

As many of the individuals supported by staff may not be able to express their increased need for fluids or are unable to access it independently, special effort must be made to anticipate this need by staff.

RULE OF THUMB:
If a staff person is consuming a beverage, the person that they support should have one as well.

HEAT ILLNESSES
•	Heat Cramps occur after vigorous activities like running or playing tennis. Their signs are painful abdominal spasms and cramps in major muscles such as the legs and abdomen. Cramps subside with rest, cooling down and plenty of water. 
•	Heat Exhaustion has many symptoms-fever, heavy sweating, fainting, rapid pulse, low blood pressure, clammy skin, ashen skin tone and nausea. Over exertion and not drinking enough water is the usual cause. To treat it, go indoors with a fan or air conditioning or to a shady spot, apply cool clothes, immediately lie down with your legs elevated, loosen tight clothes, and drink cool water or sports beverages. 
•	Heat Stroke (Sunstroke) can be life-threatening and requires immediate medical help. The symptoms include not only those associated with heat exhaustion, but also very rapid pulse and breathing, delirium, unconsciousness, and lack of perspiration to cool the body. 

      Risk factors for heat stroke include: 
•	Dehydration
•	Age over 65
•	Obesity
•	Having chronic heart or lung disease
Taking medications that interfere with the body’s heat-regulating system

To prevent a heat illness

•	Avoid direct sun from late morning until 4pm
•	Limit vigorous exercise or chores to early morning or late afternoon
•	Dress in light colored, loose-fitting clothes
•	Continually drink plenty of water or juice
•	Avoid caffeine 
•	Eat light meals
•	Do not ever leave someone attended or unattended in a hot car or van for even a short period of time

SUN EXPOSURE
Whenever you or the people you support are in the sun, you need to apply sunscreen.  Buy a quality product rated at least SPF (Sun Protection Factor) 15 and  apply it liberally to all exposed skin at least 15-30 minutes before going out into the sun and frequently thereafter especially during peak sun hours or after sweating or swimming. Not only will this help prevent sunburn but skin cancer as well.  

Too much sun is also a risk factor for cataracts, so use sunglasses that block UVA and UVB ultraviolet rays. And don’t forget your wide brimmed hat.

Remember,
Certain medications (like anticonvulsants, antipsychotics and high blood pressure medications) can cause people to burn more rapidly and more severely.

Summer Dining

Fresh food, picnics and dining out are part of the great summertime experience.  When eating out, just remember:
•	Be aware of individuals’ allergies, dietary restrictions and needs, especially with the availability of more and different summertime and outdoor foods.
•	Ensure that family and friends are equally aware of the individuals’ allergies and restrictions.
•	Ensure that specific dietary plans are clear, and that any protocol in place for eating at home is also implemented in community settings.  For instance, ensure that the individuals’ food is of the appropriate consistency.
•	Remember that typical picnic and barbecue foods are not always optimal for all individuals, and come prepared with alternatives.  For instance, certain individuals may not be able to eat sandwiches, peanut butter, and/or hot dogs safely.
•	Keep cold foods cold and hot foods hot to avoid food poisoning from bacteria.
•	Keep track of any new reactions to new foods eaten- breaking out in hives when eating different fresh fruit, for instance.  
•	Encourage individuals to sit and dine, rather than to eat on the run.
•	Closely supervise individuals during meals.  Be alert to any signs of choking or difficulty eating, and know what to do in an emergency. 

Call 911 if the person is:  
•	Blue, can’t talk or make a sound or is not breathing (Attempt Heimlich Maneuver) 
•	Having difficulty breathing
•	Looks very ill 

If you think there might be a problem with swallowing:
•	Document what you see
•	Tell other staff, the nurse, and your supervisor what you see
•	Stop the meal if the symptoms worsen and report it to the nurse or your supervisor according to your agency’s policy
•	Have the person eat at a slow pace
•	Tell the doctor what you see 

A common problem for many of the people that you work with is dysphagia (any problem a person may have with swallowing). Swallowing problems can lead to aspiration. Aspiration is a word that means food or fluids that should go into the stomach go into the lungs instead. There are several ways to tell if someone has dysphagia or aspiration problems. You may first notice these signs and symptoms when out and about.  Make sure that you report any of these signs and symptoms to your supervisor.  The person’s doctor will order the tests that they think will be best for each person.

Common signs of dysphagia and/or aspiration are:
•	Coughing before or after swallowing
•	Much drooling, especially during meals
•	Pocketing food inside the cheek
•	Choking on certain foods, for example white bread
•	Nose running or sneezing during dining
•	Trouble chewing
•	Trouble swallowing certain types of food or fluids 
•	Taking a very long time to finish a meal
•	Getting tired during the meal
•	Refusals to eat certain foods or finish a meal
•	A complaint of feeling like something is caught in the throat
•	A gurgly voice during or after eating or drinking
•	Much throat clearing after a meal
•	Repeated episodes of choking, frequent colds, pneumonias or “allergies”
•	Unexplained weight loss
•	Unexplained fevers that come and go
•	Coughing when lying flat or sitting up quickly from a reclined position

Picnic Checklist

As you head out this summer to enjoy the warm weather and outdoor activities, here is a checklist to help you make sure you have everything you need to make it a safe outing for you and those you support.

__ Broad spectrum sunscreen (SPF 15 or greater)

__ Plenty of water or caffeine- free beverages 

__ Lightweight clothing to cover up if very sunny

__ Epipens (if ordered for anyone allergic to insects or food)

__ First aid kit 

__ Equipment to allow food to be prepared to correct consistency (if applicable)

__ Plenty of gas

__ Information about site you will be visiting (directions, bathroom access, parking, wc access, etc.)

__ Towels if swimming planned

__ Bug spray

__ Fully charged cell phone for  emergencies

__ Emergency fact sheets for all individuals

__ Lots of ice and coolers to keep cold foods cold

__ Hats to protect from the sun

__ Food that can be safely  maintained in hot weather (to prevent food poisoning)

__ Enough staff to assure safety

__ Adapted utensils (if  applicable)

__ Change of clothes for swimmers or those with toileting issues

__ Blankets and chairs for seating
CREEPY CRAWLEES and OTHER PESTS  

•	Bee, wasp or hornet stings can cause a medical emergency if one is allergic to  them. You should be aware of those you are responsible for who have this problem and make sure you know what to do if they get stung. Most people,  however, only experience a sharp pain that goes away after a few minutes. It is  important to remove the stinger promptly: use a flat edge such as a credit card to scrape it from the welt, Wash the area and apply ice. Continue to monitor for signs of infection or increased inflammation.

•	Deer ticks are tiny insects that live in low brush and can spread Lyme disease in a small percentage of the people they bite. Use bug repellant with DEET whenever out in such areas to keep these pests and others away. Wear a long-sleeved shirt, long pants, socks and a hat if you are in tick country. When you get home, carefully check yourself and the person you support for ticks. And don’t panic! Generally, a Lyme disease carrying tick usually has to be attached for at least 24 hours to spread the disease. Ticks can be difficult to kill so it is best to flush them whenever possible.

•	Mosquitoes: Avoid outdoor activities at dusk or dawn. That is when they are most active. Use a mosquito repellant. Most repellants are effective for many hours so there is no need to keep reapplying it.  Wash it off carefully after going back inside. Wear light-colored clothing as mosquitoes are attracted to dark or bright colors.

If you would like further information on these topics or others, we suggest you visit the following website:
                                   www.state.ma.us/dph

MAP Reminder:
A HCP order is Not needed for the use of
Bug Spray
or
Sunscreen
West Nile Virus
(And we don’t live anywhere near the Nile)

So what is it?
West Nile Virus (WNV) was first diagnosed in New York City in 1999. This potentially fatal disease has spread across the country more quickly than expected. Its continued spread means that it is here to stay. Last year Massachusetts had 23 cases reported and 3 deaths.

How do I get it? 
WNV is principally a disease of birds. It grows inside an infected bird and is spread to other birds, animals and people through mosquito bites. Not all species of mosquitoes carry the disease. Even in areas where mosquitoes carry the disease, much less than 1% of the insects are infected. 

Although adults are more likely to be bitten by mosquitoes than children and men are bitten more often than women, anyone can become infected with WNV. The disease cannot be spread through normal contact with infected animals or people. 

What are the symptoms?
Most infected people will not know that they have the disease because they will have either very mild symptoms or no symptoms at all. 
The symptoms may include: 
•	Fever
•	Headache 
•	Body aches
•	Skin rash (rare) 
•	Swollen lymph nodes (rare)

The symptoms usually occur within a few days to a couple of weeks after infection. Persons who have flu-like symptoms that continue for more than 2-3 days should contact their physician immediately. If a mild infection exists, fluids and rest will be prescribed. Those who have symptoms of a more severe infection will be given a blood test to see if there are antibodies to the virus present.

What if I have a severe case?
Because so specific treatment currently exists, people who develop a severe infection are hospitalized to receive supportive care to help their bodies fight the disease. That care might include intravenous fluids, respiratory support, and prevention of other infections which can weaken the body’s ability to fight the WNV. Most people fully recover from WNV. 
So what can I do to prevent it?
There are several things you can do to lower the risk of WNV by lowering the risk of mosquito bites:
•	Remove all open containers of water and fill all pools of standing water near your home 
•	Stay indoors at times when mosquitoes are most active-dawn, dusk, and early evening
•	When outdoors, wear long-sleeved shirts and long pants
•	Be on the lookout for dead birds, especially crows and jays, and report them to local and state authorities
•	Avoid floral-scented perfumes and toiletries, such as soaps, lotions and shampoos
•	Spray clothing with insect repellent that contains 35%-50% DEET. Use repellent sparingly on exposed skin, and follow manufacturer’s  instructions
•	Vitamin B and ultrasonic devices are not effective against mosquitoes

The risk from WNV is real but extremely low. By taking a few precautions and being aware of the WNV symptoms, you’ll be ready to enjoy all of the pleasures of summer.

Have a safe summer!