Department of Developmental Services
Office of Quality Management

Living Well
WINTER 2013

Department of Developmental Services 
Office of Quality Management

Living Well/Winter 2013

Welcome to the Winter 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 winter 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

Massachusetts Department of Developmental Services Risk Management 

Bed Rail Entrapment

Individuals supported by DDS who need supportive and protective devices for their beds can be at risk for injury or death if the equipment is not properly installed or is the wrong size for the bed or mattress. The following information can be helpful in preventing such an event.

What is it?

 Entrapment is defined as an event in which an individual is caught, trapped or entangled in the spaces in or about the bed rail, mattress or bed frame. 
What risk does it present?
Entrapment can result in serious injury or death. Deaths usually involve entrapment of the head, neck, or thorax, while most injuries involved fractures, cuts, and abrasions to the extremities.  The majority of the deaths and injuries involved elderly patients or frail adults. Individuals at high risk for entrapment include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. 
How is it managed?  

The FDA recommends the following actions to prevent deaths and injuries from entrapment in bed side rails:
•Inspect all bed frames, bed side rails, and mattresses as part of a regular maintenance program to identify areas of possible entrapment. Regardless of mattress width, length, and/or depth, alignment of the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. 
•Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position.
The seven areas in the bed system where there is a potential for entrapment are identified in Figure 1.

Zone 1: Within the Rail
Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support
Zone 3: Between the Rail and the Mattress
Zone 4: Under the Rail, at the Ends of the Rail
Zone 5: Between Split Bed Rail
Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board
Zone 7: Between the Head or Foot
 
Figure 1

SUMMARY OF ENTRAPMENT ZONES 

While recognizing that there are seven potential entrapment zones, entrapment zones 1-4 account for the majority of entrapments and deaths from entrapments. Focusing on these high risk areas allows us to prioritize strategies for deceasing risks. For dimensional limits and test methods for zones 1, 2, 3, 4, refer to FDA Guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (Document issued on: March 10, 2006).

Where and to whom does this apply?

All residential/day programs serving individuals that use bed rails.

Where can I find additional help?
•	www.Mass.gov/DDS: http://www.mass.gov/eohhs/docs/dmr/awp/hpci-risk-bed-rail-entrapment.pdf
•	NIH – www.nih.gov 
•	CDC – www.cdc.gov 
•	DPH – www.mass.gov/dph 
•	DMH – www.mass.gov/dmh
•	http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm072662.htm   Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (Document issued on: March 10, 2006).  (document number 1537)

Warning Signs That a Person is Having Swallowing Difficulty

Individuals served by DDS have a higher incidence of aspiration pneumonias and choking. This is usually caused by an issue they have with swallowing that may be due to a physical or medical problem or may be a side effect of a medication. If such a problem is noticed it must be brought to the attention of the Health care provider.

Some of the signs and symptoms of difficulty swallowing listed below can occur during or after meals.

o	Gurgle/wet voice quality

o	Weight loss for unknown reason / malnutrition

o	Frequent respiratory infections

o	Dehydration

o	Aspiration pneumonia 

o	Low-grade temperature or spiking a temperature 30 minutes to 1 hour  after meal

o	Prolonged change in appetite

o	GERD (Regurgitating food/vomiting/gagging/rumination)

o	Coughing or excessive throat clearing during meals or after meal

o	Food remaining in the mouth after eating/swallowing (pocketing) 

o	Audible and/or multiple swallows on a single mouthful of food or   liquid

o	Incidents requiring the use of the Heimlich Maneuver

o	Impulsive behavior during meals ~ overstuffing food in the mouth or stealing food or guzzling liquids

o	Food or liquids coming out of the nose 

o	Initially very hungry but quickly becomes disinterested in eating

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General Rules for Safe Dining
	Check for upright posture, close to table.  Provide lap trays or other supportive equipment as needed.
	Provide needed adapted dining equipment as specified by dining plan. 
	Never offer a tablespoon for eating non-finger foods.  Use of tablespoons can result in putting too much food in the mouth at once. 
	Serve small to moderate amounts of food at a time as per individual need to discourage overfilling of utensil and the mouth at one time. This will also decrease spillage and increase dignity when dining.
	Serve small amounts of a beverage at a time.  Encourage sips throughout the meal to help with safe swallowing.  Allow for a drink at the end of the meal for clearing of mouth and throat.  “Guzzling” beverages is an unsafe behavior.
	A fork provided for cut-up finger foods may promote a safer eating pace as needed.
	Avoid dumping food into one pile on the plate, e.g. pasta, chips, fruit, cereal bar. Separate food or offer separately.
	Follow individual protocols to the letter as these have been devised for the purpose of keeping the individual safe while dining as well as to promote nutrition, dignity, and independence.
	Request assistance from familiar staff if you are not sure or do not understand a dining program.  Do not guess as you may be putting someone at risk
	Report any suspected eating, chewing or swallowing problem to your supervisor.
	Offer the individual their glasses, hearing aids or dentures prior to dining.
	Try to reduce chaos and distractions in the environment.  Eating should be fun, relaxing and pleasurable.  Turn down the television, play soft music and reduce clutter.
	THERE IS NO SUBSTITUTE FOR CLOSE SUPERVISION DURING DINING!
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Do I Just Have a Cold or Is It …..THE FLU?!!

Flu season is upon us (November through April) and everyone should be alert to early signs and symptoms of the disease. But how do you know if it’s the flu or just a cold (rhinovirus)? Here are some clues:

If you have the flu…
•	You have a fever (sometimes as high as 102+) Know a person’s normal body temperature. A change in their normal temperature by as little as 2 degrees is significant and should be reported to their Health Care Provider or the agency nurse immediately.
•	You have a headache
•	You are very tired (can even be extreme)
•	You have a dry cough (that may progress to a productive cough) 
•	You may have a sore throat
•	You have nasal congestion
•	You have severe body aches
•	It probably came on quite suddenly (some people can even tell you the moment they felt ill) 
•	You will be very ill for several days and take up to several weeks to recover fully
•	You are unable to go about your daily routine

If you have a cold…..
•	You probably don’t have a fever (and if you do it is very low grade)
•	You have a runny nose
•	You may have a loose productive cough
•	You may have a headache from coughing
•	You are able to continue your daily routine
•	You feel a little “under the weather” for a few days 
•	The symptoms probably came on gradually over several days

Uh oh, I have the flu. Now what do I do? 
•	The flu is very contagious so stay home!
•	Rest
•	Drink plenty of liquids
•	Wash your hands often!
•	Avoid alcohol and tobacco
•	Take medication to treat the symptoms (like acetaminophen for the aches and pains and cough syrup for the cough)
•	Never give aspirin to a child or teenager who has the flu! (it can cause serious neurological damage)
•	See your physician if you are not improving after several days.

Well…how contagious is it? 
•	A person can spread the flu starting one day before they feel sick
•	Adults can continue to pass the flu virus to others for another 3-7 days after symptoms start (children can pass it on for longer than 7 days)
•	Symptoms start 1-4 days after the virus enters the body
•	Some people can be infected with the virus but have no symptoms. They can still pass the virus on to others though. ( I don’t know how you are supposed to spot these people)

How did I get it?
•	The flu is spread when a person who has the flu coughs, sneezes or speaks and sends flu virus into the air and other people inhale the virus
•	The virus enters the nose, throat, lungs of a person and begins to multiply, causing flu symptoms. 
•	Flu may, less often be spread when a person touches a surface that has flu virus on it -a door handle for instance- and then touches his or her nose or mouth. 

How do I prevent the flu?
•	This is a very simple answer: Get a flu shot!  While it is best to get one before the end of November, it is never too late.. 

Information about where flu shots are being offered in your area can be found by going to: www.Masspro.org.

We know about the flu….but what about other adult vaccines?

Though once considered eliminated in the U.S., measles, mumps, rubella and pertussis (whooping cough) are becoming a growing health issue as cases are popping up in greater and greater numbers. While this does not place most adults at risk due to likelihood of immunity, it does pose a significant health risk, even life threatening, for infants, non-immunized children and frail adults. When accompanying an individual to their annual physical exam, ask their Health Care Provider (HCP) about these immunizations or boosters. They are:

•	MMR (measles, mumps, rubella): If born after 1957, unless the individual has a laboratory- confirmed immunity to this disease, they should receive 2 doses of the vaccine. Those born before 1957 are considered immune.

•	Tdap/TD (tetanus, diphtheria, pertussis): Tdap vaccine once and then a Td booster may be recommended every 10 years. Check with HCP.

•	Varicella (chicken pox): If immunity cannot be validated by laboratory-confirmed immunity, or HCP diagnosis of varicella or herpes zoster, consideration should be given to receiving vaccine. Consult HCP.

•	Pneumovax (pneumonia): For individuals over 50 at risk. Even if an individual has already received the vaccine, they may need a booster. Consult HCP.

•	Zoster (shingles): Adults over 60 should receive this vaccine unless they have a poor immune system. Consult HCP.

This past year we had outbreaks of both chicken pox and whooping cough in adults in residential programs. Please make sure individuals at risk are vaccinated appropriately.

This is a particularly active flu season so please make sure both you and the people you support receive the flu shot.  It’s not too late!

You’re Mother Was Right…Wash your Hands!

The return of cold and flu season seems the right time to review with everyone the need to wash their hands often, including the hands of the people we support. Besides the flu vaccine, hand-washing is cited as being the single most preventative step you can take to protect yourself from the flu. Recent studies have confirmed that hand –washing with soap and water or applying alcohol-based handrubs between caring for different individuals and throughout the day reduces the transmission of bacteria or viruses (germs) significantly; in some settings as much as 85%! Below are some facts that you may find very interesting and that may help you, your family and the people with whom you work to stay healthy, especially during flu and cold season.

	Improved hand washing or use of alcohol-based handrubs has been shown to actually end outbreaks of infections, reduce the transmission of antibiotic-resistant bacteria (like MRSA) and reduce overall infection rates.
	The CDC is recommending the use of alcohol-based handrubs for people who provide personal care to others because they can address some of the obstacles staff encounter when taking care of people. For example, lack of appropriate hand-washing opportunities when out in the community.  
	Hand-washing with soap and water is still highly recommended to reduce the spread of germs. Using an antibacterial soap like Dial is also recommended. Use of liquid or foaming soaps in pump bottles is better than bars of soap.
	You should wash your hands for the length of time it takes you to sing “Happy Birthday”. 
	When your hands are visibly soiled you should wash with soap and water.
	The use of gloves does not eliminate the need for hand-washing and hand washing does not eliminate the need for gloves. Gloves reduce hand contamination by 70-80% , prevent spreading germs to others and protects everyone from infection. Handrubs should be used before and after care is provided just as gloves should be changed before and after providing care. 
	Alcohol-based handrubs significantly reduce the number of germs on the skin, are fast-acting and cause less skin irritation than many soaps. Allergies are very uncommon.  
	Staff should avoid wearing artificial nails and keep natural nails less than ¼” long if they are caring for individuals at high risk for acquiring infections.  
	Just as you encourage people to “cover their nose or mouth” when coughing or sneezing, you should encourage them to wash their hands after doing so as well as frequently throughout the day. 

Remember, the infection you prevent may be your own!

WINTER WEATHER SAFETY

Snow can be beautiful as it falls, but dangerous as it accumulates on the ground.  So…

•	Make sure equipment for shoveling is in good repair and readily accessible. 
•	Make sure outdoor lighting is operating properly. Darkness falls early in winter and navigating icy paths without proper lighting can be treacherous.  
•	Have salt or sand handy to use after a snowfall or when icy. Place it in readily accessible places both inside and outside.
•	Now that the equipment is handy, shovel quickly after a snowfall and use salt or sand on icy surfaces to ensure that all exits, not just the main exit from the home, are clear and safe to travel at all times.  Also remember that wet leaves and grass can be slippery too.  
•	Keep a couple of blankets in the trunk in case you break down or get stuck. It will keep people warm while you wait for help to arrive. Remember, people who are not able to move around much on their own will feel the cold much more quickly. Never leave anyone unattended in the vehicle for any reason. 
•	Have flashlights strategically located in the event of a power outage. 
•	Individuals should be dressed warmly with properly fitting clothing. Several thin layers will help keep them dry as well as warm. Clothing should include long johns, turtlenecks, one or two shirts, pants, sweater, coat, warm socks, boots, gloves or mittens, and a hat. 
•	Do not let individuals stay out in the cold too long.  Time limits depend on how cold it is.   Call individual inside periodically to warm up. 
•	When possible, individuals who are particularly at risk (e.g. elderly, people with poor circulation, non-ambulatory status) should not go outdoors when it is colder than 32 F (or 4 degrees C). 
•	Use common sense: For example, if there is a cold or frostbite warning issued, do not let the individuals go outside at all.  If they must go out, accompany them and ensure that they continue to wear the protective clothing (such as coat, hat, and gloves) throughout the time that they are outdoors. 
•	 Make sure the individual’s clothing is dry.  Change into dry clothing immediately as wet clothing can make frostbite occur quicker.
•	Change the batteries in all battery operated smoke detectors, carbon monoxide detectors and flashlights. 
•	Ensure that the fireplace is inspected and cleaned for winter use.
•	Arrange for the furnace to be inspected and cleaned, and ensure that there is plenty of fuel to begin the winter.  Space heaters should not be utilized as a heating solution. 
•	Make sure that all outside heat ventilation outlets are free from snow and debris. 
•	All residential locations are required to have at least one Carbon Monoxide detector within 10 feet of bedroom doors. 
•	Continue to ensure that there is adequate staffing, especially during and around holidays, winter storms, and possible illness.
•	Inform all staff of individuals’ holiday plans and routines.

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Frostbite:  Prevention and Recognition *

Submitted By Froukje Timmer RN, NP
Southeast Residential Services
What is Frostbite?

Exposure to cold temperature without adequate protection can result in frostbite. Frostbite means that a part of a body has been frozen and this can be quite dangerous. Usually it is the face, nose, ears, fingers and toes that get frostbitten. Frostbite can occur during any outdoor activity including play, and especially fast moving sports such as skating, skiing, snowboarding and tobogganing. Obviously the colder and windier it is, the quicker an unprotected body part or area will become frostbitten. The skin around a frost bitten area initially becomes red then pale and very rarely bluish. As the skin warms up there can be some blisters.

Frostbite Prevention:  
•	ndividuals should be dressed warmly with properly fitting clothing. Several thin layers will help keep them dry as well as warm. Clothing should include long johns, turtlenecks, one or two shirts, pants, sweater, coat, warm socks, boots, gloves or mittens, and a hat. 
•	Do not let individuals stay out in the cold too long.  Time limits depend on how cold it is.   Call individual inside periodically to warm up. 
•	When possible, individuals who are particularly at risk (e.g. elderly, people with poor circulation, non-ambulatory status) should not go outdoors when it is colder than 32 F (or 4 degrees C). 
•	Use common sense: for example, if there is a cold or frostbite warning issued, do not let the individuals out outdoors at all.  If they must go out, accompany them and ensure that they continue to wear the protective clothing (such as coat, hat, and gloves) throughout the time that they are outdoors. 
•	 Make sure the individual’s clothing is dry.  Change into dry clothing immediately as wet clothing can make frostbite occur quicker 

What Are The Signs of Frostbite? 

The signs and symptoms of frostbite include: 
•	Numbness or pain in the fingers, toes, nose, cheeks or ears 
•	Skin may be blue, white and/or blotchy 
•	The skin is blistered, hard to the touch or shiny 

What Should be Done when Frostbite is Suspected?

Remember that prevention of frostbite is the best approach; if there is a possibility of frostbite, take the following steps: 
•	Take the individual indoors immediately 
•	Ask the individual to gently move the affected body part to increase blood supply to that area 
•	Be gentle, as frozen tissue can be damaged easily. Do not rub or break blisters and do not massage the frozen area or rub it with snow or ice
•	Bring the individual to the nearest Emergency Room for evaluation and treatment.
•	Inform the nurse and/or supervisor

Adapted from Dr. Paul Roumeliotis’ (an American Board of Pediatric certified MD web site: http://www.drpaul.com .

Preparing for a Disaster Emergency
________________________________________
Disasters can happen anytime, anywhere, and sometimes without warning. A winter storm could keep you and those you care for at home for days. A fire, flood, tornado, or any other disaster could stop water, electricity, and telephone services. You could have to leave the home. 
Be prepared for a disaster emergency before it happens. Make a Disaster Supplies Kit. Keep these supplies on hand:
•	Water – a 3-day supply for each household member 
•	Food – a 3-day supply for each household member
•	First Aid Kit
•	Essential medications – prescription and over-the-counter
•	Special equipment and supplies for individuals with special needs
•	Generator, if an individual is dependent of machines using electricity
•	Sanitation supplies (toileting and hygiene)
•	Flashlight with extra batteries
•	AM/FM portable radio with extra batteries
•	Cellular phone with extra battery
•	Cash
•	Extra clothing and bedding 
•	Important documents
•	A copy of the Emergency fact Sheet for each individual
•	Important phone numbers
•	Other tools and supplies
Tip: Keep the phone number of an out-of-state or out-of-immediate- area contact person in the Disaster Supplies Kit. Sometimes, it is easier to contact a person in another state or out of the area during a disaster.
For more information on Disaster Planning, contact the Federal Emergency Management Agency (FEMA) at 800-480-2520 or 800-621-3362 (TTY). You can also contact your local American Red Cross Chapter. Many communities have community emergency or disaster teams that work with FEMA and can give people local help.