FREQUENCY 6

i

TUB RlSlk ACTIVITY OF ADULTS WITH SLIPS AND FALLS

* While adult s are in a low state of potential energy and danger while sitting, the process of rising requires steps .that are unique- with a sequence of user failures and product

failures: together generating injury. s

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FREQUENCY 16

TUB STANDING ACTIVITY OF ADULTS WITH SLIPS AND FALLS .

Tub activity of a&Its and resultant injuries suggested special intervention strategies relating +& adults. Weight, height and body dimension conditionsas well as needs and goals miiht be intervened upon fcjr this group. A separate scenario was indicated.

Wheh the goals, activities and injuries were correlated together--re&lts were diverse and would have diverged into a whole field of minor scenario subtypes. l The central issue remained--the.aduIt was standing in the tub when he slipped and fell injuring himself against the tub.

intervention strategies dealing with this central theme were called for.

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FREQlENCY 25 . .

.

TUB ENTERING OR LEAVING ACTIVITY WITH SLIPS AND FALLS

Whileyalue of life and reduction of injury is claimed an equal issue between adults and children, in practice, more interest and responsibility is felt toward children.

Also, ‘of course different capabilities and physical characteristics of thke groups differentiate them even under otherwise similar accident sequences. Thus, user-product

- interactions and intervention strategies may differ. *

The negotiation of the tub wall in leaving and entering is a case in point. This activity has characteristics that suiggest its separate scenario treatment.

.

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MYWEEK

“9 SUndO)

MOdOY

Tuesday

Wednedoy

Friday

Sotudoy

(4)

(5)

(3)

(1)

(6)

(3) (3)

-* AREA

xub (13) in 4 out of tub (12)

:RITPROD

-tub bottom (22) soap in tub (1)

ng (2)

POSTPROD

~~~plicabla (24)

towel rock come

off wall (1) PREPROD ’

ng/notapplicgble (23) ADDITIONAL

EII oil (1) ne m

ENERGY

(1) map water In tub !2! TKIJ&dgl/rim/

bath 011 on bb bOCk

.-e.

t “I

HYSICAL LIQUID bottom -b/shower -7KGtvbwet + empty

(2) tub

bubble borh (1) tub bottom ;:1

1 cornblnatfon (19 (no water &&g)(3) toilet bowl bo8e (1)

I, I: crondod rixs tub& shower woter run- w (2)

onamsl surface (2) ning In tub (3) stondord size tub + tub full (2)

probably porqololn (I) tub water dmlnlng (1) porcelain tib + tub water running (1)

probably ~tondotd (I) w (15)

6

old forhion hlgh-

sided tub (1) SAFETY

E Gerber bathrub (I) none (14

B non-1 ip unlace ‘(4

2 bath mot/ not In

24 hi: rail ?I

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- .,’ .- . . __ _,__ ._. . . . --.. - - -- “_l___ ._ . -_- _ ~ , .- . . . _.. Ic _. _ ..- _ - ..- _ ._.. --. -. -..

The people or. bet-

woon rh0 ages of m e!!d

65+ (24) wfth on. l xcep-

tlon under 20 (1). Their

he&h Is nonnot. Thor.

ore slightly more fomolar

Involved thar moior

(16 to 9).

lho iwaltlruul~ how0r tr hoi~0d in oli of thorn camar When glvon, the ma/wlty of the t&a m

ovot 4 yoan old (12 of 13)

Morr of rho paJpi* ore 1m ,L. c A-L,-!-- -- . . . . ..= =e! 31 ~u,IcaIII,y “I

ieoving the tub (22 of 25).

Excsp t for one case, they

ore oil in motion: Step-

ping over edge or ieovlng

tub (20), ciimblng over

edge (I), rrachtng or

grabbing accessory (2))

or towering into tub over

hJ@ (W

VI. ana of tit. ~O~IlO I,

ho edgo-rim-tldr of the

bathtub, in ail c-8 whore

given,, thhr tub hoa wotor

in It.

In oli coser, Iho person

whiio entering or ieoving

the tub slips cmd/or loses

hhIlce. They ore In

trmsltion, uruolly with

one foot itwldr thr tub

and the other whldo.

ill ail Cuml, rim tub

ixtttom to silppery, l lther

hcouw it Is wat or thore

is a dlpplng agent, aoag

or Ott, on the bottom

UWfOC@.

Ail the victims foli as a

result of slipping or losing

bolonce: downward (19),

bockword (2), forword (I),

to side (I), or their foot

dragged ocmss tub (1) or

nachod for towel rock (1).

in ftrlilng, ali lh0 vio- time hit ugalntt the tub tldo

ad~0, Am, bock (20) or

bottom (7). in fatting out-

ward, (1) hih tha tofiot

bowl,

C

The pnr! er !ly LFdK hi tori cases, he .

most injured ir the mid- victim WYS treated ‘and

section (13) the ribs bc;ng released in the sane duy

in/uried more (IO of 13). (23). Two (1) wei hos- The hood reccivad injutiel pitoiired, one for on

(5) and limbs 17). extended period.

The severity of the

injurIes was conrideroble,

(8) ranked OS severity 5 on

the NEISS Index, and (2)

OS nwriry 6,

_-__ - .- _-. _ .- -.-_____-_____ ____13-^- -

i . :

i

FREQUENCY 12 ---I

,‘, .

. . i -

SHOWER STALL AREA ACTIVITY RESULTS IN LACERATION - .

Showering most frequently takes place in tub/shower combination. - * However, the shower stall is a second area of shower activity. The dota revealed that this area is not only infrequently involved in injuries

(perhaps 6s a indicator of the relative numbers of shower stalls), but when+jured in the shower stalls, the injuries are more,homogeneous in character.

Correlatiok of the physical factors of the shower stall with the activities and injuries revealed patterns resulting In glass and door lacerations.

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FREQUENCY 11 .

- - TUB E;NCLOSE GLASj BREAKS

‘% RESULTING IN LACERATION

,.- 7 .- ‘.‘,’ .:g- . . ’ ;

_ A breakdown of physical characteristics of tub/shower combinations indicated that

where glass enclosures in tub were present and breaks in the glass occurred, lacerations . were a consistant result.

This scenario emerged when the adult user, while. leaning against, striking, bumping

or closing the encfosure shattered the glass resulting in a variety of cuts over the lower

portion of arms and body.

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In all of th0 cm. rhdin mprrwntod by rhlr SCOW

aria. No 0t)r.r llfwuol

bckm OT rlgnlflccwtf

obf Iha uwlnmutf,

#. - . .-. . . , ,-w ‘I

were upuit or tired, md Dno WOI both upset ad ibsl. ihe maiority WCN

in the pmceu of shower-

ing (6) ad entering/leov=

ing the bathtub (3). 7~

(2) orhcn were fnvolvai

in activities in the both-

man unrelated to shower ing. All of the penons

war8 engaged in active movement In or auund th

tub.

The precri tic01 octfvity

was Ming place in tub

(6) ubterhg or Iwving

tub. (l), iuct ouhIde tub (2) 01 In onother area of

the bathrom (I), Thhr hrl

wno WI1 In fwd OMW (0

of 1 I), kr (4) mnee, h permon web btldtng the glan door qWt*

n~fnosr nott the victims lipped or lost their balance 3) on the inside of *he t&

(2) on the both- floor mct to the tub. In other :oses, the victims or otheo

Iresent were sliding the

rloss door open (4). In 0th ncidents, elbows were

wung against the gloss

rhils the penons were

taxiing, sitting djocen)

o the door (2).

A slippery tub floor or

bathroom floor ocawnh for (4) critical incidenh.

In three (3) cams the

howar dmr broke, H In

(I) cm. hue was glew

trltwdy ucw~kwl (

Those peaons who lort their balance or slippd (6) cd: a$JairIsi + rhru the dwr

*tructute, uwolly their om went thrv the glass. When

the glass dam fell king

moved (4), the &tim triec

to ovoid it. In the cases of the elbow striking the glox

in animated motion, the penon was immediately

lacerated.

ill octivltiar resulted in

,malcing ti glou (11). In

even (7), it WCS broken by I part of,the body either

‘tilling or onn morlon.fhe

hov moving crises (2) lnvo-

vfxl Ihe ck~r iumf111tg out If ItrtlWC CWUJ f44lll,q& ct

ctI4. I(148 tlltI@t (t0IWwwl 144wt

dm whut fwcul tqwm,

3rd In on. pWIouBly cmc&

d &a fell out.

All of the inipries were locerotions to the Iimhr: (9) to the arm and bond

region, and (2) to the leg in cases where the door

fell out of the track.

Them were other minor

locerotions to tho shoulder md thighs. fhe severity

according to NEISS Index

was relatively low (9) in nevorlty 2 and (2) in

rverltler 3 and 4.

Most of the victims were 7e~:& Gad r&d ho

me day (lo), 0~ was qitalired for 1 - 5 days,

- _. .__-- _-.- --_--- -- .._. -.--__

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.

FREQUENCY ,lO

-TUB AND SHOWER STALL ENCLOSURE

GLASS FRAME AND TRACK CONTACTS e

Originally, the tub/shower combination door was viewed as belonging to a single

accident scenario of interactions with these devices.

Closer analysis revealed thlat the product played two separabfe and consistant roles;

one involving the glass with its particular sequence and injuries (see Scenario 14) and

the other involving the frame and track with its scenaAo.sequence.

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FREQUENCY 15

.

.

. PROTRUDING FIXTURES CONTACTS

(OTHER THAN DOOR FRAMES AND GLASS)

Slipping and falling, it can be seen, was a significant factor of event in most

scenarios. However, its universality may be somewhat akin to death as always

occuiping by heart attack. True, slipping occurs in mose cases, but is it the result of other factors ?

.- .$

Slips are one issue in the sequence and e1.iminatiot-r or reduction of injury can

develop at many points in the sequence.

Slips and falls diverged into many sudden stops. While in some scenarios, the

bathroom floor, tub or tub/shower combination door was the energy transfer point,

in fifteen cases protruding fixtures were interacted with the user,

As-such the group separated into a singular pattern.

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.

FREQUENCY 7

FIXTUR:E FAILURES UNDER LOAD

(OTHER THAN DOOR FRAMES AND GLASS)

Accident evolution, it his been noted, is sequential in character. Intervention strategies may be applied at variom points in the sequence, ta prevent initiation or

once the initiation of the sequence has begun to change or elimina!e the next step, or reduce or eliminate the consequences. .

Normal user activities and user self-develdped accident prevention strategies involve expectations of performaxe by products.

$I seven case studies,fixtures in use did not perform to normal expectation stand- ards, some directly injured the user while others failed to stop on acciclent sequence. or actually precipitated a sequence. .

The unique character of these patterns suggested their formation into a separate scenario.

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Other Cases

Frequency 4

Those cases which lay outside the seventeen scenarios constructed were of a unique type,

The narrative of these cases is reproduced below:

1. Mother was bathing 2 year old male child in apartment bathtub. She left to take

cookies out of oven. She returned almost immediately. Child was in a dazed condition - and anoxic. Taken to Holyoke Hospital by police cruiser. No bruises on head or body. No water in lungs. Child was treated and released. .

Youngster was observed on day of interview. He appeared to be a normcal, heal thy,

active child.

2, Victim’s mother stated the accident was the fault of her 2 year old son. She said he

was standing on the bathroom floor on the outside of the tub. She said he first dove into

the pool, headfirst. She said her other sons do this and he was just imitating them. When he dove in, his chin hit the bottom of the tub, causing a laceration to the chin which required five stitches to close.

3, Female victim, four years old, was taking a shower in a combination bathtub/shower equipped with a Rubbermaid Safety Grip Bath Mat. She reached forward and either slipped or lost her balance, striking a plastic bottle of bath oil which was standing uncapped in bathtub. . It is unknown whether rubber mat contributed to accident. Victim could have stepped off of mat prior to slipping (she was reaching for water valves), or she may not have slipped at all, merely losing her balance instead. Also, possible is the case where the mat itself may have slipped (the rubber suction cups were small [7/4” diameter] and worn; and the surface was rough with hard-water deposits. In addition, the mat surface [on which the user stands] was slippery).

Victim fell backwards, striking bottle (which has since been destroyed) and sustaining 1” cut to lower back. Bottle was; plastic and did not break. Victim has no history of balance difficulties. Five stitches were taken to close wound.

4. John, four years old, 3’5” - 42 Ibs., had just finished eating at 4:45 PM and was told to take a bath and prepare himself for bed. Mrs. D stated that John had been very active that day and she hoped the bath *would calm him. down. About 500 PM, Mrs. D said John came out of the bathroom with blood pouring down his feg. When questioned about what happen& to him, John said one of the toy animals he was playing with in the tub had bit him. The tub is the old fashioned type, about 46” long and 25” deep, being half full when John took his bath. Naturally, Mrs. D said she did not believe John and it warn?

until she emptied out the bath water that she saw her hair mirror broken, John said he did not realize he had broken the mirror (4” x 4”) because of the bubble

bath he used. He could not see the broken mirror. Mr. D applied a bandage about 505 PM and when the bleeding didn’t stop they took John to the Chester County Hospital with a cut about 1 l/21’ long whlere he received six sutures and was released,

John had no physical disabilities. *

59 *

3.0 *

INTERVENTION STRATEGIES

1 I

3.1 Approach

As described in the previous section, seventeen

accident scenarios were developed by the project team which

represented all the major factors associated with lbathtub and

shower accidents and the way these factors are commonly grouped

to form the "accident chain" or scenario. Identification of

these basic accident scenarios was necessary in order to pro-

ceed to the development of accident prevention measures, or

- intervention strategies. An intervention strategy may inter-

vene at any point in an accident scenario from the setting to

post-critical incident, to prevent an injury from occurring

or to minimize the injury. The task of the project team thus

became the examination of each component of the accident scen-

arios for a means to avert injury.

A series of lists of intervention strategies were

developed during this phase of the study, as is shown in the

following diagram:

b

Accident Scenarios Haddon's Taxonomy Manufacturers, of Intervention

t Strategies :iT

Government and Consumer Reaction

c 1 . w Initial *List of Comprehensive List Final list of Intervention of Intervention ) viable Inter- Strategies Strategies ve:ntion Strategies

4 b . c 4

The initial list referred to in the diagram was produced in

conjunction with the accident scenarios and is responsive to

the *&ix parts of the scenarios: accident setting factors, pre-

critical incident factors, critical incident factors, postcritical

incident consequences, and incident recovery consequences, In

this initial- list, intervention strategies were specified in

one or two sentences, and it was discovered that certain stra-

tegies tended to reappear in most of the scenarios. The inter-

3 60

i’ ,

vention stritegies which would later be singled out for closer

study were those which reappeared in this way. Prominent

among these strategies were those relating to supervision of

children in the bathtub, increasing the coefficient of friction

on tub eduges and bottom, providing for maintenance of balance

(generally through the use of handholds), .and anti-scald devices.

The primary result of this initial generation of

intervention strategies was that it became apparent that a wide

range of measures existed for examination, ranging from changing

the design of bathtubsand showers or changing the materials

'from which they are constructed to designing retrofit products

and educating users. Clear1y.a comprehensive framework was

needed with which to examine all these possibilities and within

which the intervention strategies might be classified. Examina-

tion of the literature showed that one such taxonomy had been

developed by Dr. William Haddon 1 , and this taxonomy was adapted

.-.. _._e to the problem of bathtub injuries/The result-of qworking

with this classification method was that the team was able

to generate a comprehensive list of 436 intervention strategies.

Haddon's system is based upon the consideration of an accident

scenario as a system where damaging transfer of energy occurs,

and intervention strategies thus focus on prevention of this

energy transfer. The system of intervention strategies may

be summarized as follows:

I

I. Prevent the initial marshalling of the form of energy

A measure such as nuclear disarmament exe:mplifies

this intervention strategy, which aims at making the environ-

ment such that-an injury cannot occur because the potential

sourc 8 of damaging energy is not present. The intervention

strategies developed for the bathtub in this category included ; user-alternatives to bathing,

, :.:I' bathing without water or soap,

or bathing without hot water. A number of strategies were

proposed to reduce the potential energy of the user, such as

1 William Haddon, Jr., M. D., "Energy Damage and the Ten Countermeasure Strategies," The Journal of Trauma, Vol. 13, NO. 4, PP- 321-331, 19'73.

61

I I

designing the bathtub such that the user sits, thus elimina-

ting the possibility of falling from a standing position. The

purpose of generating ideas as unconventional as bathing with-

out soap was to thoroughly reexamine the bathing process, so

that truly innovative concepts would emerge. For that reason,

certain of the intervention strategies are less immediately

practical than others; however, these strategies suggest guide-

lines for future means of making the bathing process safer.

II. Reduce the amount of energy marshalled

This strategy resembles the first one in principle.

In bathroom situations in which the marshalling of energy is

essential for functional purposes, this strategy of limiting

the amount of energy may be applied. For example, although

auser might not choose to eliminate hot water entirely, bathing

in lukewarm or mildly hot water might be an acceptable and

safer substitute.

III. Prevent the release of energy

This principle covers a multitude of intervention

strategies. The presence of a responsible attendant will

prevent most drownings and burnings of children. Handholds

will often prevent slips and falls for users of all ages, and

increased friction of bathtub surfaces will also help prevent

this release of energy.

IV. Modify the rate or spatial distribution of the release of energy from its source

By modifying the rate or spatial distribution of

eneggy release, the potential for injury will be reduced. For

example, construction of protruding fittings from a resilient . i- material would also serve to reduce injuries. Alteration of the

shower stream in terms of temperature, volume, or stream shape

could serve to minimize possible scalding.

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