Winter Safety Measures for Health Care Providers

Hypothermia is an unintentional lowering of the body temperature to 95 degrees Fahrenheit (F) or below.

Hypothermia is most likely to occur at very cold temperatures; however, it can occur even at cool temperatures (above 40 degrees F) if a person becomes chilled from rain, sweat, or submersion in cold water.

Warning signs of hypothermia in adults are shivering, confusion, memory loss, drowsiness, exhaustion, fumbling hands, and slurred speech. In infants, warning signs include bright red, cold skin and very low energy.

Hypothermia is a medical emergency that needs immediate treatment. During hypothermia, all body systems function in an increasingly sluggish manner. Heart and respiratory rates decrease, reflexes slow, muscles become soft and flaccid, and shivering ceases.

Tissue anoxia (deprivation of oxygen) further robs the brain of awareness of the emergency that is occurring, and the individual may not be aware enough to seek warmth and shelter or may not be able to verbalize how they feel.

Statistics show that approximately one-half of all hypothermia deaths occur among persons 64 years old and older. The elderly are at greater risk for hypothermia than the general population because the body’s ability to produce its own heat declines with age.

Additionally, there is a loss of subcutaneous fat, impaired thermoregulation, and a decrease in the ability to feel cold as intensely as when young. These factors result in little motivation to seek warmth.

Other factors that increase the risk for hypothermia include:

• diabetes
• cardiovascular and cerebrovascular diseases
• infections (bronchopneumonia)
• falls
• fractures
• confusion
• dementia
• mental illness
• cognitive impairments
• certain medications, (e.g., phenothiazines or antidepressants)
• consumption of alcohol.

Victims of hypothermia are most often:

• elderly;
• persons with cognitive or judgment impairments who leave a warm environment unsupervised and unnoticed;
• persons with inadequate food, clothing or heating;
• infants sleeping in cold bedrooms;
• persons who remain outdoors for long periods, e.g., the homeless or those who do not have access to or use of motor transportation and rely on walking, sometimes for great distances;
• persons who are uninformed about precautions and actions they should take to protect themselves from the extreme cold;
• persons with acute alcohol intoxication who are exposed to extreme cold;
• persons with serious mental illnesses, developmental or cognitive disabilities who may not hear temperature or weather advisory warnings broadcast on TV or radio or may not fully recognize the significance of the cold weather warnings;
• persons with diabetes or other medical conditions that require medications; and
• persons who are non-English speaking who may not be able to interpret warnings broadcast only in English.

All providers need to evaluate each resident, client or patient and ensure environmental safeguards, staff training, policies, procedures and practices are in place that will protect vulnerable people from the dangers of cold weather, especially those with impaired cognition or judgment.

Persons who are dependent on others for safety and protection, regardless of the type of provider, must be prevented from leaving alone without the appropriate apparel and personnel to protect them from hypothermia and other dangers.

Of additional importance is that all safety exits must remain functional.

The following preventive measures are recommended for the care and supervision of persons who are apt to wander:

1. Identify all persons who have a history of confusion with associated wandering. Also evaluate those who are at risk but may not yet have had an episode of wandering.

   Persons with cognitive impairment or judgment impairment who are ambulatory or have wheelchair mobility are at particular risk of hypothermia in every setting, even if they have not yet exhibited a history of wandering.

2. Evaluate all instances of wandering and all at-risk persons to establish individual interventions that will prevent the person from leaving the warm environment or will provide staff with foolproof signals and procedures if someone starts to leave unexpectedly.

3. For nursing home residents, certain sections of the Minimum Data Set (MDS), version 3.0, may help identify individuals with potential risk for wandering who need further assessment.

   Some pertinent MDS sections are as follows: (This list is not all-inclusive. A comprehensive assessment is needed for resident evaluation).

   • Wandering (Section E0900 and E1000)
   • Mood and behavior patterns (Section E)
   • Alterations in cognitive patterns (Section C)
   • Difficulties in communication (Section B, especially B0700 and B0800)
   • Incontinence (Section H)
   • Hypothyroidism, diabetes mellitus, cardiovascular disease, arthritis, Parkinsonism, Alzheimer's disease, dementia, mental illness (Section I)
   • Dehydration, History of falls (Section J)
   • Antipsychotic, antianxiety or antidepressant medications (Section N0400)
4. For each individual at risk, regardless of the type of provider, a comprehensive assessment of the person should identify the areas needing attention in order to develop and implement an effective care plan or service plan. The preventative plan should:
   • Establish a pattern and root cause for wandering and proactively eliminate triggers.
   • Promote participation in group activities.
   • Encourage communication with persons who have similar interests.
   • Work with family members or other volunteers to establish visit patterns if possible, especially at times when the person is most restless.

   • Promote comfort, meaningful activities and programming, safe ambulation and mobility, as well as good nutrition, hydration and elimination assistance that will meet his/her needs.

     Often a person who wanders is searching to find a way to meet unmet needs, such as hunger or loneliness.

   • Promote increased exercise and fresh air to combat restlessness and sleeplessness.
   • Review the care or service plan to assess effectiveness and ensure that it contains sufficient measures to prevent wandering or elopement.
   • Assure that persons are dressed in appropriately warm clothes, even when indoors, as hypothermia can also occur in indoor settings among individuals who are at risk.

Providers are responsible for ensuring there is sufficient staff on duty to provide appropriate supervision to prevent accidents. Providers need to ensure there is an adequate number of staff present on each shift to meet the assessed needs for each patient, resident or client. It is the provider's responsibility to ensure all staff, especially direct-care staff in all residential facilities and community-based programs, knows the danger of extreme cold and the importance of assessing and planning for prevention for each patient, resident or client.

1. Staff on duty should frequently observe the location of each potential wandering person according to an interval that is safe for protecting that person.

   It may be necessary to transfer responsibility for these observations at certain times of the day, for instance, when the person goes to a therapy department. Transfer of responsibility must be formally carried out and not assumed by either party.

2. All facility and contracted staff, including dietary, housekeeping, office and administrative staff and maintenance, should recognize the identified persons and be prepared to intervene according to the plan of care and with emergency safety measures if needed.
3. If provided, all existing surveillance/monitoring devices, e.g., door alarms, must operate 24 hours a day. These devices should routinely be scheduled for maintenance checks. Locking devices require review and approval prior to installation.
4. Ensure the ability of staff to act quickly and prudently should an elopement occur. For example, evaluate how staff respond to alarms and the actions they take (or fail to take) when locating a missing person or resetting an alarm system.
5. An alarm system may be electronically functional, but how staff uses the system and what they do when an alarm sounds is critical.
6. Be aware that more than one person who wanders may be involved in an incident that triggers an alarm, therefore when an alarm sounds; the whereabouts of all persons should be quickly ascertained.
7. Does all staff know how to proceed if someone is missing? Could someone elope without staff awareness?

8. Prior arrangements with community resources, e.g., the local police, sheriff or wilderness patrol, should be reflected in the policy and procedure formulation with timetables for notification specified.

   Many local law enforcement departments or community canine club volunteers have effective canine rescue patrols that can be called into action to search for individuals when given a timely alert.

   Quick action by staff and the sharing of critical information about any missing persons is essential.

9. In case of accidental hypothermia, treatment must begin immediately. Staff competency in assessing for hypothermia and taking quick appropriate action is essential. This must also be done for persons who are unable to verbalize how cold they are.

   The severity of the exposure will determine the interventions to be taken, but treatment should not be delayed while establishing the severity of the exposure. Any amount of hypothermia is an undesirable outcome.

10. A rectal temperature of 95 degrees F or lower indicates a medical emergency that is likely to be fatal.

    If persons are discovered outdoors in cold weather, staff should treat them as if they are hypothermic even though their symptoms may not be obvious, especially if they are cognitively impaired and cannot express how they feel.

    The symptoms of hypothermia may not be obvious, but can occur in a very few minutes, especially if the person is elderly, frail or poorly clothed.

11. Get medical attention immediately; call 911. While waiting for medical assistance, get the person to a warm area and remove any wet clothing. Warm the center of the body first - chest, neck, head and groin - using an electric blanket, if available. Or use skin-to-skin contact under loose, dry layers of blankets, clothing, towels, or sheets. Warm beverages can help increase the body temperature. Do not try to give beverages to an unconscious person. After body temperature has increased, keep the person dry and wrapped in a warm blanket, including the head and neck.

    A person with severe hypothermia may be unconscious and may not seem to have a pulse or to be breathing. In this case, handle the victim gently, and get emergency assistance immediately. Even if the victim appears dead, CPR should be provided. CPR should continue while the victim is being warmed, until the victim responds or medical aid becomes available. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated.

Additional information from the federal Centers for Disease Control and Prevention (CDC) is available at Winter Weather: Before, During, and After.

Staff in community-based programs can help clients prepare their homes for the winter season.

Prevention plans can include making referrals to local power companies or energy assistance programs for tips on safely heating homes and home safety checks, monitoring inside temperatures, and devising home emergency plans in case a power failure occurs.

If your area is prone to long periods of cold temperatures, or if clients' homes are isolated, plans might also include the stocking of additional amounts of food, water and necessary medications.

Clients should be instructed to eat well-balanced meals, avoid alcoholic beverages, and drink warm beverages.

In extremely cold temperatures, heating systems may be pushed beyond their capacity to maintain warmth in all resident rooms. Restricting or blocking outdoor air intakes is prohibited per SPS 364.

Extra measures may be needed; however, portable space heating devices are prohibited in hospitals, nursing homes, facilities serving people with developmental disabilities and community-based residential facilities and not recommended for use by other providers due to safety concerns.

Portable space heaters have been the cause of accidental fires. Any heating device, other than a central heating plant, shall be so designed and installed that it or its appurtenances (accessories) will not ignite combustible material.

If a heating device is fuel fired, it is to be connected to a vent or chimney and must operate by taking air for combustion directly from the outside. It also shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.

Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure (Life Safety Code (LSC 2012 edition), Chapter 18.5.2.2).

When the weather is extremely cold, especially if there are high winds, clients should be encouraged to stay indoors or to make any trips outside as brief as possible.

Prevention plans might include tips on how to dress safely for winter weather - always wear several layers of loose-fitting clothing, a hat and scarf to cover one's face and mouth, mittens, and water-resistant coat and shoes.

Help clients understand wind chill - as the speed of the wind increases, it can carry heat away from the body more quickly. When there are high winds, serious weather-related health problems are more likely, even when temperatures are only cool.

Avoid ice - many cold-weather injuries result from falls on ice-covered sidewalks, steps, driveways and porches. Assist clients by keeping these areas free of ice.

Finally, instruct consumers and staff to carefully watch for signs of cold-weather health problems such as hypothermia and frostbite for themselves and their neighbors.

The Winter Weather: Before, During, and After webpage provides additional information.

Winter ice, snow and drifting snow conditions can complicate fire egress/exiting. Nursing homes, facilities serving people with developmental disabilities and hospitals must comply with the following exit requirements.

They are also recommended for other community service providers, such as community-based residential facilities, adult family homes and all other providers.

All exits from a building must be provided with safe access to a street, alley or parking area (public way) (LSC 2012 Edition Section 7.7.1).

Facilities with an exit that discharges to yards that do not have a public drive around the building shall make provisions to ensure that a cleared path from each exit is maintained that is free of ice and snow to a public way that is at least 28 inches wide for existing facilities and 36 inches wide for new buildings, with 48 inches recommended.

Facilities that do have a surrounding drive shall keep the drive clear, i.e., free of ice and snow, and shall provide at least a 48-inch wide clear path to the drive.

For facilities with non-ambulatory residents, the cleared path will be a "hard surface pathway" of sufficient structural capacity to maintain safe egress of wheelchair or bedridden residents.

Note: Local fire departments should also be contacted to ensure there are no local rules that may be more restrictive.

All exit doors shall be checked frequently to ensure that freezing conditions have not caused any exterior concrete, asphalt pads or thresholds to heave up and block the exit door from opening.

All doors shall be capable of being opened freely and normally to full opening width without sticking in the door frame.

Nursing homes, facilities serving people with developmental disabilities and hospitals must comply with the following requirements related to combustibles.

They are also recommended for other community service providers, such as community based residential facilities, adult family homes and all other providers.

Many of the holiday decorations that are used can be highly flammable or pose an unusual fire hazard. The references cited in parentheses are from the National Fire Protection Association (NFPA) Life Safety Code (LSC) Standard 101, 2012 Edition.

The following precautions are advised:

1. Combustible decorations are prohibited unless they are flame-retardant (LSC Section 18.7.5.6).
2. No furnishings, decorations or other objects shall be placed so as to obstruct exits, corridors or exit signs (LSC Section 7.10.1.8).
3. No open flame devices, such as kerosene heaters, shall be used (LSC Section 18.7.8).
4. Christmas trees shall not be used unless flame-retardant (LSC Section 18.7.5.6). Retain manufacture labeling or certification of flame retardancy.

5. Decorative power lighting will be permitted if power circuits do not become overloaded and light strings are listed and in good condition. Decorative lighting is prohibited within 6 feet of a resident bed or patient treatment chair (NFPA 99 Section 3.3.139).

   The number of light strings in series shall not constitute an electrical hazard and manufacturer's safety precautions must be followed. Please be mindful of the tripping hazards associated with electrical cords or other holiday paraphernalia.

6. Fire extinguishers shall not be obstructed or obscured from view (NFPA 10 Section 6.1.3.3).
7. Sprinkler piping shall not be used to support decorations (NFPA 13 Section 9.1.1.7).
8. Open flame candles are prohibited in the area of oxygen use or administration (NFPA 99 Section 11.5.1.1.2).