For example, in , patients were discharged from hospitals after 4. The first wave of the cohort will reach age 65 in , and by , the cohort will have reached age 85, 33 resulting in a dramatic increase in the number of older Americans. For example, in , An even greater magnitude of growth is projected for the extremely elderly cohort.
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In , less than 1 million Americans were 85 years or older; by , this number had increased to 4. Combined, the result will strain the services provided to the elderly, including home care services. Even though the home care workforce is large, with an estimated 1.
These demographic changes in the U. By , this is expected to increase substantially as the baby boomer cohort ages, with perhaps as many as 20 million or more patients needing home care. Other shifts in home care are noted as well. For example, while currently about half of home care patients aged 64 or younger are female, there are nearly twice as many females in the 65 years and older age group.
There are also current and projected changes related to the health condition of home care patients. A large proportion of current home care patients have heart disease diagnoses 47 percent , followed by injuries 16 percent , osteoarthritis 14 percent , and respiratory ailments 12 percent , 22 and increasingly frail and vulnerable patients continue to enter home care with many highly complex medical problems and multiple diagnoses, thus requiring a greater intensity of care.
All these trends suggest that home care will become even more challenging and that the expectations placed upon the sector, including the caregivers, will most likely become more demanding. By increasing our awareness and understanding of the health hazards inherent in the home care environment, it may be possible to reduce the risk of injury and illness to the home care patient and to improve the quality of work life for the caregiver.
Most of our information regarding home health hazards comes from anecdotal or qualitative reports, and only a few surveys have been conducted. Although there is a wide range of hazards, the hazards generally fall into two major categories: A good overview of the scope of home hazards is provided in a recently published qualitative study by Markkanen, et al. The study participants also raised environmental concerns, including overheated room temperatures, poor indoor air quality, and unsanitary conditions, such as the presence of insects and rodents.
Unsanitary conditions are a special concern, since the spread of infectious disease within the household is well documented, and various procedures in home care could present a risk of infection. One household area of potential concern in this regard is the bathroom. Household laundry is also a concern because it has been shown to be a route for the spread of disease.
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For example, spread of Staphylococcus aureus via laundry has been documented. Studies have also documented the survivability and spread of microbes in the kitchen. Pathogens associated with raw or undercooked food items, such as poultry, have caused disease in household members, including those who are especially vulnerable due to age or immune status. Mismanagement of medical waste may also be a cause for concern in the home care environment because it can be a source of pathogenic microbes. Although each State regulates the transportation, storage, and disposal of biomedical waste, usually via individual health departments, the home care setting is not easily regulated.
Anecdotal reports of improperly disposed sharps e. Another area of concern is the reuse of certain single-use disposable items. For example, it has been reported that many diabetes patients repeatedly reuse insulin syringes, without disinfection, until the needle is no longer sharp. Urinary drainage systems, normally kept intact for patients with indwelling catheters, may be breeched when the home care patient needs to use a leg bag.
The issue of home hygiene, including disinfection practices, needs addressing. Unfortunately, we still do not yet have a national surveillance system in place in the United States for health care-associated infections in home care settings, even though this has been suggested. The CDC Web site also provides useful references in this regard. Finally, a topic of special concern in home care, especially urban home care, is the issue of crime and violence. A recent article by Geiger-Brown, et al. In —, a health and safety survey was constructed following extensive developmental steps, including in-depth interviews, focus groups, cognitive interviews, and pilot testing.
The survey was designed to assess the health hazards associated with the delivery of home health care. The item survey included items that addressed the following: The survey was designed to be completed within 30 minutes and was prepared in English at a sixth-grade reading level to facilitate rapid completion. The survey responses were primarily categorical, although some items had 4- to 5-point Likert-type scale response choices, and several items were open-ended.
Personal Security in a Violent World
The survey and codebook are available by contacting the corresponding author. Although the survey was anonymous, each participant was asked to sign an informed consent form, and all procedures involving subject participation had the prior approval of the Columbia University Institutional Review Board. A brief one-page document describing the study was provided to potential participants. Because of the well-established difficulty in surveying HHCWs in general, and the additional challenges in recruitment of individuals for whom English may be a second language as is the case for many home health aides , an in-person recruitment strategy was employed.
To facilitate this, a collaborative relationship was formed with an occupational health organization that conducts mandatory health assessments and screenings for home care agencies throughout New York City. Participants could complete the study survey in private areas located adjacent to the waiting rooms. In some cases, the data collector helped to facilitate the survey administration by reading the questions out loud, although generally, data were collected through self-administration. Data collection days were held until the targeted goal of a convenience sample of 1, aides was reached.
Participating aides represented numerous agencies. All completed surveys were returned to the study office where they were checked for legibility and completion. Surveys missing substantial amounts of data were not included in the data analysis. All data were double-entered into a database and then reviewed by a data manager to ensure accuracy. Data editing, including recoding and collapsing of variables and the formation of new variables, was followed by basic descriptive analysis of the data, including the calculation of means, medians, percentages, proportions, and standard deviations.
Demographic information is provided in Table 1. The sample of participants was predominantly middle-aged women mean age, Most aides 83 percent reported that English was spoken at their own home. Participants were more likely to report that they worked as a home health aide rather than as a personal assistant, and nearly 15 percent reported that they performed both jobs. Description of the sample, home health care aides, and personal assistants: Most participants had worked in the home care sector for slightly more than 8 years, but some had worked in the field for as many as 35 years.
The sample was predominantly unionized 67 percent. The vast majority of the sample 91 percent commuted to and from work i. Most aides provided care for a single patient, although some aides had as many as 10 or more patients in a typical week. Typically, patients were elderly 64 percent , long-term patients 83 percent , although adults 26 percent in long-term care 77 percent constituted a sizeable portion of their patient population.
Children 7 percent were also provided care, generally on a long-term basis 66 percent. As expected, the job duties consisted primarily of assisting with activities of daily living Table 2 , including bathing, toileting, dressing, etc. Although 24 percent of participants reported that they provided wound care, only a small proportion 13 percent reported using needles.
Performing household chores was common: Participants reported activities with the potential for back injuries and muscle strain, such as transferring patients 77 percent , walking and ambulating patients 87 percent , and turning and positioning patients 68 percent.
Self-reported compliance with infection control measures was generally good. For example, most of the aides 92 percent reported the use of gloves when the possibility of contact with blood and other bodily fluids was present. Frequent handwashing was very common 97 percent , as was the use of hand gels or foams 83 percent. Many aides 79 percent used protective aprons as a clothing barrier. Nearly all participants 92 percent reported quickly cleaning up blood or bodily fluid spills. While most aides 79 percent avoided eating or drinking in areas where the client received care, a sizeable percentage 21 percent , nevertheless, reported that this sometimes did occur.
Poor compliance was noted for handling of contaminated needles, with 66 percent of aides reporting that they usually recapped needles. Sharps containers were used by 80 percent of the sample. Personal protective gear, gowns, or aprons were reportedly available to just over half 57 percent of aides. Other protective gear, such as eye goggles and face masks, were only available to 18 percent and 34 percent of aides, respectively. Disposable gloves were the most commonly available item of personal protective gear; 89 percent of aides reported that these were readily available to them.
Eight percent of the aides reported that they felt they were at risk of exposure to contagious diseases. However, self-reported hepatitis B virus HBV vaccine rates were suboptimal; only 57 percent of participants reported that they had received all three doses, and 10 percent received only one or two doses; 2 percent reported that they had not been vaccinated, because they were HBV antibody-positive.
The majority of aides reported tuberculin skin testing i. Potential health hazards in the home Table 3 were frequently reported. Most commonly reported hazards were unsanitary conditions e. Violence, threats of violence, and abuse were also commonly perceived threats, with threatening neighbors most frequently reported 55 percent , followed by threatening family members 38 percent , threatening patients 31 percent , and aggressive pets 17 percent. Twenty-eight percent of participants reported verbal abuse, and 9 percent of the aides reported racial or ethnic discrimination.
Other potential personal safety hazards included evidence of drug use in the home 5 percent and guns in the home 2 percent. Signs of patient abuse e.
When noted, 77 percent reported this to their supervisor, but 13 percent did not, and the remainder stated that they sometimes reported the abuse. Practices that could result in harm to both the caregiver and the patient were reported by most of the respondents, for example, turning and positioning, walking and ambulating the client, and transferring and lifting the client.
Reports of hazards that could lead to slips, trips, and falls—such as excessive clutter, loose rags, etc. Poor lighting, which could also result in injuries, was also noted 5 percent. Other potential health hazards included exposure to irritating chemicals, which were mainly used for cleaning spills. Diluted bleach was most commonly used 51 percent , followed by full strength bleach 9 percent and bleach mixed with other chemicals 8 percent. Almost all aides 90 percent reported training in workplace health and safety.
This included training on safe lifting 83 percent ; the proper use of Hoyer lifts 73 percent ; electrical safety 58 percent ; fire safety and evacuation 81 percent ; personal safety 74 percent ; respiratory protection 52 percent ; slip, trip, and fall prevention 73 percent ; and standard precautions and infection control 78 percent.
However, in the past 12 months, 6 percent said they did not receive any safety training, and 53 percent reported receiving only one to two sessions of safety-related training, including infection control. Roughly one-third 36 percent of the aides reported receiving three or more safety-related training sessions in the previous 12 months. These results document a high prevalence of a number of health and safety hazards associated with home care. They generally support earlier, primarily qualitative findings on home health hazards and establish that home care patients and HHCWs may be at risk of exposure to a range of unsafe conditions.
While this large data set was limited to just one geographic area, it is representative of the New York City home care aides population and is most likely representative of any large urban area in the United States. Several aspects of these findings deserve special mention. First, the infection control practices, although generally acceptable, were suboptimal in certain areas.
The lack of availability of even the most basic personal protective equipment, such as gloves 11 percent and aprons 43 percent , is worrisome. These needles are often left for disposal by the aide. If sharps containers are not provided, aides recap before discarding them in the regular trash or, in some cases, into household containers. Given the fact that more than 50 percent of the aides received safety-related training only once or twice a year or less, additional training, specifically on infection control, appears warranted.
Agencies should not only ensure that aides have all the necessary equipment and supplies, but also that they are trained in their proper use. This is especially true for safe transfer equipment, such as Hoyer lifts, which can be difficult to use. However, very few aides actually had these available to them. Unsanitary conditions were quite common. During questionnaire development, the study team conducted field observations and, almost uniformly, observed clutter, unhygienic practices, poor lighting, overheating, and loose rugs.
The quantitative data presented here confirm these observations. These conditions may result from the inability of patients—many of whom are infirm and elderly and often live alone with few resources—to maintain a safe and orderly household. In some cases, the personal care attendant does perform household chores and thus has more control over the situation. However, in cases where other household members perform these chores, additional training or support may be required. Policies and procedures for addressing this issue should be the subject of further inquiry and interventional studies.
This is important, not only in terms of the risk that unsanitary conditions present for the transmission of infectious disease, but also because some of these hazards increase the risk of injury e. Hepatitis B vaccination rates were generally lower than recently published rates for other health care work groups. A large sample of nonhospital-based registered nurses had an 84 percent rate of complete series. Under the Bloodborne Pathogens Standard, home health aides would be classified as having potential risk of exposure to blood and potentially infectious materials.
Therefore, the hepatitis B vaccine and annual bloodborne pathogen training must be offered to them at no cost. Given the close personal contact with patients and body fluids, such low rates of HBV vaccine coverage are a concern. Since infected aides might also present a risk of HBV transmission to their patients, universal vaccination should be encouraged and supported.
The perception of risk of personal injury was high. Threatening neighbors, clients, and family members; dangerous neighborhoods; and the presence of illicit drugs and guns in the home increased this perception. As noted in earlier studies, verbal abuse was common. A large proportion of our HHCW sample 68 percent reported that they can refuse a case, and 65 percent said that they had done so in the past.
These results are somewhat lower than those reported by Kendra, et al. It was telling that, while all administrators in the Kendra, et al. The potential adverse impact on patients who were refused was acknowledged by both administrators and staff in that study.
Personal Security in a Violent World
In our sample, in cases where aides refused to provide care, it is unknown how this affected their employment or the provision or quality of the care their patients received. Agencies and staff have implemented several strategies to improve the safety of home health care staff. These include extensive preplanning, personal escorts, frequent communication, providing cell phones, additional training, and encouraging staff to carry chemical spray and weapons.
Other strategies that have been considered include alternative care sites, early morning visits, and reliance on local police for protection. This study had several strengths and limitations. As noted, the sample was confined to one geographic area, although aides were employed by many different agencies, and the sample demographics were representative of New York City aides as a whole. Because the survey was available only in English, there may have been response bias. However, in instances where it was requested, the questions were read out loud, which may have mitigated this bias to some extent.
Also, in order to be employed in New York State, aides were required to have at least a basic understanding of the English language. Another potential concern is that aides may have given socially desirable responses to some of the sensitive questions e. However, the surveys were anonymous, and there was no evidence that certain questions were left largely unanswered. In summary, this study presented evidence from a large sample of home health aides indicating a high prevalence for certain home care-associated health hazards, many of which might be amenable to intervention.
Much more research is needed in this understudied health care sector. Additional risk assessment studies, especially targeting home care patients, and intervention-type studies are especially warranted. The underlying question of these home care-associated hazards is the extent to which they adversely impact patient quality of care.
When staff are concerned about personal risk and are at risk of exposure to numerous and varied health hazards, quality of care may be compromised. Unaddressed household health hazards also present a direct risk to the health and safety of the patient and other household members. The financial constraints currently imposed on agencies are significant and may only increase with time.
Agencies need to be reimbursed adequately so that aides can be hired as full-time employees with eligibility for benefits, including health care benefits.
Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment).
Training time, both for trainers and trainees, must also be reimbursed so that training does not impose a financial hardship. Adequate funding is also needed for appropriate safety equipment and supplies. The impetus for improvements for reimbursement is made clear in a timely article on the pathways to improvement in the health of the U. In order to improve the health and well being of home care populations, these larger issues will require policy changes at the highest levels. Turn recording back on. And this trail is followed assiduously not just by giant corporations, but also by governments and their security services — as vividly illustrated by the revelations of Edward Snowden.
What's astonishing is how unconcerned many people appear to be about this. Is it because they are unaware of the extent and comprehensiveness of the surveillance? Or is it some weird manifestation of Stockholm syndrome — that strange condition in which prisoners exhibit positive feelings towards their captors? What we've learned above all from the Snowden leaks is that the scale and capability of the NSA surveillance are much greater than anyone imagined. But nobody realised that, as the latest revelations showed, all the encryption technologies routinely used to protect online transactions https, SSL, VPN and 4G encryption , plus anything going through Google, Microsoft, Facebook and Yahoo, have been cracked.
What this means is that no form of electronic communication handled by commercial companies can now be assumed to be secure. What can you do if you're someone who feels uneasy about being caught in this web?
Internet security: 10 ways to keep your personal data safe from online snoopers
The honest answer is that there's no comprehensive solution: But there are things you can do to make your communications less insecure and your trail harder to follow. Here are 10 ideas you might consider. Rethink your email setup. Assume that all "free" email and webmail services Gmail etc are suspect. Be prepared to pay for a service, such as Fastmail ,that is not based in the US — though some of its servers are in New York with backups in Norway. My hunch is that more non-US email services will appear as entrepreneurs spot the business opportunity created by the Snowden revelations.
It would also be worth checking that your organisation has not quietly outsourced its email and IT systems to Google or Microsoft — as many UK organisations including newspapers and universities have. The real difficulty with email is that while there are ways of keeping the content of messages private see encryption , the "metadata" that goes with the message the "envelope", as it were can be very revealing , and there's no way of encrypting that because its needed by the internet routing system and is available to most security services without a warrant.
Encryption used to be the sole province of geeks and mathematicians, but a lot has changed in recent years. In particular, various publicly available tools have taken the rocket science out of encrypting and decrypting email and files. GPG for Mail , for example, is an open source plug-in for the Apple Mail program that makes it easy to encrypt, decrypt, sign and verify emails using the OpenPGP standard.
And for protecting files, newer versions of Apple's OS X operating system come with FileVault , a program that encrypts the hard drive of a computer. Those running Microsoft Windows have a similar program. This software will scramble your data, but won't protect you from government authorities demanding your encryption key under the Regulation of Investigatory Powers Act , which is why some aficionados recommend TrueCrypt , a program with some very interesting facilities, which might have been useful to David Miranda.
Since browsing is probably what internet users do most, it's worth taking browser security and privacy seriously. If you're unhappy that your clickstream the log of the sites you visit is in effect public property as far as the security services are concerned, you might consider using freely available tools such as Tor Browser to obscure your clickstream. And to protect yourself against the amazingly brazen efforts by commercial companies to track your online behaviour you should, at the very minimum, configure your browser so that it repels many of these would-be boarders.
The message of the Snowden revelations is that you should avoid all cloud services Dropbox, iCloud, Evernote, etc that are based in the US, the UK, France and other jurisdictions known to be tolerant of NSA-style snooping. Your working assumption should be that anything stored on such systems is potentially accessible by others. And if you must entrust data to them, make sure it's encrypted.
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An option that an increasing numbers of people are exploring is running their own personal cloud service using products such as PogoPlug and Transporter that provide Dropbox-type facilities, but on internet connected drives that you own and control. Delete your Facebook account.
Why do the CIA's work for it? And if you must use it, don't put your date of birth on your profile. Why give identity thieves an even break?