preventing home fall injuries - monash universitydesign concepts so that all home will be friendly...

VICTORIAN INJURY SURVEILLANCE & APPLIED RESEARCH UNIT HAZARD 59 page 1

Hazard(Edition No. 59)Summer 2005Victorian Injury Surveillance& Applied Research System (VISAR)

www.monash.edu.au/muarc/visar

Monash UniversityAccident Research Centre

This edition of Hazard is mainly focused on analysing the latest Victorian injury surveillance data on home fall injuries that areamenable to structural and design solutions.

Preventing home fall injuries:structural and design issues and solutionsAjith GunatilakaAngela ClappertonErin Cassell

SummarySignificant proportions of fatal and non-fatalunintentional injury occur in the homeenvironment. Analysis of the latest year ofinjury surveillance data for Victoria showsthat the home was the location of 16%(n=166) of all unintentional injury deaths in2002 and 23% (n=19,560) of unintentionalinjury hospital admissions in 2002/3.

Falls are the major cause of home injury.Falls in the home accounted for approx-imately one-fifth (n=31) of all unintentionalhome injury deaths that occurred in 2002,and two-thirds (n=12,977) of home injuryadmissions in 2002/3. One-third ofunintentional home injury EmergencyDepartment presentations were also fall-related (n=24,608).

Research indicates that a large number ofthese home fall-related deaths and injuriesare related to structural or design features ofthe home.

Inappropriate flooring material and pavingand poorly designed or constructed stairs,steps, windows and balconies are the mostfrequently identified structural features ofthe home that contribute to home fall injury.Slippery and non-impact absorbing flooringmaterials and small level changes in floorsare common hazards.

Research also shows that stairs with one ortwo steps, inappropriate geometry, or non-uniform dimensions, and stairways withpoorly designed or no handrails areimplicated in a high number of fall-relatedinjuries and deaths. Falls from or throughbalconies and windows are another cause ofhome fall injury.

RecommendationsDesign and materials engineering solutionsthat eliminate structural deficiencies havethe potential to reduce home fall injuries.

Measures such as requiring slip resistantflooring in toilets, bathrooms, kitchens, andlaundries and the use of appropriatelydimensioned stairs and handrails in all homesare recommended.

Australian building codes should mandateAustralian Standards based on universaldesign concepts so that all home will befriendly to all users especially children, theelderly and disabled.

This issue also includes a supplementaryreport on hand entrapment (finger jam)injury in doors. This is another cause ofhome injury that appears amenable toinnovative design solutions.


IntroductionUnintentional home injury, especiallyfalls, are a significant problem in Victoria.In 2002, 166 Victorians died, and afurther 20,000 were admitted to hospital,as a result of unintentional injuries thatoccurred in the home environment. Thetoll of home injury on the health ofVictoria is not well recognized bygovernment and the community with theresult that home injury prevention isrelatively under-resourced.

In this issue of Hazard, measures toaddress falls in the home, the major causeof unintentional home injury, arediscussed, with an emphasis on identify-ing the design and structural elements ofthe home that contribute to fall injury,and potential solutions. Analysis of thelatest available year of injury surveillancedata (2002 for deaths and 2002/3 forhospital-treated injury), showed that fallsin the home accounted for 19% of allunintentional home injury deaths, two-thirds of unintentional home injuryhospital admissions and one-third ofunintentional home injury EmergencyDepartment presentations. In these years,the home was the highest-ranked locationfor hospital-treated unintentional injury(admissions and ED presentations) andthe second-highest ranked location forunintentional injury fatalities, behindtransport locations.

Significant reductions in injury mortalityand morbidity have been achieved in theroad transport setting by designing roadinfrastructure to be more forgiving andmotor vehicles to be crashworthy1,2.There is emerging evidence that past useof building regulations to improve homesafety (such as those mandating that hotwater systems deliver bathroom tap waterat a maximum temperature of 50∞C,fitting of smoke alarms, erection of safetybarriers around home swimming pools,and the use of toughened glass in doorsand windows) are beginning to showbenefits in terms of injury reductions.

For example, analysis of the yearly trendin scald injury hospital admission ratesfor young children and older people aged

70 years and over indicates that the rateof hot water scald admissions hasdecreased in both groups since regula-tions were introduced in 19983. From1996/7 (the year before the publicityleading up to the introduction of the hottap water regulation) to 2002/3, theannual scalds hospitalisation rate foryoung children has decreased by 12%per year on average and the scaldshospitalisation rate for the elderly hasdecreased by 6% per year on average.

Home falls are the other obvious priorityfor injury prevention through safe design.This report reviews the latest injurysurveillance data and research literatureon the prevention of home fallsóincluding same level falls, falls from stairsand steps and falls from balconies andwindowsóto identify intervention pointsand preventive strategies and measureswith a focus on design solutions.Potential areas for further research arealso identified.

MethodInjury data for this report were obtainedfrom the Australian Bureau of Statisticsñ Death Unit Record File (ABS-DURF),Victorian Admitted Episodes Dataset(VAED), and Victorian EmergencyMinimum Dataset (VEMD) (See Box 1at the end of this report for more detailsof data sources and extraction methods).An Internet search using Google and aliterature search of Medline wereundertaken to identify the latest researchfindings on the epidemiology andprevention of same level falls (slips, tripsand loss of balance) and falls from stairsand steps, balconies and windows.

Background

Pattern and causes ofhome fall injuryAnalysis of the latest available year ofinjury surveillance data (2002 for deathsand 2002/3 for hospital-treated injury),showed that falls caused 19% (n=31) ofall unintentional home injury deaths, 66%

(n=12,977) of home injury hospitaladmissions and 32% (n=24,608) of homeinjury Emergency Department presenta-tions.

Table 1 shows the detailed breakdown ofthe causes of home fall injury deaths,hospital admissions and emergencydepartment presentations for the latestavailable year of injury surveillance data.The specific cause of the fall was notgiven in 24% of fall hospitalisations(n=3,067 cases) recorded on the VAED.Fall injury ED presentations are classifiedinto only two causal groups on theVEMD: ëFall-low (same level or lessthan one metre, or no information onheight)í and ëFall-high (greater than 1metre)í. For this comparative analysis,presentations were re-classified to matchICD-10 falls cause codes (Table 1) basedon information in case narratives. Only35% (n=8,703) of falls ED presentationscould be re-classified to falls sub-causecodes; the remainder were classifiedunder ëother same level fallsí or ëotherdifferent level fallsí.

ï Different level falls carry a higher riskof fatal consequences ñ 61% of falldeaths are caused by different levelfalls yet they comprise just over one-quarter of fall admissions and EDpresentations. Different level fatalfalls most frequently involved stairsand steps (23%), ladders (13%) andbuildings and structures (10%).

ï Same level falls accounted for half offalls admissions and three-quarters ofED presentations. In 2002/3 hospitaladmissions for same level falls codedto slips (fall due to slipping oncontaminated or polished surfaces),trips (fall due to tripping on or overperson, animals, objects and otherprojections and indentations), andstumbles (fall due to loss of balance)were disaggregated. Of the 4,140slip, trip and stumble admissions, 33%were slips (n=1,377), 55% were trips(n=2,272) and 12% were stumbles(n=491). Analysis of VEMD narrativedata indicates that of the 2,856 samelevel slip, trip and stumble EDpresentations, 42% were slips (n=1,200),


57% were trips (n=1,631) and 1%(n=25) were stumbles.

Age and gender patternsOver the 3-year period 2000-2002, thehome fall fatality frequencies and rateswere much higher in older persons (fromage 65 years), than in children aged 0-14years and adults aged 15-64 years (Figure1). The male fatality rate was muchhigher than the female rate for all 5-yearage groups from age 15 years, excludingages 15-29 when the rate was the samefor males and females (Figure 1).

The home fall hospital admission ratewas higher for older Victorians,increasing almost exponentially with agebeyond 40 years (Figure 2). From age 50years, females have a higher home fallshospitalisation rate than males (Figure2). Analysis of the frequency of homefall hospitalisations over the same periodshowed that 30% of hospital admissionsoccur among persons aged less than 65

Causes of unintentional home fall injury deaths (2002), hospital admissions and Table 1Emergency Department presentations, non-admissions (2002/3), Victoria

Source: Deaths: ABS DURF, 2002; Hospital Admissions: VAED, 2002/3; Hospital ED presentations: VEMD, 2002/3

years (Figure 3) suggesting the issue ofhome falls should not be overlooked inthe younger age groups.

Rates cannot be calculated for EDpresentations due to incomplete injurydata as not all Emergency Departmentscontributed to VEMD in 2002/3.Analysis of frequency data revealed thathome fall injury presentations werehighest in children, peaking in 0-4 yearolds (Figure 4). Males were over-represented in all 5-year age groups toage 29 years, whereas females were morelikely than males to present to ED withhome fall injuries in all age groupsupwards of age group 30-34 years.

Interventions toreduce injuryThe analysis of fall injury data aboveidentified a number of areas whereimproved home design and construction,

and tighter controls at the home buildingstage, could lead to significant reductionin falls and fall injury in the home. Theseinclude strategies and measures to supportthe widespread installation of slipresistant surfaces and impact absorbingsurfaces throughout the home, andimprovements in the design and construc-tion of stairs and steps, high windowsand balconies

1. Installation of slip-resistantsurfaces in domestic housing

Analysis of hospital-treated data for theyear July 2002-June 2003 showed therewere 1,377 admissions and at least 1,200ED presentations for fall injuries resultingfrom slips in the home.

ï Females accounted for 75% of slip-related fall admissions (n=1,033) and57% of ED presentations (n=682)

ï Seniors aged 75 years and olderaccounted for more than 50% of


ï The most frequently occurring injuryamong ED presentations was fracture(n=335, 28%), followed by openwounds (n=283, 24%) and sprains orstrains (n=252, 21%). Upper extremityinjuries were more frequent (n=370,31%) than lower extremity injuries(n=329, 27%).

More detailed analysis of the locationsand surfaces involved in ED presentationsfor slips utilising word searches ofnarrative data yielded the followingadditional information.

ï Specific information on the location(room) or the surface/item involvedwas used to classify slips as occurringindoors or outdoors. This informationwas available in 71% of slipsnarratives (n=848). Sixty per cent ofslips occurred indoors (n=512) and40% occurred outdoors includingverandah/garage/shed (n= 336)

ï Of the 332 case narratives of indoorslips that specifically mentioned theroom in which the slip occurred, 222(67%) occurred in the bathroom(including bath, shower stall and spa),59 (18%) occurred in the kitchen and36 (11%) occurred in the lounge/living/rumpus room. Of the 179 casenarratives of outdoor slips thatspecifically mentioned the site of theslip, 120 (67%) occurred in the yard/garden, 24 (13%) occurred on thedriveway/path, 10 (6%) occurred onswimming pool surrounds and 8 (5%)occurred in the workshop/garage.

ï The type of surface on which theperson slipped was not well docu-mented in narratives. Specified indoorsurfaces included tiles, timber andwood, carpet and rugs, lino, marble,shelves, cot, couches, tables and benchtops. Specified outdoor surfacesincluded concrete/cement, grass,stones, bricks, and gravel.

Only 10% of the 1,200 slip narrativesmentioned that the surface was wet at thetime of the slip. The literature, however,suggests that slips typically occur on wetsurfaces or a surface contaminated withoil, grease, dust, dirt or some sort ofspillage4-7.

Crude mean annual rate (per 100,000 population) Figure 1of home falls deaths by gender, Victoria 2000/02

Note: Frequencies are total frequencies over the three-year period not mean annual frequencies.Source: ABS-DURF 2000-2002.

Crude mean annual rate (per 100,000 population) Figure 2of home falls hospital admissions by gender,Victoria July 2000-June 2003.

Source: VAED July 2000 to June 2003.

admissions for slip injuries (n=716,52%), yet this age group made uponly 10% of ED presentations(n=125). Note that ED presentationsdata under-estimate cases of slips dueto the generally poor quality of thenarrative data describing the falls forthe older age groups.

ï Children aged 0-14 years comprised32% of presentations (n=380) yet only5% of admissions (n=63)

ï Among admissions, almost two-thirdsof slip injuries were fractures (n=888,65%). Upper extremity injuries (n=668,49%) were more common than lowerextremity injuries (n=304, 22%)


better suited to the lifestyle of manyolder residents because these homesgenerally have less fall risks.Surprisingly, in the sample of homesthat was inspected it was found that agreater percentage of trip and slipproblems existed in one-storey homes asopposed to two-storey homes.

Prevention of slipping requires theprovision of an appropriate level offriction between shoe soles or bare feetand floors. Given the difficulty ofcontrolling the types of shoes peoplewear, the development of tests formeasuring the slip-resistance ofpedestrian surfaces is regarded as themore important of the two and receivedpriority attention from StandardsAustralia from the mid-1990s. TheAustralia/New Zealand StandardGuidelines for Safe Housing Design(ANZS 4226-1994) rates most of thetypical flooring materials currently usedin domestic homes as very poor to fair interms of general slip-resistant character-istics when wet9 (although the source ofdata for the ratings is not specified).This suggests that an effective strategyfor preventing injurious slips could be torequire, by way of regulation, theinstallation of slip-resistant flooring andsurfaces in ëwetí indoor areas (thekitchens, laundry and bathroom includingbaths and shower bases) and pedestrianoutdoor areas of new houses, and inexisting houses when renovationsinvolving wet areas are being carriedout. Australian Standard AS 4299 ñ199510 on adaptable housing requiresfloor surfaces in bathrooms, laundries,toilets, kitchens and all external pavedsurfaces to be slip-resistant to complywith AS/NZS 3661.111. AS 1428.112 andAS 1428.213 on design for access andmobility also require slip resistantsurfaces for disabled access.

Standards Australia Handbook 197: 2005(in preparation), a revision of Standardof Australia Handbook 197:199914, Anintroductory guide to the selection ofslip resistant surfaces will establish abasis for specifying pedestrian surfacematerials for various locations based on

Mean annual frequency of home falls hospital Figure 3admissions by age and gender, Victoria July 2000-June 2003

Source: VAED July 2000 to June 2003.

Mean annual frequency of home falls hospital Figure 4presentations by age and gender, Victoria July 2000-June 2003

Source: VEMD July 2000 to June 2003.

A similar picture emerges from a reporton home inspections carried out byArchicentre from January 2000 to August2002 in 11,264 homes in MelbourneMetropolitan and 2,771 homes in ruralVictoria occupied by older residents over60 years of age8. Trip and slip hazardswere found in 19% of the homes. Themost common structural slip and triphazards found were shower bases,defective floor finishes, dangerous

staircases and obstacles like protrudingdoor thresholds. These homes are not anunbiased random sample of Victoriaíshome stock. Nevertheless, the report onthese inspections highlights importanthome hazards encountered by the home-dwelling elderly in Victoria.

About 91% of older homeownersincluded in the sample of homes inspectedlived in single-storey homes, which are


wet slip resistance classifications thatare obtained when testing surfacematerials to the newly published standardAS/NZS 4568: 2004 Slip resistanceclassification of new pedestrian surfacematerials15. The revised handbook willinclude new recommendations fordomestic residences and balconies. AS/NZS 4568: 2004 provides manufacturerswith a range of test methods that can beused to classify slip resistance of theirmaterials. The Standard for measuringthe slip resistance of existing pedestriansurfaces (AS/NZS 4663: 2004 Slipresistance measurement of existingpedestrian surfaces) has also been revisedand recently published16.

The updated Standards provide a soundbasis for developing building regulationsto require the installation of slip-resistantsurfaces in internal wet areas and externalpedestrian areas of new and renovatedhomes. The Local Government andShires Associations of NSW are consider-ing action to require that residentialpremises meet minimum levels of slipresistance and have taken the positionthat it is unacceptable to issue certificatesof occupancy where new and renovatedbuildings have floors that pose a sliphazard17. The Associations are seekingto have the recommendations forresidences in the revised HB 197referenced into the Building Code ofAustralia (BCA)17. The effectiveness ofthese standards and codes should beevaluated.

Extending the slip resistance require-ments to all housing by adopting auniversal design approach will not onlymake homes friendly for the elderly anddisabled, but also reduce injuries for allusers.

A strategy to encourage owners ofexisting homes to increase the slipresistance of existing in situ surfacesshould also be developed. Hard floormaterials such as tile, granite, andterrazzo are popular in domestic kitchens,laundries, dining rooms, toilets andbathrooms. These floors are widely usedin public places such as restaurants,

building lobbies and shopping malls aswell because of appearance, resistanceto wear, and ease of maintenance.However, these smooth surfaces offerlittle slip resistance, particularly whenwet, unless especially treated in themanufacturing process. Falls on thesehard surfaces can result in severe injuriesbecause they do not offer any impactabsorption.

Methods such as safety grooving, acidetching, blasting, grinding, paint andsand, and a number of proprietarychemical treatments can be used toimprove the slip resistance of existingflooring11. Safety grooving techniqueinvolves making permanent, shallow,circular groves using a diamond tool intoexisting tile or concrete floors to channelwater away from the surface to minimizehydroplaning and improve traction18.One disadvantage of this process is thatit changes the visual appearance of thefloor.

Acid etching and some proprietarychemical treatments improve the slipresistance by creating micro-pits on thesurface19 or by growing tiny abrasivecrystals onto the floor surface18. Thesechemical treatments may not be suitablefor all hard surfacing materials11 and theeffectiveness of these treatments maydepend on the strength of the solution,the time of exposure, and the temperature.Because liquids are susceptible to gravitythey tend to flow down slopes and groutjoints. The raised portions of floors thatpeople tend to walk on may receive lesstreatment than depressed areas (Personalcommunication, Richard Bowman,CSIRO, December 2004).

Microscopic pits may become pluggedby sediment particles, which can impairslip resistance and visual appearance ofthe surface. The roughened surfacescreated through chemical treatment maymake the previous cleaning processesless effective. Some proprietarytreatments require the use of expensivecleaning products to maintain the slipresistance (Personal communication,Richard Bowman, CSIRO, December2004).

While many proprietary chemicaltreatment processes claim to improvethe slip resistance of tile, stone, terrazzo,and concrete surfaces, these claims ofeffectiveness need to be verified usingindependent systematic scientific studies.The longevity of treatments, cost,maintenance requirements etc. also needto be assessed before these products canbe recommended.

According to the ABS Safety in the HomeMelbourne survey in 1992, 114,700(35.4%) households with older residentsand 193,000 (24.3%) households withoutolder residents had slip-resistant surfacesin the bath or shower20. Seriousconsideration should be given to thedevelopment of a standard and associatedregulation to ensure that only slip resistantbaths and shower bases are installed inVictorian homes. Local and overseasmanufacturers would then be encouragedto develop design solutions that make allbath and shower bases slip resistant.

2. Installation of impactabsorbing floor surfaces

The properties of surfaces associated withfalls are a major determinant of injuryseverity. Hard, non-resilient surfacesproduce large impact forces and causesevere injuries. Soft impact absorbingsurfaces tend to cushion a fall and reduceinjury severity.

Information on the types of surfacesinvolved in injurious falls can provide someuseful clues about the safety implicationsof different floor types. However, thisinformation is not systematically enteredin Victorian injury surveillance databases.The only current source of surveillancedata on fall surfaces can be found in textnarrative data entered in the VEMD.Analysis of home fall injury narrativesrecorded on the VEMD between July 2002and June 2003 showed that the specificsurfaces on which injurious falls occurredwas identified in only 6% of EDpresentations for falls (n=1,355/24,608),so reliable data are lacking. Table 2 showsthe specific surfaces as a percentage of allrecords where a surface could be identified.Concrete (n=421, 31%) and tiles (n=220,


16%) were the most prominent of theidentified specific surfaces. Weconservatively estimate from these datathat two-thirds of injurious home fallsrequiring hospital treatment are onto hard,non-impact absorbing surfaces. There isno exposure data on hours of pedestrianuse of the various surfaces in the home.

Maki and Ferni studied impact forces ona number of common floor coveringmaterials using a fall simulator21. Thesimulator height and weight were chosento simulate a 50th percentile elderly (aged65-79 years) female. The drop heightwas selected to simulate a fall from anerect standing posture. This studyindicated that linoleum, vinyl, vinylcomposition, terrazzo, and wood tilefloorings have the poorest impactattenuation. Padded carpet provided thebest impact attenuation. A clinical studybased on 864 falls and 18 hip fracturesfor five types of floor coverings,conducted by Booth et al showed thatcarpet results in fewer hip fractures inproportion to the number of falls, andthat vinyl and concrete floors result inhigher proportions of hip fractures22.These researchers also confirmed thisdependence of fracture incidence on floor

covering type experimentally, using animpact transducer23.

Carpet can attenuate impact during a falland reduce severity of injury. In additionto providing more comfort than hardfloor covering, carpet also reduces noise,glare, and slipperiness. If incontinenceis an issue, then maintaining carpetbecomes difficult. Urine and other spillspenetrate through the backing into thesubfloor causing odours. Because carpettends to encourage dust mites, its usagemay be problematic for persons who haveasthma and allergy. Movement ofwheeled equipment, including wheel-chairs, require larger push and pull forceson soft surfaces such as carpet and Flotexcompared to those on hard surfaces suchas tile or vinyl24.

A new material called PowerBond RS,which combines the benefits of soft-surface floor covering with the durabilityof sheet vinyl, is gaining popularity innursing homes in USA25,26. PowerbondRS has a superdense surface constructedof single filament tufted nylon carpetloops and a solid sheet of cushionedvinyl backing27. The manufacturer claimsthat Powerbond RS is easy to install,improves thermal and acoustic qualities,

reduces glare, provides good slipresistance while reducing the resistanceto wheeled equipment, and is easy tomaintain. While soil and spills can seepthrough regular carpet or the edges ofVCT, leading to breeding of bacteria,Powerbond RS eliminates this and thepossibility of trapped moisture under thefloor covering by providing a non-flow-through vinyl backing and chemicallywelded seams. However, this productneeds to be independently evaluated todetermine the validity of the claimedbenefits and the suitability for domesticuse.

Casalena et al have reported, in 1998, aconcept of a safety floor called PennState Safety Floor (PSSF) that attemptsto simultaneously achieve two competingdesign goals necessary for preventingfall injuries28,29. The first design goal isthat the flooring system needs to remainrelatively rigid during normal daily livingactivities such as walking. The seconddesign goal is that the floor shouldeffectively minimize peak forcesexperienced by a femur during a fall-related impact. These researchers usedcomputer simulation and experimentationusing a fall simulator to measure peakfemoral neck force during a fall impacton the PSSF. A prototype surfaceachieved a 15.3% reduction in peakfemoral neck force while exhibiting lessthan 2mm deflection during normalwalking. Furthermore, the top surface ofthe PSSF returned to within 0.2mm of itspre-impact configuration after 5min fromthe impact, demonstrating that thissurface is resilient and need not bereplaced after experiencing a fall relateddeflection. Although this safety floorsystem seems to be a promising approachfor preventing hip injury, furtherdevelopments of this product could notbe found in the literature or on theInternet.

Independent testing should be undertakento substantiate the claims made by themanufacturers of innovative floorcovering and flooring including invest-igations of their suitability for domesticuse, especially in housing developments

Fall surfaces identified in home falls case narratives, Table 2VEMD July 2002-June 2003 (n=1,355)

Source: VEMD July 2002 to June 2003.


aimed at the seniorsí market. Also,further research is required to developimpact-absorbing flooring that canattenuate sufficient energy to consistentlyreduce peak impact forces transmitted tothe femur to levels below fracturethreshold.

3. Improving the design andconstruction of stairs andsteps

According to Safety in the Home surveysconducted by the ABS in 1992 and 1998,the number of households in Melbournewith inside steps or stairs increased from270,000 to 354,800 between the twosurveys, and the proportion of houseswith steps or stairs also increased, from24.1% to 28.6%20,30. Furthermore, thenumber of households where older peoplewere resident with steps or stairsincreased from 62,000 to 78,700 from1992 to 199820,30. It is probable that theexposure of the population to steps andstairs in domestic dwellings has increasedsince 1998 as the trend toward higherdensity housing has continued, with aconcomitant increase in the risk of fallson and from stairs and steps. This trendtowards higher density housing is alsopredicted to continue in Melbourne.

Pattern and trend in stair andstep home fall injuryAlthough the deaths, hospital admissions,and hospital presentations for fall injuryon and from stairs and steps in the homeare fewer in number than same level falls(Table 1), when extent of usage(exposure) is taken into account, stairsare clearly a relatively hazardousstructural feature of the home31.

Analysis of Victorian home falls data for2002, showed that there were 7 deaths(23% of home fall deaths) caused byfalls from stairs and steps (Table 1), fouradult males aged over 35 years and 3females aged over 70 years. Stair andstep fall injury also accounted for 7%(n= 894) of home fall hospital admissionsand at least 6% (n=1,493) of home fallsED presentations (Table 1).

The frequency of stair and step fall injuryhospitalisations increased by more than70% over the decade 1993/4 to 2002/3(from 373 admissions per year on averagein 1993/6 to 639 admissions per year onaverage in 2000/3). In males, theirfrequency increased by 95% (from 103admissions per year on average to 202)and in females by 62% (from 270admissions per year on average to 438).

Age-adjusted rates were calculated toexamine the trend in hospital admissionsfor stairs and step falls (Figure 5). Sameday records were excluded to reduce theinfluence of changes to admissionspolicies over the period. To reduce theeffect of year-to-year fluctuations due torelatively small numbers, the analysescompare the 3-year average admissionrate at the start of the decade to the 3-year average at the end.

The all-persons stair and step fall injuryhospital admission rate increased by 47%over the decade, from 9 admissions/100,000 population per year on averagein 1993/6 to 13.1 admissions/100,000population in 2000/3. The male injury

hospital admission rate increased by 68%(from 5/100,000 to 8.4/100,000) and thefemale rate increased by 39% (from 12.8/100 to 16.2/100,000).

How much of the increasing trend is dueto increased exposure to steps and stairsin the home is not known. However, themajor escalation in both the frequencyand rate of stair and step home fall injuryin Victoria over the past decade highlightthe importance of designing andconstructing safer stairs and steps inVictorian homes.

The crude mean annual rate of hospitaladmissions for stairs and steps fall injuryincreases almost exponentially with agebeyond 40 years (Figure 6) similar to theall-cause home falls injury rate. Olderfemales were over-involved in hospitaladmissions for stair and step fallscompared to males. Other studies haveconsistently reported that older femalesform a greater proportion of hospitaladmissions for stair and step fall injurythan older men32-34.

The frequency and rate of hospitaladmissions for stair and step fall

Trend in stair and step home fall hospital admission Figure 5rates, by gender, Victoria July 1993- June 2003.

Source: VAED July 1993-June 2003


The pattern of hospital-treated stair andstep fall injury among children and adults,separately, is summarised in Tables 3and 4. Among children aged 0-14 years,males were over-represented in bothadmissions and ED presentations dataand the hospital admission rate andfrequency of ED presentations was muchhigher in 0-4 year olds compared to olderchildren. Head and neck injuriespredominated in both admissions andpresentations. Fractures and openwounds were the most common injuries.

Amongst adults aged 15 years and older,females were much more likely thanmales to be hospitalised or present to EDwith injuries from stairs and step falls.Hospital admission rates increased withage, as did the frequency of EDpresentations. By far the most commoninjury among admitted cases was headinjury, followed by upper extremityinjury, whereas lower extremity injury(mostly to the ankle and foot) was themost common injury among ED presenta-tions. Fractures were the most prominentinjury among admitted cases, whereasdislocations/sprains and strainspredominated in ED presentations.

Victorian injury surveillance systemsrecord only sparse detail on the circum-stances of the fall. Research indicatesthat most stair falls occur during descentand these tend to cause relatively seriousinjuries such as fractures35. Many fallsduring descent occur when the user missesthe next lower tread or catches their heelon the nosing or the riser, which pushesthe user forward causing a forward fall.A fall during descent may result in alarge initial impact followed by severalsmaller subsequent impacts on a numberof steps as the user descends the fullflight35.

Falls that occur during ascent are usuallyless severe because they tend to betowards the higher steps and involverelatively small impacts35. Some of thesefalls occur as a result of the toe trippingon the stair nosing as the foot swingsupward. Another possible fall scenarioduring ascent is the user misjudging the

Crude mean annual rate (per 100,000 population) Figure 6of stair and step home fall hospital admissionsby age and gender, Victoria July 2000-June 2003

Note: Frequencies are total frequencies over the three-year period not mean annual frequencies.Source: VAED July 2000-June 2003

Mean annual frequency of stair and step home fall Figure 7hospital ED presentations by age and gender,Victoria July 2000-June 2003

Source: VEMD July 2000-June 2003

hospitalisation increase as age increasesfrom age 15 years until persons aged 75years having the highest frequency andrate of all age groups (Table 3+4).Among child hospitalisation the youngestchildren have the highest frequency andrate of stair and step falls hospitalisation.This indicates that very young childrenand older adults should be the special

target of stair and steps falls intervention.Importantly, however, Tables 3 & 4 showthat when frequency is considered, 57%of admitted cases of step and stair relatedfall injuries and 93% of ED presentationswere less than 75 years of age. Thisclearly indicates that step and stairinjuries are not only a problem of thevery young and the very old.


Frequency and pattern of hospital-treated home injury caused by stair and step falls, Table 3children 0-14 years, July 2000 to June 2003

Sources: Hospital admissions: Victorian Admitted Episodes Dataset (VAED) July 2000 to June 2003Emergency department presentations (non-admissions): Victorian Emergency Minimum Dataset (VEMD) July 2000 to June 2003


Frequency and pattern of hospital-treated home injury caused stair and step falls, Table 4adults 15 years and older, July 2000 to June 2003

Sources: Hospital admissions: Victorian Admitted Episodes Dataset (VAED) July 2000 to June 2003Emergency department presentations (non-admissions): Victorian Emergency Minimum Dataset (VEMD) July 2000 to June 2003


next tread position resulting in an under-step and miss, or slip-off the edge of theupper step.

Preventing stair and step homefall injuryThere are at least three major factors instair falls: user behaviour, maintenance,and design35. User behaviour-related fallsinclude those caused by running on stairsor tripping on objects placed on steps.Maintenance-related stair injuriescomprise injuries caused as a result ofbroken treads or handrails, loose staircoverings or nosings, or slips due toexcessively polished stairs. Althougheducational programs such as safetycampaigns can target user behaviour andmaintenance-related falls, these havelimited effectiveness as they requireconsistently applied changes in userbehaviour. Design solutions, on the otherhand, have the potential to be moreeffective in preventing stair injuries.Priorities for improved safety andusability of stairways are: appropriatestep geometry, visibility of the steps, andprovision of functional handrails31.

Improving stair and step geometryThe number of steps or risers is animportant design parameter that affectsfall risk on stairs. Several researchershave found that a disproportionatenumber of falls occur on stairways thathave a small number of risers. Fiftypercent of 40 stair falls investigated byJackson and Cohen36 occurred in stairswith four or fewer risers. Of those 20cases, 60% were on stairways with onlyone or two risers. Templer also foundthat fall risk was low on stairways withmore than 6 risers32. One leading causeof stair falls is the failure to notice a one-or two-riser stairway in the path37.Therefore, safe home design guidelinesrecommend grouping steps for bettervisibility9. Each group is recommendedto have at least three steps, and singlesteps should be avoided.

While building codes specify certaindesign guidelines on stair design, someof these are not based on scientific

evidence32. Some recent researchattempts to provide scientific evidenceto improve stair design guideline38-40.Roys at Building Research Establishment(BRE) in England recently investigatedthe effect of the size of risers and goings(Figure 8) on stair use38,39. Anexperimental rig with eight slidingcarpeted steps whose rise and going sizeswere adjustable was used for theseexperiments. Subjective opinions of 24males and 36 females who walked upand down the stairs with different riseand going dimensions were collectedusing a set of questions. Hesitations,glances at feet, use of handrails andmissteps were observed. The foot angleand overhang were measured. A seriesof experiments where the rise was fixedat 175mm and the going dimension variedbetween 150mm to 425mm demonstratedthat smaller goings increase the likelihoodof subjective dissatisfaction, observedincrease in missteps and use of handrails,increased foot angle, and the maximumoverhang. Based on his research, Roysrecommends a minimum going size of275mm - 280mm for private stairs and aminimum going size of 300mm for publicstairs (Personal communication, MikeRoys, BRE, November 2004). The fullresults and recommendations from thisstudy will be presented at the ErgonomicsSociety Conference in April 2005. Asecond paper discussing the theoretical

relationship between foot overhang andslip will also be presented at thisconference.

Roys and Wright investigated how thegoing size and the uniformity of the goingdimension affect the occurrence of largeoversteps on a flight of stairs41.Interventions, such as the installation ofproprietary nosings, are recommendedfor stairs that are frequently used, havelarge dimensional non-uniformities, andhave goings smaller than 350mm. Havinga step with a smaller going immediatelyfollowing a larger one makes the stairdangerous during descent. Paulsrecommends maintaining closetolerances preferably 5mm betweenadjacent treads and between adjacentrisers with no more than twice thistolerance within a stair flight31.

Building codes give guidelines on riseand going sizes that are acceptable forpublic, semi-public, and private stairs35,42.These guidelines are based on thefollowing criteria: risers should not betoo large as to make the climb excessiveor too small as to make the steps a trippinghazard; the combination of riser and goingdimensions should allow a user tomaintain a comfortable stride on thestairs; and the going should allowsufficient room for the user to place thefoot.

Stair definitions and dimensions Figure 8


Pauls recommends using the larger goingsize required for public stairs for domesticstairs as well31. Because many users,especially older persons, may not havesufficient physical control to negotiatestairs with reduced goings, they have ahigh risk of a fall from stairs with smallergoings. The building industry has resistedto increasing the size of goings claimingthat it takes extra space for the staircaseand, hence, increases cost43. However,innovative design may overcome this byutilizing the space under the staircase fora toilet or storage. Mandating this changewould potentially provide a level playingfield for the whole industry.

A 1992 report published by NationalAssociation of Home Builders ResearchCentre43 questioned the validity ofprevious studies calling for deeper treadsand smaller risers alleging that thesestudies were based on stair incidents,such as missteps, rather than actual stairaccidents that caused injury. Jacksonand Cohen responded to these allegationsby conducting a survey of 40 in-depthstair accident cases36. They concludedthat the strongest pattern for stairwayaccidents lies in dimensional inconsist-ency within stairways. Jackson andCohen also cite several previous studiesthat found dimensional inconsistenciesof treads and risers to be a major riskfactor for stair falls. Even a 5mmirregularity, particularly at the top orbottom of a stairway, can disrupt footmovements to cause a fall. In buildinginspections for stair dimensions andirregularities, the finished step dimen-sions with carpeting or other floor finishesmust be considered, rather than theunfinished stairs, because the floorcovering thickness cannot be ignored31.

Stairway lightingProper lighting is required near stairwaysso that the user can see the treads easily.Self-illuminating strips44 are availablethat allow stair edges to be seen in thedark. Automatic dawn/dusk lights thatrespond to ambient light levels and turnon when it is dark or sensor lights thatturn on for a preset duration when apersonís presence is detected can be

installed near stairways to ensure thatthey are adequately lit. These lights mayalso be useful for bathrooms and otherlocations where lack of illumination cancreate a hazard.

Floor coveringsThe covering used on tread affects therisk of slipping on stairs. The risk ofslipping on stairs is increased if the treadsurface is smooth, if the steps are wet, orif the nosing is rounded41. Smoothmaterials such as glazed ceramic tiles,polished terrazzo, and finished timberdo not provide enough protection againstslipping, especially if the treads are wet.A study by Roys found that falls werethree times more likely on stairs withother floor coverings compared tocarpet45. Thin carpet that is securedtightly to the step is, thereforerecommended for stairs. The slightimpact absorbing effect of carpet mayprevent lacerations in a fall but may notbe effective in preventing fracture. Thickcarpets or carpet with underlay are notrecommended for use on stairs31. Ifcarpeted stairs are heavily used, the carpeton the nosing can become smooth andwear through, creating a trip hazard41.Non-domestic stairs that are exposed towet conditions and contamination callfor rough materials such as clay tileswith a carborundum finish, cork tiles,asphalt, and resin-based products withenhanced slip resistance41.

Non-slip coatings and covers areavailable for a variety of industrial,commercial, and residential applicationson steps, stairways, decks, ramps, etc.These products are applied over existingsteps, walkways, platforms, etc toimprove their slip resistance. Further-more, these are available in high visibilitycolours to make stair nosings morevisible. Non-slip stair covers are mainlyused in industrial and commercial settingsthat have higher traffic and high levels ofcontamination. However, these may beuseful for outside steps in privatedwellings, where many falls occur. Fallson outside steps can cause severe injuryif the victim falls onto concrete paving.Rubber-based impact absorbing material

(commonly used as playgroundsurfacing) or similar materials could beused instead of concrete paving aroundoutside steps to reduce injury.

HandrailsA substantial proportion of stair falls hasbeen attributed to the lack of handrails32.A study by Roys found that fall risk onstairs doubles if just walls are on bothsides of the stairway compared to havinghandrails or barriers on both sides45. Therisk increased four fold when there wasnothing to hold onto on at least oneside45. The absence of handrails isespecially hazardous for the elderly usersof staircases32. Handrails are used forguidance and balance or simply used in afall to grab and break the fall.

Australian standard AS 1657:1992requires provision of a handrail through-out the length of each stairway flight46.Handrails must be provided on each sideif the stairway width exceeds 1000mm46.Provision of handrails is important evenwhen there are only one or two risers, assuch stairs cause a disproportionatelylarge number of falls31. In addition toproviding support during stair use,handrails also provide a useful visualclue about the presence of the stairs.Handrails should be able to withstandthe weight of a person. The AustralianStandard AS 4226-1994 recommendsthat handrails should be able to resist a1.5kN load applied at any point9.

As a sudden discontinuity in a handrailcould make the user lose balance duringdescent AS 4226-1994 recommends thathandrails should continue aroundlandings9. Handrails should extend300mm beyond the end of the flight ofstairs and have a downward sloping end,which helps people with impaired visionknow that the end of the stairs has beenreached47.

Maki et al conducted biomechanicalstudies of handrail use to inform moreeffective design guidelines48. Anexperimental study involving humansubjects on a mock stairway showed thatsubjects can grab a handrail and generate


sizeable stabilizing force very quickly inresponse to a postural disturbance, evenwhen the hand is distant from the railwhen the loss of balance occurs. Trialswhere handrails were absent resulted insignificantly more falls compared to thosewhere handrails were present, indicatingthe functional significance of handrailsfor preventing falls48. The researcherssuggest that the influence of stanceposition on the trajectory of the arm, andthe angle of attack of the hand on the railmay have implications for designing theshape of the rail. While the angle ofattack is not critical if the handrail has acircular cross section, it becomesimportant for handrails with edges ormore complex shapes.

If the hand cannot easily conform to theshape of the handrail or if the shape andthe size do not provide sufficient fingerpurchase on the rail, the userís hand maynot be able to generate sufficientstabilizing force. A handrail with acircular cross section and a diameter ofabout 30mm-50mm allows an adult tohave a power grip where the thumb andindex finger can encircle the rail. Thistype of grip optimises grip forces in thehand32. Based on biomechanical tests onstaircase handrails, Maki et al suggestthe optimal handrail to be a cylindricalshape with a diameter of 38mm49. Tomaximize grip forces for children, asmaller diameter is recommended. Dualhandrails provide one solution to thedifferent needs of adults and children.

Rectangular shaped boards tipped on thenarrow edge are commonly used ashandrails because of their decorativeeffect and ease of attachment to the wall.However, with such handrails, the userísgrip is limited to a pinch grip, which isthe weakest type of grip32. Many newhomes use architectural decorativehandrails that have large diametersmaking them difficult to grip, especiallyfor children. Such decorative handrailsmust be augmented with functionalhandrails. Balustrades with ornamenta-tion containing sharp edges can causeserious injury if a stair user falls onthem50. Templer suggests using smooth

flat surfaces or gentle curves and alsofirm but compressible material onbalustrades and walls onto which a fallvictimís body may forcibly strike.

The Australian Standard AS 4226-1994recommends installing handrails between865mm-900mm above the pitch line.This positions the handrails at about adultelbow height. Based on recent humansubject testing conducted using a moving-platform system, Maki et al51 recommenda handrail that is considerably higherthan many existing building codes suggestand also mounted farther from the wall.These changes are suggested to increasethe rail reaction force relative to the feetand to allow the hand to attack the railwith fingers fully extended. Thesebiomechanical study findings haveresulted in the development of a handrailsystem, which is mounted above andparallel to the regular handrail of a stairand shaped so it can be grasped similarlyto an underarm crutch, for the benefit ofstair users with poor hand strength51.

It is important to offset handrails at least50mm from the wall9 and to avoid roughwalls behind handrails to prevent injuryto knuckles of the gripping hand. CurrentUK guidelines increase this offset to 60-75mm from the wall (Personalcommunication, Mike Roys, BRE,November 2004).

Ishihara et al40 conducted a study in Japanto determine the optimum handraildiameter, handrail height, and thehorizontal extension suitable for elderlyJapanese people. Based on this study,the handrails were recommended to be33-35mm in diameter, 670-780mm inheight, and have approximately 400mmhorizontal extension. They alsodeveloped a regression model forchoosing the optimal handrail height foran individual based on the body heightand body weight. Because of thedifference in size of average Japaneseand US persons, these dimensions aresmaller than those recommended incorresponding US studies, which showsthe importance of choosing appropriatedesign guidelines to suite the targetpopulation of users. While the

dimensions for the mainstream Australianpopulation may agree with the Americanresults, these may not be appropriate forthe increasing overseas-born population.Universal design approaches such asincorporating multiple or adjustablehandrails may allow all users, regardlessof their height, to get the full benefit ofhandrails.

Just as handrails can help to prevent fallson stairs, handrails and grab bars canprevent falls in other locations within thehome. Several such products that can beinstalled by the bed or toilet to help olderpersons to stand up are commerciallyavailable (eg. SturdyGrip51, SuperPole,and SuperBar52). The effectiveness ofthese and similar products in preventingfalls must be evaluated.

Stair gatesChild safety stair gates at the top andbottom of stairs are a useful interventionagainst stair falls for infants and toddlers.The Australian Standard AS 4226-1994recommends any stair gate to be the sameheight as the handrail or balustrade9. Itfurther recommends easy-to-operatehinged stair gates over sliding ortelescopic gates, as there is a temptationfor adults to step over the latter types ofgates, which may pose a fall hazard toadults. However, accordion type stairgates are not safe as they may pose astrangulation or entrapment hazard tochildren53. Stair gates that are mountedusing an expanding pressure bar are notrecommended for use at the top of aflight of stairs as these gates can pop outif a child pushes on them causing thechild to fall down the stairs53.

One innovative stair gate has a fixedsection and a hinged section that can beopened by an adult for passing throughthe gate easily54. Once the child hasgrown to an age that he learns how toopen the gate, it can be used in a tumbler-stopper mode. That is, the two stair gatesections are separated and one part ismounted on one side of the stair and theother section is mounted on the oppositeside of the stair at a lower height. Nowthe gate allows the child to walk on the


stairs and provides a means to break afall and prevents the child fromdescending the full flight if the child fallson the stairs. While this tumbler-stoppermode seems to be useful to break fallsand reduce injury severity in adult fallsas well, it needs to be investigatedwhether the presence of these partialstair gates themselves would actually actas a hazard. Another potential aid to theuse of stair gates would be the routineprovision of fixed attachment points ondomestic stairs, allowing ease of fittingand transfer of these barriers to homesvisited.

Another stairway design featurerecommended by Roys is having alanding or hall at the top of the stairs. Hefound that having a room at the top ofstairs increased the likelihood of a fall by1.75 times compared to having a landingor hall at the top45.

4. Preventing falls fromwindows and balconies

Hospital admissions data do notdisaggregate falls from balconies andwindows as the code covers all falls outof or through buildings and structures.Hospital emergency departmentpresentation data for the period July 2000ñ June 2003 in Victoria show at least 140falls from verandas or balconies and 216falls from windows. These data do notgive information on exactly how theperson fell from the balcony or window.

A Dallas, Texas study reported on 98child falls from buildings where 39 fellfrom windows and 34 from balconies55.In 65% of balcony related falls, the childfell from between the rails, which weremore than 100mm apart, and in 29% ofcases the child had climbed over therails. The results of a 1998 UK studysuggests that stair guarding of 900mmheight presents no difficulty to themajority of active children aged betweenfour and six years to climb onto or overthe guarding56. The Australian StandardAS 4226-1994 recommends providingbalustrades with at least 1000mm heightwith no clear gaps larger than 100mmbetween balusters9. Solid balustrades or

balustrades with only vertical balustersshould be used, as horizontal ordecorative elements provide footholdsfor children to climb. These designfeatures should be included in Australianbuilding standards, regulations, andcodes. The allowable fall height beforewhich a balustrade is required should bedecreased in Australian buildingregulations and codes. While adherenceto these design guidelines can preventmany falls, they cannot eliminate allbalcony related falls as other items suchas furniture placed on balconies mayallow a child to climb over a balustradeand fall. Kid Shield banister guard is aclear and almost invisible banister shieldmade of shatterproof and flexible plasticwhich can be used to prevent children fromtrying to squeeze through balusters57.Another product, Kid Safe deck netting,is a plastic mesh that can be attachedaround the balustrade of a deck to preventfalls57.

Apart from falling over or throughbalustrades of a balcony, people can alsobe injured or killed due to balconycollapses58. Because balconies areexposed to the elements, they can failunless they are constantly monitored andregularly maintained. Decay of timberand rusting of steel bolts and brackets intimber balconies and rusting of steelreinforcements in concrete balconies maycause collapse (Figure 9). The suitabilityof weather resistant products such asrecycled plastic lumber for constructionof balconies should be investigated toprevent balcony collapses.

Several design solutions have beensuggested for preventing falls fromwindows. One strategy is to use windowsthat cannot be opened more than 100mmif the window is over 1200mm above thefloor59. The installation of window guardsis a proven preventive strategy thatresulted in a dramatic reduction of childwindow falls in multi-story dwellings inNew York City60. This intervention wasopposed in some US states on the groundsthat window guards limit fire egress61.However, the advice from fire servicesto residents in multistorey buildings is

not to egress through windows andemergency services have the equipmentto break through window guards.

An alternative to fixed window bars isthe use of operable window guards thatcan be removed by an adult withoutexcessive force or a special key in anemergency, but is difficult for a child toopen60. An innovative design solutionwould be to have a bimetallic strip-basedlocking pin that can automatically bendand release the window guard if thetemperature of the room rises todangerous levels.

Recommendations

Slip resistant surfaces for homesï Use recently updated slip resistance

standards to develop building codesand regulations requiring installationof slip-resistant surfaces in internalwet areas and external pedestrian areasof new and renovated homes.

ï Victorian Local Government Associa-tions should adopt the fall injuryprevention initiative of the LocalGovernment and Shires Associationsof New South Wales, which wouldmake it unacceptable to issue

A collapsed timber Figure 9balcony (Photo courtesy Archicentre)


certificates of occupancy wherebuildings have flooring that does notmeet recommendations on slipresistance of pedestrian surfaces inthe revised Standards AustraliaHandbook HB 197: 2005.

ï Consider the introduction of buildingregulations to ensure that only slip-resistant baths and shower bases areinstalled in new and renovated homes.

ï Manufacturers and retailers of flooringmaterials, baths, and shower traysshould provide comparative informa-tion about slip resistance to assistcustomers to choose safer products.

ï Conduct scientific studies to evaluatethe effectiveness, longevity, cost ofapplication and maintenance, andharmful by-product generation ofvarious proprietary treatments thatclaim to improve the slip resistance oftile, granite, terrazzo, and otherflooring materials.

Impact absorbing surfaces forhomesï Undertake independent scientific

studies to substantiate the claims madeby manufactures of innovative floorcoverings such as PowerBond RSregarding their impact absorbance andother properties to assess theirsuitability for domestic use, especiallyin the dwellings of older residents.

ï Encourage the use of rubber-basedimpact absorbing material (commonlyused as playground surfacing) orsimilar materials as paving outsidethe home in high risk pedestrian areas(e.g. at the base of steps or high usepathways) instead of concrete, toreduce injury severity in falls.

ï Further research is required to developimpact-absorbing flooring that canattenuate sufficient energy toconsistently reduce peak impact forcestransmitted to the femur to levelsbelow fracture threshold.

Steps and stairsï Avoid unnecessary changes in levels

in homes wherever possible.

ï Single steps should be avoided, as theyare difficult to notice. Steps should be

grouped for better visibility, with eachgroup having at least three steps.

ï Stairs in private buildings should usea minimum going size of 275 mm ñ280 mm and a minimum going size of300 mm should be used in publicbuildings.

ï Stair construction should maintainclose tolerances preferably 5 mmbetween adjacent treads and betweenadjacent risers with no more than 10mm within a stair flight.

ï Building inspections for stairdimensions and irregularities mustconsider the finished step dimensionswith carpeting or other floor finishesrather than the unfinished stairsbecause the floor covering thicknesscannot be ignored.

ï Thin carpet that is secured tightly tothe steps without underlay isrecommended for domestic stairs.

ï Provide at least one handrail, prefer-ably one on each side, throughout thelength of each stairway flight, evenwhen there are only one or two risersin the stairway.

ï Handrails of a circular cross sectionwith a diameter of between 32 mmand 50 mm should be used to improvethe grip. Decorative handrails withlarger diameters should be augmentedwith functional handrails.

ï Balustrades with ornamentationcontaining sharp edges should beavoided and smooth flat surfaces orgentle curves and also firm butcompressible material should be usedon balustrades and walls, which a fallvictimís body may strike.

ï Install hinged child safety stair gatesat the top and bottom of stairs toprevent falls of infants and toddlers.

ï Accordion type stair gates should not beused as these may pose a strangulationor entrapment hazard. Stair gates thatare mounted using an expandingpressure bar must not be used at the topof a flight of stairs.

ï Avoid having a room at the top of stairs;providing a landing or a hall at the topreduces the likelihood of a fall.

ï Automatic sensor lights, self-illuminating strips or other form oflighting should be provided to enablethe user to see the stair treads easily.

Safer balconies and windowsï Australian building standards,

regulations and codes should addresssafe design of balcony and verandahbalustrades.

ï Provide balustrades with at least a 1mheight with no clear gaps larger than100 mm between balusters to preventfalls from balconies. Horizontal ordecorative elements should be avoidedto prevent children from climbingover.

ï The suitability of weather resistantmaterials such as recycled plasticlumber for construction of balconiesshould investigated to prevent timberrot-related balcony collapse.

ï Consider the introduction of buildingregulations requiring installation ofwindow guards, which can be easilyremoved in a fire emergency, toprevent falls from windows ofmultistorey residential dwellings.

Otherï Provide grab bars in toilets and

bathrooms, and by the bedside inbedrooms in homes of older persons.

ï Educate architects, homebuilders andthe community about safe designguidelines for preventing falls andother home injuries.

Surveillance and researchï Remedies should be sought by

responsible government departmentsand hospitals to

- reduce unspecified cause of falldata (3,067 cases in VictorianAdmitted Episodes Dataset in oneyear)

- increase the proportion of VictorianEmergency Minimum Dataset(VEMD) cases that includeimportant aetiological informationin narrative data (e.g. only 6% ofVEMD fall cases indicated specificsurfaces on which injurious fallsoccurred).


AcknowledgementsWe are grateful to Mike Roys of BuildingResearch Establishment, UK, Jake Paulsof Building Use and Safety Institute,USA, Robert Caulfield, ManagingDirector of Archicentre and RichardBowman of CSIRO for providingvaluable information and comments.

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Box 1. Methods of extracting home fall cases from death andhospital-based injury databasesFatality dataFatality data were extracted from the Australian Bureau of Statistics (ABS) DeathUnit Record File (DURF). ABS death data are coded using the World HealthOrganisation (WHO) International Classification of Diseases (ICD) coding system.Death records were selected if ëhomeí was recorded as the ëplace of deathí.

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Hospital dataHospital-treated home injury data were extracted from the Victorian AdmittedEpisodes Dataset (VAED) and the Victorian Emergency Minimum Dataset (VEMD)using different methods due to database-specific coding issues.

Hospital admissionsThe VAED records hospital admissions for all Victorian hospitals, both public andprivate. The three-year study period are coded to ICD version 10 with Australianmodifications (editions 2 and 3). Injury records were selected if ëhomeí wasrecorded as the ëplace of occurrenceí.

Falls admissions were identified using ICD-10 codes and related sub codes: ëfallsí(W00-W19). Admissions classified to X59 (exposure to unspecified factor) wererecoded and considered falls admissions if they had at least one diagnosis coded asa ëfractureí.

Hospital Emergency Department presentationsThe VEMD currently records public hospital presentations to 28 EDs, representingapproximately 80% of statewide ED presentations. Injury records were selected ifëhomeí was recorded as the ëplace of occurrenceí.

Falls records were extracted using the VEMD injury cause codes: Fall- low (samelevel or less than 1 metre, or no information on height) and Fall (greater than onemetre). Records were then matched to the ICD-10 cause codes in the ABS andVAED datasets.


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59 Routley, V, Ashby K. Safe home design. Hazard1997;32:1-13.

60 American academy of pediatrics: Committee on injury andpoison prevention. Falls from heights: windows, roofs, andbalconies. Pediatrics 2001;107(5):1188-91.

Report on the use of VISARís dataand information request service, 2004VISAR offers an injury data andinformation request service for researchand prevention purposes that can beaccessed by telephone or email. Victoriandatasets that can be accessed through theservice include Australian Bureau ofStatistics deaths data for Victoria, theVictorian Admitted Episodes Dataset(hospital admissions to all Victorianpublic and private hospitals) and theVictorian Emergency Minimum Dataset(Emergency Department presentations to28 Victorian hospitals).

In 2004 VISAR responded to 231information requests. Regular VISARclients include education bodies(undergraduate and post-graduatestudents and schools), organisations andindividuals from the public health sector,government bodies (national, state andlocal), research groups (MUARC andexternal), media, industry/business andthe community (Figure 1).

The most frequently requested topics over2004 were: elderly fall injury, playground

and play equipment injury, DIY homemaintenance injury, home injury, dogbite, sports injury poisoning, nurseryfurniture and equipment injury, off-roadvehicle injury (ATVs and motorcycles)and local community injury profiles (byLocal Government Area).

ï Who can access VISAR injury data?

The VISAR data and information requestservice is open to government and non-government organisations, the highereducation and schools sector, industryand business and community members.We are not able to provide a direct serviceto primary and secondary school students.

ï How do I make a request?

Data and information requests can bemade by telephone (9905 1805) or email:[email protected]

ï Any charges?

A standard format response is free-of-charge. Additional analysis may bepurchased for a cost-recovery fee of $100per hour, (GST exclusive).

Data & information requests 2004 Figure 1

61 Lehman, D, Schonfeld N. Falls from heights: a problem notjust in the northeast. Pediatrics 1993;92:121-4.


Preventing hand entrapment injury from doorsAjith GunatilakaErin CassellAngela Clapperton

Another common injury that occurs inthe home that may be amenable to adesign solution is entrapment of the hand(mostly the finger) in a closing door.These injuries usually occur when thehand/finger is either trapped between theopposing surfaces of the door and theframe or trapped in the hinged side of thedoor as the door is closed.

In Victoria in 2002/3, there were 145hospital admissions for hand/fingerentrapment injuries from doors in thehome. Children (mostly 0-4 year olds)were over represented in theseadmissions, accounting for 72% of cases(n=105). Thirty seven percent ofadmissions (n=54) were finger/thumbamputations.

Figure 1 shows that the door entrapmenthand/finger home injury hospitalisationrate was highest in 0-4 year olds, morethan eight times the rate for all agescombined.

In addition, 475 ED presentations (non-admissions) for hand/finger entrapmentinjuries from doors were recorded on theVEMD in 2002/3. Rates cannot becalculated because not all hospitals withemergency departments contributedinjury cases to VEMD in 2002/3. Asshown for hospital admissions, childrenwere over represented in emergencydepartment presentations, particularly 0-4 year olds.

Tables 1 summarises the pattern of hand/finger entrapment injury from doors forboth admissions and presentations.

ï The youngest children (aged 0-4 years)were over-represented in each dataset,accounting for 72% of childadmissions and 64% of presentations.

ï The most common admitted injuriesamong children were finger amputa-tions or partial amputations (40%) andopen wounds (35%). Crushing injuries

(25%), superficial injuries (22%) andopen wounds (20%) accounted for themajority of presentations.

ï Younger adults (aged 15-29 years)account for 42% of adult presenta-tions, whereas they account for only23% of adult admissions

ï Females were over-represented inadult admissions (60%) whereas males

were over-represented in presentations(55%).

ï The most common admitted injuriesamong adults were finger fractures(48%) and amputations (28%). Openwounds (25%), crushing injuries(21%) and fractures (19%) accountedfor the majority of adult presentations.

Age specific rates of home injury hospital admissions Figure 1for hand and finger entrapment from doors by gender,Victoria July 2002-June 2003 (n=145)

Source: VAED, 2002/3

Frequency of home injury ED presentations for hand Figure 2and finger entrapment from doors by age and gender,Victoria July 2002-June 2003 (n=475)

Source: VEMD, 2002/3


Frequency and pattern of hospital-treated hand and finger entrapment injury Table 1from doors, July 2002 to June 2003

Sources: Hospital admissions - Victorian Admitted Episodes Dataset (VAED) July 2002 to June 2003Emergency department presentations (non-admissions) - Victorian Emergency Minimum Dataset (VEMD) July 2002 to June 2003


DiscussionFingertip and nailbed injury caused bydoors is common in children, particularlyamong 0-4 year olds1-5. Finger injuriescause disruption to the injured childísdaily activities such as eating, playingand schoolwork, and anxiety in bothchildren and parents about the possibilityof deformity, disability and shortening.

There are a small number of publishedin-depth studies of child patientspresenting with finger entrapment injuryto emergency departments, and theseprovide more detail on the pattern, causeand circumstances of these injuries1-5.Children under 5 years of age, and boys3,5

are generally reported as more frequentlyinjured. The majority of finger entrap-ment injuries to younger children arereported to occur on the hinge side of thedoor, rather than the lock side3,6,7 but thispattern appears to reverse with age3,6,7.Additional information provided from aprospective study of 283 child patientspresenting to the Accident andEmergency Department of the RoyalHospital for Sick Children in Glasgow2,3

indicates that the middle finger isinvolved most often in door jam injury,perhaps because it is the longest; thedoors are commonly being closed bysomeone at the time of the injury, mostoften by the injured child; and that theliving room and toilet/bathroom doors,rather than kitchen doors, are mostfrequently involved.

At present there are no regulatoryrequirements for safety measures to doorsin Australia or any of the other countriesthat share a reputation for proactive injuryprevention policies and regulations2.What preventive measures currentlyexist? Use of door stops, hooks, wedgesand stoppers to hold doors open arecommon measures to prevent doors fromslamming shut. The finger pinch guard,a U-shaped soft and flexible piece thatcan clip on to the front edge of a dooralso prevents the door from fully closingand jamming a finger. All of thesemeasures are inexpensive but they relyfor effectiveness on continuous vigilanceand action by householders to ensurethat their protective effect is maintained.

Plastic finger jam protector guards thatfit over the hinge side of the door,

developed in Australia, can prevent theseinjuries but their uptake has mainly beenin child care centres as they are functionalbut aesthetically unappealing (Personalcommunication, Barbara Minuzzo, RoyalChildrenís Hospital Safety Centre).Installing slow releasing door closersrather than spring operated ones is arelatively popular measure and poten-tially more effective, as it is permanent.However, slow closing doors may pose asafety hazard in that young children canslip out the door during the delayedclosing period. Householders alsodeactivate them in winter as they let coldair into rooms.

A promising alternative is the Danish'pinch free' door (40 mm KLG FD30)2.A rubber seal on the edge yields so thefinger is not crushed between the woodenparts of the door when the fingers arecaught between closing surfaces. Thisdoor type is not available in Australiaand market access for this product shouldbe investigated. Doors with integralround pivot posts that remove the gapbetween the door frame and the pivotpost and eliminate the risk of fingerentrapment at the hinge side are availablefor use in public buildings such asschools8. These may be adaptable fordomestic use.

Another possible simple design solutionto prevent or reduce damage to the fingersis to round the edges of doors7. Unlikefinger jam protector guards and doorclosers, this solution does not require theaddition of unsightly devices. A researchstudy to evaluate the effectiveness ofrounding and different levels of roundingin reducing injury severity and anyadverse effects (such as letting indraughts) is recommended. Venema hasrecommended biomechanical studies tobetter understand entrapment forces andtheir effects on the human finger7. Inaddition to rounding of door edges,attaching an impact absorbing materialsuch as rubber along the edge also hasthe potential to reduce injury severity.The use of compression material on dooredges has been demonstrated in Australiain the Latrobe Valley safety house9. Thisinnovation has not been evaluated.

In terms of higher technology, contactsensors are being installed in the

surrounds of power windows in cars toreduce the risk of finger pinch injuries10.Sonic and infrared non-contact sensorsare also being developed for use in carwindow surrounds (in the weatherstripping or the doorframe) as consumershave shown preference for non-contactwindow retraction systems10. Similarsensor technologies are being appliedoutside the automotive industry to garagedoor openers, elevator doors and powersliding doors (and commercial anddomestic water taps to turn taps on andoff)10. Innovative applications of thesetechnologies to retract closure of doorsin domestic dwellings appear entirelyfeasible.

Recommendationsï A further study is required to update

earlier evidence indicating that thehinged side of the door was involvedin 60% of child door jam injuries.

ï Further research is recommended todevelop an acceptable safe house doorthat can prevent finger entrapmentinjuries or reduce their severity.

ï There is a need to develop a bio-fidelichuman finger model to investigatebiomechanical forces involved in fingerentrapment in different door and doorjam configurations.

ï Studies should be conducted to assessthe feasibility and acceptability ofusing doors with an integral roundpivot post in homes.

References1 Macgregor, DM, Hiscox JA. Fingertip trauma in childrenfrom doors. Scottish Medical Journal 1999;44(4):114-5.

2 Doraiswamy, NV. Childhood finger injuries and safeguards.Injury Prevention 1999;5:298-300.

3 Doraiswamy, NV, Baig H. Isolated finger injuries inchildren-incidence and aetiology. Injury International Journalof the Care of the Injured 2000;31:571-3.

4 Fetter-Zarzeka, A, Joseph MM. Hand and fingertip injujriesin children. Pediatric Emergency Care 2002;18(5):341-5.

5 Ljungberg, E, Rosberg HE, Dahlin LB. Hand injuries inyoung children. Journal of hand surgery 2003;28B:376-80.

6 Watson, W, Day L, Ozanne-Smith J, et al. Consumerproduct-related injury to children. Report No. 168. MonashUniversity Accident Research Centre, Melbourne.2000.

7 Venema, A. Entrapment between doors in houses.International Jouranal for Consumer Safety 1995;2(1):13-9.

8 Marian Door Systems. http://www.mariandoors.co.uk/pages/steel_single_swing1.htm Retrieved on 21.09. 2004

9 Routley, V, Ashby K. Safe home design. Hazard 1997;32:1-13.

10 Schweinsberg, C. Pinch Free. http://waw.wardsauto.com/ar/auto_pinch_free/ Retrieved on 04.11.2004


- INDEX -Subject Edition Pages

Babywalkers, update ......................................................................................................................... 16,20,25,34 ................... 1-4,12-13,7-8,7-8Baseball ............................................................................................................................................................. 30 ...................................... 10-12Boating-related recreational injury ................................................................................................................... 56 ........................................ 1-16Bunkbeds ........................................................................................................................................................... 11 ............................................ 12Bicycles - Bicycle related .................................................................................................................... 6,34,44 ....................... 1-8,8-12,10-11

- BMX bikes ............................................................................................................................. 31,44 .................................. 9-11,7-8- Cyclist head injury study ................................................................................................... 2,7,8,10 .................................. 2,8,13,9

Burns - Scalds ........................................................................................................................................3,25 .................................... 1-4,4-6- Burns prevention ......................................................................................................................... 12 ........................................ 1-11- Unintentional burns and scalds in vulnerable populations ........................................................ 57 ........................................ 1-17

Child care settings ............................................................................................................................................. 16 ........................................ 5-11Client survey results ......................................................................................................................................... 28 ............................................ 13Data base use, interpretation & example of form .............................................................................................. 2 .......................................... 2-5Deaths from injury (Victoria) ..................................................................................................................... 11,38 ................................ 1-11,1-13Dishwasher machine detergents - Update ....................................................................................................... 18 ............................................ 11DIY maintenance injuries ................................................................................................................................. 41 ........................................ 1-12Dog bites, dog related injuries ...................................................................................................... 3,12,25,26,34 ................. 5-6,12,13,7-13,2-5Domestic architectural glass .................................................................................................................... 7,22,25 ............................. 9-10,1-5,12Domestic Violence ...................................................................................................................................... 21,30 .................................... 1-9,3-4Drowning/near drowning, including updates .................................................................................... 2,5,7,30,34 ....................... 3,1-4,7,6-9,5-7Elastic luggage straps ....................................................................................................................................... 43 .......................................... 2-6Escalator ............................................................................................................................................................ 24 ........................................ 9-13Exercise bicycles, update ................................................................................................................................. 5,9 ................................... 6,13-14Falls - Child, Older Persons, Home ................................................................................................. 44,45,48,59 ............... 1-17,1-15,1-12,1-21Farm ............................................................................................................................................................. 30,33 ..................................... 4,1-13Finger jam (hand entrapment) ..................................................................................................... 10,14,16,25,59 .............. 5,5-6,9-10,9-10,1-21Fireworks ........................................................................................................................................................... 47 .......................................... 2-7Geographic regions of injury ............................................................................................................................ 46 ........................................ 1-17Home ...................................................................................................................................................... 14,32,59 ...................... 1-16, 1-13,1-21Horse related ..................................................................................................................................................7,23 .................................. 1-6,1-13ICD-10 AM coding developments ................................................................................................................... 43 ........................................ 8-13Infants - injuries in the first year of life ............................................................................................................. 8 ........................................ 7-12Injury surveillance developments ..................................................................................................................... 30 .......................................... 1-5Intentional ......................................................................................................................................................... 13 ........................................ 6-11Latrobe Valley - First 3 months, Injury surveillance & prevention in L-V .............. 9, March 1992, Feb 1994 ....................... 9-13, 1-8, 1-14Lawn mowers .................................................................................................................................................... 22 .......................................... 5-9Marine animals .................................................................................................................................................. 56 ...................................... 18-20Martial arts ........................................................................................................................................................ 11 ............................................ 12Motor vehicle related injuries, non-traffic ....................................................................................................... 20 .......................................... 1-9Needlestick injuries ............................................................................................................................... 11,17,25 .............................. 12,8,10-11Nursery furniture ......................................................................................................................................... 37,44 .............................. 1-13,11-13Older people ...................................................................................................................................................... 19 ........................................ 1-13Off-street parking areas .................................................................................................................................... 20 ...................................... 10-11Playground equipment ......................................................................................................... 3,10,14,16,25,29,44 ..... 7-9,4,8,8-9,13,1-12,13-14Poisons - Domestic chemical and plant poisoning ..................................................................................... 28 .......................................... 1-7

- Drug safety and poisons control ................................................................................................... 4 .......................................... 1-9- Dishwasher detergent, update ..................................................................................................10,6 ..................................... 9-10,9- Early Childhood, Child Resistant Closures ....................................................................... 27,2,47 ........................... 1-14,3,11-15- Adult overview ............................................................................................................................ 39 ........................................ 1-17

Power saws, Chainsaws .............................................................................................................................. 22,28 .............................. 13-17,8-13Roller Blades, Skateboards .............................................................................................................. 2,5,25,31,44 ............ 1-2,11-13,12,12 3-7,8School ................................................................................................................................................................ 10 .......................................... 1-8Shopping trolleys ................................................................................................................................... 22,25,42 ........................... 10-12,8-9,12Smoking-related ................................................................................................................................ 21,25,29,44 ............................. 10-12,6-7,8Socio-economic status and injury .................................................................................................................... 49 ........................................ 1-17Sports - Child sports, Adult sports ....................................................................................................... 8,9,44,15 ................. 1-6,1-8,15-16,1-10Surf sports ......................................................................................................................................................... 56 ...................................... 16-18Suicide - motor vehicle exhaust gas ................................................................................................. 11,20,25,41 ........................ 5-6,2-4,3-4,13Tractor ......................................................................................................................................................... 24,47 .................................. 1-8,8-10Trail bikes .......................................................................................................................................................... 31 .......................................... 7-9Trampolines ................................................................................................................................................. 13,42 .................................. 1-5,1-11Trends in road traffic fatality and injury in Victoria ....................................................................................... 36 ........................................ 1-13Vapouriser units ................................................................................................................................................ 43 .......................................... 7-8Venomous bites and stings ............................................................................................................................... 35 ........................................ 1-13VISS: How it works, progress ...............................................................................................................1,26 .................................... 1-8,1-5

A decade of Victorian injury surveillance .................................................................................... 40 ........................................ 1-17VISAR: Celebration of VISAR's achievements ............................................................................................... 50 ........................................ 1-25Work-related .......................................................................................................................................... 17,18,58 ....................... 1-13,1-10,1-17


VISAR Executive /Editorial BoardProf Joan Ozanne-Smith, Monash University Accident Research Centre (Chair)Prof Ian Johnston, Monash University Accident Research CentreAssoc. Prof James Harrison, Research Centre for Injury Studies (SA)Ms. Jan Norton, Department of Human ServicesAssoc. Prof David Taylor, Royal Melbourne HospitalMs Erin Cassell, Monash University Accident Research CentreGuest Editors:Mr. Mike Roys, Centre for Human Interaction, Building Research Establishment, UKDr. Richard Bowman, CSIRO Manufacturing & Infrastructure Technology

VISAR StaffDirector: Ms Erin CassellCo-ordinator: Ms Karen AshbyResearch Assistant: Ms Angela Clapperton

Ms. Melinda ConguiMedico/Clerical Support Officer: Ms Christine Chesterman

General AcknowledgementsParticipating hospitals

How to access

VISAR data:VISAR collects and analyses informationon injury problems to underpin thedevelopment of prevention strategies andtheir implementation. VISAR analysesare publicly available for teaching,research and prevention purposes.Requests for information should bedirected to the VISAR Co-ordinator orthe Director by contacting them at theVISAR office.

Contact VISAR at:MUARC - Accident Research CentreBuilding 70Monash UniversityVictoria, 3800

Phone:Enquiries (03) 9905 1805Co-ordinator (03) 9905 1805Director (03) 9905 1857Fax (03) 9905 1809

Email:[email protected]

Coronial ServicesAccess to coronial data and links withthe development of the Coronial's Services statistical database are valued by VISAR.

National Injury Surveillance UnitThe advice and technical back-up provided by NISU is of fundamental importance to VISAR.

From October 1995Austin & Repatriation Medical CentreBallarat Base HospitalThe Bendigo Hospital CampusBox Hill HospitalEchuca Base HospitalThe Geelong HospitalGoulburn Valley Base HospitalMaroondah HospitalMildura Base HospitalThe Northern HospitalRoyal Children's HospitalSt Vincents Public HospitalWangaratta Base HospitalWarrnambool & District Base HospitalWestern Hospital - FootscrayWestern Hospital - SunshineWilliamstown HospitalWimmera Base Hospital

From November 1995Dandenong Hospital

From December 1995Royal Victorian Eye & Ear HospitalFrankston Hospital

From January 1996Latrobe Regional Hospital

From July 1996Alfred HospitalMonash Medical Centre

From September 1996Angliss Hospital

From January 1997Royal Melbourne Hospital

From January 1999Werribee Mercy Hospital

From December 2000Rosebud Hospital

All issues of Hazard and otherinformation and publications of theMonash University Accident ResearchCentre can be found on our internethome page:

http://www.monash.edu.au/muarc/visar


VISAR is a project of the Monash University Accident Research Centre.

Hazard was produced by the Victorian Injury Surveillance and Applied Research System (VISAR)with the layout assistance of Glenda Cairns, Monash University Accident Research Centre.

Illustrations by Jocelyn Bell*

ISSN-1320-0593

Printed by Work & Turner Pty Ltd, Tullamarine

*Copyright clause: Copyright for all creative property as commissioned including sketches,remains under the exclusive ownership of Jocelyn Bell.

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