0 Factors contributing to non-occupational falls from ladders in men 50 years and over. Katherine Myra Schaffarczyk A thesis in fulfilment of the requirements for the degree of Master of Public Health (Research) School of Public Health and Community Medicine Faculty of Medicine October 2017 1 2 3 Acknowledgements I wish to acknowledge the following people for their support during my candidature. To Associate Professor Roslyn Poulos, Dr Sally Nathan and Dr Brahmaputra Marjadi; what a privilege it has been to have you as my academic supervisors. Your patience, perseverance, dedication and teaching have been extraordinary. There were many times when I doubted I would finish the journey but your belief in me and ‘my ladders’ helped me to avoid the potholes, keep me on track and moving forward. I will be forever grateful to you for such a remarkable experience. To the Director of Trauma; thank you for your support of this research right from the start. Your ongoing encouragement and reassurance have been appreciated. It was a pleasure to learn from someone who is committed to clinical research in trauma care. To the Trauma Data Manager; for your valuable assistance in retrieving the data required from the hospital trauma registry. Your expertise and time spent was greatly appreciated. To the Statistician; for your guidance on the statistical analysis of this research. To my many nursing colleagues; thank you for lending me your ear when I needed to a moment to ‘rant and rave’. Thank you also to my managers for their support with study leave to undertake this research and to my administrative colleagues for their support. To my husband and my children; thank you for your tolerance, patience and understanding. And, to the most important people of all: the men and their spouses who agreed to be interviewed for this research. It was your honesty and openness in sharing your story and your passion to make a positive change to ladder safety that enabled this research to achieve its objective. 4 Preface Looking at George (pseudonym), I struggle to understand how falling one metre from a ladder can cause such severe injury. As an experienced trauma nurse clinician and educator, I have nursed many patients who have sustained traumatic injury. But it is the fact that this mechanism of injury is potentially preventable, that makes my understanding of George’s case more difficult to process. Aged in his 70’s, George has sustained injuries to his head, spine, chest, abdomen and extremities. Complications have included pneumonia, sepsis, deep venous thrombosis, a skin pressure injury and anaemia. He has required surgery to his spine and fractured extremity and the formation of a tracheostomy to help him breathe. I reflect on the clinical scenario in front of me. How and why did this happen? How can such a potentially preventable incident occur? What is my role as a trauma nurse in the prevention of ladder falls? George spent almost three months in hospital, more than one week of which was in the Intensive Care Unit. He went on to a specialised rehabilitation unit. He required further surgery to his abdomen. On discharge home with his wife, George was mobilising with the assistance of a walker. He was surrounded by support from his wife, family and rehabilitation staff and was positive about his future. And so my research journey began, with George’s story being my primary catalyst. This is the story of many men just like George. 5 Contents Acknowledgements .................................................................................................................... 3 Preface........................................................................................................................................ 4 List of tables ............................................................................................................................. 10 List of figures ........................................................................................................................... 11 List of abbreviations ................................................................................................................ 12 Chapter 1 Introduction ............................................................................................................. 13 1.1 Rationale ........................................................................................................................ 13 1.2 Research questions ......................................................................................................... 15 1.3 Context and setting of this research ............................................................................... 15 1.4 Methodological approach used in this research ............................................................. 16 1.4.1 Use of mixed methods in public health research .................................................... 16 1.5 Ethical considerations .................................................................................................... 19 1.6 Thesis structure .............................................................................................................. 20 Chapter 2 Non-occupational ladder falls in older people — a review of the literature ........... 23 2.1 Ladder fall definitions .................................................................................................... 23 2.2 Epidemiology of ladder falls – a global problem........................................................... 24 2.3 Incidence of falls from ladders in Australia ................................................................... 25 2.4 Trends in ladder falls ..................................................................................................... 27 2.5 Mechanism, causes and height of ladder falls ............................................................... 28 2.6 Outcomes from falls and injury types ............................................................................ 30 6 2.6.1 Non-fatal outcomes ................................................................................................. 30 2.6.2 Burden of injury in Australia .................................................................................. 31 2.6.3 Fatal outcomes from ladder falls in Australia ......................................................... 32 2.7 Normal physiological changes with aging and the implications for ladder use ............ 34 2.7.1 Visual changes ........................................................................................................ 34 2.7.2 Musculoskeletal changes, posture and balance ....................................................... 34 2.7.3 Neurological and reflex changes; dizziness and vertigo ......................................... 36 2.7.4 Respiratory and cardiovascular changes ................................................................. 37 2.8 Pharmacology, the elderly and falls risk ........................................................................ 38 2.9 Injury severity scaling .................................................................................................... 39 2.9.1 Abbreviated Injury Scale (AIS) .............................................................................. 40 2.9.2 Injury Severity Score (ISS) ..................................................................................... 42 2.10 Late-Life Function and Disability Instrument (LLFDI) .............................................. 43 2.10.1 The original LLFDI............................................................................................... 43 2.10.2 LLFDI –CAT (computer adaptive test) ................................................................ 44 2.11 The Public Health Model ............................................................................................. 46 Chapter 3 Ladders .................................................................................................................... 49 3.1 Types of ladders ............................................................................................................. 49 3.1.1 Stepladders .............................................................................................................. 50 3.1.2 Single/straight ladder .............................................................................................. 52 3.1.3 Extension ladder...................................................................................................... 53 7 3.2 Principles and considerations around the safe use of ladders ........................................ 54 3.2.1 Surface/coefficient of friction (COF)...................................................................... 55 3.2.2 Angle of inclination ................................................................................................ 56 3.2.3 The three-point rule of contact ................................................................................ 59 3.2.4 Other considerations ............................................................................................... 59 3.3 Australian and New Zealand Standards ......................................................................... 61 Chapter 4 Quantitative component .......................................................................................... 63 4.1 Methods.......................................................................................................................... 63 4.1.1 Study inclusion and exclusion