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Bathing Safety for the Elderly and Disabled

September 1, 2004
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An expert on water delivery highlights the latest technology to prevent bacterial growth and minimize the risk of scalding by Bruce Fathers

Bathing safety for the elderly and disabled

Can residents be protected from all hazards posed by bathing water? Technology's answer It's a catch-22 for bathing operations in a nursing home: The demands of safer technology and risks of Legionella liability have stirred a trend toward institutional acceptance of the need to store hot water at 140¦F or more and maintain water at 124¦F or more in hot-water lines-temperatures that will neutralize or kill all bacteria. Yet those same higher temperatures pose the need to protect elderly residents from scalding injuries. Both risks-infection and scalding-can be life threatening.

Scalding Risks
A few years ago, an elderly man had a seizure while taking a shower at a nursing home. In his last moments of consciousness, he grabbed for the shower fixture's handle as he fell, activating full-hot temperature. With no preset thermostatic valve for protection, scalding water poured down on him while he lay unconscious on the floor of the shower enclosure, his body blocking water from draining properly. He was found an hour later and, by that time, although the water heater's supply had turned cold, the damage was done. He suffered permanently debilitating fourth-degree burns. Much of his skin, stripped off by the heat, required months of painful grafting to heal. Muscle tissue and bones were damaged, as well.

Medical statistics reveal that scald burns caused by hot water flowing into a tub or shower enclosure are among the leading causes of severe burn injuries in the United States. According to the American Hospital Association, more than 112,000 people go to hospital emergency rooms each year for scald-related injuries. Children under the age of five, the elderly, and people with mental and physical disabilities are among the most susceptible. The elderly are also particularly susceptible to infection and are among those most vulnerable to Legionella exposure because of weaker immune defenses.

Among older people, the threat of scalding attributed to pressure and temperature changes is dramatically increased because:
  • Older people lose the ability to respond quickly; the blunting of reflexes worsens with age.
  • With assistive bathing, temperature changes are not felt by the person controlling them.
  • Individuals receiving postsurgical or burn care have delicate, healing tissues and need carefully controlled bathing temperatures.
  • Bathers may be left unattended for extended periods of time, even though they are unable to change the water temperature.
Figure 1. Water temperature risk levels.

Another important factor to keep in mind is that most residents of long-term care facilities-either because they're disabled or simply because they're elderly-have delayed reactions to a sudden rise in water temperature. Therefore, residents can be subjected or can unknowingly subject themselves to the risk of severe tissue damage and burns (figure 1). At a water temperature of 130¦F, only 20 seconds of exposure can produce a first-degree burn. Even momentary exposure to scalding water can result in second- or third-degree burns. At 135 to 140¦F, it takes an elderly person only 5 to 6 seconds to sustain third-degree burns that can potentially destroy all skin layers. This can cause permanent injury and disfigurement and'depending on the level of exposure'possibly death. It's not uncommon for scald-related injuries to require skin grafts and an average hospitalization of 17 days. Moreover, the many dangers of scalding water can expose your facility to numerous liabilities, lawsuits, bad publicity, and public ill will.

Risk of Infection
Recent studies have shown that water temperatures as high as 180¦F within potable distribution systems cannot immediately kill "biofilm-insulated" bacteria on contact. (Biofilm forms when bacteria adhere to surfaces in aqueous environments and begin to excrete a slimy, glue-like substance that anchors them to the inner walls of plumbing pipes; a biofilm can be formed by a single bacterial species but more often consists of many species of bacteria, as well as fungi, algae, protozoa, debris, and corrosion products). Simply superheating and flushing water lines and fittings periodically will not necessarily ensure disinfection. Even at temperatures of 180¦F or more, it takes time to pasteurize water within the pipes, and lower temperatures require even more time. At 151¦F, Legionella bacteria die within two minutes; at 140¦F, Legionella die within 32 minutes; and at 131¦F it takes five to six hours.

Some facilities distribute hot water at temperatures as low as 120¦F, and some even lower (e.g., 110¦F), to eliminate any risk of scalding. Unfortunately, Legionella will grow in temperatures as high as 122¦F, with an ideal growth range of 95 to 115¦F (Figure 2).

OSHA's technical manual on Legionnaire's Disease (section III, Chapter 7) states that water should not only be stored at a minimum of 140¦F, but it should be "delivered at a minimum of 122¦F to all outlets" to "minimize the growth of Legionella in a system." The combination of 140¦F water with constant circulation (to prevent stagnation) and combination thermostatic/pressure balancing (Type T/P) valve technology is the only reliable way to kill bacteria and maintain sanitary potable water pipes.
Figure 2. Legionellae growth chart.