Problems with moving patients in buildings

Publisher’s version / Version de l'éditeur:

Vous avez des questions? Nous pouvons vous aider. Pour communiquer directement avec un auteur, consultez la première page de la revue dans laquelle son article a été publié afin de trouver ses coordonnées. Si vous n’arrivez pas à les repérer, communiquez avec nous à [email protected].

Questions? Contact the NRC Publications Archive team at

[email protected]. If you wish to email the authors directly, please see the first page of the publication for their contact information.

https://publications-cnrc.canada.ca/fra/droits

L’accès à ce site Web et l’utilisation de son contenu sont assujettis aux conditions présentées dans le site LISEZ CES CONDITIONS ATTENTIVEMENT AVANT D’UTILISER CE SITE WEB.

Building Research Note, 1978-02

READ THESE TERMS AND CONDITIONS CAREFULLY BEFORE USING THIS WEBSITE.

https://nrc-publications.canada.ca/eng/copyright

NRC Publications Archive Record / Notice des Archives des publications du CNRC :

https://nrc-publications.canada.ca/eng/view/object/?id=e4cb0e35-534a-410f-bf3c-4d7b581b2a2a https://publications-cnrc.canada.ca/fra/voir/objet/?id=e4cb0e35-534a-410f-bf3c-4d7b581b2a2a

NRC Publications Archive

Archives des publications du CNRC

This publication could be one of several versions: author’s original, accepted manuscript or the publisher’s version. / La version de cette publication peut être l’une des suivantes : la version prépublication de l’auteur, la version acceptée du manuscrit ou la version de l’éditeur.

For the publisher’s version, please access the DOI link below./ Pour consulter la version de l’éditeur, utilisez le lien DOI ci-dessous.

https://doi.org/10.4224/40000583

Access and use of this website and the material on it are subject to the Terms and Conditions set forth at

Problems with moving patients in buildings

Johnson, B. M.; Jones, B. K.

ISSN

0701-5232

National Research con;&/ national

I

$

Council Canada de recherches-Canada

PROBLEMS WITH MOVING PATIENTS IN BUILDINGS by

*-

B.M.

Johnson and

B.K.

Jones

INTRODUCTION

Emergency h e a l t h c a r e s e r v i c e s a r e expanding r a p i d l y and a r e playing

an i n c r e a s i n g l y important r o l e i n t h e t o t a l h e a l t h c a r e system. I t i s

not widely recognized, however, t h a t an i n t e g r a l p a r t of t h i s emergency c a r e s e r v i c e , i . e . , ambulance s e r v i c e , i s made d i f f i c u l t because

buildings a r e not being designed with ambulance a t t e n d a n t s and t h e i r p a t i e n t s i n mind. I n many cases t h e r e i s i n s u f f i c i e n t c o r r i d o r o r

e l e v a t o r space t o allow a s t r e t c h e r t o be kept i n a h o r i z o n t a l p o s i t i o n . This n e c e s s i t a t e s moving t h e p a t i e n t i n an angular p o s i t i o n i n e l e v a t o r s o r down stairways, r e s u l t i n g i n t i m e delays and e x t r a manhandling which could have c r i t i c a l consequences f o r t h e p a t i e n t .

Ambulance s e r v i c e s involve not only emergency t r i p s t o h o s p i t a l s but a l s o nonemergency t r a n s f e r s such a s t h e t r a n s p o r t i n g of a p a t i e n t t o and from a nursing home t o a h o s p i t a l f o r treatment. According t o t h e Ontario Ambulance Service Information System (OASIS), 450,000 ambulance t r i p s were made i n t h e Province of Ontario i n 1973. This organization c o l l e c t s and analyzes d a t a on a l l ambulance t r i p s made i n t h i s province. From t h e i r a n a l y s i s we now know t h a t of t h e t o t a l number of t r i p s made i n 1973, approximately 70 p e r c e n t involved c a l l s t o b u i l d i n g s and of t h e s e , approximately 45 p e r c e n t were i n t e r - h o s p i t a l nonemergency t r a n s f e r s of t h e type j u s t described.

This p r e s e n t study was designed t o gather information on t h e type and e x t e n t of t h e p a t i e n t moving problem i n order t o d e s c r i b e t o $ u i l d i n g designers and b u i l d i n g code committees t h e d i f f i c u l t i e s faced i n emergency e g r e s s v i a s t r e t c h e r s with t h e goal of eliminating o r a t l e a s t reducing t h e problems faced by ambulance a t t e n d a n t s and t h e i r p a t i e n t s .

METHODS OF STUDY

The o b j e c t o f t h e emergency ambulance s e r v i c e s

i s

t o g e t t o t h e p a t i e n t a s quickly a s p o s s i b l e and begin preliminary treatment ( t h e administering of oxygen f o r example), while t r a n s p o r t i n g t.he p a t i e n t t o an emergency ward i n a way t h a t has t h e l e a s t d e t r i m e n t a l e f f e c t on him. Without question, t h e reduction i n t r a n s p o r t a t i o n time and i n t h e

physical manipulation of t h e p a t i e n t i s d e s i r a b l e . In nonemergency t r a n s f e r s i t u a t i o n s , while time reduction

i s

not c r i t i c a l , t h e l a t t e r o b j e c t i v e i s s t i l l of concern.

The emergency h e a l t h c a r e system c o n s i s t s of a number of s t e p s o r s t a g e s aimed a t g e t t i n g t h e p a t i e n t t o a h o s p i t a l without undue d e l a y . Figure 1 i s a diagrammatic r e p r e s e n t a t i o n of t h e s e v a r i o u s s t e p s . Each ,of t h e s e can b e examined t o deternrine,>how t h e time taken may be reduced and t h e c a r e o f t h e p a t i e n t improved. While every s t a g e i n t h i s p r o g r e s s i o n i s important, t h i s r e p o r t is concerned with t h e

" p a t i e n t i n c o t taken t o ambulancef1 phase, focusing on t h e d i f f i c u l t i e s ambulance a t t e n d a n t s encounter due t o b u i l d i n g design.

A s mentioned, b u i l d i n g s a r e n o t u s u a l l y designed with ambulance a t t e n d a n t s and t h e i r p a t i e n t s i n mind. In t h i s regard t h e s i t u a t i o n of ambulance a t t e n d a n t s i s very s i m i l a r t o t h a t of d i s a b l e d persons.

Neither h a s a v o i c e i n t h e d e s i g n p r o c e s s , being v i r t u a l l y ignored by a r c h i t e c t s and o t h e r b u i l d i n g d e s i g n e r s , y e t both a r e a d v e r s e l y

a f f e c t e d by e x i s t i n g b u i l d i n g s . I n o r d e r t o d e s c r i b e t h e problems faced i n emergency e g r e s s v i a s t r e t c h e r , information on t h e t y p e and e x t e n t o f t h e problems encountered i s necessary. To t h i s end, two s e p a r a t e y e t i n t e r r e l a t e d methods were adopted.

The f i r s t involved t h e s e t t i n g up of a l i m i t e d number of mock-up studies. Ambulance a t t e n d a n t s were asked t o mmeliver an occupied s t r e t c h e r through a number o f d i f f e r e n t p h y s i c a l arrangements i n o r d e r t o determine t h e amount of inconvenience and d e l a y each arrangement would produce. The mock-ups, along with t h e i r diagrammatic

r e p r e s e n t a t i o n s a r e d i s c u s s e d i n g r e a t e r d e t a i l l a t e r i n t h i s paper.

THE

OASIS

SURVEY

The second phase of t h i s i n v e s t i g a t i o n c o n s i s t e d of an a n a l y s i s of t h e r e c o r d s of t h e O n t a r i o Ambulance S e r v i c e s Information System

(OASIS) f o r Ottawa and Hamilton f o r f i v e weeks i n February 1975. OASIS r e q u i r e s t h a t an Ambulance C a l l Report, o r Form ASSA (See Appendix A) be f i l l e d o u t f o r each c a l l t o which t h e ambulance

s a t t e n d a n t s respond. A s w e l l a s being r e q u i r e d t o i n d i c a t e t h e p i c k up

l o c a t i o n and t h e n a t u r e and cause o f t h e i n j u r y , t h e a t t e n d a n t s a r e a l s o o b l i g e d t o n o t e , among o t h e r t h i n g s , t h e observed c o n d i t i o n o f t h e p a t i e n t , t h e s i t e of major i n j u r i e s o r p a i n , t h e a s s i s t a n c e given t h e p a t i e n t p r i o r t o t h e i r a r r i v a l a s w e l l a s t h e c a s u a l i t y c a r e t h e y adminis- t e r e d and t h e changes i n t h e p a t i e n t ' s c o n d i t i o n t h a t occurred en r o u t e .

With t h e co-operation of OASIS, t h e Division of Building Research of t h e National Research Council of Canada conducted a five-week survey u t i l i z i n g t h e "Special Occurrence1' box and t h e "Notes" s e c t i o n on t h e ASSA form. A r e p o r t code was developed (Figure 2 ) f o r t h i s S p e c i a l Occurrence box and was a t t a c h e d t o t h e a t t e n d a n t s ' c l i p b o a r d s . Thus, if t h e t r i p was between h o s p i t a l s o r t o a roadway work s i t e o r farm and no b u i l d i n g was involved, t h e number 50 was recorded. I f t h e t r i p d i d involve a b u i l d i n g o t h e r t h a n a h o s p i t a l and no s p e c i f i c problems occlirred, t h e n 49 was recorded. When some problem d i d occur, however, then depending on t h e n a t u r e of t h e problem a number between 37 and 97 was recorded. Furthermore, f o r each problem t h e r e were t h r e e a d d i t i o n a l

-3-

numbers t h a t were used t o i n d i c a t e t h e time delay caused by t h e problem i n reaching t h e p a t i e n t . The "Note Section" was t o be used t o g i v e a more ' f e t a i l e d d e s c r i p t i o n of t h e problem encountered, a b r i e f d e s c r i p t i o n of t h e i b u i l d i n g type (e.g., s i x - s t o r e y a p a r w e n t b u i l d i n g , single-family dwelling, four-storey o f f i c e b u i l d i n g , t h r e e - s t o r e y nursing home, t h e a t r e , and s o on), and t h e e f f e c t t h a t t h e b u i l d i n g problem had on t h e p a t i e n t .

The recorded intended a r i s e

.

following examples d e s c r i b e t h e type of problems t h a t could be i n each box. The list i s by no means exclusive and i s only t o provide some of t h e many problems t h a t could conceivably No Building 50

T r i p s between h o s p i t a l s , t o road a c c i d e n t s , o r o t h e r t r i p s i n which a building, o t h e r than a h o s p i t a l , was not involved.

No Problem 49

T r i p s involving a b u i l d i n g t h a t d i d not p r e s e n t any problems.

In o t h e r words, t h e a t t e n d a n t s had no d i f f i c u l t y g e t t i n g i n our out of t h e building, finding t h e p a t i e n t , parking and s o on.

Elevator Unavailable

37 i f l e s s than 3 minutes delay

38 i f r e s u l t i n g delay was between 3 and 6 minutes 39 i f delay was more than 6 minutes

Elevator Too Small

# 78 i f l e s s than 3 minutes delay

79 i f r e s u l t i n g delay was between 3 and 6 minutes 80 i f delay was more than 6 minutes

When t h e e l e v a t o r was too small t o s a t i s f a c t o r i l y accommodate t h e s t r e t c h e r , t h i s block was used. The note s e c t i o n was used t o describe t h e r e s u l t s . For example, t h e ambulance c o t had t o be put on an angle, t h e s t a i r s had t o be used, and s o on.

Elevator Other

83 i f l e s s than 3 minutes delay

84 i f r e s u l t i n g delay was between 3 and 6 minutes 85 i f delay was more than 6 minutes

-4-

! i ! 1

.

.

This block was used f o r a l l e l e v a t o r problems n o t included i n t h e " e l e v a t o r unavailable" o r " e l e v a t o r t o o small" c a t e g o r i e s . Problems such a&, t h e e l e v a t o r door n o t opening, o r t h e e l e v a t o r going t o t h e

: wrong f$oor would be l i s t e d h e r e , and t h e n o t e s e c t i o n was t o b e used

< !

! : t o r e c o r d t h e type of problem encountered. For t h i s s t u d y , t h e

non-existence o f an e l e v a t o r was n o t considered a problem. I f t h e l a c k of an e l e v a t o r was seen a s a r e a l h a r d s h i p by t h e a t t e n d a n t s , t h e y were t o record t h i s f a c t i n t h e n o t e s . , ! I S t a i r Problem . , 86 i f l e s s than 3 minutes d e l a y . .

I

j j

I

y

87 i f r e s u l t i n g d e l a y was between 3 and 6 minutes 88 i f d e l a y was more than 6 minutes

One of t h e s e numbers was t o be used when t h e a t t e n d a n t s encountered d i f f i c u l t i e s with t h e s t a i r s such a s being t o o narrow, t o o s t e e p , n o t enough t u r n i n g space a t t h e landing, o r t o o many f l i g h t s .

Doorway Problem

89 i f l e s s t h a n 3 minutes d e l a y

90 i f r e s u l t i n g d e l a y was between 3 and 6 minutes 91 i f d e l a y was more than 6 minutes

Doors t h a t were t o o narrow f o r t h e s t r e t c h e r , locked, t o o small a v e s t i b u l e o r o t h e r door problems, excluding t h o s e concerning e l e v a t o r doors, were t o be recorded i n t h i s set of numbers.

Gorridor Problem

92 i f l e s s than 3 minutes d e l a y

93 i f r e s u l t i n g d e l a y was between 3 and 6 minutes 94 i f d e l a y was more t h a n 6 minutes

C o r r i d o r s t h a t were t o o narrow o r had t u r n s t h a t were t o o sharp t o

Kermit

easy movement of a s t r e t c h e r were t o be recorded h e r e . The s t e p s t a t had t o be taken by t h e a t t e n d a n t s t o overcome t h e problem were t o be

recorded

i n

t h e n o t e s e c t i o n . Other Problems

95 i f l e s s t h a n 3 minutes delay

96 i f r e s u l t i n g d e l a y was between 3 and 6 minutes 97 i f d e l a y was more than 6 minutes

If the attendants were confronted with a problem(s) other than one that

I

would seem to fit into the existing categories, they were to record it

I

via,%one

of the above three numbers and describe it in the note section.

I I

An e)(ample of one such problem would be th:*lack

of

a

building

directory which would make finding the patlent

very

difficult and

time consuming.

If the attendants encountered more than one problem per trip, they

were instructed to record the most serious in the special occurrence box

and then describe the other problems in the note section.

MEDICAL SIGNIFICANCE OF STUDY

It is not possible to assess accurately the effects of delays

on

a

patient's condition. The ability of the ambulance crew to monitor

vital signs is limited and any monitoring that was done would likewise

cause delays. The matrix of problems indicates

a

significant number of

cases where a patient's condition was critical yet there were delays due

to building problems. Appendix B cites case histories illustrating that

transportation of the patient is occasionally significantly delayed in

emergency situations.

An

analysis of the significance of the problem

versus change of patient's condition indicated only slight correlation.

The amount of monitoring will have

to

be increased to draw any conclusions

in this respect. Spinal injuries and certain fractures may be worsened

by special maneuvering on stairs or in elevators, but the OASIS survey

gives no indication of just how significant this problem might be.

Tables I and IT show the incident rate of problems according to various

categories. The coding of columns is the same as in the preceding

section.

PHYSICAL STUDIES

In addition to the OASIS survey a limited number of mock-up studies

were undertaken. Regular ambulance attendants carried an occupied

@

stretcher through a series of fabricated turn arrangements to determine

the degree of inconvenience that resulted from the various geometries.

The degree of difficulty would vary slightly depending upon the size of

the patient and agility of the attendants.

Records were made of these trials in both 35

mm

slides and Super

8

film. Similar records were made of the attendants' use of a small

elevator and two stair configurations.

For the mock-up simulation a 6-

by 6-in. grid was made on the floor

and 4 ft high walls used to simulate turn situations (Figure

3).

The

Super

8

filming was done from a fixed position overhead while the

35 mm

shots were taken from a number of camera angles. Combinations of

corridor widths from

30

to 54 in. were considered and the results

recorded below.

- 6 -

I t was found t h a t f o r t h e 75-in. s t r e t c h e r t o e n t e r f l a t

i n t o a c o r r i d o r 30 i n . wide e x i t c o r r i d o r must be 54 i n . wide 36 i n . wide q. 48 i n . wide

42 i n . wide 42 i n . wide 48 i n . wide 36 i n . wide

Height t o which p a t i e n t must be t i l t e d when l e a v i n g

I l

36 i n . c o r r i d o r t o e n t e r 36 i n . c o r r i d o r = 5 f t

36 i n . c o r r i d o r t o e n t e r 42 i n . c o r r i d o r = 4 f t 42 i n . c o r r i d o r t o e n t e r 42 i n . c o r r i d o r = no t i l t

A t u r n i n g a r e a approximately 90 i n . i n diameter i s n e c e s s a r y i f

s t r e t c h e r i s t o be k e p t f l a t .

EQUIPMENT AND PROCEDURES FOR TRANSPORTING PATIENTS

Most ambulances a r e equipped w i t h a s t r e t c h e r , a s t a i r c h a i r and a back b r a c e f o r t r a n s p o r t i n g p a t i e n t s . This equipment i s designed t o a s s i s t most p a t i e n t s , r e g a r d l e s s of h e i g h t o r weight. I t i s , however, common p r a c t i c e t o t r y t o move a l l p a t i e n t s on t h e s t r e t c h e r .

S t r e t c h e r s

Although t h e r e i s a wide v a r i e t y of models t h e b a s i c dimensions and c a p a b i l i t i e s of s t r e t c h e r s v a r y l i t t l e (Figure 4 ) . The width i s

g e n e r a l l y about 22 i n . (550 nun) and t h e l e n g t h 75 i n , (1875 mm). Although most s t r e t c h e r s a r e a b l e t o be folded i n such a manner t h a t t h e p a t i e n t

i s i n a s i t t i n g p o s i t i o n , many p a t i e n t s a r e unable t o be t r a n s p o r t e d t h i s way. I t

i s

conceivable t h a t m o d i f i c a t i o n s i n s t r e t c h e r design would a l l e v i a t e some problems. Only 5 p e r c e n t of t h e a d u l t population a r e s o

Q

t a l l a s t o r e q u i r e a s t r e t c h e r longer than 72 i n . i n o r d e r t o be c a r r i e d supine, consequently i f t h e s t r e t c h e r could be t e l e s c o p e d i n some manner

it would be e a s i e r t o maneuver when shortened. S t r e t c h e r s g e n e r a l l y have a wheel diameter of 5 i n . which means any abrupt l e v e l change

g r e a t e r t h a n 29 i n . w i l l r e q u i r e t h e s t r e t c h e r t o be r a i s e d a t t h e f r o n t . Any l e v e l change w i l l cause problems, even i f i t i s only 1 i n .

The following i n d i c a t e s t h e approximate s t r e t c h e r l e n g t h s f o r v a r i o u s c o n f i g u r a t i o n s .

Supine 75 i n . (1875 mm) Legs r a i s e d 703 i n . (1760 mm) Semi- s i t t i n g 633 i n . (1613 mm)

- . ~ , - . . - . . ...,... ... . . .

-7-

S t a i r Chairs

<<,The s t a i r c h a i r (Figure 5) i s designed f o r handling p a t i e n t s i n narr& o r cramped q u a r t e r s ; however, it is p o t normally taken i n t o buildings unless a s t r e t c h e r cannot be used" i n t h e building. A s it must be supported continuously it i s d i f f i c u l t t o c a r r y l a r g e p a t i e n t s on a s t a i r c h a i r .

DIMENSIONS FOR MANEUVERING Doors and Corridors

In 12 p e r cent of t h e OASIS r e p o r t s doors were c i t e d a s being t o o small f o r t h e s t r e t c h e r s . A s s t r e t c h e r s a r e seldom wider than 23 i n . and doors a r e a minimum of 32 i n . wide, they could only be considered t o o small i f t h e s t r e t c h e r had t o be turned t o pass through t h e door; t h e swing of t h e door could a l s o cause problems. These two d i f f i c u l t i e s were common i n residences, where 64 p e r cent of t h e problems reported occurred. In nursing homes a high percentage o f t h e door problems was due t o t h e i r being locked.

I n c o r r i d o r s t h e lack of space f o r maneuvering through t u r n s i s t h e major source o f problems. The r e s u l t s of t h e mock-up s t u d i e s described previously showed t h a t i n s u f f i c i e n t space a t t u r n s causes problems f o r a f u l l - l e n g t h s t r e t c h e r . S p e c i f i c a l l y , when t r y i n g t o maneuver a s t r e t c h e r through any t u r n where both c o r r i d o r s a r e l e s s than 40 i n . (1.0 m), t h e s t r e t c h e r w i l l have t o be t i l t e d . I f a 42-in. c o r r i d o r i n t e r s e c t s a

36 in. c o r r i d o r it i s necessary t o r a i s e t h e s t r e t c h e r 4 f t . I f both c o r r i d o r s a r e only 36 i n . wide then t h e s t r e t c h e r must be r a i s e d 5 f t

(Figure 6 ) .

I n t h e case where t h e r e i s a door i n t o a c o r r i d o r t h e amount of d i f f i c u l t y depends on t h e dimensions of both t h e door and t h e c o r r i d o r .

# i f a s t r e t c h e r is t o remain h o r i z o n t a l and go through a 2 - f t 10-in. door

then it needs a c l e a r space of 52 i n . i n t h e c o r r i d o r and a clearance of 12 i n . between t h e adjacent wall and t h e door. I f t h e c o r r i d o r i s only

36 i n . witie then t h e s t r e t c h e r w i l l have t o be r a i s e d more than 5 f t . Pronounced frames, o b s t a c l e s i n t h e c o r r i d o r and t h e d i r e c t i o n of door swing, can a l l make t h i s maneuver more d i f f i c u l t .

Elevators

In 9 per cent of t h e c a l l s t h e ambulance a t t e n d a n t s had a problem with t h e e l e v a t o r when movement of t h e p a t i e n t was e s s e n t i a l . In 27 per cent of t h e s e instances t h e e l e v a t o r was unavailable and i n 50 per cent of those t h e delay exceeded s i x minutes. I t i s not known i n how many cases t h e e l e v a t o r was too small f o r h o r i z o n t a l e n t r y thus n e c e s s i t a t i n g a s l i g h t r a i s i n g ; it i s only known how o f t e n t h e delay t h u s caused was considered s i g n i f i c a n t by t h e ambulance crew. In h o s p i t a l s t h e main e l e v a t o r problem i s probably t h e i r slowness, but it i s u n l i k e l y t h a t a c r i t i c a l l y i l l p a t i e n t would be delayed because of t h i s . In t h e OASIS

r e p o r t s t h e instances of e l e v a t o r s being t o o small when t h e pick-up l o c a t i o n was a h o s p i t a l a r e more l i k e l y t o r e f e r t o t h e el.evator i n t h e d e s t i n a t i o n than t h a t i n t h e h o s p i t a l . I t seems t h a t t h e e l e v a t o r s i n nursing homes a r e occasionally too small.

The a v a i l a b i l i t y of an e l e v a t o r could be assured by giving t h e ambulance crew an over-ride key such a s t h e f i r e department have. This would enable them t o gain c o n t r o l of t h e e l e v a t o r f o r both taking t h e s t r e t c h e r up and bringing t h e p a t i e n t down.

The 5 p e r cent of t h e cases when e l e v a t o r s were t o o small i n d i c a t e s a r a t e of 220 problems p e r 100,000 people. The small, y e t common,

e l e v a t o r s i z e s w i l l not allow easy e n t r y of s t r e t c h e r s . Occasionally i n o r d i n a t e delays of more than 5 minutes a r e caused (17 per cent of t h e instances) and i n some cases t h e s t a i r s had t o be used i n s t e a d (see Appendix 3). Many p a t i e n t s should n o t be delayed and some should n o t be r a i s e d .

The minimum s i z e required t o have a s t r e t c h e r e n t e r an e l e v a t o r h o r i z o n t a l l y depends on t h e door design. A side-opening door (Figure 7)

permits t h e s t r e t c h e r t o e n t e r a smaller e l e v a t o r than t h e centre-opening doors. Figure 8 i n d i c a t e s t h e cab depth necessary depending on t h e

d i s t a n c e between t h e cab wall and t h e n e a r e s t door edge. The width of t h e door i s assumed t o be 36 i n , (which is f a i r l y standard although i n small apartments 30 i n . i s common). The width of t h e c o r r i d o r i s a l s o c r u c i a l a s t h e r e may n o t be enough room t o t u r n t h e s t r e t c h e r .

Figure 9 (centre-opening door) and Figure 10 (side-opening door) show t h e d i f f e r e n t e l e v a t o r and c o r r i d o r s i z e s required f o r t h e s t r e t c h e r t o e n t e r h o r i z o n t a l l y .

I f t h e e l e v a t o r i s smaller than those shown t h e s t r e t c h e r w i l l

have t o be folded o r t i l t e d . I f a 2500-lb e l e v a t o r has a centre-opening door t h e p a t i e n t w i l l have t o be t i l t e d up 3 f t .

s

If t h e e l e v a t o r i s l e s s than 75 i n . wide then t h e s t r e t c h e r w l l l

e i t h e r have t o be c a r r i e d t i l t e d o r p a r t i a l l y collapsed. A p a r t i a l l y collapsed s t r e t c h e r w i l l pass i n t o a 2500-lb centre-opening e l e v a t o r a s

it i s only 71 i n . long (Figure l l ) , and i n t o a 2000-lb side-opening e l e v a t o r (Figure 12), i n most cases.

The following s t a t i s t i c s from t h e BASIS study represent t h e number of times various p o s i t i o n s were noted and when t h e r e was a problem with e l e v a t o r s , t h e -second column r e p r e s e n t s t h e percentage of t h e p o s i t i o n s i n buildings

.

E l e v a t o r Problem P o s i t i o n s noted i n b u i l d i n g s

(%I

(%I

Prone 0 1 Semi-prone 2 3 S e m i - s i t t i n g 56 55 S i t t i n g 2 0 11 Ambu 1 a t o r y 3 10

These f i g u r e s i n d i c a t e t h a t t h e problems a r e aggravated i f t h e p a t i e n t i s supine o r s i t t i n g and a s expected v i r t u a l l y non-existent if t h e p a t i e n t i s ambulatory.

Stairways

There a r e two i n s t a n c e s where s t a i r w a y s cause problems. Stairways t h a t have r e t u r n s such a s t h e common dog l e g s t a i r can be an

inconvenience t o t h e a t t e n d a n t s and a hazard t o t h e p a t i e n t . Doors i n s t a i r w e l l s can, according t o t h e OASIS r e p o r t s , cause c o n s i d e r a b l e

d e l a y s because o f t h e s p e c i a l maneuvering sometimes needed. While t h e r e a r e many p o s s i b l e c o n f i g u r a t i o n s of s t a i r w a y s t h e requirements f o r

s t a i r w e l l r e t u r n s and doors i n stairs a r e g e n e r a l l y a p p l i c a b l e .

S t a i r r e t u r n s of t h e t y p i c a l dog l e g w i l l p r o h i b i t easy movement of a f l a t s t r e t c h e r i f t h e c l e a r d i s t a n c e between w a l l s i s l e s s than 90 i n . (Figure 13)

.

Pronounced h a n d r a i l s should be considered a s reducing t h e width t o a c e r t a i n degree.

Doors with s p r i n g c l o s i n g mechanisms r e q u i r e s p e c i a l maneuvering a s do doors a t c e r t a i n p l a c e s i n t h e s t a i r w e l l (Figure 14).

d

RECOMMENDATIONS

Without a complete c o s t - b e n e f i t a n a l y s i s it i s n o t p o s s i b l e t o do more t h a n merely suggest t h e d i r e c t i o n t o t a k e t o reduce t h e number of problems. In general t h e r e appears t o be two main problem a r e a s .

I n d i v i d u a l homes f r e q u e n t l y seem t o o confined f o r t h e use of s t r e t c h e r s . Apartment b u i l d i n g s o c c a s i o n a l l y have e l e v a t o r s t h a t a r e t o o small. The following recommendations a r e made p r i m a r i l y w i t h t h e s e problem a r e a s i n mind. Appendix C i n d i c a t e s t h e d i s t r i b u t i o n of t h e v a r i o u s types of housing s t a r t s .

1. Doorways

Entrance doors, doors i n t o s t a i r s and doors i n t o bedrooms should have adequate space about them t o allow t h e maneuvering of a

-

10-

2. Elevators

Buildings that require a 2000-lb elevator either because of

!

,

passenger demand or because of legislation should have a 2500-lb

5

elevator with side-opening door. In%uildings where small elevators

would normally be installed the nature of the occupants should be

considered to determine whether a 2500-lb elevator would be

worthwhile. In 2500-lb elevators or smaller only side-opening doors

should be installed.

Elevators should have some mechanism such as keyed operation

to ensure their availability to ambulance crews.

This should be

worked out with the building manager.

3.

Stairs

In buildings without elevators or where the elevator is too small

to be used or unavailable stairways should be wide enough ro

allow the maneuvering of stretchers both at turns and through

doorways, this requires landings with

a

minimum clear width of

90 in.

4. Corridors

Turning at the junction of two corridors is difficult if either of

the corridors

is less than 40 in. wide. Turning into doors is

exceptionally difficult in narrow corridors and generally requires

a corridor 52 in. wide.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the assistance, cooperation and

support of the Ontario Ambulance Services Information System and the

Ottawa and Hamilton Ambulance Services, without whom this report would

not have been possible.

TABLE

I

Incidences of Problems According to OASIS Reports

Elevators - Total Number of Calls to Buildings = 2421

-

EU2 EU5 EU6 ES2

EST

E S ~ E02 EO5 E06

37 38 39 78 79 8 0 8 3 84 85 PROBLEM RESIDENCE 5 _{51 1 7 1 2} TRANSPORT TERMINAL 1 0 1 6 32 1 3 NURSING HOME DR. OFFICE/CLINIC TRANSFER TYPE 8 12 22 26 1 10 ACUTE ILLNESS STABLE ILLNESS 4 25 1 0 CONVALESCENT OBSTEIRICS

VITAL SIGNS ABS 5

OBSERV COND-DANGER 1 2 11 1 3 37 1 7 MAJOR INJURY-BACK FACTORS-SPINE INJ. FACTORS-DANGEROUS CASU CARE-VITAL 0 3 2 11 7 1 0 1 0 171 CASU CARE-FRACTURE 1 1 I 1 1 1 o 1 o 3 6 POSITION-SUPINE 2 4 8 12 6 6 1 1 1 365 POSITION-PRONE 0 0 0 0 0 0 0 0 0 9 POSIT-SEMI-PRONE 1 0 1 2 0 0 1 0 0 4 2 POSIT-SEMI-SITTING 12 13 24 44 12 1 0 5 4 8 952 POSITION-SITTING 6 4 3 14 7 1 1 0 1 15 4 0 0 0 1 0 0 0 0 0 1 AMBULATORY 0 0 2 2 1 1 0 0 1 221 COA UNCHANGED 20 21 37 71 23 1 8 8 3 11 1669 COA IMPROVED 0 0 1 2 2 0 0 1 0 5 3 COA DETERIORATED 0 0 0 0 0 0 0 0 0 8

VITAL SIGNS ABS 13 0 0 0 1 0 0 0 0 0 6

ESSENTIAL 15 12 32 52 1 3 14 5 3 7 1183

ESSEJJTIAL-EXPENUA. 5 8 4 10 8 2 1 1 2 274

NON ESSENTIAL 1 0 1 5 0 0 0 0 0 32

There were 3h78 calls. 2421 ( 7 0 % ) of which were calls to buildings. Of the calls

TABLE

I1

Incidence of Problems According to OASIS Report Stairs, Doors, Corridors_

Total Number o f Calls t o Buildings = 2421

CIRCU&TABCES VS. TYPE ST2 ST5 ST^ D R 2 DR5 D R ~ CR2 CR5 C R ~ N 0 86 87 88 8g* 9 0 91 9 2 9 3 94 PROBLEM RESIDENCE 126 30 1 6 151 2 3 9 111 21 6 807 TRANSPORT TERMINAL 0 0 0 0 0 0 0 0 0 6 HOSPITAL 32 7 8 60 4 4 1 8 4 5 798

(

NURSING HOME 2 0 4 1 25 3 1 1 3 2 1 146 DR. OFFICE/CLINIC 3 2 0 3 1 0 3 1 0 4 4 TRANSFER TYPE 43 1 0 8 7 2 6 3 31 5 4 775 ACUTE ILLNESS 3 4 3 6 4 3 6 2 4 0 4 2 239 STABLE ILLNESS 68 21 5 80 1 4 4 43 1 3 2 4 39

1

CANVALESCENT 10 3 1 21 2 1 1 0 3 1 144

I

OBSTEIRICS

VITAL SIGNS ABS 5 4 0 1 4 1 0 2 1 0 21

OBSERV COND-DANGER 93 2 2 1 7 123 20 9 8 4 1 9 6 829 MAJOR INJURY-BACK 11 2 2 1 0 2 1 1 1 2 1 31 FACTORS-SPINE INJ. 1 0 0 1 0 0 0 0 0 3 FACTORS-DANGEROUS 4 6 8 6 45 7 5 40 6 2 286

I

CASU CARE-VITAL 3 1 3 6 34 5 2 30 3 2 171 CASU CARE-FRACTURE 8 2 1 8 0 1 6 0 _{1 3 6} POSITION-SUPINE 3 5 7 3 4 6 4 0 35 3 o ₃₆₅ POSITION-PRONE 1 1 0 2 0 0 1 0 0 ₉ POSIT-SEMI-PRONE 4 . 3 0 9 1 0 5 2 0 4 2 < 7 POSIT-SEMI-SITTING 97 25 1 7 123 17 1 0 6 5 1 8 _{9 9 5 2} POSITION-SITTING 2 7 2 1 41 6 3 2 8 3 2 154 SHOCK AMBULATORY COA UNCHANGED COA IMPROVED COA DETERIORATED VITAL SIGNS ABS 13 ESSENTIAL

ESSENTIAL-EXTENUA. NON ESSENTIAL

The classification o f other types of problems is not included because of the

- .

. ... .

4

-A2 -

OASIS STUDY PROGRAM

Prb~essing

2.

*-

This program processes the AS5A Ambulance Call Reports recorded on magnetic tape.

Each call report or record is read and immediately classified as referring to either the Ottawa or the Hamilton service areas. The record's pick-up location is then inspected: if not a building

(a residence, transport terminal, hospital, nursing home or doctor's office or clinic), the record is ignored because we are only interested

in

calls to buildings.

Following this, an acceptable record is handled according to the contents of the special code fields. There are seven such fields per record and the special codes that may occupy them are as follows:

PROBLEM

CATEGORY MEANING

5 0 No building involved. 49 No problem incurred.

37, 38, 39 Elevator unavailable: delay under 3 min, between

3 and 6 min, over 6 min,-respectively. 78, 79, 80 Elevator too small: delays as above

83, 84, 85 Elevator (other): delays as above

"

86, 87, 88 Stair problem: delays as above

-- 89, 90, 91 Doorway problem: delays as above

- -- - -

92, 93, 94 Corridor problem: delays as above 95, 96, 97 Other problem: delays as above

-

-

-

Code 50

The call (record) is treated as not applicable to a building and is skipped for the next record, regardless of the other special code fields.

-A3-

t o t a l s a r e updated. No Recognizable Codes

The c a l l i s t r e a t e d a s f o r Code 4 9 . A l l Other Codes

I f more than one o f t h e members o f a category i s found i n any r e c o r d ( i , e . , 37 and 39) t h e r e c o r d i s considered ambiguous.

The number o f such r e c o r d s i s t o t a l l e d b u t t h e s e do n o t c o n t r i b u t e t o any o f t h e o t h e r t o t a l s s i n c e t h e y a r e ignored a s soon a s i d e n t i f i e d .

Where t h e problem codes a r e l e g i t i m a t e , t o t a l s a r e updated f o r each problem c a t e g o r y and d e l a y c l a s s contained i n t h e record.

OUTPUT

MATRIX: Problem t y p e s from 37 t o 97 and t h e no-problem c a s e a c r o s s t h e t o p and v a r i o u s c a l l circumstances, taken from t h e AS5A form, down t h e s i d e .

Since c e r t a i n circumstance t y p e s such a s "OBSERVED CONDITION -

DANGEROUS" ( s e e a c t u a l l i s t i n g ) , a r e composites o f s e v e r a l p o s s i b l e s i t u a t i o n s which can be r e p r e s e n t e d on a record i n more than one i n s t a n c e , t h e c o r r e l a t i o n t o t a l f o r such circumstance t y p e s and an a p p l i c a b l e problem type i s incremented by 1 where a t l e a s t one

i n s t a n c e of t h e circumstance t y p e i s found (and n o t f o r each i n s t a n c e found i n t h e same c a l l o r r e c o r d ) .

G

Statements

The ilumber o f c a l l s r e a d on t h e t a p e , t h e number of c a l l s made t o b u i l d i n g s , t h e number of t h e l e t t e r s which were ambiguous and t h e number which p r e s e n t e d a t l e a s t one problem a r e enumerated as well as a p p r o p r i a t e percentages.

Problem Occurrence L i s t

APPENDIX B Case I i i s t o r i e s

The following a r e n o t a b l e c a s e h i s t o r i g s f o r Hamilton d u r i n g t h e p e r i o d 1 t o 14 February 1975. Each of t h e s e c a s e s had some problem w i t h t h e b u i l d i n g .

1. A p a t i e n t w i t h a h i s t o r y of a s t h m a t i c a t t a c k s was taken from h e r 9 t h s t o r e y apartment because s h e complained o f s h o r t n e s s o f b r e a t h and had t h e f l u . Unfortunately, t h e a t t e n d a n t s r e p o r t e d l y had t o w a i t more than f i v e minutes f o r an e l e v a t o r ; t h i s w a i t was i n t h e words o f t h e a t t e n d a n t s "too long1'. F o r t u n a t e l y , w i t h a s s i s t a n c e t h e p a t i e n t was r e s t o r e d t o a s t a b l e c o n d i t i o n .

2. An ambulance crew were confronted with a s e r i e s of d e l a y s when t r y i n g t o remove a man who was s u f f e r i n g from a seemingly a c u t e h e r n i a . The house where t h e p a t i e n t l i v e d had s t a i r s t o o ''steep and narrowf1 r e s u l t i n g i n more than a f i v e minute d e l a y ; narrow c o r r i d o r s and doors a l s o r e s u l t e d i n s i g n i f i c a n t d e l a y s .

3 . I n an o l d e r apartment house t h e doorway was t o o small f o r t h e

s t r e t c h e r , however, t h e p a t i e n t was w i l l i n g t o walk. The r e s u l t i n g d e l a y exceeded f i v e minutes and, a s t h e p a t i e n t was s u f f e r i n g from a drug overdose, might have been v e r y s e r i o u s .

4 . A narrow s t a i r w a y t o t h e f r o n t door caused a couple o f minutes d e l a y i n t h e removal of an 80 y e a r o l d p a t i e n t s u f f e r i n g from a h e a r t a t t a c k .

5. When attempting t o remove a woman with back problems from h e r

6 t h f l o o r apartment t h e a t t e n d a n t s were unable t o g e t t h e s t r e t c h e r i n t o t h e e l e v a t o r . The s t r e t c h e r was l e f t on t h e main f l o o r and

@ t h e p a t i e n t walked t o t h e e l e v a t o r ; t h e r e s u l t i n g d e l a y exceeded

f i v e minutes.

6. The ambulance crew was unable t o g e t t h e s t r e t c h e r i n t o t h e house of a man s u f f e r i n g from a h e a r t ailment. Apparently t h e porch was t o o small t o allow t h e s t r e t c h e r t o p a s s i n t o t h e house, only a minute o r s o was l o s t with t h i s problem.

7. Despite t h e u s e of a s t a i r c h a i r a problem a r o s e when t r y j n g t o r e t u r n a 96 y e a r o l d woman t o h e r home. Narrow s t a i r s and a t i g h t t u r n a t t h e bottom were t h e problem.

8 . Severe d e l a y s were encountered when t r y i n g t o move a s t r o k e p a t i e n t from h e r o l d e r apartment. The s t a i r c h a i r was used y e t t h e r c were s t i l l problems with t h e narrow c o r r i d o r s and doors. The p a t i e n t ' s c o n d i t i o n was s t a b l e , f o r t u n a t e l y ; otherwise t h e d e l a y of more than 10 minutes might have been s e r i o u s .

9. When t r y i n g t o remove a h e a r t p a t i e n t from t h e bedroom of h i s house a d e l a y o f a couple of minutes was caused because of narrowness of t h e c o r r i d o r .

10. I n t r a n s f e r r i n g a p a t i e n t from one h o s p i t a l t o a n o t h e r an e l e v a t o r being used f o r o t h e r purposes caused a d e l a y i n excess o f f i v e gninutes.

i

11.

k

two s e p a r a t e i n s t a n c e s t h e same ambu?iance crew were unable t o g e t a s t r e t c h e r i n t o t h e "pick-up" houses. I n t h e s e i n s t a n c e s , however, t h e d e l a y s experienced were o n l y a couple of minutes. 12. A d e l a y o f s e v e r a l minutes was encountered when t r y i n g t o remove a

p a t i e n t w i t h a p o s s i b l e u l c e r . I n t h e words o f t h e a t t e n d a n t , t h e door opened "towards s t a i r s i n s t e a d of away, making it d i f f i c u l t t o move t h e s t r e t c h e r " .

13. A h e a r t p a t i e n t i n c r i t i c a l c o n d i t i o n r e q u i r e d immediate

a t t e n t i o n . He was removed from h i s house i n a supine p o s i t i o n . The few minutes d e l a y caused by t h e "very narrow s t a i r s " could have been c r i t i c a l .

14. When t r y i n g t o remove a woman s u f f e r i n g from poisoning, a d e l a y o f over f i v e minutes was caused because h e r t h i r d f l o o r apartment was not served by an e l e v a t o r .

15. A s t a i r c h a i r had t o be used t o move a 61 y e a r o l d woman from h e r house. Although t h e r e s u l t i n g d e l a y amounted t o s e v e r a l minutes t h e p a t i e n t was i n a s t a b l e c o n d i t i o n . A s h e r problem was

something t o do with h e r h i p it i s l i k e l y t h a t t h e u s e of a s t a i r c h a i r caused h e r some discomfort.

16. Reportedly, c h i l d r e n p l a y i n g on t h e e l e v a t o r caused a d e l a y of s e v e r a l minutes when t a k i n g a 60 year o l d woman from h e r 19th f l o o r apartment.

17. An e l d e r l y woman s u f f e r i n g from a f r a c t u r e d forearm had t o have t h e f o o t o f t h e s t r e t c h e r c a r r y i n g h e r cranked "up f u l l t o g e t on

.6' _{t o t h e e l e v a t o r " . This caused a d e l a y of s e v e r a l minutes.}

18. A p a t i e n t being given oxygen and s u f f e r i n g from poisoning had t o be t r a n s p o r t e d i n a. s t a i r c h a i r from h e r t h i r d - f l o o r apartment. 19. A 72 y e a r o l d man had s u f f e r e d a s t r o k e and was i n a s t a t e of

semi-consciousness when t h e ambulance a r r i v e d ; oxygen was r e q u i r e d . The a t t e n d a n t s were delayed f o r s e v e r a l minutes because of "steep s t a i r w a y w i t h s h a r p t u r n a t bottom".

20. Problems w i t h t h e doors and c o r r i d o r s caused a few p r e c i o u s minutes d e l a y f o r a 73 y e a r o l d h e a r t p a t i e n t . Despite t h e u s e o f

ambulance emergency l i g h t s and t h e presence of a d o c t o r t h e p a t i e n t d i e d en r o u t e .

21. A confined hallway and " s t a i r s q u i t ( s i c ) steep" caused a d e l a y i n t h e removal o f a p a t i e n t with v i t a l s i g n s absent a f t e r having taken ',an overdose of p i l l s . Emergency l i g h t s and s i r e n were used both t o

khe scene and t o t h e d e s t i n a t i o n . Sev;gral s p e c i a l p r a c t i c e s were employed t o t r y t o r e v i v e t h e p a t i e n t but without success.

22. Steep s t a i r s caused a problem f o r t h e ambulance a t t e n d a n t s when t h e y t r i e d t o remove a 48 year o l d woman who had f a l l e n down them and i n j u r e d h e r back.

2 3 . A long f l i g h t of stairs prevented t h e a t t e n d a n t s from g e t t i n g t h e s t r e t c h e r up t o t h e 2nd f l o o r o f a house and consequently t h e p a t i e n t had t o be c a r r i e d down without t h e b e n e f i t o f a s t r e t c h e r . 24. I n t r y i n g t o remove an a i l i n g 66 y e a r o l d woman from a n u r s i n g home

t h e a t t e n d a n t s had s e v e r a l problems. F i r s t because t h e doors t o t h e n u r s i n g home were locked t h e y had t o w a i t s e v e r a l minutes, then it took s e v e r a l more minutes t o maneuvre up and down t h r e e f l i g h t s of s t a i r s .

CONCLUSION

--.-.--- -

I f c o n s i d e r a t i o n i s given t o t h e number o f problems faced on a

nationwide s c a l e over a y e a r and t h e consequence i n terms of f a t a l d e l a y s , t h e r e seems l i t t l e doubt t h a t an improvement i n t h e s i t u a t i o n i s necessary.

APPENDIX C

The following figures from Canadian H o u p g Statistics 1976 indicate

the distribution of new housing units in terms of height. The figures

are based on housing starts from 1966 to 1976.

41%

-

of which approximately

50%

are

less than

34

storeys.

Row Houses

7%

Semi-Detached

6%

Detached Houses

46%

-

of which approximately 65% are

bungalows

100%

It appears that almost 20 per cent of the units would be in buildings

8

storeys and over (i.e., in buildings where

CMHC

requires a 2000-lb

elevator).

About

25

per cent of the units might be affected

by any

provision for ensuring adequate space for maneuvering in stairways.

COT TAKEN TO P A T I E N T COT T A K E N F R O M A M B U L A N C E A M B U L A N C E A R R I V E S C O M M U N I C A T I O N S . TRAVEL P A T I E N T M O V E D ONTO COT P A T I E N T A N D COT T A K E N TO A M B U L A N C E P A T I E N T A N D COT P U T ON A M B U L A N C E A M B U L A N C E D R I V E N TO H O S P I T A L P A T I E N T

E l

Figure 1 Steps t o transport p a t i e n t s r a p i d l y P A T I E N T A N D COT REMOVED F R O M A M B U L A N C E R E S U L T I N G D E L A Y I N M I N U T E S N O P R O B L E M E L E V A T O R ( O T H E R ) - S T A I R P R O B I EM--- N O B U I L D I N G D O O R W A Y P R O B I E M - N O T E S ( D E T A I L S . B U I L D I N G T Y P E , A F F E C T O N P A T I E N T ) Figure 2

Figure 3

Moving stretcher through turn

Figure 4

Figure 5

Common s t a i r c h a i r design

Figure 6

Figure 7

Maneuvering patient into small elevator

D I S T A N C E F R O M S I D E O F D O O R , i n .

( 3 6 " E L E V A T O R D O O R )

Figure 8

Figure 9

Maneuvering stretcher into elevator with centre-opening door

Figure 10

Figure 11

Partially collapsed stretcher

Figure 12

Figure 13

Maneuvering f l a t stretcher i n s t a i r well

Figure 14