• 
  Rey Albert Tablazon
  
• 
  Kim Harper
  

Healthcare associated infections develop in a patient as a result of their exposure to healthcare facilities or procedures. They include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), C. difficile and other infections caused by bacteria and viruses encountered in healthcare facilities (CUPE, 2009). Hospital acquired infection can result in prolonged or permanent disability and some hospital acquired infections prove fatal (Taylor, Plowman, & Roberts, n.d.).The rates of these hospital acquired infections in the acute care setting have increased especially in Alberta. For example, in 2007, a preliminary surveillance report on MRSA in patients from 47 Canadian acute-care sentinel hospitals found that the MRSA rate was 8.62 per 1000 admissions (AHW, 2011). Also, since reporting began in 1999, a cumulative total of 1,241 VRE infected cases were reported to the Public Health Agency of Canada (Agency) through December 31, 2011 (PHAC, 2013). With the incidences of these super-infections occurring in the acute care setting, the health of the individuals being admitted in the hospital is further placed at risk. The individuals at risk include mostly children and the elderly. According to the population projections of the Alberta Treasury Board and Finance (2013), the number of Albertans aged 80 years and older would more than triple from the current level of about 115,000 in 2012 to over 383,700 by 2041 (p. 3). This means that more and more elderly individuals will be at high risk for infections such as MRSA which according to the report by AHC (2011), have infection rates highest in the elderly (70 years and older). Acquiring infections in the acute care setting can have a great impact on the affected person’s life. This might mean he can no longer go to work while being treated in the hospital which would mean financial losses which not only affect the individual, but also his family. Furthermore, treating super infections in a hospital care setting can significantly impact the country’s economy. A survey of Canadian hospitals (reported in 2000) estimated the direct costs of hospital acquired infections in Canada to be approximately $1 billion annually. In 2007, MRSA alone was estimated to be costing Canada’s healthcare system $200-250 million per year (CUPE, 2009).

Identifying Solutions to Prevent Super-infections

Super-infections can be costly to treat and most often than not, prove fatal for the individuals afflicted with such. However, over the years, methods have been developed to further prevent individuals admitted to in an acute care setting from contracting such infections. Such methods involve adding more healthcare cleaning and infection control staff with proper training. Knowing how to deal with a situation where infection occurs can greatly reduce the risk of certain infections from spreading further among individuals in an acute care setting. Hospitals in Canada and Europe have demonstrated that investment in more cleaning and infection control staff, training and workforce stability has brought infection rates down (CUPE, 2009). Most infections acquired in the acute care setting can be transferred through direct contact. It can either be direct contact with an infected individual or an object that has come into contact with an infected individual. Transfer of infectious bacteria can be prevented through proper hand washing. Hospitals nowadays tend to have hand sanitizers placed strategically over the entire hospital. While antimicrobial soap and water are still recommended for hands that are visibly soiled or have been exposed to bodily fluids, alcohol-based gels or rubs are now preferred for routine decontamination of hands after most patient contact. These products rapidly kill bacteria and most viruses, and actually are gentler on the hands than repeated use of soap and water (IHI, 2012). The nurse’s role is to educate, not only the individuals being admitted into an acute care setting, but also the visitors coming in and out of the hospital to wash their hands properly.

Nursing Care Plans

There are three nursing care plans that were drafted from this scenario which may apply to potential high risk individuals involved. First nursing diagnosis is an actual problem, fear/anxiety (see Appendix A for a breakdown of the care plan). Second nursing diagnosis is a potential problem, risk for infection (see Appendix B for a breakdown of the care plan). The last nursing diagnosis is an educational need, knowledge deficit (see Appendix C for a breakdown of the care plan).

Conclusion

Preventing the spread of super-infections involves team effort. Not only is this limited to the health care workers, but also extends to families and visitors in an acute care setting. The addition of more staff that are trained and knowledgeable in dealing with infection prevention certainly helps keep such infections at bay. Most of these infections are acquired through direct contact; therefore, proper hand washing should be performed before and after coming into contact with an individual or any object that is present in the hospital. Not only will it reduce the risk of contracting a super-infection towards oneself, it will also prevent the spread towards other individuals.

References

Albert Health and Wellness, (2011).

Methicillin Resistant Staphylococcus Aureus (MRSA) –


2010 AHW Report.

Retrieved from

http://www.health.alberta.ca/documents/MRSA-

Alberta-Report-2006-2010.pdf

Alberta Treasury Board and Finance, (2013).

Alberta population projection

. Retrieved from

http://www.finance.alberta.ca/aboutalberta/population-projections/2013-2041-alberta-

population-projections.pdf

Canadian Union of Public Employees, (2009).

Health care associated infections: a


backgrounder.

Retrieved from

http://cupe.ca/health-care/health-care-associated-

infections

Doenges, M.E., Moorhouse, M.F., Murr, A.C., (2006).

Nursing care plans. Guidelines for


individualizing client care across the life span 7



^th



ed.

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Elsevier, (n.d.).

Infection, risk for universal precautions; standard precautions; CDC guidelines;


OSHA.

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http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/

Constructor/gulanick33.html

Institute for Healthcare Improvement, (2014).

Reducing MRSA Infections: Staying One Step


Ahead.

Retrieved from

http://www.ihi.org/knowledge/Pages/ImprovementStories/ ReducingMRSAInfectionsStay

ingOneStepAhead.aspx

Nanda Nursing Interventions, (2012).

Nursing diagnosis knowledge deficit – gestational diabetes


mellitus.

Retrieved from

http://nanda-nursinginterventions.blogspot.ca/2012/08/nursing-

diagnosis-knowledge-deficit.html

Nursing Care Plan, (n.d.).

Nursing care plan.

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criticalcare_1/98/25168/6443016.cw/content/index.html

Nursing Care Plan, (2012).

Nursing care plan for deficient knowledge.

Retrieved from

http://nanda-nursing-care-plan.blogspot.ca/2012/02/nursing-care-plan-for-deficient.html

Public Health Agency of Canada, (2013).

Vancomycin-resistant enterococci infections in


Canadian acute-care hospitals: Surveillance Report January 1, 1999 to December 31,


2011.

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http://www.ammi.ca/media/55895/cnisp_vre_surveillance_report_ 1999_to_2011-en.pdf

Taylor, K., Plowman, R., Roberts, J.A., (n.d.)

The challenge of hospital acquired infection.

USA. Stationery Office

Appendix A

Nursing Diagnosis Fear/Anxiety related to threat of acquiring an infection as evidenced by client’s expressed feelings of concern and restlessness

Planning Client Goals: Client will have decreased feelings of fear and anxiety Expected Outcomes: Within 8 hours of my shift, client will have reported decreased fear and anxiety reduced to a manageable level as evidenced by verbalization of feeling less anxious or exhibit a relaxed state.

Interventions Validate source of fear. Provide accurate factual information (Doenges, Moorhouse, & Murr, 2006) Orient patient to the environment and new experiences or people as needed (Doenges, Moorhouse, & Murr, 2006). Acknowledge awareness of patient’s anxiety (Doenges, Moorhouse, & Murr, 2006). Rationale for Interventions: Identification of specific fear helps client deal realistically with it (Doenges, Moorhouse, & Murr, 2006). Orientation and awareness of the surroundings promote comfort and may decrease anxiety (Doenges, Moorhouse, & Murr, 2006). Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of these feelings (Doenges, Moorhouse, & Murr, 2006).

Evaluation Achievement of Expected Outcomes and Goal Goal totally achieved. Within 8 hours of my shift, client reported a decrease in level of fear and anxiety as evidenced by appearing to be in a relaxed state and verbalizing “I don’t feel so anxious or afraid anymore after all the information you have presented to me” Based on your Assessment Critical Analysis above: Goal was met because the client was able to overcome fear and anxiety by appearing calm and relaxed and verbalizing that the level of fear and anxiety was reduced after appropriate nursing interventions were rendered.

Appendix B

Nursing Diagnosis Risk for infection related to possible exposure to a contaminated area in the acute care setting

Planning Client Goals: Client will be free of infection while admitted in an acute care setting Expected Outcomes: Within 8 hours of my shift, The client will be free of infection as evidenced by negative cultures.

Interventions Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care (Elsevier, n.d.). Use strict aseptic technique when handling invasive lines and equipment (Nursing Care Plan, n.d.). Limit use of invasive devices/procedures when possible. Remove lines/devices when infection is present and replace if necessary (Doenges, Moorhouse, & Murr, 2006). Rationale for Interventions: Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; handwashing reduces these risks (Elsevier, n.d.). To decrease risk of nosocomial infection (Nursing Care Plan, n.d.). Reduces number of sites for entry of opportunistic organisms (Doenges, Moorhouse, & Murr, 2006).

Evaluation Achievement of Expected Outcomes and Goal Goal totally achieved. Within 8 hours of my shift, client did not acquire an infection as evidenced by vital signs being normal and reported negative cultures from lab. Based on your Assessment Critical Analysis above: Goal was met. After interventions were rendered and being extra careful in dealing with the client and the environment, the client was free from infection by the end of my 8 hour shift.

Appendix C

Nursing Diagnosis Knowledge deficit in preventing spread of infection related to lack of information as evidenced by client verbalizing “I don’t know how infection is transferred”

Planning Client Goals: Client verbalizes understanding of desired content Expected Outcomes: Within 8 hours of my shift, the client will verbalize understanding of how infection is transferred in the acute health care setting.

Interventions Determine client’s learning style especially if client had learned and retained new information in the past (NCP, 2012). Instruct client/family in disease process, progression, what to expect, and answer all questions honestly (NCP, 2012). Discuss recognize the signs of infection (Nanda Nursing Interventions, 2012). Rationale for Interventions: Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method facilitates success in mastery of knowledge (NCP, 2012). Promotes optimal learning environment when client shows willingness to learn (NCP, 2012). It is important to seek medical attention early to avoid complications (Nanda Nursing Interventions, 2012).

Evaluation Achievement of Expected Outcomes and Goal Goal totally achieved. Within 8 hours of my shift, client was able to verbalize understanding of how infection is transferred from one person to another as evidenced by client verbalizing “I should really wash my hands more often if infection is easily transferred through direct contact with contaminated objects in the area” Based on your Assessment Critical Analysis above: Goal was met. After interventions were rendered the client was able to understand how infection is commonly transferred in the hospital and how to reduce the risk of contracting them.

The medical record also shows that Mr. Lim has Type 2 diabetes (DM). His blood glucose level is 6.5mmol//L which according to Changi General Hospital (2009), is well-controlled for a diabetic patient. DM may be the major cause of Mr. Lim’s development of chronic renal failure (CRF) as suggested by Daniels and Hostetter (1992). Diabetes results in kidney damage by accelerating atherosclerosis and inducing hypertension (Rachmani, & Ravid, 2003). A recent research links diabetes with atherosclerosis by the large amount of advanced glycation end products produced in diabetic patients that suppress the enzymes capable of dilating blood vessels and inhibiting inflammation of blood vessels (University of Rochester Medical Center, 2008, March 17). Inflammation of the glomerulus can result in hardening with scar formation, inducing tubulointerstitial injury in diabetic nephropathy causing it to progress into CRF (Brosius et al, 2008).

The medical record shows that he has history of hypertension. On assessment, he exhibits high blood pressure (B/P) of 165/105, jugular venous distension (JVD), bilateral lower limb edema and change in skin turgor. Hypertensive nephrosclerosis is the second most common cause of CRF after DM. It causes CRF by increasing pressure in the arterial wall leading to stiffening and thickening of the afferent arteriolar and subsequently damages the glomerulus (Hill, 2008). However, hypertension as the only cause of CRF only occurs in those who are genetically predisposed (Freeman, & Sedor, 2008). The other way round, Mr. Lim’s elevated B/P could be due to increased cardiac output associated with sodium and fluid retention as a complication of CRF (Hortom-Szar, 2007). Hypertension is exacerbated in CRF because damaged kidney is no longer able to maintain electrolyte balance and excreting of sodium is impaired due to damaged nephrons, leading to more amount of water reabsorbed, and hence hypertension and edema (Moorthy, 2009).

As a result of fluid retention, Mr. Lim may report experiencing breathlessness and paroxysmal nocturnal dyspnea. On assessment, he exhibits tachypnea with increased respiration rate of 22/min, may be accompanied with crackles. This is associated to decreased oxygen saturation of 95% leading to an increased in respiratory rate as the body attempts to compensate by exhaling more carbon dioxide (Broscious, & Castagnola, 2006). Left ventricular heart failure can also occur as a result of compensatory mechanism to reduced cardiac output in fluid overload (Thomas, 2008).

The blood test results show increase in both creatinine (Cr) to 1.7mg/dL more than normal range of and blood urea nitrogen (BUN) to 28mg/dL, more than normal range of 0.6-1.3mg/dL and 10-20mg/dL, indicating decrease in renal ability to excrete waste product of metabolism (Hattersley, & Mahon, 2002). Estimation of glomerular filtration rate (eGFR) is a better indicator of kidney function than serum creatinine level as it also takes into consideration of individual’s body mass according to race (Thomas, 2008). Mr. Lim’s eGFR of 41 indicates stage 3 kidney damage.

Mr Lim’s hemoglobin level of 12g/dL falls in the normal range of 12-18g/dL but in the lower end as anemia only starts to occur in state 3 CRF as suggested by Moorthy (2009). He is likely to become anemic if left uncontrolled as CRF progression results in fewer production of erythropoietin leading to a shortage of red blood cells (Moorthy, 2009).

2. Sleeping

Mr. Lim reports insomnia. It could be due to pain, itchy skin, breathlessness or feelings of powerless, anxiety and financial stress. Depression and anxiety are also hurdles to Mr. Lim’s compliance to medical and dietary management of CKF as suggested by Kopple and Massry (2004). He may find life meaningless when challenged with poor health leading to spiritual deprivation and lack of impetus to improve his conditions.

3. Maintaining a safe environment

Mr. Lim exhibits hyperthermia with temperature 37.8°C, higher than normal temperature of 37.0°C. Mr. Lim should be assessed for other signs of infection such as chills, aches, nausea, vomiting and cloudy urine caused by pus or bacteria. This is important because indwelling catheter and intravenous line provide entrance for harmful microorganisms and infection is likely as his immune system is suppressed due to disease progression (Heinzelmann et al, 1999). Lower leg edema also increases Mr. Lim’s risk for infection by ulcer development (Stalbow, 2004).

Mr. Lim may complain of sudden onset of itching skin. According to Brewster (1996), Mr. Lim has a high risk of getting severe uremic pruritus because of his gender and high BUN level. Pruritus is caused by excretion of calcium, phosphorus and urea in the skin (Thomas, 2008). Assessment may reveal scratch marks. Scratching can cause blooding and bruising in Mr. Lim because of capillary permeability and altered clotting functions due to disease progression (Thomas, 2008).

A nurse should assess Mr. Lim’s risk for injury associated with uremia induced central nervous system disorder. Mr. Lim may exhibit mental disabilities such as poor memory, loss of concentration and slower mental ability (Moorthy, 2007). Mr. Lim has high risk for fall if his mental status is altered.

A nurse should also assess for signs of head injury associated with Mr. Lim’s fall.

4. Pain

Mr. Lim reports a pain score of 4. He may describe flank pain as dull, aching and steady pain at the posterior costal margin. He may also complain of leg pain due to edema. Joint pain could also occur due to renal bone disease resulted from releasing of calcium may be released from bone to compensate decreased serum calcium (Broscious, & Castagnola, 2006). Serum calcium level decreased due to albumin loss in CRF because some calcium is bind to protein. CRF also reduces vitamin D synthesis, resulting in less calcium absorption in the gut. He exhibits muscular spasm and tetany due to hypocalcemia (Moorthy, 2007).

5. Eating and drinking

Mr. Lim may report loss of appetite due to metallic taste in mouth and prescribed unpalatable renal diet. Weight measurement may show rapid weight loss. Mr. Lim also requires a high-calcium diet to replace low serum calcium level.

6. Communication

Effective patient education may be impeded by his lack of attention and fatigue as treatment requires a lot of patient participation. Ineffective communication would also prevent patient from discussing his concerns with his sons, making him feel more helpless and powerless.

7. Personal cleansing and dressing

Mr. Lim reports extreme fatigue, weakness resulting in difficulty performing the activities of daily living. On assessment, Mr. Lim exhibits unkempt appearance and decreased range of motion especially of lower extremities.

8. Mobilising

Mr. Lim may have difficulties ambulating due to pain from lower limbs swelling and renal bone disease. It could also be due to Wittmaack-Ekbom’s syndrome and paresthesia of feet associated with sensory neuropathy from uremia (Moorthy, 2008).

9. Eliminating

Mr. Lim reports oliguria for last 24 hours and his urine output is measured to be 20 to 25ml/hour, below than normal volume of 33 to 84ml/hour suggested by Dugdale (2009). As a result, his urine colour appears dark due to decrease urine excretion. Urine output decreases because kidney is unable to excrete water due to damaged nephrons with decreased GFR (Broscious, & Castagnola, 2006). Weight measurement may show rapid weight gain. However, fluctuation of weight may not occur due to malnutrition.

Mr. Lim may exhibit hematemesis and ‘tarry’ stool associated with gastrointestinal bleeding due to irritation by ammonia which is released in the gut by the breakdown of urea (Thomas, 2008).

Mr. Lim may report difficulty in passing motion. Constipation occurs in patients with CRF as fluid intake is restricted and patient is inactive due to fatigue (Thomas, 2008).

Nursing Diagnosis

1. Fluid overload related to inability of the kidneys to produce and eliminate urine as evidenced by high B/P of 165/105, edema and decreased urine output to 20 to 25mL/hour

2. Powerlessness related to lack of understanding of diagnosis and treatment plan and feeling of loss of control as evidenced by patient verbalization of financial concerns and appearing anxious and worried.

3. Risk for imbalanced nutrition: less than body requirements, related to decreased calcium absorption and decreased oral intake associated with loss of appetite and prescribed unpalatable diet as evidenced by low serum calcium of 2.0mg/dL, weight loss and patient verbalizes lack of energy.

4. Pain

5. Activity intolerance

6. Knowledge deficit

7. Risk for impaired skin integrity

8. Risk for prolonged bleeding

9. Risk for infection

10. Risk for fall

C) Nursing Interventions

1. Fluid overload

A nurse should monitor circulating volume by evaluating Mr. Lim’s daily weight, fluid intake and output records, JVD and circumference of edematous parts and vital signs, particularly blood pressure and pulse. Nursing care should also include assessing for crackle and S3 heart sound. Close monitoring allows the nurse to consult a physician if signs and symptoms of fluid overload worsen so interventions can be taken to prevent complications such as pulmonary edema or cardiac failure (Martchev, D).

Medications such as diuretics which increase excretion of urine and arterial vasodilators to increase renal perfusion should be administered. This is important as controlling of hypertension and primary diseases are the only interventions proven effective in preventing progression of CRF (Thomas, 2008). Since Mr. Lim is diabetic, he requires B/P lower than 130/88mmHg to achieve same benefits as non-diabetic patients whose target B/P is 140/85mmHg (as cited in Thomas, 2008). However, Mr. Lim should not be intensely treated to become edema-free because of the danger of hypotension (Carpenito-Moyet, 2009).

A nurse should collaborate with dietician in planning a renal diet with strict fluid restrictions, low sodium and low protein with high biological protein and encourage Mr. Lim to adhere to the diet. The amount of fluid given to Mr. Lim is restricted to 24-hour urine output plus 500mL to replace insensible loss to maintain fluid balance. Low-sodium diet is beneficial to prevent further fluid retention. High biological proteins from meats, cheese and milk provide amino acids essential for cell growth and repair but release less BUN during metabolism (Carpenito-Moyet, 2009).

A nurse should assist Mr. Lim to sit in a semi-Fowler position since not contraindicated and elevate his feet when sitting up. Literature review shows that this increases lung volume, allowing him to breathe better and reduces venous return to the heart and thus decreases blood pressure (Bixby, 2005).

Expected outcomes: During treatment in hospital, Mr. Lim does not develop complications of CRF. Before discharge, Mr. Lim’s B/P returns to his baseline prior to onset of renal failure, his edema is decreased and his electrolytes are normal or at baseline.

2. Powerlessness

Since Mr. Lim expresses financial concerns, the nurse can inform Mr. Lim and his family that he is included in the Medisave for Chronic Disease Management Programme as he suffers from DM and hypertension which are covered in the programme, as such, he can activate Medisave to pay most of the bill when he visits general practitioner which can total up to $150 per visit (Health Professionals Portal, 2008).

A nurse should encourage Mr. Lim to verbalize his concerns about potential changes in body image, life style and express feelings and frustrations. Patients with CRF feel inferior due to a restricted life style and dependence on others (as cited in Carpenito-Moyet, 2009). Effective communication between the nurse and the patient is necessary for a successful discharge planning including reduced anxiety and better quality of life (Carroll, & Dowling, 2007).

A nurse should and tell him not to see himself as a victim of disease as he has the capability to control the disease progression by complying with diet, fluid restriction and follow-up care. The nurse should provide adequate information about the multiple facets of the illness and therapy options encourage him to make decisions with the new knowledge. Self-worth and dignity can be enhanced when patient actively participates in decision making. Literature review shows that increasing patient’s self-worth is an effective treatment for depression in elderly (Ku et al, 2008).

A nurse should explore the effects of the disease on Mr. Lim’s family as chronic illness has negative impact for the whole family, not just the individual with the disease.

Expected outcomes: The nurse provides a holistic care to Mr. Lim and his family. Mr. Lim participates actively in decision-making for plan of care and identifies personal strengths and factors he can control and as a result is highly compliant to the treatment.

3. Risk for imbalanced nutrition

A nurse should explain to Mr. Lim and his family about the reasons for dietary and fluid restrictions. Interaction between patient and nurse and family can enhance adherence to treatment by empowering them with knowledge (Kopple, & Massry, 2004).

The nurse should encourage good oral hygiene before and after meals and provide a pleasant environment during mealtimes to stimulate appetite. The nurse should be aware that individual’s cultural background influences his food choices and relationship between diet and health (Kopple, & Massry, 2004). He/she may discuss with Mr. Lim dietary options rather than restrictions as he might become discouraged if the diet is too restrictive and unpalatable (as cited in Kopple, & Massry, 2004).

A nurse can provide methods for Mr. Lim to relieve dry mouth with metallic taste and maintain fluid restriction as required by his condition. He/she can suggest Mr. Lim to take ice chips instead of water as one cup of ice equals only half cup of water and he can attain more satisfaction from ice as it stays in the mouth longer. He may also keep hard candy with him as it can alleviate dry mouth by stimulating saliva secretion. Frequent rinsing is also useful.

Administer vitamin D or calcium supplements as ordered. Calcium supplements can replace calcium and decrease risk of tetany. Vitamin D facilitates calcium reabsorption in the gut.

Expected outcomes: Mr. Lim understands the importance of adequate nutritional intake and complies with the prescribed dietary regime within 2 days. His calcium level increases after 1 week and he reports no muscular spasm and tetany. He maintains ideal weight and adequate nutrition during the hospital stay and after he is discharged.

Safety Engineering

TMA 1

At the start it is fair to surmise that health and safety was never at the forefront of any business or company. But over many years it can clearly be seen and noted that a company cannot flourish without it. This being said it was not until the early 1930’s that the first formal Health and safety text book was introduced by H.W. Heinrich which speaks volumes of how poor the health and safety situation was coming up to this time. Moving forward through the ages it can be seen that things where moving in the right direction from the emergence of more responsible and co-ordinated attitudes in the 50’s to the all powerful Health and Safety at Work Act in 1974 to our current day Acts that protect workers in every which way imaginable.

Companies that work hard and invest in overall workplace health and safety should experience reductions in illnesses, injuries and fatalities. This will return financial savings in a number of the companies sectors, such as reducing employees’ compensation fees and medical costs, avoiding preset penalty fines, and reducing the amount of money used to train new/replacement staff and the cost of conducting accident investigations. Overall, employers commonly find that improvements to workplace health and safety can mean substantial improvements to their companies’ financial performance and productivity.

By investing in health and safety a company can improve business and must see that complying with health and safety should not be looked at as a regulatory load that has been forced upon them as it offers significant opportunities. Benefits can include:

• Cut costs;
• Lower risks;
• Reduce employee sickness/absence and staff turnover;
• Less accidents;
• Smaller risk of lawful action;
• improved status with suppliers and partners;
• Greater reputation for business responsibility among investors, customers and communities;
• More productivity, because employees are happier, fitter, healthier and more motivated.

HSE figures show the personal and economic cost of failing to meet health and safety standards each year:

• Masses of working days and hours are used up because of work-related illness and injury.
• Thousands deceased from occupational diseases/illness.
• Over a million employees have self-reported distress from a work induced illness.
• As much as one worker is fatally injured every working day.

It is clear to see that without an adequate health and safety setup within a company no matter how big or small they may be that they cannot compete or even exist without Safety.

From a purely financial business mind the risks are far too great to waver safety and from a humanist perspective the loss of life should never be something to be risked against.

2A.

1. What caused the event
2. By what route(s) or mechanism(s) did the deviation or hazardous event occur?
3. What should be done to prevent its recurrence or, if it is not technically or economically possible to prevent repetition, how can its probability be reduced to an acceptable level?
4. Can the knowledge gained be applied elsewhere?

2B.

The quantitative approach to health and safety simply put can be defined as a set of equations used to determine levels of safety.

Quantitative safety levels are data and numbers put forward in order to try and estimate achievable levels of safety and measure how well they perform in quantitative results.

It should be made clear that if a quantitative safety performance level has been set, it must be able to be measured or estimated in quantitative terms. Quantitative data does give a very clear picture of a system and should be applied if possible.

Setting up a reliable quantitative system for safety target levels helps and enables companies to measure and record all achieved levels of safety, and could help provide a sound basis for managers and directors to make decisions.

The desired target safety outcome should be presented in either relative or absolute terms. Mathematical models are the common practice used to define quantitative safety target, for example to make an estimate of a target rate of safety occurrences of a stated severity. It is also very important to note that it is often impractical or even impossible to quantify all factors.

3A.

What is a hazard?

The meaning of a hazard is often very misleading and can be very confusing as many dictionaries do not give specific definition and at times combine the term “risk” causing great confusion between the two. Most describe a hazard as a danger or a risk which explains why many substitute one for the other.

The way that I feel best describes a hazard is- any source of potential harm, damage or ill health effects on someone or something under normal working conditions.

Realistically it is something that can cause harm or ill effects to either individuals (health effects) or organizations (property damage or equipment loss).

For example any working system whether it is mechanical, electrical or chemical can reach its potential to destruct through use by any amount of means i.e.; fire, explosion, mechanical fault. It would not be good practise to measure a hazard confidently against size or severity.

What is risk?

Risk can be foreseen as the probability or the chance of ill effect that someone may experience an adverse health effect or even be caused harm by being exposed to a hazard. It can also very easily apply to a companies, property or equipment loss or damage.

An example of risk could be: the risk of developing lung cancers from smoking could be shown as – “smokers are 10 times (for example) more likely to contract and die of cancer than non smokers”.

An alternative way of reporting risk is by using a number or lettering system i.e. “a number “X”, of smokers per 100 smokers will have a chance of developing lung cancer” (dependent on age and the amount of years they had been smoking).

This type of risk is expressed a likelihood or probability of a person developing a disease or incurring an injury. These differ to hazards because they refer to the likely or possible consequences (e.g., emphysema, lung cancer and heart disease from cigarette smoking.)

3B.

Ordinary (industrial)

Ordinary risks are a common in all industry related businesses and are caused predominantly by employee’s everyday work and activity whilst carrying out their jobs.

Classic examples of these can range from; slipping and tripping hazards, objects falling on personal from heights, personal falling from heights, physical injuries caused from lifting, physical injuries causes from interference with industrial equipment.

All of the above risks are only applicable to staff working in an industrial environment and not the general public

Residual

A danger or risk of an event or action irrespective of being in line with science and fact can be seen as a residual risk, residual risks can and will conceive dangers, even if all possible measures of safety are theoretically applied. An example could be of a water tank or pump failing and the residual risk being flooding.

Process

Process risk can be seen as the result of a risk differing from predicted estimates based on the pure random chance of an event.

For example if a die is thrown 6 times. It could be estimated that it will land on the number 1 once every 6 throws if the nice is fair. Process risk can be explained that the number of one’s thrown could be more or less than once due to the randomness of chance in the dice throwing process

Societal risks

Societal risk, as its name suggest is the risk to the society or local group of people that may be subject or exposed to a major hazard. The risk is best surmised and worked out by area and location ranging from factors like blast radius, flood radius, predictable wind direction when measuring a gas release.

An example where societal risk would need to be factored in would be when any company plans to build or produce something that could/would hold some kind potential societal hazard. This can be plotted and calculated using a FN curve to determine the full risk of the set up.

4.

Classify the following situations in terms of type of risk and complete the

risk table by assigning probabilities between 0 (not possible) and

1 (certain) with 0.1 – 0.3 (low), 0.4 – 0.6 (average), 0.7 – 0.9 (high) for

injury and equipment damage for each hazard.

State concisely the reasons for

your

choices and any qualifications you feel are required.

Factors such as weather, location and population density should be

considered and stated.

(i) Object falling from scaffold.

(ii) Tripping over a low level pipe in a petrochemical plant whilst on

nightshift.

(iii) Electric shock from overhead cable/line struck by lightning.

(iv) Radioactive leak into a river from nuclear power station.

(v) Electricity supply interruption in an equipment store with emergency

lighting.

(vi) Not replacing a walkway grating on an oil rig.

(vii) Hydrogen sulphide release from pocket in the end of a blanked off

pipe in a crude oil fractionation plant.

Situation	Ordinary risk	Residual risk	Process risk	Societal risk	Probability of risk	Probability of damage
(i)					0.5	0.8
(ii)					0.3	0.2
(iii)					0.1	0.9
(iv)					0.1	1
(v)					0.1	0.1
(vi)					0.9	0.9
(vii)					0.3	0.7

(i). I have selected the object falling from a scaffold as an ordinary risk and scored the probability of risk as 0.5 as is the nature of the risk there will always be the risk of objects falling from a height when working at height, I have not scored it to high as safety measures are always in place when working at heights to prevent and limit this type of risk. I have scored the probability of damage higher as generally anything falling has the potential to cause damage and at 0.8 this highlights that fact.

(ii) I have categorised the tripping situation as a ordinary risk as well as a process risk, ordinary because tripping situations are overly common and happen day to day in industry and a process risk because process risks can be seen as the result of a risk differing from predicted estimates based on the pure random chance of an event i.e. tripping over a low level pipe that you may or may not have passed over safely 100 times before. I have scored the probability as low because if it was a pipe that has always been there it should be clearly marked as a danger and known to employees working around it and scored the risk of damage as low to reflect the low risk of probability of falling over the pipe and causing injury or damage to equipment.

(iii) I have selected residual risk, process risk and societal risk to cover this as all 3 risks or at least parts of them can be seen. Residual as all risks and dangers can be covered and measured but not account for a lightning strike, process risk as the chances of lighting striking are extremely low but the pure chance and randomness of the event prove the process risk element and societal risk as the local area may be affected be power cuts and disruptions to their everyday functions. I have scored the probability as low as the chances statistically of lightning striking are low but have scored the risk of damage as extremely high as damage to life and equipment could be irreversible.

(iv) I have selected the radioactive leak as a societal risk as the potential ecological damage to the surrounding area would be detrimental, not only affecting local wildlife but also human life and in fact any other business or being that depended on the river. I have scored the probability as low as current nuclear Power stations operate under extremely strict safety laws and practises. This being said I have scored the probability of damage as 1 the highest possible as this sort of incident could not happen without massive amounts of damage.

(v) I have scored this event very low on both damage and risk probability as the only risk present would be ordinary and since safety measures are in place i.e. emergency lighting I could not foresee a high risk or probability of danger.

(vi) I have scored this risk as high as the risk is very high that damage or injury will occur. I have classed it as a ordinary industrial risk as it would be caused by employee’s everyday work and activity whilst carrying out their jobs or negligence thereof.

(vii)

A danger or risk of an event or action irrespective of being in line with science and fact can be seen as a residual risk, residual risks can and will conceive dangers, even if all possible measures of safety are theoretically applied. An example could be Hydrogen sulphide released from a pocket in the end of a blanked off

pipe in a crude oil fractionation plant, and the societal risk would be placed on anyone in the direct area.

5.

The incident in my opinion could very easily been avoided, to look at the reasons why I will discuss measures that I feel should have been in place and followed, and as a result of them not being followed the incident occurring.

What where the operators training and skills? Was the operator fully trained to operate is this kind of hazardous environment? Could the operator have been trained but simply forget a crucial step by not replacing the man hole cover and put it down to human error.

What was the H&S culture like in the workplace? His own and the companies? Could this be to blame, was there a permit to work in operation? Safe system of work in operation? Had the operator read it and signed on. These are all vital steps that need to be taken into account when working in hazardous areas and are often over looked. These would have highlighted what he could do and how to complete the task, including replacing the manhole cover when not in use.

Had the operator carried out this task before? If not should the operator been supervised by someone with experience of the job at hand? And should the operator been working alone at all?

Should the vessel have been charged again with nitrogen before work began again to ensure/minimize low chance of ignition? As the manhole had been left open allowing air to fill the chamber.

Could an intrinsically safe scraper rod have been used? One not causing a spark?

Risk Assessment/COSHH assessments? Were any done?

Had the user Followed “Safe working with flammable substances” regs and abided by the five principles of control;

• Ventilation
• Ignition sources
• Exchange of a flammable substance for a less flammable one
• Separation.

Without knowing the answer to any of the questions above any of them could very easily caused the incident. In my personal opinion I would have put the incident down to not following safe working practise on the job, i.e. not replacing the manhole cover and not re-charging the vessel with nitrogen to minimise the chance of ignition.

Children and youth who sustain a traumatic brain injury (TBI) and/or spinal cord injury (SCI) may have temporary or permanent disabilities that affect their speech, language and communication abilities. Having a way to communicate can help reduce a child’s confusion and anxiety, as well as enable them to participate more actively in the rehabilitation process and thus, recover from their injuries. In addition, effective communication with family, care staff, peers, teachers and friends is essential to long-term recovery and positive outcomes as children with TBI and SCI are integrated back into their communities. This article describes how rehabilitation teams can use augmentative and alternative communication (AAC) and assistive technologies (AT) to support the communication of children recovering from TBI and SCI over time.

1. Introduction

Children and youth who sustain a severe traumatic brain injury (TBI) and/or a spinal cord injury (SCI) often experience sequealae that can affect their ability to communicate effectively. In early phases of recovery, many children with TBI and SCI are unable to use their speech or gestures for a variety of medical reasons related to their injuries. As a result, they can benefit from augmentative and alternative communication (AAC) interventions that specifically address their ability to communicate basic needs and feelings to medical personnel and family members and ask and respond to questions. AAC approaches may include having access to a nurse’s call signal; strategies to establish a consistent “yes” “no” response; techniques that help a child “eye point” to simple messages; low-tech boards and books that encourage interaction with family members and staff; communication boards with pictures or words; and speech generating devices (SGDs) with preprogrammed messages, such as “I hurt” “Come here,” “Help me please!” “When’s mom coming?”

As children with TBI and SCI recover from their injuries, many no longer will need AAC. However, some children face residual motor, speech, language and cognitive impairments that affect their ability to communicate face-to-face, write or use mainstream communication technologies (e.g., computers, email, phones, etc.). A few may require AAC and assistive technology (AT) throughout their lives. Having access to communication through AAC and AT enables these children to participate actively in the rehabilitation process and ultimately, in their families and communities. Without an ability to communicate effectively, children with TBI and SCI will face insurmountable barriers to education, employment, as well as establishing and maintaining relationships and taking on preferred social roles as adults.

All AAC interventions aim to support a child’s current communication needs while planning for the future (Beukelman and Mirenda, 2005). However, the course of AAC treatment for children who sustain TBIs and SCIs is different because of the nature of their injuries is different. In addition, the focus of AAC interventions will differ for very young children (e.g., shaken baby syndrome) who are just developing speech and language and for those who were literate and have some knowledge of the world prior to their injuries (e.g., 16 year-old involved injured in a motor vehicle accident). For young children, the AAC team will focus on developing their language, literacy, academic, emotional, and social skills, as well as ensuring that they have a way to communicate with family members and rehabilitation staff. For older children, AAC interventions build on residual skills and abilities to help remediate speech, language and communication impairments as well as provide compensatory strategies that support face-to-face interactions and ultimately communication across distances (phone, email) with team members, family and friends. AAC intervention goals seek to promote a child’s active participation in family, education, community and leisure activities and aim to support the establishment and maintenance of robust social networks (Blackstone, Williams, and Wilkins, 2007; Light and Drager, 2007; Smith, 2005).

While a variety of AAC tools, strategies and techniques are available that offer communication access, successful AAC interventions for children with TBI and SCI also require that medical staff, family members and ultimately community personnel know how to support the use of AAC strategies and technologies because the needs of these children change over time. Speech-language pathologists, nurses, occupational therapists, physical therapists, physiatrists, pediatricians, and rehabilitation engineers work collaboratively with the child’s family and community-based professionals to establish, maintain and update effective communication systems. Ultimately, the goal is for children to take on desired adult roles; AAC can help them realize these goals.

2. Pediatric TBI and AAC

AAC intervention for pediatric patients with TBI and severe communication challenges is an essential, complex, ongoing and dynamic process. AAC is essential to support the unique communication needs of children who are unable to communicate effectively. It is complex because of the residual cognitive deficits that often persist and because many children with TBI have co-existing speech, language, visual, and motor control deficits (Fager and Karantounis, 2010; Fager and Beukelman, 2005). AAC interventions are ongoing and dynamic (Fager, Doyle, and Karantounis, 2007) because children with TBI experience many changes over time and undergo multiple transitions. Light et al. (1988) described the ongoing, three-year AAC intervention of an adolescent who progressed through several AAC systems and ultimately regained functional speech. DeRuyter and Donoghue (1989) described an individual who used many simple devices and a sophisticated AAC system over a seven month period. Additional reports describe the recovery of natural speech up to 13 years post onset (Jordan, 1994; Workinger and Netsell, 1992).

2.1. AAC Assessment and Intervention

Assessment tools can help identify and describe the cognitive, language and motor deficits of patients with TBI and provide a framework for AAC interventions. The Pediatric Rancho Scale of Cognitive Functioning (adapted by staff at Denver Children’s Hospital in 1989) is based on the Ranchos Los Amigos Scale of Cognitive Functioning (Hagan, 1982). Table 1 describes general levels of recovery, based on the Pediatric Rancho Lost Amigos Scale, and gives examples of AAC intervention strategies that rehabilitation teams can employ across the levels as described below.

Levels IV and V. AAC Goal: Shaping responses into communication

In the early phase of recovery, pediatric patients at Levels IV and V on the Pediatric Rancho Scale are often in the PICU, the ICU, acute hospital or acute rehabilitation environment. At Level V (no response to stimuli) or Level IV (generalized response to stimuli) AAC interventions focus on identifying modalities that children can use to provide consistent and reliable responses. For example, staff can use simple switches (e.g., Jelly Bean®, Big Red® and Buddy Button from AbleNet), latch-timers (e.g., PowerLink® from AbleNet) and single message devices (e.g. BIGmack® and Step Communicator® from AbleNet) to support early communication (see Table 1 for some examples). Because children’s early responses may be reflexive rather than intentional, the family and medical/rehabilitation team can also use AAC technologies to encourage more consistent responses. Families provide valuable input about the kinds of music, games and favorite toys a child finds motivating. The team can then use these items to evoke physical responses from the child. For example, if the family identified the battery-operated toy Elmo® from Sesame Street®, the rehabilitation team might present Elmo singing a Sesame Street song and then observe to see if the child’s responds. If the child begins to turn her head when Elmo® sings, the team might attach a switch with a battery interrupter to the toy and ask the child to “hit” the button and “play the Elmo® song”. In doing so, the team can learn several things. For example, the team may note that a child is able to follow commands, indicating cognitive recovery. The team may also begin to consider alternative access methods for children with severe physical impairments, i.e., head movement may become a reliable way to operate an AAC device or computer in the future. It is difficult to predict whether a child will recover natural speech during early stages of recovery.

2.2. Middle Levels II and III: AAC Goals: Increase ability to communicate with staff, family and friends and support active participation in treatment

Pediatric patients at Levels III (localized response to sensory stimuli) and II (responsive to environment) become more engaged in their rehabilitation programs as they recover some cognitive, language and physical abilities. During this phase, long-term deficits that affect communication become apparent (e.g., dysarthria, apraxia, aphasia, attention, initiation, memory, vision, spasticity). Dongilli, Hakel, and Beukelman (1992) and Ladtkow and Culp (1992) also report natural speech recovery in adults after TBI at the middle stages of recovery. Continued reliance on AAC strategies and technologies is typically due to persistent motor speech and/or severe cognitive-language deficits resulting from the injury (Fager, Doyle, and Karantounis, 2007).

AAC interventions at these levels focus on using a child’s most consistent and reliable response to communicate messages, encourage active participation in the rehabilitation process and increase interactions with family and staff. AAC interventions always take into account the child’s developmental level and interests. Table 1 gives some examples of AAC technologies employed during these Levels III and II. For example, Jessica was admitted to the hospital at 18-months with shaken baby syndrome. At Level II, she began responding to her parents by smiling and laughing and also began to manipulate toys with her non-paralyzed hand when staff placed a toy within her intact field of vision. However, she did not exhibit any speech or imitative vocal behaviors and her speech-language pathologist noted a severe verbal apraxia. Nursing staff and family members noted that Jessica seemed frustrated by her inability to express herself. Prior to her injury, she could name over 30 objects (toys, pets, favorite cartoon characters) and was beginning to put two word sentences together (Momma bye-bye, Daddy home).

AAC interventions included the introduction of a BIGmack®, a single-message speech generating device (SGD) that enabled the staff and family members to record a message that Jessica could then “speak” during her daily activities(e.g., “more”, “bye-bye”, “turn page”). Because the BIGmack® is a colorful, large and easy to access SGD, Jessica was able to “press the button” despite her upper extremity spasticity and significant visual field cut. Within a month, Jessica had progressed to using a MACAW by Zygo®, an SGD with eight-location overlay that staff programmed with words she had used prior to her injury (e.g., mommy, daddy, more, bottle, book, bye-bye). Staff also designed additional overlays to encourage her language development by providing vocabulary that enabled her to construct two-word combinations (e.g., “more crackers”). Jessica began to express herself at a developmentally appropriate level, but she had residual memory deficits that required cuing and support from her communication partners. For example, initially, she did not recall how to use her AAC system from session to session so staff needed to reintroduce it each time. However, after several months, Jessica began to “search” for her SGD to communicate. Jessica, like many children with TBI at this level, was able to learn procedures and strategies with repetition and support (Ylvisaker and Feeney, 1998).

2.3. Level II and Level I. AAC Goals: Support transitions, recommend AAC strategies and technologies for use at home and in the community

As pediatric patients transition from Level II (responsive to environment) to Level I (oriented to self and surroundings), they often move from an acute rehabilitation facility to an outpatient setting, home or a care facility. Thus, before discharge, AAC teams will conduct a formal AAC assessment and provide long-term recommendations for AAC strategies and technologies that can enable children to be integrated successfully back into community environments. Table 1 illustrates the types of AAC technologies and strategies employed at Levels II and I, as described below.

For children who continue to use AAC and AT when they return to their communities, the rehabilitation team identifies a long-term communication advocate. This person, often a family member, becomes actively involved in AAC training and collaborates with rehabilitation staff to prepare the child’s educational staff, extended family and other caregivers (Fager, 2003). Having a link between the rehabilitation team and community professionals is essential because most teachers and community-based clinicians have limited experience working with children with TBI and may need support to manage the cognitive and physical deficits often associated with TBI. For example, McKenzie, a 12 year-old with a severe TBI secondary to a car accident, was quadriplegic with severe spasticity and no upper extremity control. She also had cortical blindness and significant communication and cognitive impairments. As she recovered, McKenzie used a variety of AAC systems (e.g., thumbs up/down for “yes” “no”, two BIGmacks® to communicate choices, and a scanning Cheap Talk by Enabling Devices with four messages to participate in structured activities). Prior to discharge, the rehabilitation team conducted a formal SGD evaluation and recommended the Vmax by DynaVox Mayer-Johnson, a voice output device. McKenzie was able to access the device via a head switch mounted to the side of the head rest on her wheelchair. Using auditory scanning, she could create and retrieve messages. Because she was literate prior to her injury and could still spell, the staff set up her device to include an alphabet page as well as several pages with pre-programmed messages containing basic/urgent care needs, jokes and social comments. Family and friends participated in her rehabilitation and learned to use tactile and verbal prompts to help her participate in conversational exchanges. Due to her residual cognitive deficits, however, McKenzie had difficulty initiating conversations and remembering where pre-stored messages were in her device. When prompted, she would respond and initiate questions and could engage in conversations over multiple turns. Over time, she began to participate in meaningful, social interactions, often spelling out two-three word novel phrases using her alphabet page

While her parents were renovating their home to handle her wheelchair, McKenzie transitioned to a regional care facility that specialized in working with young people with TBI. The acute rehabilitation team identified McKenzie’s aunt as her AAC advocate because she had participated actively in earlier phases of McKenzie’s recovery, was proficient with the maintenance (charging, set-up and basic trouble-shooting) of the Vmax and could customize and program new messages into the system. The care facility staff met with McKenzie’s aunt weekly so they could learn how to support McKenzie’s use of the SGD. Specific training objectives included maintenance and basic trouble-shooting, set up, switch-placement and how to program new messages to use in specific and motivating activities. Staff learned how to modify the placement of her switch when McKenzie became fatigued or her spasticity increased. Additionally, McKenzie’s school staff (special education coordinator, speech-language pathologist, occupational therapist, and one of her regular classroom teachers) visited McKenzie at the rehabilitation and the care facilities to help prepare for her return home and learned how to support her in school, given her physical and cognitive limitations.

2.4. AAC themes in TBI

When working with pediatric patients with TBI, three AAC “themes” emerge.

1. Recovery from TBI is dynamic and takes place over time. In early stages of recovery, most children with TBI have physical, speech, language and cognitive deficits that affect their communication skills. Depending on the nature and severity of their injuries, however, most recover functional speech, although some will have life-long residual speech, language and communication deficits. Acute rehabilitation teams can employ AAC interventions to support communication, as well as monitor the child’s changing communication abilities and needs over time.

2. The cognitive-linguistic challenges associated with TBI make AAC interventions particularly challenging for rehabilitation staff, as well as for families, friends and school personnel. Because of the complex nature of the residual disabilities caused by TBI, collaborations among rehabilitation specialists, family members and community-based professionals are essential. Some children with TBI require AAC supports throughout their lives. Family members, friends and school personnel rarely know how to manage their severe memory, attention and/or initiation deficits that can affect long-term communication outcomes.

3. There is a need to plan carefully for transitions. Children with TBI will undergo many transitions. While research describing these transitions in children is not available, reports of the experiences of adults with TBI describe multiple transitions over time. Penna et al. (2010) noted that adults with TBI undergo a significant number of residence transitions particularly in the first year following injury and Fager (2003) described the different transitions (acute care hospital, outpatient rehabilitation, skilled nursing facility, home with adult daycare services, and eventually assisted living) for an adult with severe TBI experienced over a decade, documenting significant changes in his cognitive abilities, as well as his communication partners and support staff. Children with TBI are likely to experience even more transitions over their lifetimes.

3. Pediatric SCI and AAC

Pediatric patients with SCI often have intact cognitive skills and severe physical disabilities that can interfere with their ability to speak. In addition, they often have significant medical complications and may be left with severe motor impairments that make it difficult, if not impossible, for them to write, access a computer or participate in the gaming, online and remote social networking activities embraced by today’s youth (e.g., texting, email). A subgroup may also present with a concomitant TBI sustained as a result of the fall, car accident or other traumatic event that has changed their lives. For them, AAC treatment must reflect guidelines that take into account both SCI and TBI.

As with TBI, the growth and development inherent in childhood and adolescence and the unique manifestations and complications associated with SCI require that management be both developmentally based and directed to the individual’s special needs (Vogel, 1997). Initially, AAC interventions typically focus on ensuring face-to-face communication when speech is unavailable or very difficult; over the long term, however, enabling children to write and engage in educational, recreational and pre-vocational activities using computers and other mainstream technologies becomes the focus.

3.1. AAC Assessment and Intervention

The ASIA standard neurological classification of SCI from the American Spinal Injury Association and International Medical Society of Paraplegia (2000) is a tool that rehabilitation teams frequently use to assess patients with SCI because it identifies the level of injury and associated deficits at each level. This can help guide the rehabilitation team’s clinical decision-making process for AAC interventions. As shown in Table 2, children with high tetraplegia (C1-C4 SCI) have limited head control and are often ventilator dependent. They often require eye, head, and/or voice control of AAC devices and mainstream technologies to communicate. While switch scanning is an option for some, it requires higher-level cognitive abilities, endurance, and vigilance and may be inappropriate for very young children and those who are medically fragile (Wagner and Jackson, 2006; McCarthy et al., 2006; Peterson, Reichle, and Johnston, 2000; Horn and Jones, 1996). Children with low tetraplegia (C5-T1 SCI) demonstrate limited proximal and distal upper extremity control. If fitted with splints that support their arm and hand, some are able to use specially adapted mouse options (e.g., joystick mouse, switch-adapted mouse, trackball mouse), large button or light touch keyboards and switches to control technology. These children are also candidates for head tracking and voice control of AAC devices due to the fatigue and physical effort involved in using their upper extremities. For example, a multi-modal access method to AAC technology and computers may include voice control to dictate text, hand control of the cursor with an adaptive mouse to perform other computer functions (e.g., open programs), and an adaptive keyboard to correct errors that are generated while dictating text. This multi-modal approach can be more efficient and less frustrating than using voice control alone for these children. Table 2 provides examples of appropriate access options to AAC and mainstream technologies.

3.2. Supporting face-to-face communication

For children with high tetraplegia, being dependent on mechanical ventilation is frightening especially when they are unable to tolerate a talking valve (Padman, Alexander, Thorogood, and Porth, 2003). Thus, providing these children with a way to communicate is essential to their recovery and sense of well-being. As children with lower levels of injury are weaned from a ventilator, they may experience reduced respiratory control and be unable to speak (Britton and Baarslag-Benson, 2007). Medical specialists can provide access to AAC strategies and technologies, which enable these children to communicate their wants, needs and feelings throughout the day. This allows them to interact with direct care staff, participate in their rehabilitation process, and maintain relationships with family and friends.

Pediatric rehabilitation teams may use a range of AAC strategies and technologies to support face-to-face communication in children with SCI. Some examples include low tech communication boards used with eye gaze or eye pointing, partner-dependent scanning, an electro larynx with intra-oral adaptor, or laser light pointing to a target message or letter on a communication board (Britton and Baarslag-Benson, 2007; Beukelman and Mirenda, 2005). Introducing AAC and AT technologies early in the recovery process, particularly for children who demonstrate high tetraplegia, will also begin to familiarize them with approaches they may need to rely on extensively throughout their lives, even after speech returns.

For example, Jared, a 17-year-old high school senior, sustained a SCI in a skiing accident at the C2 level. In addition to his injuries, he developed pneumonia and a severe coccyx wound during his hospitalization, which lengthened his hospital stay. He was unable to tolerate a one-way speaking valve due to the severity of his pneumonia and decreased oxygenation during valve trials. Although Jared had minimal head movement, he was able to control an AccuPointâ„¢ head tracker to access his home laptop computer and spell out messages he could then speak aloud using speech synthesis software. He used his AAC system to indicate his medical needs to caregivers and later reported that having the ability to communicate helped alleviate some of the anxiety he experienced due to his condition and extended hospitalization. After Jared recovered the ability to use a talking valve, his work with the AccuPointâ„¢ focused on computer access to meet written and social communication needs. Once his wound had healed, he was able to return home 11 months later. At that time, all of his classmates had graduated. Using the AccuPointâ„¢, Jared was able to complete his GED at home and enrolled in online classes at the local community college.

3.3. Supporting written communication and education

At the time of their injury, some pediatric patients with SCI are pre-literate, others are developing literacy skills, and others have highly developed literacy skills. However, most children with tetraplegia will require the use of assistive technologies to support written communication because their injuries preclude them from using a pencil and/or typing on a traditional computer keyboard. In a report describing the educational participation of children with spinal cord injury, 89% of the children with tetraplegia relied on AAC to support written communication needs (Dudgeon, Massagli, and Ross, 1996).

For example, Max, a 6 year-old boy who suffered a C6 SCI after an All Terrain Vehicle accident, was reading age-appropriate sight words and developing his ability to write single words prior to his injury. After the initial recovery period, formal testing revealed that Max had no residual cognitive or language impairments. However, he faced significant barriers not only to his continued development of age-appropriate reading and writing skills, but also to his ability to learn and do math, social studies, science, play games, use a cell phone, etc. Due to his tetraplegia, he needed ways to access text and write, calculate, draw and so on. Max learned to access a computer using a large button keyboard, joystick mouse, and adaptive hand-typers (cuffs with an attached stylus that fit on the ulnar side of the hand and allow the user to press the keys of a keyboard) to support writing activities and computer access. During rehabilitation, he was able to continue with his schoolwork by developing the skills to use the technology and keep up with his classmates. He returned home during the summer and participated in an intense home tutoring program. By the fall, he was able to join his classmates and was able to perform at grade level in all classes. Essential to Max’s future educational success and development, as well as his future employment, may well depend on his ability to write, calculate and perhaps even draw using a variety of assistive technologies that support communication.

3.4. Support social participation and pre-vocational activities

Access to assistive and mainstream technologies not only facilitates participation in education, but also has implications for future employment as these children transition into adulthood. Assistive and mainstream technologies are now available at modest cost that can help individuals with SCI to compensate for functional limitations, overcome barriers to employability, enhance technical capacities and computer utilization, and improve ability to compete for gainful employment In addition, these technologies also provide access to life-long learning, recreational activities and social networking activities. Specifically, computers are described as “great equalizers” for individuals with SCI to engage in employment opportunities and distant communication (McKinley, TewksBury, Sitter, Reed, and Floyd, 2004).

Social participation in the current technological age includes more than face-to-face communication. Social participation has expanded with the popularity of social networking sites (e.g., Facebook â„¢and MySpaceâ„¢), video web-based communication (e.g., Skypeâ„¢) and instant communication and messaging (e.g., Twitterâ„¢). Advances in the field of AAC have allowed individuals with the most severe injuries access computer technologies to engage in these social communication activities. For example, Crystal was a 10-year-old who sustained a C1 SCI due to a fall. Crystal’s injury left her with no head/neck control and her only consistent access method to computerized technology was through eye tracking. With an ERICA eye gaze system from DynaVox Mayer-Johnson, Crystal quickly became independent with computer access. She emailed and texted her friends and family daily, communicated via her Facebookâ„¢ account, and engaged in online gaming programs with her friends and siblings. This technology allowed her to begin to communicate again with her school friends while she was still undergoing acute rehabilitation. Maintaining these social networks is an essential component to emotional adjustment children with SCI go through after sustaining a severe injury (Dudgeon, Massagli, and Ross, 1997). Additionally, Crystal’s friends began to understand that while her impairments were severe, she was essentially the same person with the same interests, humor, goals, and expectations as before her injury.

3.5. AT/AAC themes in SCI

When working with pediatric patients with SCI, three AAC “themes” emerge.

1. For those with high tetraplegia, AAC may facilitate face-to-face as well as distant and written communication needs, depending on the developmental level of the child. Introducing AAC technology early, when face-to-face communication support is needed, helps the child become familiar with the technology they will need to rely on after natural speech has recovered.

2. Return to an educational environment is a primary goal with many children with tetraplegia returning to school within an average of 62 days post discharge (Sandford, Falk-Palec, and Spears, 1999). Development of written communication skills is an essential component to successful educational completion and future vocational opportunities (McKinley, Tewksbury, Sitter, Reed, and Floyd, 2004).

3. Introduction to methods of written and electronic communication provides an opportunity for patients with SCI to engage in social networks through email, texting, and social networking sites. As these children with severe physical disabilities face a life time of potential medical complications (Capoor and Stein, 2005), the ability to maintain and develop new social connections via electronic media allow them to stay connected during times when their medical conditions require them to be house or hospital-bound.

4. Conclusion

Communication is essential for continued development of cognitive, language, social, and emotional skills. Children with TBI and SCI have physical and/or cognitive-language deficits that interfere with typical communication abilities. Their communication needs are supported through AAC strategies and technologies. A myriad of technology options are available that not only support face-to-face interactions, but equally important distant social networking and educational activities. AAC interventions in the medical setting that not only support communication of basic medical needs, but also facilitate engagement in social, educational, and pre-vocational activities will result in successful transition to home, school and community environments for these children.