Rehab Considerations for Bath Safety

The Clinical Benefits of a Safe Bathroom

Bathrooms are inherently dangerous. Confined, wet and hard surfaces make for a slippery environment that can be treacherous regardless of ability level. Bathrooms are the second major site of drowning in the home for unattended children, as well as the elderly, who are at risk for falls. The bathroom is the primary location for falls in the home for people of all ages, and most injuries each year involve the bathtub or the shower.

But for people with disabilities, such as paraplegia and quadriplegia, the wet conditions, protruding fixtures and smaller space make bathrooms even more hazardous. There are several challenges people in wheelchairs face when making their bathrooms safe for daily usage, but there are also several clinical factors that clients need to consider.

Some of the challenges to a safe bathroom for people with limited mobility include lack of space between tub and adjoining fixtures, lack of a proper transferring device, slippery floor conditions, inadequate lighting, insensitivity to temperature, and dizziness. Clinical risks for people with limited mobility using the bathroom include an increased risk for falls, skin abrasions, infections, pressure sores, scalding and burns.

“There are several key benefits to using bath safety products for individuals with varying degrees of physical disability,” says Gary Werschmidt, president at Columbia Medical. “Depending on the degree of disability, a quality bath safety product can aid in maintaining postural control for the patient and can also be instrumental in preventing falls. It may also allow for more independence and dignity for the individual while bathing.”

Safely Transferring Is the Biggest Challenge

Safely transferring in a bathroom is one of the most challenging issues for clients with limited mobility. Some people use unsafe practices such as transferring by holding onto the shower door or sink. Other people drag their legs, which can result in injury. The risk for safely transferring increases as the client transfers out of the tub because the body is damp; the tub, shower and/or floor are wet and slippery; and the client may be fatigued or dizzy. Maintaining balance is a challenge for transfers in the slippery environment of the bathroom. Falling and colliding with hard surfaces or pointed fixtures is typically the biggest danger.

Werschmidt says, “A critical point for bathing is the transfer from the wheelchair into the bathing chair and back again. To increase safety, transfers should not be done when the patient or the floor is wet. If available, the use of a transfer system can minimize the number of times a patient may need to be lifted while toileting and bathing. Minimizing the number of times a patient must be lifted can improve safety. For some patients, straps might be needed to prevent falling, but it is important that the straps don’t compromise the ability to access, clean and rinse body parts. For those who may be susceptible to pressure sores, it may be necessary to use padding.”

Kim Eberhardt, MS, OTR/L, a differentiation specialist for spinal cord injury (SCI) patients at the Rehabilitation Institute of Chicago, says, “People who have no sensation need to be on padded bathroom equipment. If they do not have much sensation, they need a padded shower bench and a padded commode.”

For bathing, Eberhardt recommends transfer benches and boards for clients who are able to safely transfer. “Skin is very important with the way people transfer,” Eberhardt says. “A lot of our clients use a sliding board or transfer board, and we tell them to put a pillow case on top of the board so the client can slide with it. Some people get nylon equipment, similar to windbreakers. It’s a rectangular piece of material that can slide them over on the board.”

Clients who typically make such transfers position their wheelchairs parallel with the bathtub and therefore need to ensure that they don’t hit the wheels of the chair when transferring. “If they are transferring to a tub bench, they are parallel to it; the wheel will be in their path, and they tend to drag rather than lift up or pop up,” Eberhardt says.

Whether clients have the ability level to transfer on their own or with a caregiver, Eberhardt says all clients making transfers in the bathroom should inspect their skin with a mirror after bathing to make sure they are clearing obstacles. Not sitting in a shower seat correctly can result in an abrasion or injury to the skin. “We recommend that patients do pressure relief in the shower — leaning forward or leaning to the side,” Eberhardt says.

Werschmidt recommends transfer systems that are multi-functional and include bathing and toileting options: “A quality transfer system features a chair that can attach to different bases depending on the function needed. The chair can be moved from one base to another by sliding on the rails to facilitate the transfer. This transfer should be a smooth and easy operation. Metal construction is a better choice than plastic or PVC because it’s more durable, compact, and facilitates smooth and easy transfers. It is also advisable to look for a system that has an auto-locking system which prevents the chair from sliding off the transfer rails accidentally. Such a device can minimize the chance of falls.”

Clients who have had sores in the tailbone area typically need to check with physicians prior to purchasing a tub bench that has holes in it, as those holes can irritate the sore and may lead to an infection.

The higher the level of paralysis, the more dangerous hard surfaces become.

“Hard surfaces are the worst for the skin,” Eberhardt says. “If (clients) are on a hard surface even for a half hour, such as a standard toilet, they can actually tear the skin.”

Doorways, countertops, medicine cabinets and toilets all present challenges to safely moving in the bathroom.

“A lot of people in wheelchairs have to back into their wheelchair into the bathroom and could be damaging their skin due to the type of transfer,” Eberhardt says. “They also have to approach a bathroom countertop parallel or from the side. If clients don’t have shoes on, they could twist their ankles if they get their feet caught under the footrest of their wheelchairs.”

Israel Gamburd, owner of Gamburd Medical Equipment and Services, Los Angeles, says, “It is important to consider the material because rust becomes a major concern… Many devices are made of steel or other metals that are not waterproof. It is important to make sure bath safety devices are made with material that will not rust, such as stainless steel or aluminum. Other major concerns are cushions, and in general, the comfortableness of the device. Many people prefer softer cushions, but sometimes the softer ones are not ideal for the situation. Softer cushions tend to break down quickly and in many cases, puncture. Once punctured, the cushion needs to be replaced because the bacteria will start to build up, making the cushion unhygienic. Firmer cushions tend to last longer and will stay cleaner for a greater length of time. Firmer cushions also offer more support for the patient’s posture.”

Clients with higher levels of disability should use reclining shower chairs due to hypotension, or low blood pressure. “People with hypotension are at risk for getting dizzy,” Eberhardt says. “People with tetraplegia, for example, have a higher level of impairment and might be prone to getting dizzy.” Abdominal binders are also recommended to help prevent dizziness.

Pearl Goldstein of Wenzelite Re/hab Supplies says that Wenzelite offers products that feature angle-adjustable seats and backs: “This assists clients that cannot sit at a 90-degree angle. The adjustable straps and headrest provide suitable positioning.”

“Clients with C4 (injuries) and up can’t use the tub bench, and some at the C5 level (can’t) because of spasticity,” Eberhardt says.

Goldstein agrees, “Proper positioning is essential, especially for clients that are spastic.”

In order to avoid severe injury or other clinical complications, Gamburd recommends that clients avoid equipment that does not securely attach to the shower or bath, avoid equipment that isn’t rustproof and avoid equipment where many lifts and transfers are required.

Eberhardt recommends bath safety products that include shower chairs with supported or cushioned backs, as well as shower chairs with toileting options, and — for more complex clients who cannot safely use transfer boards — the ability to roll into curbless showers. She also supports manufacturers that offer customized options for the varying needs of the SCI patients.

Werschmidt recommends bath safety products that are positionable to improve postural support and comfort as well as products that are sterile, rustproof, antimicrobial and easy to store. Werschmidt also suggests products that are “growable” and can accommodate the growth of the pediatric patient: “Growth kits increase the usable lifespan of the product at a fraction of the cost of replacing the entire bath chair.”

Wet Conditions Can Increase Client Risk for Falls, Burns

One of the most important factors for clients with a lack of sensation is adequately regulating water temperature.

“We recommend the anti-scald device for the shower, for people who are more impaired. We tell other clients to test the water on parts of their body that they can feel,” Eberhardt says.

“Grab bars are another product that we recommend,” she adds. “If grab bars are not included on the toilet, we also recommend them on the wall. We tell (clients) to make sure they put grab bars up on reinforced walls.”

Handheld shower devices clean hard-to-reach areas and can improve accessibility. “Streaming water coming at clients with SCI makes them feel unstable,” Eberhardt says. “With a handheld shower, you don’t have that concern, and if there’s a certain area that can’t get wet, you don’t have to worry so much with a handheld shower. The user or caregiver has more control over where it goes. It is a more manageable bathing option.”
Handheld showers can offer ease of use over the inflexibility of shower and tub controls, as well as reduce the physical strain of overexertion.
Bathroom storage should facilitate accessibility. Articles need to be within comfortable reach. Towels, shampoo and soap should all be easy to reach.

Accessories such as bath mittens and brushes can increase access to parts of the body for people with upper-body mobility. Many bath brushes come with curved handles for improved accessibility.

“Another important factor we recommend for the bathroom is adequate ventilation,” Eberhardt says.

For people bathing and toileting independently, Eberhardt recommends that they keep a cell phone on the seat of their wheelchair as they make transfers and bathe. The phone should always be within reach in case of a fall. “It’s a difficult transfer to get back in the chair, especially when wet. Always have a call system.”

Bath Safety Products Can Reduce Stress

Another clinical consideration for clients in wheelchairs is the level of stress experienced. Client-related stress can result from the physical condition of the client and the overall willingness to face the challenges a bathroom presents. However, the structure of the bathroom and the availability of bath equipment that transforms a bathroom into a safer place can significantly reduce environmentally related stress. Does the client have transferring devices? Is the client aware of products that can assist with maneuvering in the slick environment of the bathroom? Educating clients on the number of options available can help solve the challenges that lead to stress.

Help Your Clients Change What They Can

Typically, many of the controls in the bathroom, such as faucets and showerheads, require the ability to reach and a wide range of motion. Ideally, a bathroom and its controls should be modified to be more accessible to clients in wheelchairs, but that often comes with a price tag some clients cannot afford.

When it comes to a safe bathroom, changes can run from the small, such as improving the lighting, to the more complex, such as building a curbless shower or lowering countertops. Transfer boards and benches, shower chairs, padded commodes and grab bars as well as home modifications can help facilitate safety and independence for clients.

“Normal daily living activities can be once again performed in private with minimal assistance from family members or caregivers,” says Laura Hummer, VP of marketing for Roscoe Medical. “Our products restore comfort, safety and self-confidence to patients with daily activities, such as bathing that we take for granted.”

Goldstein says, “Bath safety products maximize client independence and provide clients with a measure of privacy.”

“Many of the products currently available in today’s market are there to help both the caregiver and the patient be safe and comfortable with their day-to-day routines,” Gamburd says. “Bath safety products can ultimately give the patient the ability to use the restroom with ease, dignity and minimal help from their caregiver. The freedom the patient gains is priceless.”

This article originally appeared in the November 2007 issue of Mobility Management.

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