Article Archive

Summer 2010

Going Up! Keeping Elevators Safe for Older Adults
By Maura Keller
Aging Well
Vol. 3 No. 3 P. 8

Communicating to older adults the real prospects for significant injury and raising their level of caution are critical to elevator safety.

Stand near any elevator—whether it’s located in a hospital, shopping mall, casino, or long-term care facility—and you’ll notice a common trend: People jostling their way into it, using their hands to negotiate the door or, in the case of older adults, having their walkers or canes get stuck as the elevator doors close, resulting in frequent injuries.

The fact that more older adults are sustaining elevator-related injuries should come as no surprise, especially considering the related statistics. According to the U.S. Consumer Product Safety Commission (CPSC), between 1990 and 2006, approximately 44,870 older adults experienced elevator-related injuries severe enough to warrant a visit to the hospital.

Despite these statistics, “We want to stress that elevators are a safe form of transportation for elders,” says Greg Steele, DrPH, MPH, an associate professor of epidemiology in the department of public health at the Indiana University School of Medicine. However, healthcare practitioners must communicate to their older patients the hazards associated with this mode of transportation.

In a recent epidemiological study, Steele and Joseph O’Neil, MD, MPH, an associate professor of pediatrics at Riley Hospital for Children at the Indiana University School of Medicine who studies preventable injuries, examined elevator-related injuries in older adults. Their study, which looked at the frequency and nature of these injuries, was published in the January issue of The Journal of Trauma: Injury, Infection, and Critical Care. O’Neil and Steele have previously published studies on elevator-related injuries in children as well as escalator-related injuries in older adults.

“Looking at this particular database, which was the CPSC’s National Electronic Injury Surveillance System, we saw that a fraction of the falls older adults sustained were associated with elevators because of a slip, trip, or a fall,” O’Neil says. “But the problem is the database doesn’t always give you an idea of why that fall occurred. Was it because it was uneven? Was it because the floor was slippery or there was water on the other side? Was it because of an uneven surface or a footwear issue? Or was it because they were impatient and they were trying to prevent the door from closing or, because of walking speed, they weren’t able to exit the elevator in a safe, timely manner?”

As Steele explains, in the epidemiological study the pair identified many injuries associated with individuals stepping into elevators with walkers. “The light found in the sensors in many elevators passes through walkers so, to the sensor, it doesn’t appear as though anything is there,” Steele says. “The elevator door closes, knocks the walker out of the individual’s hands, they lose balance, and they end up falling.”

The majority of these fall injuries resulted in soft-tissue injuries—namely sprains or bruising. Fractures, lacerations, and finger and toe amputations were the next most frequently recorded types of injuries. However, about 15% of the injuries Steele and O’Neil observed in this study were more serious, requiring hospital admission—a large proportion of which were for fractured hips. And while approximately three fourths of the injuries involved women, the overall injury rate was seven times higher in elders aged 85 and older.

“Again, it’s one of those things that, especially in older adults, when the elevator door closes, it may not always retract back,” Steele says. “They can get compressed between the door and the wall and lose their balance and fall. With hip fractures being a major concern and a major cause of hospitalizations, it is a huge debilitating injury and is totally preventable in this situation.”

O’Neil emphasizes that three fourths of elevator-related injuries involved older women. More than one half of the older adults’ injuries were the result of a slip, trip, or fall, and about one third were the result of the elevator door closing on the individual.

In addition to the problems created by the swiftness of today’s elevator technology, older adults often struggle with myriad physical issues influencing their mobility, including vision loss, hearing loss, and medications that may cause balance issues.

“We did see increasing risk with age, especially for those 65 and older,” Steele says. “And of course, you are talking about a population that is on a variety of medications, some of which may affect balance, sight, response times. So there needs to be an increased awareness on how these issues can affect their elevator use.”

Some debilitating injuries are also prevalent with elevators, although they’re not as prevalent among older adults. These types of injuries occur when individuals slip their hands between closing doors, attempting to open them. “The sensor may not be responding properly, and you may end up with abrasions or complete amputation of fingers,” Steele says.

The misalignment of an elevator, in which the floor of the elevator fails to match the level of the floor of the hallway or room, is also a major cause of falls among older adults. “Patients may be trying to hurry on or off an elevator and don’t always see the misalignment,” Steele says. “This can cause them to trip and experience soft tissue injuries, abrasions, or even broken bones.”

Preventive Measures
Hospitals, long-term care facilities, health clinics, and other locales where large numbers of older adults visit work diligently to ensure patents’ safety, regardless of age. However, there are some key techniques practitioners can use with their elder patients when it comes to elevator safety.

“In our study, we saw that the occurrence of elevator injuries is pretty standard across long-term care facilities, assisted-living facilities, shopping malls, casinos, or hospitals,” Steele says. “And while many injuries involving elevators took place in hospitals, the risk of elevator injuries has more to do with the behaviors associated with handling an elevator than where the elevator is located.”

As with many things in life, when it comes to using an elevator, patience is a virtue. “There are some things we can do that are important to be aware of,” Steele says. “And probably the one that affects most is patience. People in general, but especially older adults, need to not hurry on or off of an elevator. If the elevator doors are closing, let them close. It is only a few more minutes before another elevator will be there. It is important that a patient safely maneuvers getting off an elevator without feeling the need to rush.”

“Many of the injuries resulted in slips, trips, or falls because older adults often will put their walker, cane, or other mobility device in the elevator doors to prevent it from closing on them, but this can lead them to lose their balance,” O’Neil says. “You need to communicate the importance of [older adults] taking their time and finding someone to hold the door open for them when they are entering the elevator.”

Steele recommends applying different colors of paint to the edge of the room floor and the edge of the elevator compartment to help differentiate where the elevator compartment begins and ends. This is particularly important to help older adults identify misalignment issues when entering or exiting the elevator.

Another beneficial fix would be to make the “Door Open” button larger. “Often when I’m in an elevator and someone is trying to get on as the door is closing, I’m searching for the ‘Door Open’ button, and it sometimes takes a while to find it,” Steele says. “That’s when people get jostled or bumped, resulting in some sort of a soft-tissue injury.”

Steele and O’Neil both say “Door Open” buttons should be made twice as large as the current standard size in most elevators to allow for swift identification and accessibility by individuals in the elevator who are trying to prevent the door from closing on those approaching the elevator or on older adults who are placing their walkers between the doors ahead of themselves.

The researchers have recently learned of a company considering placing reflective devices at certain heights on the walkers they manufacturer to allow them to project a reflection to the elevator sensors. Another company that creates sensors for elevators is looking to provide a wider beam so it will detect a walker, cane, or other device that will be recognized before an older adult enters an elevator.

More elevators also feature verbal warnings or voice descriptions that warn individuals when the doors are opening or closing. “Most of the facilities I see, a lot of the elevators are stock elevators that are very standardized,” O’Neil says. “We need to think about as our population ages, we need to modify elevators accordingly with bigger buttons, better lit, voice warnings are helpful, but with a population that may suffer from impaired hearing, visual warnings are also important.”

Residential Facility Elevator Safety
Carol Story, RN, BSN, RAC-CT, clinical services director at Risk Management Solutions, a healthcare consulting firm headquartered in Columbus, Ohio, and comprised of clinical professionals with expertise in all facets of the risk-management field, including long-term care, acute care, rehab, home health, behavioral health, and other healthcare environments, recommends that administrators at long-term care facilities, assisted-living centers, and other residential communities servicing older adults educate residents about basic elevator safety.

“Residents need to be instructed to be aware of level alignment of the elevator car with the adjacent floor, the dangers of placing an extremity or mobility device between the elevator doors to prevent them from closing, and the importance of not rushing to enter an elevator,” says Story, who is responsible for assisting organizations in establishing risk-management functions. “Residents also need to allow enough time for safe entry into the elevator car. Also, administration and personnel need to be aware of not only adherence to the above mentioned safety instructions but that elevator operation is not accessible to residents with cognitive impairments.”

Story stresses that the most important measure of success in elevator safety is educating older adults and raising their awareness of the true risk of elevator-related injuries.

“Ongoing preventive maintenance of elevators is equally as important,” Story says. “As part of the ongoing preventive maintenance program, the facility should document routine checking of the level of the elevator lip and if it is even with the adjacent floor when the elevator car comes to a stop. Some facilities have brightly painted a corresponding line at the elevator lip and the adjacent floor to help older adults’ visually determine that the area is level and does not present a tripping hazard.”

For facilities housing cognitively impaired residents, measures should be in place to prevent their unassisted use of the elevator system, such as making adjustments to the elevator controls by coordinating the elevator service with a wandering-prevention device. Another method is adjusting access to the elevator call buttons by installing a clear enclosure with a small opening for calling the car.

For healthcare providers working in nonresidential settings, patient communication is paramount for reducing elevator-related injuries. Both Steele and O’Neil stress the importance of talking with older adult patients about the risks elevators pose.

“This is especially important when prescribing medications that may affect their vision or balance. As they get older, communicate to them that they are more susceptible to balance problems, medication issues, vision reduction, and footwear problems,” O’Neil says. And for those who may be ushering older adults into or out of elevators, they should pay particular attention to helping them exit or enter safely.

“Especially with individuals that are going to mobility-assistance devices, including canes and walkers, make them aware that when they are getting on and off an elevator that they have ample time and that someone is holding the door open for them,” Steele says. “With simple fixes such as paint colors, larger buttons, and consistent education and monitoring on the part of healthcare professionals, older adults’ use of elevators can be made safer. There needs to be a continuous awareness of ‘take your time and be patient.’ Eventually you will be there and be there safe.”

— Maura Keller is a Minneapolis-based writer and editor.


Escalator Safety
Although both Greg Steele, DrPH, MPH, and Joseph O’Neil, MD, MPH, emphasize that elevators provide a safe form of transportation for elders, they strongly discourage older adults from using escalators. Here’s why: In their study on escalator safety published in the March 2008 issue of Accident Analysis and Prevention, the researchers found that the number of escalator-related injuries suffered by older adults more than doubled, resulting in nearly 40,000 elders being injured on escalators between 1991 and 2006. Balance issues, vision issues with the moving floors, and difficulty stepping on or off the escalator resulted in numerous falls, trips, and serious injuries.

“Elevators are still the way to go for older adults,” Steele says. In their escalator-safety study, Steele and O’Neil saw older adults wearing improper footwear or carrying too many packages onto the escalator, causing them to lose their balance and fall.

“Also, stepping on or off the escalator was an issue associated with escalators,” O’Neil says. “People may not take the appropriate care, such as being patient when stepping onto or off of the escalator, not walking around people who are having difficulty entering or exiting the escalator, and or holding onto the escalator railing. All of these issues caused older adults to fall and sustain injuries of varying types.”

— MK


Provider Perspective
• Make your patients aware of safety practices associated with operating and using elevators.

• Remind patients with mobility devices such as walkers and canes to be particularly alert and cautious when using elevators.

• Use different colors of tape or paint to call attention to the alignment of elevator cars and adjacent floor surfaces.

• Use colored tape or a large-print sign to call attention to an elevator’s “Door Open” button.

• Take steps to prevent cognitively impaired patients from operating elevators alone.