1. Carbon monoxide monitoring and response in long-term care facilities (LTCFs)

2. Overview Carbon Monoxide What are the health risks? Who is at risk? CO in LTCFs What are the issues? What is being done to address these issues? CO Monitoring and Response Framework

3. CARBON MONOXIDE

4. Typical sources of CO are (but not limited to): Fuel-burning (propane, oil, wood, gasoline) appliances Boilers Laundry equipment Water heaters Fireplaces Kitchen equipment, gas-stoves Generators Exhaust from cars, delivery trucks (garages, loading bays) A gas that you cannot see, smell, or taste A combustion by- product Must be monitored by a CO detector

5. CO impairs oxygen delivery to cells in the body Binds tightly to hemoglobin, competing with oxygen Particularly affects high-oxygen demand organs like the heart and brain You may not experience symptoms (or not obvious) and still be exposed to unsafe CO levels Exposure to low levels of CO for long periods CARBON MONOXIDE

6. What are the health risks? If inhaled at sufficient levels, for sufficient period of time…

7. Who is at risk? Everyone, all ages Residents and staff Particularly among young, pregnant, and elderly Lower tolerance to CO Individuals with chronic lung and cardiovascular conditions are more susceptible Coronary heart disease Respiratory disease

8. Examples in the media Regina, Saskatchewan – Fire department and gas utility provider responded to elevated CO levels detected by security and maintenance personnel. CO levels from approx. 20 to 33 ppm were reported on all three floors of the facility. CBC News. Carbon monoxide leak at Regina seniors residence. 2016 Available from: http://www.cbc.ca/news/canada/saskatchewan/c arbon-monoxide-regina-seniors-residence- 1.3564003 http://www.cbc.ca/news/canada/saskatchewan/c arbon-monoxide-regina-seniors-residence- 1.3564003 Wakaw, Saskatchewan – Code brown (hazardous releases) activated in response to elevated CO levels detected in a boiler room and service wing; three staff and one resident reported feeling unwell. Giles, D. ‘Code Brown’ alerts staff to CO leak at care home. 2013. Available from: http://globalnews.ca/news/771806/code-brown- alerts-staff-to-co-leak-at-care-home/ http://globalnews.ca/news/771806/code-brown- alerts-staff-to-co-leak-at-care-home/

9. CO IN LTCFs

10. Background CO incident in Humboldt, Saskatchewan, 2010 Staff and residents were exposed to CO from an improperly ventilated appliance in a long- term care facility Resulted in evacuation of one wing Contributed to 3 deaths

11. CO is colourless, odourless Can only be detected through monitoring CO detectors are not routinely required to be installed, especially in older buildings Initial symptoms may be non-specific mimic other diseases (especially low-level exposure) What are the issues?

12. CO detectors do not alarm or notify at low levels They are designed to prevent CO poisoning (acute, high level exposure) and are not designed to prevent sub-acute exposures *Installation of CO detectors alone is not enough to mitigate this risk Residents at long-term care facilities may have conditions which make them more susceptible to the effects of low-level CO exposure (10-25 ppm) What are the issues?

13. What is being done to address CO risks in LTCFs? Saskatoon Heath Region (SHR) has developed and implemented a CO monitoring, reporting, and response framework in their LTCFs Adopted by the province of Saskatchewan in 2014 Health Canada, BC Centre for Disease Control, and National Collaborating Centre for Environmental Health were involved in evaluating the CO framework and promoting the implementation of the CO Monitoring and Response Framework in LTCFs. This work is built upon a stakeholder consultation meeting in 2013 to promote the development of a health-protective CO management framework that incorporates education, monitoring, prevention, and mitigation, with practical means to support program implementation and evaluation.stakeholder consultation meeting

14. CO MONITORING AND RESPONSE FRAMEWORK

15. Objectives Implement a health- protective CO management framework that incorporates education, monitoring, prevention, and mitigation Enhance the capacity of health regions and LTCFs to prevent and reduce CO exposure in LTCFs Reduce the risk of harmful CO exposure among residents and staff

16. EDUCATION Increase staff awareness of CO health effects, sources, and importance of monitoring Train staff on established CO monitoring and response protocols

17. MONITORING Develop protocols for CO monitoring Installation of CO detectors near sources of CO Identify all potential sources Daily monitoring and recording of detector readings (instant and peak level) Identify elevated CO levels (>10 ppm)

18. REPORTING Data to be recorded on weekly log Facility Maintenance personnel Other team members as required for coverage when Facility Maintenance not available Submit weekly logs on a monthly basis to regional management Retention of monitoring records for 12 months

19. PREVENTION AND MITIGATION Develop resources related to identification and maintenance of CO sources Maintenance plans, schedules, etc. Perform routine maintenance on combustion appliances Establish protocols for responding to elevated CO levels Respond to elevated readings or alarms Investigate potential sources, procedures in place Mount instructions by all CO monitors Familiarize staff with procedures, including actions taken depending on level of CO

20. Resources BC Safety Authority Licensed gas fitters in BC http://safetyauthority.ca/contact/find-contractor Health Canada Residential Indoor Air Quality Guideline for Carbon Monoxide: http://healthycanadians.gc.ca/publications/healthy-living-vie-saine/carbon-monoxide-carbone/index- eng.php US EPA CO fact sheets (information for older adults and their caregivers) http://www2.epa.gov/healthresearch/aging-factsheets-carbon-monoxide-poisoning-prevention