United States Lifeguard Standards Coalition Evidence Review

Transcription

1 United States Lifeguard Standards Coalition Evidence Review On the following pages, you will find a primary question (and in some cases ancillary questions), reviewed by the United States Lifeguard Standards Coalition (USLSC), the draft consensus recommendation of the USLSC, and the Scientific Review Forms (usually two) that detail the specific evidence upon which the consensus recommendation was based. In most cases, for each question, two independent investigators researched existing evidence, including scientific research and other material, related to the question. Each investigator then completed a Scientific Review Form, listing the evidence and an evidence summary. The level and quality of evidence was rated using a standardized evidence evaluation process. The evidence reviewed included, but was not limited to, the following: a. Population-based studies b. Epidemiological studies c. Case-control studies d. Historic research e. Case studies f. Large observational studies g. Review of past research summaries, and h. Extrapolations from existing data collected for other purposes The scientific reviews were presented to the entire USLSC. Each topic was presented, discussed and critiqued by the assembled experts until consensus was reached. You are invited to comment on this question (as well as the others) and particularly whether you believe that the evidence adequately supports the consensus recommendation. If you are aware of any additional evidence (e.g. scientific research) that was not considered by the Lifeguard Standards Coalition, please list that evidence in your comments. In any comments you choose to make, please be sure to cite the line number, if you are referring to specific wording of the item. Before commenting, please review the document in full. This includes an initial document, which contains the question or questions investigated and the consensus recommendation. This is followed, in most cases, by two Scientific Review Forms, which list the evidence that was considered in arriving at the consensus recommendation. Thank you for your time and consideration in reviewing this question. The deadline for comments is December 12, 2009.

2 US Lifeguard Standards Coalition VISUAL AND BEHAVIORAL CUES Question What visual and behavioral cues are useful for identifying high-risk patrons? Introduction Identification of high-risk patrons may or may not be appropriate within lifeguard training. Some current training list high-risk behaviors for which lifeguards may need to intervene. Scanning techniques for lifeguards need to address all patrons equally rather than identifying separate groups. Epidemiologic studies have described risk factors and can provide a profile of those who are at greater risk of an aquatic accident. Evidence Summary Studies reviewed indicated that some characteristics were related to drownings, namely, male, young, ethnicity, and other sociocultural parameters. The following studies included information relating to specific behaviors and cues. Bell, Amoroso, Yore, Senier, Williams, and Smith (2001) documented drowning risk factors for active duty, male US Army Soldiers. Most drownings occurred when no lifeguard was present, but almost two-thirds occurred in the presence of others. Drownings involving minority victims were less likely to involve alcohol but more likely to occur in unauthorized swimming areas. While most drownings did not involve violations of safety rules, over one-third of the cases involved some form of reckless behavior, particularly for those younger than 21 years old. Driscoll, Harrison, and Steenkam (2004) reviewed the role of alcohol in drowning associated with recreational aquatic activity. They discovered that drowning appears to be the overwhelming cause of death associated with recreational aquatic activity with alcohol detected in the blood in 30%-70% of people who drown while involved in the activity. The few relevant studies on degree of increased risk suggest that people with a blood alcohol level of 0.10 g/100 ml have about 10 times the risk of death associated with recreational boating compared with those who have not been drinking. Other studies focused primarily on population characteristics rather than on visual or behavioral cues. In summary, evidence from 11 studies (LOE 1a-4) and 16 additional studies (LOE 4-) document that risky behavior and alcohol are behavioral cues that should be given special attention regarding swimming or aquatic activities. Open water alcohol-related drownings occur in unguarded facilities and while boating. Although risky behavior was cited as a cue, the actual identification of specific risky behaviors was not noted. The use of alcohol is a behavioral cue that can be recognized by lifeguards, and certifying agencies should emphasize this in lifeguard training. Consensus Recommendations: Standards: Consumption of alcohol is a behavioral cue of an individual who may be at greater risk of drowning. Guidelines: None Options: Individuals who are under the influence of alcohol should be discouraged or excluded from participation in aquatic activities.

3 Unites States Lifeguarding Standard Coalition Scientific Review Form Author: Michael C. Giles, Sr. Organization Representing: The University of Southern Mississippi Recreational Sports Question: Visual and Behavioral Cues Date Submitted: November 26, 2007 Question and Sub-Questions: This should include the major question originally planned and any changes which occurred during the review process. Please also list any original sub-questions and the changes and those added during the review process. What visual and behavioral cues are useful for identifying high-risk patrons? Introduction/Background: Provide any relevant background on the subject and the need to address this question. Identification of high-risk patrons may or may not be appropriate within lifeguard training. Some current training list high-risk behaviors where lifeguards may need to intervene. Scanning techniques for lifeguards needs to address all patrons equally rather than identifying separate groups. Evidence Identification and Review List the approach to gathering evidence. This should include any electronic databases searched with the terms used and numbers of articles found and reviewed. Also list any reports, prior evidence reviews analyzed and/or position papers evaluated. Database Search Engines 1.Google 2. Suite 101.com 3. realhomesafety.com 4. injurypresention.dmj.com. upmc.com 6. webmd.com 7. emedicinehealth.com 8. American Journal of Public Health.com 9. Aquaticsintl.com 10. lib.niu.edu 11. pubmed.com 12. ncbi.nlm.nih.gov 13. ARC Lifeguard Training 14. Star Guard 3 rd edition 1. National Pool and Water park Lifeguard Training 16. National Aquatic Safety Company Lifeguard Manual 17. Jpepsy.oxfordjournals.org Key Words Lifeguards, scanning, techniques, vigilance, swimmer distress, high-risk behavior, risk factors, surveillance profiling 14 articles reviewed

4 Summary of Key Articles/Literature/Reports/Data Found and Level of Evidence (Please fill in the following table for articles that were used to create your recommendations and/or guidelines) Author(s) and Full reference Year published Schwebel, D; Lindsay, S.; Simpson, J (April 2007) Schwebel, D; Lindsay, S.; Simpson, J (May 2007) Ellis, Jeff (2002) Pia, Frank (May 2006) Saluja, G; Brenner, R.; Trumble, A.; Smith, G; Schroeder, T; Cox, C (April 2006) Journal of Pediatric Psychology; Brief Report: A Brief Intervention to Improve Lifeguard Surveillance at a Public Swimming Pool. Pubmed.com; Ecology of Drowning Risk at a Public Swimming Pool. Lib.niu.edu; Lifeguards may look but they don t always see. Aquaticsintl.com; Guarding against misconceptions. Ajph.org; Swimming Pool Drownings Among US Residents Aged -24 Years: Understanding Racial/Ethnic Disparities Emedicalhealth.com; Drowning Symptoms Upmc.com; Drowning (Near drowning, submersion Summary of Article (if abstract available, first past abstract and then provide your summary This article describes risky behaviors of patrons and the frequency of distracted lifeguards. Intervention and education of scanning techniques for lifeguard is recommended. This study used nonintrusive observational methodology to examine risk taking by swimming patrons. Vigilance is one of the most difficult tasks for lifeguards. Numerous factors influence lifeguard vigilance. Automated tools may be necessary to enhance lifeguard victim recognition. Article listed several misconceptions about lifeguard training and discussed each one. Targeted interventions are needed to reduce the incidents of swimming pool drownings across racial/ethnic groups particularly adult supervision at public pools. Distress swimmer symptoms, drowning sequence, and signs of a drowned person are discussed in this article. Definition, causes, riskfactors, symptoms, Level of Evidence (Using table below) 1a 1a 1b

5 Quan, L.; Cummings, P (2003) White, Jill Ellis and Associates incident) Injuryprevention.bmj.com; Characteristics of Drowning by Different Age Groups. Realhomesafety.com; Drowning: The Facts. Starfish Aquatics Institute, Starguard Lifeguard Manual (3 rd Edition) National Pool and Waterpark Lifeguard Training Manual (2 nd edition) NASCO Lifeguard Manual (2007) American Red Cross Lifeguard Training Manual (200) diagnosis and treatment are discussed in this article. The characteristics of drowning episodes vary greatly by age. Different prevention strategies may be needed for different age groups. Children and water do not mix well unless supervised by a vigilant and responsible adult. Discussion of events that may lead to drowning. This manual lists several high-risk groups among them are: children between age of 7 & 12, parents with small children, guests who have been drinking, guests with extreme body proportions, guests wearing life jackets, elderly guests, disabled guests, guest wearing clothes. List high-risk victims: first timers, the working poor, children who are 4 feet tall in 4 feet of water and about 7 years old, head back nose up-dry heads, ethnic background, teenage males, overweight individuals, arrow shapes, followers and elderly. This manual also lists high-risk times during facility operation and high-risk behaviors that must be corrected during facility operations. Manual stresses victim recognition vs. identifying high-risk traits or 1a

6 Speech Key Note Address at 1994 Reflections on Lifeguarding Conference, University of Victoria, British Columbia behaviors. Speech describes trait centered surveillance teaches lifeguards to look for specific characteristics in defining high-risk facility guests. Level of Evidence Level 1a Level 1b Level 2 Level 3a Level 3b Level 3c Level 4 Level Level 6 Level 1-6E Criteria Population based studies, randomized prospective studies Large non-population based epidemiological studies, meta-analysis or small randomized prospective studies Prospective Studies which can include, controlled, non-randomized, epidemiological, cohort or case-control studies Historic which can include epidemiological, non-randomized, cohort or case-control studies Case series: subjects compiled in serial fashion without control group, convenience sample, epidemiological studies, observational studies Mannequin, animal studies or mechanical model studies Peer-reviewed works which include state of the art articles, review articles, organizational statements or guidelines, editorials, or consensus statements Non-peer reviewed published opinions, such as textbooks, official organizational publications, guidelines and policy statements and consensus statements Common practices accepted before evidence-based guidelines or common sense Extrapolations from evidence which is for other purposes, theoretical analyses which is on-point with question being asked. Modifier E applied because extrapolated but ranked based on type of study.

7 Summary Table of Evidence Place all the evidence listed in the previous sections in one of the following three columns using the follow approach: 2. Place each article or report in one of the columns and in its own row 26. List articles with highest level of evidence first 27. In box place name of lead author and in parenthesis year published 28. In addition in each box put a one to two sentence summary of how the article either support, opposes or has no position with regard to the question(s) Supportive of Recommendation Pia, Frank (May 2006) - working memory for lifeguards maybe at or near capacity when guards divide attention between looking at visual images and making educated guesses about a persons safety. Based on these precepts, lifeguard training agencies should avoid surveillance policies and scanning rules that exceed lifeguards working memory capacity. Speech Key Note Address at 1994 Reflections on Lifeguarding Conference, University of Victoria, British Columbia - the use of trait centered surveillance and the depiction of people as highrisk guest who need special surveillance has no place in modern lifeguarding. American Red Cross Lifeguard Training Manual (200) decisions by lifeguards to assist swimmers must be based on victim Opposing Recommendation Ellis and Associates this manual describes actual rescue statistics and guest profiles describes by Ellis and Associates to include: children between age of 7 and 12, parents with small children, intoxicated guests, extreme body proportions, guest wearing life jackets, elderly jackets, disabled guests, guests wearing clothes. NASCO Lifeguard Manual (2007) List high-risk victims: first timers, the working poor, children who are 4 feet tall in 4 feet of water and about 7 years old, head back nose up-dry heads, ethnic background, teenage males, overweight individuals, arrow shapes, followers and elderly. This manual also lists highrisk times during facility operation and high-risk behaviors that must be corrected during facility operations. Quan, L.; Cummings, P (2003) difference prevention strategies may be needed for different age groups to protect them from drowning. No Position Ellis, Jeff (2002) study calculated how quickly the guard could spot a swimmer in trouble under water. Many factors work against using standard scanning techniques. Some of these include: vigilant capacity, signal noise, noise by itself, monotony, stress, fatigue, and heat. Realhomesafety.com; Drowning: The Facts.- children and water don t mix well unless supervised by a vigilant responsible adult. Parents should be wary of aids such as baby seats or flotation devices.

8 behavior not physical characteristics, appearance, age, ethnic or racial backgrounds. Starfish Aquatics Institute, Starguard Lifeguard Manual (3 rd Edition) there are many common patron behaviors that may contribute to drowning such as: lack of adult supervision for children, breath holding contest, being a non-swimmer in deep water, slip off a flotation devise by a non-swimmer, having a seizure or heart attack while in the water, becoming exhausted while swimming, being under influence of alcohol or drugs. Schwebel, D; Lindsay, S.; Simpson, J (April 2007) article lists incidents of five risky behaviors around the pool 1. pushing people under water, 2. dangerous diving, 3. aggressive acts, 4. jumping into water near someone else,. running on the deck. Emedicalhealth.com; Drowning Symptoms signs that someone many be in trouble include swimmer flailing his or her arms, displaying uneven swimming motions, lying face down in the water, only the head showing above water with the mouth open. Schwebel, D; Lindsay, S.; Simpson, J (May 2007) risk taking behavior is common in public swimming pools, therefore, emphasis needs to increase awareness and adherence to safety rules by swimmers Upmc.com; Drowning (Near drowning, submersion incident) list of risk-factors for drowning: age, gender, race, location, inability to swim, use of drugs or alcohol, horseplay, unsafe diving, child abuse, hypothermia, poor medical condition, not knowing how to swim, having an unprotected pool or spa at home. For children less than 1year old the most common risk factor is being left in a bathtub unattended. Saluja, G; Brenner, R.; Trumble, A.; Smith, G; Schroeder, T; Cox, C (April 2006 targeted interventions are needed to reduce the incident of pool drownings across racial/ethnic groups particularly adult supervision at public pools.

9 Textual Summary of Evidence: Please provide a textual summary of the all of the evidence reviewed and explain in detail how these lead to the guidelines, recommendations and/or options which you are proposing Out of 14 articles reviewed, seven articles had supportive information, five had opposing information and two had no position. There is no specific evidence to suggest that there are visual or behavioral cues to identify high-risk patrons. Many of the articles defined high-risk behaviors and high-risk situations. Both of these should be handled by better preventative lifeguarding techniques used by the lifeguard staff. Training agencies should provide a large range of high-risk behaviors that might lead to swimmer distress within their training. However, more emphasis should be placed on recognition traits of swimmers in distress or drowning.

10 Preliminary Guideline Document Section: Place your suggested recommendations into one or more of the three categories listed below and then briefly summarize the issue, your overall recommendations including answers to the question which was addressed as we should included it in the final document Recommendations and Strength (using table below): Standards: Guidelines: Options: There is no specific evidence to suggest that there are visual or behavioral cues to identify high-risk patrons. Many of the articles defined high-risk behaviors and highrisk s ituations. B oth o f t hese s hould be ha ndled b y b etter pr eventative l ifeguarding techniques used by the lifeguard staff. Training agencies should provide a large range of high-risk behaviors that might lead to swimmer distress within their training. However, more e mphasis s hould be pl aced on r ecognition traits of s wimmers in distress o r drowning. No Recommendations: Guideline Definitions for Evidence-Based Statements Statement Definition Implication Standard A standard in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendation standards may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. One should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. Guideline Option A guideline in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. Options define courses that may be taken when either the quality of evidence is suspect or, level and volume of evidence is small or carefully performed studies have shown little clear advantage to one One would be prudent to follow a recommendation but should remain alert to new information. One should consider the option in their decisionmaking.

11 No recommendation approach over another. No recommendation indicates that there is a lack of pertinent evidence and that the anticipated balance of benefits and harms is presently unclear. One should be alert to new published evidence that clarifies the balance of benefit versus harm Attach Any Lists, Tables or Summaries Created As Part Of This Review (Please include any tables, lists of items or procedures and tables which you created as part of the review that would be helpful for final analysis or publication in the final document)

12 Unites States Lifeguarding Standard Coalition Scientific Review Form Author: Greg Finlayson Question: What visual and behavioral cues are useful for identifying high-risk patrons? Organization Representing: American Public Health Association Date Submitted: Question and Sub-Questions: This should include the major question originally planned and any changes which occurred during the review process. Please also list any original sub-questions and the changes and those added during the review process. What visual and behavioral cues are useful for identifying high-risk patrons? Introduction/Background: Provide any relevant background on the subject and the need to address this question. Epidemiologic work has described risk factors, and can provide a profile of those who are at greater risk of an aquatic accident. The majority of drownings occur in locations where there is no lifeguard Definition: High-risk patrons: Individuals with personal characteristics or exhibiting behaviors that could cause an adverse event in an aquatic environment. Evidence Identification and Review List the approach to gathering evidence. This should include any electronic databases searched with the terms used and numbers of articles found and reviewed. Also list any reports, prior evidence reviews analyzed and/or position papers evaluated. Databases Searched Databases Searched Scopus 2, PubMed, Web of Science, Google, Google Scholar 2 Scopus is the largest abstract and citation database of research literature and quality web sources. It includes: 1,000 peer-reviewed journals from more than 4,000 publishers, over 1000 Open Access journals, 00 conference proceedings, over 600 trade publications, 33 million abstracts, and results from 386 million scientific web pages.

13 Keywords used Behavior/Behaviour and o Risk o Drowning o Swimming Additional items were identified from the reference lists of papers that were reviewed Exclusions: Non-English, pre-1990

14 Summary of Key Articles/Literature/Reports/Data Found and Level of Evidence (Please fill in the following table for articles that were used to create your recommendations and/or guidelines) Author( s) and Year publishe d Full reference Summary of Article (if abstract available, first past abstract and then provide your summary Level of Evide nce (Usin g table below Bell, N. S., Amoros o, P. J., Yore, M. M., Senier, L., William s, J. O., Smith, G. S. et al. (2001) Alcohol and other Risk factors for Drowning among male active duty U.S. Army Soldiers. Aviation, space, and environmental medicine 72[12], Background: Risk factors for drowning are largely undocumented among military populations. Hypothesis: Accident report narratives will provide important information about the role of alcohol use and other behaviorsin drownings among active duty male U.S. Army soldiers. Methods: Using a case series design, we describe drowning deaths reported to the U.S. Army Safety Center ( ), documenting associated demographic factors, alcohol use, and other risk-taking behaviors. Results: Drowning victims (n = 32) were disproportionately young, black, and single, with less time-in-service, and no college experience. Most drownings occurred off-duty (89%). Alcohol use was involved in at least 31% of the cases overall. Alcohol use was also associated with a 10-fold increase in reckless behavior (OR 9.6, 9% Cl ) and was most common among drownings in Europe (OR = 4.3, 9% Cl ). Most drownings occurred where no lifeguard was present (68%), but almost two-thirds ) 3b

15 Centers for Disease Control and Preventi on (2004) Centers for Disease Control and Preventi on (2007) Nonfatal and Fatal Drownings in Recreational Water Settings --- United States, MMWR Weekly, 3, Water-Related Injuries: Fact Sheet. Accessed at: 3A// wn.htm occurred in the presence of others, with CPR initiated in less than one-third of these cases. Drownings involving minority victims were less likely to involve alcohol, but more likely to occur in unauthorized swimming areas. While most drownings did not involve violations of safety rules, over one-third of the cases involved some form of reckless behavior, particularly for those under age 21. Conclusions: Intervention programs should be tailored to meet the needs of the demographic subgroups at highest risk since behavioral risk factors vary by race and age. CPR training and skills maintenance can improve survival rates. Narrative data are important for developing hypotheses and understanding risk factors for injuries. Nonfatal and fatal injury rates were highest for children aged 4 and under, and for males of all ages. 7% of nonfatal injuries occurred in pools, 70% of all fatal injuries occurred in natural water settings. For every child 14 years and younger who dies from drowning (in 2004), receive emergency department care for nonfatal submersion injuries. Groups at risk: - males - children 14 and under, and particularly 4 and under - minorities Risk factors: - lack of supervision and barriers - recreation in natural water

16 Driscoll, T. R., Harrison, J. A., & Steenka mp, M. (2004) Review of the role of alcohol in drowning associated with recreational aquatic activity. Injury Prevention, 10, settings - recreational boating - alcohol use - seizure disorders Objective and design: To assess the role of alcohol in drowning associated with recreational aquatic activity by reviewing the English language literature published up to October Results: Alcohol is widely used in association with recreational aquatic activity in the United States, but there is minimal information regarding the extent of use elsewhere. A priori and anecdotal evidence suggests that alcohol is an important risk factor for drowning associated with recreational aquatic activity. Specific studies provide good evidence supporting this, but the extent of increased risk associated with alcohol use, and the attributable risk due to alcohol use, is not well characterised. Drowning appears to be the overwhelming cause of death associated with recreational aquatic activity with alcohol detected in the blood in 30% 70% of persons who drown while involved in this activity. The few relevant studies on degree of increased risk suggest persons with a blood alcohol level of 0.10 g/100 ml have about 10 times the risk of death associated with recreational boating compared with persons who have not been drinking, but that even small amounts of alcohol can increase this risk. The population attributable risk seems to be in the 4

17 Howlan d, J., Hingson, R., Mangio ne, T. W., Bell, N., & Bak, S. (1996) Internati onal Life Saving Why Are Most Drowning Victims Men? Sex Differences in Aquatic Skills and Behaviors. American Journal of Public Health, 86, Australian Males Most At Risk. Accessed at: range of about 10% 30%. Conclusions: Alcohol consumption significantly increases the likelihood of immersions resulting in drowning during aquatic activities. However, more information is required if appropriate prevention activities are to be planned, initiated, and evaluated. This includes better information on alcohol use, and attitudes to alcohol use, in association with recreational aquatic activity, and the nature and extent of increased risk associated with alcohol use. Evaluation of interventions is also needed. Men have higher drowning rates than women for most age groups. Data from a 1991 national household survey (n = 3042) on aquatic activities were used to examine hypotheses about differential drowning rates by sex. Men and women were compared by (1) exposure to aquatic environments; (2) frequency of aquatic activities involving or potentially involving, submersion; (3) swimming training and ability; (4) aquatic risk-taking behaviors; and () alcohol use on or near the water. Men had elevated risks for exposure, risk taking, and alcohol use. It was concluded that several factors contribute to their relatively high drowning rates, including a possible interaction between overestimation of abilities and heavy alcohol use. 44% of males and 2% of females swim in unsafe areas. 3b 6

18 Federati on (2007) Liller, K. D., Kent, E. B., Arcari, C., & McDer mott, R. J. (1992) Risk Factors for Drowning and Near- Drowning Among Children in Hillsborough County, Florida. Public Health Reports, 108, The authors obtained data from 700 households in Hillsborough County, FL, in a telephone random survey to determine risk factors for incidents of drowning and near-drowning among children in the county. The survey was conducted from August through December A combination of forced choice and open-ended questions was used to assess adults' drowning-related knowledge, attitudes, and prevention behaviors, as well as the incidence of and the circumstances surrounding drowning and near-drowning among children who lived in those households. The results showed that although most respondents had some knowledge of the epidemiology of drowning and near-drowning among children, deficits were noted in their knowledge of the importance of adult supervision and the recommended age at which to begin children's swimming instruction. Results showed a need for isolation fencing, that which separates a swimming pool from a house and yard. Most respondents reported that they did not know how to perform cardiopulmonary resuscitation (CPR) on an infant or child. More than 40 percent reported not knowing how to perform CPR on an adult. Respondents reported no drowning or near drowning incidents among children of their household within the last 3 years. However, the respondents did 3b

19 Michals en, A. (2003) Risk assessment and perception. Injury Control and Safety Promotion, 10, describe water-related immersions that involved children who experienced difficulty in the water, but recovered by themselves or with the aid of a nearby person. In some instances the child's breathing pattern was altered. There were three episodes during which difficulty in breathing occurred. The respondents reported a total of nine childhood water-immersion episodes within their families, none of which had been reported to treatment facilities. Recommendations are provided for programs for prevention of childhood drowning. People are aware of the risk factors, including age 1-4 and male. Injury prevention efforts often focus on reducing the risk of potentially dangerous activities, facilities or equipment, such as diving, swimming pools or flotation devices. This paper aims to clarify the concepts of risk assessment and risk perception. Statistically, risk denotes the probability of an untoward event, often expressed in terms of potential financial loss. Subjectively, though, risk denotes an individual's perception of the likelihood and the seriousness of an undesirable event. Individual perception appears to be strongly influenced by personal traits and socio-cultural parameters. Risk assessment helps to form the basis for public health interventions. The implementation and effectiveness of these are influenced by individual risk perception. Therefore, preventive efforts need to incorporate and 4

20 Minneso ta Departm ent of Health (2004) Saluja, G., Brenner, R., Trumble, A., Smith, G., Schroed er, T., & Cox, C. (2006) Best Practices to Prevent Drowning. Accessed at: st/best.cfm?gcbest=drown Swimming pool drownings among US residents aged -24 years: Understanding racial/ethnic disparities. American Journal of Public Health, 96, hopefully influence the determinants of risk perception among the target populations. Considering drowning, both hazard and incidence of submersion injuries are underestimated, whereas treatment options are usually overestimated. Consequently, individual risk alertness needs to be improved -- drowning remains a ubiquitous risk. Risk factors: Age 1-14 Male Male 1-19 Overconfidence in swimming ability Alcohol African Americans, American Indians and Asian Americans Objective. We examined circumstances surrounding swimming pool drownings among US residents aged to 24 years to understand why Black males and other racial/ethnic groups have high drowning rates. Methods. We obtained data about drowning deaths in the United States ( ) from death certificates, medical examiner reports, and newspaper clippings collected by the US Consumer Product Safety Commission. Results. During the study period, 678 US residents aged to 24 years drowned in pools. Seventy-five percent were male, 47% were Black, 33% were White, and 12% were Hispanic. Drowning rates were highest among Black males, and this increased risk persisted after we controlled for income. The majority of Black victims (1%) drowned in public pools, the 3b

21 Schweb el, D. C., Lindsay, S., & Simpson, J. (2007) A Brief Intervention to Improve Lifeguard Surveillance at a Public Swimming Pool. Journal of Pediatric Psychology Advance. doi: /jpepsy/jsm019 majority of White victims (%) drowned in residential pools, and the majority of Hispanic victims (3%) drowned in neighborhood pools (e.g., an apartment complex pool). Foreign-born males also had an increased risk for drowning compared with American-born males. Conclusions. Targeted interventions are needed to reduce the incidence of swimming pool drownings across racial/ethnic groups, particularly adult supervision at public pools. Objectives Drowning is the second leading cause of unintentional death for American children in middle childhood, but behavioral research designed to prevent pediatric drowning is limited. This study tested the efficacy of a brief intervention to improve lifeguard attention and surveillance at a public swimming pool. Method Observational data on patron risktaking and lifeguard attention, distraction, and scanning were collected at a public swimming pool, both before and after a brief intervention. The intervention was designed to increase lifeguards perception of susceptibility of drowning incidents, educate about potential severity of drowning, and help overcome perceived barriers about scanning the pool. Results Postintervention, lifeguards displayed better attention and scanning and patrons displayed less risky behavior. Change was maintained for the remainder of the season. Conclusion Theoretically driven brief interventions targeting lifeguard attention and surveillance might 6

22 Schweb el, D. C., Simpson, J., & Lindsay, S. (2007) Ecology of drowning risk at a public swimming pool. Journal of Safety Research, 38, prove effective in reducing risk of drowning in public swimming pools. This study reports the following risktaking behaviors: - running - pushing under - jumping near others - diving into shallow water - aggression Introduction: The fourth-leading cause of death in middle childhood is drowning, but there is remarkably little known about swimmer or lifeguard behavior patterns at public swimming pools. Method: This study used nonintrusive obserxvational methodology to examine risktaking by swimming patrons (predominantly children) and surveillance habits of lifeguards at a public swimming pool. The study also examined whether risk-taking behavior might be associated with density of swimmers, temperature, or lifeguard behaviors. Results: Results suggested risk-taking behavior was common, with dangerous incidents observed over 90 times per hour. Particularly high were rates of running on the deck, which exceeded 100 incidents per hour near the deepest water of the pool, and jumping into the water dangerously close to other swimmers, which was witnessed about once every two minutes in the shallow water of the pool. Lifeguards tended to scan the pool well, and remain attentive to the areas under their responsibility, but they were distracted about 10 times per hour and warned patrons only about once for every 3b

23 World Health Organiz ation (2003) Drowning and injury prevention. In Guidelines for safe recreational water environments. Volume 1, Coastal and fresh waters. (pp. 20-3). World Health Organization. 14 dangerous incidents observed. Conclusions: No consistent correlates to risk-taking behavior by swimming pool patrons were identified. Results are discussed with respect to previous findings and implications for intervention. Impact on Industry: Findings emphasize the need to increase awareness and adherence to safety rules by swimmers at swimming pools; to educate and remind lifeguards about proper swimming pool surveillance techniques; and to consider environmental changes at public swimming pools that might increase swimmer safety. Also found that when density of swimmers increased, dangerous behaviors also increased. In costal and fresh water, contributory factors to drowning and near drowning include: Alcohol consumption Cold Current (including rip currents, river currents, and tidal currents) Offshore winds (especially with flotation devices) Ice cover Pre-existing disease Underwater entanglement Bottom surface gradient and stability Waves (coastal, boat, chop) Water transparency Impeded visibility (including coastal configuration, structures and overcrowding) Lack of parental supervision (infants) Poor or inadequate equipment (e.g. boats or lifejackets) Overloading of boats Overestimation of skills Lack of local knowledge

24 In costal and fresh water, contributory factors fpr spinal injuries include: Alcohol consumption Diving into water of unknown depth Bottom surface type Water depth Lack of adult supervision Conflicting uses in one area Diving into water from trees/balconies/structures Poor underwater visibility In costal and fresh water, contributory factors for fractures, dislocations and other impact injuries include: Diving into shallow water Underwater objects (walls, piers) Poor underwater visibility Adjacent surface type (e.g., of water fronts and jetties) Conflicting uses in one area In costal and fresh water, contributory factors for cuts, lesions and punctures include: Presence of broken glass, bottles, cans, medical wastes Walking and entering water barefoot World Health Organiz ation (2006) Drowning and injury prevention. In Guidelines for safe recreational water environments. Volume 2, Swimming pools and similar environments (pp. 12-2) In swimming pools and similar recreational water environments, contributory factors for drowning and near drowning are: Falling unexpectedly into water Easy unauthorized access to pools Not being able to swim Alcohol consumption Excessive horseplay or overexuberant behaviour Swimming outside the depth of the user Breath-hold swimming and diving

25 High drain outlet suction and poor drain and drain cover design High water temperatures In swimming pools and similar recreational water environments, contributory factors for spinal injuries are: Diving into a shallow pool or the shallow end of a pool Diving into a pool of unknown depth Improper diving Jumping or diving into water from trees/balconies/other structures Poor underwater visibility Alcohol consumption Lack of supervision Lack of signage In swimming pools and similar recreational water environments, contributory factors for limb, minor impact injuries, cuts and lesions are: Diving or jumping into shallow water Overcrowded pool Underwater objects (e.g. ladders) Poor underwater visibility Slippery decks Glass or rubbish around the pool area Swimming aids left poolside In swimming pools and similar recreational water environments, contributory factors for hazards associated with temperature extremes are: Cold plunge when not conditioned Prolonged immersion in hot water

26 Level of Evidence Level 1a Level 1b Level 2 Level 3a Level 3b Level 3c Level 4 Level Level 6 Level 1-6E Criteria Population based studies, randomized prospective studies Large non-population based epidemiological studies, meta-analysis or small randomized prospective studies Prospective Studies which can include, controlled, non-randomized, epidemiological, cohort or case-control studies Historic which can include epidemiological, non-randomized, cohort or case-control studies Case series: subjects compiled in serial fashion without control group, convenience sample, epidemiological studies, observational studies Mannequin, animal studies or mechanical model studies Peer-reviewed works which include state of the art articles, review articles, organizational statements or guidelines, editorials, or consensus statements Non-peer reviewed published opinions, such as textbooks, official organizational publications, guidelines and policy statements and consensus statements Common practices accepted before evidence-based guidelines or common sense Extrapolations from evidence which is for other purposes, theoretical analyses which is on-point with question being asked. Modifier E applied because extrapolated but ranked based on type of study.

27 Summary Table of Evidence Place all the evidence listed in the previous sections in one of the following three columns using the follow approach: 29. Place each article or report in one of the columns and in its own row 30. List articles with highest level of evidence first 31. In box place name of lead author and in parenthesis year published 32. In addition in each box put a one to two sentence summary of how the article either support, opposes or has no position with regard to the question(s) Supportive of Recommendation Bell et al. (2001) - male - young - black - single - alcohol Howland et al. (1996) - male - alcohol Liller et al. (1992) - children male Saluja et at. (2006) - black males - foreign-born males Driscoll et al. (2004) - alcohol Michalsen (2003) - risk is influenced by personal traits and socio-cultural parameters CDC (2004) - children 4 and under - males CDC (2007) - male - children 14 and under, particularly children 4 and under - minorities - alcohol use - seizure disorders International Life Saving Federation (2007) Opposing Recommendation No Position

28 - swimming in unsafe areas Minnesota Department of Health (2004) - age male - male overconfidence in swimming ability - alcohol - African American, American Indian, Asian American WHO (2003) - provides a long list of potential contributory factors to drowning and near drowning, spinal injuries, fractures, dislocations and other impact injuries, cuts lesions and punctures that may occur in costal and fresh water. WHO (2006) - provides a long list of potential contributory factors to drowning and near drowning, spinal injuries, limb, minor impact injuries, cuts, lesions and hazards associated with temperature extremes. Schwebel, Lindsay and Simpson (2007) This study utilizes common sense rules as the basis of risk assessment Schwebel, Simpson and Lindsay (2007) This study assesses the frequency of rule-breaking

29 Textual Summary of Evidence: Please provide a textual summary of the all of the evidence reviewed and explain in detail how these lead to the guidelines, recommendations and/or options which you are proposing Epidemiologic evidence indicates that the following characteristics are associated with increased risk of aquatic incident: - male - children 14 and under, and particularly children 4 and under - African American - Asian American - American Indian No study has identified whether the risk is the same in lifeguarded settings as it is in other settings. The reasons for differential risk between races has not been determined. Alcohol is recognized as the most common factor that increases risk. No studies were identified that identify specific behavioral cues that could be used by lifeguards to assess risk, although it is recognized that individuals engaging in risky behavior (e.g., swimming in unsafe areas, diving into shallow water) are at risk.

30 Preliminary Brief Evidence Summary and Guideline Document Section: Please provide a brief summary of the evidence from the previous section using the template language below and summarize the recommendation also using the template language. Then place each of the recommendations in the table at the end. Descriptions of how to determine the strength of the recommendations are listed below. Evidence from four epidemiologic studies and additional consensus statements, persons under the influence of alcohol in any aquatic environment are at high risk of injury or death. Therefore, it is recommended that individuals who are under the influence of alcohol be excluded from participation in aquatic events as a standard. Evidence from multiple epidemiologic studies have identified the following characteristics are associated with increased risk of drowning: - male - children 14 and under, and particularly children 4 and under - African American - Asian American - American Indian As a guideline, lifeguards should be aware that, on a population basis, these characteristics are associated with increased risk of drowning. Recommendations and Strength (using table below): Standards: Individuals who are under the influence of alcohol should be excluded from participation in aquatic events. Guidelines: Lifeguards should be aware that, on a population basis, the following characteristics are associated with increased risk of drowning: o male o children 14 and under, and particularly children 4 and under o African American o Asian American o American Indian Options: No Recommendations:

31 Guideline Definitions for Evidence-Based Statements Statement Definition Implication Standard A standard in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendation standards may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. One should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. Guideline Option No recommendation A guideline in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. Options define courses that may be taken when either the quality of evidence is suspect or, level and volume of evidence is small or carefully performed studies have shown little clear advantage to one approach over another. No recommendation indicates that there is a lack of pertinent evidence and that the anticipated balance of benefits and harms is presently unclear. One would be prudent to follow a recommendation but should remain alert to new information. One should consider the option in their decisionmaking. One should be alert to new published evidence that clarifies the balance of benefit versus harm Attach Any Lists, Tables or Summaries Created As Part Of This Review (Please include any tables, lists of items or procedures and tables which you created as part of the review that would be helpful for final analysis or publication in the final document)