U.S. Lifeguard Standards: A Lifeguarding Practice Research Synopsis Mike Espino Mike is the Aquatics Safety and Risk Specialist for the YMCA of the USA. Previous to joining the YMCA of the USA, he was with the American Red Cross, where he served as Manager of Aquatics Technical Development at its national headquarters in Washington, D.C. Mike has been involved in the aquatics field for over 25 years and has also held various aquatic positions in California, Florida and Virginia. Abstract The United States Lifeguard Standards Coalition process represented the most comprehensive evidencebased review of lifesaving and associated literature performed. The process included efforts to uncover and evaluate all of the available and pertinent evidence-based science and research. In some instances, strong evidence was identified which offers guidance for improved standards and guidelines. In other instances a lack of evidence for current standards and guidelines has revealed weaknesses in the foundation of existing practices, along with the need for future research and studies in lifesaving. The outcomes of the process may have relevance for lifesaving worldwide, since the evaluated research was itself global. These final outcomes can be used by lifesaving organizations to modify existing standards or formulate new ones. National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 1
UNITED STATES LIFEGUARD STANDARDS: A LIFEGUARDING PRACTICE RESEARCH SYNOPSIS World Aquatic Health Conference Seattle, Washington October 13, 2011 PRESENTER Mike Espino Aquatics Safety & Risk Specialist YMCA of the USA 2 BACKGROUND Many lifeguarding techniques, skills and protocols are historically based Lack of scientific evidence Limited studies and research Expert opinion Need for validating protocols 3 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 2
UNITED STATES LIFEGUARD STANDARDS COALITION Mission of the Coalition To research, identify and promote evidence-based standards for lifeguarding and water rescue Collaboration American Red Cross United States Lifesaving Association YMCA of the USA 4 LEVELS OF PARTICIPATION Participant organizations include: Not-for-profit national professional or scientific associations relevant to field Governmental agencies relevant to field Roles and Responsibilities: Fulfill roles through appointment of a representative Attend all meetings Participate and complete evidence reviews assigned Vote on recommendations Review final publications 5 LEVELS OF PARTICIPATION Governmental Observer Fulfill roles through appointment of representative May attend meetings at their discretion and expense May review final publications Does not vote on recommendations 6 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 3
7 LEVELS OF PARTICIPATION Organizational Observer Fulfill roles through appointment of representative; involvement may be limited by conflict of interest rules May attend meetings at their discretion and expense May participate in meetings after disclosing any conflicts of interest May review final publications Does not vote on recommendations LEVELS OF PARTICIPATION Individual Participant Recognized national and/or international expert in the field Possesses unique knowledge base needed for one or more of the questions to be reviewed Roles and Responsibilities: Attend meetings related to their area of expertise Assist with evidence reviews Does not participate in voting Review relevant sections of final publications 8 PARTICIPANTS American Academy of Pediatrics American Association for Physical Activity and Recreation American Camping Association American College of Emergency Physicians American Heart Association American Public Health Association Boy Scouts of America International Life Saving Federation National Association of EMTs National Association of EMS Physicians National Intramural-Recreational Sports Association National Park Service National Recreation and Park Association US Coast Guard USA Swimming 9 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 4
OUTCOMES Evidence-based standards for most effective lifeguarding and water rescue skills Where evidence is lacking, promote research through the identification of these gaps Make final guidelines and evidence review publicly available and distributed freely 10 PROCESS Modeled after the process used to develop CPR and first aid guidelines Four major actions included: 1. Review of science and development of evidence evaluation worksheets 2. Discussion of worksheets and final recommendations 3. Development and release of consensus on science and treatment recommendations documents 4. Development and release of guidelines for treatment and care 11 STEPS IN THE PROCESS 1. Investigated history of currently used safety and rescue protocols 2. Established definition for key terms in this field 3. Defined scope of process and questions to be addressed 4. For each area to be addressed, a hypothesis and/or scientific question was developed 12 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 5
13 STEPS IN THE PROCESS 5. Reviewed available evidence using a validated and standardized approach At least two experts reviewed each topic Rated the level and quality of evidence Assigned levels of evidence Considered: Population-based studies Epidemiological studies Case-control studies Historic research Case studies Large observational studies Review of past research summaries and rational conjecture Extrapolations from existing data collected for other purposes STEPS IN THE PROCESS 14 STEPS IN THE PROCESS 6. Presentation and review by coalition members of the evidence. Each topic was presented, discussed and critiqued until a consensus was reached 7. Open comment on proposed guidelines. Draft guidelines was posted to the Coalition s website for a public comment period Feedback was reviewed to determine if any alterations were warranted 15 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 6
16 STEPS IN THE PROCESS 8. Publication of guidelines with evidence review Peer-reviewed Journal Proceedings document 9. Public distribution of final guidelines GUIDELINE DEFINITIONS FOR EVIDENCE-BASED STATEMENTS Statement Definition Implication Standard Guideline Option No Recommendation High-quality evidence, clear benefits Evidence is not as strong, anticipated benefits outweigh the harms. Quality of evidence is suspect or, level and volume of evidence is small, unclear clear advantage to one approach over another. Lack of pertinent evidence, unclear benefits Follow Prudent Consider Await 17 PREVENTION AND VIGILANCE 1. What evidence is there to support the effectiveness of scanning techniques in identifying patrons in need of assistance? G. Training and protocols should include: Scanning all fields with maximum head movement (no pattern evidence) Practice and frequent supervision Instruction that similarities among individuals within populations increases difficulty Limitations on distractions. O. Backup, field size, number of patrons. 18 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 7
PREVENTION AND VIGILANCE 2. What evidence is there that has identified external factors that positively influence vigilance among lifeguards? S. Supervision and regular encouragement during each 30 minutes of watch improve vigilance G. Avoid sleep deprivation. Screen for sleep apnea. Protect from high ambient temperature. O. Prohibit recreational drugs. Positive influence of aerobic exercise & nonsugared caffeinated drinks. 19 PREVENTION AND VIGILANCE 3. What are effective strategies to avoid inattentional blindness? G. None O. None Comment: Agencies and employers should emphasize scanning training for the surface and underwater in environments where water clarity permits. 20 PREVENTION AND VIGILANCE 4. What visual and behavioral cues are useful for identifying high-risk patrons? S. Consumption of alcohol is a cue that an individual may be at greater risk of drowning. Lifeguard training should emphasize this fact. G. Individuals under the influence of alcohol should be discouraged or excluded from participating in aquatic activities. O. None 21 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 8
PREVENTION AND VIGILANCE 5. How long should a lifeguard be assigned to continually watch the water before interruption of duty? G. None O. None Comments: Evidence from three high-level studies in laboratory settings and other industry standards and recommendations indicates that vigilance declines after 30 minutes. Extrapolation to the lifeguard setting is difficult because the risks of decreased vigilance over time may be offset by the unique aspects of lifeguarding duties. 22 RESCUE AND STANDARDS OF THE LIFEGUARD 1. Is there evidence to support recommending a minimum physical competence level for lifeguards to be met and maintained? - Evidence for: A job-related skill set for lifeguards? Fitness components in the LG skill set? Physiologic demands of the skills? CPR Minimum level of fitness for all LGs? Specific laboratory protocols to test fitness? Higher levels of fitness for different venues 23 RESCUE AND STANDARDS OF THE LIFEGUARD 1. Is there evidence to support recommending a minimum physical competence level for lifeguards to be met and maintained? S. All employed lifeguards meet the minimal fitness level required for the PSS. Assess by completion of a venue specific water rescue competency test (WRCT) which includes: entry, approach, dive, retrieve, return, remove, CPR, continuous. G. Test every 10 to 12 weeks, (time?) Open water may require testing of additional skills O. Laboratory fitness testing may be used for fitness screening of applicants but does not substitute for the pre-employment WRCT/fitness test. 24 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 9
RESCUE AND STANDARDS OF THE LIFEGUARD 2. Is there evidence to support recommending a minimum age for lifeguards? S. Supervision and regular encouragement during each 30 minutes of watch improve vigilance G. Low-stress and low-risk jobs, such as guarding pools and some types of waterpark attractions 15 years old. High-stress and high-risk jobs, such as guarding open water, wave pools, etc, - 16 years old. O. Lifeguards should be 18 years old for more demanding jobs (e.g., beaches, open-water lakes, high-use pools, water parks with more demanding features). 25 RESCUE AND STANDARDS OF THE LIFEGUARD 3. Is there evidence to support recommending a minimum hearing standard for lifeguards? G. Minimum hearing standards should be in place for individuals performing lifeguarding duties. O. The minimum hearing threshold of lifeguards should be no more than an average of a 25- decibel loss in both ears over a range of frequencies 26 RESCUE AND STANDARDS OF THE LIFEGUARD 4. Is there evidence to support recommending a minimum vision standard for lifeguards? G. A minimum vision standard for lifeguards should be identified and instituted. O. Each facility is encouraged to require testing of corrected and uncorrected vision and to then develop venue specific standards. 27 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 10
RESCUE AND STANDARDS OF THE LIFEGUARD 5. Is there evidence to support recommending use of equipment during aquatic rescues for lifeguards? G. None O. Appropriate equipment should be used for inwater rescue, provided that the rescuer has received proper training specific to its use. 28 RESUSCITATION, FIRST AID, AND EDUCATION 1. Are there unique aspects of establishing and maintaining the upper airway during the process of resuscitation after drowning? In the water? S. Airway management awareness and skills must be included in prehospital and hospital protocols. Prevent aspiration. Airway management and early rescue breathing is the highest priority. In the water: Shallow water, a trained rescuer with a flotation aid in deep calm water, or two or more trained rescuers. Positioning, drainage and airway-clearing skills Training to minimize vomiting and regurgitation. 29 RESUSCITATION, FIRST AID, AND EDUCATION 1. Are there unique aspects of establishing and maintaining the upper airway during the process of resuscitation after drowning? In the water? G. Education should emphasize the challenges of airway management in drowning resuscitation. In-water resuscitation should not be attempted in deep water by a single rescuer without flotation support. Priority should be rescue to shore. Procedures or issues that distract from airway management should be identified and minimized. Process for unconscious or recovering victims, or during transport of drowning victims. O. None 30 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 11
RESUSCITATION, FIRST AID, AND EDUCATION 2. Is there any evidence that there are safe, effective and feasible positioning, maintaining and extrication techniques in maintaining peripheral neurological function or outcome of a cervical spinal injury? - Risks in the submersion victims? - Accuracy of lifeguards identifying C-spine injury? - Improved outcomes? G. Resuscitation has highest priority If required for resuscitation, remove from water ASAP. Immobilization only required with high-risk/impact activity and signs of injury or unreliability. Lifeguards must restrict C & T spine motion in water manually and with spine board. O. None 31 RESUSCITATION, FIRST AID, AND EDUCATION 3. Can resuscitation skills needed for the victim of the drowning process be acquired through online learning? G. None O. Provide online training for selected BLS and lifeguarding skills and knowledge that have been shown to be effectively learned using an on-line format with documented, objective assessment. 32 RESUSCITATION, FIRST AID, AND EDUCATION 4. Is suction safe, effective and feasible in the drowning process resuscitation? G. The routine use of suctioning is not recommended. If the oropharynx is blocked by debris preventing ventilation, suction and manual methods should be used for removal. O. Training lifeguards on manual and powered suctioning equipment should be considered. 33 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 12
RESUSCITATION, FIRST AID, AND EDUCATION 5. Is oxygen safe, effective and feasible in the drowning process resuscitation? G. None O. The use of supplemental oxygen by lifeguards for the drowning process resuscitation can be considered, but its use should never delay resuscitation including airway, ventilation and compression as needed. Comment: Scuba diving is a special circumstance for which oxygen during resuscitation may be helpful; this circumstance was not studied in this review. 34 WHAT DOES THIS MEAN? For individuals: Follow your existing training protocols For organizations: Training protocols will be adjusted as appropriate Overall: More research is needed! The report highlights and targets areas where there is inadequate evidence. It is the Coalition s hope that this will help spur research in these areas. 35 WHAT DOES THIS MEAN? United States Lifesaving Association Perspective As protocols evolve, this evidence will be a touchstone As opportunities emerge, USLA will encourage and participate As future opportunities for collaboration arise, USLA will embrace American Red Cross Perspective New Lifeguard Program YMCA of the USA Perspective New Y Lifeguard Program New YMCA of the USA Aquatic Safety Guidelines 36 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 13
37 UNITED STATES LIFEGUARD STANDARDS COALITION WEBSITE www.lifeguardstandards.org QUESTIONS? THANK YOU! National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 80919 (719)540-9119 www.nspf.org 14