Time to Rethink How Pool Operators Protect Swimmers?
(Photo by Massery Photography, Courtest of WTW Architects)
The pool of excuses for not knowing how to swim shrinks every year. Last month, the third annual World's Largest Swimming LessonTM, held at more than 100 aquatic facilities across the United States, attempted to teach an estimated 20,000 people to swim — for free.
Meanwhile, the National Swimming Pool Foundation in May embarked on a 10-year initiative to add as many individuals to the swimming population as possible, with the goal of reducing drownings and creating a healthier society. The "Step into SwimTM" campaign will work with organizations in both the public and private sectors to help place greater emphasis on aquatic activity.
Despite those admirable intentions, an average of 3,880 people drowned in the United States each year between 2005 and 2009, while an estimated 5,789 people were treated at hospitals after near-drownings, according to the U.S. Centers for Disease Control and Prevention. Drowning remains the leading cause of injury-related death among children ages 1 through 4, and furthermore, 70 percent of African-American children and 62 percent of Hispanic children cannot swim, USA Swimming officials say. Available data suggests the percentage isn't much lower for adults.
Added to this, recreational water illness is becoming an increasingly dangerous problem. A total of 134 outbreaks were reported to the CDC between January 2007 and December 2008 (the most recent period documented), resulting in almost 14,000 individual cases — the majority of them associated with pools, interactive fountains and other treated recreational water. That's the highest number of outbreaks ever reported during a two-year period. And because RWI symptoms can be subtle, the majority of outbreaks still go unreported, according to health department officials.
Statistics like these fuel fear in pool operators, forcing them to ask themselves on a daily basis, "What can I do to keep my swimmers safe?" It's a question with so many answers that entire books are written, weeklong conferences are held and expansive websites are dedicated to the topic. And, according to aquatics experts, it should prompt facility managers, lifeguards and other employees to rethink how they do their jobs. "We just can't continue to do things the same way," says Tom Griffiths, president of State College, Pa.-based Aquatic Safety Research Group, who is among those industry leaders pushing for new methods of doing everything from generating better lifeguards to reducing RWI and other risks. "We can do a lot better."
Lifeguards should be on the front lines in the battle to keep swimmers safe. But their minds are often elsewhere. Offering support of the National Safety Council's claim that multitasking is a myth, an ongoing (and anonymous) online survey of lifeguards conducted by the Aquatic Safety Research Group reveals that the majority of lifeguards — regardless of age, experience or gender — think about everything but the actual people in the pool. They also confess to talking on cell phones and texting while on duty. "People are admitting this to us," Griffiths says. "These are reasons why even the best lifeguards can be a weak link. You can't train someone to see what he or she doesn't want to see. You can't train someone to see what he or she doesn't expect to see. And you can't train a brain not to be distracted."
"It's a tough job, being a lifeguard," says Julie Gilchrist, a medical epidemiologist and researcher at the CDC's National Center for Injury Prevention and Control, which recently strengthened its recommendations that parents be more vigilant poolside, even when lifeguards are present. "It's hours and hours of boredom until something horrible happens, and then you hope all that training kicks in. You need to make sure your lifeguards are at their best."
That's why experts recommend repeated training in such methods as the Five-Minute Scanning Strategy (in which on-duty lifeguards make significant changes in posture, position and eye patterns every five minutes) and the S.T.A.R.R. method (Scan, Target, Assess and, if necessary, Rescue and Removal).
Bob Ogoreuc, president of the National Drowning Prevention Alliance and an aquatics professor at Slippery Rock University, even encourages pool managers to allow their lifeguards time for a workout on the clock, either swimming laps or exercising elsewhere in a pool's multipurpose facility, to stay sharp and focused. "I have no problem with that," he says. "When I take my kids to the pool, I want to know that the lifeguards are physically fit. I want to know that they're going to be able to rescue me or anybody else. Seeing lifeguards working out is important, gives them an opportunity to recharge themselves and shows the community that you're putting good guards on the stand."
Ogoreuc also recommends that all supervisors, lifeguards and other employees be trained in Incident Command System protocol, used by EMS and disaster response agencies. It provides a set of definitions and procedures to follow to create a structured environment rather than a chaotic one, and employs such terms as "incident commander," "liaison officer" and "logistics chief." Although incident command is used at large venues such as stadiums and arenas, Ogoreuc uses a smaller scenario to liken ICS to a school fire drill; designated students and administrators are assigned various tasks throughout the procedure. (The Federal Emergency Management Agency provides free introductory courses at www.fema.gov; keywords "incident command.")
"Even though it's still perfectly fine to use an emergency action plan, you need to communicate effectively with your first responders responding to emergencies at aquatic facilities," Ogoreuc says. "When first responders show up, they are going to be handling that incident using ICS. The better the lifeguards and managers understand and embrace that, and the more effective the overall communication, the more effective the rescue will be."
In some cases, he adds, a lifeguard will be the incident commander — even after fire and rescue personnel arrive on the scene — because that individual may be the most knowledgeable about the emergency incident. "Everybody has a role in incident command," Ogoreuc says. "Your cashier will be greeting EMS at the gate, while other employees might be helping out with crowd control. Everybody should understand the 'what ifs' and the roles they're going to have in an incident."
ICS and an emergency action plan go hand in hand, and Ogoreuc suggests pool operators hold in-service training with local emergency-response officials to train all staff members in ICS, as well as work with lifeguards to practice in-water backboarding and other spinal-injury management procedures. "Most aquatic facility operators are going to find that EMS and fire/rescue people are going to be more than happy to come in, establish a dialogue and do training," he says. "And those operators will hopefully sleep a little better at night knowing that they're communicating better with first responders in their community."
Both Ogoreuc and Griffiths think lifeguarding technology, as it becomes more affordable to facilities, will play a larger role in lifesaving tactics. They and others cite such advances as Poseidon (a computer-aided drowning detection system marketed as "the lifeguard's third eye"), Safety Turtle (a water sensor attached to a lifeguard's rescue tube or wrist signaling that a rescue is under way) and a remote-controlled robot lifeguard called E.M.I.L.Y. (Emergency Integrated Lifesaving Lanyard). Weighing only 25 pounds, E.M.I.L.Y. is playing an increasingly large role in beach patrol as it navigates to victims at a maximum speed of 40 miles per hour, and it can act as a flotation device for up to six people. The technology is being deployed, among other places, along the Los Angeles coast. "I would love to see, at the end of the summer, how it was employed and what kind of success it had," Ogoreuc, a former lifeguard and beach patrol training officer, says about E.M.I.L.Y. "I'm very open to seeing how a device like that is being used."
A robot, Griffiths adds, is never on its cell phone. "The first thing the plaintiffs in a drowning case do is get hold of lifeguards' cell phone records, and it's unbelievable how many of the lifeguards on duty at the time of the incident were texting," he says. "That data, which is so easy to get, is literally worth millions of dollars."
While lifeguard vigilance is crucial in controlling not only drowning incidents but the spread of recreational water illness, experts say swimmers themselves can play a vital role in reducing the number of RWI outbreaks. For starters, because surveys suggest as few as one in five adults don't realize that swimming with diarrhea can get others sick, the CDC recommends pool operators become more aggressive in educating swimmers — who, in turn, can help prevent the spread of Cryptosporidium, an extremely chlorine-tolerant parasite that causes gastrointestinal illness and comprises three-quarters of all reported RWI incidents.
Signs requesting patrons take frequent restroom breaks, not swallow pool water and not even enter the water if they are suffering from diarrhea have proven effective, as have fines (some as high as $250) levied on individuals who are responsible for fecal accidents and force extended pool shutdowns.
The same rules should apply to pool employees, according to Tracynda Davis, director of environmental health programs for NSPF. She cites a California waterpark where Cryptosporidium affected 336 people in August and September 2004 after three lifeguards (and 16 patrons) admitted entering the water while ill with diarrhea, thereby triggering the outbreak.
Swim teams need to be careful, too. In New Mexico in 2008, the Cryptosporidium parasite infected more than 90 people at 25 different pools after ill swimmers competed in Albuquerque pools. People in those infected pools then took the parasite to their home-team pools, fueling its spread. "A swim team is a really hard group to convince," says Michele Hlavsa, chief of the Waterborne Disease Prevention Branch of the CDC's Healthy Swimming Program. "When members become sick, they want to continue to swim. They don't want to stop, because they're afraid of losing college scholarships, and their coaches give them no option but to swim."
Other common offenders are parents of young children who change baby and toddler diapers on the pool deck. Contamination from dirty diapers can then leach onto the deck and work its way into the pool. Davis, who says many state pool codes do not address diaper-related issues, recommends establishing conveniently located diaper-changing stations in restrooms or locker rooms, within reach of running water and soap. Again, signs and posted policies also help.
"Swimmers are used to going into the pool — which is basically a big communal bathtub, when you think about it — and presuming everything will be taken care of regarding sanitization issues," Hlavsa says. "Most people think chlorine works instantly. Cryptosporidium has totally changed that paradigm, and now swimmers have to be actively involved in maintaining water quality."
Cryptosporidium may not necessarily be caused by poor pool treatment, according to Hlavsa, but because most aquatic facilities keep their chlorine levels set between one and three parts per million, the parasite can survive in typical pool water for more than 10 days. That said, chlorine dioxide, a broad-spectrum disinfectant, can be an effective and efficient alternative to superchlorination — the process of raising pool chlorine levels to 10 to 20 times the normal levels for up to 16 hours in order to deactivate Cryptosporidium.
Another crypto combatant can be ultraviolet light systems, which deactivate the parasite and other bacteria (not to mention cut down on burning eyes and the smell of chlorine). But installation of the systems isn't cheap. The Edgewater Resort and Waterpark in Duluth, Minn., recently announced plans to invest $100,000 in four UV water treatment units after a Cryptosporidium outbreak in March resulted in at least nine confirmed cases of the illness in Minnesota and Wisconsin. Still, most health officials warn that technology will never replace hygiene in the battle against RWI.
The Model Aquatic Health Code, finally nearing completion after being in the works for more than five years, seeks to address many issues related to patron safety — including fecal/vomit/blood contamination response, lifeguarding and swimmer supervision, ventilation and air quality, disinfection and water quality, and operator training. Officials close to the process say they anticipate that a finalized version of the MAHC, developed by the CDC with funding from NSPF and volunteer input from approximately 200 facility operators, industry organizations, health officials and researchers, will be available by the 2103 swim season.
"We always knew it would take a while, because everybody was a volunteer. Nobody was getting paid to do this, and everybody has day jobs," says NSPF's Davis, who also is a member of the MAHC's steering committee. "But I don't think anyone thought it was going to take this long."
When all is said and done, 14 modules — posted at some point along the way on the CDC's website for public review and comment — will be merged into a huge version 1.0 document. Like the U.S. Food and Drug Administration's Food Code, it is expected to be updated regularly. Although nothing in the MAHC will be mandated, states and local jurisdictions are encouraged to adopt the guidelines.
"The intention here is to create an evolution of promoting healthy and safe swimming; it's not a revolution," Hlavsa says. "I think if this were public health officials dictating to the aquatics industry, it would be much harder to get industry buy-in. Getting the aquatics industry involved right from the beginning makes it a stronger code while also making it more acceptable."
"The MAHC is going to become the de facto standard of care for the aquatics industry," Davis predicts. "It is a science-based document that will provide an affirmative defense indicating that a facility that follows the MAHC is meeting the foremost standard of care. Anyone can sue you if you have an incident, but if you can say you're following the foremost standard of care in the industry, you're showing due diligence."
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