Meeting the Challenges of 21st Century Aquatic Risk
By Hayli Morrison
Aquatics safety is reaching new heights. Some say the aquatics industry has historically appeared slow to embrace change. However, there is no doubt that the industry is now diving headlong into the 21st century with new technology, more expansive research and a completely different approach to lifeguard recruitment and training.
A series of events propelled the changing approach to aquatics safety. Pool seasons and operating hours are growing longer, leaving staff managers scrambling for adequate lifeguard coverage. There also has been a rash of recreational water illnesses (RWIs) in recent history. Despite years of "This is the way we've always done it," many facility managers are learning it's time to move away from that line of thinking and the operational status quo. But because the status quo has prevailed for so long, there are many challenges to overcome before the aquatics industry can undergo a sweeping change.
There were nine drowning deaths on average every day in 2004, according to the Centers for Disease Control and Prevention (CDC). In fact, drowning is the second leading cause of accidental, injury-related death for children under age 15, according to the National Center for Health Statistics. Granted, many of these incidents occur in private residential swimming pools. Nevertheless, the statistics are alarming and demand that aquatics professionals sit up and take notice.
One factor in this equation is lifeguard fatigue from long shifts in the blazing sun. As aquatics facilities extend their operating hours and seasons—some even yearlong—the staffing challenge becomes even more pronounced. There is a tendency to draw heavily from the international workforce, particularly on the beaches of coastal states. However, that is an option that has become severely limited by tighter restrictions on work visas.
"Some of (the staffing challenge) is seasonal, and some of it is that certain areas just don't have an adequate workforce to build from," said Dr. Peter Wernicki, an orthopedic surgeon who volunteers on the American Red Cross Advisory Council on First Aid, Aquatics, Safety and Preparedness. Another aspect of the staffing challenge is the reality of increased competition for qualified employees, as there are now more aquatics facilities than ever before.
Unfortunately, lifeguards are among the first people to come under fire in the event of a pool accident, but they are only human. In many cases, a significant amount of fault could be placed with the managers and funding sources of aquatics facilities. Lifeguarding teams may be overworked, understaffed and some would even say underpaid. The equipment may be inadequate or unsafe. The initial and ongoing staff training may not have been quite comprehensive enough. These are the exact problems the industry is swiftly moving to fix.
Dr. Tom Griffiths suggests that current drowning statistics may not create a complete picture of the problem facing America. Griffiths founded the Aquatic Safety Research Group and works as director of aquatics and safety officer for athletics at Penn State University. A 30-plus-year industry veteran, Griffiths believes that as many as one-third of drowning deaths in lifeguard-supervised pools cannot be prevented because they are related to other causes.
"The horrible thing in our country is that if a middle-aged man goes to the gym and runs on the treadmill and has a heart attack, there's probably not going to be a lawsuit," Griffiths said. "If a middle-aged man goes to the gym and does laps in the pool and has a heart attack, the coroner's going to label it a drowning. We could immediately and significantly reduce drownings in America if we just redefine what drownings are."
Griffiths advocates the elimination of the term "passive drowning," which indicates a person who is unconscious and motionless in the water, versus one who is conscious and actively fighting for air.
"Coroners and medical examiners have to say in their reports, 'This could have been a drowning, but it could have been cardiac arrhythmia, stroke or heart attack,'" Griffiths said.
One less disputed, yet equally alarming, area of aquatics safety is that of recreational water illness (RWI). There were 59 outbreaks of water-borne disease in 23 states in 2001 to 2002, according to the CDC. In 2003 to 2004, there were 62 outbreaks in 26 states and Guam. Because one outbreak has the potential to touch hundreds, or even thousands, of people, the victims were many. The outbreaks affected 2,093 people in 2001 to 2002 and 2,698 people in 2002 to 2003.
Disease-causing pathogens can be transmitted via direct contact, like swallowing water, or indirect contact. It can also be airborne with the inhalation of infected water droplets, or it can be vector-borne, transmitted through the bite of an infected insect or animal. The most common disease-causing pathogens found in water include parasites, bacteria that can cause "swimmer's ear" or Legionella pneumophilia, viruses like Hepatitis A or Norovirus gastroenteritis, and fungus like ringworm or athlete's foot.
Amazingly, education about recreational water illnesses is not part of the standard training given to lifeguards, lifeguard supervisors, swimming coaches and aquatics facility service technicians.
"We're seeing education levels improve about modules that will raise the level of awareness of recreational water illnesses," said Sam Fruia, natatorium coordinator for Conroe Independent School District in Texas. "It's a direct reaction to the concerns the CDC has had over the last several years over the safety of the water in private and semi-private aquatics facilities."
Water scanning is one area where more technology is needed. A 2001 lifeguard vigilance study conducted by Jeff Ellis and Associates identified how quickly lifeguards could spot an underwater swimmer who was in danger. The study, consisting of more than 500 tests at 90 U.S. pools and waterparks, found that it took lifeguards an average of one minute and 14 seconds to spot the test mannequin underwater. The results came in spite of the fact that all lifeguards were using the appropriate visual scanning techniques, according to video surveillance tapes. The groundbreaking study brought attention to the fact that, even when a lifeguard is performing as trained, the human eye is fallible.
Like lifeguards, pool service technicians are only human. They can only check the water's chlorination and filtration systems every so often and can't be there around the clock in case of emergency. Even in aquatics facilities where there is an around-the-clock supervisor, there needs to be a backup water filtration and chlorination system to fill in any gaps created by human error, according to Fruia.
"Just having the lifeguard test the water with a test kit every hour is no longer acceptable in today's aquatics industry," he said.
The issue of water sanitation is a particular problem in scenarios where there may not be an ever-present lifeguard or other supervisor on site to check the water levels.
One example is splash pads or spray parks, playgrounds with interactive water fountains that are often found in city parks. These often are designed for water runoff to drain back down into the original holding tank—along with any sunscreen, spit, sweat or other bodily secretions the water may pick up along the way. The problem lies in the holding tanks' filtration and chlorination systems, which are often insufficient or sometimes even non-existent.
In most cases, spray parks have no site supervisor present around the clock to check the water's sanitation levels. Upkeep duties are usually designated to city maintenance crews, whose many responsibilities usually allow them to stop by only a few times a day at best. The inadequacy of this system became painfully evident in 1999 and 2005, when disease outbreaks in two different U.S. cities were linked to spray parks.
In 1999, gastrointestinal illness was reported in nearly half the attendants at a new beachside park spray area in Florida. The symptoms included diarrhea, vomiting, fever and cramps. In 2005, a similar outbreak was seen in at least 1,300 visitors to a spray park in New York's Seneca Lake State Park. These and other outbreaks have state lawmakers and aquatics industry manufacturers working on new regulatory laws and better water sanitation equipment so that spray parks are a safe investment for any municipality.
With all types of aquatics facilities, the standards of sanitation vary. This is because pool codes vary from state to state, as they are determined and enforced at the local level. So states like Florida, Texas and California have very structured codes, while other states have virtually no regulatory structure whatsoever when it comes to aquatics facilities. Additionally, even in the states that have very comprehensive codes, there is a problem with enforcement. This is primarily due to an inadequate number of enforcement officials and the large workload they are given.Ohio.
Even with lifeguard and facility audits offered by private companies, the specific task of testing water quality often falls through the cracks, according to Fruia.
"They're looking at whether the lifeguard on the stand is meeting the standard, whether the lifeguard is scanning, whether there are ring buoys and so on," he said. "They don't test the water quality or chlorine levels. Their only concern is whether the lifeguard can see the bottom of the pool, but they have no training as to why that water quality might be bad."
The companies serve a very legitimate purpose, Fruia and Wernicki agreed, but not every auditing company takes a fully comprehensive approach.
"I think they can work. I also think they can be overblown," Wernicki said. "I think at times you're just getting a snapshot of something and maybe not the whole picture."
While there is no federal oversight or enforcement when it comes to pool codes, the CDC is currently fine-tuning its Model Aquatic Health Code. The model will serve as a uniform guide for health departments and code enforcement officers at the local level across the United States. The endeavor is made possible through an initial grant from the National Swimming Pool Foundation (NSPF), and enlists the input of public health and aquatics industry representatives from around the country.
As aquatic facility operating hours expand, there is a need for more staff to alleviate lifeguard fatigue. As operating seasons stretch beyond summer vacation, there also is a need for older workers who can work during the school year. Thus, facility managers are recruiting more stay-at-home moms, emergency service workers and retired baby boomers. Additionally, lifeguard training class schedules are becoming more flexible, and recruiters are starting to work with kids at younger ages to make lifeguarding seem more attractive early on. Many junior lifeguarding programs and mentoring programs start working with kids as young as 13.
"By the time they turn 15 or 16, they've gotten rid of their bad habits and figured out how to be a good lifeguard before they actually have to lifeguard," Griffiths said.
To further improve the supply of lifeguards, Griffiths recommended that training take a different approach. He cited a survey of 10,000 lifeguards over a five-year span that showed most lifeguards feel their most valuable training came on the job, not in a classroom before they were hired.
"Most of the information you need to give them isn't in the water safety textbooks," Griffiths said. "You need every water safety book from every agency that's out there in your library. Take the best from each, and then on top of that—particularly if you're hiring adolescents—you need to use adolescent psychology and look for pertinent information in resources like newspapers, TV, radio and magazines."
Griffiths' organization, the Aquatic Safety Research Group, recommends that trainers create real-life emergency scenarios using test mannequins in the water. The training scenarios should get progressively more creative, and certainly more creative than the scenarios discussed in training manuals, Griffiths said. Anxiety tests are not currently part of the lifeguard hiring process, but creative training scenarios can help determine if employees are able to remain clear-headed in the midst of emergencies.
"You might want to disconnect the emergency phone, or you might want to introduce a blood-like substance in the water, or you might want to drop two mannequins," Griffiths said.
Above all else, there needs to be ample lifeguard supervision, particularly when younger employees are involved, Griffiths said. Decision-making and judgment are the last two centers of the brain to develop, and most researchers agree that most brains don't even fully develop until age 25.
"We base our safety of our facilities with lifeguards, many of whom are not old enough to drive," Griffiths said. "We put them in a position of making professional, adult, mature decisions with an immature brain. If we're going to continue to make these teenage lifeguards our first line of defense against drownings and catastrophic events in the pool, we have to give them tremendous adult support and supervision."
Researchers now have a hard time compiling studies on drowning statistics because there is no uniform language used in incident reports. Even if there were uniformity, it would be difficult to find words that translate to mean the same thing across many different languages. This dilemma was the focus of an international congress that convened in Amsterdam in 2002, with the results published the following year by the American Heart Association. The professionals convened to discuss recommended guidelines and terminology for reporting drowning data, in the interests of facilitating future research studies and accurate record-keeping.
The group looked at many drowning-related terms, among them the terms "active drowning" and "passive drowning." The group determined that those terms should be done away with. Their rationale was that the term "passive drowning" can be misleading, in that no one saw the victim enter the water and there is no apparent movement.
"Underwater cameras, however, have shown that even victims who are apparently motionless to observers at the surface usually make some movement. In addition, cloudy or murky water may preclude accurate observation," the report states. It goes on to suggest that the terms "active" and "passive" be replaced with "witnessed" and "unwitnessed" drownings.
The report discusses different precipitating events that can increase the likelihood of drowning. These include loss of consciousness from cardiac arrhythmia, stroke, concussion or any other cause. Other circumstances include major trauma or spinal injury which may be associated with vehicular accidents or diving. Seizures, hypothermia, or alcohol and drug use can also impact the likelihood of drowning. The report states that any precipitating events or contributing circumstances should be noted in incident reports, though this is sometimes easier said than done.
"In some situations it may be difficult to identify the primary cause of death as drowning or another condition," the report states. "For example, drowning in an older person may trigger a heart attack, whereas a heart attack may precipitate a drowning event."
The report cites studies from around the world that state drowning is a leading cause of cardiac arrest in children and adolescents. Hypothetically, if such were the case, where the final cause of death could be directly linked to drowning, the incident should be labeled a "death due to drowning."
The most common cause of death in hospitalized drowning victims is posthypoxic encephalopathy, having to do with inadequate oxygen supply to the brain. This is an example of a case where death could occur after weeks of hospitalized treatment, but would still be labeled a "death due to drowning." On the other hand, if the final cause of death was something that could not be definitively linked to drowning, the incident report should refer to it as a "death not related to drowning."
While it is true that even the most experienced professional will run into circumstances beyond their control at times, it is also true that even the most experienced professional can make mistakes. Technology can provide an extra layer of protection, and thus new gadgets are becoming increasingly visible on the horizon of the aquatics industry. The market currently offers underwater drowning protection systems involving high-tech cameras and an alarm that sounds when a body has not moved in 10 seconds.
"Stress makes us stupid and the brain shuts down," Griffiths said. "Even though we might see a person on the bottom of the pool, it may not really register. We need technology as backup."
Great technological strides have been made in the area of sanitation as well. Automatic chlorinators monitor and regulate pH levels, based on the volume of foot traffic going in and out of the water. Automatic filtration has sensors that determine whether water filters are too dirty. An aquatics facility operator could even set up a wireless connection and voice command connection, complete with cell phone alerts when the pool's filtration or chlorination system is out of balance. Because it allows operators to stay tuned in to water quality issues at all times, regardless of their location, this technology would be ideal for spray park service technicians. However, don't look for technology to replace human operators any time soon, Fruia said.
"My feeling is that you need both," he said. "You need to be able to have an operator who knows how to operate the systems, even if it's an auto-filtration system. And you definitely need to have an auto-chlorinator, even if you have an operator. The monitoring of chlorine is essential, and those things need to be done every hour that the facility is in use."
One of the biggest sanitation threats facing the aquatics world today is cryptosporidium. First identified in 1907, cryptosporidium was not widely recognized until the 1970s. Chlorine and other chemicals cannot necessarily be counted on to kill this parasite, which features a tough, highly resistant outer shell. Supplementing chlorine with UV or ozone disinfectant can provide a more comprehensive approach, said Michael Beach, team leader of Water and Environment Activity for the CDC's Division of Parasitic Diseases. UV and ozone disinfectants are currently used in sterilizing everything from fish tanks and ponds to hospital surgical instruments.
"Focus groups we've done have shown that people tend to think of swimming pools as this sterile, safe environment," Beach said. "Not even drinking water is sterile, let alone bathing or swimming in water."
Those infected with cryptosporidium carry the disease in their intestines and can release and spread the infection through a bowel movement. Symptoms include diarrhea, stomach cramps, nausea, dehydration and fever. Not surprisingly, diaper-aged children frequently carry the disease—particularly those who attend daycare.
When a cryptosporidium threat arises, "ground zero is usually the kiddie area," Beach said. It is why some cities have decided to require children to wear shoes and diaper covers when playing in public spray park areas. While parents need to be vigilant in protecting others from the threat of their child's illness, facility operators are equally responsible for spreading awareness of the gravity of recreational water illnesses in pools and spray parks.
"We can do all we want in the pump room and behind the scenes, but we have to get the public to understand hygiene issues, and that you don't swim when you're ill," Beach said. "That seems like a light-bulb moment for some people, and we wish it wasn't."
RWI awareness and education is the focus of the CDC's educational push each Memorial Day holiday weekend. The ongoing education is facilitated by local health departments, pediatrician's offices and professional organizations within the aquatics industry.
"Even though these outbreaks have been documented, we don't think the issue has been raised to the level it should have been," Beach said. "This is not something new and different; this is just another risk that has to be managed, just like people take precautions against lightning and tornadoes."
In addition to its educational efforts, the CDC is also currently in the midst of forming a technical committee to create a Model Aquatic Health Code. They are accepting nominations for committee members nationwide, who would participate in the discussions by conference call as they are able. The resulting Model Aquatic Health Code would simply be suggested guidelines for the aquatics industry, created by aquatics industry professionals in the know, addressing disease and injury prevention and risk reduction.
All legislative planning and regulatory enforcement would be handled at the local level, but the CDC hopes its guidelines may be referenced in creating those local aquatic codes. To nominate someone for the committee, contact Doug Sackett of the New York State Department of Health at email@example.com.
Much as the CDC hopes to improve legislative uniformity across the 50 states with its Model Aquatic Health Code, the Association of Pool and Spa Professionals (APSP) is targeting the same goal. The organization has committees reviewing and updating 14 ANSI standards. The standards, in various stages of review and revision, address everything from hot tubs to pool enclosures to avoiding suction entrapment. APSP has even organized a Recreational Water Quality Committee, which is looking at similar issues as CDC's Model Aquatic Health Code committee.
"State codes can become very outdated and cumbersome, and may not be up to industry standards," said Jill White, chair of the writing committee for APSP-12, a brand new standard that will address aquatic safety and risk management. "If all the states look to one guide as a basis for updating their codes, then it will bring everyone up to date and ultimately save lives."
The APSP creates its standards specific to the nine different classifications of aquatic facilities. That way, it takes into account the specific characteristics and practical safety and risk management considerations of each different type of facility. The writing committees are taking a very thorough, research-oriented approach to crafting the standards. For instance, APSP-12 includes categories like lifeguard definition, lifeguard physical attributes, safety signs, child protection, volunteer training and even rafts and flotation toys.
In analyzing existing state codes regarding aquatic safety and risk management, the writing committee found a lot of inconsistencies from state to state, White said. Furthermore, there was very little information about patron responsibility and patron education on risk minimization. White said the new standards will be ideal because they are crafted by people with first-hand knowledge of aquatic safety and risk management issues.
"These are very highly respected leaders in the industry. Truly, the standards come from those people who understand how those facilities operate and what is practical," she said. "We're trying to put forth guidance that states the objective of safety without being so restrictive that it would hinder operations.
"A seemingly well-intended law could create unintended consequences and restrict operations of an aquatics facility because it was written by people who don't really understand," White added. "Involving aquatics professionals in the process creates a much more user-friendly product."
Changes in staffing, technology, terminology, sanitation and regulation are just a few of the considerations aquatic facility operators should keep in mind going into the future, according to Fruia. For instance, with growing concern about kidnappings and child predator cases, should cities provide fencing around public spray parks? Since spray parks are just as likely to cause disease or injury as a swimming pool might be, should a crowd supervisor with first-aid training be on-site at all times? Any operator who has never considered these issues should keep in mind not only patron safety, but facility liability as well.
"The most important thing that we can't omit is that not all the responsibility can just be laid on the parent," Fruia said. "There is much more responsibility that needs to go into the planning of the facility, not only for the safety of the children, but for the safety and liability of the facility owners themselves."
The aquatics industry is certainly undergoing a revolutionary transformation. The experience may be met with some resistance, confusion and second-guessing, but one thing is certain. The current of change will keep the industry on a trajectory to newer, better heights.
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