Preventing Drowning · drowning fatality, three children visit the emergency department for submersion-related injuries and about 40% of those are admitted to hospital.12 Locations

PreventingDrowningIn Manitoba

A Review Of Best Practices

Prepared for Manitoba Health by

TABLE OF CONTENTS

INTRODUCTION 1

METHODOLOGY 3

Literature Search 3

RISK FACTORS 4

Individual Factors 4

Age 4

Gender 4

Epilepsy 5

First Nations 5

Lack of Training 5

Activities & Environmental Factors 5

Boating 5

Snowmobiles 5

Swimming Pools 6

Situational Factors 6

Alcohol Use 6

Lack of Supervision 6

Personal Flotation Non-use 6

INTERVENTIONS 7

Overall Findings 7

Scientific Rigor 7

Pool Fencing 7

Personal Flotation Devices 8

CPR Certification for Pool Owners 8

Adult Supervision 8

Lifeguard Supervision 9

Swimming Lessons for Young Children 9

“Boating while Intoxicated” Enforcement 9

Strength of Evidence 9

Inquest Outcomes 11

Preventing Drowning in Manitoba

i


ii

Unevaluated Interventions 11

Anticipatory Guidance for Water Safety 11

Water Safety Training and Education 11

RECOMMENDATIONS 15

Methodology 15

Recommendations 15

Strongly Recommended 15

Recommended 15

Recommended Based on Expert Opinion 15

Drowning Prevention Best Practices 16

APPLICATION OF FINDINGS 17

REFERENCES 19

APPENDIX A: EVALUATION CRITERIA 26

Drowning is the second leading cause of uninten-tional injury death for Canadian children and youth0-19 years of age and the fourth leading cause ofinjury death for all ages.1,2 This report is a summa-ry of drowning and near-drowning data, risk andprotective factors, and best practice recommenda-tions. It is designed to be a resource for communi-ties and organizations working to reduce drowningand near-drowning incidents, and summarizesinterventions applicable to varying levels of respon-sibility within communities. These include educa-tional interventions, engineering/design interven-tions, and legislation.

Drowning and Near-Drowning: The Problem in Manitoba

Unintentional drowning and submersion is a lead-ing (top 5) cause of injury death across most agegroups.3 When only unintentional injury categoriesare included drowning is the leading cause of deathfor children one to four years of age and the secondleading cause of death for individuals five to 34years of age. However, when intentional causes areincluded drowning is the sixth leading cause ofdeath for Manitobans, preceded by suicide, motorvehicle collisions, falls, fractures (cause unspecified),choking/suffocation, and assault. The latter two tiedas the fifth leading cause of death. The figures3

below illustrate drowning deaths and hospitaliza-tions by age groups and gender.


1

INTRODUCTION

Figure 1. Deaths Due to Unintentional Drowning and Submersion 1992-1999

0

2

4

6

8

Total 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Rate

per

100

,000

Age

205 11 15 40 18 16 0

2.2 1.6 3.6 2.2 1.7 2.4 0.0

31 3 2 2 1 1 0

0.7 0.9 0.3 0.3 0.8 0.3 0.0

174 8 13 38 17 15 0

3.9 2.3 6.8 3.6 1.1 5.0 0.0

0-1 1-4 5-9 10-14

0.0 4.9 1.5 2.3 2.9 0.7 2.1

0.0 3.8 0.6 0.6 0.2 0.3 0.8

0.0 5.9 2.4 4.0 5.4 3.2 4.1

0 26 10 23 32 5 9

0 10 2 1 6 1 2

0 16 8 22 26 4 7

Males Females All

No.

Rate

No.

Rate

No.

Rate

Figure 2. Hospitalizations Due to Unintentional Drowning and Submersion 1992-2001

0

5

10

15

Total 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Rate

per

100

,000

Age0-1 1-4 5-9 10-14

2.2 6.3 13.2 4.2 1.7 1.7 1.8 1.4 0.8 1.0 0.6 1.3 1.4 0.0

125 5 44 18 7 7 7 12 7 7 3 5 3 0

1.3 2.6 11.6 2.2 1.8 0.8 0.5 0.1 0.6 0.1 0.6 0.4 1.2 0.0

76 2 37 9 7 3 2 1 5 1 3 2 4 0

1.8 4.5 12.4 3.2 1.7 1.2 1.1 0.8 0.7 0.6 0.6 0.9 1.3 0.0

201 7 81 27 14 10 9 13 12 8 6 7 7 0

Males Females All

No.

Rate

No.

Rate

No.

Rate

Between 1992 and 1999 there were 205 deaths dueto drowning and submersion. This correlates withresults from the most recent decade (1993-2002) ofChief Medical Examiner data, with an average of25 drowning deaths per year.4 Statistics Canadadata (1990-1992) demonstrate that Manitoba has asignificantly increased child drowning rate com-pared to the national average (3.1 per 100,000 ver-sus 1.7).1 Males are significantly more likely to beinjured or die from drowning than females, andaccount for 85% of deaths. This increased risk ismore pronounced for drowning than for injuriesoverall (5.6X vs. 2.1X).3 When all ages are com-bined, drowning is the third largest cause of poten-tial years of life lost, with an average of 43.8 poten-tial years of life lost per person.

Drowning and submersion was not a leading causeof hospitalization for any age group. Hospitalizationsbetween 1992 and 2001 for drowning and sub-mersion included 201 cases, with 62% being male.As the above rates indicate, children less than 15years of age were hospitalized most often, especiallytoddlers and infants. Adults 75-84 years of age andyouth 15-19 years of age were also hospitalized atincreased rates. In the same period 148 children

under 17 years of age visited the WinnipegChildren’s Hospital Emergency Department forpool-related injuries.5 With most types of injuriesthe number of hospitalizations far exceeds thenumber of deaths, yet with drowning and submer-sion the morbidity to mortality ratio is nearlyequal, resulting in a steep “injury pyramid”.6 Thisindicates that drowning and submersion incidentshave a much higher likelihood of death than othertypes of injuries

Recent Drowning Inquests

Case 1 & 2

During the summer of 2000 there were twocases where children drowned at Birds HillPark Beach (6 & 7 years of age).

Case 3

In June 2002, a boy, five years of age,drowned while on a field trip with his kinder-garten class to a City of Winnipeg pool.


2

This section of the report identifies the key risk fac-tors for drowning and submersion. In Manitoba,toddlers and young males are the population groupsmost at risk of drowning, while boating is the activ-ity implicated in most drowning cases.

Literature Search

Databases

Seven electronic databases were searched forresearch literature regarding drowning and near-drowning. These databases included CINAHL(1982-2004/07), EMBASE (1980-2004/08),MEDLINE (1966-2004/08 wk 3), PsycInfo (1972-2004/08 wk 3). PubMed (1951-2004), SportDiscus(1830-2004/08) and Social Sciences Full Text(1983/02 to 2004/06). Search terms included‘drowning best practices’, ‘drowning prevention’,‘drowning review’, submersion, near-drowning,water safety, and ‘drown*’ (searches all extensions).On-line archives of the Injury Prevention journalwere searched (ip.bmjjournals.com) using the head-ings ‘drowning’, ‘drown’ and ‘submersion’ to identifyany additional articles or relevant editorial content.Cochrane databases were also searched for systemat-ic reviews and studies of drowning prevention inter-ventions.

Internet Searches

The Google search engine (www.google.ca) wasused to search for best practices and systematic

reviews using the search terms above. In addition,many injury-specific websites were targeted andsearched manually, including:

• Centre for Disease Control’s NationalCentre for Injury Prevention and Control(NCIPC) (www.cdc.gov/ncipc),

• Safe Kids Canada (SKC) (www.safekidscanada.ca),

• Health Canada’s Injury Section (www.hc-sc.gc.ca/pphb-dgspsp/injury-bles),

• Harborview Injury Prevention & ResearchCentre (www.depts.washington.edu/hiprc),

• World Health Organization’s Departmentof Injuries and Violence Prevention(www.who.int/violence_injury_prevention),

• and international injury prevention centres.

Other Sources

Additional sources included the IMPACT libraryresource material, reference texts, and published sys-tematic reviews of child and youth injury preven-tion best practices.


3

METHODOLOGY

Individual Factors

Knowledge of risk factors associated with drowningand near drowning can aid in the development ofeffective prevention strategies. These have beenclearly identified and include:

Age

Drowning is the second leading cause of uninten-tional injury death for Canadian children less than 20years of age.7 Toddlers have a significantly increasedrisk of drowning.7-10 In Manitoba, drowning is theleading cause of injury death for toddlers one to fouryears of age, with seven fatalities per year (1996-2000).3,11 Recent research has shown that FirstNations toddlers are one of the populations at great-est risk of drowning in Manitoba.7 For each pediatricdrowning fatality, three children visit the emergencydepartment for submersion-related injuries and about40% of those are admitted to hospital.12 Locations ofdrowning incidents vary by age group, with infantsdrowning more often in bathtubs, buckets, and toi-lets, and toddlers drowning more often in artificialpools and bodies of freshwater. Older children moreoften drown in freshwater.13,14 For near drowning,infants are at greatest risk in bathtubs, while toddlersare at greatest risk in swimming pools.15

Unintentional falls into water are common causes ofpool and freshwater drowning in young children.14,16

In addition to swimming pools, unfenced spas haveled to drowning incidents.17 Standing water is apotential drowning risk for young children. Childrenhave drowned in many types of accessible gardenitems including bins, dustbins, wading pools, ponds,buckets, tanks, or pots where water existed or hadaccumulated.18 Drowning and near drowning inyoung children is often the combined result of easyaccess to water and a lack of supervision, oftendescribed as a momentary lapse.

Bath seats are a drowning risk for young children.According to the Consumer Product SafetyCommission (CPSC), bath seat drowning hazardsinclude the seat tipping over, children becomingtrapped in the leg openings, and children climbingout of the bath seat.19 The main risk with bath seats

is the false sense of security that parents are given,which leads to infants being left alone.20 CPSCStatistics demonstrated that between 1996 and1999, 10% of bathtub drowning incidents amongchildren less than five years of age were the result ofusing a bath seat.21 Canada has seen seven bath seat-related drownings in the past five years, representing58% of bathtub drownings.22 This equates to anaverage of 1.4 incidents per year. In Manitoba, twobath seats drowning incidents have been document-ed in the past year.

A recent 10-year data report by the Canadian RedCross Society found that adult males, youth, andyoung children are the age-related subgroups mostat risk of drowning.2 For adults and youth, alcoholand drugs, risk taking behaviour and inadequateswimming ability have been identified as significantcontributing factors.23,24 In adolescence and adult-hood alcohol plays a significant role in drowningdeaths. Boating is a major risk factor for adults andteens, and young males are also at risk of drowningfrom swimming activities.25-28

Drowning Hazards: Home and Yard

• Bathtub

• Toilet

• Bucket

• Wading pool

• Pool

• Hot-tub or spa

• Fish pond

• Drainage ditch

• Dugout

Gender

Drowning rates are significantly higher for males thanfemales in Canada, however females outnumbermales for bathtub drowning.28 Overall, 92% of


4

RISK FACTORS

Canadian boating victims, 83% of Canadian drown-ing fatalities, and 79% of Manitoba drowning victimsare male.29-31 In Manitoba the child drowning rate istwice as high for males than females (3.9 vs. 1.9 per100,000).7 A study of pediatric pool immersions inCalifornia found that there were 1.9 times as manymale near-drowning incidents compared to femalecases.32 The Canadian Institute for HealthInformation has documented that 68% of water-related injury hospitalizations involve male victims.33

Typical profiles of male drowning victims includemale risk takers aged 18-34 years who power boat,swim, fall into bodies of water, and are often con-suming alcohol; adults aged 35-64 years in similarscenarios; and teens consuming alcohol and divinginto shallow water.34 Shallow water diving is themost frequent cause of severe water-related injurynot resulting in drowning.28,35 Males are less likelyto use protective devices in water-related and otherrecreational activities (e.g., bicycle helmet use) 8,9,36

One study found that females were 1.5 times morelikely to wear a personal flotation device (PFD) rel-ative to males.37 This may be one importantexplanatory factor for the gender difference in boat-ing-related drowning.

Epilepsy

Epilepsy has been identified as a risk factor fordrowning, especially for children.2,38-40 A review ofnational drowning data found that the most com-mon risk factor for bathtub drowning was a seizurefrom epilepsy.2

First Nations

In Manitoba First Nations communities, drowningand submersion is the third leading cause of injurydeath preceded by suicide and motor vehicle trafficinjuries.3 These higher drowning rates have beenattributed to higher rates of alcohol use and higherPFD nonuse documented in First Nations drown-ing victims compared to non-First Nations popula-tions.41 The magnitude of the difference betweenFirst Nations and non-First Nations Manitobans isevident when mortality rates are examined.Drowning is four times more likely in First NationsManitobans (8.8 deaths per 100,000 vs. 2.0).3 Thisdrowning mortality discrepancy is much (6.5X)greater when First Nations and non-First Nationschildren are compared (12.4 vs. 1.9 per 100,000respectively).7

Lack of Training

A lack of training in boating safety has been identi-fied as a drowning risk factor for boaters.29

Transport Canada is attempting to counter thisproblem by phasing in requirements for boat opera-tors to obtain Pleasure Craft Operator Cards andrequiring operators to be at least 16 years of age.Initially requirements will target young adults, fol-lowed by operators of small boats (<4m). TheTransport Canada Office of Boating Safety(www.tc.gc.ca/boatingsafety) requires operators ofmotorized recreational watercraft to have proof ofcompetency on board at all times. All motorizedrecreational boat operators must obtain the card bySeptember 15th, 2009. The accredited coursesinclude basic boating safety information (i.e., safetyequipment, sharing waterways, and regulations) andemergency preparedness. Training is not required ifan individual challenges the test and is successful.

Activities & Environmental Factors

Boating

In Canada, boating results in the greatest number ofdrowning incidents, with failure to wear a PFD andalcohol consumption being the most common con-tributing factors.2,28,34 Most incidents result fromrecreational boating (i.e., leisure, sport) as opposedto other types of boating.28 A 10-year review ofwater-related fatalities in Manitoba demonstratedthat boating accounts for 30% of deaths.34 Typicallythose who drown while boating either fall overboardor capsize (66% of cases), are not wearing a PFD,nor have one present (25%) in the boat, and fewboat owners report being educated regarding boat-ing safety.29,42 In Canada, 91% of boating-relateddrowning victims are males, 48% are 35-64 years ofage and 33% are 18 to 34 years of age.27

Power boating accounts for over half of Canadianboating deaths, particularly in small vessels (lessthan 18 feet).29 There is almost twice the risk ofdeath from power boating (seven versus four deathsper 100,000) relative to unpowered boating.

Snowmobiles

While boating is a significant risk factor for drown-ing in spring and summer, in winter, snowmobileriders are at an increased risk, as snowmobiles areoften ridden without adequate protection (e.g.,flotation suit), and while the operator is under the


5

influence of alcohol.30 Should an incident occur,extreme weather conditions, falls through ice andsubsequent hypothermia affect the likelihood of res-cue and survival. Wearing appropriate protectiveequipment and not operating the vehicle under theinfluence of alcohol are as relevant with snowmobileoperators as they are with power boaters.

Swimming Pools

In Canada, swimming pool drowning is the mostcommon type of toddler drowning, with over half ofall backyard pool deaths involving children underthe age of five.14,42 Studies show that caregiver fac-tors and supervision are not enough to preventdrowning.43 Toddler drowning in swimming poolstends to occur at the child’s own home or at poolslacking fencing, having inadequate fencing, or dueto propping or leaving gates open.7,44,45 The absenceof adequate fencing surrounding private swimmingpools is the main contributing factor in drowning.46

Spas, hot tubs and whirlpools present similardrowning risks, with the added risk of hair entan-glement in suction drains.47

Situational Factors

Alcohol Use

Boating while intoxicated (BWI) is a criminaloffence under the Criminal Code of Canada.Results from a decade of Canadian drowning datashow that the use of alcohol during boating is a sig-nificant risk factor for drowning.2 The WorldHealth Organization (WHO) states that alcoholconsumption prior to swimming or falling in wateris a common contributing factor for drowningamong older children and adults in many coun-tries.48 Alcohol use is most prevalent for drowningvictims 35-64 years of age, followed by 20-34 years,and finally 15-19 years.25 In 2000 in Manitoba,55% of water-related fatalities involved or werebelieved to involve alcohol use, with 27% of thoseat or exceeding three times the legal limit.31 Alcoholis recognized as a key risk factor in many boatingfatalities in Canada, with 40% of fatal power boat-ing victims exceeding the legal limit.27,49 In 2002 inManitoba, alcohol and drug use was detected indrowning victims as young as 13 years.50

A study examining the influence of alcohol on recre-ational aquatic activity found that having a blood alco-hol concentration over 0.10 g/100ml was associatedwith a 10-fold increased risk of drowning for recre-

ational boaters.51 An Australian study of water-relateddeaths found that 56% of men 30-64 years of age hadblood alcohol concentrations over 0.08 g/100ml, yetno women exceeded this level.52 Alcohol has also beenshown to adversely affect performance in swimming,snowmobile use and diving activities.2,30

Lack of Supervision

When children drown it is often the result of a lackof supervision or brief supervisor distraction. TheWHO states that a lapse in adult supervision is thelargest contributor to child drowning.48 InManitoba, recent findings demonstrate that overhalf of pediatric drowning victims were alone at thetime of the incident, and half occurred during amomentary lapse in supervision.31,34,53 Parents maysubstitute sibling supervision, which is inadequate.One study found that all bathtub drowning amongchildren less than five years of age were associatedwith supervision by a sibling less than seven years ofage.16 Canadian data show that toddlers were super-vised by a minor in 17% of drowning cases.54

Parents of children less than five years of age reportleaving their children unsupervised in the bathtubfor up to five minutes.55

Areas without lifeguards are also associated withhigher drowning rates. A Center for DiseaseControl report states that trained, professional life-guards have positively affected drowning preventionin the United States.56 Supervision of public areasby lifeguards leads to fewer rule violations by swim-mers.57 Fewer rule violations also tended to occurwhen adult to child ratios were smaller, indicating apositive association between parental monitoringand rule compliance.

Personal Flotation Device Non-use

Between 1991 and 2000, 85% of Canadian boating-related drowning victims were not wearing a personalflotation device.30 In Manitoba, boating is one of theleading causes of water-related fatalities, and not usinga personal flotation device is a significant issue amongboat operators and passengers.29,50 Recent Manitobaobservational data found that 53% of boaters, includ-ing 61% of power boaters, were not wearing a PFDwhile boating.58 In 50% of Manitoba’s fatal boatingcases where a PFD should have been used there wasnot one present.53 Other studies have reported similarlow PFD use rates and the tendency for PFD non-useamong power boaters.1


6


7

INTERVENTIONS

Overall Findings

Scientific Rigor

Analysis of the drowning literature demonstratesthat the evaluation of potential prevention interven-tions has been limited. In general, there are few well-evaluated interventions for reducing sport andleisure injuries.59 Similarly, a review of injury pre-vention interventions for children concluded thatfew interventions exist that have been evaluated in arigorous manner.60

Pool Fencing

The most effective intervention to prevent swim-ming pool drowning is four-sided fencing with aself-closing, self-latching gate.61,62 Four-sided fenc-ing serves as a barrier between the hazard (pool) andthose at risk (children).63,64 However, pool fencingwill only be an effective intervention strategy if thegate is consistently closed to restrict access, and ifthe home itself is not considered one of the “sides”of the fence.60 Several systematic reviews have con-cluded that pool fencing is the best strategy forreducing the risk of young children drowning indomestic swimming pools.15,59,63,65 A review by theCochrane Collaboration concluded that pool fenc-ing significantly reduces the risk of drowning andthat isolation fencing (four-sided) is superior toperimeter (three-sided) fencing.62,66 Isolation fenc-ing separates the pool entirely from the rest of thebackyard and the home, while perimeter fencingonly limits access to the property.67 Pool fencinglaws have led to fewer fatalities and near-drowningincidents when compared to jurisdictions withoutlegislation.10,69

The CDC reports that 69% of young drowning vic-tims gain unintended access to the pool and often(77%) have been missing for five minutes or less.8Most of the research on the effectiveness of poolfencing has not assessed fencing type (three or foursides) but rather the presence or absence of fencing.One study estimated that the likelihood of drown-ing in an unfenced pool is 2-5X greater than for afenced pool.70 The Harborview and Cochrane sys-

tematic reviews concluded that four-sided fencing isan effective preventive strategy for restricting accessto swimming pools by toddlers.62,71 While poolinspectors and safety experts strongly support theneed for isolation fencing, compliance with theserecommendations and even with existing fencingby-laws is poor.69 One Florida study found that only10% of pool owners had isolation fencing inplace.72 Only 3% of Canadian pool drowning casesoccur in a swimming pool with a self-latching, self-closing gate and a fence that meets local by-laws.14

Of note, the City of Winnipeg does not require iso-lation fencing.68

City of Winnipeg By-Laws forOutdoor Private Swimming

Pools68

All outdoor pools must be fully enclosed with afence or suitable barrier including: a self-clos-ing, self-latching gate at least 5 foot high, aminimum vertical height of 5 feet, and thefence must be kept in good repair.

Pool owners’ attitudes towards pool safety have beenfound to be inconsistent with their safety prac-tices.73,74 In one study, owners stated that they sup-ported CPR certification and pool fencing, yet onlyhalf had a household member with certification andonly 35% of those favouring a complete pool barrierhad fenced their pool. Those with young childrenwere also found to be more supportive of pool fenc-ing legislation.73 Evidently, legislation and enforce-ment are important in ensuring that effective safetymeasures are being adopted.75

Specific pool fencing guidelines are available for poolowners. The Consumer Product Safety Commissionrequirements for effective pool barriers include afence which is at least five feet tall with no openingsexceeding four inches between the vertical slats.19 Thefence should be installed completely around the poolwith a self-closing, self-latching gate.19,76,77 The needfor an effective barrier is also applicable to hot tubs

and spas as drowning and near-drowning haveoccurred with these products. Owners should checktheir local by-laws and building codes with respect tospecific pool and spa safety requirements.

Pool safety devices such as pool covers and poolalarms have not been sufficiently evaluated yet mayprovide an extra layer of protection. ASTM providesstandards for these devices for swimming pools andspas. These devices are not recommended as asource of primary prevention.78

Personal Flotation Devices

To date, no rigorous studies have confirmed theeffectiveness of personal flotation devices in pre-venting drowning.41 Instead, water safety expertsand organizations cite the high prevalence of PFDnon-use among drowning fatalities, and estimatethe number of potential lives saved. For example, aUnited States Coast Guard study concluded that in2000 approximately 445 lives could have been savedif PFDs had been worn by boating victims (factor-ing in inevitable deaths), while an Arkansas studyclaimed that approximately 38 lives were saved byPFDs in the absence of other protective factors.79,80

Thus far attempts to increase PFD use through edu-cation have not been rigorously evaluated and havedemonstrated marginal results.81-83 In Canada, cur-rent laws require that a PFD be on board, whileTransport Canada encourages that individuals weara properly fitting PFD at all times.49 CurrentCanadian legislation is clearly not sufficient, as mostdrowning victims are found not wearing a PFD.27

In addition, boating incidents often separate theboat from the passenger (e.g., capsized), it can bedifficult to fasten a PFD while in deep or cold water,and some victims may be rendered unconsciousduring the incident.

Legislation regarding mandatory PFD wearing onboats has been introduced in the majority (77%) ofUS states as well as in Australia. However, legislationhas addressed only mandatory wearing by childrenfor all of these jurisdictions except Tasmania.41

These laws are also variable, in terms of age, othercriteria, and exceptions. For the states without PFDwear legislation, an interim rule has been developedby the United States Coast Guard (2002) requiringall children under 13 years of age to wear PFDsunless they are in an enclosed area on the vessel. Theeffectiveness of PFD wear legislation on wear rates isnot known. However, mandating the use of protec-

tive equipment has been effective in increasing usefor bicycle helmets.84 It is expected that similartrends would occur with PFD wear legislation.Legislation should target all ages, especially powerboat and motorized boat users (e.g., personal water-craft).37,85

CPR Certification for Pool Owners

The ability to perform cardiopulmonary resuscita-tion (CPR) has not been well studied but is recom-mended for all pool owners.19,86 The US ConsumerProduct Safety Commission recommends providingdrowning victims with early resuscitation at thescene.76 Having a bystander provide CPR immedi-ately following submersion has been found to be themost important factor contributing to survival andneurological outcome.15,87-90 Documented benefitsof early resuscitation at the scene, suggest that poolowners and their families can benefit from CPR cer-tification. CPR training has also been recommendedfor teens.78,92 Given the reported attitude-practicegap among pool owners, with only 50% of thosewho favoured a CPR certification requirement hav-ing a current household member with that qualifi-cation, mandatory certification has been suggestedin the literature.74

What about SupervisionRatios?

The Manitoba Lifesaving Society recommendshaving a ratio of one parent or childcareprovider for every four swimmers (1:4), oneparent or childcare provider for every twoyoung children (1:2), and one parent or child-care provider for each very young child or childwith special needs such as epilepsy (1:1).91

Adult Supervision

Infants and young children should never be leftalone near water. In order for supervision to beeffective it must be constant and the supervisorshould be within arm’s reach of the child.26 Onerecent child supervision study concluded that phys-ical proximity was the only form of supervisorybehaviour (compared with visual or auditory super-vision) that was protective for children.93 Anotherstudy reported lower case fatality rates for general


8

and bathtub supervision as opposed to no supervi-sion. In this study, victims being supervised byadults had lower case fatality rates than those super-vised by lifeguards or peers.94 The need for adultsupervision around water is emphasized in mostcommunity drowning campaigns and water safetymaterials. Some researchers have concluded thatadult supervision of public swimming areas may beassociated with injury reduction.83,95

Lifeguard Supervision

Lifeguard supervision has not been found to directlydecrease drowning rates.56 This could be the resultof insufficient lifeguard coverage, poor lifeguard topatron ratios, or poor study design. It is recom-mended that when lifeguards are present, swimmersshould remain in the supervised areas.34

Swimming Lessons for Young Children

Both the Canadian Pediatric Society (CPS) and theAmerican Academy of Pediatrics (AAP) have pub-lished position statements on the issue of swimminglessons for young children.95,96 These organizationshave concluded that swimming lessons do not pre-vent drowning in children less than four years of age.However, participation in swimming and water safe-ty programs is supported by both organizations, andhas been associated with improved swimming abilityand better on-deck practices (e.g., not running).60,95

Swimming lessons in isolation do not provide suffi-cient protection against drowning; strong swimmersare a subset of drowning victims every year.97 There is however a need to study the extent to which

swimming lessons can be protective in reducing therisk of drowning and near drowning, especially inthose over the age of four.3,95

‘Boating While Intoxicated’ Enforcement

In order to prevent alcohol-related drowning theonly solution lies in separating alcohol consumptionand water-related activities (i.e., swimming, diving,and boating).10,98,99 Not surprisingly, increasingblood alcohol levels are associated with an increasedrisk of drowning.100 The Canadian Red CrossSociety recommends making the use of alcohol nearwater illegal or socially unacceptable.28 A US studydocumented that banning alcohol in public water-front areas resulted in a significant decrease indrowning incidents.101 Another study found that25-50% of adult drowning victims had consumedor were exposed to alcohol.102

When considering strengthening legislation, it isvital to build in enforcement strategies.103 HealthCanada emphasizes that drowning preventionefforts should include reinforcing Article #253 ofthe Criminal Code, which stipulates that boatingwhile intoxicated is not permitted. They also advo-cate for the extension of this regulation to includepassengers, not merely vessel operators.1 Mandatinga ban on alcohol use in open waters and ensuringthat it is upheld would target many of the deathsthat occur among the high risk subcategories ofboaters as well as adult and adolescent swimmers. Itmay also enhance parental supervision at water-fronts and while boating.


9


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row

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atio

nIn

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ldLi

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child

ren

less

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ic s

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ar

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as a

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Inquest Outcomes

Two inquests into three Manitoba drownings led tomany recommendations for swimming pool andbeach safety. Results from the inquest into thedrowning death that occurred at a city pool duringa school outing targeted supervision and trainingchanges. The report recommended that public poolsshould ensure appropriate supervision levels foryoung children, particularly for groups. It also high-lighted the need for enhanced supervision and policychanges at public pools.106 In particular, the PublicHealth Act should be amended to ensure that alllifeguards are sufficiently qualified (e.g., First Aid,NLS Lifeguard Service Award), and an adequateratio of lifeguards to children is satisfied (1 for 0-30,2 for 1-74, 3 for 75+). It is also recommended thatoperators develop and display written emergencyprocedures, that the provincial government launch awater safety, and that the Department of Educationand Youth develop field trip guidelines.

Recommendations from the combined inquest intothe drowning deaths of two children at the Bird’sHill Park Beach include:107

• Continuing to have Beach Safety Officerson provincial park beaches since childsupervision by parents and guardians isoften insufficient

• Assessing training needs for these officersand determining if heightened medicaltraining is required

• Increasing the staffing of officers at theBird’s Hill Site

• Development of a Risk Management Plan,a Beach Patrol Station, child-supervisorguidelines for group outings, and a strategyto increase public education efforts

Unevaluated Interventions

Anticipatory Guidance for Water Safety

Drowning prevention counselling by physicians isrecommended for routine health care encounters,and is generally tailored to the specific risks associ-ated with the child’s stage of development.108 Age-related recommendations include discussing super-vision and home-related hazards such as bathtubsupervision with parents of young children andfocusing on alcohol-related risks and the risks asso-

ciated with boating for adolescents.7,55 TheAmerican Academy of Pediatrics recommends thatphysicians provide prevention counselling followinginjury incidents, on the basis of age, injury and sur-rounding circumstances.109 Pediatric nurses caneducate parents about drowning prevention concep-tions and associated risk factors.110

Research has not determined whether counselling iseffective in reducing drowning and/or near-drown-ing. What has been assessed is the likelihood of pro-viding such information and the topics that merit dis-cussion, based on evidence. Female health careproviders are nearly twice as likely as male providersto discuss drowning prevention. Some practitioners(nurse practitioners, physicians, pediatricians) intro-duce other injury prevention topics (e.g., poison pre-vention) which they deem more important.79 In thisstudy, perceiving other injury topics as more impor-tant was associated with an odds ratio of 0.73 [95%CI 0.61-0.85] for providing drowning preventioninformation. One study assessed parents’ ability torecall prevention advice provided during a visit to theEmergency Department. While written messageswere well received by parents, recall was low (41%).81

Water Safety Training and Education

Many organizations provide recommendations andinformation to the community regarding water safe-ty. Researchers have concluded that community edu-cation and awareness is necessary for drowning pre-vention.78 However the effectiveness of communityeducation and awareness programs in terms of adopt-ing safer practices or reducing drowning and near-drowning rates is not known. A wide range of topicsis covered in water safety promotion efforts by localand national agencies. The common goal of theseagencies is to prevent drowning through the use ofprotective devices, barriers, judgment (no alcohol,drugs), “common sense” tips, and greater awareness.As stated by the Centers for Disease Control, manyrecommendations exist, yet few have been rigorouslyevaluated.111 Community-oriented and population-specific water safety resources can aid in the publichealth approach to drowning prevention; these havebeen developed for northern and remote areas, whichhave been shown to have unique needs and risks.112

A summary of water safety guidelines and theirendorsing organizations is provided in Table 2. Thesetend to be directed at the general public and reflect“best practices” to a varying degree.


11

Given that Canada is still in the process of institut-ing the boat operator education program, evalua-tions have not been conducted regarding the effec-tiveness of this training. The boating safety course isintended to focus of safety issues, safety equipment,and the potential risks of speeding and alcohol use.The ability to spot the hazards is emphasized, as arethe risks of carbon monoxide poisoning. Rigorousevaluation of the impact of such guidelines on

behaviour change and injury outcomes is required.It is important to determine the effectiveness ofthese programs in order to allocate resources effi-ciently. In some instances safety education andwater safety-oriented campaigns have led to negativeoutcomes.113 Research showed that safety trainingwas associated with an increase in unsafe boatingpractices, likely the result of over-confidence.114,115


12

Table 2. Organizational Support for Drowning Prevention Strategies

Alcohol Use

Ban on alcohol for boating • • • •

No alcohol during water-related • • • • • • • • • •activities

Education/Training

Boating

Be aware of the risk of carbon •monoxide poisoning in boating

Drive responsibly (powerboat, • •personal watercraft, snowmobile)

Get trained (boating safety course) • • • • • •

Restrict watercraft operation to children over 16 years (PWC, • • • •motor boats)

General

Know weather, risks before you go • • • • • •

Parents should learn water • •safety skills

Parents, pool owners, public should • • • • • • • • • •be trained in CPR & First Aid

Provide anticipatory guidance on • •drowning prevention

Epilepsy

Need constant supervision • •near water

Those with epilepsy should shower • •rather than bathe

Am

eric

an A

cad

emy

of

Ped

iatr

ics8

5,96

,108

,116

Cen

ters

fo

r D

isea

se C

on

tro

l8,8

9,11

7

Can

adia

n P

aed

iatr

ic S

oci

ety9

5

Co

nsu

mer

Pro

du

ct S

afet

yC

om

mis

sio

n19

,76,

77

Can

adia

n R

ed C

ross

So

ciet

y2,1

4

Euro

pea

n C

hild

Saf

ety

Alli

ance

118

Hea

lth

Can

ada1

Life

savi

ng

So

ciet

y30,

42,1

19

Man

ito

ba

Life

savi

ng

So

ciet

y50,

92

Man

ito

ba

Co

nse

rvat

ion

120

Nat

ion

al S

pa

and

Po

ol I

nst

itu

te12

1

Safe

Kid

s C

anad

a122

Safe

Kid

s (U

SA)1

23

Tran

spo

rt C

anad

a49

US

Hea

lth

Dep

artm

ent1

24

Wo

rld

Hea

lth

Org

aniz

atio

n48

,125

Intervention

Home/Yard

Don’t leave five gallon buckets filled • •

Don’t use bath seats •

Eliminate standing water • • • • •

Fill or cover garden ponds •

Personal Flotation Devices

PFDs should be worn when boating or swimming in deep water, and • • • • • • • • • • •for non-swimmers

Pools/Spas

Avoid drain entrapment • • •

Don’t allow young children to use • • •spas and hot tubs

Don’t leave toys near or in the pool • • •

Don’t prop open the pool fence gate •

Don’t rely on pool alarms to • •prevent drowning

Don’t rely on pool covers to prevent • • •drowning

Install isolation pool fencing • • • • • • • • •

Install pool fencing (unspecified) • • •

Fences need a self-closing, self-latching gate • • • • • • • • •

Have vertical slats less than 4 inches • •apart, with a height over 4 feet

Have an Emergency action plan • •

Have lifesaving equipment and a phone nearby • • • • • • • • •

Supervision

Infants should be bathed in • •small tubs

Provide constant, arms-length adultsupervision in, near, and around • • • • • • • • • • • • • •water

Swimming

Be aware of strong currents • •

Don’t assume floating aids can prevent drowning or substitute for • • • • •supervision (vs. PFDs)


13

Am

eric

an A

cad

emy

of

Ped

iatr

ics8

5,96

,108

,116

Cen

ters

fo

r D

isea

se C

on

tro

l8,8

9,11

7

Can

adia

n P

aed

iatr

ic S

oci

ety9

5

Co

nsu

mer

Pro

du

ct S

afet

yC

om

mis

sio

n19

,76,

77

Can

adia

n R

ed C

ross

So

ciet

y2,1

4

Euro

pea

n C

hild

Saf

ety

Alli

ance

118

Hea

lth

Can

ada1

Life

savi

ng

So

ciet

y30,

42,1

19

Man

ito

ba

Life

savi

ng

So

ciet

y50,

92

Man

ito

ba

Co

nse

rvat

ion

120

Nat

ion

al S

pa

and

Po

ol I

nst

itu

te12

1

Safe

Kid

s C

anad

a122

Safe

Kid

s (U

SA)1

23

Tran

spo

rt C

anad

a49

US

Hea

lth

Dep

artm

ent1

24

Wo

rld

Hea

lth

Org

aniz

atio

n48

,125

Intervention

Swimming

Don’t dive into water under 9 ft. deep or of unknown depth • • • • • • •

Don’t eat or chew gum while swimming, diving, or playing in • •water

Don’t engage in rough play around water • • • •

Feet first, first time; diving safety • • • • • • •

Have a lifeguard on duty in public areas • • •

Learn to swim (above 4 years) • • • • • • •

Obey public signage • • •

Swim where the lifeguards are, use only designated swim areas • • •

Swim with a buddy (never alone) • • • • • • • • •

Swimming lessons do not prevent drowning • • • •

Winter Safety

Practice safe snowmobile use (no alcohol, use flotation suit) • • • • •and avoid thin ice


14

Am

eric

an A

cad

emy

of

Ped

iatr

ics8

5,96

,108

,116

Cen

ters

fo

r D

isea

se C

on

tro

l8,8

9,11

7

Can

adia

n P

aed

iatr

ic S

oci

ety9

5

Co

nsu

mer

Pro

du

ct S

afet

yC

om

mis

sio

n19

,76,

77

Can

adia

n R

ed C

ross

So

ciet

y2,1

4

Euro

pea

n C

hild

Saf

ety

Alli

ance

118

Hea

lth

Can

ada1

Life

savi

ng

So

ciet

y30,

42,1

19

Man

ito

ba

Life

savi

ng

So

ciet

y50,

92

Man

ito

ba

Co

nse

rvat

ion

120

Nat

ion

al S

pa

and

Po

ol I

nst

itu

te12

1

Safe

Kid

s C

anad

a122

Safe

Kid

s (U

SA)1

23

Tran

spo

rt C

anad

a49

US

Hea

lth

Dep

artm

ent1

24

Wo

rld

Hea

lth

Org

aniz

atio

n48

,125

Intervention


15

RECOMMENDATIONS

Methodology

A hierarchical method was used to evaluate the qual-ity of the evidence, adapted from the Canadian TaskForce on Clinical Preventive Health Care and theCommunity Guide (see Appendix).104 Manydrowning prevention interventions have been insuf-ficiently assessed and therefore cannot be stronglyrecommended; some interventions have limited orconflicting evidence.59

Recommendations

An alphabetical grading system indicates whetherthe level of research evidence for each interventionwas determined to be good (A), fair (B) or poor (C).Similar systems have been employed in other assess-ments of intervention effectiveness.83 This gradetranslates into a recommendation of strongly recom-mended (or discouraged), recommended, recommend-ed based on expert opinion, or insufficient evidence torecommend (see Appendix).

Strongly Recommended

Recommendations that receive a ‘good’ (A) grade(strongly recommended) are supported by the besttype of evidence, and are effective methods to pre-vent drowning and near drowning. These are inter-ventions have been evaluated using randomizedcontrolled trials. Unfortunately, the drowning pre-vention literature does not include any evidence ofthis calibre.

Recommended

Recommendations that receive a ‘fair’ (B) grade (rec-ommended) are supported by fair evidence andinclude quality ratings beginning with ‘II’ (i.e., II-1,II-2, II-3). The highest level of evidence found with-in the drowning and submersion literature was II-2,which includes cohort or case-control studies.

Recommended Based on Expert Opinion

Much of the drowning prevention literature isdescriptive, or represents recommendations ofrespected authorities or expert committees.

Other investigators have found similar results afterexamining the body of evidence for drowning pre-vention interventions. The Canadian Guide toPreventive Health Care (1994) came to the follow-ing conclusions in addressing child and adultdrownings.126,127

Children Under Fifteen Years

Teach young children water safety and swimming skills

• Requiring private and public pools to con-form to safety standards reduces drown-ing10 – ‘Fair’

• Anticipatory guidance on water safety andswimming classes for young children6 –‘Poor’

Never leave young children alone in the bathtub

• Association found between drowning andunattended infants128 – ‘Fair’

• Anticipatory guidance on bath supervi-sion128 – ‘Poor’

Adults

Do not drink and dive (in water sports)

• Association between alcohol/drug use andrecreational drowning in adolescents129 –‘Fair’

• Anticipatory guidance could benefit thoseat increased risk of injury (i.e., adolescents,young adults, alcohol and drug users)126 –‘Poor’

Best practice recommendations supported by thecurrent literature are summarized below and manycan be applied within the community setting to tar-get drowning prevention on a local scale.

Drowning Prevention Best Practices

Recommended

Pool fencing

Pool fencing legislation

Isolation (four-sided) pool fencing

Early/bystander resuscitation for the victim (CPR training)

Recommended based on expert opinion

PFD wearing when boating

PFD wearing campaigns – education/social marketing

Arms-length adult supervision of young children near water

Lifeguard supervision of public waterfronts and pools

Self-closing and self-latching pool gates

Swimming lessons for children over four years of age

Eliminate standing water in the home and yard

Do not use bath seats for infants

Enhanced staffing and training of personnel supervising public beaches and pools

Development of appropriate guidelines for group outings and water-related emergencies

Public education on issues related to water safety and drowning prevention


16

Recommendations for preventing drowning areapplicable to the general public (including parents),individuals and organizations in the health care sec-tor, private and public waterfronts, and all levels ofgovernment. Outlined below are strategies to reducedrowning deaths and injuries.

Parents

• Parents should be familiar with homedrowning prevention practices (e.g., notusing bath seats, constant supervision, nostanding water).

• Parents should supervise young childrennear water at all times – at arms’ length dis-tance for infants and toddlers. Infants andtoddlers should never be left unattended inthe bathtub. This should be communicatedto all other caregivers.

• Water-related home hazards should beeliminated.

• Parents must ensure that their children wearPFDs at all times when boating.

• Backyard pools should be secured by a four-sided (isolation) fence installed around thepool and a self-closing, self-latching gate.

• Pool owners should familiarize themselveswith CPR and First Aid and have rescueequipment and a telephone near the pool.

• Swimming lessons are encouraged once achild is four years of age. Infants, toddlersand their parents can benefit from watersafety and recreation programs.

Waterfronts Operators (Public or Private)

• Waterfront operators should encourageindividuals to wear PFDs at all times whenboating.

• Waterfront operators should insist on ade-quate supervision of children.

• Use of alcohol around water should be dis-couraged.

• Where possible, lifeguards or other trainedpersonnel should supervise public and pri-vate waterfronts.

Physicians

• Physicians should provide anticipatoryguidance regarding drowning prevention,emphasizing continuous supervision ofinfants and toddlers around water, elimi-nating or restricting access to standingwater in or around the home (e.g., toilets),and not using bath seats.

• For pool owners, pool fencing recommen-dations and other pool safety issues shouldbe discussed.

• Physicians should encourage young adultsand adults not to mix alcohol and boatingand to wear a PFD at all times when boating.

• Continuing Medical Education activitiesshould include sessions for physicians andtrainees on the risk factors and interven-tions associated with drowning and neardrowning.

• Physicians should be encouraged to educatethe public regarding drowning prevention,through the media or other venues.

• Age-specific standardized checklists andpatient information materials should bedeveloped to facilitate these efforts.

Public Health Nurses

• During home visits and other encounterswith families public health nurses should pro-vide anticipatory guidance to prevent drown-ing among young children in the home.

• Home visitors and health care providersshould be alert for drowning hazards inhomes they visit, and inform parents ofobserved risks.

• Age-specific standardized checklists andparent information materials could bedeveloped to facilitate these efforts.


17

APPLICATION OF FINDINGS

Regional Health Authorities (RHAs)

• RHAs should ensure that sufficient dataregarding drowning are collected and mon-itored. This should include the considera-tion of sentinel or periodic surveillance ofemergency department visits.

• RHAs should work with community part-ners such as municipalities, recreation cen-ters, schools, child care providers, and otherorganizations to build regional capacity forimplementing drowning prevention pro-grams and strategies.

• RHAs should ensure that drowning preven-tion strategies are implemented and evalu-ated.

• RHAs should provide educational opportu-nities for their employees regarding the bestpractices for designing, implementing andevaluating drowning prevention programs.

Manitoba Health

• Manitoba Health should consider the use ofthe National Ambulatory Care ReportingSystem (NACRS) in regional EmergencyDepartments to improve the data collec-tion, analysis and monitoring of drowning.

• Manitoba Health should support the devel-opment of standardized assessment toolsand educational materials for drowningprevention strategies, for use by the RHAs.

• Age-specific standardized checklists andparent information materials could bedeveloped to facilitate these efforts.

Manitoba Government

• Manitoba Government should considerPFD wear legislation, prohibitions on boat-ing while under the influence of alcohol,and mandatory four-sided pool fencing leg-islation.


18

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3. Manitoba Health. Injuries in Manitoba: A10-Year Review. January 2004.

4. Office of the Chief Medical Examiner.Annual Review. 1993-2002. ManitobaJustice.

5. Canadian Hospitals Injury Reporting andPrevention Program. Pool injuries. DataReport. Winnipeg, 2002.

6. Spyker DA. Submersion injury:Epidemiology, prevention and management.Pediatr Clin North Amer 1983;31(1):113-125.

7. Bristow, KM, Carson JB, Warda LW,Wartman R. Childhood drowning inManitoba: A 10-year review of provincialPediatric Death Review Committee data.Pediatr Child Health 2002; 7(9):637-41.

8. Centers for Disease Control, National Centerfor Injury Prevention and Control. DrowningPrevention Fact Sheet. Accessed June 26,2004 at www.cdc.gov/ncipc/factsheets/drown.htm

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APPENDIX A: EVALUATION CRITERIA

In developing grades of recommendation for eachintervention, first the body of evidence was gradedaccording to the level of evidence, which reflectsstudy design (Table A). For levels of evidence, theCanadian Task Force on Preventive Health Caremethods were used. These correspond to grades ofrecommendation (good, fair, conflicting, and insuf-ficient). Then a summary grade of recommendation

was assigned, using the Community Guide methods(Table C), in order to provide a common frameworkfor this series of Manitoba injury prevention bestpractices reports. This system provides a clear hier-archy of recommendations, and clearly indicateswhere expert opinion is considered to increase thestrength of the recommendation.

Table A. Levels of Evidence and Grade of Recommendation

Grade Level of Evidence Criteria

Good I Evidence obtained from at least one properly randomized control trial

Fair II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from one or more cohort or case-control analytic studies

II-3 Evidence obtained from comparisons between times or places with or without an intervention. Dramatic results in uncontrolled experiments could be included

Poor III Opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees

Table B. Recommendations Grades for Specific Clinical Preventive Actions

A There is good evidence to recommend the clinical preventive action.

B There is fair evidence to recommend the clinical preventive action.

C The existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action, however other factors may influence decision-making.

D There is fair evidence to recommend against the clinical preventive action.

E There is good evidence to recommend against the clinical preventive action.

I There is insufficient evidence (in quantity and/or quality) to make a recommendation, however other factors may influence decision-making.

Table C. Grades of Recommendation

Evidence Canadian Task Force Community GuideCode Level of Evidence Recommendation Strength of Evidence Recommendation

I Good Strongly recommended Strong Strongly recommendedor Discouraged

II-1 Fair Recommended or Sufficient RecommendedII-2 Recommended based on II-3 expert opinion

III Insufficient Recommended based on Insufficient empirical Recommended based on expert opinion information supplemented expert opinion

by expert opinion

Available studies do not Insufficient evidence to provide sufficient evidence determine effectivenessto assess

Any level Insufficient evidence to Sufficient or strong evidence Discourageddetermine effectiveness of ineffectiveness or harm

Adapted from ‘Canadian Guide to Clinical Preventive Health Care’ www.hc-sc.gc.ca/hppb/healthcare/pdf/clinical_preventive/methe.pdfand the Community Guide www.thecommunityguide.org/.


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Documents

Preventing Drowning · drowning fatality, three children visit the emergency department for submersion-related injuries and about 40% of those are admitted to hospital.12 Locations