Abstract and Figures

Background Drowning is a significant public health issue with more than 320,000 deaths globally every year. These numbers are greatly underestimated, however, due to factors such as inadequate data collection, inconsistent categorization and failure to report in certain regions and cultures. The objective of this study was to develop a standardised drowning dictionary using a consensus-based approach. Through creation of this resource, improved clarity amongst stakeholders will be achieved and, as a result, so will our understanding of the drowning issue. Methodology A list of terms and their definitions were created and sent to 16 drowning experts with a broad range of backgrounds across four continents and six languages. A review was conducted using a modified Delphi process over five rounds. A sixth round was done by an external panel evaluating the terms’ content validity. Results The drowning dictionary included more than 350 terms. Of these, less than 10% had been previously published in peer review literature. On average, the external expert validity endorsing the dictionary shows a Scale Content Validity Index (S-CVI/Ave) of 0.91, exceeding the scientific recommended value. Ninety one percent of the items present an I-CVI (Level Content Validity Index) value considered acceptable (>0.78). The endorsement was not a universal agreement (S-CVI/UA: 0.44). Conclusion The drowning dictionary provides a common language, and the authors envisage that its use will facilitate collaboration and comparison across prevention sectors, education, research, policy and treatment. The dictionary will be open to readers for discussion and further review at www.idra.world.
Content may be subject to copyright.
Commentary
and
concepts
Drowning
and
aquatic
injuries
dictionary
David
Szpilman
a,b,c,d,
*,
Jose
Palacios
Aguilar
a,e
,
Roberto
Barcala-Furelos
a,d,f,g
,
Shayne
Baker
a,h,i
,
Cody
Dunne
a,d,j
,
Amy
E.
Peden
a,c,k
,
Rob
Brander
a,l,m
,
Andreas
Claesson
a,n
,
Stathis
Avramidis
a,o,p
,
Justine
Leavy
a,q
,
Jamie
Linnea
Luckhaus
a,r
,
Leonardo
A.
Manino
a,d,s,t
,
Olga
Marques
a,u,v
,
Nina
Joy
Nyitrai
a,w
,
Luis-Miguel
Pascual-Gomez
a,x,y
,
Leonardo
Springer
a,z,aa,ab
,
Teresa
Jane
Stanley
a,ac
,
Allart
M.
Venema
a,ad
,
Ana
Catarina
Queiroga
a,c,d,ae,af
a
IDRA
International
Drowning
Researchers’
Alliance,
Kuna,
Idaho,
USA
b
Brazilian
Lifesaving
Society
(SOBRASA),
Barra
da
Tijuca,
Rio
de
Janeiro,
Brazil
c
Drowning
Prevention
Commission,
International
Lifesaving
Federation
(ILS),
Leuven,
Belgium
d
Medical
Committee,
International
Lifesaving
Federation
(ILS),
Leuven,
Belgium
e
Grupo
Internacional
de
Actividades
de
Prevencio
´n
y
Socorrismo
(GIAPS),
Spain
f
REMOSS
Research
Group,
Facultad
de
Ciencias
de
la
Educacio
´n
y
del
Deporte
de
Pontevedra,
Universidade
de
Vigo,
Pontevedra,
Spain
g
CLINURSID
Research
Group,
Department
of
Psychiatry,
Radiology
and
Public
Health,
Universidad
de
Santiago
de
Compostela,
Spain
h
Royal
Life
Saving
Society
(RLSS),
The
Commonwealth,
Worcester,
UK
i
Rescue
Commission,
International
Lifesaving
Federation
(ILS),
Leuven,
Belgium
j
Department
of
Emergency
Medicine,
University
of
Calgary,
Calgary,
AB,
Canada
k
School
of
Public
Health
and
Community
Medicine,
Faculty
of
Medicine,
University
of
New
South
Wales,
Sydney,
NSW,
Australia
l
School
of
Biological,
Earth
and
Environmental
Sciences,
UNSW,
Sydney,
NSW
2052,
Australia
m
UNSW
Sydney
Beach
Safety
Research
Group,
Sydney,
Australia
n
Centre
for
Resuscitation
Science,
Karolinska
Institutet,
Stockholm,
Sweden
o
Greek
Lifesaving
Sports
Association,
Greece
p
National
Public
Health
Organization,
Greece
q
Collaboration
for
Evidence,
Research
&
Impact
in
Public
Health,
School
of
Public
Health,
Faculty
of
Health
Sciences,
Curtin
University,
Australia
r
Boy
Scouts
of
America,
USA
s
EPSA
Argentinian
Life
Saving
Aquatic
Team
Rosario,
Santa
Fe,
Argentina
t
Board
of
Directors
International
Lifesaving
Federation
(ILS),
Leuven,
Belgium
u
University
of
Coimbra,
Portugal
v
Faculty
of
Sport
Sciences
and
Physical
Education,
Portugal
w
University
of
Newcastle
Australia,
Australia
x
Escuela
Segoviana
de
Socorrismo,
Spain
y
AETSAS
(Spanish
Association
of
Professional
Lifesavers),
Spain
z
FEPONS,
Portugal
*
Corresponding
author
at:
SOBRASA,
Av
das
Américas
3555,
bloco
2,
sala
302
-
Barra
da
Tijuca
-
Rio
de
Janeiro
-
RJ
-
22631-004
-
Brazil.
E-mail
addresses:
david@szpilman.com
(D.
Szpilman),
jose.palacios@udc.es
(J.
Palacios
Aguilar),
roberto.barcala@uvigo.es
(R.
Barcala-Furelos),
shayne.d.baker@gmail.com
(S.
Baker),
cody.dunne@ucalgary.ca
(C.
Dunne),
a.peden@unsw.edu.au
(A.E.
Peden),
rbrander@unsw.edu.au
(R.
Brander),
andreas.claesson@telia.com
(A.
Claesson),
elagreece@gmail.com
(S.
Avramidis),
J.Leavy@curtin.edu.au
(J.
Leavy),
jamielinnea4@gmail.com
(J.L.
Luckhaus),
leomanino@yahoo.com.ar
(L.A.
Manino),
olgagaboleiro@gmail.com
(O.
Marques),
Nina.Nyitrai@uon.edu.au
(N.J.
Nyitrai),
dtecnica@sossegovia.com
(L.-M.
Pascual-Gomez),
leonardospringer@yahoo.com
(L.
Springer),
teresa.Stanley@dpanz.org.nz
(T.J.
Stanley),
a.m.venema@umcg.nl
(A.M.
Venema),
queiroga.ac@gmail.com
(A.C.
Queiroga).
http://dx.doi.org/10.1016/j.resplu.2020.100072
Received
21
October
2020;
Received
in
revised
form
20
December
2020;
Accepted
20
December
2020
Available
online
xxx
R
E
S
U
S
C
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T
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T
I
O
N
P
L
U
S
5
(
2
0
2
1
)
1
0
0
0
7
2
Available
online
at
www.sciencedirect.com
Resuscitation
Plus
journal
homepage:
www.journals.elsevier.com/resuscitation-plus
aa
ISEC
Lisboa
Polytechnic,
Portugal
ab
CIEBA-FBAUL,
Portugal
ac
Drowning
Prevention
Auckland,
University
of
Auckland,
Auckland,
New
Zealand
ad
Department
of
Anesthesiology,
University
Medical
Center
Groningen,
University
of
Groningen,
Groningen,
The
Netherlands
ae
EPIUnit,
Instituto
de
Sau
´de
Pu
´blica
da
Universidade
do
Porto,
Porto,
Portugal
af
ASNASA
Associac¸a
˜o
de
Nadadores
Salvadores
Patra
˜o
Salva
Vidas
Ezequiel
da
Silva
Seabra”,
Portugal
Abstract
Background:
Drowning
is
a
significant
public
health
issue
with
more
than
320,000
deaths
globally
every
year.
These
numbers
are
greatly
underestimated,
however,
due
to
factors
such
as
inadequate
data
collection,
inconsistent
categorization
and
failure
to
report
in
certain
regions
and
cultures.
The
objective
of
this
study
was
to
develop
a
standardised
drowning
dictionary
using
a
consensus-based
approach.
Through
creation
of
this
resource,
improved
clarity
amongst
stakeholders
will
be
achieved
and,
as
a
result,
so
will
our
understanding
of
the
drowning
issue.
Methodology:
A
list
of
terms
and
their
definitions
were
created
and
sent
to
16
drowning
experts
with
a
broad
range
of
backgrounds
across
four
continents
and
six
languages.
A
review
was
conducted
using
a
modified
Delphi
process
over
five
rounds.
A
sixth
round
was
done
by
an
external
panel
evaluating
the
terms
content
validity.
Results:
The
drowning
dictionary
included
more
than
350
terms.
Of
these,
less
than
10%
had
been
previously
published
in
peer
review
literature.
On
average,
the
external
expert
validity
endorsing
the
dictionary
shows
a
Scale
Content
Validity
Index
(S-CVI/Ave)
of
0.91,
exceeding
the
scientific
recommended
value.
Ninety
one
percent
of
the
items
present
an
I-CVI
(Level
Content
Validity
Index)
value
considered
acceptable
(>0.78).
The
endorsement
was
not
a
universal
agreement
(S-CVI/UA:
0.44).
Conclusion:
The
drowning
dictionary
provides
a
common
language,
and
the
authors
envisage
that
its
use
will
facilitate
collaboration
and
comparison
across
prevention
sectors,
education,
research,
policy
and
treatment.
The
dictionary
will
be
open
to
readers
for
discussion
and
further
review
at
www.
idra.world.
Keywords:
Drowning,
Dictionary,
Prevention,
Definition,
Terminology
To
understand
the
true
burden
of
drowning
we
need
to
be
able
to
use
the
same
terminology
and
definitions”
Szpilman
(2017)
Introduction
As
one
of
the
most
common
causes
of
unintentional
injury-related
morbidity
and
mortality
worldwide,
drowning
remains
a
significant
public
health
issue.
1
The
World
Health
Organization
(WHO)
estimates
that
there
are
approximately
320,000
deaths
globally
every
year
due
to
unintentional
drowning.
1
These
numbers
are
likely
to
be
greatly
underestimated
due
to
factors
such
as
inadequate
data
collection,
a
lack
of
consistent
categorization
methods,
and
failure
to
report
a
drowned
person
in
certain
regions
and
cultures,
among
others.
1
These
estimates
also
do
not
include
the
number
of
people
impacted
by
non-fatal
drowning.
2,3
The
true
burden
of
drowning
on
public
health
is
unknown
partly
due
to
a
lack
of
high-quality
epidemiological
data
in
the
field.
Furthermore,
lack
of
uniform
and
internationally
accepted
definitions
related
to
drowning
have
hampered
data
collection.
This
pertains
to
both
fatal
and
non-fatal
cases.
Individuals
and
groups
still
frequently
use
inconsistent
language
to
describe
drowning
terms,
including
water
safety
and
health
organisations,
experts
in
the
field,
publications
in
the
scientific
medical
literature
and
lay-persons
including
both
main-
stream
and
social
media.
46
These
inconsistencies
result
in
difficulties
comparing
data
among
different
collectors,
and
create
many
gaps
in
knowledge
that
have
hindered
the
improvement
of
the
understanding
and
mitigation
of
the
drowning
problem.
7
In
the
past,
multiple
terms
and
definitions
relating
to
aspects
of
drowning
have
been
proposed
and
used
in
the
literature.
Examples
where
multiplicity
exists
includes
the
use
of
the
following
terms:
drowning,
near-drowning,
wet
and
dry
asphyxia,
drowning
with
and
without
aspiration,
immersion,
submersion,
and
submersion
injury,
among
many
others.
8
Efforts
in
creating
a
uniform
data
collection
and
reporting
framework
started
a
few
decades
ago,
when
a
group
of
experts
in
the
field
began
debating
the
need
for
standardised
terms
and
definitions.
This
resulted
in
a
new
definition
of
drowning
being
agreed
upon
at
the
World
Conference
on
Drowning
in
the
Netherlands,
in
2002.
In
2003,
the
International
Liaison
Committee
on
Resuscitation
(ILCOR)
released
an
advisory
statement
endorsing
this
definition
and
a
set
of
guidelines
for
the
uniform
reporting
of
data
from
drowning.
9
The
World
Health
Organization
endorsed
this
new
definition,
and
it
was
published
in
the
Bulletin
of
the
WHO
in
2005.
8
The
use
of
out-dated,
incorrect
and
confusing
drowning-related
terminology
is
still
observed
in
peer-reviewed
literature.
A
systematic
review
found
that,
between
2005
and
2011,
32%
of
drowning-related
articles
included
non-uniform
terminology,
10
including
some
in
high
impact
factor
journals.
The
US
National
Library
of
Medicine
database
is
still
using
the
MeSH
term
near-drowning
to
index
papers
regarding
non-fatal
drowning
incidents.
It
is
also
possible
to
find
numerous
documents
online
which
refer
to
outdated
materials
and
incorrect
information.
The
use
of
obsolete
terms
circulated
on
social
media
and
picked
up
by
print
and
broadcast
media
also
increases
confusion
and
misinformation
among
the
general
public
regarding
drowning.
4
Confusing
terminology
and
inconsistencies
in
the
literature
hinder
efforts
to
track
and
characterise
the
epidemiological
impact
of
this
disease
and
the
efficacy
of
therapeutic
interventions.
Drowning
prevention
and
aquatic
safety
professionals
(lifeguards
included),
have
a
responsibility
to
promote
the
use
of
internationally
agreed
upon
terminology
to
the
public,
in
current
practice,
in
medical
reports
and
through
the
media.
1012
A
more
precise
public
health
2R
E
S
U
S
C
I
T
A
T
I
O
N
P
L
U
S
5
(
2
0
2
1
)
approach
13
will
allow
the
use
of
data
(collected
using
consistent
terminology)
to
guide
interventions
that
benefit
the
community
more
efficiently,
especially
for
prevention.
The
objective
of
this
dictionary
is
to
provide
standardised
terminology
and
definitions
for
greater
clarity
amongst
a
range
of
stakeholders
across
research,
practice
and
policy
development
with
the
aim
of
improving
the
understanding
and
communication
between
these
groups.
The
dictionary
will
be
open
to
readers
for
discussion
and
reviewed
continuously
at
www.idra.world.
Methodology
Term
identification
After
establishing
the
need
to
create
a
drowning
dictionary,
two
authors
(DS,
JPA)
met
to
establish
the
format
of
the
dictionary,
the
fundamental
concepts,
the
references
to
follow,
and
to
list
the
definitions
of
terms.
Terms
were
categorized
into
those
which
were
in
agreement
in
the
literature
already
and
those
which
needed
further
clarity.
Subsequently,
a
third
author
(ACQ)
joined
the
coordinating
authors
(CA).
A
first
draft
of
the
dictionary,
with
a
list
of
terms
and
their
definitions,
was
created.
This
initial
list
was
based
on
the
drowning
timeline
phases
(Fig.
1).
14
The
CA
sent
an
invitation
to
participate
to
46
international
drowning
experts
via
email.
Experts
contacted
were
all
members
of
the
International
Drowning
Researchers
Alliance
(IDRA).
The
experts
who
agreed
to
participate
had
to
choose
one
specific
field
of
preference
from
five
different
options:
preparation
(data
collection,
problem
identification,
planning,
and
education),
prevention,
reaction
(rescue),
mitigation
(basic
and
advanced
life
support)
or
equipment.
A
total
of
16
experts
from
Australia,
Argentina,
Canada,
Greece,
New
Zealand,
Netherlands,
Portugal,
Spain,
Sweden,
and
United
Kingdom
replied
(representing
4
continents
and
6
distinct
languages).
Of
note,
37%
of
responders
were
English
native
speakers.
To
confirm
that
the
reviewers
had
a
range
of
knowledge
and
skill
expertise,
a
survey
prepared
by
IDRA
co-founders
was
sent
to
all
of
its
members
in
order
to
establish
a
distinction
between
expert
and
person
with
advanced
experience
in
a
selection
of
areas.
Members
were
asked
to
classify
themselves
based
on
the
following
definitions:
(a)
consider
yourself
a
Fig.
1
The
drowning
timeline
(reproduced
with
permission
from
the
authors).
Triggers,
actions
and
interventions
are
arranged
to
reflect
the
real
chronological
sequence
of
the
drowning
process.
The
overlap
between
the
reaction
and
mitigation
actions
represents
the
diffuse
transition
between
the
two
actions.
This
occurs
when
the
victim
is
still
being
rescued,
but
some
of
the
interventions
of
the
rescuer
can
already
be
regarded
as
mitigating
interventions.
The
original
article
is
mentioned
as
footnote
of
the
figure
and
can
be
consulted
for
a
detailed
description
of
all
components
of
the
drowning
timeline.
R
E
S
U
S
C
I
T
A
T
I
O
N
P
L
U
S
5
(
2
0
2
1
)3
person
with
advanced
experience
in
a
topic
if
you
understand
a
wide
range
of
terms/definitions/actions
of
that
topic
but
might
need
to
search
further
before
providing
an
update
on
its
scientific
evidence;
(b)
consider
yourself
as
an
expert
if
you
would
not
need
to
conduct
a
search
on
the
topic
before
providing
an
update
on
its
scientific
evidence.
Table
1
presents
the
results
from
this
survey
for
the
members
that
collaborated
in
the
process
of
building
the
dictionary.
The
reviewers
who
agreed
to
participate
were
assigned
to
a
smaller
panel
based
on
their
field
of
preference:
Pre-event
Preparation
(3);
Pre-event
Prevention
(4);
Event
Reaction
(3);
Post-Event
Mitigation
(3);
and
Equipment
(3).
The
CAs
created
five
documents,
one
per
field
of
preference,
and
a
guide
for
the
review
process.
Table
1
outlines
the
instructions
provided
to
each
reviewer.
The
CA
decided
to
employ
a
modified
Delphi
process
to
reach
consensus
amongst
participants
due
to
its
validated,
systematic,
and
interactive
forecasting
method
which
relies
on
a
panel
of
experts.
15
It
was
decided
a
priori
that
the
Delphi
method
would
stop
after
5
iterations.
Each
definition
included
text,
and
if
applicable,
followed
by
an
illustration,
picture,
or
figure
and
a
reference
to
the
scientific
literature.
An
effort
was
made
to
apply
this
format
to
as
many
terms
as
possible.
The
CA
used
and
cited
pertinent
terms
from
the
literature
if
available.
The
dictionary
contained
some
original
illustrations/pictures/figures,
while
others
were
modified
from
the
original
and
appropriately
cited.
In
the
first
round,
each
group
separately
received
a
draft
with
the
guide
for
reviewers
(Table
2).
The
panel
was
given
15
days
to
provide
their
reviews.
The
CA
compiled
and
examined
all
edits
and
comments
received
from
the
reviewers.
This
resulted
in
a
revised
and
refined
version
that
was
sent
back
to
the
same
five
groups
of
experts
(Round
2).
After
the
second
iteration,
the
CA
prepared
one
document,
with
all
the
terms
included
from
the
five
groups
combined.
This
document
was
again
sent
individually
to
all
16
participating
experts
(Round
3).
The
complete
document
underwent
commenting
and
revision
two
more
times
until
a
final
document
was
prepared
after
the
fifth
round.
Validation
of
the
content
To
evaluate
the
content
validity
of
each
term,
Yosoffs
content
validity
index
(CVI)
was
calculated.
16
The
CA
recruited
an
external
panel
of
10
drowning
experts
(outside
authors,
but
inside
IDRA
members)
and
invited
them
to
evaluate
the
degree
of
agreement
of
each
item.
A
four-
point
Likert
scale
was
used
(1
=
do
not
agree;
4
=
highly
agree).
Their
responses
were
coded
as
0
if
do
not
agree
and
somewhat
agree
were
selected,
or
as
1
if
quite
agree
and
highly
agree
agreed.
A
blank
space
for
their
comments
was
also
available.
The
CA
defined
a
priori
an
acceptable
Item
Level
Content
Validity
Index
(I-CVI)
value
for
10
reviewers
as
0.78
or
greater.
This
represents
the
proportion
of
content
experts
who
quite
agree
or
better
with
the
proposed
term
and
definition.
17
Scale-level
content
validity
index
based
on
the
average
method
(S-CVI/Ave)
and
Scale-level
content
validity
index
based
on
the
universal
agreement
method
(S-CVI/UA)
were
also
calculated.
16
Definition
Each
word,
definition,
figure,
or
pictogram
previously
published
in
peer-reviewed
literature
and
used
in
the
dictionary
was
referenced.
Those
which
do
not
contain
references
were
the
result
of
the
iterative
review
process.
The
authors
decided
not
to
include
generic
medical
terms,
or
obsolete
terms
related
to
drowning.
This
project
constitutes
research
not
involving
human
subjects
and
is
therefore
exempt
from
IRB
review
and
ethical
approval.
Table
1
Drowning
dictionary
reviewers
fields
of
expertise
and
research
experience.
Expertise
fields
Alcohol
related
issues
Inland
waterways
drowning
Rescue
boat
operations
Aquatic
disaster
Intentional
drowning
Rescue
technology
Beach
safety
Lifesaving/lifeguarding
Resuscitation
Boating/transport
a
Low-
and
middle-income
countries
drowning
Rip
currents
Coastal
drowning
Marginalized
communities
River
drowning
Coastal
processes
Marketing
School
based
education
Cold
water
immersion
Non-fatal
drowning
Scuba
injuries
a
Critical
care
Ocean
lifeguarding
Special
needs
group
a
Elderly
drowning
Oceanography
Spinal
cord
injuries
Emergency
medicine
Paediatrics
Submerged
vehicle
Epidemiology
aquatic
injuries
Physiology
Surf
lifesaving
clubs
Epidemiology
drowning
Pool
lifeguarding
Swim/water
safety
instruction
Flood/disaster
Pre-hospital
Care
Tourist
drowning
Graphic
design
Public
health/promotion
(prevention)
Hospital
care
Public
policy
Research
experience
Computer
modelling
a
GIS
(geographic
information
system)
a
Qualitative
methods
Data
collection
Grant
writing
Research
design
and
methodology
Data
visualization
Structured
literature
review
Risk
analysis
English
manuscript
writing
Peer
review
Statistical
methods
Epidemiologic
methods
Policy
analysis
Survey
designs
Ethics/institutional
research
Program
evaluation
a
Advanced
experience
but
not
expert.
4R
E
S
U
S
C
I
T
A
T
I
O
N
P
L
U
S
5
(
2
0
2
1
)
Results
Nineteen
experts
(3
CA
plus
16
invited)
in
fields
related
to
drowning
selected
terms,
definitions
and
categorizations
included
in
the
dictionary
were
involved.
This
process
resulted
in
more
than
350
terms,
sub-terms
and
categorizations.
Of
these,
less
than
10%
of
terms,
sub-terms
and
categorizations
had
been
previously
published
in
peer
review
literature
and
were
referenced
in
the
document.
The
drowning
dictionary
includes
a
list
of
acronyms
that
were
used
throughout
the
dictionary
that
are
provided
in
alphabetical
order
(Appendix
1
Acronyms).
Both
the
list
of
acronyms
and
the
complete
list
of
terms
are
provided
as
complementary
material
(Appendix
2
Terms,
definitions
and
categorizations).
Using
the
average
method,
the
scale
content
validation
index
(S-CVI/Ave)
was
0.91,
exceeding
the
scientific
recommended
value,
and
endorsing
the
drowning
dictionary.
Ninety
one
percent
of
the
items
received
an
I-CVI
value
considered
acceptable
(>0.78).
Nine
percent
did
not
reach
the
a
priori
I-CVI
validity
cut
off,
although
their
values
were
equal
to
or
greater
than
0.50,
showing
that
they
were
not
yet
consolidated
and
will
require
further
revision
in
the
near
future
before
acceptance.
The
authors
(CA)
used
consensus
to
amend
these
words.
There
was
not
significant
universal
agreement
among
the
external
panel
(S-CVI/UA
=
0.44).
After
content
validity
evaluation,
the
CA
reviewed
the
document
and
identified
five
words
based
on
the
external
panels
comments
that
needed
further
consideration
and
were
updated.
Other
reasons
cited
by
the
external
panels
for
terms
scoring
low
on
the
validity
evaluation
included:
improper
English
grammar,
confusion
regarding
how
to
evaluate
a
term
when
see
the
definition
in
other
item
was
listed
for
related
concepts
(e.g.,
aquatic
versus
water),
feeling
that
the
term
was
out
of
their
field/
knowledge
expertise,
or
that
the
term
was
already
self-explanato-
ry,
among
others.
Discussion
Drowning
is
an
extremely
complex
process
and
there
is
no
simple
or
single
solution
to
this
public
health
problem.
However,
having
a
standard,
consistent
and
evidence-based
communication
platform
to
describe
all
terms
related
to
drowning
can
greatly
assist
the
collection
of
data.
This
allows
for
more
robust
research
to
be
conducted
and
permits
better
examination
and
potentially
mitigation
of
the
drowning
burden.
Until
now
however,
scarce
common
language
was
available
in
the
field
of
drowning.
The
benefit
of
this
dictionary
includes
the
involvement
of
authors
with
different
native
languages
and
incorporation
of
cultural
differ-
ences
across
four
continents.
The
suggested
terminology
is
meant
to
be
useful
for
a
variety
of
situations,
heterogenous
contexts
environ-
ments
and
research
purposes.
In
part
due
to
the
representation
of
many
cultures
and
experiences,
and
inclusion
of
a
high
number
of
terms/definitions,
an
overall
consensus
had
to
be
reached
rather
than
universal
agreement.
However,
use
of
the
acceptable
validity
CVI
values
to
evaluate
each
term
scientifically
strengthened
the
consensus
process.
Despite
the
many
differences
between
contributors,
the
consensus
process
demonstrated
that
common
ground
can
be
found
for
the
range
of
drowning-related
terms
in
use
and
authors
envision
that
future
revaluations
will
increase
universal
agreement.
The
vast
number
of
potential
terms
and
sub-terms
that
could
have
been
used
to
describe
the
whole
drowning
process
was
a
limitation
of
this
process.
A
decision
had
to
be
made
at
some
point
regarding
how
included
sub-terms
could
be
applied
and
to
what
level
of
detail
was
considered
sufficient
(e.g.,
the
decision
to
use
both
aquatic
and
water
words
as
peer
reviewed
terms
in
the
literature).
A
further
limitation
is
that
the
majority
of
terms
and
their
definitions
were
a
consensus
of
opinion
instead
of
scientific
study
confirmation
(e.g.,
authors
decided
via
consensus
to
avoid
referring
to
the
drowning
Table
2
Instructions
sent
to
international
drowning
experts
for
the
initial
round
of
the
drowning
dictionary
document
review.
“Resilience
to
get
something
instead
of
nothing”
Dear
[reviewer’s
name],
when
reviewing
words,
definitions
and
categorization,
please
consider
the
following:
Be
simple,
short
and
easily
understandable;
Include
language
suitable
to
high,
middle
and
low-income
countries;
Take
into
account
the
need
to
promote
data
acquisition
from
a
wide
range
of
individuals:
layperson,
lifesavers,
lifeguards,
pre-hospital
care,
ambulance
services,
doctors,
persons
filling
out
hospital
and
death
statistics,
etc.;
Respect
and
consider
language
diversity
and
the
need
to
have
terms
and
concepts
translated
to
other
languages
in
a
manner
such
that
readily
definable
events
will
have
high
internal
and
external
validity
(e.g.,
reproducibility,
low
sensitivity
to
recall
biases,
etc.);
This
dictionary
should
be
developed
in
a
manner
in
agreement
with
the
ICD-10
revision
process
and
capable
of
integrating
it;
This
dictionary
needs
to
be
written
in
a
way
so
that
it
can
easily
and
widely
be
communicated
and
disseminated,
including
to
organizations
that
will
be
end-users
namely
those
involved
in
water
safety
issues
(e.g.,
health
public
and
epidemiologist,
lifeguard
organizations,
search
and
rescue
teams,
swimming
instructors,
etc.);
This
dictionary
should
be
developed
in
such
a
manner
that
ensures
reproducibility
and
robustness
across
a
wide
variety
of
reporting
sites
and
sources.
What
each
reviewer
needs
to
do:
Review
all
the
terms
and
definitions
established
by
the
CA;
Before
suggesting
a
new
term,
confirm
it
was
not
already
listed;
Identify
any
missing
word
that
you
think
would
be
useful
to
be
included;
Identify
any
duplicates/synonyms
or
words/items
that
can
be
aggregated;
Indicate
unnecessary
words/items,
if
you
consider
them
too
generic,
not
relevant
for
drowning
or
because
there
is
already
a
good
consensus
for
their
use
in
literature;
From
the
given
term,
provide
your
best
definition
using
the
fewest
words
possible;
Propose
a
simple
categorization
to
the
dictionarys
terms,
if
you
feel
necessary;
Suggest
obsolete
terms
to
be
included
in
a
warning
list.
R
E
S
U
S
C
I
T
A
T
I
O
N
P
L
U
S
5
(
2
0
2
1
)5
person
as
a
victim
in
the
text,
as
this
implies
a
random
event
instead
of
a
preventative
one).
Although
participants
were
all
from
the
same
source
organisation
(IDRA),
there
is
no
membership
fee
to
join
and
is
open
access
to
everyone
resulting
in
the
widest
representation
of
the
scientific
global
drowning
community.
Furthermore,
this
is
a
work
in
process
and
future
reviews
by
anyone
outside
the
field
of
research
(e.g.,
service
users)
will
result
in
improvements.
Like
all
terminology
definitions,
this
document
will
only
reflect
current
practice
at
the
time
of
publication.
Future
iterations
will
focus
on
maintaining
an
updated
compilation
as
new
information
and
data
about
the
drowning
process
is
obtained.
Conclusions
This
drowning
dictionary
provides
a
common
ground
and
language,
and
authors
envisage
that
its
use
will
facilitate
discussion
across
drowning
prevention
sectors,
including
education,
research
and
treatment.
It
is
not
presented
as
a
final,
definitive
list
of
terms
and
definitions,
but
provides
the
foundation
for
a
living
document
that
can
be
updated
in
future
when
a
need
exists
to
include,
exclude
and
modify
definitions
and
categorizations.
The
dictionary
will
be
open
to
readers
for
discussion
and
further
review
continuously
at
www.idra.world.
Conflict
of
interest
The
authors
declare
that
they
have
no
known
competing
financial
interests
or
personal
relationships
that
could
have
appeared
to
influence
the
work
reported
in
this
paper.
Acknowledgements
The
authors
want
to
acknowledge:
Justin
Sempsrott,
William
Koon,
Cristian
Abelairas,
Tom
Mecrow,
Dan
Graham,
Danielli
Mello,
Fabian
DEramo,
Luis
Rama,
Santiago
Cervantes,
Antonio
Caballero
Oliver,
for
scoring
evaluation,
Kevin
Moran
and
Jonathon
Webber,
for
direct
inputs
to
the
content
and
structure
and
Martín
Otero-Agra,
for
the
statistical
analysis.
Appendix
A.
Supplementary
data
Supplementary
material
related
to
this
article
can
be
found,
in
the
online
version,
at
doi:https://doi.org/10.1016/j.resplu.2020.100072.
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E
F
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R
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N
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A tragédia do afogamento está presen¬te em nosso dia-a-dia com 15 mortes diárias (ano 2019). Incidente silencioso, cercado de mistérios e frequentemente atribuído a uma fatalidade inevitável do destino, ocor¬rem no ambiente extra-hospitalar em sua grande maioria e envolve principalmente a assistência pré-hospitalar prestada por lei¬gos, guarda-vidas, socorristas e profissionais de saúde. Portanto, é essencial que profis¬sionais de saúde tenham conhecimento da cadeia de sobrevivência no afogamento, que inclui desde a assistência pró-ativa de pre-venção praticada em ambientes de saúde, a identificação de comportamentos e situações de risco iminente no ambiente aquático, passando pela assistência pré-hospitalar de atender uma ocorrência em seu ambiente fa¬miliar, até finalmente a internação hospitalar se necessária.
Article
Introduction Flooding causes significant mortality and morbidity, with impacts expected to increase with climate change. Ensuring adequate country-level flood mitigation and response capacity is key. Lifeguards, traditionally used for drowning prevention, may represent an additional workforce for flood emergency response. Methods Through an anonymous, online survey, we explored experiences, beliefs, and attitudes of a convenience sample of surf lifeguards from Australia and England towards lifeguards’ involvement in flood response. Respondents were recruited via Surf Life Saving Australia and Great Britain and had prior training in flood rescue. Analysis comprised descriptive statistics and thematic coding of free-text responses. Results Forty-four responses were received (93.2% male, 34.1% aged 50–59 years; 61.4% from Australia; 61.4% with ≥16 years lifesaving experience). Twenty-nine respondents (65.9%) self-reported having previously responded to flooding, 15 of which responded prior to receiving flood training. Lifeguards commonly reported being involved in the flood response phase (n = 28). Respondents identified rescue skills (n = 43; 97.7%), awareness of water conditions (n = 40; 90.9%), and radio communication protocols (n = 40; 90.9%) as relevant in a flood scenario. Respondents broadly agreed lifeguards were an asset in flood response due to transferrable skills, including to bolster existing capacity. However, respondents noted need for greater recognition, for involvement earlier in flood response and for flood-specific training and equipment prior to deployment. Discussion & Conclusions: Lifeguards represent a willing and able workforce to support flood mitigation and response, some of whom are already being tasked with such work. Provision of flood-specific training and equipment are vital, as is addressing interoperability tensions.
Article
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Drowning has been described as a major global public health problem and has recently been acknowledged by a United Nations Declaration on Global Drowning Prevention. While drowning impacts countries of all income levels, the burden is overwhelmingly borne by lowand middle-income countries (LMICs) who account for 90% of the global death toll. In addition, there is scarce data collection on drowning in LMICs, so the magnitude of drowning may be far greater than is represented. A range of factors including sex, age, education, income, access to water, a lack of swimming skills, certain occupations like commercial fishing, geographically isolated and flood-prone locations, preexisting medical conditions, and unsafe water transport systems, influence the risk of drowning. Some behavioral factors, such as alcohol or drug consumption, not wearing life jackets, and engaging in risky behaviors such as swimming or boating alone, increase drowning risk. Geopolitical factors such as migration and armed conflict can also impact drowning risk. There is a growing body of evidence on drowning prevention strategies. These include pre-event interventions such as pool fencing, enhancing community education and awareness, providing swimming lessons, use of lifejackets, close supervision of children by adults, and boating regulations. Interventions to reduce harm from drowning include appropriate training for recognition of a drowning event, rescue, and resuscitation. An active and/or passive surveillance system for drowning, focusing on individual settings and targeting populations at risk, is required. Drowning requires coordinated multisectoral action to provide effective prevention, rescue, and treatment. Therefore, all countries should aim to develop a national water safety plan, as recommended in the WHO Global Report on Drowning. Further research is required on the epidemiology and treatment of drowning in LMICs as well as non-fatal and intentional drowning in both high-income countries (HICs) and LMICs. Effective and context-specific implementation of drowning prevention strategies, including pilot testing, scale up and evaluation, are likely to help reduce the burden of both fatal and non-fatal drowning in all countries. Keywords: drowning, injury, risk factors, prevention, epidemiology, alcohol, swimming, rescue, resuscitation, migration
Article
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There are five sources of validity evidence that are content, response process, internal structure, relation to other variables, and consequences. Content validity is the extent of a measurement tool represents the measured construct and it is considered as an essential evidence to support the validity of a measurement tool such as a questionnaire for research. Since content validity is vital to ensure the overall validity, therefore content validation should be performed systematically based on the evidence and best practice. This paper describes a systematic approach to quantify content validity in the form of content validity index based on the evidence and best practice.
Article
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Background: Drowning is a leading and preventable cause of death that has suffered an attention deficit. Improving drowning data in countries would assist the understanding of the full extent and circumstances of drowning, to target interventions and evaluate their effectiveness. The World Health Organization identifies data collection as a key strategy underpinning effective interventions. This study compares unintentional fatal drowning data collection, management and comparison using the databases of Australia, Canada and New Zealand. Methods: Cases of fatal unintentional drowning between 1-January-2005 and 31–December-2014 were extracted. Cases were combined into a single dataset and univariate and chi square analysis (p < 0.01) were undertaken. Location and activity variables were mapped and combined. Variables consistently collected across the three countries were compared to the ILCOR Drowning Data Guideline. The authors also recommend variables for a minimum core dataset. Results: Of 55 total variables, 19 were consistent and 13 could be compared across the three databases. When mapped against the ILCOR Drowning Data Guideline, six variables were consistently collected by all countries, with five compared within this study. The authors recommend a minimum core dataset of 11 variables including age, sex, location, activity, date of incident, and alcohol and drug involvement). There were 8176 drowning deaths (Australia 34.1%, Canada 55.9%, New Zealand 9.9%). All countries achieved reductions in crude drowning rates (Australia − 10.2%, Canada − 20.4%, New Zealand − 24.7%). Location and activity prior to drowning differed significantly across the three countries. Beaches (X2 = 1151.0;p < 0.001) and ocean/harbour locations (X2 = 300.5;p < 0.001) were common in Australia and New Zealand, while lakes/ponds (X2 = 826.5;p < 0.001) and bathtubs (X2 = 27.7;p < 0.001) were common drowning locations in Canada. Boating prior to drowning was common in Canada (X2 = 66.3;p < 0.001). Conclusions: The comparison of data across the three countries was complex. Work was required to merge categories within the 20% of variables collected that were comparable, thus reducing the fidelity of data available. Data sources, collection and coding varied by country, with the widest diversity seen in location and activity variables. This study highlights the need for universally agreed and consistently applied categories and definitions to allow for global comparisons and proposes a core minimum dataset.
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Objectives The epidemiology of fatal drowning is increasingly understood. By contrast, there is relatively little population-level research on non-fatal drowning. This study compares data on fatal and non-fatal drowning in Australia, identifying differences in outcomes to guide identification of the best practice in minimising the lethality of exposure to drowning. Design A subset of data on fatal unintentional drowning from the Royal Life Saving National Fatal Drowning Database was compared on a like-for-like basis to data on hospital separations sourced from the Australian Institute of Health and Welfare’s National Hospital Morbidity Database for the 13-year period 1 July 2002 to 30 June 2015. A restrictive definition was applied to the fatal drowning data to estimate the effect of the more narrow inclusion criteria for the non-fatal data (International Classification of Diseases (ICD) codes W65-74 and first reported cause only). Incidence and ratios of fatal to non-fatal drowning with univariate and Χ ² analysis are reported and used to calculate case-fatality rates. Setting Australia, 1 July 2002 to 30 June 2015. Participants Unintentional fatal drowning cases and cases of non-fatal drowning resulting in hospital separation. Results 2272 fatalities and 6158 hospital separations occurred during the study period, a ratio of 1:2.71. Children 0–4 years (1:7.63) and swimming pools (1:4.35) recorded high fatal to non-fatal ratios, whereas drownings among people aged 65–74 years (1:0.92), 75+ years (1:0.87) and incidents in natural waterways (1:0.94) were more likely to be fatal. Conclusions This study highlights the extent of the drowning burden when non-fatal incidents are considered, although coding limitations remain. Documenting the full burden of drowning is vital to ensuring that the issue is fully understood and its prevention adequately resourced. Further research examining the severity of non-fatal drowning cases requiring hospitalisation and tracking outcomes of those discharged will provide a more complete picture.
Article
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Drowning is a common and often preventable cause of death, especially in children. The mass media often propagate misinformation about “dry” and “secondary” drowning, diverting attention from appropriate efforts to prevent drowning and rescue and treat those who do drown.
Article
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International data severely underestimates actual drowning numbers. Almost all victims are able to help themselves or are rescued in time. This study aims to report the occurrence of Drowning Chain of Survival actions and resuscitations needed in a fully operational lifeguard service. Methodology: Data was collected from Dec-2009 to Mar-2015 by lifeguards at a 6km-long beach in Brazil. The Drowning Chain of Survival links were summarized into 3 main action-response sections: Prevention; rescue; and provide care. Rescues were classified by severity. Results: Lifeguards reported 1,565,699 actions during the study period. Preventative actions comprised 1,563,300(99.8%) and 2,044 (0.1%) involved recognizing a person in stress/distress and rescuing them. Of those requiring rescue, 355(0.02%) needed medical assistance due to respiratory symptoms, isolated respiratory arrest, or cardiopulmonary arrest. Those cases were classified by severity as: Grade 1 = 234(65.9%), grade 2 = 78(22%), grade 3 = 22(6.2%), grade 4 = 7(2%), grade 5 = 4(1.1%), and Grade 6 = 10(2.8%). From all 2,044 rescues, 14(0.7%) were grade 5 and 6 and needed respiratory or cardiorespiratory resuscitation. An estimative incidence of 1 rescue for 4,227 peoples, 1 drowning for 24,338 and 1 CPR done to 617,142 for each day at a guarded beach was showed. The prevalent misconception that majority of drowning require resuscitation is perpetuated by the media and publishers. We are only just seeing the tip of the iceberg and urgently need to look at the problem in its entirety. Considering all the intervention undertaken by lifeguards in a fully operational system, the incidence of resuscitation being performed is only one in every 112,000 lifeguarding actions (0.0009%).
Article
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Background: The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD. Methods: A search in Pubmed, Embase, the Cochrane Library, Web of Science and Scopus was performed to identify studies that used the USFD and were published between 01-10-2003 and 22-03-2015. We also searched in Pubmed, Embase, the Cochrane Library, Web of Science, and Scopus for all publications that cited the two publications containing the original ILCOR advisory statement introducing and recommending the USFD. In total we identified 14 publications by groups that explicitly used elements of the USFD for collecting and reporting their data. Results: Of the 22 core and 19 supplemental USFD parameters, 6-19 core (27-86%) and 1-12 (5-63%) supplemental parameters were used; two parameters (5%) have not been used in any publication. Associations with outcome were reported for nine core (41%) and five supplemental (26%) USFD parameters. The USFD publications also identified non-USFD parameters related to outcome: initial cardiac rhythm, time points and intervals during resuscitation, intubation at the drowning scene, first hospital core temperature, serum glucose and potassium, the use of inotropic/vasoactive agents and the Paediatric Index of Mortality 2-score. Conclusions: Fourteen USFD based drowning publications have been identified. These publications provide valuable information about the process and quality of drowning resuscitation and confirm that the USFD is helpful for a structured comparison of the outcome of drowning resuscitation.
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We read with great interest the recent case report by Galbiati et al. on a 15-year-old drowning victim with favourable outcome despite a long period of submersion.(1) We applaud the authors for raising awareness of drowning and its treatment, but were surprised the manuscript included the term 'nearly drowned'. In 2003 this journal co-published an advisory statement of the International Liaison Committee on Resuscitation (ILCOR) which recommended the use of a uniform way of reporting data on drowning: the ‘Utstein Style for Drowning’.(2) This consensus-based document was created to provide more consistency in describing drowning research and improve comparability between individual studies. In this statement drowning was defined as “a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident”.(2) The use of the term ‘near-drowning’, which was considered to be confusing, was thus abandoned.(2) For more than a decade now this ‘new’ definition of Drowning has been adopted by the World Health Organisation (WHO) and it has also been incorporated in the European Resuscitation Council Guidelines for Resuscitation.(3,4) We still do not fully understand why some victims survive a drowning incident with good neurological outcome as described in the current case report, whereas others do not. To study this, more research is needed. We believe that the use of uniform terminology describing drowning incidents is vital for good, qualitative comparisons of drowning research, and improving patient outcomes. We therefore urge all authors to describe drowning incidents using the terminology advised by ILCOR and the WHO. References 1. Galbiati S, et al. Neurocognitive and behavioral outcomes in a nearly drowned child with cardiac arrest and hypothermia resuscitated after 43min of no flow-time: A case study. Resuscitation (2017), http://dx.doi.org/10.1016/j.resuscitation.2017.06.028 2. Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: the "Utstein style". Resuscitation 2003;59:45-57. 3. van Beeck E, Branche C, Szpilman D, Modell J, Bierens J. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ 2005;83:853-6. 4. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015;95:148-201.
Article
Background Lifeguards are integral to beach safety and collect data which is used for a variety of purposes, although guidelines and best practice have yet to be established. This study served to identify and characterise existing beach lifeguard service provider (BLSP) data collection procedures in order to identify the degree of uniformity and areas for improvement. Methods The ‘International Beach Lifeguard Data Collection and Reporting’ online survey was distributed via the International Drowning Researchers’ Alliance to BLSP supervisors and managers. The survey included questions on beach conditions and lifeguard activity data collection practices, and respondent’s opinions on their own BLSP’s methods. Results Variability in data collection practices was evident in surveys obtained from 55 lifeguard leaders in 12 countries. Discrepancies exist in definitions for ‘rescue’ among BLSPs, a significant amount of information related to beach conditions are recorded and beach visitation is primarily obtained by visual estimate. Respondents expressed challenges with getting frontline staff to collect information in the field and ensuring reporting consistency between recorders. They identified rescue victim demographic factors as key data they would like to collect in the future. Conclusions Inconsistencies in lifeguard data collection present challenges to operations, safety education and prevention efforts, research and policy relying on these data. Variation in definitions, methods and collected variables generally restricts analysis to a single BLSP with limited generalisability to other beach settings. Some gaps in lifeguard data collection may soon be addressed by technology, but developing uniform, internationally acceptable standards and definitions should be prioritised.
Article
Better surveillance data and analyses are urgently needed to control disease in the developing world, argue Scott F.
Article
Drowning is one of the major causes of trauma, killing 372,000 people, particularly children, every year. As an estimated 90% of all drowning deaths occur in low- and middle-income countries, significant under-reporting is known to contribute to a greatly underestimated burden of drowning. Additionally, drowning is not just death, but a process with outcomes that range from mild to severe. Therefore, there’s a need to respond to the challenges of new times reaching out more effectively to communities affected by drowning incidents, using a new conceptual framework that captures the full constituents of the drowning process. The systematic model presented is a new interpretation of a complex phenomenon valuable to unravel key points in the process facilitating the measurement of the impact of drowning prevention and preparedness to mitigate its adverse impacts. It integrates experts’ opinions and experience of the last 20 years with interests and developments in society. It proposes a change in the paradigm of drowning research to include non-fatal drowning. The new systematic model for drowning proposed in this study constitutes a powerful tool to improved and standardized data collection and better understanding of the process to effectively prevent, react and mitigate it. It also highlights the most effective deployment of resources allowing for the measurement of future cost/benefit ratios related to outcomes in terms of public health, financial aspects, political scope and social impacts. Furthermore, the increasing use of common terminology by all people involved, and specifically by the professionals and academics from different fields of knowledge, will rise the quality of data and information available about fatal and non-fatal drowning, allowing for optimization of worldwide quantification of victims, and subsequently, improved efficiency in supporting new policies and preventive measures.