Burden of fatal drowning in California, 2005-2019.

OBJECTIVE: To characterise risk factors for fatal drowning in California, USA to inform priorities for prevention, policy and research. METHODS: This retrospective population-based epidemiological review of death certificate data evaluated fatal drowning events in California from 2005 to 2019. Unintentional, intentional, and undetermined drowning deaths and rates were described by person (age, sex, race) and context-based variables (region and body of water). RESULTS: California's fatal drowning rate was 1.48 per 100 000 population (n=9237). Highest total fatal drowning rates occurred in the lower population density northern regions, among older adults (75-84 years: 2.54 per 100 000 population; 85+: 3.47 per 100 000 population) and non-Hispanic American Indian or Alaska Native persons (2.84 per 100 000 population). Male drowning deaths occurred at 2.7 times the rate of females; drowning deaths occurred mainly in swimming pools (27%), rivers/canals (22.4%) and coastal waters (20.2%). The intentional fatal drowning rate increased 89% during the study period. CONCLUSIONS: California's overall fatal drowning rate was similar to the rest of the USA but differed among subpopulations. These divergences from national data, along with regional differences in drowning population and context-related characteristics, underscore the need for state and regional level analyses to inform drowning prevention policy, programmes and research.

Gender Discrimination and Reporting Experiences among Academic Pediatric Faculty: A Qualitative, Single-institution Study.

OBJECTIVE: Gender-harassment is well-described in academic medicine, including pediatrics. We explored academic pediatricians' qualitative descriptions of: 1) workplace gender-harassment; 2) its professional and emotional tolls; 3) barriers to and outcomes of reporting gender-harassment; and 4) tools to intervene. METHODS: We conducted a cross-sectional, anonymous, survey-based study within a single, large pediatrics department. Surveys included demographic items, validated measures to assess prevalence of gender-harassment, and optional, free-text boxes to elaborate. Here, we present the directed content analyses of free-text responses. Two trained qualitative researchers coded participant comments to identify types of gender-harassment, its impact, and participants' experiences reporting it. Final agreement between coders was outstanding (Kappa>0.9). A secondary, inductive analysis illustrated the emotional burdens of and opportunities to interrupt gender-harassment. RESULTS: Of 524 total faculty, 290 (55%) completed the survey and 144 (27% of total, 50% of survey-respondents) provided text-responses. This sub-cohort was predominantly white women >5 years on-faculty. Compared to the full cohort, sub-cohort participants had more commonly witnessed/experienced workplace-harassment; 92% of sub-cohort women and 52% of men endorsed fear of reporting it. Respondents described harassment by institutional staff (24% of respondents), patients/families (35%), colleagues (50%), supervisors/leadership (50%), and the system (63%). Women used stronger emotional descriptors than men (ie, "humiliated" vs "uncomfortable"). Only 19% of women (and no men) had reported witnessed/experienced harassment; 24% of those described a negative consequence and 95% noted that no changes were made thereafter. CONCLUSIONS: This single-center study suggests gender-harassment in academic pediatrics is common. Faculty feel fear and futility reporting it.

Gender Discrimination and Sexual Harassment in a Department of Pediatrics.

The last substantial description of gender discrimination and harassment described in the journal Pediatrics was in 2019. It is unclear whether the field has made progress toward its goal of equity. We aimed to describe: (1) the recent gender-equity climate according to women and men faculty in the department of pediatrics at a single, large academic center, and (2) institutional efforts to address persistent gender discrimination and harassment. In late 2020, we distributed an anonymous survey to all department faculty that included demographic data, a modified version of the Overt Gender Discrimination at Work Scale, questions about experiences/witnessed discriminatory treatment and sexual harassment, and if those experiences negatively affected career advancement. Of 524 pediatrics faculty, 290 (55%) responded. Compared with men, women more commonly reported gender discrimination (50% vs. 4%, P < .01) and that their gender negatively affected their career advancement (50% vs 9%, P < .01). More than 50% of women reported discriminatory treatment at least annually and 38% recognized specific sexist statements; only 4% and 17% of men reported the same (P < .01 for both). We concluded that a disproportionately low number of male faculty recognized the harassment female faculty experienced. In the 18 months since, our department and university have made efforts to improve salary equity and parity in leadership representation, created an anonymous bias-reporting portal, mandated bias training, and implemented new benchmarks of "professionalism" that focus on diversity. Although we acknowledge that culture change will take time, we hope our lessons learned help promote gender equity in pediatrics more broadly.

Disparities in Adolescent Reported Drowning Prevention Strategies.

PURPOSE: Describe use of drowning prevention strategies among diverse adolescents. METHODS: We analyzed 47,051 responses to 2012-2018 Washington statewide surveys of 8th-12th grade students, regarding formal swimming lessons, comfort in deep water (a measure of perceived water competency), and life jacket use in small watercraft. Using survey-weighted Poisson regression, we measured these strategies in relation to race/ethnicity, primary language, maternal education, and urbanicity. RESULTS: 78.6% of students spoke English at home. Most students reported having had formal swimming lessons (62.2%), being comfortable in deep water (65.8%), and wearing life jackets (58.5%). Students primarily speaking Spanish (11.2%) reported formal swimming lessons (PR: 0.72; 95%CI: 0.67-0.78) and perceived water competency (PR: 0.75; 95%CI: 0.70-0.80) less often than primarily English-speaking. All prevention strategies were associated with higher maternal education. DISCUSSION: Drowning prevention strategies, access to swimming lessons, life jackets, and water competency should be promoted among low-income children and those whose primary language is not English.

Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing?

OBJECTIVES: Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization. METHODS: We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses. RESULTS: There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits. CONCLUSIONS: Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.

Prevention of Drowning.

Drowning is a leading cause of injury-related death in children. In 2018, almost 900 US children younger than 20 years died of drowning. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in prevention of drowning.

Factors Associated With Opioid Prescribing for Distal Upper Extremity Fractures at a Pediatric Emergency Department.

OBJECTIVE: The aims of this study were to describe the prescribing patterns of oxycodone for patients with distal upper extremity fractures and to evaluate factors that influence the quantity of oxycodone prescribed at discharge. METHODS: We retrospectively studied oxycodone prescriptions for patients with upper extremity fractures presenting to a single center tertiary pediatric emergency department (ED) from June 1, 2014, to May 31, 2016. We used logistic regression models to evaluate the association of opioid administration in the ED, fracture reduction under ketamine sedation, initial pain scores (low, medium, and high), patient demographics, and type of prescriber (residents, attendings, fellows, and advanced registered nurse practitioners) with oxycodone prescription at discharge and the number of doses prescribed (≤12 or >12 doses). RESULTS: A total of 1185 patients met the inclusion criteria. Of these, 669 (56%) were prescribed oxycodone at discharge. Children with fractures requiring reduction had 13 times higher odds [95% confidence interval (CI), 9.45-20.12] of receiving an oxycodone prescription compared with children with fractures not requiring reduction. Opioid administration in the ED was associated with 7.5 times higher odds (95% CI, 5.41-10.51) of receiving an outpatient prescription. Children were more likely to have a higher quantity of oxycodone prescribed if they had a fracture reduction in the ED [odds ratio (OR), 1.73; 95% CI, 1.20-2.50], received an opioid in the ED (OR, 2.13; 95% CI, 1.43-3.20), or received their prescription from an emergency medicine resident (OR, 2.8; 95% CI, 1.44-5.74). CONCLUSIONS: Opioid prescribing differs based on patient- and provider-related factors. Given the variability in prescribing patterns, changing suggested opioid prescriptions in the electronic medical record may lead to more consistent practice and therefore decrease unnecessary prescribing while still ensuring adequate outpatient analgesia.

Association of designated open water swim area regulations and open water drowning rates.

BACKGROUND: Although most persons over 5 years of age drown in open water, few laws have sought to regulate open water swim sites. We examined the association between regulations for designated open water swim sites and open water drowning death rates by state. METHODS: Using International Classification of Disease (ICD)-10 codes in the CDC Web-based Injury Statistics Query and Reporting System (WISQARS), we identified and calculated open water drowning deaths involving all ages from 2012 to 2017 for 50 states and calculated open water drowning death rates. We then identified and categorised types of state regulations (lifeguards, water quality, rescue equipment, tracking/planning/reporting and signage) for open water swim sites in place in 2017 for a sample of 30 states (20 high-drowning, 10 low-drowning). Analyses evaluated associations between open water drowning rates in three groups (overall, youth and non-white) and the total number and types of state regulations. RESULTS: Swim site regulations and open water drowning death rates for 10 839 victims were associated in all regression models. States with more types of regulations had lower open water drowning death rates in a dose-response relationship. States lacking regulations compared with states with all five types of regulations had open water drowning death rates 3.02 times higher among youth (95% CI 1.82 to 4.99) and 4.16 times higher among non-white residents (95% CI 2.46 to 7.05). Lifeguard and tracking/planning/reporting regulations were associated with a 33% and 45% reduction in open water drowning rates overall and among those aged 0-17 years. CONCLUSION: States' open water swim area regulations, especially addressing tracking/planning/reporting and lifeguards, were associated with lower open water drowning death rates.

Studying outcome predictors of drowning at the scene: Why do we have so few answers?

BACKGROUND: Identification of predictors of outcome at the scene of drowning events could guide prevention, care and resource utilization. This review aimed to describe where, what and how scene predictive factors have been evaluated in drowning outcome studies. METHODS: We reviewed studies reporting scene drowning predictors published between 2003 and 2019. Data extraction included study populations, data sources, predictor factors (victim, incident, rescue, resuscitation and hospital-related), outcome measures and type of analyses. RESULTS: Of 49 studies, 87.6% were from high-income countries, 57.1% used data from only one source (92.9% of these from either hospital or EMS), 73.5% included cases who received medical care and 53.1% defined outcomes as survival or death. A total of 78 different factors were studied; the most commonly studied group of factors described victim demographics, included in 42 studies (85.7%), followed by resuscitation factors, included in 30 studies (61.2%). Few studies described rescue (6.1%). The most frequent statistically significant single predictors of outcome known at the scene were submersion duration (evaluated in 19, predictor in 14) and age (evaluated in 31, predictor in 16). Only 38.7% of studies employed multivariable methods. CONCLUSIONS: Gaps to be addressed in drowning outcomes research include data from low- and middle-income countries, standardized definition of factors to allow evaluation across studies, inclusive study populations that can be generalized beyond those receiving medical care, study rescue and resuscitation factors, use of more meaningful outcomes (survival with good neurologic status) and advanced analyses to identify which factors are true predictors versus confounding variables.

Adolescent Water Safety Behaviors, Skills, Training and Their Association with Risk-Taking Behaviors and Risk and Protective Factors.

Background: Drowning remains the third leading cause of unintentional injury death for adolescents in the United States. Aims: This study described adolescent swimming lessons, behaviors (life jacket wear while boating) and comfort (swimming in deep water) and their association with protective and risk factors and risk-taking behaviors reported by Washington State students in Grades 8, 10, 12, primarily comprised of youth ages 13 to 18 years. Methods: This study used the 2014 Washington State Healthy Youth Survey (HYS), a publicly available dataset. Results: Most students reported having had swimming lessons, using life jackets, and comfort in deep water. Differences reflected racial, ethnic and socioeconomic disparities: being White or Caucasian, speaking English at home and higher maternal education. Lowest rates of comfort in deep water were among Hispanics or Latino/Latinas followed by Blacks or African Americans. Greater life jacket wear while boating was reported by females, those in lower grades and negatively associated with alcohol consumption, sexual activity and texting while driving. Having had swimming lessons was associated with fewer risk-taking behaviors. Conclusions: The HYS was useful to benchmark and identify factors associated with drowning risk among adolescents. It suggests a need to reframe approaches to promote water safety to adolescents and their families. Multivariate analysis of this data could identify the key determinants amongst the racial, ethnic, and socioeconomic disparities noted and provide stronger estimation of risk-taking and protective behaviors.

Promoting Equity, Social Justice, and Saving Lives with Life Jacket and Clothing Policies.

Worldwide, diverse racial/ethnic groups have disproportionately higher drowning rates. Learning to swim and wearing life jackets decrease drowning risk. We evaluated aquatic facilities' policies regarding use of life jackets, clothing, and diapers through a lens of social justice, equity, and inclusion to ensure they met the needs of the diverse high-risk groups they serve and changing aquatic activities and programs. Public recreational pools, beach and waterpark facilities in the US and international organizations were surveyed regarding their policies on life jacket use, clothing, and diapers between 2015 and 2016. A total of 562 facilities responded, mostly pools. Almost all facilities allowed wearing life jackets in the shallow end but less so in the deep end, and wearing of T-shirts, shorts, and clothes for modesty reasons. Policies varied most on wearing non-swim clothes. Almost universal requirement of diapers applied to infants only. Respondents' reported themes included cost, access, safety, hygiene and equipment maintenance. Reviewed policies generally reflected facilities' responsiveness to diverse populations' specific needs. However, policy variations around wearing clothing and swim diapers could be costly, confusing, and impede participation in aquatic activities by vulnerable populations, specifically young children and racial and ethnic minorities. Standardization of these policies could assist aquatic facilities and their users. A best-practices-based policy is outlined.

Long-Term Survival After Drowning-Related Cardiac Arrest.

BACKGROUND: Long-term outcomes after drowning-related cardiac arrest are not well characterized. OBJECTIVE: Our aims were to estimate long-term survival and identify prognostic factors in a large, population-based cohort of drowning victims with cardiac arrest. METHODS: We conducted a population-based prospective cohort study (1974-1996) of Western Washington Drowning Registry (WWDR) subjects with out-of-hospital cardiac arrest and attempted professional resuscitation. The primary outcome was long-term survival through 2012. We tabulated Utstein-style exposure variables, estimated Kaplan-Meier curves, and identified prognostic factors with Cox proportional hazard modeling. RESULTS: Of 2824 WWDR cases, 407 subjects (median age 17 years [interquartile range 3-33 years], 81% were male) were included. Only 54 (13%) were still alive after 1663 person-years of follow-up. Most deaths occurred after termination of initial resuscitation or during initial hospitalization. Risk of subsequent death after hospital discharge was 9.6 (95% confidence interval [CI] 5.7-15.9) per 1000 person-years. Long-term survival differed by Utstein variables (older age, illicit substance use, pre-drowning activity, submersion duration, cardiopulmonary resuscitation duration, intubation, defibrillation, and medications) and inpatient markers of illness severity (vital signs, Glasgow Coma Scale, laboratory values, shock). In adjusted analyses, older age (hazard ratio [HR] 1.01; 95% CI 1.01-1.02), epinephrine administration (HR 1.92; 95% CI 1.31-2.80), antiepileptic administration (HR 0.53; 95% CI 0.35-0.81), initial arterial pH (HR 0.49; 95% CI 0.26-0.92), and shock (HR 2.19; 95% CI 1.16-4.15) were associated with higher risk of death. CONCLUSIONS: Most cases of drowning-related cardiac arrest were fatal, but survivors to hospital discharge had a low risk of subsequent death that was independently associated with older age and clinical evidence of shock.

Prevention of Drowning.

Drowning is a leading cause of injury-related death in children. In 2017, drowning claimed the lives of almost 1000 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

Use of life jackets and other types of flotation for in-water recreation in designated swim areas in Washington State.

Most fatal drownings worldwide occur in open water. Flotation devices may protect swimmers. Their use by those recreating in water has not been described. METHODS: Observational survey of swimmers and waders at designated swim sites at lakes and rivers evaluated them by age group, sex, type of flotation used (life jacket vs substandard flotation, eg, water wings, noodles, inflatables) and, for children <6 years, being within arm's reach of an adult. RESULTS: Of 1967 swimmers/waders observed, 37% used some type of flotation device. Use rates, especially of life jackets, decreased with increasing age. Children <6 years had the highest use of some type of flotation (140/212, 66%) and the highest use of life jackets (50.5%). Children <13 years were more likely to use flotation devices and life jackets than teens (RR 6.78, 3.62 to 12.71); boys were more likely than girls to wear life jackets (RR 1.47, 1.18 to 1.83). While teenagers and adults used flotation (29.5% and 23.5%), they rarely used life jackets (2-3%). Boys <6 years who were further than arm's length of an adult were more likely to wear life jackets than girls. Substandard flotation use did not differ among age groups (15.5-26.5%) but their use was greater among females in most age groups. CONCLUSIONS: Flotation devices were frequently used for recreational wading and swimming in open water by all age groups. Life jacket use was limited to children. Promoting use of flotation devices with safety standards that provide protection as well as fun could potentially decrease open water drowning rates.

The ocean lifeguard drowning prevention paradigm: how and where do lifeguards intervene in the drowning process?

Drowning is a global health problem that can be addressed with multiple strategies including utilisation of lifeguards in recreational swim areas. However, few studies have described lifeguard prevention activities. We conducted a retrospective analysis using lifeguard activity data collected in real time with a Computer-Aided-Dispatch (CAD) system to characterise the nature of lifeguard primary and secondary drowning prevention at a popular ocean beach in California. Preventative actions constituted the majority (232 065/423 071; 54.8%) of lifeguard activities, while rescues represented 1.9%. Most preventative actions and rescues occurred during summer months, weekends and afternoons. Statistically significant geographical clusters of preventative actions were identified all over the beach, while rescue clusters were primarily restricted to two sites. Using the most reliable and valid collection system to date, these data show spatial and temporal patterns for ocean lifeguard provision of primary prevention as well as secondary drowning prevention (rescue).

Do wave heights and water levels increase ocean lifeguard rescues?

OBJECTIVE: To investigate the association of wave height and tidal water level changes with the frequency of ocean lifeguard rescues. METHODS: All ocean lifeguard rescues recorded by Newport Beach Lifeguards in 2015 and 2016 were linked by time and location to weather and ocean variables contained in other historical databases. We performed separate multivariable analyses using mixed effects negative binomial regression to evaluate the total effects of wave height, mean water level (primarily set by tidal elevation), and rising vs. falling water level, on the frequency of ocean rescue in the study location, controlling for confounding variables. RESULTS: Newport Beach Lifeguards made 8046 rescues during the study period. In all areas of the beach, rescue frequency increased as waves got larger (IRR: 3.25; 95%CI: 2.91-3.79) but then decreased in large surf (IRR: 0.52; 95%CI: 0.37-0.73). In two sections of beach, lifeguards made more rescues during lower water levels, but in the third section of beach, made more rescues during higher water levels. Rescue frequency increased in two sections of beach with rising water levels, but did not in the other section. CONCLUSIONS: Wave height, water level, and water level direction were associated with rescue frequency, but the environmental factors included in the analysis did not fully account for most variation in rescue frequency. Other factors need to be evaluated to identify major determinants of rescue frequency.

2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: An ILCOR advisory statement.

BACKGROUND: Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning. METHODS: An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details. RESULTS: The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture. CONCLUSIONS: The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.

2015 Revised Utstein-Style Recommended Guidelines for Uniform Reporting of Data From Drowning-Related Resuscitation: An ILCOR Advisory Statement.

BACKGROUND: Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning. METHODS: An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details. RESULTS: The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture. CONCLUSIONS: The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.