Aquatics: Risk Management Strategies for the Therapy Pool Marilou Moschetti, BS, PTA AquaTechnics Consulting Group, Aptos, CA
Andrew J. Cole, MD Baylor University Medical Center, Department of Physical Medicine and Rehabilitation, Tom Landry Sports Medicine and Research Center, Dallas, TX Risk management planning for employees and owners provUling therapy services in the aquatic environment is preventive medicine. Being familiar with regulations, codes, operations, maintenance, contraindications, and appropriate personal safety in and around the therapy pool is essential for a safe environment for both patients and staff Keywords: Aquatic environment; therapy pool; risk management; aquatic policy
The purpose of this article is threefold: (1) to define risk management and explain/state the relationship of risk management to aquatic therapists; (2) to delineate the areas of risk in aquatic therapy environments; and (3) to give recommendations for basic risk management in aquatic therapy environments.
DEFINING RISK MANAGEMENT AND ITS RELATIONSHIP TO AQUATIC THERAPY Risk Management is the practice of assessing risks inherent in a program or facility and attempting to eliminate or minimize them through implementation of change. I
Risk management in aquatic settings is preventive medicine. It is necessary in order to prevent major and minor accidents, and, in many cases, to comply with state and federal laws. The practices of risk management are especially important in places or activities that may be hazardous to the health and safety of people. Aquatic therapy is such a place and activity. There are many health
hazards associated with aquatic environments, and many people know little about personal safety in aquatics, having swimming skills insufficient to save themselves in the event of an emergency in, on, or around water. In situations where health and safety are at risk, there are state and federal codes and regulations governing all aquatic facilities in all 50 states. Such codes are generic and are referred to as state bathing codes. They are not uniform in all states. Bathing code violations are considered misdemeanors, punishable by fines. 2 The codes cover the physical plant site, maintenance room equipment, water sanitizing materials, and all elements of safety for patients and staff. Some of the codes overlap. Following are several major guidelines and public laws that regulate how pools operate. OSHA Universal Precautions and BloodBorne Pathogens Exposure Control Plan (BPS). [29 CFR1910.1030]. Designed to lessen exposure to pathogens (fungi, germs, bacteria, hepatitis B, HIV) where employees are at risk. Provides equipment and procedures where lifeguards and aquatic personnel could come into contact with another person's blood or body fluids. Personnel who have a high probability of exposure must be
BACK AND MUSCULOSKELETAL REHABILITATION / OCTOBER 1994
provided with a pre-exposure hepatitis B vaccine at no charge to the employee. Environmental Protection Agency, Superfund Amendments, and Reauthorization Act (SARA) Title III. The "Emergency Planning and Community Right-to-Know Act" requires reporting of hazardous materials storage, permits, inventory, and maps per site where used. Reportable quantities of hazardous substances that are spilled or released into the environment must be telephoned in and a written report filed. U.S. Environmental Protection Agency - Department of Agriculture "Pesticide Safety Training." Training is required for employees who apply, mix, maintain, service, or clean contaminated equipment or antimicrobial products. Appropriate labeling with EPA registration number on canisters of material is required. Chlorine and other halogens are considered pesticides. A pesticide (economic poison) is defined as substances or mixtures of substances that are intended to prevent, destroy, repel, or mitigate fungi, bacteria, or any other form of plant or animal life that is-or which the director may declare to be-a pest. U.S. Department of Labor Federal Occupational Safety and Health Administration (OSHA) "Hazard Communication Standards." [29 CFRI910.1200]. Ensures evaluation and communication to prevent and minimize employee exposures to hazardous substances produced in or imported into the United States. Employers must inform employees of hazardous materials, and of safety equipment needed to protect them. This applies to all hazardous materials including sanitizing agents used to clean flooring and decking around swimming pools. Exposure records must be maintained for two years, and must include date of application, location, commodity used, and name of antimicrobial. Within this regulation it is required that Material Safety Data Sheets be posted. These are used to maintain inventory of all hazardous substances used at the facility, and to appropriately label all containers where antimicrobial materials are stored. Written Employee Injury and Illness Prevention Program. [B3203(a)(2)]. (Where there is no labor union): injury and illness prevention programs train all employees who are at risk of daily
exposure. Respiratory protection trammg must be provided when product labeling requires it. Emergency medical care, labels, washing stations, and safety equipment must all be provided by employers in the locations where hazardous chemicals are used. Compliance with Uniform Fire Code, Article "Hazardous Materials." Stipulates where the storage and maintenance of gas chlorine is used. Local fire district regulations apply and must be followed. Compliance of Americans with Disabilities Act (ADA). Mandates that "no individual be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation." [s.302(a)]. Applies to employers with 25 or more employees. Requires public accommodations in new facilities designed and constructed after January 26, 1993. ADA lists hotels/motels, stadiums and other places of exhibition or entertainment, professional offices of health care providers, parks or places of recreation, schools, social service center establishments, gymnasiums, health spas, and other places of exercise or recreation. Barrier-free access to pools and spas located within these facilities is implied. 3-5 Failure to comply with these codes intending to ensure the safety of both patients and staff in an aquatic therapy facility can create liability due to negligence by facility owners and employers. Aquatic therapy is increasing in popularity as a method of treatment for patients with musculoskeletal and neurological conditions. 6,7 Over 2,000 facilities now provide aquatic therapy services. 8 The medical community is joining approximately six and a half million public and private swimming pools, spas, above-ground pools, and water parks to provide aquatic rehabilitation, and wellness programs. 9 Also, hospitals, therapists, and other providers are building pools to accommodate their patients' needs. Given this tremendous interest and increase in providing aquatic therapy for patients, it is surprising that water safety issues are not addressed during the training periods for either therapists or physicians.
Anyone in an aquatic environment can drown; therefi)re, basic water safety skills are of paramount importance in therapeutic settings. In addition, there are many potential hazards in any aquatic environment. According to the specific problems and areas of concern for aquatic therapy, there are basic principles and policies that should be part of the aquatic therapy facility. In the following section are the basic requirements of risk management in aquatic therapeutic environments.
SPECIFIC PROBLEMS AND AREAS OF CONCERN In any aquatic environment the number-one risk is drowning. The American Red Cross identifies the three most prevalent causes of drowning in pools: (1) failure to recognize hazardous conditions and practices; (2) inability to get out of dangerous situations; and (3) lack of knowledge ofthe safest way(s) in which to aid a drowning person. 10 All three are preventable through training in basic water safety skills. For instance, alcohol and drug use, diving into shallow or unknown water, over-
estimating physical ability/stamina, and medical emergencies in or around bodies of water cause most drowning.IO For safe swimming therapy pools must have, for example, nonslip surfaces, emergency communication systems, water-depth markings, and lifeguards on duty. The staff must be trained in personal water safety measures such as breath control and bobbing, floating on the back, survival floating, treading water, and releasing a cramp. Simple, safe reaching rescues are all basic methods for aiding a person in trouble in the pool. (Further basic water safety information is listed in Table 1.) There can also be problems with maintenance, such as water sanitation and chemicaVequipment handling, II and unexpected environmental emergencies can occur, such as earthquakes, gas leaks, power outages, and floods. Lighting fixtures and other building materials can fall into the pool causing injury or electrocution during an earthquake. Power outages and floods create emergency evacuation problems, especially when the pool is located in the basement of a building. Gas leaks can cause respiratory emergencies for both patients and staff. These situations need to be
Policies and procedures. 1,3-5,9,10,21,23,25 Aquatic Management Policies
Standards for therapy pools in relation to conduct vis-a-vis liability: 1. Medical intake prescriptions, informed consent, assumption of risk, and general release forms must be part of the procedures manual. 2. Pool regulations, visible signage identifying water depth, chemical storage, emergency phone, locker rooms schematic, and deck equipment must all be listed in the procedures manual and posted in the pool area, administration office, and with the insurance company. 3. Insurance policies, progress notes, accident/ incident forms, compliance with local, state, and federal health and safety codes must all be listed in the procedures manual. 4. Patient signs waiver, release, and indemnity agreements prior to treatment. In the event of an emergency, the forms release and hold harmless the staff and workers of the facility.
Prudent man laws apply to emergency situations if staff has acted appropriately, all aquatic staff certifications are current, and aquatic and first-responder rescue techniques are documented. 5. Aquatic department accident and incident report forms are used to identify specific actions taken by the stafr in detail, procedures followed, EMT response and medical treatment rendered, witnesses, and follow-up information. 6. General pool rules must be signed by patients prior to initiating pool therapy. 7. Rules include use of equipment, bathing suit requirements, usc of drugs, lost and found policies, diving, deck safety, spa use, showering pre and post treatments, and staff supervision requirements. (continued)
BACK AND MUSCULOSKELETAL REHABILITATION / OCTOBER 1994
Confidential medical questionnaire and statement: I. Patients sign medical questionnaire form and staff uses it to identifY heart disease, respiratory system problems, muscular condition, medication, swimming abilities, or other conditions that may alter the patient's response to aquatic therapy.
2. A medication list should be formulated to identifY how drugs may affect participation of patients in aquatic therapy. Some drugs to include but not limited to are: beta blockers (perceived exertion changes), Corgard, Lopressor, Atenolol, Tenormin, Prednisone, Tavist, Actifed, Valium, and Feldene.
Contraindications to pool therapy: 1. Complete evaluation by medical team prior to patient's participation in aquatic rehabilitation program determines appropriate program and identifies contraindications. 2. Contraindications are theoretically absolute. This leaves multiple precautions (see below). Contraindications may include but are not limited to: Cardiac failure Urinary infections Open wounds/contagious skin rash (draining boils)
Infectious diseases (must be a channel of transmission: conjunctivitis, primary (draining) herpes, airborne infections) Uncontrolled bowel or bladder incontinence Vomiting Scabies/lice Severe burns Menstruation without internal protection Premature rupture of membranes in pregnancy Supra-pubic catheter Non-tunnel IV catheters-high risk for serious infection (peripherally inserted catheters, single, double, or triple lumen)
Precautions to pool therapy: Concerns are aesthetic or require clinical judgment: 1. Hypersensitivity to sanitizing agents!chemicals
9. Ostomy-evaluate for odor, discoloration. used in pool Empty collection pouch prior to pool session 2. Thermoregulatory problems (e.g., heat 10. IV lines-cover with transparent dressing and plastic bag. Tunnel catheters are acceptable intolerance) due to Ditropan following individual assessment. Hickman! 3. Excessive fear of water 4. Severely weakened or deconditioned state Broviac, Groshong, implanted access device (Port-a-cath) 5. Compromised respiratory function. Vital capacities' predicted values should be stated as 11. Peripheral vascular disease a decreased percentage in parameters, in 12. Incipient cardiac failure predicted values rather than volume 13. Dysphagia (inability to swallow or difficulty in swallowing) 6. HIV is susceptible to chlorine/bromine (Opportunistic infections which pose greater risk) 14. Epilepsy 7. Multiple sclerosis> 88 degrees may be too 15. Unstable high/low blood pressure 16. Fever fatiguing and cause stress 8. Perforated ear drum In addition, entering the pool can be hazardous for some patients. If transfer equipment is not available, or if staff-to-patron ratio is high, then additional precautions and the staff's personal safety would need to be evaluated. (continued) anticipated and planned for, in order to minimize the risks they pose. When oxidizing and sanitizing agents are inadequate therapeutic pools can create infectious conditions. 12 Buildup of bacteria can cause infec-
tion, especially in warm water temperatures. This is an environment favorable to bacterial growth. Some microbiological agents are (1) intestinal (coliform) bacterium, which enters the body through cuts and abrasions; (2) infection caused by Giardia
Table 1. (continued) Procedures for the Therapy Pool I. Safety rules and procedures for staff and patients: a. Inflatable tubes, air mattresses, and artificial supports such as flotation belts should not be substituted for a person's swimming ability. b. Never allow anyone to enter the water without staff present. c. Avoid long periods of immersion in hotwater baths, hot tubs, or spas where water temperature affects heart rate and respiration. d. Emergency exit paths should be clearly posted in the pool area and dressing rooms. Emergency communication system should be made available in the dressing rooms. e. Keep emergency evacuation equipment on the pool deck and inspect all equipment on a regular basis. Equipment includes: shepherd's crook, life ring, rescue tube, resuscitation equipment, spine board, blanket, and scissors. £ Keep a well-stocked first-aid kit on or near the pool deck. 2. Emergency evacuation procedures (a partial list): a. Identify the position of the patient and equipment the patient may be using. What position are they in (vertical, prone, or supine)? Which way would they need to be turned to open the airway, and what equipment would need to be removed to do so? b. Outline the procedures to follow in each type of scenario: passive or active drowning. c. Prepare for the evacuation: get emergency equipment ready. d. Aquatic personnel responsibilities: Who calls 911, who evacuates the patient, who directs pre/post EMT response?
lamblia, which is transmitted after fecal discharge; (3) Pseudomonas aeruginosa, which causes swimmer's ear and folliculitis; and (4) staphylococcal bacterium, causing skin boils. 13 ,14 The risk of illness depends on the duration of time in the water, skin hydration with altered skin flora, and toxic reaction to enzymes or endotoxins produced by specific bacterium. 13,15,16 Exposure to endotoxins (airborne particles from the cell walls of dead bacteria) can create respiratory problems in the enclosed therapy pool. The Solar Energy Research Institute, Har-
g. Keep a list of patrons' telephone numbers and combination lock numbers on file in the event of emergency evacuation where personal belongings may need to be returned or nearest relatives reached. h. Means of entering pool by stairs, ramps, or ladders should be appropriate for patients' ambulatory ability. Provide a lift for non-ambulatory patients where necessary. 1. Keep all pool decking and dressing areas free of excess water. J. Benches, chairs, and toilet seats in the dressing rooms should conform to code, be the correct height for patients, and be in good working order at all times. k. Provide adequate ventilation in the dressing rooms. I. Avoid electrical shock by eliminating hair dryers where water may be present in the dressing rooms. e. Schematic diagram of pool for emergency exit drawn t.o identify exact location for response team. £ Unlock exit doors and notify administration office. g. Follow-up accident/incident documentation should be completed immediately after the accident, the insurance company should be notified, and information kept on file.
vard Medical School, and the National Centers for Disease Control have conducted research on the topic of endotoxin conditions. The City of Westminster, Colorado, whose pool was closed because of endotoxin proliferation in 1987, attributed the situation specifically to the sanitizing agents used in facility operations. I? Exposure to blood-borne pathogens is another risk that must be managed by aquatic therapy staff and owners. An exposure is defined as a situation where transmission can take place and where there is a carrying agent, an active carrier, and a
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Table 1. (continued) Procedures for the Therapy Pool (continued)
3. Aquatic personnel rescue scenarios and training documentation: a. Each staff person should be,able to perform e. Each staff person should learn the American safe reaching rescue techniques. Red Cross Head/Chin Support and Head b. In-service training for staff should be held Splint for immobilizing the cervical spine. on a regular basis. Simulated emergency £ An inspection log of the facility'S situations intended to test and evaluate maintenance room, dressing rooms, pool area, chemical use, and cleaning schedule as response systems for individual and group situations should be conducted every three well as all other health and safety regulations months. All typical emergency scenarios must be kept on file at all times. g. If a gas chlorinating system is used, the should be documented in the employee procedures manual. mechanical room emergency response c. Emergency telephone 911 system, security hazard system identification should conform cameras, and direct voice communications to to all health and safety codes for local and administration from pool area should be state guidelines. provided during facility operational hours. h. If the accident involves a child, accident d. A log of in-service training dates, type of records must be kept on file in the facility's training, and personnel present must be office until the child reaches the age of 18 kept on file for insurance purposes for five years, 6 months. years minimum.
susceptible recipient. Lifeguards and other persons who are exposed daily to potential carriers must be trained for any environmental hazard they may encounter on the job. 14 The Centers for Disease Control indicate that there are approximately 280,000 hepatitis B exposures per year by fire and first-responder personnel. 20 Many states' health and safety codes classify lifeguards in the first-responder category. A patient's fall on the pool deck or in the facility's dressing room may constitute an exposure for aquatic personnel. There is little evidence, however, that viral particles can be transmitted through the medium of pool water, because of water's chemical and physical properties, even without chlorine or other halogens present. 14
RECOMMENDATIONS AND CONCLUDING REMARKS Appropriate supervision on or around the pool means having a certified lifeguard on duty, over the age of eighteen, during operating hours. 1 Those under 18 are not oflegal age, and cannot be held responsible for their actions. The mini-
mum recommended certifications for all aquatic therapy personnel is Basic and Emergency Water Safety, First Responder (Advanced First-Aid), and Cardiopulmonary Resuscitation. Employees may also want training in the practice of universal precautions for emergency medicine. Ideally, at least one member of the staff should be a lifeguard and water safety instructor, certified by a nationally recognized training agency such as the YMCA, YWCA, American Red Cross, or Ellis & Associates. 21 I t is recommended that a staff person also take a certified pool operators (CPO) course offered by a reputable consultant company or provider. This type of course provides information on engineering controls for the maintenance and management of sanitizing agents, circulation and recirculating equipment, and general pool operation. In addition, the cost of lost-work-day injuries can be reduced with an injury, illness, and prevention program. The program must meet local, regional, and state uniform health and safety code requirements. 22 Aquatic center employers and owners must provide protective clothing and equipment to employees who are handling hazardous materials in order to minimize or prevent exposure to potentially infectious materials.
Staff risk management must include safety training, and staff must learn how to professionally handle patient situations in the pool, including the following: (1) discomfort or inability to swim in deep water with or without a flotation support; (2) physical fatigue; (3) respiratory distress; (4) muscular conditions (e.g., cramps); and (5) choking. Training must also prepare staff for emergencies in or around the pool, including: (1) obstructed airway; (2) severe bleeding; (3) cardiac conditions, including cardiac arrest and myocardial infarction; (4) cervical or lumbar spine injury; (5) seizure; (6) heat!cold-related emergencies; (7) diabetic shock!coma; (8) broken bones; (9) electric shock; (10) vision impairment; (11) hearing impairment; and (12) tainting. Safety in the aquatic environment hinges on the observation of rules designed to protect patients and staff from hazards in and around pools. The development of formal personnel policies and procedures, pool facility operations and management guidelines, emergency and nonemergency
communication standards, and records documentation are the first steps in pool facility management. Specifically, management policies and procedures should include documentation and implementation of the following: (1) standards of conduct vis-a.-vis liability; (2) confidential medical questionnaire to be completed by every patient; (3) contraindications to and precautions in pool therapy;24 (4) rules for patients; (5) emergency evacuation procedures; and (6) staff training, including personnel rescue and training scenarios. (See Table 1.) The implementation of policies and procedures outlines the rights and duties of patients and staff and expresses the philosophy of the facility and the rationale for the existence of programs. Primary consideration should be given to accident and illness prevention associated with the aquatic therapy environment. Adequate methods of problem identification, evaluation of safety methods, and careful documentation of daily operations will render the facility a safe, pleasing, therapeutic environment for both patients and staff.
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10. American National Red Cross. Lifesaving: rescue and water safety. Washington, DC: Water Safety Program, 1989. 11. Decker WJ. Chlorine poisoning at the swimming pool: an overlooked hazard. ] Clin Toxicol 1978; 13:377-381. 12. County of Santa Cruz. Procedures for evaluating exposure incidents. Santa Cruz, CA: Health Services Agency, 1992. 13. Kozlowski Jc. OSHA cites ocean lifeguarding and mouth-to-mouth resuscitation as risk activities. NRPA Aquatic Newsletter 1992; May:9-1O. 14. HighsmithAK, Kaylor BM, Calhoun MT. Microbiology of therapeutic water. Clin Mgmt 1991; 11 :34-37. 15. Occupational Safety and Health Administration (OSHA). Bloodborne facts: hepatitis B vaccinationprotection for you. Washington, DC: U.S. Government Printing Office, 1992. 16. Favero MS. Problems and solutions. Postgrad Med 1986; 80:282. 17. Matthews-Sargeant PJ. Swimming with the enemy. Pool and Spa News 1993; March:42-48. 18. Penny P. Swimming pool wheezing. Brit MedJ 1983; 287:442-461.
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19. Herman E. A mystery solved? Pool and Spa News 1993; july:20. 20. Occupational Safety and Health Administration (OSHA). Hepatitis B vaccination-protection for you. Washington, DC: U.S. Government Printing Office, 1993. 21. Moschetti M. Aquatic therapy: procedures and strategies for therapists. Paper presented at the Aquatic Therapy Symposium, Saint joseph's Hospital, Marshfield, WI, April 1993. 22. Occupational Safety and Health Administration (OSHA). Hazardous waste operations and emergency response. Washington, DC: U.S. Government Printing Office, 1992.
23. San jose State University. Aquatic center safety manual, blood-borne pathogens (supPI). San jose, CA: Environmental Health and Safety, 1992. 24. Shanda LD. Physiological responses to therapy in water. Paper presented at the Annual Meeting of the Aquatic Exercise Association, Aquatic Therapy Symposium, Minneapolis, MN, October 1993. 25. County of Santa Cruz. Regulation of the use of pesticides, definitions, label requirements, and codes. Santa Cruz, CA: Agricultural Commissioner Weights and Measures, 1992.
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