IMRF Members Società Nazionale di Salvamento (National Rescue Society of Italy - NRSI/SNS) have provided information prepared by Adm. (MD) rt. Dr. Francesco Simonetti, member of the SNS Medical and Scientific Committee, titled "A Proposal for Bathing Area Safety Assessment”.

The theme is focused on beach rescue with the vision of "a seamless rescue service from the beach to the open sea". The SNS would like to share the information with IMRF organizations that specialise in this kind of rescue, or for those that deal with a department devoted to beach rescue.

Many thanks to Admiral Romano Grandi, Vice Precident of the National Rescue Society of Italy, for providing this paper.

A Proposal for Bathing Area Safety Assessment - Method & Criteria

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A Proposal for Bathing Area Safety Assessment

Author: ADM. (MD) ret. Dr. Francesco Simonetti. - Società Nazionale di Salvamento (National Rescue Society of Italy - NRSI) – Medical and Scientific Committee – Genoa.

The proposal is aimed to define a method to evaluate the safety level of bathers and to publicize the outcome through a website called "Water Portal" (managed by the Ministry of Health) to the millions of tourists that spend their summer holidays on the Italian beaches. The co-operation between the Ministry of Health and the National Rescue Society of Italy has the intention of characterizing the bathing areas in three risk categories: high, medium and low.

For this purpose, objective criteria need to be developed and relevant data to be collected. The safety assessment is referred to the "bathing area" (BA), broader term than the beach alone, i.e. a stretch of coast or lake or river bank that can be considered with uniform characteristics on the basis of its natural (geo-morphology, hydrology) and anthropogenic (administrative boundaries, crowding, etc.) profiles. Furthermore, each BA is already defined for safety health reasons, placing in each of them a single water sampling point, periodically checked for its hygienic quality.

Risk Analysis in the BA

The evaluation process of the risks associated with a given environment or activity consists of a formal succession of logically ordered phases. They are: 

•	Analysis of risk factors;
•	Risk assessment;
•	Risk reduction measures.

Analysis of BA Risk Factors

Risk factors can be in the environment or in individuals, such as their behaviour, metabolic disorders, diseases, lifestyle, age, etc.

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Environmental Risk Factors

The following table provides an overview of environmental risks, the way in which they can cause injuries and their risk of damage to humans.

RISK FACTOR	MECHANISM OF INJURY	RISKS
Shore steepness >5%	Seabed steepness – Difficulties getting in and out of the water for children, elderly and disabled -High and fast waves	Traumas and wounds/Drowning
Cliffs impending over shore	Falling rocks	Traumas and wounds
Nearshore oblique bars	Rip currents	Drowning
Groynes perpendicular or parallel to shore	Rip currents	Drowning
Underwater reefs with gaps	Rip currents and seabed holes	Drowning
Submerged structures of any kind	Rip currents	Traumas and wounds Drowning
Low and rocky seabed	Poor visibility of obstacles	CVT – Multiple injuries
Sudden seabed vertical drops (gap or hole)	Difficulties for swimmers	Drowning
Sudden flood or water level increase	Surprise factor and problems for swimmers and non-swimmers	Drowning
Excessive wave motion	Problems for swimmers and non-swimmers	Drowning

Individual Risk Factors

They concern the BA users, who can be endangered by their behaviour, or be carriers of deficiencies or other factors which, in the given scenario, can trigger serious and even fatal outcomes. Children, when they escape from their parents’ supervision, fall into a special category.

The following table provides a summary of individual risk factors.

RISK FACTOR	MECHANISM OF INJURY	RISKS
Behaviour	Diving in shallow waters or onto submerged rocks	CVT - Drowning
Behaviour	Little or no swimming skill – overestimation of one’s own abilities	Drowning
Behaviour	Sudden contact with cold water – pre-diving prolonged hyperventilation – failure to pause during digestion	Drowning
Behaviour	Imprudence, defiance, exibitionism	Drowning
Behaviour	Drug or alcohol use	Drowning
Cardio-vascular	Heart attack – malignant arrhythmias	Sudden Death (SD)
Age (children, elderly)	Lack of supervision, weakness, indecision, delayed or wrong reactions	Drowning
Disability	Mental or motion impairments - Injuries	Drowning

Risk Assessment

It is defined as the likelihood that the exposure to one or more risk factor results in a damage. It is a function of the occurrence frequency and the severity of damage. The main risk to be prevented in the BA is drowning. However, other risks of damage or injuries must be considered, such as cranio-vertebral traumas (CVT) and sudden death (SD).

Risk Reduction Measures

The beneficial effect can be achieved both by preventing the start of the chain of events that might lead to adverse results (primary prevention), and, if already started, by interrupting the progression to more severe consequences (secondary prevention). Such are the cases of a favourable outcome with basic life support (BLS) in near-drowning, spine stabilization with spinal board and cervical collar in CVTs, successful application of automated external defibrillator (AED) in a situation of SD. Here follows a list of risk reduction measures:

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Environmental Risk Factor Warnings

These warnings can be conveyed through:

•	Boards, with beach safety signs and appropriate symbols;
•	Buoys, to indicate the outer boundaries of the “swimmer area” or areas reserved for sailing or motor boats, to which access is prohibited;
•	Safety flags, rapid means of communication, clearly visible to all, indicating unfavorable sea conditions and high winds: in particular, the red flag indicates dangerous swimming or lack of rescue service.

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Surveillance

Surveillance is the lifeguard core activity and embodies the primary prevention activity in two ways: surveillance itself, i.e. careful visual observation of the BA; information on the BA risks, coupled with indications on behaviour to be taken or stopped.

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Rescue

Distressed people in water tend generally to struggle, trying to draw attention, before eventually going down. In these cases, to prevent drowning, there is no alternative for rescue but the direct intervention of the lifeguard.

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Basic Life Support (BLS)

This can be defined as the sequence of observations and actions on the part of the lifeguard, to restore and maintain the main vital functions (breathing and blood circulation) of the rescued individual.

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Emergency Aid Tools (EAT)

BLS procedures can be applied without any additional equipment. However, best results are achieved using devices aimed at more effective results and rescuer safety: pocket mask, disposable face-shield, AMBU bag, portable aspirator, portable oxygen cylinders, cervical collar, spinal board.

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Advanced Life Support (ALS)

The lifeguard, as a professional rescuer, is integrated into the rescue chain with other professional operators, and with those of medical emergencies. He maintains the vital functions until their intervention, when re-assessment and, if needed, treatment continuation takes place, with more complex procedures and drug administration. The timeliness of emergency-trained nurse and doctor intervention is of paramount importance. Emergency vehicles (car, van, boat or helicopter) must access the BA within 20 minutes from call, this time being in Italy generally considered a standard.

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BA Safety Score (SS)

The risk for bathing in a specific BA can be deduced as it appears from the following table by the presence (or absence) of the safety measures listed above. The final score is defined as the AB Safety Score (SS). The SS is comprised between a minimum of 0, indicating the absence of any preventive measure, and a maximum of 31, when all possible preventive measures are in place.

The SS is a safety indicator and therefore is inversely related to the bathing risks in a specific area: the higher the SS, the greater the safety, the lower the risk.

Risk Reduction Measures	Risks	Score				Applicability
			Absence		Presence
Boards	Drowning – CVT		0		1-3
Buoys	Drowning		0		3
Flags	Drowning		0		3	If permanent lifeguard is present
Surveillance	Drowning – SD - CVT		0		4	Same as above
Rescue	Drowning – SD - CVT		0		3	Same as above
BLS	Drowning - SD - CVT		0		3	Same as above
Emergency Aid Tools	Drowning - SD - CVT		0		9	Same as above
ALS Within 20’ from Call	Drowning - SD - CVT		-10		3	Same as above
Safety Score			min 0		max 31

BA Classification into Risk Classes

A BA can be classified as:

"High Risk", if the SS is less than 10. It applies mainly to the so called "free beaches", where it is not compulsory to organize a beach rescue service with permanent lifeguards.

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"Medium Risk", if the SS is between 10 and 22. It applies to a BA where the lifeguard is permanently present, but the EAT equipment is absent or incomplete. This category also includes a BA which is manned by a permanent lifeguard and equipped with the full range of EAT, but cannot be timely reached by emergency medical teams.

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"Low Risk", if the SS is over 22. It applies to a BA with a permanent lifeguard and a full EAT equipment. The BA can be defined "cardioprotected" because an AED is available. Moreover, the rescue chain continuity is ensured, and ALS can follow on from the BLS without interruption. This situation corresponds to the highest possible state of safety.

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Conclusions

The wide publicity to BA riskiness ensured through the Ministry of Health "Water Portal" can be a powerful stimulus for promoting safety.

This should result in directing users to consider safety as an essential part of bathing quality, and a growing awareness of the safety value in organizations, public or private, providing such services. In fact, postponing the protection of human lives in exchange for a short-term economic advantage appears ethically and culturally unsustainable.

The constant improvement of bathing safety must be pursued with determination, applying clear and widely shared criteria, establishing quality processes and employing every necessary means to ensure that opportunities for recreation, health and close contact with nature do not become tragedies. Above all, this goal is demanded by the silent voices of the drowned, resounding in national statistics and media.

Download the PDF Version below:

A Proposal for Bathing Area Safety Assessment