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Jamie Holland, MD
Wendi Wendt, MD

Drowning is the leading cause of death in children ages 1 to 4 and is the second leading cause of unintentional injury related death in adolescents ages 5 to 14 in the United States. Prior works have reported that rates of drowning death vary with age, sex, and race. In addition, age has been found to be an important determinant of drowning location, with infants being more likely to drown in bathtubs and buckets, preschool-aged children being more likely to drown in swimming pools, and older children and adolescents being more likely to drown in natural bodies of water.

This study aims to describe encounters for patients presenting to a single emergency department after a drowning event to identify possible risk factors for these events to help target future interventions.

We performed a retrospective chart review for a single tertiary-care, academic emergency department from November 2012 to June 2023, including patients age 0-17 presenting after a drowning event. Data collected included both patient specific information, as well as details of the drowning or submersion event. Summary statistics were used for descriptors, whereas Chi-Square, Wilcoxon, and Kruskal-Wallis tests were used for comparisons.

We identified 161 children presenting for care after a drowning event. The median age for patients was 4.0 years, with a greater proportion being male (53.4%). When a location was listed, drownings most often occurred around the home (16.1%), at a natural body of water (16.1%), or at a hotel pool/spa (14.9%). Saturday was the most common day for drowning events to occur (28.0%). When separated by age, patients 0-4 years were more likely to drown around the home compared to older children. Patients >4 years were more likely to drown at private pools and hotel pools/spas compared to younger children. Public pools and natural bodies of water posed a drowning risk for children of all ages.

For the majority of patients (59.0%), a parent or family member was identified as being the supervisor at the time of the drowning event. The rescuer was most often a parent or family member (49.1%), followed by a bystander (15.5%).

Similar to prior studies, our results found that young children, as well as males are at highest risk for drowning events. With regards to event details, we identified natural bodies of water, specifically Lake Michigan, as a common location for drowning events. In addition, our findings highlighted the dangers of hotel pools/spas that do not have lifeguards on duty and are frequently locations for parties and gatherings where supervisors may easily become distracted. Parents and family members were often both the supervisor and the rescuer at the time of these drowning events. Results from this project may be used to shape future drowning prevention efforts and lead to improved water safety in our community.

1. Recognize the frequency of drowning related deaths in children and the impact it has on our communities
2. Discuss possible risk factors for pediatric drowning events
3. Emphasize the need for further drowning prevention efforts to promote water safety for children

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Phyllis Agran, MD, MPH
Van Greco
Diane Winn
Jaya Bhalla, BS
Nakia Best
Romeo Ignacio
Chaksu Soni
Soheil Saadat
Shahram Lotfipour

Drowning is the leading cause of unintentional injury death among U.S. and California 1-4-year-old children. The California EpiCenter Injury database provides information on rates of childhood drowning over time by victim demographics and location. However, addressing limitations to adequately inform prevention requires improved documentation of key variables for specific ICD-10 CM coding. Our goal is to improve data documented in medical records by creating a data collection tool that can be used in the hospital setting. Specific objectives were to 1) determine key elements for hospital-based record documentation and create a data collection tool; 2) review a sample of cases to indicate documentation gaps; and 3) create a simple guide for data collection and local surveillance.

We reviewed child drowning surveillance and data collection tools used at the national, state, and local levels, and produced a reference table and a “Flowchart: Outcomes and Sources of Data for Drowning Incidents” indicating portals for hospital record data entry. A team of healthcare experts participated in the development of the data collection tool. We then conducted a retrospective review using a convenience sample of 12 hospital records to identify data element gaps. We then developed the “Child Drowning Surveillance Guide.”

Portals of data entry for drowning cases were identified. The retrospective chart review of participant facilities revealed the following. General demographic information was well documented except for gaps in race (67%) and ethnicity (42%). Incident narratives included the location of the pool (documented in 92% of cases), child location prior to the event (83%), pool access (75%), and supervisor location (100%). Shortcomings included safety device (25%) and pool fence (33%) descriptions. All cases had a Social Worker consult.

Gaps identified in the state database resulting in “unspecified” and “unknown” codes that provide no further context to the drowning incident, such as location, can be addressed by improved hospital discharge data ICD-10 CM coding. However, ICD-10 code limitations call for more comprehensive surveillance systems. Our surveillance guide can be used for hospital documentation/surveillance, physician, nurse, and social worker training; child death team case review; and, social worker and home visitation professionals charged with assisting with a family safety plan to prevent drowning incident recurrence. The California Legislature found a solution to the statewide drowning data collection gap through the implementation of SB 855 (Newman, Ch. 817, Stat. 2022: Childhood Drowning Data Collection Pilot Program). This bill requires the State Department of Public Health to establish and administer the Childhood Drowning Data Collection Pilot Program for fatal and nonfatal incidents. Our Child Drowning Surveillance Guide can contribute to the establishment of electronic tools used for the state data collection system that will further inform prevention. Child Drowning Surveillance (UCI Institutional Review Board #1940, #1953)

1. Statewide Vital Statistics and Hospital Discharge Data are limited in contextual information regarding child drowning incidents.
2. ICD-10 CM coding gaps hamper hospital-based surveillance of child drowning incidents.
3. Enhanced medical record documentation of variables addresses these coding gaps.

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Rohit P. Shenoi, MD
Linh Nguyen, PhD.

Drowning is the leading cause of unintentional injury death in US children aged 1-4 years. Texas led the US in fatal pediatric drownings between 2018-2021. We assessed the economic burden of unintentional fatal and non-fatal pediatric drowning in Texas.

This was a cross-sectional study involving children aged 0-17 years treated for unintentional drowning in Texas hospitals during 2016-2022. We obtained inpatient (IP) and outpatient (OP) data from the Texas Health Care Information Collection. We selected fatal and non-fatal unintentional drowning (including water-transport related) encounters and excluded undetermined intent drowning, subsequent and sequela encounters. Data included demographics, diagnoses, procedure codes, body of water, length of stay, discharge status, and facility charges. The economic burden comprised direct medical costs (DMC) and indirect costs (IC) associated with drowning IP and OP treatment. DMC includes facility and professional costs. Facility costs (accommodation, ancillary services, outpatient charges, ambulance fees) were estimated by multiplying the facility charges by mean year-specific, county-specific cost-to-charge ratio. Professional costs were the product of facility costs and professional fee ratio for drowning. DMC was converted to 2022 US$ using the Consumer Price Index for All Urban Consumers Medical Care Services. To estimate IC, we measured the caregiver productivity loss based on time needed to care for a hospitalized patient or to visit the emergency department (ED). Workdays lost (#inpatient days or 1 day for ED visit) were multiplied by the average daily compensation for full-time employees and the average wage multiplier incurred by the employer due to worker absence to compute economic loss of productivity. We performed descriptive analysis and utilized non-parametric tests to estimate the economic burden and cost variations among groups.

There were 1,339 pediatric hospitalizations in Texas during 2016-2022. Most drownings occurred in swimming pools (41%); Fatal drownings occurred in 15% of hospitalizations. Most hospitalizations occurred in children aged 1-4-years (64%). Males, non-Hispanic White children, and commercially-insured constituted the majority (63%,39% and 52%, respectively) of drowning patients.

DMC IP costs averaged $62,398 with no significant differences in mean costs by sex, race/ethnicity, or insurance. Fatal drownings incurred significantly higher mean IP costs ($99,248) than non-fatal drowning ($55,852)(p<0.001). Watercraft-related drownings ($121,393) and bathtub drownings ($107,070)(p<0.001) had the highest mean IP costs. Mean DMC OP costs were $2,593 and varied by race/ethnicity, insurance, and body of water (p<0.001). Watercraft-related drownings incurred the highest mean OP costs ($3,324). The mean productivity loss was 6.2 days. IC averaged $3,299 and varied by age, race/ethnicity, insurance, discharge status, and water body (p<0.05). Non-fatal drownings had higher mean IC ($3,356) than fatal drownings ($2,974). Watercraft-related drownings had the highest mean IC ($8,707), followed by bathtub drownings ($4,982)(p<0.001).

Pediatric drowning is a significant economic burden in Texas. Costs varied by age, discharge status, and body of water. Fatal IP and watercraft-related drownings incurred the highest direct and indirect costs.

1. Compute direct and indirect costs from drowning injuries
2. Discuss the economic burden of pediatric drowning in Texas.
3. Recognize groups that incur the highest drowning-related costs

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Victoria Thompson, DO
Micaela Parson, MS4
Brit Anderson, MD
Kerry Caperell, MD, MBA, MSC

Drowning is a leading cause of injury-related death in the pediatric population. The circumstances surrounding drownings are varied, impacting primary prevention. The purpose of this study was to evaluate pediatric drownings seen in a pediatric emergency department (ED) and drowning-related deaths in the metro area surrounding a pediatric trauma center, to determine annual injury rates and describe injury characteristics.

Retrospective chart review was completed for patients <18 years old who lived in the metro area of this land-locked state and were seen at a pediatric ED with a chief complaint, or ICD-10 code, related to drowning from 1/2016-1/2022. Coroner’s data with the same inclusion criteria completed the dataset, and duplicates were excluded. We extracted demographic information, relevant past medical history, disposition, location of residence, and water source. Injury rates were calculated using census data. Descriptive statistics, chi-square, and mapping software were used for analysis. Injury rates are expressed as injuries per 100,000 children per year.

219 patient encounters met inclusion criteria. The mean age was 4.2 years (SD 3.7), 55.7% male, 69.4% white, 20.1% Black, 6.9% Hispanic ethnicity. The majority (61.2%) occurred in the summer and nearly half on the weekend (43.8%). 14.2% of patients had a diagnosed neurologic/neurodevelopmental condition, while only 1.4% and 0.5% had a documented psychiatric and cardiac history, respectively. Pools were the most common site (71.2%), followed by bathtubs (20.6%) and open water (5.9%). Evaluation of disposition showed that 54.7% went home from the ED, 25.1% were admitted to the medical-surgical floor, 12.3% were admitted to the pediatric intensive care unit (PICU), and 6.9% died. Of the children that died or were admitted to the PICU, 26.2% had a previous neurologic/ neurodevelopmental diagnosis. The overall injury rate for the included region ranged from 9.6-15.5 during the study period. 2022 had the highest injury rate at 15.5.

Drownings in our metro area are more common in pools, during the summer, and disproportionally on weekends. A considerable number of children had a previous neurologic/neurodevelopmental diagnosis. Along with mapping, this critical information will be used to target finite resources for local primary injury prevention. This methodology could be employed to inform injury prevention in other locations.

1. Describe how local data sources can be used to describe injury epidemiology.
2. Examine characteristics associated with pediatric drowning and consider targeted injury prevention strategies.
3. Evaluate geographic distribution of pediatric drownings to target injury prevention.

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Aedan Villegas, BS
Shaila Zaman, PhD
Rohit P. Shenoi, MD

Media reports are a source of information on fatal drowning. The narratives provide information about demographics and contextual information of victims. We sought to describe the epidemiology of fatal drowning in the metropolitan Houston region using artificial intelligence to analyze media report narratives.

This was a cross-sectional study of victims of unintentional drownings of all ages who drowned in the 8-county metropolitan Houston region from 2016-2022. We queried the search platform – NexisUni using keywords “drown” and “submersion” to access online media archives of fatal drownings from the following formats: print; blog, video, and audio records. Temporal data, demographic information (age, sex, ethnicity, race), risk and protective factors were obtained from the narratives. We developed an automated method to extract the information using the natural language processing (NLP) capabilities of OpenAI's GPT-3.5 model. The OpenAI API significantly enhances the efficiency and accuracy of extracting structured information from unstructured text by implementing advanced NLP techniques, facilitating efficient handling of large datasets with precision that surpasses manual methods. Using OpenAI API, we focused on extracting key factors such as swimming ability, supervision status, alcohol use, and life vest use from narrative descriptions of drowning circumstances. Our approach involved prompt engineering that guided the model to output structured responses in a dictionary format, ensuring consistency in the extracted data. The method was implemented in Python, where we utilized the OpenAI API to process each narrative in our dataset. The responses were then parsed and organized into a structured format suitable for further analysis. We used descriptive statistics for reporting results.

There were 133 media reports of drowning between 2016-2022 in metropolitan Houston. We analyzed 110 cases of drowning after excluding non-fatal (n=16), homicides (n=4) and those external to the Houston region (n=3). The mean age of drowning victims was 25.5 years (Std. Dev. ±23). There were 49 (44.5%) children; males constituted 81% of reports. The majority of drownings occurred in natural water (73%). The rest occurred in confined water (swimming pools, bathtubs)(26%) and unknown (1%) Life jackets were used by 33% of drowning victims; their use was unknown in 67% of cases. Fourteen percent of drowning victims knew how to swim, whereas 19% did not know how to swim. Swimming ability was unknown in 67% of cases. A majority of drowning victims did not consume alcohol (65%). Only 1% consumed alcohol and its use was unknown in 34%. Among children, 65% were supervised, 10% were unsupervised. Supervision was unknown in 25%.

Media reports are an alternate source of data on fatal drowning. Artificial intelligence is a novel method to extract drowning information from media report narratives for epidemiological purposes. However, the utility of media reports in drowning surveillance and prevention is limited, given biases in reporting and sub-optimal reporting of information on protective and risk factors. Engagement with media outlets to include drowning prevention information during reporting is encouraged.

1. Explain how artificial intelligence can be used in injury surveillance
2. Discuss the epidemiology of drowning obtained from media reports.
3. Recognize the limitations of media reports in describing the epidemiology of drowning

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Barbara D. Cosart, MLIS, MPH, CHES
Stewart R. Williams, MBA
Karla A. Lawson, PhD, MPH
Molly B. Johnson, M.AmSAT, PhD

Among children with autism, drowning is the leading cause of death through age 14. Autistic children are more likely to drown than neurotypical children. Attributes, such as wandering, sensory issues, impulsivity, and a limited sense of danger, could increase risk. In addition, autistic children often have trouble participating in structured group activities, such as swimming lessons. The purpose of this study is to better understand water safety experiences of parents of children with autism.

Parents of children with autism were asked to complete a brief online survey and to participate in a focus group about their water safety experiences. Six focus groups consisting of 2-6 participants, and one individual interview were held. Focus groups and interviews were recorded and transcribed by the study team. The codebook, created using both deductive and inductive approaches, was revised throughout the study period to aid in thematic analysis of the participants’ contributions.

Twenty-one parents participated in a focus group or interview (95% female, 5% male, average age 44 years). Participants were parents of 1-3 children with autism (n=25, 72% male, 20% female, 8% Trans/non-binary, average age 11 years). Parents reported that 43% of the children had completed multiple years of swim lessons; 33% had completed multiple sessions; 14% had attempted, but not completed more than one session; and 10% had never attempted swim lessons. Several major themes were identified that were near-universal among participants. Parents viewed the experience and training of swim instructors teaching autistic children as being of paramount importance. They highlighted characteristics such as impulsivity, elopement, poor sense of danger, and sensory and communication challenges that affect risk of drowning and participation in learn-to-swim programs. Parents pointed out barriers in accessing adaptive swim lessons due to scarcity of experienced instructors and high cost of these lessons, and that they have often received inadequate information about water safety in the context of autism. Parents indicated that autistic children have uniquely different characteristics and needs presenting complexities in scheduling and adjusting activities around therapy. Parents contributed valuable insight into what would make a learn-to-swim program successful for their autistic children. This includes instructors who have a deep understanding of autism, tailored instruction according to their child’s unique sensory, behavioral, and motivational needs, and a sensory-friendly environment with few distractions.

Water safety needs to be elevated in importance for families of autistic children. Information on drowning risk and prevention should be proactively provided. Barriers to adaptive swim lessons such as cost, scheduling, and availability need to be addressed. More training opportunities need to be provided to swim instructors to improve teaching children with complex needs, such as those with autism.

Identify several individual characteristics that are prevalent among autistic children that contribute to a higher risk of drowning
Identify several prevalent challenges to water safety faced by families of autistic children
Identify barriers and facilitators to successful learn-to-swim instruction for children with autism