Safety First

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July 2003

By Mary O. Wykle, PhD, ATRIC

The field of aquatic therapy is expanding. While therapy pools are commonly found in sports medicine centers, retirement facilities, rehabilitation centers, and public service agencies, a current trend finds private facilities also providing aquatic therapy and rehabilitation. Practitioners in these facilities are often independent owners or contractors, while other aquatic therapy practitioners gain employment by private agencies holding contracts with health care companies for use of private and public pools.

As the field of aquatic therapy grows, the quality of service must be commensurate with current professional guidelines. Aquatic therapy professionals accept the ethical commitment to abide by a standard of care that reinforces basic water safety and risk management criteria for patients and practitioners. To further solidify this commitment, Standards and Guidelines for Therapy Pools and Safety Standards for Aquatic Therapy and Rehabilitation Practitioners have been created, and are now in the final approval stages.

A NEED FOR GUIDANCE

Approximately 3 years ago, the Aquatic Therapy and Rehabilitation Institute (ATRI) began defining the Standard of Care for the rapidly growing specialization of aquatic therapy and rehabilitation. These standards are additions to the Industry Standards already in existence.

ATRI is a nonprofit organization created to further the education of health care professionals working in the aquatic environment. One of its goals is to ensure aquatic therapy and rehabilitation practitioners are professionally trained and certified to provide the highest quality of care. ATRI discovered there were no standards directly pertaining to therapy pools or practitioners who work in them, and undertook the challenge to develop standards and guidelines for both.

Founded in 1918, the American National Standards Institute (ANSI) is a nonprofit membership organization serving as administrator and coordinator of the United States private sector voluntary standardization system. Standards developed in accordance with ANSI criteria will withstand scrutiny while protecting the rights and interests of all participants. Among the 51 ANSI standards on swimming pools, none currently address therapy pools and aquatic therapy practitioners.

The National Spa and Pool Institute (NSPI) develops comprehensive technical standards for the pool and spa industry. NSPI currently has seven standards addressing swimming pools, spas, and hot tubs. These standards meet the criteria of ANSI and carry approval as ANSI/NSPI Standards. None address therapy pools. ATRI accepted the challenge to develop standards and guidelines for therapy pools and standards for aquatic therapy and rehabilitation practitioners to fill the identified void.

GETTING THERAPY POOLS IN LINE

The purpose of the standards and guidelines for therapy pools is for the safe operation of the facility and for safety in the practice of aquatic therapy and rehabilitation. The standards are not intended for design and construction of a therapy pool. Statutes developed by NSPI and health agencies at the state, county, and local level have regulations and administrative codes identifying practices and standards for construction and design of swimming pools. Public regulatory agencies oversee quality control. Pool design is often beyond the control of practitioners.

The first standard addresses the necessity of an appropriate and comprehensive Emergency Action Plan (EAP). The EAP defines steps taken in a timely response to emergencies and situations endangering the health and safety of the users. The EAP is a written document posted with the facility. The plan is practiced on a regular basis and records kept of those participating in the training session. The EAP covers the recognition of an emergency, plan activation procedures, and the role of all staff in providing care. Also included in a documentation file maintained for the annual competency assessment is the Bloodborne Pathogens Plan and documentation of any incidents, and plans showing surveillance, evacuation routes, copies of current certifications and licensures with expiration dates, and rescue and first aid/CPR equipment available on deck.

The last item is the policy on pool closure for environmental conditions based on recommended guidelines of the National Weather Service and the National Lightning Safety Institute.

The second standard addresses administrative requirements of the person with supervisory responsibility to ensure a safe environment for staff and clients. Daily safety checks of the facility are documented.

Signage is posted in accordance with ANSI guidelines listing therapy pool rules, warnings, and regulations. The standards highly recommend that the pool supervisor is certified as a pool operator. ATRI stresses the importance of certified lifeguards supervising the therapy pool whenever it is in use. The National Aquatic Coalition (NAC) has approved lifeguard guidelines. The position paper is posted on the NAC Web site. Accepting patients for therapy and rehabilitation follows standard indications, precautions, and contraindication guidelines. Individual therapy pools make final decisions on whom to treat.

The third standard alerts all practitioners to the importance of complying with applicable published national, state, and local government agency rules, regulations, health codes, and published standards. It is the responsibility of the supervisor or independent aquatic therapist to obtain copies of and prudently review relevant codes, regulations, checklists, and information sheets. In addition, adherence to precautions established by the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Rule and the Preventing Disease Transmission plan is documented. A Hazard Communication Standard referencing Material Safety Data Sheets on all chemicals stored at the facility is in the Exposure Control Plan.

The last standard addresses maintenance of proper water chemistry, air quality, and ventilation. Results of regular water quality testing are in the analysis log and posted for review. Therapy pools require properly operating filtration and drainage systems. Water circulation and filtration systems of appropriate size operate 24 hours a day. Water clarity determines the use or closure of the therapy pool. The therapy pool must have a recirculation system separate from any nontherapeutic pool. These four standards address basic policies. Details are provided upon request from ATRI.

PRACTITIONER STANDARDS

The standards for aquatic therapy and rehabilitation practitioners are specific to the practitioner rather than the pool or facility. The first standard addresses professionalism. In addition to licensure specific to practitioners, they are encouraged to qualify for and maintain certification through the International Council for Aquatic Therapy and Rehabilitation Industry Certification (ICATRIC). Emergency skill certification includes training in first aid and CPR. Automated External Defibrillation (AED) training and Supplemental Oxygen training will be requirements in 2004.

Lifeguarding skills are essential. Any complete lifeguarding course satisfies this requirement. The majority of practitioners are not lifeguard certified and many do not have certified lifeguards on duty when treating patients. ATRI coordinated with Ellis and Associates to develop a course specific to the needs of the practitioner. Risk Assessment and Safety Training (RAST) teaches rescue skills in the therapy environment and emphasizes the elements of risk management.

Supervisory guidelines make up the second standard and address surveillance, precautions, and contraindications. State and county codes limit ratios of practitioners to patients for effective surveillance or monitoring. Water depth is another consideration. Staff are trained to assist in emergencies and practice the EAP. The advantages and potential risks of aquatic intervention determine the appropriateness of aquatic therapy. Proper care requires adherence to medical guidelines and infection control policies. Education of referring doctors is at times necessary. Knowledge and understanding of bioethics include familiarization with resuscitation orders, refusal of care guidelines, and choice of treatment options.

In the third standard, safety of the patient is essential, but personal safety of the practitioner is paramount. Immersion time for the practitioner includes length of time, continuous time in the water, temperature of the water, personal heat retention devices, and water and air chemistry. Current recommendation is a maximum of four continuous hours per day in an enclosed area. Practitioners must have an emergency communication system available at all times. They must also have the skills to self-rescue in an emergency. Practitioners in deep water should have a monitor or assistant on deck with the ability to effect a rescue. The preference is to have a lifeguard on deck.

The safety of the client begins from entry into the facility until departure. In the pool area, transfers in and out of the pool are appropriate to the needs of the patient. Nonslip surfaces on floors and transfer equipment are maintained in good condition. Safety extends to communication between patient and practitioner. Special concerns for visual-impaired and hearing-impaired clients require prior planning. Noise distractions should be minimal, pool markings clear, and prearranged emergency signals understood. The Standards and Guidelines for Therapy Pools address the fourth and fifth standards emphasizing the risk management program. Legal and liability issues require adherence. Practitioners are reminded of the importance of having and being able to implement basic assists, rescues, and extrication from the pool. Americans with Disabilities Act (ADA) guidelines ensure a safe and accessible facility. The OSHA standards including the EAP, Bloodborne Pathogens Plan, and Exposure Control Plan are delineated.

The fifth standard emphasizes the practitioner’s responsibility for the safety of their patients. Implementation of safety measures, including the EAP, is dependent upon the ability to recognize emergencies quickly.

First, physiologic stress in patients is of primary importance. Facility evaluations ensure the safe working environment. Water chemistry testing and knowledge of optimum water and air temperatures and humidity levels determine usage of the therapy pool. Facility evaluations are important for the well-being of the patient and the practitioner. The practitioner is often called upon to decide whether the therapy pool is open or closed. The final point addresses hygiene rules. Hot or warm soap showers are encouraged by all using the pool to remove body oils, perfumes, and lotions that can affect pool chemistry.

Summary

Many aquatic therapy and rehabilitation practitioners have excellent protocol knowledge, but little knowledge of codes, regulations, and safety issues. Surveys of attendees at ATRI training events show many practitioners are working one-on-one in pools with no other staff in the facilities. Appropriate rescue equipment is not available and most have never seen or heard of a rescue tube. Emergency communication systems are hit-or-miss. There are no lifeguards on deck. The aquatic therapy industry is extremely fortunate not to have accident cases documented. As the popularity of aquatic therapy expands, it is essential to train and educate practitioners to assess their environment, patients, training, and safety. Standards provide the guidelines. Spread the word that help is available. The ATRI continues to promote all facets of training and education. It is there to answer questions and to support aquatic therapy and rehabilitation practitioners.

Mary O. Wykle, PhD, ATRIC, is assistant professor of physical education, Northern Virginia Community College, Annandale, Va. She holds ATRI, Aquatic Exercise Association, and Aquatic Red Cross Instructor Trainer certification. She codeveloped the Risk Assessment and Safety Training (RAST) course with Ellis and Associates, and wrote the Safety Standards and Guidelines for Therapy Pools and Safety Standard for Aquatic Therapy Practitioners currently under copyright approval through ATRI.

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