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Hot Tub, Whirlpool, and Spa-Related Injuries in the U.S., 1990–2007
Hot Tub, Whirlpool, and Spa-Related Injuries in the U.S., 1990 –2007 Maya Alhajj, BS, Nicolas G. Nelson, MPH, Lara B. McKenzie, PhD, MA Background: Recreational use of hot tubs, whirlpools, and spas has increased within the past 3 decades. Injuries due to hot tubs, whirlpools, and spas can affect people of all ages and can result in serious disabilities. Purpose:
This study examines nonfatal hot tub, whirlpool, and spa-related injuries on a national level.
Methods:
The National Electronic Injury Surveillance System database was used to examine cases of nonfatal hot tub, whirlpool, and spa-related injuries treated in U.S. emergency departments from January 1, 1990, through December 31, 2007. Analysis was conducted from November 2008 to March 2009.
Results:
An estimated 81,597 patients, aged ⬍1–102 years, were treated in U.S. emergency departments for hot tub, whirlpool, and spa-related injuries, with the number increasing 160% over the 18-year study period (p⬍0.001). Nearly 73% of injuries occurred in patients aged ⱖ17 years. Lacerations were the most common diagnosis (27.8%) and accounted for 58% of all head injuries. Slips and falls were the most common mechanism of injury (47.6%); were more likely to result in an injury to the trunk than other body parts (OR⫽2.49, 95% CI⫽1.83, 3.39); and were more likely to result in concussions and fractures/dislocations than any other diagnosis (OR⫽7.813, 95% CI⫽2.194, 27.823 and OR⫽3.017, 95% CI⫽2.057, 4.425, respectively).
Conclusions: Given the increase in hot tub, whirlpool, and spa ownership and the 160% increase in injuries during the study period, more research is needed to identify the cause of the increase in hot tub, whirlpool, and spa-related injuries and what injury-prevention solutions and policies may be appropriate. (Am J Prev Med 2009;37(6):531–536) © 2009 American Journal of Preventive Medicine
Introduction
I
n the U.S., private sales of hot tubs, whirlpools, and spas (for the purpose of this paper, hot tubs will refer to hot tubs, whirlpools, and spas) began increasing in the early 1980s. In 1988, there were an estimated 1.8 million hot tubs in use in the U.S., with approximately 250,000 spas being sold annually across the nation.1 Today, hot tubs are a ubiquitous feature in homes, hotels, fitness centers, health spas, and pools. Previous studies of hot tubs have predominantly focused on infectious diseases associated with use such as Pseudomonas aeruginosa dermatitis, folliculitis, and “hot From the Center for Injury Research and Policy (Alhajj, Nelson, McKenzie), The Research Institute at Nationwide Children’s Hospital; and Department of Pediatrics (McKenzie), College of Medicine, Ohio State University, Columbus, Ohio Address correspondence and reprint requests to: Lara B. McKenzie, PhD, MA, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus OH 43205. E-mail: lara.mckenzie@nationwidechildrens. org. The full text of this article is available via AJPM Online at www. ajpm-online.net.
tub lung” caused by aerosolized Mycobacterium avium complex.2–5 In addition to the risk of infection, use of hot tubs carries the risk of unintentional injury. Some of the most severe injuries associated with hot tubs include hair entanglement, body entrapment, disembowelment or evisceration, and drowning.6 These severe injuries are predominantly seen in the pediatric population and are typically associated with suction drain covers. From 1980 through 1996, the U.S. Consumer Product Safety Commission (CPSC) reported more than 700 deaths associated with hot tubs, with approximately one third of those incidents occurring in children aged ⬍5 years.6 The CPSC recorded 35 body entrapment incidents involving a spa drain from 1990 to 2002 in children aged 2–14 years, with at least five of those cases resulting in drowning.6,7 The CPSC reported 49 incidents between 1980 and 1996 related to hair entanglement in a drain suction cover for a hot tub.6 Despite the increasing demand for hot tubs and the risk potential for injury, little research has been conducted to determine national estimates and trends
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associated with hot tub–related injuries. The objective of this research is to determine national scope, distribution, and trends of hot tub–related nonfatal injuries for people of all ages treated in emergency departments between January 1, 1990, and December 31, 2007.
Methods The National Electronic Injury Surveillance System (NEISS) of the CPSC is a stratified probability sample of ⬃100 U.S. emergency departments, including seven children’s hospitals, representing 6100 hospitals with at least six beds and a 24-hour emergency department. This data set provides highquality data on consumer product–related and sports and recreation activity–related injuries treated in emergency departments.8 At NEISS hospitals, emergency department medical charts are reviewed by professional coders, and data regarding patients’ age, gender, race, injury diagnosis, body part injured, product(s) involved, and disposition, along with a brief narrative describing the incident are recorded.8,9 The NEISS was established in 1972, and its sampling frame was revised in the years 1978, 1990, and 1997. In 1997, a separate stratum was added for children’s hospitals. Estimates based on NEISS data are adjusted to take the sample changes into account.8,9 All injuries identified by the NEISS product code for hot tubs, whirlpools, and spas (698) were reviewed. All cases of dermatitis, conjunctivitis, and cases that involved infectious or allergic diseases were excluded. The 13 fatalities were excluded from the analysis because NEISS is generally not regarded as useful for identifying fatal injuries. National estimates generated in this study were based on weighted data for 1824 cases. This study was approved by the IRB of The Research Institute at Nationwide Children’s Hospital. Analysis was conducted from November 2008 through March 2009.
Variables Data regarding patients’ age, body part injured, injury diagnosis, and disposition were coded into categoric variables. Age was categorized into two age groups, ⱕ16 years and ⬎16 years, to separate pediatric and adult patients. Owing to significant differences in injury type and mechanism within the pediatric population, a second age variable was created to examine in more detail the ⱕ16 years age group. This variable was categorized into the following age groups: ⱕ5 years, 6 –12 years, and ⬎12 years. Body parts injured were categorized as follows: head (head, neck, face, mouth, ears, and eyes); upper extremities (shoulder, upper arm, elbow, lower arm, wrist, hand, and finger); lower extremities (upper leg, knee, lower leg, ankle, foot, and toe); trunk (upper and lower trunk, hip, and pubic region); all parts of body (defined as ⬎50% of body); and other (“other,” “25%–50% of the body,” and internal injuries). Examples of diagnoses of injuries that occur to all parts of the body include anoxia, electric shock, poisoning, submersion, and aspiration/ingestion of foreign objects. Injury diagnosis was coded as laceration (punctures and avulsions); strains/sprains; concussions; soft tissue (contusions, abrasions, hematomas, and crushing injuries); burns/scalds; fractures/dislocations; submersion; and other. Disposition was categorized as hospitalized (patients who were admitted or transferred to another hospital); not hospitalized (patients who were treated and released, held for
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observation, or left without being seen); and other (left against medical advice or not documented). Each case narrative was reviewed to generate and categorize the primary mechanism of injury. Mechanism of injury was categorized as slip and fall, twist, jump and dive, hit and scrape, heat overexposure, suction-related, near-drowning, overexertion, other, or not specified.
Statistical Analysis Data were analyzed using SPSS, version 17.0. Means are reported. Bivariate comparisons were conducted using chisquare tests, with strength of association assessed using ORs with 95% CIs. Significance was assessed using ␣⫽0.05. Trend significance of the number of hot tub–related injuries over time was analyzed using linear regression. All statistical analyses accounted for the complex sampling frame of the NEISS.9 All data reported in this article are national estimates unless specified as actual unweighted cases.
Results From 1990 through 2007, an estimated 81,597 patients (95% CI⫽63,700 to 99,494) were treated in U.S. emergency departments for hot tub–related injuries, approximately 4800 injuries annually (Figure 1). There was a 160.7% increase in hot tub–related injuries from 2549 in 1990 to 6646 in 2007 (p⬍0.001). The age range of patients was 1 month to 102 years (mean age⫽35.9 years; median age⫽35.0 years). Seventy-three percent of injuries occurred to individuals aged ⬎16 years (Table 1). Men accounted for 50.1% of injuries.
Body Part Injured and Type of Injury Lower extremities were the most commonly injured body part (27.2%) followed by injuries to the head
Figure 1. Trend of hot tub, whirlpool, and spa-related injuries presenting to U.S. emergency departments, 1990 – 2007 Note: p⬍0.001; R2⫽0.772, ⫽192.397
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Table 1. Nonfatal hot tub, whirlpool, and spa-related injuries treated in U.S. emergency departments, 1990 –2007
Characteristic Age (years) ⱕ16 ⬎16 Gender Male Female Disposition Hospitalizedc Not hospitalizedd Locale at time of injury Homee Other public property Sports/recreation facility Other
Cases (n)a
Weighted estimate (%)b
1823 544 1279 1824 911 913 1823 142 1681 1298
81,487 (100) 21,713 (26.6) 59,774 (73.4) 81,597 (100) 40,859 (50.1) 40,738 (49.9) 81,580 (100) 5,428 (6.7) 76,152 (93.3) 58,888 (100)
982 216
43,486 (73.8) 9,959 (16.9)
32,771–54,202 7,589–12,329
97
5,397 (9.2)
1,814–8,981
95% CI 16,579–26,846 46,390–73,157 30,329–51,389 32,619–48,857 3,892–6,963 59,367–92,937
3f
a
n-values may differ as a result of missing data. Percentages may not add up to 100 because of rounding. c Hospitalized includes treated and transferred to other hospital or treated and admitted. d Not hospitalized includes treated and released, examined and released, or held for observation ⬍24 hours. e Home includes home, apartment, condominium or mobile home. f Estimates based on ⬍20 cases are not considered statistically stable in the NEISS, so no estimates were made using this category. ED, emergency department; NEISS, National Electronic Injury Surveillance System b
(26.1%; Table 2). Patients aged ⱕ16 years were three times more likely to sustain injuries to the head than to other body parts (OR⫽3.6, 95% CI⫽2.8, 4.7). Patients aged ⬎16 years were more likely to sustain injuries to the trunk (OR⫽3.6, 95% CI⫽2.5, 5.2); upper extremities (OR⫽2.0, 95% CI⫽1.4, 2.9); and lower extremities (OR⫽1.5, 95% CI⫽1.1, 2.0), than to all other body parts. Women were more likely to sustain an injury to the lower extremities than to other body parts (OR⫽1.4, 95% CI⫽1.1, 1.7). Men were more likely to sustain all-partsof-the-body injuries than other specific-body-part injuries (OR⫽1.7, 95% CI⫽1.1, 2.6). Lacerations were the most common diagnosis (27.8%) followed by soft tissue injuries (18%). Patients aged ⱕ16 years were 11 times more likely to sustain submersion injuries (OR⫽11.8, 95% CI⫽5.5, 25.6) and lacerations than other diagnoses (OR⫽3.7, 95% CI⫽2.7, 5.0). Patients aged ⬎16 years were more likely to sustain sprains and/or strains and fracture and/or dislocations than any other diagnoses (OR⫽5.4, 95% CI⫽3.1, 9.3 and OR⫽2.9, 95% CI⫽1.7, 4.9, respectively). Men were more likely to sustain submersion injuries and lacerations than any other diagnoses (OR⫽2.3, 95% CI⫽1.3, 4.1 and OR⫽1.7, 95% CI⫽1.4, 2.2, respectively). Women were more likely to sustain soft tissue and sprain and/or strain injuries than other diagnoses (OR⫽1.7, 95% CI⫽1.3, 2.3 and OR⫽1.6, 95% CI⫽1.1, 2.1, respectively). December 2009
Burn and scald injuries (compared to all other types of injury) were more likely to occur to the lower extremities than to other body parts (OR⫽2.8, 95% CI⫽1.2, 6.6). Fractures and dislocations (compared to all other types of injury) were more likely to occur to the upper extremities than to other body parts (OR⫽4.1, 95% CI⫽2.9, 6.0).
Injury Mechanism Slips and falls were the most common mechanism of injury for hot tub–related injuries (50.1%). Hits and scrapes occurred more frequently in patients aged 6 –12 years than in any other age group (29.9%). Patients aged ⱕ5 years, compared to all other ages, accounted for the greatest proportion of near-drowning cases (67.7%), while patients aged 6 –12 years accounted for the greatest proportion of jump and dive injuries (42%; Figure 2). Patients aged ⬎16 years were more likely to be injured from heat overexposure (OR⫽1.9, 95% CI⫽1.1, 3.3) than from other mechanisms, compared to patients aged ⱕ16 years.
Locale at the Time of Injury Most of the hot tub–related injuries occurred at home (73.8%) followed by other public property (16.9%) and sports and recreation facilities (9.2%). Injuries occurring at home (compared to other locations) were more likely to occur in patients aged ⱕ16 years than in patients aged ⬎16 years (OR⫽1.5, 95% CI⫽1.1, 2.0).
Hospitalization A total of 6.7% of patients treated for hot tub–related injuries were hospitalized. Hospitalized patients were more likely to have all-parts-of-the-body injuries than any other specific-body-part injury (OR⫽8.8, 95% CI⫽ 5.3, 14.6). Hospitalized cases were more likely to be due to near-drowning than any other injury mechanism (OR⫽32.7, 95% CI⫽15.6, 68.2).
Discussion This is the first study to report national estimates, rates, and trends of hot tub–related injuries for all ages treated in U.S. emergency departments. There were more than 81,000 hot tub–related injuries between 1990 and 2007. The prevalence of hot tub–related injuries more than doubled during the 18-year study period. Slips and falls were the most common mechanism of injury, lacerations were the most common diagnosis, and the lower extremities and head were the most common body parts injured. Almost half of all hot tub–related injuries were due to slips or falls and were more likely to result in lowerextremity injuries. Few studies have examined the association between slips and falls and hot tub use. Among pediatric bathtub-related injuries, those resulting from slips and falls have been estimated to account for Am J Prev Med 2009;37(6)
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Table 2. Hot tub, whirlpool, and spa-related injury presenting to U.S. emergency departments, 1990 –2007 Weighted Men, na (%)b Women, na (%)b Aged <16 years, na (%)b Aged >16 years, na (%)b b c estimate, n (%) (OR, 95% CI) (OR, 95% CI)c (OR, 95% CI)c (OR, 95% CI)c 81,368 (100) 22,170 (27.2)
40,810 (100) 9,772 (23.9)
21,321 (26.2)
11,950 (29.3)
Trunk/pubic region 16,101 (19.8)
7,279 (17.8)
Upper extremityf
12,868 (15.8)
6,273 (15.4)
6,595 (16.3)
2,155 (10.0)
All parts of body
8,274 (10.2)
5,128 (12.6) (1.7; 1.1, 2.6) 408g (1.0)
3,146 (7.8)
2,910 (13.4) (1.6; 1.0, 2.4) 282g (1.3)
Body part injury Lower extremityd Heade
Other
634 (0.8)
Diagnosis Lacerationh
81,597 (100) 22,689 (27.8)
Soft tissuei
14,694 (18.0)
Sprain/strain
13,143 (16.1)
Fracture/dislocation 10,728 (13.1) Submersion Other
2,466 (3.0) 17,877 (21.9)
1,710 (4.2) (2.3; 1.3, 4.1) 9,662 (23.6) 39,140 (100) 17,162 (43.8)
Hits and scrapes 11,845 (15.3) 8,288 (10.7) Heat overexposurej
6,333 (16.2) 5,011 (12.8)
Overexertion Twists Near-drowning Jump/dive Suction Other
3,180 (8.1) 1,087 (2.8) 1,172 (3.0) 1,263 (3.2) 298g (0.8) 3,634 (9.3)
4,357 (5.6) 3,123 (4.0) 2,020 (2.6) 1,896 (2.4) 616 (0.8) 6,610 (8.5)
226g (0.6)
40,860 (100) 40,738 (100) 21,713 (100) 13,562 (33.2) 9,127 (22.4) 10,503 (48.4) (1.7; 1.4, 2.2) (3.7; 2.7, 5.0) 5,723 (14.0) 8,971 (22.0) 3,207 (14.8) (1.7; 1.3, 2.3) 5,379 (13.2) 7,764 (19.1) 982 (4.5) (1.6; 1.1, 2.1) 4,824 (11.8) 5,904 (14.5) 1,211 (5.6)
77,625 (100) 38,870 (50.1)
Injury mechanism Slips/falls
40,558 (100) 21,658 (100) 12,399 (30.6) 4,588 (21.2) (1.4; 1.1, 1.7) 9,371 (23.1) 9,972 (46.0) (3.6; 2.8, 4.7) 8,821 (21.7) 1,751 (8.1)
757 (1.9) 8,215 (20.1)
1,966 (9.1) (11.8; 5.5, 25.6) 3,844 (17.7)
38,485 (100) 20,728 (100) 21,708 (56.4) 9,684 (46.7) (1.7; 1.3, 2.1) 5,512 (14.3) 4,472 (21.6) 3,277 (8.5) 1,417 (6.5) 1,177 (3.1) 2,086 (5.3) 848 (2.2) 633g (1.6) 318g (0.8) 2,976 (7.7)
147g (0.7) 239g (1.2) 1,642 (7.9) 1,217 (1.1) 540g (2.6) 1,370 (6.6)
59,600 (100) 17,472 (29.3) (1.5; 1.1, 2.0) 11,349 (19.0) 14,350 (24.1) (3.6; 2.5, 5.2) 10,713 (18.0) (2.0; 1.4, 2.9) 5,364 (9.0) 352g (0.6) 59,774 (100) 2,186 (20.4) 11,486 (19.2) 12,161 (20.3) (5.4; 3.1, 9.3) 9,406 (15.7) (2.9; 1.7, 4.9) 500g (0.6) 14,035 (23.4) 56,787 (100) 29,186 (51.4) 7,262 (12.8) 6,871 (11.5) (1.9; 1.1, 3.3) 4,210 (7.4) 2,884 (5.1) 378g (0.7) 679g (1.2) 77g (0.1) 5,240 (9.2)
a
Estimates may not add up to total weighted estimate because of missing cases. Percentages may not add up to 100 because of rounding. ORs compare outcome of interest versus all other outcomes. Insignificant ORs were not included. d Lower-extremity injuries include knee, lower leg, ankle, upper leg, foot, and toe. e Head injuries include head, face, eyeball, neck, mouth, and ear. f Upper-extremity injuries include shoulder, elbow, lower arm, wrist, upper arm, hand, and finger. g Numbers of cases are too few to make reliable estimates. h Laceration injuries include laceration, avulsion, and amputation. i Soft-tissue injuries include contusions, abrasions, crushings, and hematoma. j Heat overexposure includes injury caused by burns (not electrically, chemically, or thermally induced or radiation induced), syncope, and arrhythmia. b c
approximately 80%.10,11 The current study found a greater proportion of slip and fall injuries in patients aged ⬎16 years (51.4%) than in patients aged ⱕ16 years (43.7%), although this difference was not significant. Mechanism of injury for hot tub–related injuries varied by age. For children aged ⱕ5 years, near-drowning was the most prevalent mechanism of injury, accounting for more than two thirds of injuries, while children aged 6 –12 years were more likely to be injured from jumpand dive-related mechanisms. Pediatric drowning and 534
near-drowning have been documented to occur most often in children aged ⱕ4 years.12 The current study supports the findings13 that nearly 90% of hot tub– related drowning were of children aged ⱕ3 years. Concerning suction-related injuries associated with hot tub use, it has been13 established that most cases occurred in children aged 9 –10 years. Although the number of suction-related injuries in the current data set was too small to make statistically reliable comparisons (n⫽21), most were in the group aged 6 –12 years. Despite the fact that suction-related injuries are a rare
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charts and which may be incomplete. For rare events such as near-drowning and suction-related injuries, sample sizes were relatively small, resulting in large CIs; however, they still met the NEISS minimum case requirement to make reliable estimates. Reliable data for factors associated with hot tub–related use and injury, such as alcohol use, were not available. Data for locale at the time of injury were frequently unavailable. Data on sales and use of hot tubs were not available. Despite these limitations, the strength of this study is that it examined a large, nationally representative sample over a 17-year Figure 2. Mechanism of injury by age for hot tub, whirlpool, and spa-related injuries treated study period. in U.S. emergency departments, 1990 –2007 Although generally considered a leisurely recreevent, legislation has been passed to prevent these ational water activity, hot tub use can pose serious risk for injuries and possible deaths. In 1982, the CPSC recominjury. Recommendations for safe public and private hot mended voluntary standards for drain covers (ASME/ tub, whirlpool, and spa use come from a published guide ANSI A112.19.8M-1987)14 in swimming pools, hot tubs, produced by the Association for Pool and Spa Professionals, reviewed by the CPSC, and further supported by whirlpools and spas to reduce hair entanglement, body findings in the literature.17 Installation of slip-resistant entrapment, and drowning caused by suction. In December 2007, the Virginia Graeme Baker Pool and Spa surfaces in and around the hot tub is recommended to Safety Act (Section 1404)15 mandated that all swimreduce slips and falls.11 Private and public facilities should ming pool and spa drain covers meet the ASME/ANSI be made aware of and comply with the time and temperA112.19.8M-1987 standards and that existing public ature regulations for hot tub use.1 In seeking to reduce facilities be in compliance by December 2008. the prevalence of pediatric drowning and near-drowning In the current study, patients aged ⬎16 years had a in hot tubs, adequate barriers or locked covers are recomhigher proportion of injuries resulting from twists and mended around these facilities, especially in the home.18 To reduce the number of suction-related injuries in heat overexposure than patients aged ⱕ16 years, who children aged 6 –12 years, all private and public hot tubs lacked enough cases in these mechanisms to yield statismust comply with the CPSC standards for suction tically reliable estimates. A previous study found that heat covers.15 overexposure was directly related to prolonged stay in a hot tub or permitting the hot tub temperature to rise above established safety limits.1 The literature supports the need Conclusion to maintain water temperature at or below 40°C and a 101,16 The prevalence of hot tub–related injuries observed in to 15-minute time limit for remaining in a hot tub. This study has several limitations. Because only injuthis study warrants more research to ascertain the ries treated in emergency departments were reported, reasons for the increasing trend and increased efforts the total number of hot tub–related injuries was underfor prevention of these injuries. estimated. The estimates in this study may not be representative of hot tub–related injuries treated by No financial disclosures were reported by the authors of this paper. other sources of medical care or those left untreated. This study does not address hot tub–related fatalities because NEISS is generally not regarded as useful for identifying fatal injuries. The injury mechanism variReferences able was created from a review of case narratives, which 1. Press E. The health hazards of saunas and spas and how to minimize them. are highly dependent on emergency department medical Am J Public Health 1991;81(8):1034 –7. December 2009
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2. Pseudomonas dermatitis/folliculitis associated with pools and hot tubs— Colorado and Maine, 1999 –2000. MMWR Morb Mortal Wkly Rep 2000; 49(48):1087–91. 3. Spitalny KC, Vogt RL, Witherell LE. National survey on outbreaks associated with whirlpool spas. Am J Public Health 1984;74(7):725– 6. 4. Rinke CM. Hot tub hygiene. JAMA 1983;250(15):2031. 5. Hartman TE, Jensen E, Tazelaar HD, Hanak V, Ryu JH. CT findings of granulomatous pneumonitis secondary to mycobacterium avium-intracellulare inhalation: “hot tub lung”. AJR Am J Roentgenol 2007;188(4):1050 –3. 6. U.S. Consumer Product Safety Commission. CPSC issues warnings for pools, spas and hot tubs. June 3, 1996. Release #96-139. http://www.cpsc. gov/CPSCPUB/PREREL/PRHTML96/96139.html. 7. American Society for Testing and Materials 010-03 Standard provisional specification for manufactured Safety Vacuum Release Systems (SVRS) for swimming pools, spas and hot tubs AG 106.3. West Conshohoken PA: ASTM International, 2003. 8. U.S. Consumer Product Safety Commission. The National Electronic Injury Surveillance System: a tool for researchers. Bethesda MD: The Division of Hazard and Injury Data Systems. U.S. Consumer Product Safety Commission, 2000. 9. Schroeder T, Ault K. The NEISS sample (design and implementation),
10.
11. 12. 13.
14.
15. 16. 17. 18.
1997 to present. Washington DC: U.S. Consumer Product Safety Commission, Division of Hazard and Injury Data Systems, 2001. Mao SJ, McKenzie L, Xiang H, Smith GA. Injuries associated with bathtubs and showers among children in the United States. Pediatrics 2009; 124(2):541–7. Spencer SP, Shields BJ, Smith GA. Childhood bathtub-related injuries: slip and fall prevalence and prevention. Clin Pediatr (Phila) 2005;44(4):311– 8. Blum C, Shield J. Toddler drowning in domestic swimming pools. Inj Prev 2000;6(4):288 –90. Shinaberger CS, Anderson CL, Kraus JF. Young children who drown in hot tubs, spas, and whirlpools in California: a 26-year survey. Am J Public Health 1990;80(5):613– 4. U.S. Consumer Product Safety Commission. Children drown and more are injured from hair entrapment in drain covers for spas, hot tubs, and whirlpool bathtubs: safety alert. 1982. Virginia Graeme Baker Pool and Spa Safety Act. In: Title XIV. U.S.A.; 2008. Galbreath RW, Reger W, Allison T, Butler K. Exceeding recommended standards for safe hot tub use. J Safety Res 1999;30(1):7–15. Association of Pool and Spa Professionals. The sensible way to enjoy your spa or hot tub. Alexandria VA: APSP, 2006; p. 22. Turner J. Prevention of drowning in infants and children. Dimens Crit Care Nurs 2004;23(5):191–3.
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This study examines nonfatal hot tub, whirlpool, and spa-related injuries on a national level.
Methods:
The National Electronic Injury Surveillance System database was used to examine cases of nonfatal hot tub, whirlpool, and spa-related injuries treated in U.S. emergency departments from January 1, 1990, through December 31, 2007. Analysis was conducted from November 2008 to March 2009.
Results:
An estimated 81,597 patients, aged ⬍1–102 years, were treated in U.S. emergency departments for hot tub, whirlpool, and spa-related injuries, with the number increasing 160% over the 18-year study period (p⬍0.001). Nearly 73% of injuries occurred in patients aged ⱖ17 years. Lacerations were the most common diagnosis (27.8%) and accounted for 58% of all head injuries. Slips and falls were the most common mechanism of injury (47.6%); were more likely to result in an injury to the trunk than other body parts (OR⫽2.49, 95% CI⫽1.83, 3.39); and were more likely to result in concussions and fractures/dislocations than any other diagnosis (OR⫽7.813, 95% CI⫽2.194, 27.823 and OR⫽3.017, 95% CI⫽2.057, 4.425, respectively).
Conclusions: Given the increase in hot tub, whirlpool, and spa ownership and the 160% increase in injuries during the study period, more research is needed to identify the cause of the increase in hot tub, whirlpool, and spa-related injuries and what injury-prevention solutions and policies may be appropriate. (Am J Prev Med 2009;37(6):531–536) © 2009 American Journal of Preventive Medicine
Introduction
I
n the U.S., private sales of hot tubs, whirlpools, and spas (for the purpose of this paper, hot tubs will refer to hot tubs, whirlpools, and spas) began increasing in the early 1980s. In 1988, there were an estimated 1.8 million hot tubs in use in the U.S., with approximately 250,000 spas being sold annually across the nation.1 Today, hot tubs are a ubiquitous feature in homes, hotels, fitness centers, health spas, and pools. Previous studies of hot tubs have predominantly focused on infectious diseases associated with use such as Pseudomonas aeruginosa dermatitis, folliculitis, and “hot From the Center for Injury Research and Policy (Alhajj, Nelson, McKenzie), The Research Institute at Nationwide Children’s Hospital; and Department of Pediatrics (McKenzie), College of Medicine, Ohio State University, Columbus, Ohio Address correspondence and reprint requests to: Lara B. McKenzie, PhD, MA, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus OH 43205. E-mail: lara.mckenzie@nationwidechildrens. org. The full text of this article is available via AJPM Online at www. ajpm-online.net.
tub lung” caused by aerosolized Mycobacterium avium complex.2–5 In addition to the risk of infection, use of hot tubs carries the risk of unintentional injury. Some of the most severe injuries associated with hot tubs include hair entanglement, body entrapment, disembowelment or evisceration, and drowning.6 These severe injuries are predominantly seen in the pediatric population and are typically associated with suction drain covers. From 1980 through 1996, the U.S. Consumer Product Safety Commission (CPSC) reported more than 700 deaths associated with hot tubs, with approximately one third of those incidents occurring in children aged ⬍5 years.6 The CPSC recorded 35 body entrapment incidents involving a spa drain from 1990 to 2002 in children aged 2–14 years, with at least five of those cases resulting in drowning.6,7 The CPSC reported 49 incidents between 1980 and 1996 related to hair entanglement in a drain suction cover for a hot tub.6 Despite the increasing demand for hot tubs and the risk potential for injury, little research has been conducted to determine national estimates and trends
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associated with hot tub–related injuries. The objective of this research is to determine national scope, distribution, and trends of hot tub–related nonfatal injuries for people of all ages treated in emergency departments between January 1, 1990, and December 31, 2007.
Methods The National Electronic Injury Surveillance System (NEISS) of the CPSC is a stratified probability sample of ⬃100 U.S. emergency departments, including seven children’s hospitals, representing 6100 hospitals with at least six beds and a 24-hour emergency department. This data set provides highquality data on consumer product–related and sports and recreation activity–related injuries treated in emergency departments.8 At NEISS hospitals, emergency department medical charts are reviewed by professional coders, and data regarding patients’ age, gender, race, injury diagnosis, body part injured, product(s) involved, and disposition, along with a brief narrative describing the incident are recorded.8,9 The NEISS was established in 1972, and its sampling frame was revised in the years 1978, 1990, and 1997. In 1997, a separate stratum was added for children’s hospitals. Estimates based on NEISS data are adjusted to take the sample changes into account.8,9 All injuries identified by the NEISS product code for hot tubs, whirlpools, and spas (698) were reviewed. All cases of dermatitis, conjunctivitis, and cases that involved infectious or allergic diseases were excluded. The 13 fatalities were excluded from the analysis because NEISS is generally not regarded as useful for identifying fatal injuries. National estimates generated in this study were based on weighted data for 1824 cases. This study was approved by the IRB of The Research Institute at Nationwide Children’s Hospital. Analysis was conducted from November 2008 through March 2009.
Variables Data regarding patients’ age, body part injured, injury diagnosis, and disposition were coded into categoric variables. Age was categorized into two age groups, ⱕ16 years and ⬎16 years, to separate pediatric and adult patients. Owing to significant differences in injury type and mechanism within the pediatric population, a second age variable was created to examine in more detail the ⱕ16 years age group. This variable was categorized into the following age groups: ⱕ5 years, 6 –12 years, and ⬎12 years. Body parts injured were categorized as follows: head (head, neck, face, mouth, ears, and eyes); upper extremities (shoulder, upper arm, elbow, lower arm, wrist, hand, and finger); lower extremities (upper leg, knee, lower leg, ankle, foot, and toe); trunk (upper and lower trunk, hip, and pubic region); all parts of body (defined as ⬎50% of body); and other (“other,” “25%–50% of the body,” and internal injuries). Examples of diagnoses of injuries that occur to all parts of the body include anoxia, electric shock, poisoning, submersion, and aspiration/ingestion of foreign objects. Injury diagnosis was coded as laceration (punctures and avulsions); strains/sprains; concussions; soft tissue (contusions, abrasions, hematomas, and crushing injuries); burns/scalds; fractures/dislocations; submersion; and other. Disposition was categorized as hospitalized (patients who were admitted or transferred to another hospital); not hospitalized (patients who were treated and released, held for
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observation, or left without being seen); and other (left against medical advice or not documented). Each case narrative was reviewed to generate and categorize the primary mechanism of injury. Mechanism of injury was categorized as slip and fall, twist, jump and dive, hit and scrape, heat overexposure, suction-related, near-drowning, overexertion, other, or not specified.
Statistical Analysis Data were analyzed using SPSS, version 17.0. Means are reported. Bivariate comparisons were conducted using chisquare tests, with strength of association assessed using ORs with 95% CIs. Significance was assessed using ␣⫽0.05. Trend significance of the number of hot tub–related injuries over time was analyzed using linear regression. All statistical analyses accounted for the complex sampling frame of the NEISS.9 All data reported in this article are national estimates unless specified as actual unweighted cases.
Results From 1990 through 2007, an estimated 81,597 patients (95% CI⫽63,700 to 99,494) were treated in U.S. emergency departments for hot tub–related injuries, approximately 4800 injuries annually (Figure 1). There was a 160.7% increase in hot tub–related injuries from 2549 in 1990 to 6646 in 2007 (p⬍0.001). The age range of patients was 1 month to 102 years (mean age⫽35.9 years; median age⫽35.0 years). Seventy-three percent of injuries occurred to individuals aged ⬎16 years (Table 1). Men accounted for 50.1% of injuries.
Body Part Injured and Type of Injury Lower extremities were the most commonly injured body part (27.2%) followed by injuries to the head
Figure 1. Trend of hot tub, whirlpool, and spa-related injuries presenting to U.S. emergency departments, 1990 – 2007 Note: p⬍0.001; R2⫽0.772, ⫽192.397
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Table 1. Nonfatal hot tub, whirlpool, and spa-related injuries treated in U.S. emergency departments, 1990 –2007
Characteristic Age (years) ⱕ16 ⬎16 Gender Male Female Disposition Hospitalizedc Not hospitalizedd Locale at time of injury Homee Other public property Sports/recreation facility Other
Cases (n)a
Weighted estimate (%)b
1823 544 1279 1824 911 913 1823 142 1681 1298
81,487 (100) 21,713 (26.6) 59,774 (73.4) 81,597 (100) 40,859 (50.1) 40,738 (49.9) 81,580 (100) 5,428 (6.7) 76,152 (93.3) 58,888 (100)
982 216
43,486 (73.8) 9,959 (16.9)
32,771–54,202 7,589–12,329
97
5,397 (9.2)
1,814–8,981
95% CI 16,579–26,846 46,390–73,157 30,329–51,389 32,619–48,857 3,892–6,963 59,367–92,937
3f
a
n-values may differ as a result of missing data. Percentages may not add up to 100 because of rounding. c Hospitalized includes treated and transferred to other hospital or treated and admitted. d Not hospitalized includes treated and released, examined and released, or held for observation ⬍24 hours. e Home includes home, apartment, condominium or mobile home. f Estimates based on ⬍20 cases are not considered statistically stable in the NEISS, so no estimates were made using this category. ED, emergency department; NEISS, National Electronic Injury Surveillance System b
(26.1%; Table 2). Patients aged ⱕ16 years were three times more likely to sustain injuries to the head than to other body parts (OR⫽3.6, 95% CI⫽2.8, 4.7). Patients aged ⬎16 years were more likely to sustain injuries to the trunk (OR⫽3.6, 95% CI⫽2.5, 5.2); upper extremities (OR⫽2.0, 95% CI⫽1.4, 2.9); and lower extremities (OR⫽1.5, 95% CI⫽1.1, 2.0), than to all other body parts. Women were more likely to sustain an injury to the lower extremities than to other body parts (OR⫽1.4, 95% CI⫽1.1, 1.7). Men were more likely to sustain all-partsof-the-body injuries than other specific-body-part injuries (OR⫽1.7, 95% CI⫽1.1, 2.6). Lacerations were the most common diagnosis (27.8%) followed by soft tissue injuries (18%). Patients aged ⱕ16 years were 11 times more likely to sustain submersion injuries (OR⫽11.8, 95% CI⫽5.5, 25.6) and lacerations than other diagnoses (OR⫽3.7, 95% CI⫽2.7, 5.0). Patients aged ⬎16 years were more likely to sustain sprains and/or strains and fracture and/or dislocations than any other diagnoses (OR⫽5.4, 95% CI⫽3.1, 9.3 and OR⫽2.9, 95% CI⫽1.7, 4.9, respectively). Men were more likely to sustain submersion injuries and lacerations than any other diagnoses (OR⫽2.3, 95% CI⫽1.3, 4.1 and OR⫽1.7, 95% CI⫽1.4, 2.2, respectively). Women were more likely to sustain soft tissue and sprain and/or strain injuries than other diagnoses (OR⫽1.7, 95% CI⫽1.3, 2.3 and OR⫽1.6, 95% CI⫽1.1, 2.1, respectively). December 2009
Burn and scald injuries (compared to all other types of injury) were more likely to occur to the lower extremities than to other body parts (OR⫽2.8, 95% CI⫽1.2, 6.6). Fractures and dislocations (compared to all other types of injury) were more likely to occur to the upper extremities than to other body parts (OR⫽4.1, 95% CI⫽2.9, 6.0).
Injury Mechanism Slips and falls were the most common mechanism of injury for hot tub–related injuries (50.1%). Hits and scrapes occurred more frequently in patients aged 6 –12 years than in any other age group (29.9%). Patients aged ⱕ5 years, compared to all other ages, accounted for the greatest proportion of near-drowning cases (67.7%), while patients aged 6 –12 years accounted for the greatest proportion of jump and dive injuries (42%; Figure 2). Patients aged ⬎16 years were more likely to be injured from heat overexposure (OR⫽1.9, 95% CI⫽1.1, 3.3) than from other mechanisms, compared to patients aged ⱕ16 years.
Locale at the Time of Injury Most of the hot tub–related injuries occurred at home (73.8%) followed by other public property (16.9%) and sports and recreation facilities (9.2%). Injuries occurring at home (compared to other locations) were more likely to occur in patients aged ⱕ16 years than in patients aged ⬎16 years (OR⫽1.5, 95% CI⫽1.1, 2.0).
Hospitalization A total of 6.7% of patients treated for hot tub–related injuries were hospitalized. Hospitalized patients were more likely to have all-parts-of-the-body injuries than any other specific-body-part injury (OR⫽8.8, 95% CI⫽ 5.3, 14.6). Hospitalized cases were more likely to be due to near-drowning than any other injury mechanism (OR⫽32.7, 95% CI⫽15.6, 68.2).
Discussion This is the first study to report national estimates, rates, and trends of hot tub–related injuries for all ages treated in U.S. emergency departments. There were more than 81,000 hot tub–related injuries between 1990 and 2007. The prevalence of hot tub–related injuries more than doubled during the 18-year study period. Slips and falls were the most common mechanism of injury, lacerations were the most common diagnosis, and the lower extremities and head were the most common body parts injured. Almost half of all hot tub–related injuries were due to slips or falls and were more likely to result in lowerextremity injuries. Few studies have examined the association between slips and falls and hot tub use. Among pediatric bathtub-related injuries, those resulting from slips and falls have been estimated to account for Am J Prev Med 2009;37(6)
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Table 2. Hot tub, whirlpool, and spa-related injury presenting to U.S. emergency departments, 1990 –2007 Weighted Men, na (%)b Women, na (%)b Aged <16 years, na (%)b Aged >16 years, na (%)b b c estimate, n (%) (OR, 95% CI) (OR, 95% CI)c (OR, 95% CI)c (OR, 95% CI)c 81,368 (100) 22,170 (27.2)
40,810 (100) 9,772 (23.9)
21,321 (26.2)
11,950 (29.3)
Trunk/pubic region 16,101 (19.8)
7,279 (17.8)
Upper extremityf
12,868 (15.8)
6,273 (15.4)
6,595 (16.3)
2,155 (10.0)
All parts of body
8,274 (10.2)
5,128 (12.6) (1.7; 1.1, 2.6) 408g (1.0)
3,146 (7.8)
2,910 (13.4) (1.6; 1.0, 2.4) 282g (1.3)
Body part injury Lower extremityd Heade
Other
634 (0.8)
Diagnosis Lacerationh
81,597 (100) 22,689 (27.8)
Soft tissuei
14,694 (18.0)
Sprain/strain
13,143 (16.1)
Fracture/dislocation 10,728 (13.1) Submersion Other
2,466 (3.0) 17,877 (21.9)
1,710 (4.2) (2.3; 1.3, 4.1) 9,662 (23.6) 39,140 (100) 17,162 (43.8)
Hits and scrapes 11,845 (15.3) 8,288 (10.7) Heat overexposurej
6,333 (16.2) 5,011 (12.8)
Overexertion Twists Near-drowning Jump/dive Suction Other
3,180 (8.1) 1,087 (2.8) 1,172 (3.0) 1,263 (3.2) 298g (0.8) 3,634 (9.3)
4,357 (5.6) 3,123 (4.0) 2,020 (2.6) 1,896 (2.4) 616 (0.8) 6,610 (8.5)
226g (0.6)
40,860 (100) 40,738 (100) 21,713 (100) 13,562 (33.2) 9,127 (22.4) 10,503 (48.4) (1.7; 1.4, 2.2) (3.7; 2.7, 5.0) 5,723 (14.0) 8,971 (22.0) 3,207 (14.8) (1.7; 1.3, 2.3) 5,379 (13.2) 7,764 (19.1) 982 (4.5) (1.6; 1.1, 2.1) 4,824 (11.8) 5,904 (14.5) 1,211 (5.6)
77,625 (100) 38,870 (50.1)
Injury mechanism Slips/falls
40,558 (100) 21,658 (100) 12,399 (30.6) 4,588 (21.2) (1.4; 1.1, 1.7) 9,371 (23.1) 9,972 (46.0) (3.6; 2.8, 4.7) 8,821 (21.7) 1,751 (8.1)
757 (1.9) 8,215 (20.1)
1,966 (9.1) (11.8; 5.5, 25.6) 3,844 (17.7)
38,485 (100) 20,728 (100) 21,708 (56.4) 9,684 (46.7) (1.7; 1.3, 2.1) 5,512 (14.3) 4,472 (21.6) 3,277 (8.5) 1,417 (6.5) 1,177 (3.1) 2,086 (5.3) 848 (2.2) 633g (1.6) 318g (0.8) 2,976 (7.7)
147g (0.7) 239g (1.2) 1,642 (7.9) 1,217 (1.1) 540g (2.6) 1,370 (6.6)
59,600 (100) 17,472 (29.3) (1.5; 1.1, 2.0) 11,349 (19.0) 14,350 (24.1) (3.6; 2.5, 5.2) 10,713 (18.0) (2.0; 1.4, 2.9) 5,364 (9.0) 352g (0.6) 59,774 (100) 2,186 (20.4) 11,486 (19.2) 12,161 (20.3) (5.4; 3.1, 9.3) 9,406 (15.7) (2.9; 1.7, 4.9) 500g (0.6) 14,035 (23.4) 56,787 (100) 29,186 (51.4) 7,262 (12.8) 6,871 (11.5) (1.9; 1.1, 3.3) 4,210 (7.4) 2,884 (5.1) 378g (0.7) 679g (1.2) 77g (0.1) 5,240 (9.2)
a
Estimates may not add up to total weighted estimate because of missing cases. Percentages may not add up to 100 because of rounding. ORs compare outcome of interest versus all other outcomes. Insignificant ORs were not included. d Lower-extremity injuries include knee, lower leg, ankle, upper leg, foot, and toe. e Head injuries include head, face, eyeball, neck, mouth, and ear. f Upper-extremity injuries include shoulder, elbow, lower arm, wrist, upper arm, hand, and finger. g Numbers of cases are too few to make reliable estimates. h Laceration injuries include laceration, avulsion, and amputation. i Soft-tissue injuries include contusions, abrasions, crushings, and hematoma. j Heat overexposure includes injury caused by burns (not electrically, chemically, or thermally induced or radiation induced), syncope, and arrhythmia. b c
approximately 80%.10,11 The current study found a greater proportion of slip and fall injuries in patients aged ⬎16 years (51.4%) than in patients aged ⱕ16 years (43.7%), although this difference was not significant. Mechanism of injury for hot tub–related injuries varied by age. For children aged ⱕ5 years, near-drowning was the most prevalent mechanism of injury, accounting for more than two thirds of injuries, while children aged 6 –12 years were more likely to be injured from jumpand dive-related mechanisms. Pediatric drowning and 534
near-drowning have been documented to occur most often in children aged ⱕ4 years.12 The current study supports the findings13 that nearly 90% of hot tub– related drowning were of children aged ⱕ3 years. Concerning suction-related injuries associated with hot tub use, it has been13 established that most cases occurred in children aged 9 –10 years. Although the number of suction-related injuries in the current data set was too small to make statistically reliable comparisons (n⫽21), most were in the group aged 6 –12 years. Despite the fact that suction-related injuries are a rare
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charts and which may be incomplete. For rare events such as near-drowning and suction-related injuries, sample sizes were relatively small, resulting in large CIs; however, they still met the NEISS minimum case requirement to make reliable estimates. Reliable data for factors associated with hot tub–related use and injury, such as alcohol use, were not available. Data for locale at the time of injury were frequently unavailable. Data on sales and use of hot tubs were not available. Despite these limitations, the strength of this study is that it examined a large, nationally representative sample over a 17-year Figure 2. Mechanism of injury by age for hot tub, whirlpool, and spa-related injuries treated study period. in U.S. emergency departments, 1990 –2007 Although generally considered a leisurely recreevent, legislation has been passed to prevent these ational water activity, hot tub use can pose serious risk for injuries and possible deaths. In 1982, the CPSC recominjury. Recommendations for safe public and private hot mended voluntary standards for drain covers (ASME/ tub, whirlpool, and spa use come from a published guide ANSI A112.19.8M-1987)14 in swimming pools, hot tubs, produced by the Association for Pool and Spa Professionals, reviewed by the CPSC, and further supported by whirlpools and spas to reduce hair entanglement, body findings in the literature.17 Installation of slip-resistant entrapment, and drowning caused by suction. In December 2007, the Virginia Graeme Baker Pool and Spa surfaces in and around the hot tub is recommended to Safety Act (Section 1404)15 mandated that all swimreduce slips and falls.11 Private and public facilities should ming pool and spa drain covers meet the ASME/ANSI be made aware of and comply with the time and temperA112.19.8M-1987 standards and that existing public ature regulations for hot tub use.1 In seeking to reduce facilities be in compliance by December 2008. the prevalence of pediatric drowning and near-drowning In the current study, patients aged ⬎16 years had a in hot tubs, adequate barriers or locked covers are recomhigher proportion of injuries resulting from twists and mended around these facilities, especially in the home.18 To reduce the number of suction-related injuries in heat overexposure than patients aged ⱕ16 years, who children aged 6 –12 years, all private and public hot tubs lacked enough cases in these mechanisms to yield statismust comply with the CPSC standards for suction tically reliable estimates. A previous study found that heat covers.15 overexposure was directly related to prolonged stay in a hot tub or permitting the hot tub temperature to rise above established safety limits.1 The literature supports the need Conclusion to maintain water temperature at or below 40°C and a 101,16 The prevalence of hot tub–related injuries observed in to 15-minute time limit for remaining in a hot tub. This study has several limitations. Because only injuthis study warrants more research to ascertain the ries treated in emergency departments were reported, reasons for the increasing trend and increased efforts the total number of hot tub–related injuries was underfor prevention of these injuries. estimated. The estimates in this study may not be representative of hot tub–related injuries treated by No financial disclosures were reported by the authors of this paper. other sources of medical care or those left untreated. This study does not address hot tub–related fatalities because NEISS is generally not regarded as useful for identifying fatal injuries. The injury mechanism variReferences able was created from a review of case narratives, which 1. Press E. The health hazards of saunas and spas and how to minimize them. are highly dependent on emergency department medical Am J Public Health 1991;81(8):1034 –7. December 2009
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2. Pseudomonas dermatitis/folliculitis associated with pools and hot tubs— Colorado and Maine, 1999 –2000. MMWR Morb Mortal Wkly Rep 2000; 49(48):1087–91. 3. Spitalny KC, Vogt RL, Witherell LE. National survey on outbreaks associated with whirlpool spas. Am J Public Health 1984;74(7):725– 6. 4. Rinke CM. Hot tub hygiene. JAMA 1983;250(15):2031. 5. Hartman TE, Jensen E, Tazelaar HD, Hanak V, Ryu JH. CT findings of granulomatous pneumonitis secondary to mycobacterium avium-intracellulare inhalation: “hot tub lung”. AJR Am J Roentgenol 2007;188(4):1050 –3. 6. U.S. Consumer Product Safety Commission. CPSC issues warnings for pools, spas and hot tubs. June 3, 1996. Release #96-139. http://www.cpsc. gov/CPSCPUB/PREREL/PRHTML96/96139.html. 7. American Society for Testing and Materials 010-03 Standard provisional specification for manufactured Safety Vacuum Release Systems (SVRS) for swimming pools, spas and hot tubs AG 106.3. West Conshohoken PA: ASTM International, 2003. 8. U.S. Consumer Product Safety Commission. The National Electronic Injury Surveillance System: a tool for researchers. Bethesda MD: The Division of Hazard and Injury Data Systems. U.S. Consumer Product Safety Commission, 2000. 9. Schroeder T, Ault K. The NEISS sample (design and implementation),
10.
11. 12. 13.
14.
15. 16. 17. 18.
1997 to present. Washington DC: U.S. Consumer Product Safety Commission, Division of Hazard and Injury Data Systems, 2001. Mao SJ, McKenzie L, Xiang H, Smith GA. Injuries associated with bathtubs and showers among children in the United States. Pediatrics 2009; 124(2):541–7. Spencer SP, Shields BJ, Smith GA. Childhood bathtub-related injuries: slip and fall prevalence and prevention. Clin Pediatr (Phila) 2005;44(4):311– 8. Blum C, Shield J. Toddler drowning in domestic swimming pools. Inj Prev 2000;6(4):288 –90. Shinaberger CS, Anderson CL, Kraus JF. Young children who drown in hot tubs, spas, and whirlpools in California: a 26-year survey. Am J Public Health 1990;80(5):613– 4. U.S. Consumer Product Safety Commission. Children drown and more are injured from hair entrapment in drain covers for spas, hot tubs, and whirlpool bathtubs: safety alert. 1982. Virginia Graeme Baker Pool and Spa Safety Act. In: Title XIV. U.S.A.; 2008. Galbreath RW, Reger W, Allison T, Butler K. Exceeding recommended standards for safe hot tub use. J Safety Res 1999;30(1):7–15. Association of Pool and Spa Professionals. The sensible way to enjoy your spa or hot tub. Alexandria VA: APSP, 2006; p. 22. Turner J. Prevention of drowning in infants and children. Dimens Crit Care Nurs 2004;23(5):191–3.
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