United States Lifeguard Standards Coalition Evidence Review

On the following pages, you will find a primary question (and in some cases ancillary questions), reviewed by the United States Lifeguard Standards Coalition (USLSC), the draft consensus recommendation of the USLSC, and the Scientific Review Forms (usually two) that detail the specific evidence upon which the consensus recommendation was based. In most cases, for each question, two independent investigators researched existing evidence, including scientific research and other material, related to the question. Each investigator then completed a Scientific Review Form, listing the evidence and an evidence summary. The level and quality of evidence was rated using a standardized evidence evaluation process. The evidence reviewed included, but was not limited to, the following: a. Population-based studies b. Epidemiological studies c. Case-control studies d. Historic research e. Case studies f. Large observational studies g. Review of past research summaries, and h. Extrapolations from existing data collected for other purposes The scientific reviews were presented to the entire USLSC. Each topic was presented, discussed and critiqued by the assembled experts until consensus was reached. You are invited to comment on this question (as well as the others) and particularly whether you believe that the evidence adequately supports the consensus recommendation. If you are aware of any additional evidence (e.g. scientific research) that was not considered by the Lifeguard Standards Coalition, please list that evidence in your comments. In any comments you choose to make, please be sure to cite the line number, if you are referring to specific wording of the item. Before commenting, please review the document in full. This includes an initial document, which contains the question or questions investigated and the consensus recommendation. This is followed, in most cases, by two Scientific Review Forms, which list the evidence that was considered in arriving at the consensus recommendation. Thank you for your time and consideration in reviewing this question. The deadline for comments is December 12, 2009.

US Lifeguard Standards Coalition

HEARING 1

Question 2 Is there evidence to support recommending a minimum hearing standard for lifeguards? 3

4 Ancillary Questions 5 If so, what is the minimum requirement? 6 Are hearing aids acceptable? 7

8 Introduction 9 Many occupations, particularly those in which individuals must be able to perform under 10 stressful situations that require a certain level of physical ability, have minimum standards 11 for performing these tasks as a prerequisite for employment. Lifeguarding requires the ability 12 to maintain attention and focus for long periods of time. Lifeguards must be able to identify 13 potentially dangerous situations and react to them in a reasonable timeframe to ensure the 14 safety of others. Many questions have been asked about the minimum requirements for 15 lifeguards, including physical ability, age, hearing, and visual acuity. 16 17 Evidence Summary 18 A thorough literature review and database searches for key words related to lifeguarding, 19 hearing standards, police, firefighting, and driving requirements identified 18 sources. The 20 studies with the highest LOEs looked at the abilities of both hearing-impaired individuals 21 and normal-hearing individuals to perform their jobs. Occupations that require intense 22 communication or increased attention are better suited for normal-hearing individuals 23 (Kramer, 2006; Weisel, 2005). In sources that involved driving standards and 24 recommendations for other professions, impaired hearing reduces people’s abilities to 25 perform complex tasks, including operating an automobile (Wood, 2006; Ivers, 1999; Garcia, 26 2005). Minimum hearing standards in their occupations are supported in articles by The 27 American College of Occupational and Environmental Medicine (2002) and by the 28 Communities and Local Government of the United Kingdom’s Medical and Occupational 29 Evidence for Recruitment and Retention in the Fire and Rescue Service. Some studies 30 suggested specific standards, with the consensus being a minimum hearing threshold or no 31 more than an average of a 25-decibel loss in both ears over a range of frequencies (500, 1000, 32 2000, and 3000 Hz). 33 34 An assessment of specific employment applications for law enforcement, firefighting, the 35 Federal Aviation Administration pilot’s license, and lifeguarding provided a consensus that a 36 minimum hearing standard should exist. Most of these applications also set minimum 37 hearing thresholds for employment. There was only one opposing citation in which although 38 it was recognized that some type of hearing standard is needed, there are still some 39 opportunities for hearing-impaired officers in law enforcement (Punch, 1996). 40 41 In summary, six studies involving case series and observations studies had an LOE of 2 42 through 3b, and 12 additional studies had an LOE of 4 through 5. This expert opinion and 43 consensus, along with the fact that most applications set minimum hearing thresholds for 44 employment, indicate the need for a minimum hearing standard. 45

US Lifeguard Standards Coalition

Consensus Recommendation 46 There is enough evidence to recommend that there should be minimum hearing standards for 47 lifeguarding. However, because the amount of direct research about a minimum hearing 48 standard in lifeguarding is limited, and indirect studies had lower LOEs with most 49 information as consensus opinions, we feel we can make only a guideline decision. Formal 50 adoption of a standard in lifeguarding would require additional research. 51 52 Therefore, we recommend that a minimum hearing standard for lifeguards should be 53 instituted as a guideline. In addition, specific minimum hearing thresholds of no more than an 54 average of a 25-decibel loss in both ears over a range of frequencies (500Hz, 1000Hz, 55 2000Hz, and 3000Hz) should be instituted as an option. 56 57 Further research is needed to determine if adjunctive aids are acceptable for use in a 58 lifeguarding setting. Validation studies are also necessary to confirm that developed 59 thresholds are comparable for all lifeguarding settings, such as pools, lakes, and open-water 60 environments. 61 62 Recommendations and Strength 63

Standards: 64 Guidelines: 65

Minimum hearing standards should be in place for individuals performing 66 lifeguarding duties. 67

Options: 68 The minimum hearing threshold of lifeguards should be no more than an average 69

of a 25-decibel loss in both ears over a range of frequencies (500Hz, 1000Hz, 70 2000Hz, and 3000Hz). 71

No Recommendations: 72

Unites States Lifeguarding Standard Coalition Scientific Review Form

Author: Andrew Butterfass, MD FACEP

Organization Representing: American College of Emergency Physicians

Question: Is there evidence to support recommending a minimum hearing standard for lifeguards?

Date Submitted: 11/19/07

Question and Sub-Questions: Is there evidence to support recommending a minimum hearing standard for lifeguards? If yes- what are the minimum requirements. Are Hearing Aids acceptable?

Introduction/Background: Many occupations have developed minimal standards as a prerequisite for employment. Occupations that require individuals to be able to perform under stressful situations requiring physical ability have developed minimal standards for performing these tasks. Lifeguarding is a profession that requires a unique ability to maintain attention and focus for long periods of time. Individual need to be able to identify potential dangerous situations and react to them in a reasonable timeframe to ensure safety for those entrusted to their care. Many questions have been asked about minimal abilities for lifeguards with relation to physical ability, age, hearing and visual acuity. Evidence Identification and Review Internet Search Engine’s Pub med

Summary of Key Articles/Literature/Reports/Data Found and Level of Evidence

Author(s) and Year published

Full reference Summary of Article (if abstract available, first past abstract and then provide your

summary

Level of Evidence

(Using table below)

Nassau County, New York Department of Health

Application for Approval of Lifeguard Qualifications

Hearing Standards require that hearing loss does not exceed 25db between 500 and 2000Hz, 40db at 3000 and 45db at 4000Hz without correction.

Level 5

County of Los Angeles Class Specification for Ocean Lifeguard Candidate

Hearing Standards require no greater than 25dB loss in the better ear as averaged over the test frequencies 1000, 2000, and 3000 Hz. There may not be a peak loss at any of the test frequencies greater than 30 dB at 500 Hz 30 dB at 1000 Hz 40 dB at 2000 Hz 40 dB at 3000 Hz

Level 5

Las Vegas Metropolitan Police Department

Employment Medical/Vision/Hearing Standard

Pure-tone thresholds of audibility shall not exceed 25 dB Hearing loss Audiometric frequencies: 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz. Hearing aids are not permitted.

Level 5

American College of Occupational and Environmental Medicine 2002

Noise-Induced Hearing Loss

Individuals with noise-induced hearing loss may experience significant morbidity due to hearing induced speech discrimination.

Level 4

Communities and Local Government United Kingdom

Medical and Occupational Evidence for Recruitment and Retention in the Fire and Rescue Service

The article reviewed hearing requirements for firefighting employment based on English military standards. The article determined that minimal levels of hearing are necessary for firefighters. Specific thresholds were also reviewed.

Level 4

Pilot Medical Solutions, Inc

FAA Medical Certification- Hearing Standards and Evaluation

All classes of FAA medical certification must demonstrate the hearing of an average conversational voice in a quiet room, using both ears at 6 feet with back turned or use audiometric speech discrimination test. (Must score at least 70% discrimination at 65db in one ear.

Level 5

Florida State Division of State Fire Marshal

Medical Examination Require audiometric testing at 500Hz, 1000Hz, 2000Hz, and 3000Hz.

Level 5

Invest Ophthalmol Vis Sci. Wood J, Cohen RC, Holland JA, Shun A, La Hei ER.

The effect of auditory and visual distracters on the useful field of view: implications for the driving task.

PURPOSE: The driving environment is becoming increasingly complex, including both visual and auditory distractions within the in-vehicle and external driving environments. This study was designed to investigate the effect of visual and auditory distractions on a performance measure that has been shown to be related to driving safety, the useful field of view. METHODS: A laboratory study recorded the useful field

Level 3b

of view in 28 young visually normal adults (mean 22.6 +/- 2.2 years). The useful field of view was measured in the presence and absence of visual distracters (of the same angular subtense as the target) and with three levels of auditory distraction (none, listening only, listening and responding). RESULTS: Central errors increased significantly (P < 0.05) in the presence of auditory but not visual distracters, while peripheral errors increased in the presence of both visual and auditory distracters. Peripheral errors increased with eccentricity and were greatest in the inferior region in the presence of distracters. CONCLUSIONS: Visual and auditory distracters reduce the extent of the useful field of view, and these effects are exacerbated in inferior and peripheral locations. This result has significant ramifications for road safety in an increasingly complex in-vehicle and driving environment. Hearing loss reduce people’s ability to perform complex tasks such as driving and automobile.

Ann Otol Rhinol Laryngol.

Welsh LW,

Welsh JJ.

State and federal regulations for hearing.

Mandated federal and state requirements for hearing function prescribed for military and pilot performance, schoolchildren, and commercial and school bus drivers are summarized in the following review. The material is directed toward involved otolaryngologists, industrial physicians, and appropriate review boards for reference in licensure examinations or student hearing assessments.

Level 5

American Journal of Public Health Ivers RQ, Mitchel P, Cumming RG

Sensory Impairment and Driving: The Blue Mountain Eye Study

OBJECTIVES: This study examined the associations between vision, hearing, loss, and car accidents. METHODS: A cross-sectional survey of 3654 people aged 49 years and older in the Blue Mountains, Australia, was used. Each subject had a detailed eye examination and interview. RESULTS: Self-reported car accident rates in the past year among 2379 current drivers were 5.6% for those aged 49 to 79 years and 9.1% for those 80 years and older. A 2-line difference in visual acuity was associated with increased risk of accidents (adjusted prevalence ratio [PR] = 1.6), as was visual acuity worse than 6/18 in the right eye (PR = 2.0), overall moderate hearing loss (PR = 1.9), and hearing loss in the right ear (PR = 1.8). CONCLUSIONS: Sensory loss in drivers may be an important risk factor for car accidents.

Level 3b

Hearing loss reduce people ability to perform complex tasks such as driving and automobile.

J Am Acad Audiol.

Punch JL,

Robinson DO,

Katt DF.

Development of a hearing performance standard for law enforcement officers.

A task force consisting of the authors and four members of the Michigan Law Enforcement Officers Training Council developed a hearing performance standard for new police officer candidates in the State of Michigan. Ratings of the importance of hearing sensitivity and speech intelligibility in performing each of 135 specific job tasks formed the basis for pass-fail criteria. The standard, described in this report, includes specifications for unaided and aided hearing performance, types of hearing assessment measures, hearing measurement procedures, and the appropriate examining professional. The authors believe that the standard provides an appropriate accommodation to hearing-impaired law enforcement officer candidates with respect to The Americans with Disabilities Act.

Level 4

J Deaf Stud Deaf Educ.

Weisel A,

Cinamon RG.

Hearing, deaf, and hard-of-hearing Israeli adolescents' evaluations of deaf men and deaf women's occupational competence.

This study examined 74 deaf and hard-of-hearing (D/HH) and 91 hearing high school students regarding their own occupational aspirations and their evaluations of occupational competence (EOCs) for deaf adults. In the EOC, participants rated the suitability of 25 occupations (varying according to prestige and required level of communication) for deaf men and women. The results showed that occupations requiring intensive communication levels, regardless of their prestige, were evaluated as much less suitable for deaf individuals than were those requiring less communication. D/HH adolescents did not find highly prestigious occupations as suitable for deaf adults even when communication barriers were irrelevant. Both D/HH and hearing participants expressed biased evaluations of deaf women's competence, but no further evidence emerged for stereotypic attitudes. Higher educational aspirations among hearing adolescents, especially hearing males, correlated with a higher EOC of deaf adults. No such associations emerged for D/HH participants. No gender effects emerged. Implications of these outcomes for career development, especially for females, were discussed.

Level 3b

J Occup Environ Med. 1999 Apr; 41(4): 213-5.

Fitness for duty evaluations in hazardous materials

We analyzed results from the medical examinations of 340 hazardous materials firefighters and applied various objective

Level 3b

Kales SN, Aldrich JM, Polyhronopoulos GN,

firefighters. standards in simulated fitness for duty determinations. Ten percent had elevated blood pressures, 13% had far visual acuity worse than 20/30 in one or both eyes, and 38% had abnormal audiometry. The strictest standards for resting blood pressure and corrected visual acuity would have failed 2% and 1% of the cohort, respectively. For audiometry, 0%-5% of the cohort would have failed, depending on the hearing requirements set. The strictest hearing standard did not allow for corrective devices so that few failures would be reversible. Visual and audiometric testing and measurement of resting blood pressure all have significant clinical yields. Studies of simulated firefighting are needed to establish minimum hearing requirements and determine whether corrective devices can be worn safely during duty.

Int J Audiol. 2006 Sep; 45(9): 503-12

Kramer SE, Kapteyn TS, Houtgast T.

Occupational performance: comparing normally hearing and hearing-impaired employees using the Amsterdam Checklist for Hearing and Work.

This study compares the occupational performance of employees with and without hearing impairment, and aims to identify occupational difficulties specifically related to hearing loss. The Amsterdam Checklist for Hearing and Work was administered to 150 hearing-impaired employees and 60 normally hearing colleagues. A multivariate analysis of variance was performed to test group effects, and to examine differences between means. Factors predicting sick leave were identified by regression analyses. A significant group effect (p < 0.01) was found. Hearing-impaired employees differed from normally hearing colleagues in their perception of 'environmental noise', 'job control' and the 'necessity to use hearing activities' at work. Also, sick leave due to distress occurred significantly more often in the hearing impaired group (p < 0.05). 'Hearing impairment', 'job demand', and the requirement to 'recognize/distinguish between sounds' were the strongest risk factors for stress related sick leave. The importance of hearing functions besides speech communication is discussed. Implications for rehabilitation are suggested. In future research, hearing loss should be considered as a risk factor for fatigue and mental distress, which may lead to, sick leave.

Level 2

Acta Otorrinolaringol Esp. 2005 Aug-Sep; 56(7): 295-9. Garcia Callejo FJ,

Auditory requirement for group 2 vehicle driving licenses. An update in accordance with valid legislation in

INTRODUCTION: Hearing loss level admitted for acquisition of Group 2 driving licenses is actually 35%, but this measurement is not standardized. METHODS: In 35 drivers with Group 2

Level 3b

Garcia Callejo F, de Paula Vernetta C, et al

Spain license bearing of hearing loss, it was measured in the usual way -considering threshold as an average-, and also in accordance with valid legislation, which considers deafness when hearing thresholds are under 25 dB in each tone. RESULTS: Binaural hearing loss average was 41.3+/-6.3% for the first model, and 30.7+/-10.2% for the second. There was a good correlation between the two models by mean of lineal regression (y=1.4785x-30.382; R2=0.8467). CONCLUSIONS: In Group 2 licenses, hearing loss average must be standardized in its quantifying technique, because there is a wide difference in the results, depending on the model used to measure. In our country there are rules and regulations about quantifying for disable people, valid for establishing deafness measurement patterns in vehicle driving too.

Federal Bureau of Investigation

Federal Bureau of Investigation Special Agent Physical Requirements

Hearing Requirements Special Agent applicants must take an audiometer test and meet specified hearing standards. Please note that no applicant will be considered who exceeds any of the following:

a) average hearing loss of 25 decibels (ANSI) at 1000, 2000, and 3000 Hertz b) single reading of 35 decibels at 1000, 2000, and 3000 Hertz c) single reading of 35 decibels at 500 Hertz d) single reading of 45 decibels at 4000 Hertz

Level 5

Level of Evidence

Criteria

Level 1a Population based studies, randomized prospective studies Level 1b Large non-population based epidemiological studies, meta-analysis or small randomized

prospective studies Level 2 Prospective Studies which can include, controlled, non-randomized, epidemiological, cohort or

case-control studies Level 3a Historic which can include epidemiological, non-randomized, cohort or case-control studies Level 3b Case series: subjects compiled in serial fashion without control group, convenience sample,

epidemiological studies, observational studies Level 3c Mannequin, animal studies or mechanical model studies Level 4 Peer-reviewed works which include state of the art articles, review articles, organizational

statements or guidelines, editorials, or consensus statements Level 5 Non-peer reviewed published opinions, such as textbooks, official organizational publications,

guidelines and policy statements and consensus statements Level 6 Common practices accepted before evidence-based guidelines or common sense

Level 1-6E Extrapolations from evidence, which is for other purposes, theoretical analyses, which are on-point with question, being asked. Modifier E applied because extrapolated but ranked based on

type of study.

Summary Table of Evidence

Supportive of Recommendation Opposing Recommendation

No Position

Kramer (2006) Occupational performance: comparing normally hearing and hearing-impaired employees using the Amsterdam Checklist for Hearing and Work. Hearing-impaired employees differed from normally hearing colleagues in their perception of 'environmental noise', 'job control' and the 'necessity to use hearing activities' at work.

Punch (1996) Development of a hearing performance standard for law enforcement officers The authors believe that the standard provides an appropriate accommodation to hearing-impaired law enforcement officer

Wood (2006) The effect of auditory and visual distracters on the useful field of view: implications for the driving task Hearing loss reduce people’s ability to perform complex tasks such as driving and automobile.

Weisel (2005) Hearing, deaf, and hard-of-hearing Israeli adolescents' evaluations of deaf men and deaf women's occupational competence. The results showed that occupations requiring intensive communication levels, regardless of their prestige, were evaluated as much less suitable for deaf individuals than were those requiring less communication

Ivers (1999) Sensory Impairment and Driving: The Blue Mountain Eye Study Hearing loss reduce people ability to perform complex tasks such as driving an automobile.

Kales (1999) Fitness for duty evaluations in hazardous materials firefighters. Studies of simulated firefighting are needed to establish minimum hearing requirements and determine whether corrective devices can be worn safely during duty.

Garcia (2005) Auditory requirement for group 2 vehicle driving licenses. An update in accordance with valid legislation in Spain The authors support standardization of thresholds for hearing when obtaining a drivers license

American College of Occupational and Environmental Medicine (2002)

Noise-Induced Hearing Loss Individuals with noise-induced hearing loss may experience significant morbidity due to hearing induced speech discrimination. Communities and Local Government United Kingdom Medical and Occupational Evidence for Recruitment and Retention in the Fire and Rescue Service The article determined that minimal levels of hearing are necessary for firefighters. Specific thresholds were also reviewed.

Nassau County, New York Department of Health Application for Approval of Lifeguard Qualifications Sets specific hearing standard for employment.

County of Los Angeles Class Specification for Ocean Lifeguard Candidate (2006) Sets specific hearing standard for employment.

Las Vegas Metropolitan Police Department. Employment Medical/Vision/Hearing Standard. Sets specific hearing standard for employment.

FAA Medical Certification- Hearing Standards and Evaluation Sets specific hearing standard for employment.

Florida State Division of State Fire Marshal Medical Examination

Federal Bureau of Investigation Special Agent Physical Requirements Special Agent applicants must take an audiometer test and meet specified hearing standards

Textual Summary of Evidence: After a thorough review of the Internet and pubmed databases for key words related to Lifeguarding, Hearing Standards, Police, Firefighting, and driving requirements, 18 sources were identified. The highest levels of evidence-involved studies looking at hearing impaired individuals’ abilities to perform their jobs related to normally hearing individuals. Kramer (2006) and Weisel (2005) both found that occupations that require intense communication or increased attention are better suited for normal hearing individuals. The next sets of sources looked at driving standards and recommendations for other professions. Wood (2006), Ivers (1999), and Garcia (2005) all found that impaired hearing reduces people’s abilities to perform complex tasks including operating an automobile. Kales (1999), The American College of Occupational and Environmental Medicine (2002), and the Communities and Local Government of UK’s Medical and Occupational Evidence for Recruitment and Retention in the Fire and Rescue Service articles all supported minimal hearing standards in their occupations. Some studies even suggested specific standards. These studies had a consensus that there should be a minimal hearing threshold or no more than an average of a 25-decibel loss in both ears over a range of frequencies (500Hz, 1000Hz, 2000Hz, and 3000Hz). Additional sources included specific employment applications for Law Enforcement, Firefighting, the FAA pilot’s license, and Lifeguarding. Though not scientifically reviewed, these applications provide a consensus that a minimal hearing standard should exist. Most of

these applications also set minimal hearing thresholds for employment. There was only one opposing citation, Punch (1996) that looked at hearing impairment in law enforcement. They found that though their needs to be some level of hearing standard, there is room for hearing impaired officers in law enforcement. We feel that there is enough evidence to recommend that there should be minimal hearing standards for lifeguarding. Due to the fact that there was limited amount of direct research about a minimal hearing standard in lifeguarding, indirect studies were lower levels of evidence and the majority of information was individual consensus, we feel we can only make a guideline decision. Additional research specific to lifeguarding needs to be undertaken in order to formally adopt a standard. Further research needs to be completed to determine if adjunctive aids are acceptable for use in a lifeguarding setting. In additions validations studies need to be completed to confirm that thresholds developed are comparable for all life guarding settings including pools, lakes and open water environments. Preliminary Brief Evidence Summary and Guideline Document Section: Evidence from 6 studies involving case series and observations studies ranging in evidence from Level 2 through 3b and 12 additional studies ranging in evidence from Level 4 through 5 document that a minimal hearing standard should exist. There is an expert opinion and consensus that a minimal hearing standard should exist. Most of these applications also set minimal hearing thresholds for employment Therefore, it is recommended that a minimal hearing standard for lifeguards should be instituted as a guideline. In addition, specific minimal hearing thresholds or no more than an average of a 25-decibel loss in both ears over a range of frequencies (500Hz, 1000Hz, 2000Hz, and 3000Hz) should be instituted as an option. Further research needs to be completed to determine if adjunctive aids are acceptable for use in a lifeguarding setting. In additions validation studies need to be completed to confirm that thresholds developed are comparable for all lifeguarding settings including pools, lakes and open water environments

Preliminary Guideline Document Section: Recommendations and Strength (using table below):

Standards: Guidelines: There should be minimal hearing standards for Lifeguarding. Options: There should be a minimal hearing threshold or no more than an average

of a 25-decibel loss in both ears over a range of frequencies (500Hz, 1000Hz, 2000Hz, and 3000Hz) for Lifeguarding.

No Recommendations:

Guideline Definitions for Evidence-Based Statements Statement Definition Implication Standard A standard in favor of a particular action is

made when the anticipated benefits of the recommended intervention clearly exceed the harms and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendation standards may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms.

One should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

Guideline A guideline in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified Circumstances, recommendations may be made when high quality evidence is impossible to obtain but the anticipated benefits outweigh the harms.

One would be prudent to follow a recommendation but should remain alert to new information.

Option Options define courses that may be taken when either the quality of evidence is suspect or, level and volume of evidence is small or carefully performed studies have shown little clear advantage to one approach over another.

One should consider the option in their decision-making.

No recommendation

No recommendation indicates that there is a lack of pertinent evidence and that the anticipated balance of benefits and harms is presently unclear.

One should be alert to new published evidence that clarifies the balance of benefit Versus harm

Attach Any Lists, Tables or Summaries Created As Part Of This Review (Please include any tables, lists of items or procedures and tables, which you created as part of the review that would be helpful for final analysis or publication in the final document)