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DS 18 Convene Multidisciplinary Review Panels for Drowning Incident Analysis

Key area

Data Surveillance

Convene multidisciplinary partners to identify, review, and discuss fatal drowning incidents among all ages to inform the development and evaluation of actionable data-driven and evidence-informed prevention strategies.

Spectrum level: Changing Organizational Practices Fostering Coalitions and Networks

Evidence level: Low

Implementation levels: Community County National State

Rationale:

Convening a group of multidisciplinary partners to identify, review, and discuss fatal drowning incidents can help improve surveillance and examination of resultant data to identify actionable interventions.

Anticipated Impact:

After implementing this recommendation, you can expect to experience the following outcomes.

  • Establishing a group of multidisciplinary partners to identify, review, and discuss fatal drowning incidents among all ages to inform the development and evaluation of actionable data-driven and evidence-informed prevention strategies leads to improved surveillance.

Evidence:

The National Center for Fatality Review and Prevention has conducted a national evaluation that addresses the effectiveness of multidisciplinary investigation and review of drowning: https://ncfrp.org/cdr/drowning-case-registry/

There is additional evidence in the effectiveness of multidisciplinary teams related to overdose deaths, sudden unexpected infant deaths, and sudden death in the young.

Evidence Sources:

  • Multidisciplinary Team Reviews of Drug Overdose Deaths and the Use of Minigrants to Advance Recommendations: A Statewide Pilot in Rhode Island (https://journals.lww.com/jphmp/Abstract/2020/05000/MultidisciplinaryTeamReviewsofDrug_Overdose.7.aspx)

  • Overdose Fatality Review Tams Literature Review (https://icjia.illinois.gov/researchhub/files/Overdose%20Fatality%20Review%20Team%20Literature%20Review%20Final-210219T19112457.pdf)

  • Death Scene Investigation And Autopsy Practices in Sudden Unexpected Infant Deaths (https://pubmed.ncbi.nlm.nih.gov/27113380/)

  • The Sudden Death in the Young Case Registry: Collaborating to Understand and Reduce Mortality (https://pediatrics.aappublications.org/content/139/3/e20162757)

High Risk Populations Addressed:

Populations whose risk of drowning decreases the most with the implementation of this recommendation may have one or more of the following characteristics:

  • Children 1-4 years of age
  • Males
  • American Indian and Alaska Native individuals aged 29 and younger, and Black or African American individuals
  • Individuals with seizure disorders or heart conditions
  • Individuals with Autism

Evaluation Metrics:

Indicators of long-term impact:

  • Increased engagement among more partners at federal, state, and local levels
  • Enactment of policy recommendations, programmatic prevention efforts or agency changes that were identified from the multidisciplinary review
  • Better identification of risk and protective factors in the adult population

Indicators of intermediate impact:

  • Development of guidance and training for teams conducting multi-disciplinary reviews

Indicators of initial impact:

  • Increased number of states and jurisdictions convening multidisciplinary reviews of drowning deaths
  • Identification of needed policy and programmatic changes from multidisciplinary reviews
  • Increased number of states and jurisdictions entering information from reviews into a surveillance system

Implementation:

Consider the following to ensure successful implementation:

  • Develop fatality reviews that are directly linked to a community or state and are prevention oriented.
  • Develop a fatality review process grounded in health equity to understand the interconnected layers of risk factors present in drowning deaths.
  • Provide clear guidance and technical assistance to those conducting reviews.
  • Establish and engage programs with resources to implement prevention recommendations and support data and recommendations from reviews.
  • Establish a greater understanding of state and local capacity for conducting drowning reviews as well as potential funding sources.

Challenges to Implementation:

When implementing this recommendation, you might encounter challenges related to the following factors.

  • Legislative and legal authority to undertake these reviews may be lacking.
  • Linking reviews to prevention will be critical.
  • Moving prevention recommendations to action is frequently a challenge for fatality review teams.
  • Quantifying a reduction in drowning mortality due to the fatality review recommendations may be difficult.
  • Standardized drowning data collection system for all ages may be limited.
  • Standardized drowning investigation tools may be limited.
  • Funding to support multidisciplinary fatality reviews may be limited.
  • Funding support for implementation of drowning prevention recommendations may be limited.

Potential Facilitators:

The following factors might facilitate the implementation of this recommendation.

  • Support from the National Center for Fatality Review and Prevention, CDC, HRSA, and AAP may help facilitate successful implementation.

GAP Recommendation:

None