The drowning chain of survival has five links: prevent drowning, recognise distress, provide flotation, remove from water, and provide care as needed. Developed by an international group of drowning researchers and published in 2014, it is meant for both lay and professional rescuers, and it starts well before anyone is in the water.
This guide is general information, not a substitute for training. In an emergency, call 911.
What is the drowning chain of survival?
The "chain of survival" idea began in cardiac care. The authors of the drowning chain argue that drowning needs its own chain because managing it involves principles and actions that differ from sudden cardiac arrest. They say all nations would benefit from a simple, universal chain, which they built using a best-evidence approach, with the same five links for lay and professional rescuers (Szpilman et al., Resuscitation, 2014; see the abstract summarised by the International Life Saving Federation, ILSF, and the bibliographic record and DOI).
Where does it come from? The chain was published as: Szpilman D, Webber J, Quan L, Bierens J, Morizot-Leite L, Langendorfer SJ, Beerman S, Løfgren B. "Creating a drowning chain of survival." Resuscitation 85(9):1149-1152, September 2014. The same lead author co-wrote the New England Journal of Medicine review "Drowning" (Szpilman, Bierens, Handley and Orlowski, N Engl J Med 366(22):2102-2110, 2012), a general medical review of the subject that is not the source of the five-link chain. We have seen only the bibliographic record of that review, not its text.
The American Heart Association (AHA) page summarising its 2024 drowning update with the American Academy of Pediatrics describes the chain as covering prevention, early recognition, safe rescue and resuscitation (AHA, "Top Things to Know", 2024). We could not reopen that page on the day of this review, so this point rests on our earlier reading of it.
The five links at a glance
| # | Link | Where we cover it |
|---|---|---|
| 1 | Prevent drowning | How to prevent drowning |
| 2 | Recognise distress | Recognising drowning and getting help |
| 3 | Provide flotation | Below, and in Recognising drowning and getting help |
| 4 | Remove from water | Below |
| 5 | Provide care as needed | First aid and rescue breathing basics |
- Prevent drowning
- Recognise distress
- Provide flotation
- Remove from water
- Provide care as needed
The five link names are as worded in the 2014 abstract (ILSF). The explanations in the sections below come from the sources named in each section.
Link 1: Prevent drowning
Surf Life Saving New Zealand, describing the chain, says prevention is the most important factor in reducing drowning deaths and injuries and calls for multiple layers of protection (Surf Life Saving New Zealand, 2014). In the Philippines, the Department of Health was reported in 2011 to be developing a National Framework of Action on Drowning Prevention, aimed mainly at reducing drowning risk for children, and recommended training in first aid, basic life support and basic survival swimming for children and adults (VERA Files, 15 December 2011). We have not confirmed whether that framework was adopted. A 2021 paper in the journal Children discusses a later Multisector Action Plan on Drowning Prevention (title and details as listed in search results: Preventing child drowning in the Philippines).
The ILSF abstract says the chain is a guide to refine prevention in high-income countries and for policy making, resource allocation and priority setting in low- and middle-income countries (ILSF).
See How to prevent drowning and Kids and water safety. For the risks behind this link, read Where and how drownings happen.
Link 2: Recognise distress
Surf Life Saving New Zealand describes this link as spotting someone in trouble and getting help quickly, and notes that victims often cannot call out or wave, so rescuers must watch closely (Surf Life Saving New Zealand, 2014). Read Recognising drowning and getting help for what to look for and how to call 911.
Link 3: Provide flotation
Surf Life Saving New Zealand describes this link as stopping the drowning process by giving the person something to float on, which buys time for rescuers, and says rescuers should stay out of the water and throw a flotation aid, using improvised items if needed (Surf Life Saving New Zealand, 2014). The ILSF page names the link but does not describe it, and we could not open the full 2014 paper, so this description comes from the New Zealand lifesaving body's summary rather than from the paper.
A 2021 scoping review of lay rescuers (Barcala-Furelos et al., American Journal of Emergency Medicine) also names throwing or reaching with a pole, rope or flotation equipment, without entering the water, as the safest approach for an untrained bystander. It adds that throwing needs some training because untrained adults may not throw accurately.
Our Safety Buoys are one example of a throw-and-float aid. A flotation aid is a way to help from a distance, not a reason for an untrained bystander to enter the water.
Link 4: Remove from water
Surf Life Saving New Zealand describes this link as ending the drowning process by getting the person out of the water, "only if safe to do so", with options including directing a self-rescue, removing the person without entering the water, and entering only with flotation and only if safe (Surf Life Saving New Zealand, 2014).
On positioning, the American Academy of Pediatrics news release on the 2024 AHA/AAP update says that someone who is unconscious and likely in cardiac arrest should be removed from the water in a near-horizontal position, with the head above body level and the airway open, and that for a conscious person a more upright position may lower the risk of vomiting (AAP news release, 12 November 2024). We read the news release, not the full text in Circulation.
The same release says in-water rescue breathing should be given only by trained rescuers, such as lifeguards, swim instructors or first responders, and only if it does not compromise their own safety. It is a specialist skill, not for untrained bystanders.
Link 5: Provide care as needed
Surf Life Saving New Zealand describes this link as providing basic life support and medical care: starting CPR if the person is not breathing, using oxygen or an AED if available, staying with breathing victims until help arrives, and seeking medical attention for anyone with symptoms or who needed resuscitation (Surf Life Saving New Zealand, 2014). The AAP news release on the 2024 AHA/AAP update likewise says anyone who needed any resuscitation, even only rescue breaths, should go to hospital (AAP, 2024). The next article covers resuscitation in more detail: First aid and rescue breathing basics.
Who does what in the Philippines?
The chain is a shared job. The list below pairs each link with people and organisations that appear in sources we found. The pairing is our own editorial summary, not an official assignment of roles.
- Prevention: the Department of Health, reported in 2011 to be developing a national drowning prevention framework (VERA Files, 2011).
- Recognise and call: anyone, through the national 911 line (DILG, September 2025).
- Flotation and removal: trained lifeguards and rescuers. The Philippine Life Saving Society (PLSS) has taught water safety, contact and non-contact rescue and lifeguarding with local partners, for example in San Carlos City in November 2022 (Visayan Daily Star) and with the University of Baguio in November 2024 (University of Baguio). For incidents at sea, the Philippine Coast Guard's search-and-rescue powers are set out in Republic Act 9993, the Philippine Coast Guard Law of 2009 (as summarised in search-result text of the Senate copy of the law; we could not open it).
- Care: first aiders trained through the Philippine Red Cross, which lists first aid, BLS CPR and water safety programmes on its training page, plus emergency medical services and hospitals.
See Lifeguards and water safety organisations in the Philippines.
Related RESTUBE products
Sources
- Szpilman D, Webber J, Quan L, Bierens J, Morizot-Leite L, Langendorfer SJ, Beerman S, Løfgren B. Creating a drowning chain of survival. Resuscitation 85(9):1149-1152, 2014. https://doi.org/10.1016/j.resuscitation.2014.05.034 (full text not accessed; abstract read via the ILSF page and a bibliographic record)
- International Life Saving Federation, Medical Committee. "Creating a drowning chain of survival" (abstract and link to article), 2014. https://medical.ilsf.org/?p=10576
- Surf Life Saving New Zealand. "Creating a Drowning Chain of Survival", July 2014. https://www.surflifesaving.org.nz/news/2014/july/creating-a-drowning-chain-of-survival/
- Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med 366(22):2102-2110, 2012. https://doi.org/10.1056/NEJMra1013317 (bibliographic record only)
- Barcala-Furelos R, et al. Lay-rescuers in drowning incidents: a scoping review. American Journal of Emergency Medicine, 2021. https://ajemjournal.com/article/S0735-67572100072-3/fulltext
- American Heart Association. Top Things to Know: 2024 AHA and AAP Focused Update on Resuscitation Following Drowning, 2024. https://professional.heart.org/en/science-news/2024-aha-and-aap-focused-update-on-special-circumstances-resuscitation-following-drowning
- Dezfulian C, et al. 2024 AHA and AAP Focused Update on Special Circumstances: Resuscitation Following Drowning. Circulation 150:e501-e516, 2024. https://doi.org/10.1161/CIR.0000000000001274 (abstract only)
- American Academy of Pediatrics. News release on updated guidance for cardiac arrest following drowning, 12 November 2024. https://www.aap.org/en/news-room/news-releases/aap/2024/updated-guidance-says-cpr-with-breaths-essential-for-cardiac-arrest-following-drowning/
- VERA Files. "8 Filipinos die of drowning every day: DOH", 15 December 2011. https://verafiles.org/articles/8-filipinos-die-of-drowning-every-day-doh
- Children (journal), 2021. Preventing child drowning in the Philippines: the need to address the determinants of health (details from search results). https://doaj.org/article/5661d0ca4cb44386a421044a9e18e45b
- Department of the Interior and Local Government, Region IV-A. Unified 911, 5 September 2025. https://calabarzon.dilg.gov.ph/one-number-for-all-emergencies-unified-911-to-launch-nationwide/
- Visayan Daily Star. "Water-related workers undergo training", 29 November 2022. https://visayandailystar.com/?p=31514
- University of Baguio. "University of Baguio Empowers Future Professionals with Life-Saving Skills", December 2024. https://scjps.ubaguio.edu/university-of-baguio-empowers-future-professionals-with-life-saving-skills/
- Republic Act No. 9993, Philippine Coast Guard Law of 2009 (Senate legislative library copy, 2023 upload). https://issuances-library.senate.gov.ph/sites/default/files/2023-02/ra%25209993.pdf
- Philippine Red Cross. Trainings. https://redcross.org.ph/trainings
Last reviewed: 12 October 2026.
