Developing a Regional Pediatric Disaster Response Plan

Disaster Preparedness Planning:Who’s Minding the Kids? Kay Koelemay, MD, MPH King County Healthcare Coalition Co Communicable Disease Epidemiology & Immunization u cab e sease p de o ogy u at o Public Health – Seattle & King County April, 2011

Learning Objectives All hospitals with an ED must be p p p prepared to care for pediatric patients in a disaster. Children have unique vulnerabilities in a disaster situation. Special considerations impact hospital planning f pediatric victims of an MCI l i for di t i i ti f MCI. Strategies or tools can be developed that support implementation of a regional pediatric disaster response plan.

National Emphasis Institute of Medicine  1993 “Emergency Medical Services for Children” Emergency Children  2006 “Emergency Care for Children: Growing Pains” 2003 National Consensus Conference  “Pediatric Preparedness for Disasters and Terrorism” 2006 AAP & AHRQ  “Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians” October 2010  “Report of the National Commission on Children and Disasters”

http://www.ahrq.gov/prep/nccdreport/

National Emphasis Continues “NATIONAL COMMISSION ON CHILDREN AND DISASTERS: 2010 REPORT TO THE PRESIDENT AND CONGRESS”  Chairperson Mark Shriver has sent a letter to governors of all 50 states to urge them to lead state efforts to improve disaster plans for children ( p (March, 2011) , )  State advisory body to ensure focus  Staff with designated responsibility to integrate/coordinate  Directed federal emergency preparedness grants to support needs of children  Required all-hazards disaster planning standards for systems serving children  Child-appropriate standards for emergency shelters

Pediatric Patients in an MCI Critically ill or injured children may present to ANY and ALL hospitals  Accessibility issues for emergency responders  Transfer to pediatric specialty hospital may be p p y p y impossible  Unstable patient  S Shortage of vehicles f  Impassable roads or bridges  Specialized hospital cannot accommodate

Children: Not “Small Adults”  Anatomical/ physiological differences  Vital signs vary with age g y g  Smaller, shorter stature  lower “breathing zones” g  Higher minute volume  Less intravascular volume reserve

Uniquely Vulnerable Greater body surface area to weight ratio Increased skin permeability More pliable skeleton Weight is critical in determination of: g  drug dosages  fluid requirements  equipment sizes

Decontamination of Children Must be done with high-volume, low-pressure, high volume, low pressure, heated water systems Must be designed for decontamination of all ages and types of children All protocols and guidance must address:  Water temperature and pressure  Nonambulatory children  Children with special health care needs  Clothing for after decontamination

Decon Shower- child Decon Shower- infants & nonambulatory kidsPediatric Disaster Toolkit:Hospital Guidelines for Pediatrics in Disastershttp://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml

From a Child’s Perspective?

Developmental Differences Preverbal cannot describe symptoms or relate identifying information Dependent on others for food, clothing, shelter p , g, Motor skills may deter escape from site of incident Cognitive development may limit abilities: g p y  How to flee from danger  How to follow directions  How t recognize a th t H to i threat

Hurricane Katrina: Biloxi - 2005

Mental Health Issues Issues are developmentally dependent p y p Short- and long-term manifestations  PTSD, fear, depression, sleep disturbances, social or behavioral difficulties, anxiety changes in school difficulties anxiety, performance Related to parental reaction  Family-centered approach recommended Certain children may be more vulnerable  Children with pre-existing mental health problems  Low income and racial or ethnic minorities

Oklahoma City Bombing - 1995

Injuries by Age GroupShariat et al. Oklahoma City Bombing Injuries. Oklahoma State Department of Health, 1998.Shariat et al Oklahoma City Bombing Injuries Oklahoma State Department of Health 1998

Mississippi Bus Crash - 2011

Mississippi Bus Crash - 2011 Video

School Bus MCI 23.5 23 5 million kids ride to and from school Annual average: 10 bus crash deaths 8500-1200 8500 1200 bus crash injuries annually  96% minor injuries: bumps, bruises, scrapes  Based on police reports  “Not all go to the emergency department” Savage et al. Protecting Children: A guide to child traffic safety laws. National Conference of State Legislators, 2002.

Traffic Congestion Map

Minnesota Bridge Collapse - 2007

Hospitals in King County, Washington by Emergency Coordination Zones 1, 3, 5 1 1 5 3

Pediatric Resources byEmergency Response Zone 2007 survey by Mary King, MD, MPH Prehospital and Disaster Medicine, 2010 Zone 1 Zone 3 Zone 5 100 90 80 70 60 % 50 40 30 20 10 0 Population* Bedspaces Nurses Physicians*Source: 2005 Population Estimates for Public Health Assessment, Washington State Department of Health

Earthquake – 2001 Video

Assessment Hazard Identification & Vulnerability Assessment (HIVA) A Study (King et al) re: pediatric inpatient beds beds, staff, supplies, equipment Regional evacuation planning workshop Facility surge capacity evaluations

Pediatric Evacuation SupportPlanning Project KC hospitals with peds inpatient beds  PICU, NICU, Med/Surg, Behavioral Health Summary of high census bed capacity and y g p y patient care levels in each facility Surge capacity determination  Within 2-4 hours with no outside support  Within 12-24 hours using internal supplies, equipment and staffing  Within 12-24 hours, adding external resources

Evacuation Planning: ConOps “Designated Pediatric Surge Hospitals”  Hospitals to receive entire units of patients  Allows preplanning by receiving hospital  Limits locations and requirements for movement of staff, equipment & supplies  Supports efficiency of reassignment of staff with defined privileges  May ll M allow caching of supplies i receiving h hi f li in i i hospital or i it l in nearby locations  Limits locations for Family Reunification Centers  Presets large component of regional evacuation decisions  May facilitate a system for pre-credentialing & privileging pediatric providers

Perinatal Emergency Planning Survey

Length-based Resuscitation Tape Survey

“Pediatric Toolkit” y Adapted by: Healthcare Coalition Pediatric Workgroup Triage Task Force W k Ti T kF 144 pages Guidelines for: G id li f •Staffing and training •Equipment and supplies •Pharmaceutical planning •Dietary planning •Transportation •Inpatient bed planningg 42 pages •Security and psychosocial support •Decontamination of children •Hospital-based triage

Contents  Infection control guidance Staffing and training  Family Information and Equipment and supplies Support Center Pharmaceutical planning  Psychological First Aid (PFA) Dietary planning Transportation  Pediatric transport issues Inpatient bed planning  Pediatric surge strategies Security and psychosocial S it d h i l  Tracking protocol support  Job action sheets Decontamination of children  Pediatric Safe Area checklist Hospital-based triage  Sample menu

Emergency Department Resources: Wall Charts

Initial Steps Create pediatric leadership positions  Physician Coordinator Ph i i C di t  Nursing Coordinator"...Guidelines for Care of Children in the Emergency Department" g y p 2009 joint policy statement of committees of American Academy of Pediatrics American College of Emergency Physicians & the Emergency Nurses Association http://pediatrics.aappublications.org/cgi/reprint/124/4/1233 .

Color-Coding Kids  Length-based resuscitation tape  Color zones to estimate child’s weight  Pediatric disaster carts/drawer for color- coded supplies  Color-coded bags of appropriate-sized supplies and equipment  Color-coded imaging p g g protocols, emergency medication sheets, etc.

Why “Every Kid, Every Time” Pediatric resuscitations cause significant cognitive stress for care providers  high potential for error Standardized process  reduces cognitive stress  allows clinicians t f ll li i i to focus on assessment, t prioritization and interventions “Color Coding” has been sho n to decrease shown errors in care

Example: Calculating Fluids for Pediatric Patients Normal saline (NS) for volume expansion:  20 mL /kg body weight  13 kg child: Total = 260 mL Maintenance fluids:  4 mL/ kg/hour for first 10 kg  2 mL/kg/hour for second 10 kg  1 mL/kg/hour for each additional kg  23 kg child = 40+20+1 Total = 61 mL/hour

The Length-based Resuscitation Tape Using color-coding

Regional Implementation Project  Identify training “package”  “Every Kid Every Time” CD ROM Every Time CD-ROM  Just-in-time training materials  Team training resources  Communication plan  Pediatric bed tracking  Situational awareness  Surveys to track progress y p g  Exercise: “Operation Red Rover”

Implementation Highlights Implementation Objective Hospital Progress Track pediatric beds on WATrac 100% PICU, NICU and pediatric(web-based disaster response coordinating tool) Med/Surg beds are “activated” Identify pediatric leadership and 67% have designated physician and expertise within facility nursing pediatric coordinators Implement color-coding via length- 80% near-complete o co p e ed ea co p e e or completed based t b d tape t estimate weight to ti t i ht Able to activate a pediatric 70% have planning in progress or response team in a disaster have plan in place Participate in regional exercise 67% participated in the evacuation to test plan drill, “Operation Red Rover”

Drill: 3/31/11 “Operation Red Rover” Simulated evacuation of Swedish First Hill pediatric patients  76 NICU, 6 PICU, 28 Med/Surg, 4 Psych patients) Simulated transport via EMS (assets assessment)  Medic One, AMR, Rural Metro Simulated Si l t d receipt of di t ib t d patients at KC h i t f distributed ti t t hospitals it l Objectives:  test pediatric response and surge capacity  patient tracking  communication  security and crowd control

Regional Planning Progress ASPR monies applied to purchase of peds equipment/supplies Concurrent pediatric planning in Pierce County  Proposal: an interregional pediatric chat room for communication and collaboration i ti d ll b ti Pediatric Disaster Response Workshop  Pediatric l P di t i color-coding di  Pediatric disaster transport & equipment training

Challenges  Hospital participation  Costs C t  Planning/training, pediatric supplies and equipment  Staff time/ prioritization  Reallocation of facility space  Leadership “buy-in” and support  Surge planning estimates  Hospital control responsibilities

Goal: A Regional Pediatric Disaster Response Network Consistent approach across the region pp g Communication and collaboration network  Opportunities for efficiencies in training, exercises and pp g planning Coordination with pre-hospital emergency responders and emergency management agencies Increased pediatric capability and capacity Redefined relationship with pediatric specialty hospital in a large-scale medical emergency  e.g., telemedicine, pre-privileged response teams

The Child Emergency Plan

Resources “Children in Disasters: Hospital Guidelines for Pediatric Preparedness,” 3rd Edition (2008), http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds- http://www nyc gov/html/doh/downloads/pdf/bhpp/hepp peds childrenindisasters-010709.pdf King MA, Koelemay K, Zimmerman J, Rubinson L. Geographical maldistribution of pediatric medical resources in Seattle-King County. Prehospital and Disaster Medicine. July-Aug 2010; 25 (4): 326-32 National Commission on Children and Disasters: 2010 Report to the President and Congress http://www.ahrq.gov/prep/nccdreport/ Public Health – Seattle & King County/ Healthcare Coalition http://www.kingcounty.gov/healthservices/health/preparedness/hcc oalition.aspx

Questions? Comments?Thanks for your participation! Kathryn.Koelemay@kingcounty.gov

Developing a Regional Pediatric Disaster Response Plan

by Partners in Emergency Preparedness Conference

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