Speaker:  Kathryn Koelemay, Medical Epidemiologist, Public Health – Seattle & King County All hospitals should be prepared to receive pediatric patients in a mass casualty incident and to provide appropriate short-term acute care and more definitive management, depending upon the nature of the emergency and the extent of its impact on the region. Hospitals of the King County (WA) Healthcare Coalition are in the process of implementing a regional pediatric disaster response plan, with the goal of providing consistent, efficient and age-appropriate medical care to pediatric patients at every County hospital with emergency services in an MCI that involves children. Our “pediatric toolkit,” which was recognized as a 2010 NACCHO Model Practice winner, suggests guidelines for development of the hospital‟s pediatric response plan. The regional plan also includes countywide adoption of a color- coding system based on a length-based resuscitation tape to expedite accurate medication and equipment deployment.

1. 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

2. 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.

3. 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”

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Decon Shower-
child
Decon Shower-
infants &
nonambulatory kids
Pediatric Disaster Toolkit:
Hospital Guidelines for Pediatrics in Disasters
http://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml

11. From a Child’s Perspective?

12. 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

13. Hurricane Katrina: Biloxi - 2005

14. 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

15. Oklahoma City Bombing - 1995

16. Injuries by Age Group
Shariat 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

17. Mississippi Bus Crash - 2011

18. Mississippi Bus Crash - 2011
Video

19. 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.

20. Traffic Congestion Map

22. Minnesota Bridge Collapse - 2007

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

24. Pediatric Resources by
Emergency 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

25. Earthquake – 2001
Video

26. 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

27. Pediatric Evacuation Support
Planning 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

28. 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

29. Perinatal Emergency Planning Survey

30. Length-based Resuscitation Tape Survey

31. “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

32. 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

33. Emergency Department Resources: Wall Charts

34. 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 .

35. 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.

36. 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

37. 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

38. The Length-based Resuscitation Tape
Using color-coding

39. 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”

40. 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”

41. 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

42. 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

43. 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

44. 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

45. The Child Emergency Plan

46. 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

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