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Planning and Preparedness for Children's Needs in Public Health Emergencies

This resource was developed by AHRQ as part of its Public Health Emergency Preparedness program, which was discontinued on June 30, 2011. Many of AHRQ's PHEP materials and activities will be supported by other Federal agencies. Notice of transfer to another agency will be posted on this site.

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Transcript of Webcast


This is the transcript of a Webcast titled Planning and Preparedness for Children's Needs in Public Health Emergencies that took place on May 12, 2009.

Select to access the slide presentation (PowerPoint® file, 3.5 MB).


Kelly Johnson: Welcome, and thank you for joining us today for this Web conference, Planning and Preparedness for Children's Needs in Public Health Emergencies. I would like to acknowledge Dr. Sally Phillips, the Director of AHRQ's Public Health Emergency Preparedness Research Program, for making this live event possible. AHRQ has demonstrated its commitment to the field of emergency preparedness by supporting more than 60 emergency preparedness-related studies, workshops, and conferences to help hospitals and health care systems prepare for public health emergencies. Many of these projects were made possible through collaboration with the Office of the Assistant Secretary for Preparedness and Response, ASPR, at the Department of Health and Human Services and other Federal agencies. Due to this relationship between AHRQ and ASPR I am happy to be co-moderating this event with Dr. Daniel Dodgen, who will address you shortly. Dr. Dodgen is the Director of the Office of At-Risk Individuals, Behavioral Health, and Human Services Coordination at ASPR. In a moment, he will discuss some of ASPR's current initiatives focusing on children's needs in emergency preparedness and how these will help contribute to the advancement of the field. Then he and I will moderate the Q&A session at the conclusion of the event once we have heard from all of our expert presenters.

Before I introduce my co-moderator and we begin today's presentations, I would like to take a moment to recognize that one of the developers for both AHRQ resources we will discuss today, Dr. Michael Shannon, recently passed away. Dr. Shannon was a pioneer in the pediatric emergency preparedness field, and served as the Chief Emeritus of Emergency Medicine and Director of the Center for Bio-preparedness at Children's Hospital in Boston. He was also a great advocate for children. These resources are among many, many works he accomplished in his life that contribute to improving our ability to safeguard and better care for children.

Within the past decade, there has been marked progress in both emphasizing the crucial differences between adults and children and responding to these with research to help address the needs of children in emergencies. Physiologically and psychologically, children are considered a vulnerable population. These differences are of great importance and illustrate that disaster response plans should be modified for such a priority population. As you see from our agenda today, we will highlight Federal resources available to emergency preparedness practitioners representing State and local agencies, emergency responders, and school personnel to address the special needs of children in public health emergencies.

Before I begin, I want to quickly review what our Web conference producer, Zac, mentioned earlier. Sound for today's event is being brought to you via audio broadcast. If you experience challenges with the Web audio broadcast and would like to listen via teleconference on your phone, you can leave the Web audio broadcast by clicking "Communicate" at the top of your screen, and then click "Leave Audio Broadcast." Next, to obtain the teleconference information, click the "Request Phone" button at the bottom of the "Participants" panel at the right side of your screen. Your teleconference information will then appear on the screen for you to call in.

Additionally, we encourage you to submit questions for our speakers by typing them into the Q&A panel. This is intended to be an interactive forum, so please submit your questions to our speakers throughout the presentation. We will do our best to address as many questions as we can during the moderated Q&A session at the end of the Web conference.

As previously mentioned, the Office of the Assistant Secretary for Preparedness and Response, ASPR, has been one of several important partners to help make AHRQ's emergency preparedness projects possible. I now have the pleasure of introducing Dr. Daniel Dodgen, the Director of the Office for At-Risk Individuals, Behavioral Health, and Human Services Coordination at ASPR. Dr. Dodgen is also the Executive Director of the White House-directed National Advisory Group on Disaster Mental Health and is a trained American Red Cross disaster mental health worker and responded to the September 11th attack on the Pentagon. Dr. Dodgen, thank you for agreeing to moderate today's Web conference with me, and for saying a few words about ASPR's work in this area.

Dr. Daniel Dodgen: Thanks Kelly. It's great to be here. It is great to not only welcome the amazing panel we have today, but also all the people online, and I am hearing that we have up to 600 people online. Thanks to everyone for taking the time out of their busy schedules to join us today. As Kelly mentioned, we thought I would start by taking a few moments to describe ASPR's current work in emergency preparedness, focusing on the needs of at-risk populations. As many people listening today know, the September 11th attack, Hurricane Katrina, and even the recent H1N1 outbreak all reminded us to pay attention to all the vulnerable groups, especially groups that we call at-risk. HHS—the Department of Health and Human Services—and ASPR are very committed to meeting the needs of these groups.

I will start with the structure that we have to ensure that we are integrating attention to all of these issues into all of our work. Since all government talks begin with an organizational chart, I will start with ours. You can see that my office, the Office for At-Risk Individuals, Behavioral Health, and Human Services Coordination, is part of the Office of Preparedness and Emergency Operations within ASPR. That means that we are the office that coordinates many of the activities that are undertaken in direct response to a disaster. That would include things like the National Disaster Medical System, the Hospital Preparedness Program, the Emergency Care Coordination Center, and a number of other activities that we engage in during disaster response. My office, in particular, focuses on emergency support function (ESF) #8, which is the emergency support function that supports public health and medical services. Within this office, we are focusing not just on HHS, but all of HHS' partners throughout the Department and across the Federal Government, and including some non-government organizations as well. As you can see we work to include not just the at-risk individuals, which I will define better for you in a minute, but also behavioral health issues since we know all of those are critical and will really inform an effective disaster response.

If we turn to the next slide, we will see that the Pandemic and All-Hazards Preparedness Act specifically mandates that everything that we do in the Federal Government, and particularly in HHS, in response to public health emergencies includes attention to at-risk individuals. The statute defines that as children, pregnant women, senior citizens, and others with special needs in a public health emergency. So, as a Department, we pulled together our best and brightest thinkers to help us understand what we really mean by all of these groups, particularly regarding others with special needs. In doing that, we wanted to bring our efforts into conformity with what was going on across the rest of the Federal Government through the enactment of the National Response Framework.

In combining our mandate with what was going on in the National Response Framework, we decided to go with a definition that approaches special needs by looking at functional needs. If you look at the left side of slide 10, those would be one or more of the following functional areas that are defined as at-risk: that includes communication, medical care, independence, supervision, and transportation. If you look to the right-hand side of the slide, of course, you can see examples of some of the people in addition to the children, pregnant women, and seniors that you see at the top of your slide. Many of you that work with children probably know that there are certain kinds of functional needs that they are more apt to have, particularly communication needs, i.e., helping someone to understand what is happening, and supervision, particularly in the case of children who are unaccompanied. Obviously, all five of the functional needs described here are things that children could potentially experience.

On slide 11, you have a list of just a couple of activities that we are undertaking or have recently undertaken to address some of the needs of children. Obviously, there is a lot more happening across the Department, and I can refer you to a document in a minute that will help you see what some of those are. A couple of examples are the Biomedical Advanced Research and Development Authority. You can see that some of the recent expenditures on liquid potassium are $17.6 million for over 4.8 million doses. Our recent Integrated Medical, Public Health, Preparedness, and Response Training Summit included a number of sessions, including hopefully some by people that are listening in today. We had really good speakers, and you can see some of the examples of topics that were included related to children and our National Biodefense Science Board, which is the Federal Advisory Committee that provides expert advice and guidance to the Secretary regarding chemical, biological, nuclear, and radiological agents. They made a decision very early on in the activities that they would require whatever they did to demonstrate how it was addressing the needs of at-risk populations, including children.

There are a number of other things going on, and I would encourage people, when they have a chance, to go to our Web site, which is at hhs.gov, to find more information. We did a report to Congress on the activities that the Department is doing in emergency response related to at-risk populations and want to remind people who are particularly interested in the H1N1 recent outbreak that there is some very, very good information both for clinicians, parents, and other groups related to that outbreak on the CDC Web site, which you can find at cdc.gov. There is a link that will take you directly to the H1N1 page. I have probably talked a little bit too long, and I know we have some exciting speakers today, so I will turn it back to Kelly.

Kelly Johnson: Thank you, Dr. Dodgen, for sharing with us the initiatives ASPR is currently working on. AHRQ looks forward to continuing our work together in the future. As you may know, AHRQ's Public Health Emergency Preparedness Research Program has sponsored the development of resources that address a range of issues with an all-hazards approach, including community planning, mass prophylaxis, situation modeling, pandemic influenza, surge capacity, and pediatrics. Currently, AHRQ has four resources that solely address the needs of children in emergencies. Two of these resources—Pediatric Hospital Surge Capacity in Public Health Emergencies and School-Based Emergency Preparedness: A National Analysis and Recommended Protocol—will be discussed by the developers on today's Web conference. These resources separately address the two critical institutions to consider when addressing the needs of children in public health emergencies: hospitals and schools.

Dr. Daniel Dodgen: During a public health emergency, both children's hospitals and general hospital emergency departments could be faced with a large influx of pediatric patients. To respond to this surge in demand for pediatric resources, hospitals will need to have a plan in place not only for surge capacity, but for addressing the specific physiological and psychological needs of children. First on today's agenda, Dr. Edward Boyer and Dr. Jeffrey Upperman will discuss helpful resources to address hospital surge capacity for pediatric patients during a public health emergency.

Kelly Johnson: Furthermore, schools are an important element in pediatric emergency planning since children spend as much as 70 percent to 80 percent of their waking hours away from their parents in school. Schools, therefore, have a vital role in ensuring that children are cared for and proper interventions are delivered during and after a public health emergency. AHRQ's School-Based Emergency Preparedness: A National Analysis and Recommended Protocol was developed by the Center for Bio-preparedness at Children's Hospital in Boston. Today, Dr. Sarita Chung, who is a member of the Division of Emergency Medicine at the Children's Hospital Boston and a senior faculty member of the Center for Bio-preparedness, will present the Protocol. Dr. Chung, who has received training in pediatrics and pediatric emergency medicine, will discuss how her team analyzed emergency response plans from school districts around the country to create a template, which includes “best practices” for school districts to use in their development of a comprehensive emergency plan.

Dr. Daniel Dodgen: Then, Bill Modzeleski, the Acting Assistant Deputy Secretary at the Office of Safe and Drug-Free Schools, OSDFS, at the Department of Education, will review some of their school-based resources and related initiatives. The OSDFS has been working with schools on issues related to emergency management dating as far back as the Oklahoma City bombing. Through these efforts, the Office has developed numerous resources for schools on emergency management and has awarded hundreds of grants to school districts to support emergency planning efforts and recovery from traumatic events.

Kelly Johnson: Our final speaker, before the moderated Q&A session, will be Christopher Revere, who is the Executive Director of the National Commission on Children and Disasters. The Commission was established in December 2008 and is funded by Congress to investigate and recommend policies relevant to ensuring the specific needs of children and the well-being of children are incorporated into disaster planning and response. Mr. Revere will discuss the Commission's purpose, process, and recommendations. I believe the Commission has heard from all of our panelists' organizational affiliates, and their final report should address all the topics we cover today.

Dr. Daniel Dodgen: Sounds like a great panel, Kelly. Let's get started.

Kelly Johnson: Yes. I now have the pleasure of introducing our first presenter, Dr. Edward Boyer. Dr. Boyer is an emergency physician for both the University of Massachusetts and Harvard University Medical Schools. He helped develop the Pediatric Hospital Surge Capacity in Public Health Emergencies resource at the Center for Bio-preparedness at Children's Hospital Boston with his colleague, the late Dr. Michael Shannon. Dr. Boyer, you may begin.

Dr. Edward Boyer: Thanks, Ms. Johnson. Before describing how to develop recommendations to respond to surges of pediatric patients, I think it's useful to go through a few definitions. Clearly, you can spend hours going over definitions related to how to improve responses to a population as diverse as children, but I think you can narrow it down to only a few. The first is what is a child? For the purposes of this discussion, we are just going to describe it as one who fits within the parameters of a Broselow-Luten resuscitation tape1. I understand that some academic pediatric emergency medical groups might not use that, but I think it is a useful metric that can organize thought around the process today.

For surge capacity, we will use the working definition of the ability of a health care facility to provide medical care to patients from external emergencies in excess of the standard operating capacity. These are patients that arrive at a medical center from elsewhere that require a fundamentally different mode of operation within a hospital. For a pediatric hospital, we are going to use the definition of an accredited health care facility that specializes in the care of children. You can argue a little about what the upper age limit should be, but for our purposes today we will say 21 or less. A general emergency department or hospital specializes in the care of all patients, irrespective of age, and while they are able to provide care for all age groups, they, nonetheless, lack the breadth and depth of services that pediatric hospitals offer to their patients.

Kelly Johnson: I would now like to introduce Dr. Sarita Chung. Dr. Chung is a member of the Children's Hospital Boston Division of Emergency Medicine and a senior faculty member at the Hospital's Center for Biopreparedness. Dr. Chung will discuss how her team developed the School-Based Emergency Preparedness: A National Analysis and Recommended Protocol. Dr. Chung?

Dr. Sarita Chung: Thank you, Kelly and Dan. I would like to start off by saying that we know there are over 53 million children in schools daily. As was mentioned before, children spend as much as 70% to 80% of their waking hours away from their families in school. More disturbingly many recent events demonstrate that children in school might become specific targets of terrorism. Such events include the school hostage disaster in Belgium and Russia that resulted in over 300 casualties, and as Dr. Boyer mentioned, numerous school shootings by hostile individuals or groups. Schools have a vital role in ensuring that children are cared for and proper interventions are delivered after a public health emergency. Children differ from adults in many ways that are of great importance in public health emergency response plans. Their greater susceptibilities result from differences in breathing rate, skin permeability, innate immunity, communication skills, and self preservation instincts. These differences, and others, require that disaster response plans be modified for such a priority population.

When this project was undertaken in 2004, a national model for school-based public health preparedness did not exist. Consequently, school districts across the Nation had rudimentary, fragmented, or nonexistent emergency preparedness plans. We initially conducted analysis of school emergency response plans from California, Minnesota, Florida, and Massachusetts. Additionally, we spoke with safety officers from these school districts. Manuals were evaluated for the thoroughness of implementing the four phase approach for planning for a disaster, the degree to which plans provided an all-hazards approach, the specificity of instructions for response to particular emergency situations, and the clarity, practicality, and usability of plans by crisis teams, nurses, and other school staff.

What did we find? Our findings revealed that while many of the school plans were comprehensive representing hours of thoughtful work, they were not necessarily practical to implement in the particular school setting. Many manuals did not outline protocols for common emergencies including drugs and alcohol or medical emergencies. Some of the crisis manuals were voluminous and inadequately indexed making rapid access to important information difficult. While every school had a well-established evacuation plan, few had plans for relocation, fewer had lock-down plans, and virtually none had sheltering-in-place plans. Many plans omitted specific guidelines for communication between local emergency responders and the school and, lastly, there was no specific methodology for training crisis teams, school nurses, or other school personnel. Creation of a comprehensive school-based emergency response plan requires approval, commitment, and support from the highest leaders of school leadership. This process must take a top-down approach. Key leaders in understanding the project include the district superintendent, the school committee, and the local or regional public emergency response team. Communication with the emergency response teams also ensures that emergency plans created by the school do not conflict with efforts already underway. The planning team creating the district-wide school plan should include, at a minimum, at least one representative from each of the following: school principals, guidance counselors, teachers, nurses, secretarial staff, custodial staff, and parents. At least one member of the team or consultant should have experience in emergency management and the development of an emergency response plan.

I would like to review key steps to creating a school-based emergency response plan. These key steps are listed in our Protocol. First, you need to perform a needs assessment and understand what your school staff understands. Secondly, conduct a structured interview with each school principal. The planning team should survey all schools using an instrument that presents a streamlined interview, identifies the specific needs of each school building, and outlines the structural vulnerabilities and recognizes the needs of special populations. In our school preparedness plans we have included sample surveys for nurses, assistant principals, members of the crisis response team, school staff, and structured interviews with the school principal. To conduct a site survey of every school in the district you have to know the nuances, and identify areas for a lockdown and sheltering sites for each school.

Further steps include creating and planning educational and training modules for the school staff to make sure that your staff understands the emergency response plan. Create two documents: an all-hazards emergency response manual and a school specific handbook. In the emergency response manual you want to include articles and documents on general crisis management, guidelines and checklists for crisis readiness, forms that can be used to document various types of crises, scenarios for tabletop exercises, and articles related to trauma and grief in children. For the school specific emergency response handbook you want to include protocols for evacuation, lockdown, shelter-in-place, documents that detail the building-specific accommodations, a map of individual school buildings, and contact numbers for local emergency responders and support resources. Afterwards, you want to conduct practice drills and you want to encourage them, in conjunction with local emergency response teams, to evaluate the practicality and effectiveness of emergency response plans. Finally, reevaluate the plan annually and revise if necessary.

While virtually all schools have simple evacuation plans activated for situations such as fires, comprehensive emergency response plans need to include protocols for temporary relocation, sheltering-in-place, and lockdown. In our school-based emergency response protocol, we have outlined the essentials of evacuation and relocation. In order to evacuate, each school should have a map of the surrounding area indicating a safe zone for evacuation, plans for evacuation in inclement weather should be included, and needs of children with special health care needs need to be included. For example, rapid, efficient evacuation requires that each teacher has a sufficient number of wheelchairs for children with mobility difficulties. Relocation plans must also be created in order to house students after an event in which the school cannot immediately be reoccupied. Relocation sites can include neighboring churches, auditoriums, or theaters. An alternative to relocation sites includes school buses or similar vehicles that can be used to temporarily keep students warm and safe. The relocation protocol should also include plans to bring student medications from nurse's offices along with emergency evacuation material. For schools that rely on transport of the students by parents or school bus because of the schools distance from homes and public transport, relocation plans might include the use of school buses rather than simply walking to the relocation site.

One of the difficulties that became apparent as we developed the school-based emergency response protocol was the isolation of after-school programs. Staff reported that there were no crisis plans for events occurring when these programs are in session. Additionally, we found that each school's after-school program functioned independently of the other. Staff also reported the lack of coordinated planning with either the school department or the town emergency responders in the event of a crisis. School-based emergency response plans must be incorporated into those of local public health authorities and emergency response teams. Regular meetings between the school authorities and towns need to be established and, most importantly, a comprehensive school-based emergency response plan must take into account special populations including technology-dependent children, those who require ventilator support, those who require crutches or a wheelchair for mobility, and those with severe developmental delays such as autism.

So, in conclusion, our Protocol is really designed to provide a template rather than a specific action plan. What is most important in the development of a school emergency plan is the understanding that a one-size-fits-all plan will not work and instead, schools should adapt the basic guidelines for their own needs. The creation of a school-based emergency plan along with its implementation can be costly, and the costs should not be borne by the school district alone, but rather by local, State, and Federal resources. Since 2006, there has been a marked increase in awareness of the vulnerabilities in schools and the challenging logistics involved in protecting children in schools. There are many Web-based resources, including those from the Department of Homeland Security and the U.S. Department of Education. Lastly, all children remain critically vulnerable to the consequences of a large-scale disaster that occurs while they are in school, and our findings demonstrate many opportunities for improvement that will help ensure the students remain safe and can be quickly reunited with their families. The Nation's schools completely carry this burden.

I would like to thank AHRQ for their support in sponsoring this Web conference. I would also like to thank the Brookline Public Schools who worked with us in developing this report, and acknowledge my co-authors and their contributions, Janice Danielson and the late Michael Shannon. Thank you.


1 A common tool, also known as “Broselow tape,” used in pediatric emergencies to determine a child's weight, drug doses, and the size of resuscitation equipment. Typically, the Broselow tape is designed to be applied to children ages 12 and under. (http://www.ahrq.gov/prep/pedhospital/f).


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