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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Chapter 3. Responding to a Disaster (continued)

Some Roles for the Pediatrician in Regional Hospital to Community Planning

  • Meet with hospital planners to ensure children's needs are met, equipment is adequate, and contingency plans are in place.
  • Be present when hospitals work with prehospital groups on triage, stabilization, equipment, distribution, etc.
  • Help organize the response of community pediatricians to assist at the hospital and local secondary areas to redistribute care back to the community level.
  • Help coordinate the identification and movement of community pediatricians. Assure that local pediatricians have the appropriate identification needed to cross barriers, along with designated means of transportation to areas where care is needed. Local pediatricians should also be familiar with the regional disaster management plan, reporting requirements, and contingency plans for alternate forms of communication, as needed.
  • Plan for primary offices to initially use alternative areas, e.g., Disaster Medical Assistance Team (DMAT) field units, school gyms, etc.
  • Help develop education and assistance packets for family preparedness.
  • Provide community education so families are prepared with the basics, such as flashlights, alternative heating, lighting, water, food, and clothing.
  • Be familiar with protocols for the following:
    • Isolating and decontaminating victims.
    • Mobilizing additional staff.
    • Potentially using secondary-care sites (e.g., school auditoriums).
    • In-hospital care protecting existing patients, as well as medical and ancillary staff (e.g., cafeteria workers).
    • Use of reverse-ventilation isolation areas.
    • Use of decontamination showers with separate water collection systems.
  • Coordinate with the local educational system because children spend most of their time in school. Know plans for rapid evacuation and holding areas where triage and initial treatment of severely injured victims can begin.
  • Work with hospitals and schools to develop decision trees for the initial steps of decontamination, further triage, transport, and so forth.
  • Know designated sites for stockpiled antidotes, antibiotics, vaccines, and other drugs and routes for rapidly obtaining them from outside the hospital if necessary (e.g., the Centers for Disease Control and Prevention (CDC).
  • Help develop protocols for proper doses of vaccines and antidotes for use in children.
  • Coordinate with teams of health professionals dealing with post-event programs, including rehabilitation, posttraumatic stress syndrome (PTSS), and critical incident stress management for health care professionals.
  • Perform triage of pediatric victims, including those who arrive at the scene with emergency medical services (EMS) and those who arrive at the hospital without previous triage.
  • Help hospitals develop color-coded triage systems for adult and pediatric patients that arrive without previous triage. Systems should ensure that children are not separated from their caregiver(s) during the chaos (unless for valid medical reasons).
  • Help address long-term needs, such as counseling (e.g., for PTSS), rehabilitation, social support (e.g., orphaned children), triage systems, etc.
  • Work with local pediatricians to coordinate protocols for a variety of emergency processes and procedures, including disaster system management, procurement of personal protective equipment (PPE), setting up decontamination areas, hospital reporting, identification of sentinel cases, and post-incidence stress reduction. These protocols can be communicated by a variety of methods, including seminars for disaster management on the local level. These efforts should be coordinated with the hospitals and government agencies involved.

Drills and Quality Assurance Activities

It is essential to organize disaster drills in the hospital that are coordinated with community resources. These drills should include the following scenarios:

  • The incident is small and contained, with most patients triaged and transported by the EMS systems to designated facilities.
  • The facility is inundated with large numbers of anxious and worried individuals, both immediately and for a short time after the incident.

Drills should include Disaster Life Support Teams performing their respective functions.

The goal of disaster life support training is to standardize incident response across the Nation as a way of strengthening national public health. Basic disaster life support training provides a didactic review of all-hazard topics, including critical information on the role of the health care professional. Advanced disaster life support extends this training into incident-specific scenarios (e.g., decontamination of mass casualties) through didactic training and interactive sessions and drills. Drills for advanced disaster life support teams should include the following:

  • Human pediatric simulator scenarios including decontamination for biological, chemical, and nuclear hazards.
  • Essential clinical skills, performed in central and mini clinical areas.
  • Use and wear of PPE.
  • Implementation of the incident command center.

Integration with Children's Services

The pediatrician's strongest role can be in helping hospital disaster planning teams anticipate and manage pediatric victims who have been separated from their primary caregivers during a disaster. These children need immediate support until a definitive caregiver can be located.

In the event that in-hospital support services are overwhelmed, other efforts will also be needed, including the following:

  • Alternative social support from the community. Community-based organizations can provide clothing, toys, and bedside sitter support and communicate with family members who may be out of town.
  • Psychological support services from the surrounding community that can be brought to the hospital.
  • Outreach support teams, using community members, pediatricians, and mental health providers. These teams can go into the communities, schools, daycare centers, churches, etc., to provide stress debriefing, triage for further mental health care, and long-term monitoring.

In the event that community support and child-protective services are also overwhelmed, additional efforts will be needed, including the following:

  • Alternative plans need to be in place to cope with a large group of children needing immediate caretaker support (i.e., those who are orphaned or temporarily separated from caretakers because of decontamination or medical treatment needs).
  • Pediatricians can help families find alternative systems within their churches and neighborhood communities.
  • Pediatricians can create information cards of resources and supervise rehearsal scenarios.

Pediatricians also can help communities plan to provide other support services for families and children:

  • Establish a plan with existing communication systems (e.g., television, radio) to provide ongoing information support.
  • Plan for non-medical family support centers to provide water, food, clothing, etc.
  • Plan for a system to notify next of kin (anticipation of this information system can be done by pediatricians).
  • Provide for crisis counseling.
  • Provide for legal services.
  • Provide for translation services.
  • Facilitate the implementation of State and Federal disaster relief programs.
  • Plan for temporary housing alternatives, immediate, short, and long term.
  • Conduct community memorial and grieving services.

JCAHO and Emergency Management

In January 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced new disaster preparedness standards, building on its prior position that health care organizations should be prepared for all types of emergencies. These standards represent an important evolution in the concept of managing emergencies. Health care organizations are expected to address the four specific phases of disaster management—preparedness, response, mitigation, and recovery—and conduct hazard vulnerability analysis.

This "all-hazards" approach should result in a thorough review and risk analysis of credible hazards and serious threats to the facility and its surrounding community, as well as the subsequent development of plans to address the ramifications of all possible hazards. After plans are developed, the organization should implement and execute them by conducting training and drills.

The new JCAHO Guidelines require hospitals to use formal emergency management processes as the foundation of their planning. These include the following:

  • Develop a hazard vulnerability analysis (risk assessment).
  • Assure the operational needs of the hospital facility and ample resources of critical services such as water, electricity, sewage services, and ventilation.
  • Integrate with local emergency response systems.
  • Identify alternative roles and responsibilities of personnel.
  • Establish a command structure, also known as an "incident command system."
  • Perform ongoing monitoring of plan performance, including annual reevaluation.

JCAHO has published an emergency planning guide for use by officials in small, rural, and suburban communities. The guide is available at http://www.jointcommission.org/PublicPolicy/ep_guide.htm. Exit Disclaimer

Appropriate Triage

Triage to the appropriate facility can be critical for a child. Therefore, the development and implementation of a mass casualty plan that considers the unique needs of children is imperative to avoid overloading one local facility (whenever possible). The community should have designated facilities for referral of critically injured pediatric patients. At the same time, each facility should be able to care for and at least initially stabilize both children and adults. Pediatric skills and equipment should be maintained at all facilities.

Emergency departments and hospitals should have some mechanism to provide for the physical, as well as the medical needs of pediatric populations. These needs include shelter, clothing, food, supervision, and entertainment for pediatric victims, as well as protection from the media in the critical period immediately after a disaster.

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Incident Management

The incident command system (ICS) is widely recognized and used in the field of emergency management to effectively manage resources and casualties during a disaster. The ICS is a unified management system that allows for expandability and accountability based on the magnitude and needs created by the specific incident. It is an organizational system of "best practices" for on-scene, all-hazard incident management. There are five major management functions:

  • Incident command.
  • Operations.
  • Planning.
  • Logistics.
  • Finance/administration.

All have standardized position titles. The following nomenclature is used for organizational components and their supervisory personnel:

  • Incident commander.
  • Command staff officer.
  • General staff/section chief.
  • Division supervisor.
  • Group supervisor.
  • Branch director.
  • Task force leader.
  • Strike team leader.
  • Unit leader.

In a unified command structure, there is one recognizable leader—the incident commander—who has overall responsibility. Because the system is expandable, it allows for the use of many components that may be needed to manage the incident. Various component managers are granted the authority to manage their specific component, and they are held accountable for the performance of their area to the incident commander.

This type of system is widely used in everyday business. For example, in the hospital setting, the incident commander could be compared with the chairperson of the medical board, and the group managers could be compared with the various chiefs of service.

The National Incident Management System (NIMS) has been developed for use by all emergency response agencies in the country. NIMS is an updated more inclusive version of ICS. Its standardized framework, common terminology, and flexibility allow it to be used by Federal, State, and local agencies/authorities.

ICS is modular and can be expanded to meet needs that arise during an incident. In a disaster, the triage, treatment, and transportation of casualties fall to the EMS Operations Branch. The incident command officer is most often a field officer of the local EMS agency. That officer is responsible for managing all medical resources needed to effectively handle the incident and for minimizing the impact on normal operations of the EMS system. Based on the scope of the incident, the divisions of smaller functional units are formed to manage the following:

  • Staging.
  • Triage.
  • Treatment/decontamination.
  • Transport.

Staging

The staging officer is responsible for setting up an area where incoming resources, including personnel, can gather and await an actual assignment. The staging group can be broken down further into smaller units of operation for specific incident needs. For example, incoming ambulances would be directed to a vehicle staging area; personnel not assigned to a specific unit or task would be sent to a personnel staging location; and needed equipment would be directed to a logistical staging location. These areas may be off site from the incident but easily accessible to it. This allows greater accountability of who is on the incident ground and monitoring of their respective functions and performance.

Triage Group

The triage group is tasked with prioritizing casualties based on pre-established medical protocol. Simple Triage and Rapid Transport (START) allows rescuers to assess and prioritize a victim with a 30-second, hands-on assessment. Immediate life-threatening conditions are rapidly identified and corrected with minimal intervention, and casualties are identified for immediate transport (e.g., airway problems are corrected with a tilt of the head, and the patient is marked "red" for immediate transport; intubation in the field would not be done during this initial assessment). For children, a variant known as JumpSTART pediatric mass casualty triage is used (http://www.jumpstarttriage.com).

In incidents involving victims exposed to hazardous chemicals, a similar system of triage is used. Normal START procedures would be extremely difficult for rescuers in chemical protective clothing to use. In these cases, a form of triage based on observation of symptoms is used, and response to tactile stimulus determines the triage priority.

Treatment/Decontamination

The treatment group is tasked with providing a more definitive treatment regimen for incident victims. Casualties are removed from the incident ground to a safe, protected area so that treatment can be started, particularly if transport is to be delayed. Personnel in this group constantly monitor victims for changes in their condition and change their triage priority as needed. In large-scale incidents in which the patient load would cripple normal hospital resources, victims with minor injuries may be held in an off-site treatment area for an extended time. Physicians, nurses, and other ancillary staff may be assigned to staff this area.

Victims that have been exposed to a chemical or biological agent should be decontaminated. Personnel assigned to this task should be trained hazardous materials technicians because they need to operate in chemical protective equipment. This may be as simple as a splash suit and gloves or as complex as a fully encapsulated suit and positive-pressure breathing apparatus, depending on what type of chemical or agent the victims were exposed to.

Transportation

The transport group is tasked with the responsibility for transporting victims from the incident ground to field treatment centers, hospitals, or specialty referral centers (trauma, burn, replant, etc.). The group officer usually maintains listings of available hospital beds and medical evacuation and public transportation resources that may be needed to move victims. The transport group also performs the critical function of maintaining the log of destinations to which victims have been moved so that they may be tracked for public information and quality assurance reasons.

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Bibliography

Comprehensive Emergency Medical Services Systems Act of 1973. Washington, DC: United States Congress, Senate Labor and Public Welfare Committee; 1973.

Department of Homeland Security. National Incident Management System. March 2004. Available at:http://www.dhs.gov/xlibrary/assets/NIMS-90-web.pdf (PDF Help). Accessed July 10, 2006.

JumpSTART. Combined JumpSTART algorithm. Available at: http://www.jumpstarttriage.com/. Accessed August 17, 2006.

National Health Professionals Preparedness Consortium: Healthcare leadership and administrative decision-making in response to WMD incidents. Nobel Exercise Scenario Information, v.2.0. December 31, 2002.

President's Disaster Management Egov Initiative. Available at: http://www.whitehouse.gov/omb/egov/c-2-2-disaster.html. Accessed August 17, 2006.

San Mateo County Emergency Services. Hospital Emergency Incident Command System (HEICS) Update Project. January 1998. Available at: http://www.heics.com. Accessed August 22, 2008.

U. S. Department of Justice, Office for Domestic Preparedness. Hospital Emergency Management—Concepts and Implications of WMD Terrorist Incidents. Washington, DC: U.S. Department of Justice; April 2002.

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