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 9. Integrating Terrorism and Disaster Preparedness into Your Pediatric
Relevance for Office-Based Pediatricians
Emergency preparedness should be exercised at all organizational levels, and
office-based physicians (either in the hospital or free-standing practice)
should understand the role of their specific office in the general system response
to disasters. Integrating the office's response to disaster within the
overall Federal, State, regional, and community response is essential. Office-based
policies and procedures ideally should be specific to the location of the practice
and its characteristics and be consistent with the policies of affiliate institutions
and public and governmental agencies.
Preparedness for disaster by office-based physicians can be subdivided into
two broad categories:
- Internal operations of the practice.
- External operations related to communication and coordination with other
agencies, institutions, and the community.
Internal Operations of the Practice: Office Readiness
Framework for Disaster Preparedness
A child-oriented, comprehensive,
emergency care system maintains the concept of systematic intervention in response to
disasters while viewing the needs of the child in the context of family and
community. This framework is particularly suited to the office-based physician,
who attends to the whole child. Pediatric health care professionals bring knowledge
about responses and needs of children involved in disasters and should work
across public systems to render effective medical, educational, and community
interventions. The objective is to ensure that the biological and psychological
needs of children are addressed before, during, and after trauma.
Basic Office Readiness
There are several aspects to basic office readiness. They involve facilities,
equipment and supplies, and records.
Facilities. In the face of a natural or
manmade disaster, two modes of mitigating the results have been termed "hard"
or "soft." Soft mitigation refers to emergency preparedness or emergency response
as discussed throughout this chapter. Hard mitigation refers to engineering efforts in the
built environment to withstand destruction. These include building standards
for structures to withstand destruction from earthquakes, hurricanes, floods,
fires, technological hazards, etc., and on-site permanent emergency systems
such as fire suppression systems, uninterruptible power supplies, and standby
Office-based physicians should be aware of the particular vulnerabilities
of free-standing practice buildings based on geographic location, and their
practices should comply with strict building code regulations and be equipped
with emergency system back-ups. In the event of structural damage to the practice,
there should be a plan for its relocation (e.g., by making arrangements to
share facilities with another practice). Considerations in such planning include
- Partner with a practice that is unlikely to have incurred the same damage
due to geographic location and clearly work out the operations of the practices
ahead of time with respect to volume of patients, sharing of staff and resources,
- Contact vendors for a change in delivery address, notify laboratories of
relocation, and select alternative vendors and laboratories (in case the
usual vendors have also been affected).
- Ensure that all staff members are apprised of the plans.
- Develop specific evacuation plans and conduct periodic in-service and practice
- Periodically review the location of fire extinguishers, first aid, and
Equipment and supplies. Offices should have emergency kits assembled that contain
water, a substantial first-aid kit (including thermometer, blood pressure cuff, and stethoscope),
radios, flashlights, batteries, heavy-duty gloves, food, sanitation supplies, and medical
reference books and cards. Emergency supplies should be located both on-site and off-site. Lack
of refrigeration for medications and vaccines is a likely scenario in a disaster.
Back-up generators are important in case of outages. Back-up communication
systems such as cellular phones, direct telephone lines that are not part of
the regular telephone system, two-way radios, beepers, and ham radios should
be considered. Practices located within hospitals should comply with Joint Commission on Accreditation of Healthcare Organizations
Records. The Health Insurance Portability and Accountability
Act (HIPAA) mandates that copies of records be stored off-site (some experts
recommend at least 50 miles away) in case of catastrophe. This includes copies
of patient charts and other vital records, even if most records are stored
electronically. In addition to patient charts, other records that should
be stored off-site include the following:
- Contact lists.
- Chain of command list.
- Pertinent contact information for government and emergency agencies.
- Copies of insurance policies.
- Loan applications.
- Real estate leases.
- Other materials relevant to the practice operations.
A number of Web sites that provide computer data storage capability are currently
available. The choice of vendors should be researched carefully, and the various
options for secure access (e.g., wireless) should be explored. Free-standing
practices need to consider all contingencies. Practices located within larger
hospital institutions need to be aware of the provisions made by the larger institution.
Having a communication system in place for the
office—including the chain of command, a listing of contact information for all staff
members, and the delineation of staff responsibilities—is vital to office readiness in
the event of a manmade or terrorist disaster.
Chain of command. A chain of command in case of emergency situations is routine in hospital settings. However, office-based physicians also need to consider this organizational step, which includes the following:
- Deciding a hierarchy (or who will be in charge) and their responsibilities
vis-à-vis patient records.
- Informing staff members about recovery plans.
- Informing patients about new location and hours.
- Listing other important contacts.
Reviewing the nature of the catastrophe that may close or affect the practice
should incorporate ways to contact employees and patients and take into account
the possibility that phone lines will be inaccessible.
Contact list. A confidential contact list
of all physicians, nurses, and other staff that includes home numbers, cellular
phones, and alternative phone numbers should be kept by individuals designated
in the chain of command. The contact list should also include back-up providers.
Importantly, this confidential list should be kept in multiple places (e.g.,
the practice, outside location, and/or with the designated individuals). Practices
may need to consider keeping a list of technologically dependent children who,
during a disaster or emergency situation, may need specific planning (e.g.,
availability of back-up generators) and instructions about where to go in case
Staff responsibilities. Staff should be
made aware that they have a professional responsibility to discuss their availability
in case of disasters. This would include calling in to check where their services
are needed and the feasibility of responding based on previously discussed
office-readiness plans. Discussion with staff of their multiple responsibilities
for their own families, work, and the community will help to alleviate concerns
and anticipate problem areas.
Staff should prepare a "Family Emergency Plan" so that they will be assured that the
needs of their own families will be addressed while they are performing critical health care
duties. The roles of the physician, nurse, and support staff should be briefly outlined.
For example, everyone should know who will contact the police or fire department,
who will aid in evacuation, who will reschedule patients, etc. Periodic exercises
or drills can help to ensure that each staff member knows his or her role in
the event of a disaster. Practices may choose to hire a consultant to advise
staff members in the development of their plans. Again, individual practice
efforts should be coordinated with more regional efforts as described below.
Infectious Disease Identification and Control
Chemical and Radiological Injuries
The office-based physician may be the first contact for an individual who
is the victim of a biological agent and may be called on to treat or answer questions
with regard to chemical and radiation exposure. Pediatricians should understand
- The classification and qualities of possible biological agents.
- The natural history and management of biological, chemical, and radiological
injuries and exposures.
- Chemical agents that may be used and their properties.
- Types of radiological terrorism.
- Decontamination procedures, especially those specific to children.
- Availability of antidotes and other therapeutics.
The procedure and numbers for alerting the proper authorities (e.g., Department
of Health, Centers for Disease Control and Prevention [CDC], etc.) should be detailed in the practice policies and procedures
and chain of command protocol.
Triage, Screening, and Prioritization
Although office-based physicians may
feel that they have no role to play in disaster planning or management, emergency pediatricians
may need to draw on community pediatricians to provide the best possible management of children.
Office-based physicians may be asked to help hospital-based pediatricians to determine which
pediatric patients can be discharged or transferred to another hospital.
In addition, office-based physicians will need to triage their own patients who show up
at the practice to determine whether they need to go to the hospital or can be safely managed
without emergency care. Office-based pediatricians also play a critical role in screening for
psychological distress of the child and family (go to Chapter 8, Mental Health Issues).
Increasingly, risk assessment involves screening protocols applied at the
school or community level to detect psychological needs of the population after
a disaster. Leadership from the office-based physician can be instrumental
in guiding these processes in a coherent and rational way.
Practice Readiness and Staff Development
Staff development programs that
provide accurate, reliable, and timely information on disaster preparedness for the office
practice are essential. These programs can be organized by the practice, or the practice may
choose to participate in programs developed by affiliate institutions specific to the needs of
Adequate business insurance is stressed in office readiness in the face of disaster. This may include the following:
- Determining how much revenue the practice can afford to lose, preferably
slightly overestimating the necessary coverage.
- The details of the insurance policy (e.g., does it cover acts of terrorism,
- Overall cost and possible liens against the business.
Keep in mind that building code requirements are essential in determining
if insurance coverage applies. Reading and re-reading the policy is critical
to upgrade coverage based on evolving or changing potential threats.
External Operations: Communication and Coordination with Other Agencies
The office-based physician should
determine how the practice will link and coordinate efforts with affiliate
hospitals, schools, daycare centers, local response teams, the local department
of health, and city, State, regional and Federal efforts. The chain of command
established by the practice should identify the points(s) of contact within
the organizational structure for communication with the various larger agencies.
Ideally, a list of all the relevant relationships should be developed in advance
with contact numbers listed:
- Local and regional hospitals.
- Local emergency management agency.
- State and city departments of health.
- State and city police.
- State office of mental health.
- City fire department.
- City department of sanitation.
- Utility services.
- Medical equipment/supply resources.
- Poison Control Center (1-800-222-1222).
- Centers for Disease Control and Prevention (1-800-311-3435).
- American Red Cross (Disaster Assistance Info: 1-866-GET-INFO [1-866-438-4636]).
- Occupational Safety and Health Administration (OSHA).
The city Office of Emergency Management (OEM) can serve as a conduit for coordination
of the various local agencies, including other Federal and State agencies.
Practices can take advantage of already established relationships (e.g., with
school-based health centers, daycare centers, hospitals). Communication before,
during, and after a disaster would allow the efforts of the larger community
to be coordinated with knowledge of the available resources at the practice
level. Realistic scenarios can be investigated as part of community disaster
Community as a Resource
Community resources can mitigate
the adverse effects of disasters. Successful programs include extensive training
provided by fire, police, mental health, and emergency services personnel.
The office-based physician can be integrated into this larger community response
and should participate in drills and exercises. Three examples of such community
programs include citizen disaster preparedness programs, the Citizen Emergency
Response Training (CERT) programs, and the Collaborating Agencies Responding
to Disasters (CARD) programs.
Citizen disaster preparedness programs. These include
basic preparedness (e.g., a course to assist individuals in preparing their
homes), neighborhood response teams (e.g., choosing a block captain, setting
up a response area, establishing teams to address such things as search and
rescue, safety and utilities, damage assessment), and advance training to augment
public safety and response.
Citizen Emergency Response Training (CERT) programs.The
CERT programs (established in Los Angeles, CA in 1985) provide citizen training
through the fire department.
Collaborating Agencies Responding to Disasters (CARD) programs. The
CARD programs (established in 1994 after the Northridge earthquake in Los Angeles)
were originally organized to provide services for vulnerable and underserved
populations (e.g., homeless individuals, veterans, at-risk youth, people with
special needs). This group of agencies has extended its services to develop
disaster preparedness plans. This kind of program has the advantage of linking
culturally sensitive community services and preparedness, thereby addressing
ongoing issues such as homelessness, cardiopulmonary resuscitation (CPR) training,
and maintaining a set structure and mission.
The clusters of service teams provide support services such as transportation, counseling,
shelter and housing, health services, and commodities. Conceivably, this structure could
accommodate a pediatric focus in collaboration with community-based pediatric health care
Policies and Procedures
Office-based physicians should be
aware of the emergency numbers and protocols of their local department of health.
These policies should be included in the overall office practice manual for
easy reference. If practices are affiliated with a hospital, also being aware
of those policies and procedures will facilitate collaboration. When they exist,
current best practices can be adopted with respect to emergency response plans
and to physician and nurse training for disasters.
Communicating Directly with Children and Families
The pediatrician plays a central role in disaster and terrorism preparedness
with families and children. Families view pediatricians as their expert resource,
and most expect pediatricians to be knowledgeable in areas of concern. Providing
expert guidance entails both educating families in anticipation of events and
responding to questions during and after actual events.
In many areas of the country, the threat of natural disasters is ongoing,
and guiding and educating families on home disaster preparedness can be done
in the pediatrician's office or as a community focus. Family preparedness
may include training in cardiopulmonary resuscitation, rendezvous points, lists
of emergency telephone numbers, and an out-of-the-area friend or relative whom
all family members can contact after the event to report their whereabouts
Home preparedness (such as installing storm shutters or earthquake-proofing
the home) should be covered. Parents should maintain emergency supplies of
food, water, and medicine; a first-aid kit; and clothing. Family members should
know the safest place in the home, make special provisions, know community
resources, and have a plan to reunite. Medications for chronic illness and
resources for children who depend on technological means for survival should
be included in the plan (see also the American Academy of Pediatrics [AAP] Family Readiness Kit at http://www.aap.org/family/frk/frkit.htm).
Answering Questions During Events
During any event, children
and families will receive good and bad information from a multitude of sources,
including friends, media, and public officials. The problems caused by panic,
overreaction, and overwhelming the emergency health care system with anxious
families cannot be overstated. A well-educated and available pediatrician who
can appropriately respond to numerous and varied questions can be of great
Advice for Families of Children with Special Health Care Needs
should provide guidance to families of children with special health care needs.
This may include the following:
- Notifying utility companies to provide emergency support during a disaster.
- Maintaining a supply of medications and equipment in case availability
is disrupted during a disaster.
- Knowing how to obtain additional medications and equipment during times
of a disaster.
- Training family members to assume the role of in-home health care providers
who may not be available during a disaster.
- Keeping an up-to-date emergency information form to provide health care
workers with the child's medical information in case the regular care
provider is unavailable.
- Knowing back-up hospitals/providers in the region in case primary
hospital/specialists/providers become unusable or are unavailable.
- Providing advice on power of attorney, living wills, advance directives,
and other important legal tasks/documents.
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Relevance for Hospital-Based Pediatricians
In mass casualty incidents, including those involving chemical and biological
agents, casualties among children and adults could be significant. Because
children are likely to become victims in many disaster events, pediatricians
should assist in preparedness planning to ensure coordinated responses of local
hospitals that may in fact each have limited pediatric resources. In addition,
health care facilities could be a primary or secondary target themselves. Also,
facilities may be overwhelmed by massive numbers of anxious individuals and
families. Pediatricians working in or supporting hospitals can play a vital
role in ensuring the enhanced care of the pediatric disaster victim by participating
in all levels of disaster preparedness planning.
Emergency Department Readiness
The hospital disaster alert system is designed to triage victims in the field
and carefully distribute them among available resources to keep a single facility
from being overwhelmed. However, in many crisis situations, facilities are
vulnerable to inundation with patients who arrive in large numbers without
emergency medical services (EMS) transport and pre-entry triage. Pediatricians working in or supporting
hospitals should interact with the planning committee to ensure adequate training
and preparation of supplies and treatment areas in the emergency department.
Pediatricians working in hospitals can be key facilitators between emergency
department services, critical care services, and regular inpatient services.
Coordination with the local community should involve primary/prehospital/infrastructure
response (with liaison planning to State and Federal agencies) and community/citizen
response. Considerations should be made as usual referral patterns may not
typically include accepting pediatric patients.
Primary/prehospital/infrastructure response includes the following:
- Police, Environmental Protection Agency (EPA), sheriff.
- Military (local or regional).
- Regional poison centers.
- Local health department.
Community/citizen response involves the following:
- Schools, public and private.
- Daycare centers, public and private.
- Service groups (Kiwanis, Rotary, Salvation Army, parent/teacher associations
- Nonsecular groups (churches, synagogues).
- Public recreation administrations (zoos, amusement parks, sports stadiums,
Inpatient Service Readiness
Anticipating surge capacity for inpatient care is vital in preparedness planning
and perhaps is the greatest contribution of pediatricians working in hospitals.
Areas that should be considered include the following:
- Increasing the number of inpatient beds within a community (e.g., by using
several strategies such as converting cafeterias and meeting spaces into
ward capacity or making arrangements with other community hospitals). Local
hotels, school gymnasiums, etc., may be converted into low-acuity medical
facilities with some planning.
- Contingency plans for acquiring or maintaining essential services, such
as water, electricity, portable oxygen, garbage/trash removal, etc.
- Planning for stockpiling or readily acquiring medical supplies such as
vaccines, antitoxins, and antibiotics (in dosages, formulations, etc., appropriate
for pediatric patients). In addition, pediatric-specific supplies and equipment
in a full range of sizes to accommodate pediatric patients should be available.
- Networking community resources to organize volunteers to become proxy caretakers
for orphaned children.
Hospital Infrastructure Needs
Hospital and community-wide drills are essential
to preparedness planning. They need to be done on both a wide scale and with
a narrow focus. Drills should include not only the initial triage and decontamination,
but also the 48-72 hours after impact to measure readiness with all provider
and support services that will be needed. Specific drills should be planned
and practiced for evacuation in response to fire or other disasters.
Infection Control Plans
Infection control plans closely parallel quarantine
procedures in the community and on a public health basis. The in-hospital level involves
quarantine or isolation and control measures to limit spread of infection to staff and
Quarantine procedures should be a well-established means of limiting the spread of infection. Quarantine may become an active part of inpatient needs in
a given hazard-related disaster. Children who become ill may require isolation
to prevent spread of disease to other patients and health care providers.
The exact nature and severity of quarantine will depend on the specific hazard
involved. Close coordination with the public health service, CDC, and local
poison centers is essential in both the planning and execution stage.
Staff training should include the following:
- Training in use of protective gear.
- Orientation to all aspects of the plan from the disaster site to the
emergency department to hospital floors, as well as to rehabilitation
and rebuilding in the community.
- Staff preparedness for notification, transportation to treatment sites,
self preparedness (emergency packages of personal items), strategies
for coping with family demands, psychological demands, and plans for
personal health and hygiene.
- Support for families of health care workers so that the health care
workers are available to provide services.
- Mechanism for tracking resources.
- Media/public communication issues.
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Cascardo D. Preparing your medical practice for disaster. Med Pract
Caffo E, Belaise C. Psychological aspects of traumatic injury in children
and adolescents. Child Adolesc Psychiatric Clin No Am 2003;12:493-535.
Chemtob CM, Nakashima JP, Hamada RS. Psychosocial interventions for postdisaster
trauma symptoms in elementary school children. Arch Pediatr Adolesc Med
Cowan ML, Cloutier MG. Medical simulation for disaster casualty management
training. J Trauma 1988;28(1Suppl):S178-S182.
Flowers LK, Mothershead JL, Blackwell TH. Bioterrorism preparedness: II.
the community and emergency medical services systems. Emerg Med Clin
No Am 2002;20(2):457-76.
Harner A. Will you be ready when your patients need you the most? Disaster
planning for the medical practice. MGMA Connexion, Nov/Dec 2001:
Hazinski FM, Markenson D, Neish S, et al. Response to cardiac arrest and
selected life-threatening medical emergencies: the medical emergency response
plan for schools. A statement for healthcare providers, policymakers, school
administrators, and community leaders. American Heart Association, Emergency
Cardiovascular Care Committee. Policy Statement, Pediatrics 2004;113(1):155-68.
Laor M, Wolmer L, Spriman S, Wiener Z. Facing war, terrorism, and disaster:
toward a child-oriented comprehensive emergency care system. Child Adolesc
Psychiatric Clin No Am 2003(12);343-61.
Leonard RB. Role of pediatricians in disasters and mass casualty incidents.
Ped Emerg Care 1988;4(1):41-4.
Lichterman JD. A "community as resource" strategy
for disaster response. Public Health Rep 2000;115(2-3):262-5.
Mattox, K. The World Trade Center attack disaster preparedness: health
care is ready, but is the bureaucracy? Crit Care 2001;5:323:325.
Perry RW, Lindell MK. Preparedness for emergency response: guidelines for
the emergency planning process. Disasters 2003;27(4):336-50.
Redlener I, Markenson D. Disaster and terrorism preparedness: what pediatricians
need to know. Adv Ped 2003;50:1-37.
Rose MA, Larrimore KL. Knowledge and awareness concerning chemical and
biological terrorism: continuing education implications. J Cont Ed Nursing
Somers GT, Maxfield N, Drinkwater EJ. General practitioner preparedness
to respond to a medical disaster. Aust Fam Physician 1999;28(Suppl
Veenema GT. Chemical and biological terrorism preparedness for staff development
specialists. J Nurses Staff Devel 2003;19(5):215-22.
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