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Surge Capacity and Health System Preparedness: Transcript of Web Conference (continued)

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Penny Daniels: Now we are going to turn to one of the biggest concerns, I think, of our society and that is, what happens to children in the event of a mass casualty situation. We will turn to Dr. Michael Shannon who is a Pediatrician, the Chief of Emergency Medicine at Childrens' Hospital in Boston, and the Director of the Hospital Center for Biopreparedness. Dr. Shannon, thank you very much.

I understand that AHRQ is supporting your work on a number of protocols for mass casualty events involving children. Before we talk about some of the specific protocols, can you tell us in general what are the key issues in surge capacity when it comes to children?

Dr. Michael Shannon: Let's begin with planning, Penny. There are several key issues to consider in thinking about planning for surge capacity around children. Let me just emphasize two. First, in creating surge capacity plans for children it's important to keep in mind and consider every potential type of disaster, terrorist or otherwise, so the all-hazards approach which has become a new way of thinking in disaster response over the last few years, is particularly important.

Schools are a unique, but extremely important added challenge to thinking about surge capacity, particularly when one considers that children spend most of their waking hours in or under the supervision of a school. So it's critical to begin to include schools in surge capacity planning, and the way I think about it, there are two potential, distinct scenarios that must be considered in making surge capacity plans that involve schools.

The first of course would be a tragedy in which the school is a specific target for a terrorist event or a disaster of some type. The second would be when the disaster occurs in the community, but while school is in session, and in such a situation there is going to be potentially communication disruption, chaos on the street, unruly traffic, potentially even mass evacuation and it's important to ask the question: who would be taking care of the children? Who will be in contact? Who is in charge? Who will supervise that evacuation? And all those many details even though the school wasn't the primary target.

In terms of consequence management every aspect of consequence management will be challenged in a disaster involving large numbers of children. First EMS, all of the first responders, EMS, fire, police, are going to have a more difficult time when they're taking care of many injured or traumatized children. The decontamination teams that will be mobilized and those who have been—who have something on them and must be decontaminated, are going to be challenged by taking care of frightened children or children that are very small, particularly while wearing this cumbersome personal protective equipment.

General Emergency Departments, those that take care of mixed populations, children as well as adults are going to be challenged by having very large numbers of children with limited numbers of pediatric supplies.

Remembering that an effective response at the hospital involves not only the Emergency Department, but the entire hospital, many hospitals will find themselves not as prepared as they should be for many, many number of pediatric casualties.

If there are events involving an infectious agent or chemical agent with contaminated patients, there is nothing more important than effectively triaging those victims, usually out of doors, out of the facility so that the campus itself doesn't become contaminated. And so all of a sudden the security of the hospital campus is critical, and the ability to really identify every point of ingress and egress and take command of it so the contaminated or contagious patients can't enter.

There will be just enormous needs in terms of the mental health response and recovery since we know that disasters of any type natural, terrorist or otherwise lead to psychological trauma which can be enduring. Who will take the lead on creating those teams, identifying those children or parents or staff in the post-event period to make sure that everyone is healthy?

Dr. Hupert just spoke quite a bit about mass distribution of antibiotics, antidotes and vaccines, but it's important to bear in mind that if it takes, I'll use as an example; I would posit that if it takes 10 minutes to have a victim—to triage and screen a victim before you give them their antibiotic or antidote, it will take twice as long for a child, because that child is unable to provide details of that history. And so there has to be someone or there has to be some means of determining whether this child really can receive this antidote or antibiotic or if there's a contraindication of some type.

And then finally I, Dr. Hupert many others live in a part of the country where fortunately or unfortunately more than half of the year we have our temperatures under 60 degrees. So inclement weather, stormy weather, cold weather poses a serious and unique challenge particularly when you think about out-of-hospital decontamination. How will you keep your victims warm? They are completely disrobed; they are stepping into a shower before they enter the building. How will you take care of them in inclement weather?

Penny Daniels: Will you give us even some more specific examples of how children differ from adults, and need to be treated differently in a mass casualty event?

Dr. Michael Shannon: We can talk about every general type of terrorist incident or disaster and I could outline, I'm a pediatrician, I could tell you all the ways that children differ from adults. But let's go through each. In terms of a biological event, children have, I'm sure everyone knows an immature immune system which means that they are less able to resist an infection of some type leading to greater morbidity and mortality in children. If there were a chemical event with large numbers of contaminated children, children two and three year-olds, frightened, unable to speak, difficult to console, are quite a challenge for anyone to assess, manage, and then as I already mentioned, there is the additional challenge of keeping them warm should they be decontaminated.

If there were a radiologic event, children are much more susceptible to the consequences, particularly development of cancer after a radiologic event. If there were a blast injury of some type or any blunt trauma, in the field of Emergency Medicine we talk about the "golden hour of trauma" all the things that must be done effectively, efficiently, completely in one hour. And when you try to do those things in young children you find that it's quite difficult. Things as simple as starting an intravenous line in an infant, really more difficult than you think, particularly if that's not part of your skill set. So that taking in large numbers of children who are victims of a blast injury is going to be quite challenging, and many will miss that "golden hour."

And then finally, as Dr. Claypool mentioned, we are not at all well prepared for burn management, and with children there is the added issue of children having much less fluid reserves so that the fluid that is always lost during major burns is going to be exaggerated in children; and we know that burn victims are susceptible to infection, children will be even more susceptible to that infection.

Penny Daniels: You know Dr. Shannon we all had a terrible reminder that our schools have to be ready to deal with these kinds of events when there was that attack on that Russian school last month, just last month. Is there any way that our schools and communities can be prepared to deal with this type of horrible attack?

Dr. Michael Shannon: Let me first say that such guidelines are desperately needed. We've spent the last year investigating school districts around the country and it continues to concern, if not frighten me, how few really are prepared for disasters of any type. And I very much think that there needs to be logically, from the federal level as a beginning, a template that school districts can use. Now having said that, it's important to emphasis that templates are just templates, and there is no one size fits all; that a comprehensive disaster plan for a school really must bear in mind the unique population as well as the unique architecture of the school.

We've been spending the last several months working with a few school districts, and have learned quite a bit about what I consider now the main steps, the recipe in creating a school-based emergency response. I will take you through them quickly in this slide and the next. First it's important to speak with the Principal because the Principal is the de facto leader of any disaster that's going to occur in a school, and it's important to get a sense of the Principal's level of understanding and their communication with local public health authorities.

It's extremely important to speak with nurses. I think the best example of that, again in our investigations over the last year, we learned every school has an evacuation and a relocation plan. You leave the school, you go to a safe site. There needs to be a plan for taking the child's medication with them during that relocation. And what we discovered in our investigations, many schools are so large that they have multiple relocation sites. So how do you take all of the medication in one cabinet and disperse them to the different teams that will go to the different sites? So, such conversations with the school nurse are key.

There is nothing more important than a walk through with the custodian to discover where the best sites for sheltering in or lock-down would be, to make sure that you understand the unique architecture of that school, the location of the heating systems, ingress, egress, again very unique to each school.

It's very important to think about after-school activities. The one school district we've been working with most closely; Brookline, Massachusetts, there are well over 1,000 children that are in the school in after-school programs, whether they be athletics or simply an after-school program until parents pick them up. And it's key that there's a leader, that there's a plan that if an event occurs during that time that there truly is someone in charge.

Continuing, it is important to make sure that in creating the plan that you're taking advantage—you're building on what exits. For example, every school, we've learned that every school has an evacuation plan; it's part of the fire drill and for the most part they've been practiced. So the evacuation and relocation plan that you would like to the school plan should begin with that, rather than re-inventing the wheel.

I've already mentioned the importance of taking inclement or stormy weather into account, extremely important again. And Brookline School, for example, recently we were reviewing their evacuation plan and last year was a very snowy year and one day we noticed, the day of a—I believe it was the day of a fire drill, the Town's snowplows the day before had logically piled the snow where it usually does, and it made it quite difficult to evacuate and relocate those children—must be considered.

I've found in virtually—we've found in virtually every school district that we've examined that again there is an evacuation plan, but there is rarely a sheltering and/or a lock-down plan. And those are equally important when thinking about disasters. If the disaster is outdoors, if there's a cloud plume of some type that's going towards the school, there's nothing more important than keeping the children in the school, and keeping them safe in school, and that's why a sheltering end plan is some important.

And then finally, the drill, the importance of drills. And I'm a big fan of tabletop exercises where the key leaders, the key leadership of a school comes into a room one day, and with a skilled facilitator simply walk through a disaster, any disaster although in my experience it makes sense to use a very credible disaster for that school district. And so what we do, how you would call, what if this phone line is down, what will do if this child, these children? And if you have, again the right people in a room and a skilled facilitator, you can quickly discover the details that haven't really been thought through, and add to those to your plan, and really make it even more comprehensive and more ready for use when you really need it.

Penny Daniels: You've certainly given us a lot to think about in terms of schools. I understand you're also developing a protocol for Disaster Medical Assistance Team and Emergency Department. Taking the former first, the Disaster Medical Assistance Team, what is their role in response to a mass casualty incident involving children?

Dr. Michael Shannon: The so-called DMAT teams have been in existence for some time as part of the National Disaster Medical System, but again as a pediatrician I see some limitations; I see some issues that should be addressed. First among the—there's just under 30 in existence now, of those only two are really dedicated pediatric teams, and I would posit that that's not enough, and at the very least that the system should consider having regionalization of these teams so that the site can be reached more quickly if needed.

I would even suggest that among the existing DMAT teams which are designed to respond to disaster of any type, whether they involve children alone, or children and adults, you can never have enough training in taking care of children. I'll mention again, that even the simplest aspect of emergency response, starting an IV in a child can be extremely challenging if it's not part of your skill set. We'll be relying on these DMAT teams if a disaster occurs, and we would want to know that if it were a disaster involving large numbers of children, that they really could provide the care that those children need.

Penny Daniels: I would imagine hospital Emergency Departments will face particular challenges vis--vis children as well?

Dr. Michael Shannon: Emergency Departments will have challenges as well. First, there will always be the challenge of making sure that, that Emergency Department and hospital has an adequate number of pediatric supplies, and I always emphasize here, adult supplies as well because the children will be accompanied by a parent, a caretaker who will not leave their side. So there really has to be readiness for adults as well as children.

Again this issue of having decontamination equipment, protocols that are effective are important, making sure there's an effective response plan to manage large numbers of children, and making sure that there is a staff skilled at accessing young non-verbal children. The challenge is, again taking care of children while wearing personal protective equipment, I've already mentioned. There will be substantial challenges in creating the systems for identification, tracking and unification. Young children can't necessarily tell you who they are, where they live, emergency numbers, and we are going to have to find innovative systems, pictures or otherwise for identifying and tracking these children, and finding ways of reunifying them with their parents.

And then finally, the rational use of alternate sites such as schools, neighborhoods, health centers where the worried; so-called "worried well," and even walking wounded can be cared for and the Emergency department can be reserved for those who really need it. I'm going to add just one more bullet that's not on this slide, and that's the so-called 'second wave phenomenon' that we're learning more about.

A critical aspect of disaster response is to remember that if there is a large-scale disaster; take for example the Sarin incident in Tokyo in 1995. Those who will enter the Emergency department first are actually relatively healthy. They were able to walk; they were quickly able to leave the field. The sicker patients actually will come later. They have to be stabilized; they have to be transported by EMS, so the 'second wave phenomenon' means that the second group of victims that come will be sicker. And it's important to think about your resource allocation, and make sure that all the key resources aren't exhausted on the first wave, because the second wave, the sicker patients are yet to come.

Penny Daniels: Very, very clear and thank you so much. Briefly Dr. Shannon, when do you expect the guidelines you've just talked about to be released? And where will our audience be able to find them?

Dr. Michael Shannon: Our work for AHRQ is in various stages of completion. We actually have already just completed a training video entitled, "The Decontamination of Children" and are working with AHRQ on the distribution of this video. We have two best practices monographs in the stage of near completion; one on "Pediatric Aspects of Surge Capacity Planning", today's topic; a second on "The Role of DMAT in Pediatric Mass Casualty Incidents." And then in production now we have a best practices monograph on "The School-Based Response to Disasters and Other Public Health Emergencies."

Penny Daniels: Dr. Shannon, thanks very much. Now in just a moment, our audience, we will open us the discussion for your questions. But before we do that stay with us because I want to turn to Dr. Gregory Bogdan. Dr. Bogdan directs the research projects at the Rocky Mountain Poison and Drug Center at Denver Health. And he and his colleagues have been working on an AHRQ- supported project that uses call center technologies to communicate with the public during an emergency. First Dr. Bogdan, why is it so important that during an emergency we communicate with the public?

Dr. Gregory Bogdan: Well, Penny, as Dr. Claypool had mentioned earlier mass casualty incidents, especially those from weapons of mass destruction and natural disasters, will provide the greatest stress on our already taxed health care delivery systems. And one of the key components to surge response is risk and crisis communication; getting out the appropriate messages to the public so they know what is going on, and what is there to help them.

So it's really important for us to be able to effectively convey those messages to the public so we don't have a lot of people presenting to health care facilities that may not need to be seen. We kind of term them the 'worried well'. And as Dr. Hupert's modeling takes into account, it's all based on surge arrival, so if we can prevent many of those people who don't need to arrive at a hospital, then it will allow those resources to be more effectively utilized to those who need them the most.

Penny Daniels: What are some of the specific challenges in terms of communicating with the public during an emergency?

Dr. Gregory Bogdan: Let me just back up for a minute and talk a little bit about public risk perception. One of the things that it's very hard to get a handle on is how much risk people will perceive with any given event. We know that specific event characteristics such as bioterrorism, or those that target children, or those that are new or exotic things, have a tendency to produce more fear in the public and cause greater concern, and therefore lead to greater numbers of people who require information about them.

When we look at incidents in the past that have occurred such as a meningitis episode in Florida, we found out a significant percentage of the population called in about that incident because it involved children. Again, we looked at Toronto for SARS, something that was exotic, again a significant amount of the population of Toronto needed information about the event. That also was evident in Trenton, New Jersey related to anthrax exposures, and even with West Nile virus we've seen in New York City when it first emerged about 3% of the population having information concerns. And in Colorado just in 2003 that was still 1% or 2% of the population for an episode that happened there.

As far as the challenges for preparedness, it just came out in the 2004 Redefining Readiness Project from the Center for Advancement of Collaborative Strategies and Health, that all of our planning efforts are—assuming that people are just going to follow instructions that are provided, and however that may not be the case—60% of the public said that they would not heed official instructions to get vaccinated during a smallpox outbreak; and that 40% of the public would not heed official instructions to put shelter in place during a dirty bomb incident.

So what this tells us is, is that people won't just accept instructions and do them. That they're going to have to somehow come to their own conclusion that this is the best thing for them and their families, and a way of doing that is providing a mechanism for them to ask questions, ask their concerns so they can make their own decisions, and take then the most appropriate action for themselves.

Penny Daniels: So that's where call centers come in, because they're interactive?

Dr. Gregory Bogdan: That's right; that's where call centers come in.

Penny Daniels: Okay, and what do you think the public needs information on most? What do they need to know?

Dr. Gregory Bogdan: Well we know what the public needs to know is first, the general event information: the who, what, where, why, when. What's going on, and get it from a trusted source. We know that public health agencies, medical agencies still have the highest degree of trust the public conveys upon them, and are more likely to contact these types of agencies for information as opposed to just what's going on in the media.

We also know that they want to find out how they can protect themselves and their families. They want to know what State and local health departments recommend; and if they have further need, they want to be able to refer to the most appropriate agencies to take care of those needs.

And at the end, they also want help with making decisions. They want to know based on their own circumstances, their own problems, their own underlying medical conditions, what should they do next to take care of themselves and their families. What actions are needed?

Penny Daniels: What agencies specifically should be providing this type of information to the public?

Dr. Gregory Bogdan: Well some of the natural fits that really are agencies that exist today are the Poison Control Centers that exist in this country, nurse advice lines which many HMO agencies utilize; drug information centers. Also public health agencies that have set up call centers to provide information or use hotlines have also been great at doing this kind of activity.

Penny Daniels: Okay, so we've talked about what kind of information the public needs, and what kind of agencies should be providing this information; how exactly does a medical call center work?

Dr. Gregory Bogdan: Well the public and health care providers generally contact these centers through a variety of communication modes. However, most commonly today that still is the telephone. And by providing this easy option that is accessible from the home or office, the public will usually choose it first instead of going to first the hospital or health agency. This isn't going to prevent people who are injured from directly going to hospitals, and that's not what we want to do. Those should automatically triage themselves to the most appropriate agency. But for those who just have a concern or a question, or know—need information on what they should do next, this provides an easy mechanism for them to get into the system, find out what is the most appropriate for themselves.

For some that will require a visit to a facility for further evaluation. But for many their question or concern can be answered very effectively over the telephone. Therefore, their strategy helps to reduce the overall patient surges at hospitals and health departments so that those agencies can focus on those with the greatest need.

Penny Daniels: Can you explain your experiences in operating a call center in the real-world? Can you take us through some of that?

Dr. Gregory Bogdan: Sure, Penny. We have tested this approach with The Colorado Health Emergency Line for the Public or its acronym COHELP, which we've operated since January 2003. This service was created to provide a standardized prepared response to health events in Colorado, that provided consistent and accurate information. It was also a means to collect structured data so that could help us characterize these events for future responses. The requirements for the service which was funded by the State Health Department was to have the capacity and the capabilities to adapt to emerging health threats.

The COHELP service we have found out has many users. They have included the public, health care providers, hospitals, clinics, health agencies and even schools. It has even been accessed by tourists planning a visit to our State when things like West Nile virus and influenza were a concern.

Our service also helps people get to the right agencies for further assistance. We can have people with potential toxic exposures get directly right to the State's poison center, while those with more general medical concerns can get directed to nurse advice lines that serve their areas. Others are referred into their health care providers if they feel that they have symptoms that meet the definition of the current disease. And then we also get local and State Health Department guidelines and protocols to guide their actions.

Penny Daniels: What are some of the specific benefits of using a medical call center?

Dr. Gregory Bogdan: Well, Penny I think the greatest benefit is providing the public with a mechanism for one-on-one information exchange. This communication messages through mass media can effectively provide general information for the public, but it does not really afford them the ability to ask questions about specific concerns such as, like how does this affect me? I have hypertension or I have diabetes or I am taking multiple medications so what does this mean for me? Medical call centers are set up to address these specific questions and concerns, and the public has relied upon them in the past during health events.

As an example we can just look to Toronto and the SARS outbreak. It had a hotline operating that received over 300,000 calls within 4 months. They actually had over 47,000 calls in just one day. Using a hotline helps stem the further spread of disease by informing the public, providing them answers at home instead of having them congregate in central places to get that information, and even help support those that were in voluntary home quarantine. Those people were able to then stay at home, and not have to try to venture out of their house to get things like food or medicine, or to have questions answered. And that really did help keep the death toll down to just 44 individuals in Toronto, and the cases to 438.

Our experience in Colorado with West Nile virus and influenza outbreaks in 2003 showed us that, again the public had a great need for this type of service. We had over 36,000 calls in six months. The call volume was likely lower despite the greater numbers of cases and deaths that we had in Colorado in relation to SARS, because the public didn't have as great a perception of risk related to this type of event.

Penny Daniels: Dr. Bogdan I know that we have a lot more information from you in terms of lessons learned and so forth. Hopefully this is going to come out in questions. We're going to skip ahead a little bit, and just briefly if you could, show us your slide on 'Getting More Information' from you. What informational resources are available for people who want to take a closer look at your approach? And then we're go right into Q&A after that.

Dr. Gregory Bogdan: Okay, what's available is that on the AHRQ site by the end of the year will be a report about how we've examined the use of medical call centers for responding to emergencies. Also on that site, and also on the Web site for the webcast, there is a contact center assessment tool to help agencies who want to develop a call center determine what kind of support they will need for those efforts to help them do some planning, and also to help them decide whether they need to it themselves within their agency, or should they partner with the established medical contact centers that I had talked about before.

Penny Daniels: Thanks, Dr. Bogdan. Thanks to all of you. Before we open up the lines for questions now, we would like to turn the tables and get your feedback, listeners' feedback on our series. Many of you have been participating in this series on "Surge Capacity" throughout the year. Some of you also joined last year's series on "Bioterrorism and Health Systems Preparedness", and the audience has grown throughout the past two years so this tells us there is a lot of interest in these issues. To help us plan future events that will continue to meet your needs, we want to get feedback from you in two ways.

As usual at the end of our Web conference we invite you to share your thoughts about our format; how you used the information and what you find valuable. We look forward to getting the feedback, and we do use it to improve our program. And today for the first time we will ask you another question. By now a new screen should have come up on your computer with the question. This is an interactive thing that we're doing.

The question is, "Would you participate in more AHRQ Web conferences on topics related to surge capacity or other issues involving health system preparedness?" Using your mouse please check the appropriate response. Before the end of the Web conference we will show the results of this audience poll. Now I'm going to leave this question up for a couple of moments so everyone has to chance to check whether they would or not.

But now it's time for the Q&A part of our program. So as we leave the question up, I'm going to describe how you send in your questions, and there are two ways. First, if you're listening on a phone press "Star 1" to indicate that you have a question. If you're listening through your computer, and you want to call in with a question, dial 1-877-407-8037; and you'll see that number in just a few moments coming up on your screen. And use the password 'surge capacity', then press "Star 1." While asking your question on the air, please do not, do not use a speaker phone or a cell phone because we will not be able to hear you. Be sure to speak loudly and clearly, of course. And if you're listening through your computer it's important that you turn down the volume after speaking with the Operator, because there's a significant time delay between the Web and the telephone audio, and we could get feedback.

Now if you want to send a question via the Internet, simply click on the button marked Q&A on the Event window on your computer screen, you see that now. Type in your question and then click the Send button. One important thing, if you don't want to give us your name when you speak with us that's fine, but we would like to know what State you're from and the name of your department or organization. So please provide those details regardless if whether your question comes in by phone or Internet.

Now as you're formulating your questions or queuing up on the phone lines, I'd like to say a few quick words about our sponsors. AHRQ, the mission of AHRQ is "to improve the quality, safety, efficiency, efficacy and effectiveness of health care for all Americans." Two of AHRQ's operating components help to produce this series of Web conferences.

First, AHRQ's User Liaison Program serves as a bridge between researchers and State and local policymakers, purchasers, payers and health systems. ULP not only bring research-based information to you so you can be better informed, we also take your questions back to AHRQ researchers so they can better understand State and local priorities. Hundreds of health policymakers, purchasers, payers and health systems' officials participate in ULP workshops every year.

Second, AHRQ's Center for Primary Care, Prevention and Clinical Partnerships provides expertise and leadership on primary care practice and research, both within AHRQ and throughout the department of HHS. The Center supports extramural and intramural research that informs, that is, a wide range of issues related to primary care practice, prevention and policy.

I'd also like to take a moment to thank Dr. Sally Phillips, Director of AHRQ's Bioterrorism Preparedness Research program in the Center for Primary Care, Prevention and Clinical Partnerships. She has been instrumental in helping us produce this series. ULP and the Center for Primary Care Prevention and Clinical Partnerships hope that today's Web conference and the previous events in the series will provide a forum for a productive discussion between policymakers and researchers on these issues.

We would appreciate any feedback that you may have on this Web conference. Again, at the end of today's broadcast a brief evaluation form will appear on your screen with easy-to-follow instructions on how to fill it out. Please take the time to complete this form.

For those of you who have been listening by telephone and not using your computer, we ask that you stay on the line. The operator will ask you to respond to those same evaluation questions after the Webcast using your telephone keypad. Whether by phone or E-mail your comments on this Web conference will provide us with a valuable tool in planning future events to better suit your needs. Alternatively, you can E-mail your comments to the AHRQ User Liaison Program at Now we go to questions from our audience.

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