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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

Phases of Response

There are four basic phases of response to a disaster. They are:

  1. Preparedness (including prevention and planning).
  2. Actual response to the event.
  3. Mitigation.
  4. Recovery (short- and long-term) and critique.


Although we usually cannot predict disasters, we can control them through prevention and planning efforts. Prevention through preparedness is probably the most important phase of response in emergency management. During the preparedness phase, governments, organizations, and individuals develop plans to save lives, minimize disaster damage, and enhance disaster response.

Preparedness efforts include:

  • Preparedness and evacuation planning.
  • Emergency exercises and training.
  • Warning systems.
  • Emergency communication systems.
  • Public information and education.
  • Development of resource inventories, personnel contact lists, and mutual aid agreements.

Physicians participate in preparedness and prevention in many different ways, including: immunization programs, dietary advice, health education, and safety precautions and planning. As participants in an emergency action plan, physicians need to help formulate ways of preventing incidents from occurring or limiting the consequences from an incident that has already occurred. Physicians need to know what will be expected of their hospital in the case of a potential infectious disease outbreak. They should also be prepared with the knowledge and resources needed to help identify the etiology of a problem and to provide timely treatment.

In the case of acts of terrorism, law enforcement plays the lead role in prevention, although physicians are often called upon to lend their expertise in an effort to identify the impact that various scenarios would or could have on the health of the community. Part of prevention consists of participating in a pre-established medical surveillance network of communities that will alert public health and safety officials of suspicious trends. A communications network of pediatricians, school nurses, freestanding pediatric walk-in clinics, and pediatric emergency departments should be formed.

Medical staffs need to know what will be expected of them and their facilities in the event of a large-scale infectious disease outbreak. Because of their unique knowledge base, physicians, especially pediatricians, can be very valuable sources of information to law enforcement and public health policymakers in helping to identify and isolate the source of an outbreak and providing guidance on the need for isolation, quarantine, and treatment.

Planning and prevention are closely related and work hand-in-hand. The people doing the planning cannot be strangers. It is important that they routinely and regularly meet and speak with each other to facilitate communication during a crisis. Communication is a key element for success. If managers cannot communicate successfully during routine circumstances, they cannot be expected to effectively communicate during times of crisis.

Plans should be developed and then tested and refined, over and over again. For a plan to work efficiently and effectively during a crisis, it must be well rehearsed. Plans that have been tested on a regular basis enable the responders to know and understand their roles. During a crisis is not the time to find out that a vital component is missing or nonfunctional.

Response plans must be shared with the people who will be doing the actual responding. Periodic in-service training should be conducted, including tabletop exercises with key players and full-scale field exercises. Pediatricians should be proactive in providing input regarding the unique needs of children during disasters and ensure that children's issues are included in all preparedness activities. Lessons learned from either actual responses or from the exercises and discussions should be incorporated into existing plans and then tested and evaluated again.

Planners need to ask themselves over and over again: "Are we ready?" Plans must be constantly changing and evolving to meet changing circumstances, and no matter how well prepared we think we may be, we can always be more prepared. Careful review and personal communication with all involved in both incident management and potential response can always identify more opportunities for improvement. Because disasters are dynamic events, plans must be flexible so that they can be adapted to an incident as it develops. People involved in the planning process should stay current regarding new trends, technologies, and intelligence information that become available. Planning done in a vacuum cannot be successful.

Actual Response to the Event

The next phase is the response to the actual event. Response activities provide emergency assistance for casualties, reduce the probability of secondary damage, and speed recovery. Response activities include:

  • Activating public warning systems.
  • Notifying public authorities.
  • Mobilizing emergency personnel and equipment.
  • Providing emergency medical assistance.
  • Manning emergency operation centers.
  • Declaring disasters.
  • Evacuating the public.
  • Mobilizing security forces.
  • Providing search and rescue operations.
  • Suspending laws on an emergency basis.

Response to a mass casualty incident (MCI) begins at the scene by first responders. An integral role of the first responder is coordination with agencies able to recognize characteristics of MCI secondary to bombs or to biological, chemical, or radiological agents, such that ongoing risk is minimized. First responders collect casualties, triage survivors, institute treatment (including decontamination), and transport victims to emergency departments. In blast trauma, first responders should convey information to hospital personnel so that management of casualties can be facilitated.

This information should include the sorts of injuries that are expected, initial estimates of the number of casualties, and any additional risks to personnel from toxic substances. Involvement of hazardous substances such as chemical or biological agents, fires, collapsed structures, or the possibility of a radiation dispersal device (dirty-bomb) should initiate specific response protocols.

Incidents can be very dynamic, so personnel should be able to adapt plans to deal with the incident as needed. There should be an incident commander—a qualified, visible leader—who can take charge of the response and direct the responders. The incident commander must be able to think quickly, make rapid assessments, and switch direction as needed without holding a lengthy caucus. The incident commander should be surrounded by competent, knowledgeable, and trusted people. They will be called upon to provide complete and accurate information to the incident commander so that he or she has the tools needed to make rapid, informed decisions.

The National Incident Management System (NIMS) provides the framework needed to successfully manage an incident. This is a standardized plan that allows for flexibility. The NIMS can be used by local, state, and federal authorities to use resources depending on the nature and the scope of the incident. The NIMS is available online at (PDF Help).


The next phase of response is mitigation, in which actions are taken to stop the incident from doing any further damage and to stabilize the situation. Although disasters cannot always be predicted, their consequences often can be controlled by preparation and planning. Mitigation activities are also important in the preparedness phase, where they can eliminate or reduce the probability of a disaster or reduce the impact of unavoidable disasters. The damage done can be limited or confined using the dynamics of the incident management plan.

Mitigation preparedness measures include:

  • Building codes.
  • Vulnerability analyses.
  • Tax incentives and disincentives.
  • Zoning and land use management.
  • Building-use regulations.
  • Safety codes.
  • Sharing of resources among States.
  • Preventive health care.
  • Public education.

Information resources, data, and services important in mitigation activities include:

  • Geographic information systems (GIS)-based risk assessment.
  • Claims history data.
  • Facility/resource identification.
  • Land use/zoning.
  • Building code information.
  • Modeling/prediction tools for trend and risk analysis.

Recovery and Critique

The recovery phase evolves as steps are taken to mitigate the event. The objective of recovery is to return things to normal as quickly as possible, and recovery activities continue until all systems have been returned to normal or better. Depending on the scope of the incident, the recovery period can range from hours to years. Damage assessments are made, financial needs are identified, and timelines and plans are developed and implemented.

Short- and long-term recovery measures include:

  • Returning vital life-support systems to minimum operating standards.
  • Reconstruction.
  • Temporary housing.
  • Ongoing medical care.
  • Public information, health and safety education.
  • Counseling.

One aspect of long-term recovery involves assessing the infrastructure, how it held up during the incident, what the cost of the response was, and how that cost can be recovered.

Recovery efforts in economic support include:

  • Paying out insurance/loans and grants to cover damage.
  • Providing disaster unemployment insurance.
  • Performing economic impact studies.

Information resources and services related to recovery include:

  • Data collection related to rebuilding.
  • Claims processing.
  • Documentation of lessons learned.

During long-term recovery, participants also review and critique the response, evaluating how the overall plan worked in a real event, determining what needs to be done to update the plan and educate responders, and making changes necessary to improve the original response plan and prevent a recurrence.

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Regional Response

State and Federal

Communication and information sharing are key parts of successful incident management—both before and during an actual event. Although each area of the country handles emergency responses in somewhat different ways, all emergency response agencies use some form of an incident management system. Almost all use the NIMS with unified command.

Regional physicians should review community emergency response plans, as well as the collaborative efforts between responders and planners designated by pertinent emergency response agencies. Local physicians should become familiar with the following:

  • The response agencies in their area.
  • Regional medical, operational, and administration protocols.
  • The various levels of training and the roles of all the different responders in a mass casualty incident, and how these change with the changing situation. For example, some responders may move victims only after they have been triaged by other more highly trained responders. In a different scenario, those same responders may actually move victims before triage because of unstable conditions (e.g., structural collapse, hazardous materials release). The dynamics of the incident dictate whether triage or transport is done first.
  • Whether the firefighters or police officers in their community are certified emergency medical technicians (EMTs) or paramedics.
  • The person who is in charge of an incident when there is a multi-agency response.
  • Where to go for information and to offer assistance during an actual emergency.
  • The regional and State emergency planning interface. Each state has its own unique emergency planning office and incident management system that ties in with the overall National Response Plan (Figure 3.1).

Emergency Medical Services

The availability and capabilities of emergency medical services (EMS) in the United States have undergone explosive growth over the last 40 years. The Comprehensive Emergency Medical Services Systems Act of 1973 established the regional basis for coordination of emergency medical care throughout the United States. In addition, the National Highway Traffic Safety Administration (NHTSA) is charged with coordinating the development of national standard curricula for and education of EMTs.

During the past 25 years, the scope and complexity of care rendered by prehospital EMS providers have expanded greatly. Four levels of prehospital emergency medical personnel are currently recognized, in order of increasing skill level with respect to the care of the trauma patient (Table 3.1).

In recent years, the addition and expansion of initial and continuing education in prehospital pediatric trauma care (such as that provided by the Pediatric Emergencies for Prehospital Professionals [PEPP] course of the American Academy of Pediatrics), as well as the provision of expert pediatric medical direction, have greatly enhanced the capabilities of most regional EMS systems. In most regions, injured children can now receive emergency medical assistance comparable to that of injured adults.


In mass casualty incidents, including those involving release of biological or chemical agents, both children and adults are likely to be significantly affected. Children would probably be disproportionately affected by such an incident, so pediatricians should assist in planning coordinated responses for local hospitals that may have limited pediatric resources (go to Chapter 1). Health care facilities could also be a primary or secondary target. At the very least, facilities will be overwhelmed by a massive number of anxious and worried individuals.

The problems associated with terrorist incidents differ from those usually faced by hospital disaster alert systems. In the typical scenario, most victims are triaged in the field and then carefully distributed among available resources, to avoid a single facility from being overwhelmed. In a terrorist attack, facilities will be particularly vulnerable to inundation with many victims who have not been appropriately triaged or transported by EMS. Arrivals without full notification could interfere with attempts to isolate contaminated victims and ensure protection of health care personnel.In addition, terrorist events will be further complicated by the issues of security and forensics.

Hospital emergency department personnel become involved both before and after the arrival of victims. Activities prior to arrival include processing current patients in the emergency department to prepare for new arrivals, checking all equipment, activating additional personnel, assigning team leaders, and possibly assigning liaisons to government agencies. On arrival of patients, emergency department staff should ascertain (whenever possible) a victim's location with respect to detonation, whether a victim was within an enclosed space or near a body of water, or whether the victim was crushed by debris. These data provide valuable information as to the degree of injury to expect in other victims.

Triage is crucial, given the large number of minimally injured and ambulatory victims presenting to emergency departments after a terrorist incident. The importance of triage is highlighted by the Oklahoma City experience in April 1995. This explosion caused 759 casualties, of whom 167 died, 83 were hospitalized, and 509 were treated as outpatients either in an emergency room or by private physicians.

Approximately 85% of the 592 survivors sustained non-life-threatening soft-tissue injuries (including lacerations, abrasions, contusions, and puncture wounds), and 35% sustained musculoskeletal injuries (including fracture/dislocations and sprains). The 66 children who were injured in the Oklahoma City blast showed a similar pattern of soft-tissue and musculoskeletal injury.

The first wave of patients from the Oklahoma City blast arrived either by ambulance or some other means of transportation within 15 to 30 minutes of the event. Medical systems were overloaded with minimally injured patients. As would be expected, hospitals closest to the attack were overwhelmed first. More seriously ill, non-ambulatory patients tended to arrive later because of the delay associated with field triage and transport via EMS.

The experience after the World Trade Center attacks in 2001 was similar in that the vast majority of patients seen in emergency departments were ambulatory and were treated for minor soft-tissue injuries and released. However, hospital overload was mitigated somewhat due to the large number of fatalities, which decreased the number of survivors presenting for treatment. The main lesson to be learned from these experiences is that casualty profiles are event specific, but an effective triage system can better direct attention toward the critically ill.

Regional Coordination

The objective of risk assessment is to estimate the likelihood that an incident will have an impact on the hospital, as well as the size of that impact. Considerations in risk assessment include the following:

  • Attack has the potential to generate large number of causalities.
  • Effects may be immediate or delayed.
  • Response will require specialized equipment, procedures (decontamination), and medications, all adapted to pediatric needs.
  • Hospitals may be targets of secondary attacks to amplify effect.

Situations with both high probability and the potential for high impact (e.g., an earthquake in California, or a tornado in the Midwest) should receive more attention in preparedness planning than either situations of low probability with the potential for high impact (e.g., industrial plant chemical leak) or situations of high probability and the potential for low impact (e.g., community outbreak of infectious gastroenteritis).

Hazard vulnerability analysis (HVA) is an aspect of risk analysis that considers the hospital's capabilities regarding the traditional elements of risk. This analysis allows a comparison between the potential risk factor (hazard) and the hospital's ability to cope. The action plan resulting from this type of risk analysis should be directed toward those hazards against which the hospital is less able to cope (i.e., vulnerabilities). Areas of vulnerability may include attack on hospital information systems, inadequate ventilation systems (negative pressure, contained exhaust) for decontamination procedures in toxic exposures, hospital staff untrained in the proper use of personal protective equipment (PPE), and so on.

The key benefit of HVA analysis is the ability to prioritize planning for the hospital in any given situation. The key to effective HVA is a good, frequently updated inventory of the resources and capabilities (within both the hospital and the community) that are available for dealing with a particular hazard-related emergency.

Surge Capacity

Most of our medical systems operate at near capacity in normal times. Pre-event planning and preparedness are essential to develop local capacity and expand health care resources to respond to increased needs. Surge capacity should be created on all levels, including the following:

  • Emergency department space.
  • Decontamination equipment.
  • Antitoxins and medications.
  • Hospital bed capacity.
  • Extra provider capacity.
  • Increased integration back into a community that can provide mental health services.

In general, hospitals should plan to be self-sufficient for the first day or two after an incident. Most victims in the first 24 hours will be anxious or worried individuals who may or may not need decontamination before medical treatment. Assessment of hospital capacity for these victims is essential. Several teams in small areas can perform triage and rapid treatment. A system should be established to initially treat victims and then assign them to other facilities (away from the main site) for definitive treatment. There should also be followup to ensure that appropriate care is available at the other facilities. A system should also be established to rotate and supplement staff for the first 24-48 hours (or longer) until additional medical help can arrive.

The following points should be considered in measurement and management of surge capacity:

  • Surge capacity expressed in terms of beds is not specific enough. Specific pediatric surge capacity that is somewhat intervention-specific is preferable. For example, there may be 1,000 hospital beds available in a large community but only 10 pediatric intensive care unit beds. If these types of pediatric-specific resources are needed, the actual surge capacity is only 10 beds.
  • Non-disaster-related patients must be cared for in addition to disaster victims. Surge capacity and overall planning should accommodate both sets of patients.
  • Surge capacity and capabilities are determined by many factors (e.g., facilities, human resources, patients' needs, legal and regulatory issues, policies, process design, supplies, equipment, etc.). Each factor should be systematically considered and optimized. A "bottleneck" in any factor can become the limiting condition. Poor management of these issues can affect outcomes more than the skill of the health professionals caring for individual patients.
  • Assumptions that pediatric patients will be cared for by adult health providers and facilities are not universally true or necessary in at least some situations.
  • Local contexts differ regarding inpatient capacity for high-acuity pediatric patients. In large urban areas, there are likely multiple pediatric hospitals within a short distance of each other. They can collaborate and probably handle patients from all but the largest of disasters. However, many communities have only one facility that may be a significant distance that is capable of handling high-acuity pediatric cases. These facilities often operate near or even above capacity many days each year. So, surge capacity and capability for pediatric but not adult disaster victims may be critically limited. Transporting pediatric patients to facilities outside of the region may be beneficial or even required (particularly if a pediatric facility is damaged or incapacitated). Pediatricians should educate and advocate regarding this type of planning. This is similar to the situation for high-end pediatric cardiac surgery, organ transplantation, and burn unit care for which pediatricians already refer to resources outside their region.
  • The frequent practice of making superheroic efforts at an overwhelmed hospital needs to be considered against the risk/benefit and outcomes of transferring patients to hospitals that are not overwhelmed. Generally, pediatric capability and capacity are available, but they may be at distant facilities.
  • Agencies other than hospitals may be needed to care for unaccompanied but otherwise medically stable children or for children with social but no serious physical medical issues. This will not occur unless pediatricians help the responsible agencies prepare in advance.

Protection of Personnel and Levels of Precaution

Hospital staff members are at high risk for secondary exposure from contaminated victims (e.g., skin, clothing, etc). The Occupational Safety and Health Administration (OSHA) provides protective standards for hospital response, including:

  • A written plan describing how contaminated patients will be managed.
  • An Incident Command System described for each type of hazard.
  • On-the-spot training and briefing for support personnel, such as physicians.
  • A plan for providing exposed employees with medical care and surveillance.
  • Training at a first-responder level for employees involved in decontamination operations, including training in hazard containment and prevention of spread.

Biological agents are generally associated with a delay of hours to days in onset of illness. Therefore, illness may go unrecognized in the initial stages, which can result in widespread secondary exposure to others, including health care personnel and other patients. In this situation, containment of the exposing agents in negative-pressure environments is mandatory. In contrast, toxins derived from biological agents produce illness within hours of exposure. The patient exposed to a toxin does not usually pose a significant threat of secondary exposure to medical personnel, although decontamination may still be warranted (as in chemical exposure).

PPE includes specifically designed barrier clothing (e.g., gown, boots, and gloves) to protect the skin and a mask to protect the respiratory tract. Clothing is designed to provide protection against liquids, vapors, dust, and particles. Respiratory masks fall into two categories: those that filter the ambient air to rid it of hazardous particles, and direct-line masks that provide pure air under pressure.

Chemical weapons are intended to produce immediate discomfort, incapacitation, or death. Incapacitating chemical agents may be particularly toxic to small children. The mainstay of decontamination is rinsing with water, shedding exposed clothing, and in some instances, administering pharmacologic antidotes.

The risks of contamination are usually recognized at the scene, so that personnel at the receiving hospital can be alerted. However, hospital personnel are at particular risk of contamination from exposure, due to the high number of anxious or worried victims who arrive at the hospital on their own without previous triage or information on risk factors from the incident scene. Health care personnel and any adjunct personnel in contact with victims or the hospital decontamination site should wear full PPE and self-contained breathing apparatus until the risk of exposure by secondary contamination is completely eliminated. Equipment used for universal precautions, such as surgical masks and latex gloves, are inadequate. Recognition of all agents involved in the exposure and determination of their toxic potential often take time and close coordination with the regional poison center, the fire department, and the Centers for Disease Control and Prevention (CDC). Hospital personnel responsible for decontamination and protection should remember the possibility of more than one agent being used in an assault and also the possibility of terrorists using a "decoy" agent to mask and delay recognition of release of a more toxic or lethal agent.

Radiological or nuclear agents are generally associated with a delay in onset of illness. As with biological agents, illness may go unrecognized in the early stages, so that the risk of contamination of hospital personnel by secondary exposure to radiation carried from the scene is significant. Contamination varies with the emission levels.

PPE for radiological agents includes clothing barriers that prevent radioactive particles from reaching the skin. Any mask that will prevent dust from reaching the respiratory tract is protective. Gamma and neutron emitters penetrate clothing easily and require lead-type barriers. Lead aprons, such as those used for routine radiology, are not feasible for protection. Some exposure of hospital personnel may be unavoidable, and in these instances, the radiation exposure should be monitored and limited to safe doses.

Potential problems with use of PPE include the following:

  • Bulky and cumbersome.
    • Impedes bending, kneeling to reach small children, infants.
    • Impedes nimble use of hands and fingers (needed for starting an intravenous (IV) line, intubating, drawing up medications, etc.).
    • May not be adapted to stethoscope use.
  • Poor ventilation and temperature control.
    • Profuse sweating, discomfort.
    • Potential fluid losses and dehydration.
    • Hyperthermia (for personnel working in warm environments [outside tents, hospital air conditioning system down], or working over-extended hours).
  • Unfamiliar "alien" appearance.
    • Frightens children.
    • Contributes to stress of the crisis.

For additional information on PPE, go to Chapter 5 and Chapter 6.

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Incident Command Systems

Incident command systems (ICS) use a consistent organizational structure that includes individual positions for overall management of emergency situations. ICS systems are designed to facilitate interagency coordination(because each agency has organized their response on the same model). This is one of the system's most important advantages. ICS can also expand and contract to meet the needs of the particular emergency situation at hand.

ICS structure is hierarchical. For example, there will be one incident commander, three key assistants (safety officer, liaison officer, and public information officer), and four subordinate managers who report directly to the incident commander (operations, logistics, planning, and finance). Go to for more information on developing an ICS.

San Mateo County Emergency Services developed their Hospital Emergency Incident Command System (HEICS) in the 1990s to facilitate earthquake preparedness among California hospitals.  This HEICS provides a useful example of a system that employs the concept of "unified command," with establishment of an emergency operations center within the hospital, pre-designed job action sheets, response activities, lines of communication, and reporting relationships. The HEICS structure is modeled on the ICS hierarchy. Key participants in the hospital ICS include the following:

  • Hospital chief executive officer.
  • Vice president of operations.
  • Medical director.
  • Emergency manager.
  • Community affairs director.
  • Critical care manager.
  • Emergency department manager
  • Hospital communications.
  • Facilities and engineering.

For more information on the HEICS, go to

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Regional Coordination of Hospital Response

Emergency incidents also require hospitals to coordinate with community and medical stakeholders within the regional area. Coordination with community stakeholders includes liaison and planning with various local, State, and national agencies/organizations within the region:

  • Primary/prehospital/infrastructure Response:
    • EMS.
    • Fire.
    • Police, local environmental protection agency, sheriffs.
    • Military (local or regional).
    • Regional poison centers.
    • Local health department.
  • Community/citizen response:
    • Schools, public and private.
    • Day care units, public and private.
    • Service groups (Kiwanis, Rotary, Salvation Army, parent/teacher associations [PTAs], etc.).
    • Nonsecular groups (churches, synagogues).
    • Public recreation administrations (zoos, amusement parks, sports stadiums, museums, and the like).

Regional coordination with medical stakeholders includes liaison and planning with various medical entities within the region:

  • Children's hospital-based:
    • Pediatricians and pediatric subspecialists.
    • Pediatric nurse practitioners, physician assistants.
    • Administration.
    • Ancillary services (nursing, technicians, etc.).
    • Air/ground transport services.
    • Laboratory services.
    • Children's services.
    • Support services (dietary, environmental).
  • Community-based private practitioners:
    • Pediatricians.
    • Family practice physicians.
    • Emergency medicine physicians.
    • Nurse practitioners.
    • Physician assistants.
    • Other types of physicians and health care providers.
  • Community/ regional hospitals:
    • Emergency department staff.
    • Hospitalists.
    • Surgeons.
    • Anesthesiologists.
    • Administration.

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