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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 9. Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice

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 generators.

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 the following:

  • 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, etc.
  • 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 drills.
  • Periodically review the location of fire extinguishers, first aid, and emergency equipment.

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 (JCAHO) requirements.

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.

Communication System

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 equipment fails.

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 and Exposures

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 following:

  • 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 office-based physicians.


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, floods, etc.).
  • 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

Communication Systems

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.
  • Pharmacies.
  • Shelters.
  • 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 drills.

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 professionals.

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 and condition.

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 Exit Disclaimer

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 service.

Advice for Families of Children with Special Health Care Needs

Pediatricians 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:

  • EMS.
  • Fire.
  • 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 (PTAs), etc.).
  • Nonsecular groups (churches, synagogues).
  • Public recreation administrations (zoos, amusement parks, sports stadiums, museums, etc.).

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

Crisis Drills

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 other patients.

Quarantine Procedures

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

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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