Disclosure. Objectives. In the Center of it All: The Trauma Center in Pediatric Disaster Planning and Response

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1 In the Center of it All: The Trauma Center in Pediatric Disaster Planning and Response Disclosure No commercial interests to disclose Mark X. Cicero MD, FAAP Section of Pediatric Emergency Medicine Yale University School of Medicine This work was supported by an Emergency Medical Services for Children (EMSC) Targeted Issues Grant, HRSA #H34MC19349 Post an overnight shift, sleeping On December 14, 2012, I was at home sleeping at 11:00 a.m. EST. This call from a colleague awakened me: There has been a school shooting in Southern Connecticut. We don t know how many victims there are, or how many we ll receive. I think you should come here, now. Things that go through a person s mind in this situation: Was it my kid s school? What should I tell my wife? How many patients can my ED, and my hospital, reasonably take? Are we ready? Objectives 1) Identify the components of disaster ethics and triage 2) Learn to promote family cohesion and reunification 3) Understand the role of pediatric trauma centers in disaster preparation and response 4) Appreciate the trauma center s interactions with the public in a disaster 1

2 Types of Disasters Part I. Disaster Scope, Ethics and Triage Sudden Unexpected All victims ill or injured simultaneously Examples: tornadoes, school shootings, nerve gas attacks Delayed Incubation period Range of times to presentation and degrees of illness/injury Examples: pandemic influenza, biological weapons Background Disasters overwhelm health care resources Scale Duration Preexisting resources Children are disproportionally harmed Events which overwhelm medical resources MPI: Multiple-Patient Incident (up to 25 patients) MCI: Mass Casualty Incident ( patients) Disaster: Over 100 patients images.ctv.ca/gallery/photo/bus_crash_080409/image3.jpg Events which overwhelm medical resources Events which overwhelm medical resources MPI: Multiple-Patient Incident (up to 25 patients) MCI: Mass Casualty Incident ( patients) Disaster: Over 100 patients MPI: Multiple-Patient Incident (up to 25 patients) MCI: Mass Casualty Incident ( patients) Disaster: Over 100 patients 2

3 Disaster Ethics Disaster Ethics GUIDING PRINCIPLE IN DISASTER: Do the most good for the most patients, a utilitarian ethic due to overwhelmed resources. Patients Healthcare needs Community needs Media attention Personnel Medical equipment Pharmaceuticals ORs Hospital rooms ICU Space Performed at the scene of disaster or the hospital when patients arrive Patients assigned to color triage groups Immediate (Red) Delayed (Yellow) Ambulatory (Green) Deceased/Non-recoverable (Black or Blue) Triage category BLACK patients reassessed following RED category In disasters, many children may present with or without a parent or caregiver Flow within triage categories Based on clinical changes Requires communication between triage and treatment area leaders No back flow to primary triage once sorted Allows orderly progression through triage system Each triage area has a team leader Reassess venue of treatment Hospital vs. surge capacity venue vs. treating on-site Transportation to hospitals or surge capacity venues Delayed Immediate Emergency Department Triage Triage children with families present Knowledge of preexisting conditions Part II. Promoting Family Unity and Reunification Decreases need for reunification 3

4 Family Unity Triaging children and their families together important for mental health Send family unit to triage color area appropriate for most ill family member Preservation may not be possible if children and adult are all immediate (red) category Tracking system necessary in triage to ensure family reunification Separation from parents and siblings greatly increases children s anxiety Family members benefit injured children: Monitor condition Provide food and comfort Decrease anxiety Decrease demand on staff Photo Credit: FEMA Family Reunification Digitally photograph children at intake Name, gender, ethnicity, eye color, DOB Where child was found Locations of injuries National Center for Missing and Exploited Children Family Reunification Systems Digital photo strategies Feature-Attribute-Matching: automated, facial recognition User-Feedback: presents new photographs based on parent input A combination of the two works best Chung S. A novel image-based tool to reunite children with their families after disasters Consider the Needs of Children in Family Preparedness Planning Pre-designated meeting locations Listing of key phone numbers Create an emergency kit Prescription medications Common medications Formula/Food Diapers Clothes Create a list of trusted adults and a safety password Comfort objects and foods Part III. The Role of Trauma Centers in Disasters 4

5 Trauma Centers: Designation and Verification States designate trauma centers The American College of Surgeons (ACS) verifies trauma center status Adult Pediatric Trauma Centers: ACS Verification Levels Level III: resources for emergency resuscitation, surgery, and intensive care of most trauma patients Transfer agreements with a Level I or II center St. Francis Medical Center, Grand Island, NE Trauma Centers: ACS Verification Levels Level II: provides comprehensive trauma care 24-hour availability of all essential specialties, personnel, and equipment Not required to have a surgery residency or research program Level II Pediatric Trauma Center: Omaha Children s ACS Pediatric Trauma Centers,

6 The Role of Pediatric Trauma Centers in Disasters Emergency Medical Services for Children (EMS-C) in a Disaster Hub for directing and providing care Direction of EMS Resource for other hospitals A program of Health Resources and Services Administration (HRSA) Education and grant funding for development pre-hospital pediatric care Provides designations for pediatric disaster centers Emergency Department Pediatric Critical Care Center 32 The Omaha Easter Sunday Tornado of 1913 March 23, 1913, a series of tornadoes struck the north side of Omaha. 94 dead. Many displaced. If (when) this happens again, where will the mildly injured and displaced receive care? What if the trauma center is compromised? Coordinating Surge Capacity Facilities Hospitals without formal pediatrics services Community health centers Rehabilitation hospitals Urgent care centers Physicians offices Nursing homes School-based health centers Field hospitals in gymnasiums, warehouses, arenas and convention centers Religious or faith-based facilities Equipment Necessary for Pediatric Disaster Preparedness Emergency Department Readiness Airway equipment IV access devices ( intravenous lines, intraosseous needles) Warming blankets Radiant warmers Normal saline Pediatric nutrition supplies Formula, G-tube feeds, Child-friendly non-perishable items Laryngeal Mask Airway Proper equipment Airway equipment IV access devices Training Consult with pediatric experts PALs Disaster Drills 6

7 Emergency Department Readiness The Role of Nurses General EDs will see child patients Children s EDs may see adult patients Be prepared with 72 hours worth of pediatric equipment and medications Markenson D, Redlener I. Pediatric Emergency Preparedness for Natural Disasters, Terrorism, and Public Health Emergencies: A National Consensus Conference. u/files/ peds2.pdf Rapid triage and disposition Drafting, adherence to, and revising emergency plans Unit leadership Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) Nurses and Hospital Workers The Role of Physicians and Providers Survey of 1711 hospital workers (85% response rate) Willingness to respond varied by type of disaster More likely in natural disasters and trauma Less likely to respond in chemical/biological/radiologic incidents Care for patients Stabilize Treat Transport/disposition Foster a graded decline in the standard of care ESAR-VHP Pediatric Surgeons and Disasters 265/725 responded 77% of survey respondents felt responsible for disaster response 24% felt prepared (most felt they needed more training) Predictors of willingness to respond: Prior disaster experience Contractual obligation Combat experience Chokshi et al. Disaster management among pediatric surgeons: preparedness, training and involvment. Am J Disaster Med Jan-Feb;3(1):5-14. The Role of the Chaplaincy and Social Work Increased role in sharing bad news with families Coordination of family reunification Support trauma center staff 7

8 Approach to staffing protracted disasters Mass texts to staff Pre-designated, codified staffing patterns Reserve lockdowns for safety issues Staff more likely to respond if: Telecommunications are available Child and pet care needs addressed Challenges to Providing Care in Disasters Convergent volunteerism Many health care personnel arrive Need for coordination We are best at doing what we do every day Influences on Trauma Center Surge Capacity Early discharge This is the key to maximizing efficiency Throughput Rate of admission Duration of admission At the height of the surge, admission = discharge Surge Capacity Patients at disaster Admissions to Pediatric Centers Admissions to General Centers Discharges Barthel et al. Summarizing the Graphs The Impact of Pediatric Trauma Centers in Disasters PTCs impact care for child disaster victims: Halve the time until all children admitted Cut time to discharge by one third Limits to this include: Discharge may be impeded by the disasters If number of child victims exceeds PTC capacity Barthel et al. Availability of a pediatrictrauma centerin a disaster surge decreases triage time of the pediatric surge population: a population kinetics model.theor Biol Med Model Oct 12;8:38. 8

9 Role of the Trauma Center in Preparation Encourage family preparation Stockpile food, water, medications, and equipment Interface with disaster organizations Disaster medical assistance teams Medical reserve corps Part IV. The Trauma Center and the Public in Disaster Response and Recovery Community Resources Pediatric emergency and trauma centers Pre-hospital care providers, including EMS, fire departments and police Social services Schools Local health clinics Departments of Health Government (city, state and federal) Local and national media The Trauma Center and the Public Anticipate an influx people seeking information: Family and friends Media The curious public Factual statements by a predesigned spokesperson Photo Courtesy of FEMA 51 The Trauma Center, Public Health and Government State and local departments of public health work with hospitals in disasters: Ongoing hazards Availability and indications for immunizations Distribution of medications Conclusion Trauma centers are the hubs of disaster preparedness and response Much of the US has no verified pediatric trauma center Preparation matters Graded degradation of care 9

10 References 1. Daniel Mark Alterman, MD, RN; Chief Editor: John Geibel, MD, DSc, MA. Considerations in Pediatric Trauma Barthel ER, Pierce JR, Goodhue CJ, Burke RV, Ford HR, Upperman JS.Can a pediatric trauma center improve the response to a mass casualty incident? J Trauma Acute Care Surg Oct;73(4): Mason, Katherine E. MD, Urbansky, Holly RN, CPN, Crocker, Liz MEd. Pediatric emergency mass critical care: Focus on family-centered care. Pediatric Critical Care Medicine Issue: Volume 12(6) Supplement, Deliberations and Recommendations of The Pediatric Emergency Mass Critical Care Task Force, November 2011, pp S157-S Chung S, Mario Christoudias C, Darrell T, Ziniel SI, Kalish LA.A novel image-based tool to reunite children with their families after disasters. Acad Emerg Med Nov;19(11): References 5. Tepas, Flint et al. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatric Surgery, 43, , Markenson D, Redlener I. Pediatric Emergency Preparedness for Natural Disasters, Terrorism, and Public Health Emergencies: A National Consensus Conference. peds2.pdf 7. The Role of the Nurse in Emergency Preparedness. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41: Cone DC, Cummings BA. Hospital disaster staffing: if you call, will they come? Am J Disaster Med Nov- Dec;1(1): Chokshi NK, Behar S, Nager AL, Dorey F, Upperman JS.Disaster management among pediatric surgeons: preparedness, training and involvment. Am J Disaster Med Jan-Feb;3(1):