Developing a Pediatric Toolkit for Hospital Management of Pediatric Patients in Disaster

State: WA Type: Model Practice Year: 2010

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The public health issue addressed in this project is the gap in regional emergency response capacity and capability to care for pediatric patients in disaster. In a large-scale medical emergency, critically ill or injured children may present to any and all hospitals in the region. Their anatomical, physiological and developmental differences from adults require different medical management. Transfer by emergency responders to pediatric-specific hospitals may be impossible due to a shortage of vehicles, impassable roads and bridges or the instability of the patient. Pediatric hospitals may be unable to receive patients due to overwhelmed capacity or structural damage. All hospitals should be prepared to receive pediatric patients in a mass casualty incident and to provide appropriate short-term acute care and more definitive management, depending upon the nature of the emergency and the extent of its impact on the region. Goal: All King County hospitals that provide emergency services will be prepared to provide age-appropriate medical management of pediatric patients in a mass casualty incident (MCI).

Objective 1: The Pediatric Workgroup Triage and Critical Care Task Force will assess triage systems currently used in an MCI by King County hospitals with emergency services by September 2008.

Objective 2: The Task Force will develop a “pediatric toolkit” to provide basic information and guidelines for emergency management of pediatric patients to all King County hospitals that provide emergency services by December, 2009.

In July 2008 the Task Force conducted a web-based survey to assess triage systems used in an MCI by King County hospital emergency departments. Response rate was 94%. Analysis of the survey showed a need for consistency in the approach to triage and assessment of pediatric patients in an emergency, prompting the proposal to develop a “pediatric toolkit.” Development of the toolkit was an iterative process that included streamlining a document used as the framework and adapting it to local practice and resources. After peer review, the toolkit, “Hospital Guidelines for Management of Pediatric Patients in Disaster,” was introduced to regional hospital emergency managers in December 2009. In January 2010, hospital pediatric emergency planners met with members of the Task Force and the Healthcare Coalition to learn more details about the toolkit and its rationale and to discuss content of a proposed workshop to be held in March 2010. Hospital planners were encouraged to move forward with steps 1 and 2 of the implementation guidelines: 1) “surveying hospital staff to identify in-house pediatric expertise” and 2) “creating pediatric leadership positions for key personnel,” in order to identify individuals to send as delegates to the workshop.

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Public Health - Seattle and King County
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Developing a Pediatric Toolkit for Hospital Management of Pediatric Patients in Disaster
The public health issue addressed in this project is the gap in regional emergency response capacity and capability to care for pediatric patients in disaster. In a large-scale medical emergency, critically ill or injured children may present to any and all hospitals in the region. Their anatomical, physiological and developmental differences from adults require different medical management. Transfer by emergency responders to pediatric-specific hospitals may be impossible due to a shortage of vehicles, impassable roads and bridges or the instability of the patient. Pediatric hospitals may be unable to receive patients due to overwhelmed capacity or structural damage. All hospitals should be prepared to receive pediatric patients in a mass casualty incident and to provide appropriate short-term acute care and more definitive management, depending upon the nature of the emergency and the extent of its impact on the region. Goal: All King County hospitals that provide emergency services will be prepared to provide age-appropriate medical management of pediatric patients in a mass casualty incident (MCI). Objective 1: The Pediatric Workgroup Triage and Critical Care Task Force will assess triage systems currently used in an MCI by King County hospitals with emergency services by September 2008. Objective 2: The Task Force will develop a “pediatric toolkit” to provide basic information and guidelines for emergency management of pediatric patients to all King County hospitals that provide emergency services by December, 2009. In July 2008 the Task Force conducted a web-based survey to assess triage systems used in an MCI by King County hospital emergency departments. Response rate was 94%. Analysis of the survey showed a need for consistency in the approach to triage and assessment of pediatric patients in an emergency, prompting the proposal to develop a “pediatric toolkit.” Development of the toolkit was an iterative process that included streamlining a document used as the framework and adapting it to local practice and resources. After peer review, the toolkit, “Hospital Guidelines for Management of Pediatric Patients in Disaster,” was introduced to regional hospital emergency managers in December 2009. In January 2010, hospital pediatric emergency planners met with members of the Task Force and the Healthcare Coalition to learn more details about the toolkit and its rationale and to discuss content of a proposed workshop to be held in March 2010. Hospital planners were encouraged to move forward with steps 1 and 2 of the implementation guidelines: 1) “surveying hospital staff to identify in-house pediatric expertise” and 2) “creating pediatric leadership positions for key personnel,” in order to identify individuals to send as delegates to the workshop.
The local public health issue addressed in this project is the gap in regional emergency response capacity and capability to care for pediatric patients in disaster. In 2007, a member of the Triage Task Force conducted a study of hospital pediatric resources in King County. (King, Prehospital and Disaster Medicine, publication pending) The author determined that while most hospital-based pediatric staff, beds, supplies and equipment are concentrated in the City of Seattle, the majority of children and teenagers live in outlying areas of the county. King County is prone to earthquakes and weather-related disasters that can disrupt transportation routes, including vulnerable bridges over long stretches of water, impeding access to pediatric-specific hospital care. In a mass casualty incident that involves children, emergency responders might be unable to transport them to the hospitals with pediatric specialty services. In the case of a natural disaster, those services might be overwhelmed or the pediatric-specific hospitals might be structurally damaged and uninhabitable. In addition, the Healthcare Coalition recently completed an annex to the regional hospital evacuation plan to include specific planning for pediatric patients of all ages. In the process, which involved participation and input from representatives of all hospitals that provide any type of pediatric service, including intensive care units, it became apparent that hospitals which currently do not have designated pediatric beds will be called upon to surge to accommodate pediatric patients, depending on the nature of the emergency.In July 2008, the Task Force conducted a needs assessment of King County hospitals that provide emergency services to determine currently used triage systems in an MCI and use of the length-based resuscitation tape (e.g., Broselow Tape®), a tool that assists in rapidly determining appropriate dosage of medications and size of equipment for pediatric patients. The survey response rate was 94% (17 of 18 hospitals). Although all responding hospitals indicated that they have such a tape in their emergency departments, its usage varies according to condition of the patient, staff’s familiarity with proper usage or indications for use as well as simply remembering that it is available and being able to locate it. The Task Force interpreted these findings to suggest that, in a mass casualty incident involving children, King County hospital emergency departments would have varying degrees of experience and confidence in dealing with pediatric patients. The concept of bringing pediatric expertise and management consistency in a "pediatric toolkit" to all hospitals was proposed and, subsequently, presented to the region’s hospital emergency planners and trauma council for endorsement.The toolkit, “Hospital Guidelines for Management of Pediatric Patients in Disaster,” is a 42-page document with guidelines for response to an influx of pediatric patients, designed to be integrated into the hospital incident command structure. Topics related to pediatric disaster preparedness include the following: staffing and training, equipment and supplies, pharmaceutical planning, dietary planning, security and psychosocial support, transportation issues (both internal and external), inpatient bed planning, decontamination of children and hospital-based triage. Practical job aids include job action sheets for pediatric leadership positions, checklists, sample menus, patient tracking, and evacuation forms and information for medical staff and parents about psychological first aid and possible reactions of children after a disaster. The guidelines are intended to provide hospitals with consistent basic information and tools to become better prepared to receive and manage large numbers of injured or critically ill pediatric patients, along with a suggested 10-step plan for implementation. In addition, the Task Force plans to provide technical support, st
Agency Community RolesPublic Health – Seattle & King County (Public Health) is a founding member of the King County Healthcare Coalition, a network of more than 150 healthcare agencies and partners, established in 2005 with the goal of coordination of response and utilization of resources in a healthcare emergency. Public Health provides technical support to the Coalition through its Preparedness Division, which houses the Coalition Program Manager and a team of program planners. The planner for the Pediatric Workgroup of the Coalition, a Public Health employee who is a pediatrician and medical epidemiologist in the Communicable Disease Section, provided planning and technical support for the Task Force, which developed the pediatric toolkit. Coalition and Public Health staff also coordinates trainings and exercises for Coalition members. The workshop planned for hospital pediatric response planners in the spring will be sponsored and coordinated by Coalition and Public Health staff. The Coalition’s Pediatric Triage & Critical Care Taskforce, which developed the pediatric toolkit, includes community physicians and nursing from four community hospitals in the county, representing pediatric expertise in outpatient, critical care and emergency medicine. The final document was reviewed by a critical care expert at Seattle Children’s hospital and by the Disaster Committee of Harborview Medical Center, the designated regional trauma center. During the planning phase, members of the Task Force made two separate presentations to the Healthcare Coalition’s Hospital Emergency Planning Committee, which represents all county hospitals, and to the regional Emergency Medical Services (EMS) and Trauma Care Council. The first presentation concerned the proposal of the survey of King County hospitals regarding currently used hospital-based triage systems for mass casualty incidents and the second presented the proposal for the concept of developing a pediatric toolkit. A general hospital in the south region of the county hosted the January meeting to introduce the toolkit to emergency planning representatives of all King County hospitals with emergency services. Those individuals were charged with promoting the toolkit to their individual hospital’s leadership and selecting pediatric planning leadership to attend a workshop for orientation to the guidelines, discussions regarding implementation and opportunity for technical support, provided by members of the Task Force. Future training opportunities will be identified at the workshop, including interface and planning with the emergency responder community. The ultimate responsibility for implementation of the pediatric management system remains with each individual hospital, although there will be ample avenues for Coalition support, from the well-established Hospital Emergency Planning Committee to the Coalition Executive Leadership Council. The cooperative relationships established within the Coalition will foster full participation. The Task Force welcomes an opportunity for collaboration among hospital pediatric response planners to identify barriers to implementation of the toolkit as well as opportunities for efficient management of pediatric resources in creation of a regional pediatric response network. Costs and ExpendituresThe King County Healthcare Coalition is a network of more than 150 healthcare organizations and healthcare partners, established in 2005 to collaborate in a medical emergency to provide an effective and efficient response. The Coalition’s Pediatric Workgroup focuses on issues specific to children and adolescents and has acknowledged particular concern regarding the geographic distribution of the pediatric population in greater King County, Washington, compared with accessibility to pediatric hospital services, which are concentrated in the City of Seattle. In a region-wide emergency, such as an earthquake, large regions of the county could become “islands of healthcare” that have no access to pediatric-specific services. The Pediatric Triage and Critical Care Task Force, an active committee of the Workgroup, is comprised of emergency medicine, outpatient and critical care pediatric physicians and pediatric nursing. The Task Force initially conducted an assessment of triage systems used by King County hospitals in a mass casualty incident. Considering that information, the Task Force proposed to develop a “pediatric toolkit” to provide area hospitals with basic guidelines and resources to respond in the event of a large-scale medical emergency that involves children, floating that concept to the Coalition’s Hospital Emergency Planning Strategy Group and the regional EMS and Trauma Council. In its research into disaster triage systems, the Task Force was fortunate to find a recently published comprehensive document, “Children in Disasters: Hospital Guidelines for Pediatric Preparedness,” commissioned by the New York City Department of Health and Mental Hygiene (NYC). After contacting NYC to obtain permissions, the Task Force used the document as a framework, streamlining its content, adapting guidelines, equipment and supply lists to local practice and creating a 10-step approach for hospitals to move forward with implementation. After a year of deliberations, the final draft of “Hospital Guidelines for Management of Pediatric Patients in Disaster” was submitted for peer review. The completed document was introduced to a meeting of hospital emergency planners to give a broad overview of the guidelines and to discuss plans for implementation, which include an introductory workshop for pediatric planners from each hospital in March 2010. Time of support staff for Task Force $ 35,000 (includes benefits) Time of members of Pediatric Workgroup Triage Task Force (in kind) Time of hospital survey responders (in kind) Time of document reviewers (in kind) A Public Health salaried staff member provided both planning and technical support for the Task Force. Funding for that position was derived from two sources: 78% of funding was provided through an NIH/NIAID grant to University of Washington’s Northwest Regional Center of Excellence for Biodefense and Emerging Infectious Diseases Research. The additional 22% of funding was provided through federal “PHEPR LHJ Funding” to Public Health – Seattle & King County. ImplementationObjective 1: The Pediatric Workgroup Triage and Critical Care Task Force will assess triage systems currently used in mass casualty incidents by King County hospitals with emergency services by September 2008 Specific tasks: • Present needs assessment survey proposal to Healthcare Coalition planning body • Develop and approve survey instrument • Present survey and proposal to regional emergency response authorities • Publish web-based survey and send link to website in email notice to ED nurse managers • Send reminders to non-responders only and collect all survey responses • Analyze results of survey and distribute to Task Force for discussion Objective 2: Task Force will develop a “pediatric toolkit” to provide to all King County hospitals that provide emergency services with basic information and guidelines for emergency management of pediatric patients by December, 2009 Specific tasks: • Explore resources for hospital-based triage and management of pediatric patients • Review document selected as framework for toolkit • Obtain necessary permissions from NYC Department of Health and Mental Hygiene • Conduct monthly Task Force meetings to review assigned sections of document, approve material to retain, suggest new material and adapt to local standards to complete a final draft • Submit final draft to reviewers and to regional EMS and Trauma Council • Collect reviewer comments • Incorporate reviewer comments and finalize document • Introduce final document to regional Hospital Emergency Planning Committee • Develop and schedule workshop with hospital pediatric response planner to provide opportunity for technical support from Task Force and to troubleshoot barriers to implementation Objective 1: MAY 2008: Present needs assessment survey proposal to Healthcare Coalition planning body. JUNE: Develop and approve survey instrument. JULY-AUG: Present survey proposal to regional emergency response authorities, publish web-based survey and send link to website by email to ED nurse managers. AUG-SEPT: Collect survey responses; send reminders to non-responders only. NOVEMBER: Analyze results of survey, distribute to Task Force for discussion. Objective 2: FEB–APRIL ’08: Explore pediatric triage and emergency management resources. MAY: Review document selected for framework for toolkit. JUNE: Obtain necessary permissions from NYDOHMH. JUNE ’08–JUNE ’09: Monthly meetings of Task Force to complete a final draft of toolkit. JULY ’09: Submit final draft to reviewers and to regional Trauma Council. OCT–NOV: Incorporate reviewer comments and finalize document. DECEMBER: Introduce toolkit to regional Hospital Emergency Planning Committee.JAN–MARCH 2010: Provide technical support for implementation, including orientation workshop.
Goal: All King County hospitals that provide emergency services will be prepared to provide age-appropriate medical management of pediatric patients in a mass casualty incident. The Pediatric Workgroup Triage and Critical Care Task Force will assess triage systems currently used in MCI by King County hospitals with emergency services by September 2008 a) Needs assessment survey of hospital emergency departments proposal will be reviewed by regional Hospital Emergency Committee Strategy Group by May 2008 b) Task Force will develop and finalize survey instrument by June 2008 c) Survey concept and instrument will be presented to regional EMS and Trauma Council by July 2008 d) Survey will be published electronically on Survey Gizmo™ by July 2008 e) Collection of survey results will be collected by September 2008 f) Analysis of survey results will be completed by November 2008   a) Survey instrument was published electronically on Survey Gizmo and consisted of a possible maximum 17 questions. b) A notice of the survey with link to the Survey Gizmo website was sent to Nurse Managers of all King County emergency departments through the Trauma Committee Coordinator c) Data collected included degree and circumstances of use of the Broselow® Tape (or equivalent) and the triage system currently used for mass casualty incidents   a) Notice of survey with link to web-based survey on Survey Gizmo was sent to emergency department nurse managers on July 13, 2008 b) Reminders were sent only to non-responders three times over the next two monthsa) The Coalition staff planner for the Pediatric Workgroup sent out the reminders to non-responders and collected and analyzed the results of the survey b) Data results were submitted to the Triage Task Force for review and were ultimately shared with Coalition emergency planners and county emergency responders. c) Lessons learned: i) Survey response rate was 94% (17 of 18 hospitals). ii) Although all responding hospitals have the tape in their emergency departments, usage varies according to condition of the patient, staff’s familiarity with proper usage or indications for use as well as simply remembering that it is available and being able to locate it. iii) Ten of 18 surveyed hospitals listed triage systems used for mass casualty incidents; systems are not consistent among responding emergency departments     a) The Task Force successfully achieved the objective of assessment of triage systems used by King County hospital emergency departments. Outcome was intended and reflects intermediate term success, since all King County hospitals have and use a length-based resuscitation tape for children under certain circumstances and more than half indicate that they use a triage system for an MCI, although systems vary.Task Force will develop a “pediatric toolkit” to provide to all King County hospitals that provide emergency services with basic information and guidelines for emergency management of pediatric patients by December, 2009.a) Task Force will explore resources for hospital-based triage and management of pediatric patients in an MCI by April 2008 b) Task Force will review selected framework for toolkit, New York City’s Department of Health and Mental Hygiene, “Children in Disasters: Hospital Guidelines for Pediatric Preparedness,” by May 2008 c) Coalition planner will obtain necessary permissions from NYC by June 2008 d) Task Force will meet monthly to review assigned sections of document, approve material to retain, suggest new material and adapt to local standards to complete a final draft by June 2009 e) Submit draft document to reviewers and to regional EMS and Trauma Council in July 2009 f) Review comments will be incorporated into final draft by November 2009 g) Introduce final document to regional Hospital Emergency Planning Committee in December 2009 h) Task Force will provide technical support for implementation by April 2010. a) Coalition staff planner pro
The King County Healthcare Coalition was established in 2005 with the purpose of coordinating healthcare agency response and efficient and effective utilization of resources in a healthcare emergency. Over the past years, the network has tripled in size and now consists of more than 150 healthcare agencies and healthcare partners, including all King County hospitals. Agencies have experienced many benefits of regional emergency planning and exercise, including compliance with a healthy percentage of Joint Commission emergency management standards in the process. There are regular monthly meetings of emergency planners that include not only hospitals, but also regional healthcare partners. The leadership body of the Coalition has increasingly played a decisive role in urgent healthcare system issues, including the recent 2009 H1N1 Influenza spring outbreak and subsequent pandemic. Two processes over recent years have convinced Coalition members that there is a significant gap in regional emergency planning for pediatric patients: the 2007 survey of distribution of hospital pediatric resources and the development of the Neonatal & Pediatric Evacuation Annex to the Regional Medical Evacuation and Patient Tracking Mutual Aid Plan. Both confirmed the limited ability of most hospitals in the region to accommodate and manage a surge of pediatric patients in a disaster. Evacuation planning permitted hospitals to envision their potential to surge in pediatric bed capacity. The toolkit takes the next step and provides guidelines to create a system for basic management of an influx of pediatric patients. It gives each hospital a set of tools to move forward with pediatric-specific response planning. Development of the pediatric toolkit has received support from regional stakeholders, including the Coalition hospital emergency planners, regional emergency responders, and members of the pediatric healthcare community. Since its introduction in December 2009, emergency planners in an adjacent county have expressed interest and have requested permission to use the guidelines. Coalition planners have agreed that it is important to include pediatric planners from north and south adjacent counties in the March workshop. Another sign of regional acceptance is incorporation of many of the guidelines in pediatric planning for Alternate Care Facilities, which would be activated in the event of a large scale emergency, such as this winter’s threat of significant regional flooding in the Green River Valley. The toolkit is designed to facilitate development of a practical system within each hospital, utilizing internal pediatric expertise and integrating with the hospital’s incident command structure. Pediatric specialists who have developed the guidelines have committed to provide technical support, with the backing of Coalition planners, in order to promote collaboration among hospitals to overcome commonly identified barriers to implementation and to seize opportunities to achieve regional efficiencies in assuring access to pediatric-specific supplies and equipment. A regional pediatric medical disaster preparedness network that works in conjunction with the broader emergency response system is the ultimate goal.
 
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