Pediatric Disaster Readiness: Acute Medical Care

1
Pediatric Disaster Readiness Acute Medical Care
Are there any low hanging fruit ?

• Steven E. Krug, M.D.
• National Commission on Children and Disasters
• November 20, 2008

2
Blueprint for Disaster Readiness
-
All-hazard mass casualty event readiness
-
Day-to-day emergency readiness
The Elevated Hurricane Zone Housing Solution
3
So, Hows The Foundation of Our Nations
Emergency Care System?

• Existing public safety systems (EMS, fire, etc)
  are over-taxed by day-to-day demands
• Especially in urban, high-risk areas
• EMS and trauma systems are woefully under-funded
• Hospital-based EDs are dangerously overcrowded
• Pediatric capabilities of our emergency and
  disaster care systems is uncertain

4
Emergency Care At the Breaking Point

• ED visits grew by 26 between 1993 and 2003 (90
  ? 114 million)
• Number of EDs declined by 425
• Critical shortages of healthcare providers (MDs,
  RNs, etc)
• Substantial ED overcrowding
• Ambulances are frequently diverted from
  overcrowded EDs
• 500,000 diversions in 2003
• In addition to ED access concerns, overcrowding
  is associated with poor care quality medical
  error

Institute of Medicine. Future of Emergency Care
in the US Healthcare System, 2006.
5
Pediatric Emergency Experience Gap

• Children account for 5 to 10 of all EMS
  patients
• Limited training in pediatric care
• Limited experience for EMTs and paramedics with
  sick kids
• Children make 25-30 million ED visits per year
• Nearly 90 of children are cared for in
  general hospital EDs
• Many EDs care for few children
• 50 of EDs see lt 10 per day
• Limited experience with sick kids for RNs
  and MDs in most US EDs

Gausche-Hill M, et al. Pediatrics 2007 1201229.
6
Pediatric Readiness Growing Pains

• Although children make up at least 1/4 of all ED
  visits nationwide
• Most general EDs and EMS agencies do not require
  specialized pediatric training for their clinical
  staff
• Only 6 of all EDs have the full scope of
  pediatric equipment, medications, supplies
• Paucity of research on best practices,
  clinical outcomes, patient safety in
  pediatric emergency care

If there is one word to describe the current
state of pediatric emergency care in
2006, it is UNEVEN --- IOM Panel, 2006
7
Pediatric Surge Capacity Concerns

• Disaster Med 101 One plan for all victims
• Can we manage sick children like small adults?
• Most US health care systems are primarily
  designed, staffed equipped for adults
• Can we create surge capacity to care for a large
  number of children?
• Emergency care
• Ambulatory care primary specialty
• Hospital care - tertiary critical care
• Alternate care facilities
• Mental health

8
Harsh Reality Disasters and Terrorism

• Enterprise, AL - 2007
• Tornado strikes 2 schools
• 8 students die, gt 50 injured
• Oklahoma City - 1995
• Murrah Federal Building
• 186 deaths 18 children
• Beslan 2004
• Terrorists target school
• 334 deaths -- 186 children

9
Recommendations for Pediatric Disaster Readiness
10
Recommendation 1

• Invest in the capacity of the emergency and acute
  care foundation of our nations healthcare system
  
• EMS trauma systems
• Emergency departments
• Hospitals
• Emergency care providers
• This same foundation will support disaster
  readiness
• Heed recommendations from 2006 IOM report

11
Recommendation 2

• Promote the presence of consistent day-to-day
  pediatric emergency readiness as this should
  assist pediatric disaster readiness
• Facilities categorization (3.1)
• Medications, equipment, supplies, staffing
• Training, training, training (4.1)
• Define pediatric care competencies
• Coordinators for pediatric care (4.3)
• EMS, hospitals, disaster management
• EMSC program needs to continue its
  leadership in this important area (3.7)
• Develop pediatric performance measures (3.3)

IOM - 2006 Pediatric Report Recommendations are
in parentheses
12
Recommendation 3

• Build upon existing systems/strengths in our
  nations acute care portfolio
• Trauma centers/systems
• Childrens hospitals/systems
• Academic medical centers
• Pediatric surge capacity
• - Especially critical sub-specialty care
• Inter-hospital transport/evacuation
• - Interstate mutual aid relationships
• Specialized DMATs
• Training resources
• - PALS, PEPP, ENPC, PDLS, etc.

13
Recommendation 4

• Improve pediatric readiness and care
  capabilities of DMAT MRC
• Top down bottom up processes
• Equipment, meds, supplies
• Team member training
• Pediatric victim drills
• - 30 of patients are children
• Enlist pediatric team members
• Promote pediatric emergency
  and disaster training programs
• Facilitate volunteerism
• ESAR-VHP, UEVHPA

Gnauck K, et al. Prehosp Disaster Med 2007 2267.
14
Recommendation 5

• Remove barriers to study, authorization and
  deployment of pediatric specific therapies
  countermeasures
• Midazolam for status epilepticus
• Pralidoxime (2-Pam) auto-injectors
• Doxycycline - anthrax
• Resolve FDA licensing barriers
• Pediatric input in decision-making
  by BARDA and others
• Project Bioshield, PHEMCE, SNS, CHEM PACKS
• Partner with professional organizations
  to assist process, consensus, etc

15
Recommendation 6

• National standards to assure child and family
  readiness of shelters and
  alternate care facilities
• Resourced for all ages
• Food, clothing, diapers, etc.
• Social services mental health
• Safety
• Physical, infection control, violence
• Pediatric medical care
• Child identification/reunification
• Evacuate and shelter children
  with family whenever feasible

16
Recommendation 7

• Anticipate and meet the unique social and mental
  health needs of children as part of disaster
  response recovery
• Increased risk for ASD/PTSD
• Disruption of family
• Limited baseline MH resources
• Identify alternatives for MH
  
• screening and care
• - Consider the medical home
• - Consider the schools

17
Recommendation 8

• Consider primary care as a readiness asset and
  make maintenance of the medical home a priority
  for disaster recovery
• Personal office preparedness
• Involve 10 care in local planning
• Link to family preparedness
• School preparedness
• Disease surveillance
• MRC involvement
• Support PCPs post-event
• Alternate practice sites
• Funding for recovery costs

18
Recommendation s 9 10

• Require pediatric expertise in emergency and
  disaster planning
• At all planning levels federal, state, local
• Pediatric elements in all plan components
• Tie expectations to funding
• Define pediatric specific
  performance measures
• Pre-hospital first responders
• Primary care, schools, shelters
• EDs, hospitals, surge capacity
• Pediatric patient drills
• Children with special care needs

19
Are There Any Low Hanging Fruit
Sadly, no!
20
So, Where Should We Begin ?

• Pediatric involvement at all levels and aspects
  of disaster planning
• This should not be negotiable
• Tie expectations to funding
• Partner with stakeholder professional
  organizations
• We want to help AND can help
• Leverage existing assets
• Childrens hospitals, trauma systems
• Medical home, schools
• National standards and pediatric performance
  measures
• Provider training, pediatric drills
• Shelters, ACFs, DMATs, CSHCN

Child picking fruit Mary Cassatt -1893
21
Thank You For Your Commitment to our Nations
Children !