How would your local hospital respond to 15 pediatric victims of a disaster presenting to the emergency department (ED) in one hour?
A surge of pediatric patients can come from a mass casualty event like the Boston Marathon or from a chlorine spill at a pool.
The National PedsReady project from 2013 showed, on average, only 60 percent of Minnesota hospitals are sufficiently prepared for a pediatric surge of patients.
Through a grant from the AAP, I am working with a multidisciplinary group and the Minnesota Department of Health (MDH) to create and roll out an educational curriculum to improve the care of young patients during a large volume event.
Our goal is to create the curriculum, present a synopsis of the project to the state, and video each part to have it available for download.
Disaster preparedness curriculum
The curriculum is focusing on the clinical and non-clinical aspects of disaster preparedness with significant numbers of pediatric patients. Clinical aspects of traumatic and non-traumatic etiologies will be considered. Specific pediatric concerns involving triage and decontamination will be addressed. Non-clinical concerns of incident command, facility readiness and crisis standards of care will be discussed. Finally, we will have a segment on pediatric special populations.
Traumatic causes of pediatric mass injuries will focus on pediatric-specific concerns like the fast progression from hemorrhagic shock to arrest, the difficulty in accessing the mental status of infants and young children, and the complexity of getting IVs and administrating fluids. Much of this section will focus on recognition, treatment, and equipment. Non-traumatic etiologies of disasters will also be addressed, including poisoning, both accidental and intentional (terrorism). Biological causes of mass casualties, like anthrax and epidemics that focus on children will be discussed.
Pediatric triage and decontamination have unique aspects. We are working with Emergency Medicine System providers to use best practice protocols for adequate triage. These focus on close attention on respiratory distress and vital signs. From the experience of previous disasters, triage may not be done at the scene but at the door of the ED, therefore, ED nurses will need to know these tools. Decontamination, paying close attention to temperature of the water, empowering families to help the younger children and keeping families together are all advised.
The pediatric concerns in incident command and facility readiness are only slightly different than in standard disaster preparedness. Opening the Incident Command Center early and involving pediatric experts for advice in this disaster is key. The major concerns for facility readiness involve having child safe areas, appropriate ratios of adults to children for monitoring different age children and plans for reuniting families. In a truly pediatric incident, there may be many non-verbal, unidentified children. Currently, there is no perfect way to handle this identification challenge but having a plan to work with and have it ready is important.
Crisis standards of care are used when conventional care is not possible. An example of this would be if there was a shortage for pediatric ventilators, alternate methods for ventilation would be needed. MDH has a pediatric form for working from conventional care through contingent into crisis mode. (www.health.state.mn.us/oep/healthcare)
Finally, we will address the concern of special pediatric populations during disasters. This includes those with autism or special health care needs or non-English speaking families. For those with autism, we are asking advice from autism specialists and looking for straightforward communication tools. We are in bedding in the guidelines awareness of children with special health care needs. Instructions in multiple languages and picture based communication are being utilized for non-English speaking families.
We hope to teach Minnesota hospitals and care givers how to respond to the unthinkable. The roll out will include all regions of MN this summer. We will meet with hospital administrators and providers describing the curriculum. Videos explaining the modules will be on the MDH web site by this fall.
Therefore, when many pediatric patients come in from a carbon monoxide poisoning, a bus crash or a school shooting, caregivers will set up their incident command center, triage at the ED door, stabilize, treat, and transfer the sickest, confident that they were prepared.