Children In Disasters: Children In Disasters: DispositionDispositionHospital Tiering System To Match Hospital Tiering System To Match Pediatric Patients With Suitable Pediatric Patients With Suitable Pediatric ResourcesPediatric ResourcesArthur Cooper, MD, MSArthur Cooper, MD, MSProfessor of SurgeryProfessor of SurgeryColumbia University College of Physicians & SurgeonsColumbia University College of Physicians & SurgeonsDirector of Trauma & Pediatric Surgical ServicesDirector of Trauma & Pediatric Surgical ServicesHarlem Hospital CenterHarlem Hospital CenterChildren in Disasters ConferenceChildren in Disasters ConferenceNew York City Department of Health and Mental New York City Department of Health and Mental HygieneHygieneNew York, New York, March 16, 2011New York, New York, March 16, 2011Contact: ac38@columbia.eduContact: ac38@columbia.edu

Planning for Pediatric Blast TraumaPlanning for Pediatric Blast Trauma

Pediatric injuries are to be expected following Pediatric injuries are to be expected following blast trauma, with most children injured in blast trauma, with most children injured in closed or confined, rather than open, closed or confined, rather than open, spaces, greatly increasing the magnitude of spaces, greatly increasing the magnitude of forces of injuryforces of injury

Planning for Pediatric Blast TraumaPlanning for Pediatric Blast Trauma• As with adult blast terror injuries, most patients will either As with adult blast terror injuries, most patients will either

die at the scene, or sustain minor injuries, leaving only a die at the scene, or sustain minor injuries, leaving only a small number in the “penumbra” of the blast wave who small number in the “penumbra” of the blast wave who will sustain major injuries and survive to require hospital will sustain major injuries and survive to require hospital care, but who typically will not begin to arrive at the care, but who typically will not begin to arrive at the trauma center until some 30-60 minutes after the terror trauma center until some 30-60 minutes after the terror eventevent

• Most survivors with major injuries will require early Most survivors with major injuries will require early operation and subsequent care in a pediatric critical care operation and subsequent care in a pediatric critical care unit, followed by lengthy hospitalization and unit, followed by lengthy hospitalization and rehabilitation, both physical and psychologicalrehabilitation, both physical and psychological

Mitigation of Pediatric Blast TraumaMitigation of Pediatric Blast Trauma

The approximate number and likely destination of The approximate number and likely destination of casualties can be predictedcasualties can be predicted• Half arrive during the first 60 minHalf arrive during the first 60 min• Half go to the closest 3 hospitalsHalf go to the closest 3 hospitals• Half go to other Half go to other hospitals…hospitals…but are they the but are they the

right hospitals?right hospitals?

Mitigation of Pediatric Blast TraumaMitigation of Pediatric Blast Trauma

Surge capability depends upon the rate limiting Surge capability depends upon the rate limiting step for maximum victim throughputstep for maximum victim throughput• Numbers of ORs & RNs, and ICU beds & RNs,Numbers of ORs & RNs, and ICU beds & RNs,

determinedetermine hospital capability to care for critically ill hospital capability to care for critically ill patientspatients

• Numbers of x-ray machines & x-ray technologists Numbers of x-ray machines & x-ray technologists determine hospital capability to care for all other determine hospital capability to care for all other patientspatients

• Regional hospital capacity for blast trauma is likely Regional hospital capacity for blast trauma is likely adequate in most areas unless a regional resource adequate in most areas unless a regional resource trauma center is a primary or secondary targettrauma center is a primary or secondary target

TriageTiering

Transport Surge

Chain Of Events-Planning

PDC RecommendsPDC Recommends

When possible and appropriate:When possible and appropriate:•Implement expedited procedures for Implement expedited procedures for rapid evacuation and primary transport rapid evacuation and primary transport of pediatric patients in MCEsof pediatric patients in MCEs•Facilitate primary transport of pediatric Facilitate primary transport of pediatric patients to pediatric disaster receiving patients to pediatric disaster receiving hospitals (PDRHs) according to level of hospitals (PDRHs) according to level of pediatric care requiredpediatric care required

TriageTiering

Tiering

Pediatric Disaster Trauma Care:Pediatric Disaster Trauma Care:Planning AssumptionsPlanning Assumptions August 2004August 2004

• Pediatric surge capacity ≠ pediatric surge capabilityPediatric surge capacity ≠ pediatric surge capability• Federal target: 500 patients/1,000,000 peopleFederal target: 500 patients/1,000,000 people• New York also a model for qualitative analysisNew York also a model for qualitative analysis• New York State: 700 beds/1,000,000 childrenNew York State: 700 beds/1,000,000 children• New York State: 3,000 beds/1,000,000 adultsNew York State: 3,000 beds/1,000,000 adults• New York City: 248 PICU beds, 1,019 pediatric bedsNew York City: 248 PICU beds, 1,019 pediatric beds• Israeli blast terror experience: mean age 12 yrIsraeli blast terror experience: mean age 12 yr• Israeli blast terror experience: 33% need PICUIsraeli blast terror experience: 33% need PICU

Pediatric Disaster Trauma Care:Pediatric Disaster Trauma Care:Fuzzy Math?Fuzzy Math?

• Needed pediatric surge capability in NYC: 1,000 bedsNeeded pediatric surge capability in NYC: 1,000 beds• Half the patients are over 12 yrs; could be treated in Half the patients are over 12 yrs; could be treated in

adult TCsadult TCs• Surge PICU beds needed in NYC: 500 x 0.33 = 167Surge PICU beds needed in NYC: 500 x 0.33 = 167• Average PICU occupancy in NYC: 248* x 0.80 = 200Average PICU occupancy in NYC: 248* x 0.80 = 200• Staffed PICU beds typically open daily in NYC: 47*Staffed PICU beds typically open daily in NYC: 47*• NYC must therefore find about 120 more PICU bedsNYC must therefore find about 120 more PICU beds• 23 PICU hospitals could open 4 pediatric PACU beds23 PICU hospitals could open 4 pediatric PACU beds• There are 4 other PICUs and PACUs in adjacent There are 4 other PICUs and PACUs in adjacent

countiescounties

*Source: NYSDOH HERDS Critical Asset Survey August 2004, excluding KCHC NICU beds*Source: NYSDOH HERDS Critical Asset Survey August 2004, excluding KCHC NICU beds

Pediatric Disaster Trauma Care:Pediatric Disaster Trauma Care:Fuzzy Math?Fuzzy Math?

• Together they could accept about 116 Together they could accept about 116 additional patients; so,additional patients; so,

• For blast terror, there may be just enough For blast terror, there may be just enough PICU beds, PICU beds, but . . .but . . .

• The calculations are only as good as our The calculations are only as good as our assumptions, so . . .assumptions, so . . .

• How do we find the beds? And who will be How do we find the beds? And who will be staffing them?staffing them?

*Source: NYSDOH HERDS Critical Asset Survey August 2004, *Source: NYSDOH HERDS Critical Asset Survey August 2004, excluding KCHC NICU bedsexcluding KCHC NICU beds

Where Will Children Go?Where Will Children Go?

• FDNY will preferentially transport infants FDNY will preferentially transport infants and children from the scene of any and children from the scene of any disaster involving five (5) or more disaster involving five (5) or more pediatric patients to the closest pediatric patients to the closest appropriate PDRHappropriate PDRH

• Pediatric patients are defined in disasters Pediatric patients are defined in disasters not by age, but by their visual appearance not by age, but by their visual appearance (non-adolescent children who appear to be (non-adolescent children who appear to be of primary school age or younger)of primary school age or younger)

Which Patients Go Where?Which Patients Go Where?

• Tier 1 PDRHsTier 1 PDRHs Mechanical Mechanical

ventilationventilation Volume resuscitationVolume resuscitation Multiple transfusionsMultiple transfusions Multiple medicationsMultiple medications Complex wound careComplex wound care Artificial airway careArtificial airway care Extensive lab testingExtensive lab testing TPN, TENTPN, TEN

• Tier 2 PDRHsTier 2 PDRHs Oxygen Oxygen

administrationadministration Intravenous Intravenous

hydrationhydration Scheduled Scheduled

medicationsmedications

Tier 1 – Tier 1 – Pediatric Hospital (+ PICU)Pediatric Hospital (+ PICU)

• Intended to receive Intended to receive redred, , orangeorange, , yellowyellow patientspatients Committed to subspecialty pediatric careCommitted to subspecialty pediatric care Pediatric surgical servicePediatric surgical service Pediatric intensive care unitPediatric intensive care unit Pediatric emergency servicePediatric emergency service Comprehensive pediatric subspecialty supportComprehensive pediatric subspecialty support Anesthesiology, neurosurgery, orthopaedic Anesthesiology, neurosurgery, orthopaedic

surgery with experience in management of surgery with experience in management of children children

• Intended to receive Intended to receive green green patientspatientsCommitted to general pediatric careCommitted to general pediatric carePediatric surgical consultantsPediatric surgical consultantsPediatric resuscitation capable EDPediatric resuscitation capable EDPediatric transfer agreement Pediatric transfer agreement

Tier 2 – Tier 2 – Pediatric Hospital (- PICU)Pediatric Hospital (- PICU)

The hospital should sponsor the training of Pediatric Critical Care faculty to become certified instructors in a course of Pediatric Fundamental Critical Care Support (PFCCS).

The following categories of care providers should be encouraged to take the course under PFCCS instructors:

Non-Critical Care MD’s ED fellows Chief residents CNS PA’s

How We Found ThemHow We Found Them

• A detailed list of hospital requirements was A detailed list of hospital requirements was created for Tier 1 and Tier 2 PDRHs by the created for Tier 1 and Tier 2 PDRHs by the Triage Committee in Year 1 and vetted at Triage Committee in Year 1 and vetted at the 2009 Children In Disasters Conferencethe 2009 Children In Disasters Conference

• A telephone survey of all 63 911 Receiving A telephone survey of all 63 911 Receiving Hospitals in New York City was conducted by Hospitals in New York City was conducted by the Triage Committee in Year 2 and was the Triage Committee in Year 2 and was confirmed in writing by their CEOs in Year 3confirmed in writing by their CEOs in Year 3

ResourcesResources• IntroductionIntroduction• SecuritySecurity• Dietary NeedsDietary Needs• Surge Considerations/Bed Surge Considerations/Bed

AssignmentsAssignments• EquipmentEquipment• TrainingTraining• StaffingStaffing• TransportationTransportation• DecontaminationDecontamination• Pharmacy NeedsPharmacy Needs• Psychosocial NeedsPsychosocial Needs• Infection ControlInfection Control• Hospital TriageHospital Triage• Family information and Support Family information and Support

CenterCenter• New York City ResourcesNew York City Resources

http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds-childrenindisasters-010709.pdf

Pediatric Disaster Tabletop ExerciseWritten by:Marsha Treiber, MPSModerated by: George Foltin, MD Facilitated by: Michael Tunik, MDBonnie Arquilla, DO

ResourcesResources

http://www.nyc.gov/html/doh/downloads/word/bhpp/hepp-peds-tabletoptoolkit-010709.doc

ResourcesResources

Pediatric Terrorism and Disaster Pediatric Terrorism and Disaster Preparedness:Preparedness:

A Resource for PhysiciansA Resource for Physicianshttp://www.ahrq.gov/research/pedprep/http://www.ahrq.gov/research/pedprep/

pedresource.pdfpedresource.pdf

NYC Hospital Pediatric Resource DirectoryNYC Hospital Pediatric Resource Directoryhttp://www.nyc.gov/html/doh/downloads/http://www.nyc.gov/html/doh/downloads/

pdf/bhpp/hepp-peds-resdir-apr09.pdfpdf/bhpp/hepp-peds-resdir-apr09.pdf