Disaster Planning with a Surge Focus

Objectives

Discuss disaster planning and the specific challenges regarding pediatrics.

Review Hospital Incident command system with focus on surge

Discuss goals of identifying gaps and creating and implementing an action plan for surge in your hospital.

Disasters are a part of our lives. The recent Japan earthquake and tsunami are just the most recent poignant reminder that we are vulnerable.

Goal of Disaster Care:

To provide the GREATEST GOOD for the GREATEST NUMBER.

San Diego’s recent disaster/surge experience…

2003

2007

2010

The disaster system---what you can reasonably expect…

Initial help must come from within your own hospital

County/regional aid

State aid

Federal aid

San Diego County Preparedness

Office of Emergency Services

Department of Health and Human Services

Healthcare Association

Advisory Committee

• Public Health Services• Community Epidemiology• Laboratory• Emergency Medical Services• Public Health Nursing• Mental Health Services• Environmental Health• Health Care System

• Hospital• Clinics• Physician Offices

Immediate community regional response

San Diego County DisasterSystem

Goals: County-wide preparedness and an integrated response plan for all Hazard Response

Community EducationStandardized trainingStandardized equipment / suppliesCommunication systemDrillsProactive surveillance

San Diego County DisasterSystem

• County wide system of collaboration• Coordination of and best use of available

resources• Event based• Inter-facility Transfers when possible to local

specialty hospitals (i.e. burns, trauma, pediatrics, etc.)

• Transportation access may be a problem depending on the disaster scenario.

California Disaster System

San Diego is in Region VI along with San Bernardino, Riverside, Imperial, Inyo and Mono counties.

EMSA coordinates procurement of medical resources via a JEOC and mutual aid agreements via six mutual aid regions.

Delayed response to local needs

National Medical Disaster System

DMAT-Disaster Medical Assistance Teams (Levels I, II, and III)

DMORT-Disaster Mortuary Team

MHDMAT-Mental Health DMAT Team

DVAT-Disaster Veterinary Assistance Teams

Delayed Federal disaster response

What is a surge?

A large scale mass event that involves a cross section of our population such that large affected.

What are the primary components of a Surge Plan?

Expansion of emergency department, outpatient services and/or inpatient services to accommodate a large influx of patients.

Adjustments of staff assignments to maximize patient care services.

Rapid discharge of appropriate existing patients.

Degradation of services (i.e. no elective surgeries, no ECMO, limited diagnostics, etc.)

Altered standards of care

Alternate care site operations

Why Prepare for Surge?

Two assumptions you need to accept to optimize planning:

1. A disaster affecting large numbers of people could occur in our region at any time and 25% of our population is children (or) children could be specifically targeted for maximal psychological impact by terrorists.

2. Rady Children’s has a FINITE capacity, even with surge plans and strategies in place, and you could find yourself in the position of caring for kids for longer than you’re used to!

Pediatric Special NeedsChildren are more physiologically and psychologically vulnerable to trauma, biologic agents, chemical agents, radiation and other assaults on their bodies than adults: Increased susceptibility to

dehydration and shock Developmental limitations Communication limitation Psychosocial fragility Decontamination challenges Tracking and security challenges

Pathway to Decompensation

FULL ARREST

DEATH

RESPIRATORY FAILURE

Respiratory DistressDECOMPENSATED

Respiratory DistressCompensated

CIRCULATORY FAILURE

Circulatory DistressDECOMPENSATED

Circulatory DistressCompensated

Many CausesAsthma, Shock

Choking, SecretionsToxins, etc.

RESPIRATORY COMPROMISE MORE OFTEN CAUSE OF DECOMPENSATION IN CHILDREN

Rapid, Consistent Assessment

PATIENT ASSESSMENT TRIANGLE (P.A.T.)

1. Appearance

2. Respiratory Effort

3. Circulatory Status

So the Goals of Surge Planning are:

• Identify and address knowledge and resource gaps.

• Identify and remediate inadequacies of training, equipment and supplies.

Just Imagine…….

A terrorist explosion at a Disney event at a local Sports Arena specifically targeted at children for maximal psychosocial impact has just occurred.

Scores of fatalities on scene and hundreds of injured and terrified children/adults with families coming to local hospitals

Rady Children’s Hospital has also received an anonymous bomb threat, is evacuating and cannot currently receive patients until cleared by authorities

Real Time Disasters: Large and small scale………

What have we learned from our experiences with disasters

affecting children?

Disasters affect families including the children and pets. It is best to keep families together as much as possible.

The psychological impact of disasters is significant and can be delayed or protracted. Psychosocial resources are vital to acute disaster response.

What have we learned from our experiences with disasters

affecting children?

Ongoing information is crucial to families.

Advanced planning for pediatric equipment, supplies, drugs, food and safe areas with supervision is vital.

Tracking patients/families is challenging but very important.

What have we learned from our experiences (continued)

Children aren't just “little adults”—clinical care providers need to know developmental stages, vital signs for various ages, and pediatric differences in anatomy and physiology and response to injury.

Bored children can become very challenging to everyone. Toys, games, and other distracting activities are vital to have in any area sheltering or caring for children.

It pays to plan…..

The continuum of surge possibilities…

A earthquake disaster surge involves patients of all ages and many children. RCHSD is open and can receive critical patients and patients requiring hospitalization. Expect delays in transport due to volume. You may need to care for kids needing transfer for the short term. You will also need to treat and discharge large number of “walking wounded” pediatric patients requiring wound care/suturing/etc.

The continuum of surge possibilities…

A pandemic surge involves many adults and children coming to all hospitals. There are many seriously ill patients. RCHSD can receive only the most critical children. All others will need to be cared for in GHCFs. The primary organ system affected is respiratory.

Each disaster is different….

An earthquake surge involves many patients. RCHSD is open and can accept patients; however many major freeways are damaged and closed and surface transportation of patients around the region is severely hampered. You may need to care for children until air transportation can be arranged.

What are the major considerations for planning for disasters:

1. Triage and decontamination processes

2. Patient tracking and security

3. Equipment and pharmacy supplies

4. Family information and support center

5. Psychosocial/developmental considerations

6. Staffing/Training

1. Triage and Decontamination Principles

The Greatest Good for the Greatest Number can necessitate difficult decisions based on available resources, especially with children.

Have Triage tool available-it provides an objective method to sort patients in a disaster.

Familiarize your team to the basic process

Discuss the possibility and psychosocial impact of having to tag a victim “black” who is not dead and who we would, under normal circumstances, make every effort to resuscitate.

1. Triage/Decontaminationprinciples (continued)

Decontaminate most acute patients first (i.e. red, then yellow, etc.).

Keep parents with children to reduce stress and resources needed.

Take digital photo of unaccompanied children with potentially identifiable clothing or belongings for records, if possible.

2. Equipment and Pharmacy Supplies: Do you have the basic resuscitation and

emergency care equipment and supplies in your ED for patients of all sizes?

General Equipment:

Broselow system tape or system to determine sizes/doses for pediatrics

Posted or readily available pediatric drug dosage reference cards/sheets on a dose/kg basis.

IV blood/fluid warmers Warmers/ warm blankets Restraint devices Foley Catheters (various sizes) OB pack/meconium aspirator (neonates)

Monitoring Equipment:

Blood pressure cuffs (all sizes from preemie to adult and thigh)

Doppler/vascular ultrasound ECG monitor/defibrillator with

pediatric and adult paddles. End tidal CO2 monitor or detector

(adult and pediatric sizes.) Hypothermia thermometer Pulse oximeter

Respiratory Equipment:

Bag/valve/mask device, self inflating in adult (1000-2000ml) and child (450-900ml) sizes.

Endotracheal tubes (uncuffed and cuffed) all sizes from 2.5 up.

Laryngoscope (curved and straight)

Magills forceps (adult and kids) Nasal cannulas (infant, child and

adult)

Respiratory Equipment (cont.)

Nasogastric tubes (including 5 and 8 Fr feeding tubes.)

Oral airways (sizes 0-5) Clear oxygen masks (standard

and non-rebreathing) in infant, child and adult sizes.

Stylets for ETT tubes (various sizes)

Suction catheters (6-12 Fr) Tracheostomy tubes (size 0-6) Yankauer suctions

Vascular Access Equipment:

Arms boards (all sizes) Infusion pumps/devices to regulate

rate and volume (consider backup plan if no power)

Intraosseus Needles IV catheter (14-26ga) IV solutions (NS, D5.2NS, D5.45NS,

D5NS and D10W) Stopcocks (3-way) Umbilical vein catheters

Trauma equipment:

Adult & Pediatric cervical Immobilization devices.

Splints in various pediatric and adult sizes.

Spine boards (long and short) Kedsleds or papoose

immobilization devices.

Specialized trays/kits:

Adult & Pediatric Cricothyrotomy kit

Adult & Pediatic LP tray Adult & Pediatric tracheostomy

tray Thoracostomy tray with all sized

instrumentation. Chest tubes (sizes 10-28Fr) Venous cutdown tray

Drug/PharmacyEmergency Drugs

such as…..

Medications: Albuterol Dobutamine Amiodarone Epi 1:10,000 and 1:1,000

Atropine Lidocaine Adenosine Naloxone Calcium Chloride Procainamide Dextrose (25%/50%) Racemic Epi Dopamine Sodium Bicarb.

Drugs/Pharmacy

Ready access to infectious disease pharmaceuticals (i.e. Cipro, Doxy, Tamiflu) with ready access to instructions specific to children.

Access/linkage to poison control centers for information and guidance.

Don’t forget to assemble Basic Disaster Equipment and Supplies

(Austere environment)

Now that you have it……Can you replenish it????

Plan to have at least 3-7 days of all supplies on hand and know what you have as “par levels”. Discuss your plan to replenish with the organizations around/near you.Consider disaster caches.Get in the mindset of modifying care to compensate for increasingly scarce resources (alternate solutions, doing without?)

3. Family information and support center.

Primary functions:

Provides necessary reliable information and provides assistance in victim identification processes.

Assists relatives coping with uncertainty, stress and stages of adaptation. Psychological First Aid.

Enables the medical staff to concentrate on treatment of casualties while also providing a formal support system for relatives and friends of victims.

4. Psychosocial Support

Disasters are very stressful and psychosocial care is a huge part of overall disaster care.

Adults & children WORRY a lot about separation from family members, missing special blankets or toys, lost pets, having strangers around them, etc.

Have provisions for social worker and/or child life interventions in your disaster plan.

Psychologists and psychiatrists are busy members of a disaster team.

4. Psychosocial Support Expect that well or “walking wounded”

children will arrive at your hospital without caretakers. They will require triage and then a safe place with an assigned person(s) to provide child-care oversight and things/activities to keep them occupied.

Plan on also having provisions for child-care for children of staff and physicians.

Plan for issues surrounding deaths: guidelines for notifying families, locations to have private family conferences, morgue facilities, etc.

Anytime a disaster involves kids in the U.S., the media will be close behind and will require management. Plan for it.

4. Psychosocial Support

Concepts to promote:SafetyCalmnessA Sense of ConnectednessSelf-EfficacyHelpfulness

Concepts to avoid:Promising things you can’t deliverTelling people how they should feelJudgment of someone else or their situation

4. Psychosocial Support

Psychological First Aid-Core

Functions

1 Contact and Engagement

2 Safety and Comfort

3 Stabilization

4 Information Gathering

5 Practical Assistance

6 Connection with Social Supports

7 Information on Coping

8 Linkage with Collaborative Services

Core Action #1: Contact and Engagement

• Establish a connection with survivors in a non-intrusive and compassionate manner– Introduce yourself and describe your role– Ask for permission to talk– Explain objectives– Ask about immediate needs

Core Action #2: Safety and Comfort

• The goal is to enhance immediate and ongoing safety and provide physical and emotional comfort

Core Action #3: Stabilization

• The goal is to calm and orient emotionally-overwhelmed and distraught survivors

Core Action #3: Stabilization

• The goal is to calm and orient emotionally-overwhelmed and distraught survivors

Core Action #4: Information Gathering

• The goal is to identify immediate needs and concerns, gather additional information, and tailor PFA interventions

• It is used to determine:– Need for immediate referral– Need for any additional available ancillary

services– Which components of PFA may be helpful

Core Action #5: Practical Assistance

• Offer practical help to survivors in addressing immediate needs and concerns– Identify the most immediate need– Clarify the need– Discuss an action response– Act to address the need

Core Action #6: Connection with Social Support• The goal is to help establish brief or

ongoing contacts with primary support persons, such as family members andfriends, and to seek out other sources of support

Core Action #7: Information on Coping

• Provide information about stress reactions and coping to reduce distress and promote adaptive functioning– Explain what is currently known about the event– Inform survivors of available resources– Identify the post-disaster reactions and how to

manage them– Promote and support self-care and family care

practices

Core Action #8: Linkage with Collaborative Services• The goal is to link

survivors with availableservices needed immediately or in the future

4. Psychosocial Support

Psychological First Aid should not be considered therapy.

It is a system for helping the intial stabilization of a trauma survivor with guidance for enhancing adaptive coping strategies.

Any health care provider can be trained to administer PFA though social workers are generally most easily suited to it since it is based on basic premises of social work.

5. Optimize Staffing/Training

• Know who your experts are and how to contact them.

• Don’t expect that your “experts” are going to be able to handle all the specialty needs in a disaster, so……

• Give your entire staff some ongoing basic education and opportunities to use them in disaster drills and tabletops.

• If you aren't usually a primary provider of tertiary pediatric ED/Acute/Trauma care—know how to stabilize/ where to transfer….

Some Considerations….

Animals will surely accompany staff from home during disasters—have provisions for that in your disaster plan (kennels, food, water, etc.)Extended family members may arrive and need to be housed in your hospital during a disaster--some may be elderly. Create space for makeshift “dorms”…

Capacity ManagementPlanning

Reverse Triage

● Optimal management of staffing resources (retention,recruitment,performance management.)

● Core staff scheduling at ADC levels with provisions to staff higher numbers with Critical Care Core Pool and/or per diem staff.

● Acuity/census based staffing.

● Float staff appropriately from other care areas to even out staffing between units.

● Approach part time staff to augment more regular hours of staffing.

● Augment staffing with overtime shifts.

● Leadership approves incentive for shifts worked beyond FTE in the acute care hospital.

● Anticipatory planning and hiring of “travelers” for historical peak times of year.

● Level I strategies, plus:

● Consider assigning clinical educators to bedside roles.

● Augment staffing with registry personnel.

● Begin to anticipate use of administrative nurses at the bedside (brush up sessions, clinical competency testing)

● If nursing shortage specific to RCHSD and not the community, consider “borrowing” nurses from nearby hospitals (i.e. Sharp, UCSD)

● **Level I and II strategies,plus:

● Change model of nursing from primary care nursing to team nursing and make assignment congruent with safe care and no frills .

● Mobilize all available clinically competent staff from organization to augment staffing (outpatient clinic nurses, if appropriate)

● Enlist aid of parents and families to do basic nursing care (i.e. baths, feediing, etc) while nursing team focused on the essential nursing functions.

● Consider attempting to mobilize recently retired clinical nurses who are actively licensed.

● If situation local and not regional, consider patient transfers or triage to nearest pediatric hospitals (i.e. Loma Linda, CHOC.

RADY CHILDREN’S HOSPITAL, SAN DIEGOSTAFFING MANAGEMENT

NOVEMBER, 2009

LEVEL I: ACTIVE MANAGEMENT

LEVEL II. STAFFING SHORTAGES

LEVEL III DISASTER STAFFING

Real disasters help preparedness.And we’ve had our share….

But we don’t know what our future holds……

Disaster planning is a dynamic process—you learn from each and every experience and no two disasters are ever the same. The ability to anticipate needs and solutions and to think creativity during a disaster are the best preparation for optimizing disaster response.

Thank you!