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Disaster Preparedness for OB Units

Where babies come from

Kay Daniels, MDClinical ProfessorObstetrics and GynecologyStanford UniversitySchool of Medicine

Keeping mom and baby together…• In the days after Hurricane Katrina struck Louisiana, 125

critically ill newborn babies and 154 pregnant women were evacuated to Woman's Hospital in Baton Rouge

• It was at least 10 days before some of the infants and mothers were reunited

•

• Washington Post 2006

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If there is an OB Unit in your hospital..

The American College of Obstetricians and Gynecologists note:

“Providers of obstetric care and facilities that provide maternity services, offer services to a population that has many unique features warranting additional consideration”

Disaster Planning

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Northridge earthquake 1994

Earthquakes: Where art thou?• Alaska registers the most earthquakes in a given year

• California was second until 2014

• Oklahoma is now #2 with 585 quakes to California's 200• Of lower magnitude

• Earthquakes occur in other areas of the USA • ARIZONA (last night)• Missouri • South Carolina• Colorado• Montana• Virginia/Washington DC

http://earthquake.usgs.gov/

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The hospital as the “patient”Joplin Regional Medical Center, Joplin, MO 2011

Why Moms and their Babies are at Risk in Disasters?

• >97% of all births in the US occur in a hospital or clinical setting…which may not be accessible or may be severely damaged during a disaster event

• Mom and babies are physically more vulnerable to disaster-related toxins

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Why Moms and their Babies are at Risk in Disasters?

• Pregnant women are subject to the usual risks of injury at a disaster, but with more complicated care

Hospital disaster planning : OB is Unique

One size ≠ all in a disaster setting for OB

Within the same footprint of any OB unit there exists a large variety of patient acuity and needs

• Healthy postpartum patients with their newborns

• Laboring women

• Intra op and post operative patients

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Why is OB unique?

We always have 2 patients

• Ante partum = mom and fetus

• Postpartum = mom and newborn

We all need a plan…..

“In preparing for battle I have always found that plans are useless, but planning is indispensable”

~ Dwight D. Eisenhower

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Disaster Planning for OB: A Triage Algorithm

OB TRAIN* =

Triage by Resource Allocation for IN patient

*Based on the triage system created by Dr. Ron Cohen for the NICU at Lucile Packard Children’s Hospital

TRAIN

TRAIN '15 Mar R. S. Cohen, MD 14

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Lessons Learned….so far

TRAIN '15 Mar R. S. Cohen, MD 15

• TRAIN is practical, efficient and useful

• Supports EMS in transporting patients at appropriate levels of care

• Streamlines communication by using a simple code

• Decreases amount of time for assessing patient needs during evacuation

• Allows facilities to determine surge capacity

OB TRAIN for AP + L&D

(S) Specialized = must be accompanied by MD or Transport RN* MBS 6 = Patient is able to perform a partial knee bend from standing** Epidural catheter capped off

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Basis of Triage System for OB TRAIN

• Labor status

• Mobility

• Anesthesia status

• Maternal risk factors / fetal risk factors

OB TRAIN Triage Example

26yrs @ 40 weeks

• Early labor: 4cm

• Can ambulate

• No epidural

• Cat 1 FHR

• No significant

maternal or

fetal risk factors

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BLS Ambulance

OB TRAIN Triage Example #2

32 yrs @ 31 weeks with severe preeclampsia undergoing induction of labor

• Early labor: 2 cm

• Nonambulatory

• Epidural in place < 1 hr

• Cat 1 FHR

• Intermittent IV labetalol for BP control

• On 2 g IV magnesium sulfate

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Specialized

Levels of Maternity CareACOG Consensus Feb 2015

SENDING THE RIGHT PATIENT TO THERIGHT HOSPTIAL

1. Levels• Birthing Centers• Basic Care (Level l)• Specialty Care (Level ll)• Subspecialty Care (Level lll)• Regional Perinatal Health Care Centers (Level lV)

2. Capabilities

3. Types of providers

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Distance (mi) Hospital City Neonatal Maternal

Hospital Phone number

L&D Phone Number

0.0 LPCH Palo Alto 3 3 (650) 497-8000

18.4 Santa Clara Valley Medical Center

San Jose 3 3 (408) 885-5000

34.6 UCSF SF 3 3 (415) 476-9000

36.0 CPMC SF 3 3 (415) 600-6000

38.6 Kaiser Oakland Oakland 3 3 (510) 752-1000

17.0 Kaiser: Santa Clara

Santa Clara 3 3 (408) 851-1000

19.8 Good Samaritan San Jose 3 3 (408) 559-2011

36.4 Kaiser: San

Francisco San Francisco

3 3 (415) 833-6353

53.0 John Muir Walnut Creek

3 3 (925) 939-3000

9.0 El Camino Mountain View

3 2 (650) 940-7000

32.3 SF General SF 2 2 (415) 206-8000

42.7 Alta Bates Berkeley 2 3 (510) 204-4444

45.5 Dominican Santa Cruz 2 2 (831) 462-7700

78.5 Natividad Medical Center Salinas 3 2

(831) 647-7611

81.2 Salinas Valley Memorial

Salinas 2 2 (831) 757-4333

205 Sierra Vista Regional Medical Center

San Luis Obispo 2 2

(805) 546-7600

8.2 Sequoia Redwood City

2 2 (650) 369-5811

17.9 Washington Fremont 2 1 (510) 797-1111

19.9 O’Connor San Jose 2 1 (408) 947-2500

22.7 Regional Medical Center San Jose 2 1

(408) 259-5000

SHELTER IN PLACE

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Being prepared to evacuate L&D

WE’VE GOT TO GO!!

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L&D Disaster Plan: Evacuation

New Orleans Airport Triage Area

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COMMUNICATION: Peds OB

How will peds know where OB is evacuating to?

• Is there a system in place for notification?

Who from peds has been designated to go with OB ?

• To care for ‘shelter in place’ in deliveries

Pediatric planning to assist OB units

Who is bringing neonatal equipment?

What is in your grab and go bag?

• Bulb syringe

• Self inflating bag

• Hard surface

• O2 and air tanks if possible

• Intubation equipment

• Other?

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POSTPARTUM EVACUATION

OB TRAIN for Post Partum

Transport Car

(Discharge) BLS ALS SPC

Delivery VD > 6 hours

or CD > 48 hours

VD < 6 hours or CD < 48 hours

Complicated VD or CD

Medically complicated

Mobility Ambulatory* Ambulatory or

Non-ambulatory Ambulatory or Non-

ambulatory Non-ambulatory

Post Op > 2 hours

from non-CD surgery**

> 2 hours from CD < 2 hours from non-CD surgery

< 2 hours from CD Medically complicated

Maternal Risk

Low Low/Moderate Moderate/High High

!!!!OB!TRAIN!for!postpartum!

(S)!Specialized!=!must!be!accompanied!by!MD!or!Transport!RN!*!Modified!Bromage!Score!6!=!PaFent!is!able!to!perform!a!parFal!knee!bend!from!standing!

**!If!adult!supervision!is!available!for!24!hours!

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Basis of Triage System for OB TRAIN Post partum

• Delivery - NSVD versus Cesarean delivery

- Time from delivery

• Mobility

• Anesthesia status

• Maternal risk factors

Evacuation: One pediatrician in the house, X # of babies

We’ve got to go!!

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Checklist for Well Baby Discharge by OB in a Disaster All answers should be YES

If any answers are NO or DON'T KNOW, refer to peds for disposition.

YES NO DON’T

KNOW

Baby > 24 hrs old?

Is Mom going home?

Baby ≥ 38 weeks gestation?

Has the baby had a normal MD exam?

Is the baby feeding well without any issues?

Has the baby lost < 10% of its birth weight?

Does the baby have normal vital signs? HR = 100-160 bpm

RR = 30-60 /min Temp = 36.5-37.5°C

Is the bilirubin level: < 6.0 at 24 hrs

or < 9.0 at 36 hrs or < 11.0 at 72+ hrs

Have ALL (3) the following screening tests been done? Cardiac Screening (O2 sat)

Hearing (ALGO) Newborn Screen

If indicated, baby has blood glucose ≥ 45 x3?

Car seat available?

All answers should be NO

If any answers are YES or DON’T KNOW, refer to peds for disposition.

YES NO DON’T

KNOW

Does that baby have any risk factors for infection?

Maternal chorioamnionitis or endometritis, or risk factors for chorio:

o ROM ≥ 18 hrs o PROM

o GBS positive (+) with < 4hrs of antibiotics Maternal history of syphilis/genital herpes/Hep B during this

pregnancy

Is a car seat challenge needed?

Is CPS involved?

How to use obstetricians to discharge ‘Well Babies’ ?

Give them a Checklist:

Coordination of OB and Pediatrics

Ideas to insure that mom

and baby are not separated

• On baby’s transfer forms - mom’s information

• On mom’s transfer form – baby’s info

• Newborn screening # or other unique identifier

• Record where both baby and mom are being transferred to in multiple sites

• Arm bands with matching information

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Mom’s transfer forms with baby infoDisaster Transfer Summary Postpartum with Well Baby ROOM # _____________ Train Score:

Maternal Hospital Level care needed; 1 2 3 (CIRCLE ONE) Patient name: (Last, First)

MRN: (MRN)

DOB:

Primary OB provider: (PMD) Other important outside care provider(s):

Date of Admission to LPCH: Family Members/contact info: Newborn Patient name: (last, first) Primary Peds provider (PMD)

MRN: Contact #:

DOB: Date of Transfer (if different than maternal)

Time of birth Time of Transfer (if different than maternal) DELIVERY NSVD CD in labor Elective CD not in labor

Type of anesthetic: (circle one) General Regional Narcotics during surgery (circle one): IV Regional

Car seat challenge passed Y N N/A

Newborn Screening Completed Y N #__________

MATERNAL: AGE G P (CIRCLE ALL THAT APPLY)

Allergies No medical illnesses Medical illness Chorioamnionitis PPH Most recent hct Preeclampsia/Gestational HTN

Magnesium Y N dose gram/hr DM GDM/IR

AM Type amount Insulin dose:

PM Type amount Other

4th degree laceration Thromboprophylaxis med dose Other

Maternal MEDICATIONS Antibiotics: gent/clind/amp/vanc

Antibiotics Dose_______________ Last Given

Pain medication: percocet/norco/oxycodone/ibuprofen/acetaminophen

Last Dose Given

Antihypertensive meds: labetalol/procardia/hydralzine/Other

Dose Last Given

NEONATE (well baby ONLY, FOR ALL OTHERS SEE PEDS TRAIN)

No medical problems GA

Birth weight Last weight Blood type Last bilirubin CRP (if applicable) Vit k Y N Erythromycin Y N Hep B Y N Type of feed: Breastfeeding Formula

MD Signature: Date Time

Transferred to:

Location of Baby With mom Other

Blue Green Yellow Red

Both OB and nursery units should maintain records of transfer sites for both mom and baby

Disaster(Census((((((((((((((((((Unit:((((L&D((((AP((((PP((

Patient(sticker(or(write6in(for(

Mother(Mom’s(

Location/(Destination(

Patient(sticker(or(write6in(for(

Baby(Baby’s(

Location/(Destination(

(Name:(MRN:(DOB:(

(

( (Name:(MRN:(DOB:(

(

(

(Name:(MRN:(DOB:(

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( (Name:(MRN:(DOB:(

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(Name:(MRN:(DOB:(

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( (Name:(MRN:(DOB:(

(

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(Name:(MRN:(DOB:(

(

( (Name:(MRN:(DOB:(

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(Name:(MRN:(DOB:(

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( (Name:(MRN:(DOB:(

(

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(Name:(MRN:(DOB:((

( (Name:(MRN:(DOB:((

(

(Name:(MRN:(DOB:((

( (Name:(MRN:(DOB:((

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(Name:(MRN:(DOB:((

( (Name:(MRN:(DOB:((

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(

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Food for thought

• Determine how to assure mom is able to continue to breast feed during a disaster

• How to monitor that babies are being adequately hydrated and fed during a disaster

Are there long term effects on the fetus after a disaster?

World Trade Center 2001 –

• Women who were pregnant on 11 September 2001 and

were living within a 2-mile radius of the WTC showed

significant decrements in term birth weight (−149 g)

and birth length (−0.82 cm), compared with infants

born to the other pregnant women

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WTC 2001

• Women in the first trimester of pregnancy at the time of

the WTC event delivered infants with significantly

shorter gestation (−3.6 days) and a smaller head

circumference (−0.48 cm), compared with women at

later stages of pregnancy

• The WTC cohort had a 2-fold increased risk of IUGR

compared with the nonexposed cohort

Are there long term effects on the fetus after a disaster ?

Northridge earthquake 1994

• Early gestation at time of quake found to have shorter gestational length

Israel study

• Excess incidence of schizophrenia in offspring born to mothers who experienced stress in early pregnancy

Meta analysis

• Associations were not consistently found even when using the same measures such as PTB or LBW

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Next steps: Collaborative network on a regional, statewide and national level

Lessons from Katrina

• Communications essential but are always a challenge

- Phone lines may be down

- Internet may be off

• All disaster response is local for the first 48–96 hours

• The ability to mobilize resources depends on a pre-existing local collaborative network

Mattox KL. Critical Care 2006, 10:205 (doi:10.1186/cc3942)

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In summary: To accomplish a comprehensive obstetric disaster plan

there needs to be:

1. Adoption of an obstetric-specific triage system like OB TRAIN to allow a universal language for evacuation and surge processes

2. A system in place to transfer OB patients to the appropriate hospital (the right patient to the right hospital)

In summary3. An comprehensive shelter in place plan for laboring

patients that includes:• Grab and go bags/equipment• Communication with peds

4. Postpartum plan that takes into consideration transport of mom and baby

• Avoid maternal-neonatal separation when possible• Accurately track location if separated

5. Create a regional and ultimately national collaborative network of maternity hospitals

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Online access to disaster tools

Stanford Disaster OB Planning “Tool kit”

http://obgyn.stanford.edu/community/disaster-planning.html

NICU TRAIN

http://cpqcc.org/quality_improvement/qi_toolkits/can_neonata

l_disaster_preparedness_toolkit.

Kay Daniels

k.daniels@stanford.edu

THANK YOU FOR YOUR ATTENTION

Stanford University - Main Quad

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References1. Daniels K, Oakeson AM, Hilton G. Steps Toward a National Disaster

Plan for Obstetrics Obstet Gynecol July 2014;124:154–8

2. Jorgensen, A, Mendoza G, Henderson J. Emergency Preparedness and Disaster Response Core Competency Set for Perinatal and Neonatal Nurses. JOGNN 2010:39;450-467

3. Giarratano G, Sterling Y, Orlando S, Mathews P, Deeves G, Bernard ML, Danna D, Targeting Prenatal Emergency Preparedness Through Childbirth Education JOGNN, 39, 480-488; 2010

4. Orlando S, Danna D, Giarratano G, Prepas R, Barker Johnson C, Perinatal Considerations in the Hospital Disaster Management Process JOGNN, 39, 468-479; 2010

5. ACOG Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care Committee Opinion Number 555 March 2013

6. ACOG Consensus : Levels of Maternal Care Obstet Gyecol Feb 2015:125 No 2

7. Glynn et al. When stress happens matters: Effects of earthquake timing on stress responsivity in pregnancy. Am J Obstet Gynecol March 2001

8. Lederman et al. The Effects of the World Trade Center Event on Birth Outcomes among Term Deliveries at Three Lower Manhattan Hospitals. Environ Health Perspect 2004 Dec:112(17)

9. Zotti et al. Post-Disaster Reproductive Health Outcomes

Matern Child Health J (2013) 17:783–796

10. Malaspina et al. Acute maternal stress in pregnancy and schizophrenia in offspring: A cohort prospective study

BMC Psychiatry. 2008;8:71.

11. Berkowitz et al. The World Trade Center Disaster and Intrauterine Growth Restriction Research letters JAMA, August 6, 2003 Vol 290, No. 5

12. Harville et al. Obstet Gynecol Surv. 2010 November;65:713–728