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Special Considerations in Pediatric Evacuation

OSHA Training Institute – Region IXUniversity of California, San Diego (UCSD) - Extension

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Objectives

Discuss the challenges in the evacuation of pediatric populations

Identify lessons learned from disasters in the care and evacuation of perinatal and neonatal patients.

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Overview Stats

Children 25-30% ED visits in US Children 5-10% of EMS transports 90% receive care at non-children’s center Providers w/ limited exposure

Children are more vulnerable Existing plans may lack pediatric specifics Surge capacity Evacuation Psychological issues

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Children Are More Vulnerable Less blood/fluid reserves

Small changes cause big differences

Especially sensitive to vomiting/diarrhea

More sensitive to changes in body temp

Developmental differences Lack motor skills to escape Lack cognitive decision

making skills to determine dangerous situations

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Existing Plans “Uneven”

IOM Emergency Care for Children: Growing Pains Only 6% have supplies to manage pedsOnly half have transfer agreementsContinuing peds training lackingProtocols vary widelyShortage of equip in rural areasDisaster plans overlook the needs of peds

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Existing Plans Inadequate: Katrina

Baldwin in Pediatrics May 2006 Prior to Katrina—working to improve peds

planning Peds inpatient capacity limited: population

Increased geographic distance

Pediatric evac not centrally coordinated Prior to disaster declaration

Peds facilities made calls on own to start acute patient evacuation

Transfers also made on corporate level

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Existing Plans Inadequate: Katrina

Baldwin (con’t) Large #s children w/

chronic issues managed w/o formal governmental relationships

Ultimately transport of peds WAS viable Regionalization WAS

practical

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Surge Capacity Issues

Scarce resources and staff inexperience with peds critical injury/illness Fewer hospital beds for peds

General guideline is 1.5-2 peds :10 adultsBased on the ratio in the general population

Increase peds emerg treatment Mutual aid agreementsAlternate care sites

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Perinatal and Neonatal Challenges in Evacuation

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Lessons Learned: Hurricane Katrina & Rita Woman’s Hospital, Baton Rouge, La

designated as the referral center for high risk OB patients and neonates

Hurricane Katrina in a 5 day period: 87 neonates transferred in and 34 additional transports arranged for other facilities.

Hurricane Rita: 21 neonates transferred to Woman’s Hospital

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Planning for Level 3

2 days before landfall

Opened Operations Center

Multiple & alternative communications, TVs, emergency power and computers

Emergency radiology capability

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Two Days Before Landfall

MD discharged as many as possible

Additional patients supplies obtained

Identified on call MDs and MD willing to stay at hospital

Established employee labor pool

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One Day Before Landfall - Level 4 Mandatory evacuation blocked all lanes leaving

it impossible to transport infants by ground

Back up neonatologist arrived, in case others could not

Reporting of staff plans & needs to resource pool in the Command Center

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Patient Notifications & Staff Care Storm status & preparation activities

Relocation of emergency child care

Distribution of supplies to staffLights/ batteriesWaterLinens/blanketsPersonal cleaning supplies

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Thinking Ahead

Transferred respiratory therapy equipment to emergency electrical outlets

Backed-up electronic medical records off site

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Landfall

All staff were in place and ready to accept as many infant transfers as needed if required, for an immediate evacuation.

A 30 bed special care unit and the previous 20 bed unit was still available and stocked with rented equipment.

Each patient space was duplicated.

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Transport Teams

5 teams (Neonatal Nurse Practitioner & Respiratory Therapist or nurse)

Ground transports

Violence toward emergency personnel required state troopers with transports

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Helicopter Transport

16 evacuated infants 2 critical infants were held and hand

bagged by MDs - to allow for the maximum number of infants.

Non ventilated patients arrived in bassinets. Some parents not notified due to no

communication and evacuating families.

OSHA Training Institute 19 Copyright ©2006 American Academy of Pediatrics

Spedale, S. B. Pediatrics 2006;117:S389-S395

FIGURE 1 Evacuation of infants from University Hospital, September 2

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Reunification

Priority and daily effort

Social Services 24/7 operation

Transport teams working well into night

OSHA Training Institute 21 Copyright ©2006 American Academy of Pediatrics

Spedale, S. B. Pediatrics 2006;117:S389-S395

FIGURE 2 Newborns arriving in bassinets

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Two Days Post Landfall

Increasing census

Assignment divided into teams and daily meetings determined discharges or transfers of less serious infants

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Plans and Alternative Transport Cardiovascular disease infants & children were

transferred in company of surgeons.

Increased problems with obtaining transport ground units

Out of state units arrived

MDs transported infants in their cars

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Disrupted Communications Daily confirmation that Woman’s Hospital

was the designated center and had authority to arrange transport.

Daily proof of verification leads to frustration.

Decision to transfer infants thru Louis Armstrong International Airport was not followed thru due to communications.

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Situation at the the Airport

Hospital patients and family evacuations during Hurricane Katrina 2005, Louis Armstrong Airport New Orleans.

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Birth in an Austere Environment

Delivery and care of the neonate in the disaster situation requires increased attention to stable environment, temperature control, feeding and protection from infections.

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Birth in a Tent While infants were being

evacuated to Baton Rouge, this baby was born in a tent behind a drape in the middle of the Louis Armstrong International Airport.

Others were delivered in transit

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Unusual Support

Personal contacts got the job done via a US Army Corps of Engineers (Maj. General Don Riley) - relative of an administrator

Lesson learned: Personal relationships get more done than formal organizations.

Offers from NICU to take patients and families or send staff

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By Sea & By Land

Help from Wildlife and Fisheries Departments from Texas & Louisiana

Army & National Guard Transported infants by

airboat and helicopter Coordination not clear

Spedale, S. B. Pediatrics 2006;117:S389-S395

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Hurricane Rita

24 days post Katrina

3 infants transferred

Escort only required for traffic

Reimbursement arranged

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Summary of Successes Preparations for disaster, standards &

procedures Crisis response teams Published chain of command and

responsibilities Preparing for the surge List of pediatric facilities, providers, modes

of transport and evacuation routes Information sharing

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Recommend - Identify Major Services to Relocate Cardiovascular surgery Extracorporeal membrane oxygenation Critical Care units Teaching programs Shelters (may not accept woman after 34

weeks gestation concerned about births and may not accept newborns.)

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Problems

Communication

Daycare for healthcare workers’ children

Extra long hours and disruption of routines

Frequent media requests.

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Solutions

Media briefings twice a day

Accurate information to control rumors

Use hospital public relations

Designate a single MD spokesperson for medical issues

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Example of Lessons Learned in Evacuation of an NICU Staff hand carried bassinets down stairwells. Single carry was awkward and staff unable

to clearly see steps in front of them. Dual carry improved but unstable on stairs Solution: Infant carrier worn by staff keeping

infant close while still be able to visualize stairwell and use hand rails as needed.

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Lessons Learned in Drills Co-bedding was

reasonable Keeping needed

supplies with the infants assured ability to feed in alternative environments.

Solutions: use evacuation aprons and prepackaged go-bags for critical supplies.

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Neonate Airway Management in Evacuations Neonates placed in pockets

of specialized evacuation aprons occluded the airway.

Difficult to bag the neonate in transit with one person carrying bassinet and the other trying to bag inturbated infant.

Increased risk for tube displacement

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Movement of Specialized Equipment

Prepackage roller bags enable staff to take critical supplies to manage care for the mother and infant.

Evacuation offers little time to stop and collect items.

Use check lists

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Challenges of Evacuation Infants need a warm, dry

environment Fragile NICU patients

requiring suction, oxygen, & compressed air

Resources included needed transport units, refrigeration and durable supplies.

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Movement in the Arms

Extra blankets, chemical mattress warmers and keeping infants in the arms of mothers and staff may be necessary.

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Evacuation Specifics

Transport newborns and infants in transport incubators If unavailable, then leave

them in warmers as long as possible before evacuation

Hand-bag children on ventilators

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Respiratory Care in Evacuation

Consider portable O2 sources (small E-cylinders on shoulder strap, Neopuff, ventilators, self-inflating bags, etc.)

Baby sling for one RN evacuation down stairs and improved ergonomics.

Sam Splints to maintain airway. Portable suction (bulb or battery-powered, and

appropriate sized catheters, gloves) Intubation kits (all inclusive)

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More Evacuation Specifics Try to keep children

with family members Ambulatory to a

“Safe Area”-led by adults

Personnel to provide care & supervision

Method for reuniting children w/ family

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Environmental Concerns during Evacuations

Respiratory issues from dust, debris, can exacerbate underlying asthma

Humidity and temperature fluxes can cause unexpected problems

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Psychological Issues

Let kids know they are safe Let kids know this is not their fault Allow kids to talk about their fears, draw

pictures, or write stories about them Provide a safe outlet for aggression Validate fears, anxieties (kids & parents) Daily Routines

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Summary Children are more vulnerable

Fluids, temperature, respiratory, motor/cognition, trauma

Include pediatric specifics in evacuation plans

Surge capacity Increase peds emergency

treatment capacityMutual aid agreementsAlternate care sites

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Summary Evacuation

Keep w/ family membersKeep warmAdult supervision in “Safe Area”Reunite w/ family ASAP

Address children’s fear & concernsReassure, comfortRelease: talk, playDaily routine

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References

Baldwin S, Robinson A, Barlow P, Fargason C. Moving hospitalized children all over the southeast: interstate transfer of pediatric patients during hurricane katrina. Pediatrics 2006;117;s416-s420. DOI: 10.1542/peds.2006-00990

Spedale S. Opening our doors for all newborns: caring for displaced neonates: intrastate. Pediatrics Vol. 117 No. 5 May 2006, pp. S389-S395

(doi: 10.1542/peds.2006-0099J)

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References

Committee on Pediatric Emergency Medicine. The pediatrician’s role in disaster preparedness. Pediatrics 1997;99;130-133. DOI: 10.1542/peds.99.1.130

National Working Group for Women and Infant Needs in Emergencies. The White Ribbon Alliance for Safe Motherhood. Women and Infants Service Package.. Dec. 2006