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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