Transcript Slide 1

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
Immediate
• Health Care System
• Hospital
community
• Clinics
regional
• Physician Offices
response
San Diego County Disaster
System
Goals: County-wide preparedness and an
integrated response plan for all Hazard
Response
Community Education
Standardized training
Standardized equipment / supplies
Communication system
Drills
Proactive surveillance
San Diego County Disaster
System
• 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 Needs
Children 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
RESPIRATORY
COMPROMISE
MORE OFTEN
CAUSE OF
DECOMPENSATION
IN CHILDREN
Pathway to Decompensation
Many Causes
Asthma, Shock
Choking, Secretions
Toxins, etc.
Respiratory Distress
Compensated
Circulatory Distress
Compensated
Respiratory Distress
DECOMPENSATED
Circulatory Distress
DECOMPENSATED
RESPIRATORY FAILURE
CIRCULATORY FAILURE
FULL ARREST
DEATH
Rapid, Consistent Assessment
PATIENT ASSESSMENT TRIANGLE
1. Appearance
2. Respiratory Effort
3. Circulatory Status
(P.A.T.)
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 sm
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/Decontamination
principles (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/Pharmacy
Emergency Drugs
such as…..
Medications:
 Albuterol
 Amiodarone
 Atropine
 Adenosine
 Calcium Chloride
 Dextrose (25%/50%)
 Dopamine
Dobutamine
Epi 1:10,000 and 1:1,000
Lidocaine
Naloxone
Procainamide
Racemic Epi
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 childcare 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:
Safety
Calmness
A Sense of
Connectedness
Self-Efficacy
Helpfulness
4. Psychosocial Support
Concepts to avoid:
Promising things
you can’t deliver
Telling people how
they should feel
Judgment of
someone else or
their situation
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 emotionallyoverwhelmed and distraught survivors
Core Action #3: Stabilization
• The goal is to calm and orient emotionallyoverwhelmed 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 and
friends, 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 available
services 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 Management
Planning
Reverse Triage
RADY CHILDREN’S HOSPITAL, SAN DIEGO
STAFFING MANAGEMENT
NOVEMBER, 2009
LEVEL I: ACTIVE MANAGEMENT
● 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 II. STAFFING SHORTAGES
● 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 III DISASTER STAFFING
● **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.
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!