Using Two Statewide Medical Operations Coordination Centers to Load Balance in Pediatric Hospitals During a Severe Respiratory Surge in the United States.

OBJECTIVES: Report on the use of two statewide Medical Operations Coordination Centers (MOCCs) to manage a rapid surge in pediatric acute and critical care patient needs. DESIGN: Brief report. SETTING: The states of Washington and Oregon during the pediatric respiratory surge in November 2022/December 2022 which overwhelmed existing pediatric acute and critical care hospital capacity. PATIENTS: Pediatric patients requiring hospitalization in Washington and Oregon. INTERVENTIONS: Adaptations to the use of two existing statewide MOCCs to provide pediatric patient load balancing through surveillance, modifications of existing referral agreements, coordinated expansion of resources, activation of regional crisis standards of care, and integration of pediatric critical care physicians from Harborview Medical Center as subject matter experts (SMEs). MEASUREMENTS AND MAIN RESULTS: The Washington and Oregon MOCCs managed 183 pediatric requests from hospitals unable to transfer pediatric patients between November 1, 2022, and December 14, 2022. Sixteen percent of requests were for children younger than 3 months and 37% were for children between 3 months and 1 year; most had acute viral respiratory disease. Requests for children older than 13 years old were primarily intentional drug ingestions. Fifty-eight percent were for critically ill children and 17% originated from critical access hospitals. Washington's SMEs were utilized in nearly a quarter of cases with the disposition changing in 38% of these. CONCLUSIONS: Washington and Oregon statewide MOCCs have leveraged centralized coordination to effectively load balance a surge in pediatric patients which has overwhelmed existing pediatric hospital resources. Centralized coordination and surveillance informed pediatric hospitals and policy makers of unmet clinical needs and facilitated rapid expansion of clinical capacity and modifications to referral processes. Integration of pediatric SMEs enabled efficient triage of these resources. MOCCs provide an adaptable centralized resource for addressing surge and have been effective in managing overwhelmed pediatric hospital resources in Washington and Oregon.

Bacterial Brain Abscess and Life-Threatening Intracranial Hypertension Requiring Emergent Decompressive Craniectomy After SARS-CoV-2 Infection in a Healthy Adolescent.

Acute coronavirus 2 (SARS-CoV-2) infection usually results in mild symptoms, but secondary infections after SARS-CoV-2 infection can occur, particularly with comorbid conditions. We present the clinical course of a healthy adolescent with a brain abscess and life-threatening intracranial hypertension requiring emergent decompressive craniectomy after a SARS-CoV-2 infection. A 13-year-old healthy immunized male presented with invasive frontal, ethmoid, and maxillary sinusitis and symptoms of lethargy, nausea, headache, and photophobia due to a frontal brain abscess diagnosed three weeks after symptoms and 11 days of oral amoxicillin treatment. Coronavirus disease 2019 (COVID-19) reverse transcription-polymerase chain reaction (RT-PCR) was negative twice but then positive on amoxicillin day 11 (symptom day 21), when magnetic resonance imaging revealed a 2.5-cm right frontal brain abscess with a 10-mm midline shift. The patient underwent emergent craniotomy for right frontal epidural abscess washout and functional endoscopic sinus surgery with ethmoidectomy. On a postoperative day one, his neurological condition showed new right-sided pupillary dilation and decreased responsiveness. His vital signs showed bradycardia and systolic hypertension. He underwent an emergent decompressive craniectomy for signs of brain herniation. Bacterial PCR was positive for Streptococcus intermedius, for which he received intravenous vancomycin and metronidazole. He was discharged home on hospital day 14 without neurological sequelae and future bone flap replacement. Our case highlights the importance of timely recognition and treatment of brain abscess and brain herniation in patients with neurological symptoms after SARS-CoV-2 infection, even in otherwise healthy patients.

Regional pediatric disaster network guides statewide telehealth initiation during COVID-19 pandemic.

BACKGROUND: Telehealth emerged early as an important tool to provide clinical care during the COVID-19 pandemic, but statewide implementation strategies were lacking. Needs assessment: We performed a needs assessment at 15 pediatrics clinics in Washington regarding their ability to institute telehealth. Fourteen clinics (93 percent response rate) responded; none had ability to perform telehealth visits. Clinics needed the following specific support structures: (1) an easily implementable, low-cost system, and (2) parity billing for telehealth services. Disaster effort: Two weeks after the needs assessment was performed, we facilitated direct telehealth initiation support to 45 Washington clinics and created a coalition of statewide advocacy groups. These groups advocated for (1) a statewide solution for non-network or poorly resourced providers, which was delivered by the WA Health Care Authority, and (2) parity billing, which was delivered by emergency governor action. CONCLUSION: Engagement with our regional pediatric disaster network was essential in providing guidance and expertise in this needs assessment, telehealth initiation process, and subsequent advocacy efforts. The power we have as pediatricians to coordinate with regional experts helped improve access to telehealth across Washington.

Universal Level Designations for Hospitalized Pediatric Patients in Evacuation.

Children comprise approximately 22% of the population in the United States.1 In a widespread disaster such as a hurricane, pandemic, wildfire or major earthquake, children are at least proportionately affected to their share of the population, if not more so. They also have unique vulnerabilities including physical, mental, and developmental differences from adults, which make them more prone to adverse health effects of disasters.2-4 There are about 5000 pediatric critical care beds and 23 000 neonatal intensive care beds out of 900 000 total hospital beds in the United States.5 While no mechanism exists to consistently track pediatric acute care beds nationally (especially in real time), a previous study6 showed a 7% decline in pediatric medical-surgical beds between 2002 and 2011. This study also estimated there are about 30 000 acute care pediatric beds nationally. Finding appropriate hospital resources for the provision of care for pediatric disaster victims is an important concern for those charged with triaging patients in a major event.

PICU in the MICU: How Adult ICUs Can Support Pediatric Care in Public Health Emergencies.

Initial waves of the COVID-19 pandemic have largely spared children. With the advent of vaccination in many older age groups and the spread of the highly contagious Delta variant, however, children now represent a growing percentage of COVID-19 cases. PICU capacity is far less than that of adult ICUs. Adult ICUs may need to support pediatric care, much as PICUs provided adult care earlier in the pandemic. Critically ill children selected for care in adult settings should be at least 12 years of age and ideally have conditions common in children and adults alike (eg, community-acquired sepsis, trauma). Children with complex, pediatric-specific disorders are best served in PICUs and are not recommended for transfer. The goal of such transfers is to maintain critical capacity for those children in greatest need of the PICU's unique abilities, therefore preserving systems of care for all children.

Experience with clinical cerebral autoregulation testing in children hospitalized with traumatic brain injury: Translating research to bedside.

Objective: To report our institutional experience with implementing a clinical cerebral autoregulation testing order set with protocol in children hospitalized with traumatic brain injury (TBI). Methods: After IRB approval, we examined clinical use, patient characteristics, feasibility, and safety of cerebral autoregulation testing in children aged <18 years between 2014 and 2021. A clinical order set with a protocol for cerebral autoregulation testing was introduced in 2018. Results: 25 (24 severe TBI and 1 mild TBI) children, median age 13 years [IQR 4.5; 15] and median admission GCS 3[IQR 3; 3.5]) underwent 61 cerebral autoregulation tests during the first 16 days after admission [IQR1.5; 7; range 0-16]. Testing was more common after implementation of the order set (n = 16, 64% after the order set vs. n = 9, 36% before the order set) and initiated during the first 2 days. During testing, patients were mechanically ventilated (n = 60, 98.4%), had invasive arterial blood pressure monitoring (n = 60, 98.4%), had intracranial pressure monitoring (n = 56, 90.3%), brain-tissue oxygenation monitoring (n = 56, 90.3%), and external ventricular drain (n = 13, 25.5%). Most patients received sedation and analgesia for intracranial pressure control (n = 52; 83.8%) and vasoactive support (n = 55, 90.2%) during testing. Cerebral autoregulation testing was completed in 82% (n = 50 tests); 11 tests were not completed [high intracranial pressure (n = 5), high blood pressure (n = 2), bradycardia (n = 2), low cerebral perfusion pressure (n = 1), or intolerance to blood pressure cuff inflation (n = 1)]. Impaired cerebral autoregulation on first assessment resulted in repeat testing (80% impaired vs. 23% intact, RR 2.93, 95% CI 1.06:8.08, p = 0.03). Seven out of 50 tests (14%) resulted in a change in cerebral hemodynamic targets. Conclusion: Findings from this series of children with TBI indicate that: (1) Availability of clinical order set with protocol facilitated clinical cerebral autoregulation testing, (2) Clinicians ordered cerebral autoregulation tests in children with severe TBI receiving high therapeutic intensity and repeatedly with impaired status on the first test, (3) Clinical cerebral autoregulation testing is feasible and safe, and (4) Testing results led to change in hemodynamic targets in some patients.

Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage.

OBJECTIVES: Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. DESIGN: Retrospective cohort study. SETTING: Seattle Children's Hospital. PATIENTS: PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. CONCLUSIONS: A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

The Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in severe traumatic brain injury: a single-centre hybrid implementation and effectiveness study.

BACKGROUND: As far as we know, there are no tested in-hospital care programmes for paediatric traumatic brain injury. We aimed to assess implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in children with severe traumatic brain injury. METHODS: We did a prospective hybrid implementation and effectiveness study at the Harborview Medical Center (Seattle, WA, USA). We included children (aged <18 years) with traumatic brain injury (trauma mechanism and image findings). We assessed service provision, adherence to three key performance indicators, and discharge outcomes associated with the PEGASUS programme. The three key performance indicators were early initiation of enteral (oral or tube feeds) or parenteral nutrition; avoidance of any unwanted hypocarbia (PaCO2 <30 mm Hg) without brain herniation; and maintenance of cerebral perfusion pressure (>40 mm Hg) for 72 h after the diagnosis of severe traumatic brain injury. Poisson regression with robust standard errors was used to estimate the association between adhering to key performance indicators and discharge outcomes. FINDINGS: Between May 1, 2011, and July 1, 2017, 199 children (median age 11·9 years [IQR 3·4-16·1]) participated in the PEGASUS programme, of whom 193 (97%) had severe traumatic brain injury and six (3%) had moderate traumatic brain injury. 105 patients contributed data for all three key performance indicators. Adherence to at least one key performance indicator was achieved by 101 (96%) of 105 participants, and 44 (42%) achieved adherence to all three key performance indicators. Programme participants achieved adherence to the key performance indicators of hypocarbia (76 of 105 [72%]), nutrition (162 of 199 [81%]), and cerebral perfusion pressure (128 of 199 [64%]). Adherence to the nutrition key performance indicator was associated with higher discharge survival (relative risk [RR] 2·70, 95% CI 1·54-4·73) and a more favourable discharge disposition (3·05, 1·52-6·11). Adherence to the cerebral perfusion pressure key performance indicator was also associated with higher discharge survival (RR 1·33, 95% CI 1·12-1·59) and favourable disposition (1·53, 1·19-1·96). Adherence to each additional key performance indicator was associated with higher survival (RR 1·27, 1·12-1·44) and a more favourable discharge disposition (1·46, 1·23-1·72), in a dose-response manner. INTERPRETATION: The multilevel, hospital-wide, high-fidelity PEGASUS programme might benefit children and adolescents admitted to the emergency department with severe traumatic brain injury. Cerebral perfusion pressure, nutrition, and hypocarbia targets are essential components of the PEGASUS programme and are associated with favourable discharge outcomes. FUNDING: National Institutes of Health.

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes.

STUDY OBJECTIVE: Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. METHODS: We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. RESULTS: Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. CONCLUSION: Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

Evacuation of Intensive Care Units During Disaster: Learning From the Hurricane Sandy Experience.

OBJECTIVE: Data on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities. METHODS: We conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations. RESULTS: Sixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment considered most helpful included flashlights (24%), transport sleds (21%), and oxygen tanks and respiratory therapy supplies (19%). An evacuation wish list included walkie-talkies/phones (26%), lighting/electricity (18%), flashlights (10%), and portable ventilators and suction (16%). CONCLUSIONS: ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest links in the patient evacuation process were communication and the availability of practical tools. Incorporating ICU providers into hospital evacuation planning and training, developing standard evacuation communication processes and tools, and collecting a uniform dataset among all evacuating hospitals could better inform critical care evacuation in the future.

Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics.

BACKGROUND: Although nonoperative management has become the standard of care for solid organ injury, variability exists in the care patients receive, and there are limited data regarding nonoperative management in patients with high grades of organ injury and substantial overall injury. We aimed to evaluate operative intervention frequency, including splenectomy, and patient outcomes before and after institution of the pediatric solid organ injury pathway at Harborview Medical Center (HMC) in 2005. METHODS: This is a retrospective cohort study conducted at HMC for all pediatric solid organ injury patients from 2001 to 2012. Patients were identified in the Harborview Trauma Registry via DRG International Classification of Diseases-9th Rev. (ICD-9) codes for the presence of liver and spleen injuries. Demographic information, clinical characteristics, and ICD-9 procedure codes were also obtained from the trauma registry. Outcomes including splenectomy, a related abdominal surgery (exploratory laparotomy, spleen or liver repair, or splenectomy), mortality, and length of stay were compared between periods before and after 2005, adjusted for Injury Severity Score (ISS). RESULTS: The pediatric solid organ injury population at HMC (n = 712) has a high frequency of high-grade injury (35% Grade IV or V) and a high level of overall injury severity (median ISS, 21). Splenectomy was rare and remained stable over time despite an increase in severity of injury (from 2.4% to 0.8%, p = 0.44, among patients with isolated injury and from 4.0% to 3.3%, p = 0.78, among patients with nonisolated injury). Other abdominal surgeries also remained stable over time. Mortality decreased among patients with nonisolated injury (from 11.2% to 4.8%, p = 0.01). Length of stay decreased among patients with isolated organ injury, from a median of 4 days (interquartile range, 3-5 days) to 2 days (interquartile range, 2-3 days) (p < 0.0005) as well as within the lower ISS strata among patients with nonisolated organ injury (from a median of 4 days to 2 days among ISS < 12, p = 0.007; from 5 days to 3 days among ISS of 12-20, p = 0.0001; and from 7 days to 4 days among ISS of 21-33, p = 0.003). CONCLUSION: Care in the recent period (2005-2012) was associated with a stable, low frequency of splenectomy; decreased mortality for patients with nonisolated injury; and decreased hospital length of stay among most subsets of patients, suggesting improved care despite an increase in patients' severity of injury. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III.

Care of the child with Ebola virus disease.

OBJECTIVES: To provide clinicians with practical considerations for care of children with Ebola virus disease in resource-rich settings. DATA SOURCES: Review of the published medical literature, World Health Organization and government documents, and expert opinion. DATA SYNTHESIS: There are limited data regarding Ebola virus disease in children; however, reported case-fatality proportions in children are high. Ebola virus may affect immune regulation and endothelial function differently in children than adults. Considerations for care of children with Ebola virus disease are presented. CONCLUSIONS: Ebola virus disease is a severe multisystem disease with high mortality in children and adults. Hospitals and clinicians must prepare to provide care for patients with Ebola virus disease before such patients present for care, with particular attention to rigorous infection control to limit secondary cases. Although there is no proven specific treatment for Ebola virus disease, meticulous supportive care offers patients the best chance of survival.

Pediatric triage and allocation of critical care resources during disaster: Northwest provider opinion.

INTRODUCTION: Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage/allocation system. This study collected regional provider opinion on issues of care allocation and pediatric triage in a disaster/pandemic setting. METHODS: This study was a cross-sectional survey of United States (US) health care providers and public health workers who demonstrated interest in critical care and/or disaster care medicine by attending a Northwest regional pediatric critical care symposium on disaster preparation, held in 2012 at Seattle Children's Hospital in Seattle, Washington (USA). The survey employed an electronic audience response system and included demographic, ethical, and logistical questions. Differences in opinions between respondents grouped by professions and work locations were evaluated using a chi-square test. RESULTS: One hundred and twelve (97%) of 116 total attendees responded to at least one question; however, four of these responders failed to answer every question. Sixty-two (55%) responders were nurses, 29 (26%) physicians, and 21 (19%) other occupations. Fifty-five (51%) responders worked in pediatric hospitals vs 53 (49%) in other locations. Sixty-three (58%) of 108 successful responses prioritized children predicted to have a good neuro-cognitive outcome. Seventy-one (68%) agreed that no pediatric age group should be prioritized. Twenty-two (43%) of providers working in non-pediatric hospital locations preferred a triage system based on an objective score alone vs 14 (26%) of those in pediatric hospitals (P = .038).

Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: Pandemics and disasters can result in large numbers of critically ill or injured patients who may overwhelm available resources despite implementing surge-response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: The Triage topic panel reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel. RESULTS: The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This article provides 11 suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage. CONCLUSIONS: Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.

Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided. CONCLUSIONS: Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation to provide a safe continuum of critical care during a disaster.

Pediatric disaster triage education and skills assessment: a coalition approach.

OBJECTIVE: This study aims to 1) demonstrate one method of pediatric disaster preparedness education using a regional disaster coalition organized workshop and 2) evaluate factors reflecting the greatest shortfall in pediatric mass casualty incident (MCI) triage skills in a varied population of medical providers in King County, WA. DESIGN: Educational intervention and cross-sectional survey. SETTING: Pediatric disaster preparedness conference created de novo and offered by the King County Healthcare Coalition, with didactic sessions and workshops including a scored mock pediatric MCI triage. PARTICIPANTS: Ninety-eight providers from throughout the King County, WA, region selected by their own institutions following invitation to participate, with 88 completing exit surveys. INTERVENTIONS: Didactic lectures regarding pediatric MCI triage followed by scored exercises. MAIN OUTCOME MEASURES: Mock triage scores were analyzed and compared according to participant characteristics and workplace environment. RESULTS: A half-day regional pediatric disaster preparedness educational conference convened in September 2011 by the King County Healthcare Coalition in partnership with regional pediatric experts was so effective and well-received that it has been rescheduled yearly (2012 and 2013) and has expanded to three Washington State venues sponsored by the Washington State Department of Health. Emergency department (ED) or intensive care unit (ICU) employment and regular exposure to pediatric patients best predicted higher mock pediatric MCI triage scores (ED/ICU 80 percent vs non-ED/ICU 73 percent, p = 0.026; regular pediatric exposure 80 percent vs less exposure 77 percent, p = 0.038, respectively). Pediatric Advanced Life Support training was not found to be associated with improved triage performance, and mock patients whose injuries were not immediately life threatening tended to be over-triaged (observed trend). CONCLUSIONS: A regional coalition can effectively organize member hospitals and provide education for focused populations using specialty experts such as pediatricians. Providers working in higher acuity environments and those with regular pediatric patient exposure perform better mock pediatric MCI triage than their counterparts after just-in-time training. Pediatric MCI patients with less than life-threatening injuries tended to be over-triaged.