Meeting children's needs: a mixed-methods approach to a regionalized pediatric surge plan-the Los Angeles County experience.

INTRODUCTION: Children are one of the most vulnerable populations during mass casualty incidents because of their unique physiological, developmental, and psychological attributes. The objective of this project was to enhance Los Angeles County's (LAC) pediatric surge capabilities. The purpose of this study was threefold: (1) determine gaps in pediatric surge capacity and capabilities; (2) double pediatric inpatient capacity; and (3) document a plan to address gaps and meet pediatric inpatient surge. We hypothesized that LAC would be able to meet the identified pediatric surge target by leveraging resources of hospitals within the region. Deliverables included a pediatric surge plan for LAC, pediatric surge training resources, and pediatric supplies for hospitals participating in LAC's Hospital Preparedness Program (HPP). METHODS: After Institutional Review Board approval, the authors used a mixed-methods approach to explore gaps in hospital capacity and capabilities in a large urban county. Hospitals were surveyed via Qualtrics® on 38 questions regarding capacity, staffing, availability of pediatric supplies, and existing pediatric surge plans. Publicly available inpatient bed data were collected from the Office of Statewide Health Planning and Development for the year ending June 2010 and supplemented by hospital survey responses. Population data was used from US Census 2010. This combined dataset was analyzed for capacity, pediatric designations, and capabilities. To supplement this data, three focus groups were conducted between April 2011 and May 2012. Focus group topics included: supplies and training needed for pediatric surge, surge targets, and plan development and functionality. RESULTS: Hospitals varied in pediatric capacity and capability. Forty-six percent of facilities provide inpatient pediatric services. Forty-one hospitals are designated as an Emergency Department Approved for Pediatrics. Identified gaps included: limited pediatric bed capacity, geographic variability, limited pediatric intensive care unit capacity, limited pediatric specialty physician resources, varying availability of pediatric trained staff, less availability of pediatric critical care supplies, and limited ability to accept and receive children. Focus group stakeholders requested advance and just-in-time training and reference guides to supplement the plan. CONCLUSION: LAC was able to create a pediatric surge plan that doubles pediatric acute and pediatric intensive care bed capacity by using participating HPP hospitals. A tiered system was created based on capacity and capability with varying surge targets and guidance on types of patients that could be cared for at each tier. This plan will assist the LAC Emergency Medical Services Agency distribute pediatric patients during a surge event that disproportionately impacts children.

H1N1 pandemic: life span considerations.

In March 2009, a child in Mexico was infected with novel influenza A (H1N1), otherwise known as swine flu. Otherwise healthy children in that small town came down with it shortly after, as well as others from other countries who had visited Mexico or been visited by someone from Mexico, as was the case in the United States. The Centers for Disease Control and Prevention confirmed the first 2 cases in April 2009 and has been working together with local health departments to do syndromic surveillance. In June 2009, the World Health Organization raised the pandemic alert to level 6. Pandemic H1N1, as it is now called, has infected otherwise healthy people younger than 25 years. Most patients present with fever, sore throat, and cough. Transmission is via droplets; therefore, appropriate precautions should be taken. Antiviral care is usually recommended for those who are hospitalized, and the virus has been found to be susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza). Hospitals should work with local health departments for confirmation of the flu and implement pandemic plans as necessary.

Pediatric disaster preparedness in the medical setting: integrating mental health.

INTRODUCTION: The increasing prevalence of disasters worldwide highlights the need for established and universal disaster preparedness plans. The devastating events of September 11 and Hurricane Katrina have spurred the development of some disaster response systems. These systems, however, are predominantly focused on medical needs and largely overlook mental health considerations. Negative outcomes of disasters include physical damage as well as psychological harm. Mental health needs should be considered throughout the entire disaster response process, especially when caring for children, adolescents, and their families. OBJECTIVE: To provide an overview and recommendations for the integration of mental health considerations into pediatric disaster preparedness and response in the medical setting. METHODS: Recommendations were developed by a panel of disaster preparedness and mental health experts during the Childrens Hospital Los Angeles Pediatric Disaster Resource and Training Center: Workshop on Family Reunification in Los Angeles, California, March 31-April 1, 2008. Experts discussed the inclusion of mental health-specific considerations and services at all stages of disaster preparedness and response. Recommendations involve the integration of mental health into triage and tracking, the adoption of a child ambassador model, environment, and developmentally appropriate interventions, education, communication, death notification, and family reunification. CONCLUSIONS: The inclusion of mental health concerns into pediatric disaster preparedness may help prevent further and unnecessary psychological harm to children and adolescent survivors following a disaster.

Reunification: keeping families together in crisis.

BACKGROUND: In reviewing the literature, there has not been a family reunification plan that has worked consistently during disasters. During Hurricane Katrina, there were children who were sent to a shelter in a different state than their patients. When children are involved, the issues become even more difficult, because some children who are preverbal cannot tell their names or their parents names. Tracking systems have been developed but are not interoperable. No central repository has been developed. There are also issues related to transporting patients, psychosocial issues as well as safety issues that are different when children will be unaccompanied by an adult. METHODS: Two national meetings were held with experts from all over the country who have an expertise in the care of children. Six focused groups were identified: patient movement/transportation; technology/tracking; clinical issues, nonmedical issues; communication/regulatory issues; and pediatric psychosocial support. The second meeting was a consensus conference. RESULTS: Recommendations from each subgroup were presented and voted on. All recommendations were accepted. CONCLUSIONS: The issue of reunification of families in disaster is still a problem. Further work needs to be done on tracking systems that are interoperable before another large disaster strike, pediatric psychological issues after a disaster, transporting patients, and care of the pediatric patient who is not accompanied by an adult. Once a system has been developed, the system needs to be tested by large scale drills that practice moving children across state lines and from one area to another.

Disaster drill exercise documentation and management: are we drilling to standard?

INTRODUCTION: Medical errors are known to occur even in a controlled setting with adequate resources. The few studies on mass-casualty events and disaster exercises suggest errors may be amplified in these situations. We hypothesized that both the documentation and medical care provided during a pediatric disaster drill would be substandard when compared with routine care at the same institution. METHODS: Charts from the disaster exercise and matched charts from actual admitted patients were retrospectively reviewed for the presence of triage classification, allergies, weight, physical exam, vital signs, diagnosis, disposition time, disposition location, disposition instructions, and disposition vitals signs and for the appropriateness of diagnoses, medications, procedures, and disposition. Errors were quantified and classified into negligible, likely to cause temporary harm, or potential to cause admission or permanent harm. The drill charts were compared to actual charts by Fischer's Exact Test. RESULTS: Drill charts contained a significantly greater proportion of errors in regards to performance of procedures, administration of medication, and accuracy of diagnosis. Sixteen percent of these errors were judged as having the potential to cause permanent harm or admission. The exercise charts contained a significantly greater number of omissions in documentation in 9 of the 10 areas evaluated. DISCUSSION: Both the documentation and the quality of care provided during our exercise were deficient when compared with conventional care. Opportunities allowing providers to clearly document pertinent information, and linking of this documentation to relevant prompts and algorithms may minimize this potential for error.

Hospital-based disaster preparedness for pediatric patients: how to design a realistic set of drill victims.

OBJECTIVE: The purpose of this report is to describe an innovative idea for hospital pediatric victim disaster planning. DESIGN: This is a descriptive manuscript outlining an innovative approach to exercise planning. SETTING: All hospitals. PATIENTS: In this report, we describe a model set of patients for pediatric disaster simulation. RESULTS: An epidemiologically based set of mock victims. CONCLUSIONS: We believe that by enhancing pediatric disaster simulation exercises, hospital personnel and decision makers will be better prepared for an actual disaster event involving pediatric victims.

Adult rabbit offspring of mothers with secondary hypertension have increased blood pressure.

Preexisting chronic hypertension complicates up to 5% of pregnancies and is associated with an increased risk of low-birth-weight babies. Studies suggest that an adverse intrauterine environment leading to low birth weight is linked to an increased risk of cardiovascular disease, including hypertension, in the adult. In this study, the blood pressure of offspring from mothers with hypertension were followed up into adulthood. Two-kidney, 1-wrapped hypertension was induced in 7 female rabbits; 5 other rabbits underwent sham surgery. Four weeks later, rabbits were mated, at which time mean arterial pressure was 118+/-3 and 87+/-5 mm Hg in the hypertensive and sham groups, respectively (P<0.001). The blood pressure of 30-week-old females was 89+/-2 mm Hg in the offspring of hypertensive (n=14) and 79+/-1 mm Hg in the offspring of normotensive (n=13) mothers (P<0.005). Also, plasma renin activity was significantly lower in the female offspring of hypertensive mothers at 10 weeks of age (P<0.05), suggesting that development of the renin-angiotensin system was altered. In contrast, male offspring from hypertensive and normotensive mothers had similar mean arterial pressure and plasma renin activity. In conclusion, maternal secondary hypertension can "program" hypertension in female adult offspring. The results also suggest that there are gender-specific differences in sensitivity to altered in utero environmental influences.