Section 2 - Planning Guidelines
All hospitals should plan for pediatric or obstetric patients to arrive during a disaster. All hospitals need to recognize the potential for receiving pediatric and/or obstetric patients during a natural disaster, terror event or other public health emergency. In a public health emergency, the following may occur:
- Pediatric and pregnant patients might present to ANY hospital, whether or not the facilities have pediatric or obstetric units;
- Critically ill pediatric patients might present to the nearest or easiest to reach hospital; and
- Transfer of patients to specialized hospitals might not be feasible.
Therefore, during disasters all hospitals and all providers must be prepared to deliver care to pediatric and obstetric patients.
During the 9/11 terrorist event, nearly 100 different hospitals received patients. While most of these patients walked, ran, or took buses, taxis or boats, the minority waited to be transported by ambulance. Self-evacuating pediatric victims and their caregivers and women in labor will go to the nearest hospital, the most convenient hospital, or the hospital they are most familiar with regardless of the capabilities of that hospital for specialty, obstetric or pediatric care.
All hospitals, even those that are not pediatric trauma centers or specialized pediatric hospitals, might receive critically ill or injured children in a mass casualty or disaster event. Pediatric patients may initially be brought to the nearest centers, as ambulances attempt to expedite their return to the disaster scene to maximize the care of patients. Even after on-scene triage is established, severely injured children may be brought to the nearest medical center because the patient is simply too unstable to survive a longer transport time. Additionally, due to traffic congestion, unsafe conditions, or lack of appropriate vehicles, ambulances may initially be unable to travel to hospitals that are more distant.
Each hospital, even hospitals that do not routinely provide pediatric or obstetric services, needs to plan for the possibility that pediatric or obstetric patients arriving at their hospital during a disaster might require emergency evaluation, critical care, surgical services, inpatient care, and/or psychosocial support and should be prepared to offer these services accordingly. Therefore, NYSDOH recommends the development of a committee or workgroup within each hospital to develop an annex to their Comprehensive Emergency Management Plan (CEMP) that addresses pediatric and obstetric patient needs in the event of a disaster. The general guidelines for the development of such a plan follow.
Plan for Transport of Pediatric/Obstetric Patients
The first element to consider is the possibility that the number of pediatric or obstetric patients requiring admission might exceed the normal patient capacity or expertise of hospital staff. For those hospitals without specialty pediatric or obstetric services, transfer of patients to a center with specialty pediatric or obstetric services may be necessary. Therefore, these hospitals should establish relationships with appropriate hospital facilities that do admit pediatric and obstetric patients to facilitate transfer (in accordance with a signed Transfer and Affiliation Agreement), if conditions permit.
Consideration for transfer and affiliation agreements should go beyond traditional network relationships and should include geographical proximity due to the unpredictability of traffic obstructions during the acute phase of a disaster.
All hospitals must also consider the need for evacuation of pediatric/obstetric patients during a disaster that renders the hospital unsafe or inoperable. Plans need to be made that take into account the needs of current patients, as well as arriving patients.
Plan for Pediatric and Obstetric Inpatient Care if Transport is Delayed
During the first 24 to 48 hours of a disaster involving much of the region, transfer might be difficult or impossible due to local conditions, lack of transport vehicles and personnel, or lack of capacity at resource hospitals. Therefore, all hospitals must be prepared to provide emergent pediatric/obstetric care and inpatient admission, even for critically injured patients, until such time that safe transport can be arranged. For hospitals without pediatric intensivists or pediatric trauma surgeons, it is recommended that relationships be developed with pediatric intensive care specialists and pediatric trauma surgeons at outside hospitals to provide, at the minimum, telephone consultations or support for admitting physicians.
Facilities may need to plan carefully for locations where laboring women, infants and small children can be safely accepted and housed in the event of disasters, including pandemics. Key considerations in planning for delivery of obstetric services must include how to keep healthy pregnant women and neonates separate from infectious patients, and how to ensure that staff members who care for pregnant or laboring women and their infants are not putting them at higher risk for infection. Separate entrances and treatment areas with adequate signage should be considered.
Survey Staff for Pediatric and Obstetric Expertise
Many levels of staffing are required, including the ability to provide emergency evaluation and treatment of children and pregnant and/or laboring women in the hospital setting. Yet, not every hospital has a full complement of pediatric specialists, obstetricians and pediatric/obstetric nurses. It is recommended, therefore, that hospitals survey their staff and admitting physicians to develop a database of personnel with pediatric and obstetric experience and training and update that database annually.
For example, emergency department physicians may have considerable experience with children; anesthesiologists and/or otolaryngologists may be knowledgeable about intubations of children. The gaps identified by this survey should be addressed by providing physicians, nurses, social workers, and other staff the necessary skill, knowledge and training to provide timely efficient care in the event of a disaster.
Appoint a Pediatric/Obstetric Physician Coordinator and a Pediatric/Obstetric Nursing Coordinator
It is recommended that hospitals appoint both a physician and a nurse as planning coordinators for pediatrics and obstetrics. These coordinators should serve as liaisons between different internal hospital committees that are addressing emergency preparedness issues, as well as assist in the development and use of pediatric and obstetric hospital protocols and procedures. It is envisioned that these positions would advocate for the medical and nursing needs of children and pregnant or laboring women during the planning phase for a disaster.
When projecting implementation of the Incident Command System (ICS) during a disaster, the hospital's ICS chart should include a position for Pediatric Medical/Technical Specialist or similar role. It is important to list a specific person and alternates for this position before the incident occurs.
Increase Pediatric, Obstetric and Disaster Training
Increased numbers of medical and nursing staff should be trained to provide appropriate pediatric emergency care with courses such as Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Support (APLS), Neonatal Advanced Life Support (NALS), and pediatric disaster drills. Updates and re-certifications should be arranged as well.
Training and drills for handling emergency childbirth should also be initiated.
New versions of Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Hazardous Materials Classes should include pediatrics and the specific needs of children and their families during a disaster involving hazardous materials.
Web-based courses are available and should be considered.