Section 10 - Surge Considerations

Emergency Department Surge Considerations and Inpatient Bed Assignments for Pediatric Patients During a Disaster

Purpose: These recommendations are intended to help hospitals prepare for surge capacity needs, such as additional bed resources and emergency department space allocation, which may arise in the event of a disaster involving children. The section presents a model disaster scenario that can be scaled according to the predicted response of each individual hospital and includes general principles that should act as guidelines for all hospital disaster plans.

Section Contents

General Guidelines

To prepare for the reception and care of potential pediatric patients, the hospital's emergency preparedness planning committee should address each of the following issues in order to plan for surge capacity needs.

  1. Identify providers with general or specific pediatric clinical expertise. Examples may include MDs or RNs from Emergency Medicine, Nurse Practitioners, Family Medicine, Surgeons or others with recent pediatric experience. If no pediatric expertise is found, identify those who would be willing to provide pediatric services, then provide them with training as described under Section 4-Training.
  2. Identify pediatric drug dosing guidelines and pediatric equipment including ventilators, appropriately sized airway supplies (Ambu bags, facemasks, endotracheal tubes, stylets, oral airways, chest tubes, Foley catheters, over the needle IV catheter/IO needleless, etc.) that should be available to serve the potential pediatric population. (See Section 11-Equipment Recommendations.) Also, determine the availability of inpatient beds for pediatric patients, including operating rooms and pediatric surge ICU beds within the facility in the event these services are needed.
  3. The hospital committee should determine the volume of cribs, port-a-cribs, or playpens that should be in a storage area for use in possible pediatric disaster scenarios. However, many hospitals without a pediatric ward will be unlikely to have any cribs available. If adult beds are used, the following actions should be taken:
    • Children will have to be boarded in adult beds that have side rails.
    • The bed should be set at the lowest possible height.
    • The bed should be unplugged so the buttons to adjust the bed do not work.
  4. Identify the hospital's pediatric surge capacity, such as when the institution will exhaust the supply of clinicians, equipment, medications, operating rooms, and pediatric ICU beds based on the number and severity of potential pediatric patients for various hazardous events.
  5. Develop a list of other hospitals with pediatric capacity for possible transfer of patients should the hospital receive or expect to receive more children than the hospital can handle. Establish Memoranda of Understanding (MOU) or Interfacility Transfer Agreements with these other facilities, if possible.
  6. Develop a plan for stabilization and transfer of injured patients if more pediatric patients require admission than the hospital is able to handle.
  7. Set up a system to request transport teams and more MDs and RNs to help as needed.
  8. Set up a family assistance area for families of victims and a separate area for media contact.
  9. Set up a plan for decontamination of patients if chemical or radioactive contamination is suspected. See Section 8-Pediatric Decontamination/Prophylaxis for more detailed information concerning protocols for pediatric decontamination.
  10. Set up a plan to address questions raised by the news media and anxious parents and family members. As previously noted, the media and family members should be in separate spaces.
  11. Plan for enhanced security to handle large numbers of family members and other non-medically affected individuals. Expect approximately four to five visitors/family per pediatric patient.
  12. As previously mentioned, develop a Pediatric Safe Area temporarily to care for non-injured or medically released unaccompanied children. See Section 5-Security.
  13. Develop a system to identify and track pediatric victims. See Child ID Survey Form located in Section 5-Security. A frequently updated list should be maintained and relayed to the hospital emergency operating center and the hospital family assistance center.
  14. Consider what a surge in pediatrics patients would mean in terms of non-medical supplies (e.g., cribs, infant seats, diapers, formula, and baby food). See Section 12-Pediatric Dietary Needs.

Transfer Considerations for Hospitals without Pediatric Intensive Care Units

The transfer criteria for critical pediatric patients must be planned for hospitals that do not have a Pediatric Intensive Care Unit (PICU).

If a hospital does not have a Pediatric ED or a PICU, any child (especially a young child, infant or toddler) with a need for an operative procedure or PICU care may require stabilization and transfer. These children should be identified by predetermined criteria. For example, the pre-determined criteria may include:

  • Determination based on trauma score (Pediatric Trauma Score or Revised Trauma Score);
    or
  • Determination based on the need for other intensive level of care (intubation, assisted ventilations, comatose, increased intracranial pressure, shock, inotropic support, ongoing seizures, or other major organ failure).

Prearranged agreements with ambulance agencies and receiving hospitals should be in place. Hospitals should have agreements with their traditional referral hospitals as well as with those closest geographically or with the shortest transport routes. During a disaster, transportation may be difficult due to traffic closures or other obstructions.

Additional Resources

Online Revised Trauma Score Calculator may be found at:

Online Pediatric Trauma Score Calculator may be found at:

A sample of an interfacility transfer agreement can be found at the California Emergency Medical Services Authority website located at:

Planning Scenarios - Emergency Department Surge Considerations and Inpatient Bed Assignments

In order to prepare for the pediatric bed needs during a disaster, the Centers for Bioterrorism Preparedness Program (CBPP) Pediatric Task Force created a disaster scenario to better describe the necessary bed resource demands that hospitals might expect.

Assume 40 pediatric patients of all ages arrive at Hospital A following an explosive disaster.

  • 5 critically ill or injured (Red Tag)
  • 10 moderately ill or injured (Yellow Tag)
  • 25 minimally injured or uninjured (Green Tag)

The following sets of planning recommendations for emergency department surge capacity space and inpatient bed assignments address three categories of hospitals: non-trauma hospital with a pediatric intensive care unit; hospitals with general pediatric units, but without pediatric intensive care units; and hospitals without any pediatric inpatient units.

Scenario I - Non-Trauma Hospital with a Pediatric Intensive Care Unit

The following is a suggested plan for the distribution of pediatric victims upon arrival at a hospital with pediatric intensive care unit capability but not a certified trauma center. Hospitals must consider their own resources and personnel when creating their pediatric preparedness plan.

Emergency Department Surge Considerations

Red-tagged patients, or critical patients, should be placed in the most acute beds of the pediatric emergency area.

  • When this area becomes saturated, remaining critical pediatric patients should go to the adult critical care areas in the emergency department.
  • In the absence of a trauma team, overall responsibility will be with the emergency department attendings with appropriate transfer to the PICU/pediatric ward attendings.
  • Pediatric surgery should be immediately consulted in the absence of a trauma team for patients with penetrating injuries to the abdomen or thorax.
  • All other surgical specialties (neurosurgery, orthopedics, ENT, ophthalmology, etc.) should be placed on standby.

Yellow tagged patients, those moderately injured or ill, should be placed in a non-acute area of the pediatric emergency department with overflow going to non-acute care areas of the adult emergency department.

  • Yellow tagged patients need to be treated and assigned disposition in a timely manner and reevaluated frequently to ensure their condition does not deteriorate and warrant immediate medical intervention.

Green tagged patients, minor or non-injured patients should be triaged to the waiting room or to the pediatric clinic area or another large room capable of handling a large number, depending on day of week and time of disaster.

  • Green tagged patients need to be re-evaluated frequently to ensure their condition does not deteriorate and warrant immediate medical intervention.
  • When medically reasonable, Green tagged patients should be discharged as soon as possible to an appropriately identified adult caregiver as per hospital policy.

Assignment of Inpatient Bed Space

The most critical cases and/or youngest victims should receive priority for Pediatric Intensive Care Unit beds. Once the PICU is full, overflow patients could be managed by Pediatrics in the Post Anesthesia Care Unit (PACU) if the patient required surgery, or in monitored beds on the pediatric ward, adult medical or surgical ICUs.

Moderately injured or ill patients requiring admission should be admitted to the pediatric ward until all beds are utilized. At that point, the hospital must decide to increase the ward census (add 1 more bed per room if space allows) or board the oldest pediatric patients on adult wards. If possible, all children should board on the same adult ward for ease of nursing care and to improve the children's psychological wellbeing. Facilities may consider cohorting children by age.

Scenario II - Hospitals with a General Pediatric Service but without a Pediatric Intensive Care Unit

The following is a suggested plan for the distribution of pediatric victims upon arrival at a hospital without pediatric intensive care unit (PICU) capability, but has an inpatient pediatric unit. Hospitals must consider their own resources and personnel when creating their pediatric disaster plan.

Most hospitals that do not have a PICU also do not have a dedicated pediatric emergency department. If your hospital has a pediatric emergency department, follow the above guidelines. It is likely the hospital will have a general emergency department.

Emergency Department Surge Capacity Considerations

Red-tagged patients, or critical patients, should be placed in the most acute care area of the emergency department.

  • When that area becomes saturated, remaining critical patients should go to a monitored observation area in your emergency department.
  • Overall responsibility will be with the emergency department attending and transferred to the pediatric ward attending.
  • If the hospital has a trauma team, they should be immediately consulted and the trauma team attending will take responsibility for all children requiring trauma surgery.
  • Pediatric surgery should be immediately consulted in the absence of a trauma team for patients with penetrating injuries to the abdomen or thorax. All other surgical specialties (neurosurgery, orthopedics, ENT, ophthalmology, etc.) should be placed on standby.

Yellow tagged patients, moderately injured or ill, should be placed in the non-acute care areas of the emergency department with yellow tag overflow going to waiting room areas, or other designated areas, that are converted to patient care areas for the duration of the disaster.

  • Yellow tagged patients need to be treated and assigned disposition in a timely manner and re-evaluated frequently to ensure their condition does not deteriorate and warrant immediate medical intervention.
  • Admitted patients should be transferred up to the pediatric ward as soon as possible.

Green tagged patients, minimally or non-injured, should be triaged to the waiting room, lobby, or the pediatric clinic area depending on the day of the week and time of disaster.

  • Green tagged patients need to be reevaluated frequently to ensure their condition does not deteriorate and warrant immediate medical intervention.
  • When medically reasonable, green tagged patients should be discharged as soon as possible to an appropriately identified adult caregiver as per hospital policy.

Assignment of Inpatient Bed Space for Hospitals without Pediatric Intensive Care Units

Pediatric critical care patients should be transferred to a hospital that can provide a higher level of care as soon as possible. Until transfer is completed, patients can be managed by pediatric staff in the post-operative recovery room if the patient required surgery, or in monitored beds on the pediatric ward or in adult medical or surgical ICUs. Moderately injured or ill children requiring admission should be admitted to the pediatric ward until all beds are utilized. At that point, the hospital must decide to increase the pediatric ward census (add 1 more bed per room if space allows) or board the oldest pediatric patients on adult wards. If possible, all children should board on the same adult ward for ease of nursing care and to improve the children's psychological wellbeing.

Scenario III - Hospitals without a Pediatric Service

The following is a suggested plan for the distribution of pediatric victims upon arrival at a hospital without pediatric intensive care unit (PICU) capability or pediatric inpatient wards. Hospitals must consider their own resources and personnel when creating their pediatric disaster plan.

As previously recommended, all hospitals should keep a designated number of cribs or playpens in a storage area for use in possible pediatric disaster scenarios. However, it is unlikely that hospitals without a pediatric ward will have any cribs available. Use of adult beds may be considered if the following actions are taken:

  • Children will have to be boarded in adult beds that have side rails.
  • The bed should be set at the lowest possible height.
  • The bed should be unplugged so the buttons do not function.

All pediatric patients requiring admission should be transferred to a hospital that can provide a higher level of care as soon as it is medically and technically possible. Unstable patients will require initial management at the receiving hospital where they first arrive prior to transfer.

Emergency Department Surge Capacity Considerations

Red-tagged patients, or critical patients, should be placed in the most acute care area of the emergency department.

  • When that area becomes saturated, remaining critical patients should go to a monitored observation area in your emergency department.
  • Overall responsibility will be with the emergency department attending. If the hospital has a trauma team, they should be immediately consulted and the trauma team attending will take responsibility for all children requiring trauma surgery.
  • Adult surgery should be immediately consulted in the absence of a trauma team for patients with penetrating injuries to the abdomen or thorax, as they will be the most capable specialty to perform immediate intervention. All other surgical specialties (neurosurgery, orthopedics, ENT, ophthalmology, etc.) should be called into the hospital or placed on standby.

Yellow tagged patients, moderately injured or ill, should be placed in the non-acute care areas of the emergency department.

  • Yellow tagged patients need to be reevaluated frequently to ensure their condition does not deteriorate and warrant immediate medical intervention.
  • Yellow tag overflow should go to the waiting room or other designated area that will be converted to patient care areas for the duration of the disaster.
  • Patients requiring admission should be transferred up to adult inpatient wards as soon as possible. The beds should be at the lowest possible height, have side rails, and have the electronic bed functions disabled so that the buttons will not function.

Green tagged patients, minimally or non-injured, should be triaged to the waiting room, lobby, or to the adult clinic area depending on the day of the week and time of disaster.

  • Green tagged patients need to be reevaluated frequently to ensure their condition does not deteriorate and warrant immediate medical intervention.
  • When medically reasonable, green tagged patients should be discharged as soon as possible to an appropriately identified adult caregiver as per hospital policy.

Assignment of Inpatient Beds for a Hospital without a Pediatric Service

Pediatric critical care patients should be transferred to a hospital that can provide a higher level of care as soon as possible. Until transfer arrangements are completed, critical pediatric patients can be managed by Anesthesia in the Recovery Room, if the patient required surgery, or in adult medical or surgical ICUs, or monitored beds on adult inpatient wards until the pediatric patient can be safely transferred.

Non-critical patients requiring admission can be admitted to an adult ward if appropriate transfer is delayed or unavailable. If possible, all children should board on the same adult ward for ease of nursing care and to improve the children's psychological wellbeing.