HPP Special Topics National CallPediatric Preparedness for Healthcare CoalitionsMeeting SummaryThursday, June 20, 2013I. Welcome & Overview Dr. Cynthia Hansen, Senior Advisor, NHPP Dr. David Marcozzi, Division Director, . Hansen welcomed participants to the Pediatric Preparedness for Healthcare Coalitions(HCC) webinar, hosted by the ASPR National Healthcare Preparedness Program. A largeaudience is expected for this call, which highlights the importance of considering children’sspecialized needs during disaster planning and capability development. On behalf of theAssistant Secretary for Preparedness and Response, Dr. Nicole Lurie, and the Deputy AssistantSecretary and Director of the Office of Emergency Management, Mr. Don Boyce, thank you forparticipating in this call and prioritizing this issue.Dr. Marcozzi thanked participants for taking the time to join this important call. Addressingpediatric needs is important across the Capabilities, but especially for Capability 1: HealthcareSystem Preparedness (HCC development) and Capability 10: Medical Surge. Speakers will bediscussing available tools and resources to assist Awardees and other stakeholders in planningefforts. The effort to increase collaboration between ASPR, HRSA, and other federal agencies toimprove the dissemination of information on pediatric readiness will be a sustained effort.HPP is encouraging efforts in pediatric disaster planning in all disaster preparedness activities, asit is an area that can be enhanced. HPP data tells a mixed story about pediatric capabilities. Dataindicate that participation by pediatric hospitals in the Hospital Preparedness Program (HPP) isincreasing, but not every Awardee has a pediatric hospital in their jurisdiction. In addition,overall pediatric non-ICU bed capacity is decreasing. These trends reinforce the need for carefulpediatric preparedness planning to maximize available resources. Thus, it is necessary for everyHPP program and HCC to engage pediatric expertise in order to inform plans, training, exercises,and other initiatives. The speakers on this call are subject matter experts in pediatric readinessand will be discussing pediatric emergency care in the context of HCCs.ASPR also thanks all the speakers who are presenting information on their pediatric readinessinitiatives. Today’s webinar will be recorded and archived on the ASPR ABC Awardees will also be able to download tools and materials that werepresented on today’s call.1

II. Introduction to Healthcare System Preparedness for Children Daniel Dodgen, PhD, Director, Division for At-Risk Individuals, Behavioral Health, andCommunity Resilience (ABC), ASPR Office of Planning and Policy [email protected]. Dodgen thanked everyone for joining today’s very important Pediatric Emergency Carewebinar hosted by ASPR. When discussing pediatric needs in disasters, it is important to askthe following questions:1. What does the law say and why is it important?2. How might disasters affect children differently than adults?3. What expertise will the panelists share with you today and how can this information helpyou implement the Healthcare Preparedness Capabilities?4. What tools and resources are available to support your efforts?Question 1: What does the law direct us to do? The Public Health Service Act defines the term ‘at-risk individuals’ as: “ children,pregnant women, senior citizens and other individuals who have special needs in theevent of a public health emergency ” The Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA)requires that we: “ ensure that recipients of State and local public health grants includepreparedness and response strategies and capabilities that take into account the medicaland public health needs of at-risk individuals in the event of a public healthemergency ” PAHPRA puts emphasis on “at-risk individuals,” and this term includes children. As aresult, the U.S. has a legal requirement to address the needs of children and conductpediatric disaster planning. This is also considered the right thing to do.Question 2: How might disasters affect children differently than adults? (e.g., what makeschildren unique?) Children have unique anatomy, physiology, and behavior, which may impact how theyare affected by disasters:o Young children have relatively larger heads and abdomenso Experience the world through hand-to-mouth activityo Needs differ among age groups (newborns, young children, adolescents). As aresult, children cannot be grouped together in one category.o Children are not isolated, but fit within the context of family, schools, and society.Thus, children cannot be considered or treated as single individuals, but as part ofa larger group. Children have unique medical and psychological needs that must be taken into accountduring disaster preparedness and response planning, but this does not mean that it isnecessary to completely reinvent the context of how we provide care.2

Question 3: What expertise will the panelists share with you today and how can this informationhelp you implement the Healthcare Preparedness Capabilities?Addressing pediatric needs in preparedness planning and response may seem overwhelming.The purpose of today’s webinar is to give Awardees tools by sharing resources andidentifying lessons learned.Question 4: What tools and resources are available to support your efforts?Sample pediatric tools and resources available to Awardees include: Agency for Healthcare Research and Quality (AHRQ)o Pediatric Hospital Surge Capacity in Public Health al/)o Decontamination of Children ( American Academy of Pediatrics (AAP)o Children and Disasters Web Site ( Centers for Disease Control and Prevention (CDC)o Information on Caring for Children in a Disaster( Health Resources and Services Administration (HRSA)o Kids in Disasters: Facing Our ebcastDetail.asp?id 293) (Archivedwebcast highlights innovations in pediatric disaster preparedness: “A NovelImaging System for Reunification of Children Separated during Disaster” and“Refining Pediatric Disaster Triage Algorithms and Education in the Pre-hospitalSetting.”)o Emergency Medical Services for Children (EMS-C) National Resource Center’sPEDPrepared ( (A pediatric disasterresource clearinghouse that bring together information, tools, and resources toassist health care providers, emergency planners, and families to prepare for,respond to, and recover from a disaster or pandemic involving the pediatricpopulation.) National Center for Disaster Medicine and Public Health (NCDMPH)o Tracking and Reunification of Children in Disasters: A Lesson and Reference forHealth Professionals ( Learning1.htm) (Approved for CME/CE accreditation; two additional modulesunder development.) National Institutes of Health, National Library of Medicine (NIH/NLM)o Resource Guide for Disaster Medicine and Public Health( Substance Abuse and Mental Health Services Administration (SAMHSA)o National Child Traumatic Stress Network pages on Natural l-disasters) and ism) (Information and resources forchildren, parents, and providers.)3

In addition to exploring various Pediatric Emergency Planning references, it is also important toconnect with potential resources in your community: AAP Chapter Contact for Disaster Preparedness at EMSC State and Territorial Contact at Administration of Children and Families (ACF) Regional Emergency ManagementSpecialist by e-mailing [email protected]%20 FEMA Regional Disability Integration Specialist by e-mailing fema-disability [email protected]. Preparedness for Children In Disasters: A National Perspective Michael R. Anderson, MD, FAAPo Vice President and Chief Medical Officer, UH Case Medical Center and RainbowBabies and Children’s Hospital Cleveland, Ohioo Associate Professor of Pediatric Critical Care, Case Western Reserve University,o Former Vice Chair, National Commission on Children and Disasters, Washington DCo [email protected]. Hansen welcomed Dr. Michael Anderson. Dr. Anderson recently co-chaired an Institute ofMedicine (IOM) seminar on caring for children in disasters. Today, Dr. Anderson will bepresenting a national view of the following topics in regards to pediatric emergency care: The Good News The Challenging News The Road AheadThe Good NewsAs a nation, disaster readiness for children has improved in recent years. Colleagues at the local,state, and federal level have made good progress. It is important to continue to sustain the effortof advocating for the needs of children, and improving pediatric emergency care. There arevarious federal and state initiatives that have drawn attention to pediatric readiness: It’s very important that PAHPA was reauthorized with a special emphasis on consideringthe needs of at-risk populations, including children. This will reinforce state and localactivities to enhance pediatric readiness. IOM, which sets national standards of medical care, conducted a two day seminar oncaring for children in disasters. Materials and audio recordings of the IOM Seminarare archived on IOM website.1 Dr. Anderson participated in the National Commission on Children in Disasters,2 whichwrapped up in 2012. The commission drafted a 2010 report on children in disasters forthe President and Congress. There are various on-going task forces on this topic, as it is important that pediatricemergency care is a sustained

On today’s call, federal and state partners are presenting information on pediatric readinessinitiatives and various tools and resources, including websites and clearinghouses that advocatefor children’s rights. It is important for state and local representatives to explore these tools anddevelop a plan of how to apply them in their geographies and in the local and state paradigm.The Challenging NewsAs a nation, we are not prepared for large disasters that involve pediatric patients. It is importantto look at daily delivery of care and ask the question: Is this emergency department fullyprepared to care for one acutely ill pediatric patient? Ohio has six freestanding pediatrichospitals, but many states only have one specialty pediatric hospital and some have none. Thesehospitals were queried and, at a specific point in time, there were only seven available beds.Healthcare systems must develop plans to be able to handle a surge of critical pediatric patients(i.e., 20-60 patients) during a disaster.In addition, there is a current funding crisis at the federal, state, and local levels. It is key tocontinue to advocate for children and keep pediatric readiness at the forefront of disasterpreparedness planning. To keep the current level of effort sustained, senior leadership mustprioritize pediatric readiness.The Road AheadIt is important to address pediatric emergency care along the continuum of care and within thefour stages of the Disaster Management Cycle: Mitigation, Preparation, Response, and Recovery.The medical needs of children must be represented in each phase of that paradigm, as well asother aspects of pediatric planning, such as sheltering, juvenile justice, social/psychologicalaspects, and family reunification. However, medical facilities are an important part of acommunity’s resiliency after the disaster, and hospitals and healthcare systems must maintain ahigh-level of pediatric readiness.Day-to-day challenges in pediatric care include: Funding Foci on other important issues Areas without deep pediatric expertise Surge Needso Transport of critically ill childreno Pediatric intensive care unit (PICU) bedsIV. Improving the Emergency Care System for America’s Children Elizabeth Edgerton, MD, MPH, EMS-C [email protected]. Beth Edgerton will discuss: The mission and activities of the EMS for Children Program (EMS-C) as they intersectwith the Hospital Preparedness Program (HPP)5

The National Pediatric Readiness Project and its importance to the HPP GranteesOrganizationEMS-C is part of the Division of Child, Family, and Adolescent Health, which is housed in theMaternal and Child Health Bureau at the Health Resources and Services Administration(HRSA), Department of Health and Human Services (HHS). As stated by Senator Inouye, “TheEMS for Children Program addresses the entire continuum of pediatric emergency services, frominjury prevention and EMS access through out-of-hospital and emergency department care,intensive care, rehabilitation and reintegration into the community.”Synergies between HPP and EMS-CThere are synergies between the HPP and EMS-C programs, and it is important that EMS andhospitals are partners in the field to facilitate a seamless process of caring for pediatric patientsduring disasters. HPP priorities include: Enhanced Planning: HPP funding is used to enhance hospital and healthcare systemplanning and response at the State, local, and territorial levels. Increasing Integration: HPP facilitates the integration of public and private sectormedical planning and assets to increase the preparedness, response, and surge capacity ofhospitals and other healthcare facilities. Improving Infrastructure: Awardees have used HPP Grants and Special InitiativeGrant funding to improve the State, local, and territorial infrastructures that help hospitalsand healthcare systems prepare for public health emergencies.EMS-C provides the framework for successfully caring for pediatric patients during a disasteracross the continuum of care. EMS-C supports EMS providers to improve everyday readiness sothey are more prepared for a disaster. EMS-C distributes multiple grants: State Partnership Grants: Focus on EMS-C initiatives to accomplish the EMS-Cperformance measures State Regionalization of Care Demonstration Grants: Develop innovative models ofimproving pediatric emergency care in rural, tribal and territorial communities (Alaska,Arizona, California, Montana, New Mexico, Pennsylvania) Targeted Issue Grants: Demonstration projects addressing EMS-C Program prioritiesand resulting in projects that are applicable across State borders Pediatric Emergency Care Applied Research (PECARN): Six Research Nodes thatcoordinate research in 18 Hospital Emergency Departments, representing 1.2 millionpediatric visits annuallyEMS-C strives to measure the quality of pediatric emergency care in the pre-hospital andhospital arena. The following benchmarks measure progress of pediatric care on the continuumof EMS preparedness to ED preparedness: Pre-hospital:o Access to online and offline medical directiono Appropriate pediatric equipment6

o Appropriate pediatric trainingHospital:o Designation for pediatric trauma or medical careo Processes for transfer to a higher level of carePermanence measures (sustainability):o Institutionalization of pediatric emergency care within the larger systemPediatric readiness is defined as “The capability of an ED to provide the right resources and theright care at the right time to an ill or injured child.” There is a scarcity of pediatric care intoday’s healthcare system and many facilities must transfer pediatric patients to other specializedfacilities for complex care. One of EMS-C’s priorities is to assure quality in pediatric patienttransfers. Data indicate: Most children are treated at non-children’s facilities (approximately 89%) Less than 5% of all hospitals are recognized as pediatric or children’s hospitals 27% of pediatric emergencies are treated at rural/ local community EDs 50% of hospitals see less than 10 pediatric patients per day and hospitals in remote orfrontier areas may see only 1-2 pediatric patients per day Most states have one pediatric hospital and some states (e.g., North Dakota, Alaska,Montana) have noneThe data indicates that hospitals with a higher level of readiness had the followingcharacteristics: Located in urban areas Treated a high pediatric volume Had a separate care area for pediatric patients Had a physician and nursing coordinator for the EDJoint Policy Statement: Guidelines for Care of Children in the Emergency Department3This joint policy statement raised awareness regarding the necessary criteria required to provideoptimal care in an ED. The policy was authored by three organizations (AAP, American Collegeof Emergency Physicians (ACEP), and the Emergency Nurses Association) and was signed by20 other organizations. The joint policy statement indicates that having a physician and nursing“champion” or coordinator for pediatric care increases a hospital’s readiness to treat pediatricpatients efficiently. The policy identified six domains for establishing an environment foroptimal care:1. Administration and Coordination2. Physicians, Nurses, and Other ED Staff3. Quality Improvement (QI)/Performance Improvement (PI) in the ED4. Pediatric Patient Safety5. Policies, Procedures, and Protocols6. Equipment, Supplies, and Medications3PEDIATRICS Vol. 124 No. 4 October 2009, pp. 1233‐12437

The National Pediatric Readiness Project (PRP): Ensuring Emergency Care for AllChildrenThe National PRP is a collaborative quality improvement initiative to ensure that emergencydepartments are adequately ready to care for pediatric patients. Many professional associationsare involved (e.g., the Emergency Nursing Association, ACEP, and AAP). The project consistedof a national assessment which provided an opportunity to assess the nation’s ED capacity, basedon the Guidelines, and created an ongoing quality improvement initiative.National Pediatric Readiness AssessmentThe National Pediatric Readiness Assessment is a web-based assessment developed by aReadiness Working Group based on the 2009 National Guidelines for optimum care of pediatricpatients during disasters. ED Nurse leaders complete the survey, which was disseminated inJanuary 2013. The survey will be completed in July 2013. The first step of the assessment wasto measure which components are present in hospital EDs. For more details on the methodologyand sample results of the survey please see slides 42-44 of the Pediatric Preparedness for HCCspresentation available online ( of today, 72% (3,600) hospitals have completed the survey. Data trends indicate thathospitals that have higher patient volume receive higher pediatric readiness score than hospitalswith lower patient volume. Data trends also indicate that many hospitals (2,000 of the 3,600surveyed) receive a “low” to “medium” number of pediatric patients. The Delphi method wasused to weight survey domains and processes, and data indicate that physician and nursingpediatric coordinators/champions are essential to hospital pediatric readiness.The good news is that all hospitals have improved readiness scores as compared to 2003.However, there is still significant progress that needs to be made. According to the assessment,only 67% of high-volume hospitals have a pediatric-specific disaster plan. One of the futurebenefits of this survey is that it will provide a national “snapshot” of which hospitals andhealthcare systems are prepared to handle pediatric patients in a disaster and which hospitalsneed to improve pediatric readiness.There are many aspects of the National Pediatric Readiness Assessment that are specificallydesigned to assist hospital pediatric readiness activities. Individual hospitals receive a readinessscore, which is compared to all hospitals across the nation who have completed the assessment,as well as all hospitals with a similar patient load. Hospitals also receive a gap analysis whichidentifies areas where improvement is needed and provides hospitals links to importantresources, such as the national pediatric websites, or sample job descriptions of nurses orphysicians. States receive aggregate data to assist with healthcare policy decisions8

A resource that is available from the PRP is the Pediatric Readiness Toolkit.4 The toolkit isbased on national guidelines and is focused on performance improvement of hospitals and HCCs.It includes sample hospital policies and procedures (e.g., pediatric triage and transporttechniques) and a quality improvement section.An important step to improve a facility’s readiness includes prioritizing and implementing keyareas of the guidelines, including:1. Staff: Designate a nurse and/or physician coordinator to oversee ED pediatric qualityimprovement, patient safety, and clinical care activities2. Policies: Implement child-friendly policies and procedures3. Equipment: Ensure that all recommended equipment, supplies, and medication forchildren of all ages are availableThe National Pediatric Readiness Assessment found the following sample barriers toGuideline Implementation:5 Cost of personnel and training Lack of educational resources Lack of trained MDs, RNs, and Admin support Lack of policies in pediatric emergency care Lack of pediatric quality improvement plan and disaster plan Lack of interest in meeting guidelinesStakeholders and key partners of this effort include: EMS for Children Program American Academy of Pediatrics (AAP) American College of Emergency Physicians (ACEP) Emergency Nurses Association (ENA)Improving Pediatric Readiness includes national and state-level benefits. Globally, pediatricreadiness reduces the unevenness of pediatric emergency care by creating a foundation for allEDs. At the state-level, pediatric readiness improves disaster preparedness by: Improving day-to-day readiness of an ED which increases the likelihood that it will beprepared for a disaster Providing an opportunity for children to be better integrated into overall state disasterplans Determining if the facility’s disaster plan addresses issues specific to the care of children Providing an online toolkit that has sample ED disaster preparedness policies thatincorporate the needs of childrenFuture Benefits of Pediatric Readiness include: Direct linkage to the prehospital setting45www.pediatricreadiness.orgFor further information, please see slide 47 of the presentation9

EMS agencies can appoint a coordinator focused on pediatric emergency competency,quality improvement, patient safety, etc.Ultimate goal 1: EMS ability to transport a child to an ED, regardless of geographiclocation, knowing that the ED will have baseline readiness with medications, equipment,policies, and training to provide effective emergency care to stabilize a childUltimate goal 2: Facilities that cannot care for critical pediatric patients will be linked toa broader regional system.V. Hospital and Health Care System Preparedness & Pediatric Planning: Are You Readyfor Kids? Steven E. Krug, MD, FAAPo Chair, AAP Disaster Preparedness Advisory Councilo Professor of Pediatrics, Northwestern University Feinberg School of Medicine,o Head, Division of Emergency Medicine, Ann and Robert H. Lurie Children’sHospital of Chicagoo [email protected]. Hansen noted that Dr. Krug will be providing the AAP perspective and discussing currentresources, including a toolkit that was inspired by the events and response to the H1N1 outbreak.Dr. Krug acknowledged the colleagues, partnerships, and advocates that joined him as speakerson today’s call along with HRSA and ACF as organizations with a long history of beingcommitted in improving readiness for children.Dr. Krug presented data from the 2008 National Hospital Ambulatory Medical CareSurvey,6 which included questions on hospital capability to treat pediatric patients. Thepercentage of hospitals that had the following are indicated below: Tracking system for children – 43% Reunification of children and families – 34% Increasing pediatric surge capacity – 32% Plan for supplies/sheltering of children – 29% Countermeasures (Plan for distribution of KI) – 33% Disaster drills – 89%. Of all the disaster drills:o 45% included pediatric victimso 31% included a school systemo The median number of children victims included in drills was 1The EMS-C presentation indicated that less than half of hospitals have a pediatric disaster plan.It is important to have a pediatric disaster plan, or at least have a plan annex that addressesspecific pediatric needs. If healthcare systems improve care for pediatric patients, care for allindividuals will be enhanced. It is also important to test those plans. The above data indicatethat nearly all hospitals perform drills, but only about half of hospitals include pediatric patients.6Niska RW, Shimizu IM. National Health Statistics Report #37, 2011. Available at:

Drills should test hospitals limits and push hospitals out of their comfort zone. This data indicatethat hospitals were not accomplishing this in the drills that were being conducted.Step 1: Have a Plan for Kids. It is important to have a plan that specifically addresses theneeds of at-risk populations, especially children. It is also essential to implement the plan andgauge a hospital’s progress. The plan should: Engage the input/expertise of pediatricians and other pediatric SMEs on the local andregional levels Be compatible with a local hazard vulnerability assessment and the needs of the patientpopulation served Consider the requirements of children with special health care needs Address all disaster components (Mitigation, Preparedness, Response, Recovery ANDResiliency). Hospitals are a very important component of a community’s resiliencyduring and after a disaster Include pediatric-specific performance measuresStep 2: Build the Foundation:7 Hospitals and EDs should be prepared to meet the needsof acutely ill and injured children on a day-to-day basis. This is accomplished by: Aligning with activities within your state’s EMS-C program Considering how to improve emergency care quality and safety and measure performance Identifying MD and RN coordinators for pediatrics as they are essential for improvingand sustaining pediatric emergency care initiatives Collaborating with EMS and other associations such as AAP, ACEP, and ANAStep 3: Consider Your Capabilities: It is important to consider present institutional capacityand capabilities for pediatric care: All locations: inpatient, outpatient, emergency, etc. All acuity levels, including critical care All populations: neonates, older children, children with special health care needs Define core competencies for pediatric care among front-line staff in all locations Consider opportunities to increase capacity after capabilities are developed Make enhancing pediatric readiness a priority by providing staff access to resources tomaintain/expand capabilities to care for children (e.g., training courses) Partner with others: It is important to reach out to individuals in the field, (e.g. localand/or regional pediatric center) to better understand pediatric readiness concernsStep 4: Think Local: Develop a pediatric disaster readiness coalition and/or advisory council inthe local community. Even in the competitive healthcare environment, it is critical to partnerwith other institutions in regards to pediatric readiness. In addition, one coalition model/sizemay not satisfy all. There are pediatric-patient specific coalitions and coalitions caring for all7Gausche‐Hill M, Krug S, and the American Academy of Pediatrics, American College of Emergency Physicians,Emergency Nurses Association. Guidelines for care of children in the emergency department.Pediatrics 2009; 124(4):1233‐4311

populations. Coalitions for the general population should have plans or plan annexes thatspecifically address the special needs of the pediatric population. Sample coalition membersinclude: Hospitals Primary and specialty care providers, Federally Qualified Health Centers (FQHCs) Mental health: It is very important to consider mental health issues in the aftermath ofdisasters, and children have specialized mental health needs Key stakeholders (e.g., Public health, emergency mgmt., public safety, EMS, Schools,child (day) care providers, State EMS-C. It is important to bring on key stakeholders intocoalition planning activities.Step 5: Think BIG (Globally): It is critical to identify and/or help build regional coalition(s)AND participate: To address surge capacity (e.g. inpatient and critical care) To address specialized services (e.g. trauma, burns) To address special populations (e.g. obstetrics, pediatrics) For access to specialty consultation, SMEs For access to patient transportStep 6: Practice, Practice, Practice: Conduct disaster drills that include pediatric victims ofsufficient number and acuity as to exceed typical operating conditions. Exercises should includethe following components: Triage, decontamination Unaccompanied children, tracking, reunification Surge capacity (ambulatory and inpatient) Participate in local/regional disaster exercises Include schools and child care facilitiesAvailable Resources: AAP Children and Disasters Website8 provides disaster planning resources forpediatricians and other stakeholders:o Psychosocial and mental health considerations and other information on naturalhazards, influenza, CBRNE, etc.o Resources for clinicians (Practice guidance, management recommendations)o Resources for patients and familieso Link to the Disaster Preparedness Advisory Councilo Numerous external

Jun 20, 2013 · I. Welcome & Overview HPP Special Topics National Call Pediatric Preparedness for Heal