ࡱ>       U nbjbjnn Vaag1x..(((d&*&*&*0V,B/\ &*rB;r>X>>>tTD$$j(|4@..>>N@̤̤̤|.>(>̤̤̤R{i%[{>S A8<oo*Hr pN 2tl 2<[{s{2({̤r2B :  *** Template/Example*** HOSPITAL PEDIATRIC DISASTER PLAN February 10, 2012  HOSPITAL PEDIATRIC DISASTER PLAN Approved by: Acknowledgements This template/example was developed by the Tucson Medical Center and the Arizona Pediatric Disaster Coalition Subsequent use by other facilities will require review of the contents for applicability and customization. FOREWORD As in day-to-day medical emergencies, children face unique vulnerabilities during disasters. This plan provides pediatric-specific guidance to all HOSPITAL Pediatric Emergency Department, Pediatric Unit, Pediatric Intensive Care Unit and Nursery Intensive Care Unit staff. Child-centric approaches will be used for triage, treatment, and decontamination to achieve optimal outcomes in any disaster events involving pediatric patients brought to HOSPITAL. This plan supplements the HOSPITAL Pediatric patient care standards adopted and maintained in all day to day Pediatric Care. The HOSPITAL Emergency Management Committee evaluated and approved this plan and the tools that will be used to implement this plan. This plan includes references that provide supporting evidence for the recommendations and tools for implementation. Finally, the Emergency Management Committee views these guidelines as living documents to be expanded and modified as resources and new information become available. These guidelines will be reviewed, updated and presented to the HOSPITAL Emergency Management Committee for approval every 3 years or after any changes are made to this plan. PEDIATRIC DISASTER PLAN TABLE OF CONTENTS HOSPITAL CARE OF CHILDREN IN DISASTERS OVERVIEW Introduction 1 HOSPITAL SURGE CAPACITY Introduction 5 SAFETY AND SECURITY Introduction 6 DECONTAMINATION Introduction 8 PATIENT MANAGEMENT AND TREATMENT TRIAGE Introduction 10 MEDICATIONS Introduction 14 EQUIPMENT Introduction 17 FLUID MANAGEMENT Introduction 17 MENTAL HEALTH ISSUES Introduction 19 SPECIAL NEEDS POPULATION Introduction 21 DRILLS AND EXERCISES Introduction 22 FAMILY INFORMATION CENTER Introduction 25 Appendices Appendix A General Disaster Plan Checklist 27 Appendix B Hospital Surge Capacity Checklist 29 Appendix C Safety and Security Checklist 31 Appendix D Decontamination Planning Checklist 33 Appendix E Multi-Casualty Triage Checklist 38 Appendix F Medications Checklist 40 Appendix G Equipment Checklist 40 Appendix H Mental Health Checklist 41 Appendix I Special Needs Population Checklist 41 Appendix J Drills and Exercises Checklist 46 Appendix K Family Information Center Checklist 48 ACRONYMS 52 HOSPITAL CARE OF CHILDREN IN DISASTERS - OVERVIEW Introduction The Center for Medicare Services ( CMS ) requires all hospitals to have a disaster plan in place. This Pediatric Hospital Plan is specific to pediatrics situations in any disaster where Pediatric patient care would occur. The following overview outlines the necessary components of hospital preparedness for disasters involving children. Hospital Personnel Roles in Disasters Within HOSPITAL, the disaster response team personnel include clinicians and non-clinicians, both of whom have acquired the appropriate knowledge and skill and are willing responders during disaster situations. Primary clinicians include Emergency Department physicians and nurses, Critical Care physicians and nurses, surgeons and surgical nurses, and respiratory therapists. Primary non-clinicians include administrative/executive leaders or managers, safety and security personnel, psychologists/social workers, emergency planners, and facilities personnel. This group of individuals aid in the clinical operations and safety and security of the building and surrounding areas. Secondary clinicians include general pediatricians, pediatric subspecialists, family practitioners, and general surgeons. This group of clinicians can be called in for additional pediatric support, and relied upon for their knowledge about pediatric illness or injury management and their resuscitation skills. Secondary non-clinicians include laboratory personnel, pharmacy staff, engineering, secretarial support, runners/transporters, and child life personnel. These individuals or departments provide services that are vital to the hospital environment and to the management and treatment of pediatric victims. Alert, Notification, and Mobilization HOSPITAL maintains a disaster call tree in every department and unit and a web based mass notification software program to alert, notify, and mobilize their staff in disaster situations that require additional staffing. The department disaster call trees includes a variety of contact methods, such as cell phone, office phone, pager, and home phone. These numbers are called until the person is contacted one at a time from the list and the message is delivered and answers written down before going to the next person. The disaster call trees are practiced annually. The Mass Notification web based program ( Amerilert ) can send voice and text messages to all the necessary staff on e-mail, cell phone, home phone, office phone and pagers for up to 500 people all at one time. This notification system is practiced annually. Mobilization procedures take into account contingencies such as disaster related communications, transportation barriers, and the need for hospital staff to have available childcare or elder care. Transportation arrangements to and from the hospital have been planned in advance to include: use of personal vehicles, City Bus service, car pool arrangements, responding to the manpower pool, and alternative facility entry routes and parking sites. Car Pool arrangements are updated annually. Knowledge and Competencies Emergency Management HOSPITAL completes all the preparedness guidance from the U.S. Hospital Preparedness Program, Arizona Department of Health Services and Pima County Health Departments. HOSPITAL is represented on the National Disaster Medical System Committee, Metropolitan Medical Response System Committee ( MMRS ), MMRS Healthcare subcommittee, Urban Security Initiative Committee, US Infraguard Committee, AZDHS Regional Preparedness Committee and AZDHS Southern Az. Coalition Committee. All emergency management program activities, plans and after action reports are reviewed and approved by the HOSPITAL Emergency Management Committee and the HOSPITAL Safety Committee. HOSPITAL uses the Hospital Incident Command System to manage all exercises, drills and events. All personnel assigned to a Hospital Incident Command System ( HICS ) position are trained to carry out their job action responsibilities in an organized, systematic fashion. Each HICS position has 4 HOSPITAL Leadership members assigned so one trained Leadership member would be available in any situation. All trained Leadership practice in real events as well as exercises and table top exercises that allow them to maintain their skills and understand all the HICS forms needed for an event. Chemical, Biological, Radiologic, Nuclear, Explosive, (CBRNE) HOSPITAL uses in house staff, seminars, classroom and online education to make sure the HOSPITAL Hazmat team and Emergency Department and Pediatric Emergency Department nurses and physicians who are required to care for pediatric victims of a disaster, learn the skills needed to treat pediatric victims. This training includes triage, and treatment for Chemical, Biological, Radiological, Nuclear, explosive as well as pandemic events. Children are more susceptible to dehydration and shock, are more vulnerable to radiation, have greater effects from skin/inhaled agents, and must be treated with medications using weight based dosing and appropriate sized equipment. Triage During a Disaster HOSPITAL uses Jump START to triage Pediatric patients in disasters. Pediatric victims may be too developmentally immature to respond to adult oriented triage tasks, making these pediatric specific designed protocols important. Pediatric patients provide additional challenges as they may be brought in without a parent or caregiver, and may be frightened, crying, and exhibiting uncooperative behavior. As a means of comfort and support, volunteers, child life, or mental health staff are imperative. All pediatric victims, in addition to a physical assessment, may require psychological care. HOSPITAL Hazmat team and the HOSPITAL Emergency Department and Pediatric Emergency Department Physicians are trained in Jump Start Triage. Personal Protective Equipment (PPE) HOSPITALS use of PPE is essential to protect the health care worker from hazardous or potentially hazardous materials. Although necessary for the care of pediatric patients, PPE can look strange and frightening to a pediatric patient, so HOSPITAL uses emotional support and communication to help pediatric patients deal with these scary situations during treatment. HOSPITAL maintains enough stock of PPE including stocks of size appropriate masks that can be utilized for pediatric patients during transport in common areas. Decontamination Decontamination for pediatric patients can be challenging and difficult. This is due to a number of factors, including the nature of the disaster and the patients physiological and developmental stage. Pediatric patients, for instance, may chill easily, become hypothermic, and therefore require warm water during the washing component of decontamination. In addition, pediatric patients may not be able to follow directions, self-decontaminate, wash thoroughly, or be able to manipulate equipment. If possible, children should be sent through decontamination with a family member. HOSPITAL Hazmat team trains on these situations and is prepared to help family members to decontaminate their children or to decontaminate the children and get them through to the Emergency Department staff to begin the treatment process. The Hazmat team practiced Pediatric decontamination in citywide exercises in 2009, 2010 and 2011. Communication Many pediatric patients are non-verbal, and providing companionship and direction by available personnel or family members will be essential. Use of toys, coloring books, child friendly signs, or other modalities of distraction may aid in the process. Mental Health Pediatric victims of disaster have unique psychological needs. There will inevitably be fear and panic, and it is therefore important to establish a method of rapid psychological assessment. Surge Capacity It is inevitable that all hospitals in a large-scale disaster involving pediatric patients will be overwhelmed. Therefore, an inventory of space required, staffing needs, medications, equipment, and other supplies must be performed. Written arrangements and contingencies should be conducted with other hospitals and agencies so that collaboration can take place with regard to both mechanical and material needs, as well as transfer arrangements for specific patient types i.e., dialysis patients requiring a dialysis unit. Another alternative solution may include long distance consultation (e.g. telemedicine) with pediatric facilities. Evacuation A written pediatric disaster plan should outline the means of evacuating patients from patient floors to alternative sites in the event of an internal or external disaster. This plan should be documented and practiced in a drill format or simulation setting. Reunification A pediatric (family reunification) plan is used in all pediatric disaster conditions. A workable partnership between HOSPITAL and Local and state government agencies, along with the American Red Cross, media outlets, missing children agencies, websites, and reunification sites are part of the local network that helps to reconvene families during and after a disaster. Patient tracking through the Az.Dept. Of Health Services EM Track web based program allows all these agencies to see what health facility the pediatric patients were taken to for treatment. This also allows these agencies to see if the patients were discharged and where they were discharged to. HOSPITAL has a plan for internal Family Information Centers set up in Tucson Orthopaedic Institute to provide support to the families of disaster victims and facilitate reunification. Recovery and Continuity Plan The purpose of this plan is to establish clinical business procedures and to designate resources for recovery after a disaster. These business arrangements help to establish both general and subspecialty pediatric care and allow families to cope more effectively with a disaster. Management and Treatment of Pediatric Patients Several courses will help the clinician best care for the pediatric victim of disaster. Recommended courses include, the American Heart Association (AHA), pediatric advanced life support (PALS), the AAP/ACEP Advanced Pediatric Life Support course (APLS) and for the advanced pediatric provider, the pediatric emergency assessment recognition and stabilization course (PEARS), Basic Fluid Management A specific challenge to any pediatric provider is managing the dehydrated patient, secondary to the effects of CBRNE events, or a natural disaster. This Plan provides a chart outlining the treatment of mild, moderate, severe dehydration, and hypovolemic shock see dehydration chart in fluid management section of this plan. Medication and Supplies As part of pediatric disaster planning, a listing of appropriate pediatric medications and supplies is part of this plan, (see medications and supplies). In addition, items such as diapers, varying types of formulas, child friendly toys and games are included, along with supplies for the pediatric patient with special needs, such as replacement gastrostomy tubes, nasogastric tubes, tracheostomy tubes, and various sized ostomy bags. The clinician is able to calculate pediatric drug dosages and equipment sizes based on established drug dosing books, charts, or a length-based dosing tape, such as the Broselow tape. Pediatric Disaster Plan As pediatric patients historically comprise approximately 15-20% of disaster victims, special considerations exist for this vulnerable population. The following is part of the Hospital Incident Command System: Predictable chain of command and management for pediatric patients Organizational charts that allow for response to both adult and pediatric emergencies Development and maintenance of a response check list that incorporates the needs of pediatric patients Accountability among providers in disaster services Documentation both during and after the primary event using electronic charting ( One Chart Epic ) or downtime paper patient charting. Appropriate communication among victims of disaster, and within the internal and external environment HOSPITAL Pediatric Disaster Plan Individual Roles The HOSPITAL Pediatric disaster plan relies on the HICS job action sheets that outline responsibilities of Pediatric providers. From a pediatric management prospective, job action sheets list those functions unique to pediatric disaster care and/or be supplemented by job action sheets specific to the needs of the pediatric population. Applicable Pediatric Disaster Training Pediatric disaster planning strategies are completed with drills, tabletops, and exercises that incorporate children as disaster victims. These exercises are critical as they allow functional knowledge to be transformed into realistic practice scenarios. HOSPITAL SURGE CAPACITY Introduction The Agency for Healthcare Research and Quality (AHRQ) defines surge capacity as any healthcare systems' ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care and public health in the event of bioterrorism or other large-scale public health emergencies or disasters. Key issues addressed in disaster surge scenarios include psychosocial behavioral considerations, convergent volunteerism, the need for special types of expertise and supplies, such as pediatrics, the mental health impact to both health care providers and victims, and areas that may require regulatory relief. HOSPITAL also evaluates specifics of Staff, Space, Supplies, and System requirements. Pediatric specialists (pediatric surgeons, orthopedists, anesthesiologists, etc.) and pediatric beds, supplies, and equipment are kept at a level to meet facilitys present capacity to care for children and to meet a pediatric surge capacity. **It is assumed that 15-20% of victims from a mass-casualty incident will be children. PEDIATRIC SAFETY AND SECURITY Introduction Pediatric safety and security issues are critically important within HOSPITAL property. HOSPITAL plans pediatric security issues focused upon infant and child abductions. HOSPITAL established protocols for patient tracking for both accompanied and unaccompanied child and family reunification in disasters or when found roaming the facility without a parent. The identification of an unaccompanied or displaced child is a priority after triage to ensure his/her safety. This child may or may not need medical treatment. HOSPITAL staff also look for unaccompanied children, as they will likely be listed as missing, by family members and report these situations to Security. All of these children from disaster situations should be tracked, and reported to Security in Non disaster situations and the Hospital Command Center in disaster situations. These children should be reported to the Red Cross so family members can locate where they are being treated. If this does not reconnect the child with his or her family they should also be reported to the National Center for Missing and Exploited Children (NCMEC) at 1-888-544-5475. The NCMEC can then cross-check them with the names of children who have been reported missing. There are two types of accompanied children in the aftermath of a disaster that may present to your hospital: The pediatric patient who is a victim of a disaster and is with a responsible parent or a parent that is also a disaster victim. The pediatric patient who is not a victim of the disaster (does not warrant medical treatment) but is accompanying an adult victim of a disaster. The identification document, electronic medical record or band to be placed on the accompanied child should include the following, if available: Name of pediatric patient/visitor and date of birth Name of adult, relationship to child, and date of birth Admission date of adult (if the adult is a victim) Admission date of injured pediatric patient Date of visit of uninjured pediatric patient HOSPITAL has established a Pediatric Safe Area within the Pediatric unit, which is defined as an area of the hospital where unaccompanied pediatric visitors and unaccompanied released pediatric patients may be grouped together under supervision. Security personnel and Pediatric staff are trained to secure this area and allow the Child Life Specialist staff to handle and manage these children. The Pediatric Safe Area is very kid-friendly and safe: Distractions (toys, books, art supplies, etc.) are readily available. The area has been proofed from choking hazards and poisonous substances. The injury-prone objects in the area (sharp objects, etc.) are constantly monitored or removed by Child life specialist staff. Bathrooms are readily available to the children. Windows do not open. The area is away from stairwells and other fall-risks. Pediatric snacks are available. There is enough staff and security to ensure the safety of the children. DECONTAMINATION Introduction Infants and children have unique needs that require special consideration during the process of hospital decontamination. Decontamination of young children is done with high-volume, low-pressure, hot / cold mixed water that meets the temperature requirements for pediatric patients in decontamination tent systems. HOSPITAL Decontamination tent system is designed for decontamination of all ages and types of children and adults including ambulatory and non ambulatory equipment. All protocols and guidance address: Triage Start and Jump Start Water temperature and pressure Non-ambulatory child Child with special health care needs Clothing for after decontamination Heating tent when cold outside Cooling tent when extreme heat outside Tracking belongings Specific Considerations Removal of clothing alone accounts for removal of most contaminants. Attention to airway management is a priority throughout decontamination. Child sensitive soap and water are used to decontaminate skin, as bleach and other chemicals will be harmful to the sensitive skin of children. Separation of families during decontamination is avoided, but medical issues take priority. The water temperature should be maintained at 98F, to reduce the risk of hypothermia in the smaller or younger children. Decontaminating children takes longer, due to the additional time required to assist them. Decontamination team can expect up to as much as fifteen minutes per child. Older children may resist decontamination out of fear, peer pressure, and modesty issues Parents or caregivers may not be able to decontaminate both themselves and their children at the same time requiring assistance from decontamination team. The smaller the child, the bigger the problem regarding any of these considerations such as hypothermia, airway management, separation of families, and ability to effectively decontaminate the child. Extreme caution should be exercised when children who are being carried are wet as they may be very slippery  SHAPE \* MERGEFORMAT  PATIENT MANAGEMENT TRIAGE Introduction HOSPITAL Hazmat Team and providers use JumpSTART, the Pediatric Triage tool for pediatric triage in disaster and decontamination situations. HOSPITAL Hazmat Team and providers are trained and participate in drills/exercises that include pediatric patients to maintain triage skills JumpSTART Pediatric Triage System Pediatric Multiple Casualty Incident Triage Using a standardized triage system for pediatric patients, helps emergency personnel to make life and death decisions that otherwise could be influenced by emotional issues when triaging children. JumpSTART Pediatric Multiple Casualty Incident Triage is an alternative objective triage system that addresses the needs of children. The JumpSTART system takes into consideration the developmental and physiological differences of children by emphasizing breathing during triage decisions. Adding a respiratory component to triage may increase triage time by 15-25 seconds. Additionally, physiologic indicators specified for START may not apply to the pediatric victim. For example, neurological status under START depends on the patients ability to obey commands. This index is clearly not applicable to young children who lack the developmental ability to respond appropriately to commands. Determining which triage tool to use in the pre-adolescent and young teen can be challenging. The current recommendation is to use JumpSTART if a victim appears to be a child; and to use START if a victim appears to be a young adult. In children, because of mechanical reasons such as weak intercostal muscles, apnea may occur rapidly. Thus, circulatory failure usually follows respiratory failure. There may be a period of time when the child is apneic but continues to maintain a pulse. It is during this time that airway clearance and a ventilatory trial may stimulate spontaneous breathing. If spontaneous breathing begins, the child is categorized as RED for further treatment. If spontaneous breathing does not follow the initial ventilatory trial, the child is categorized as BLACK or non-salvageable. JumpSTART uses the same color-coding as START: RED (Immediate); YELLOW (Delayed); GREEN (Minor/Ambulatory); BLACK (Deceased/non-salvageable).  SHAPE \* MERGEFORMAT  The triage steps of the JumpSTART Pediatric MCI triage system are as follows: Step 1: All children who are able to walk are directed to an area designated for minor (GREEN) injuries where they will undergo a secondary and more involved triage. Infants carried to this area or other non-ambulatory children taken to this area must undergo a complete medical and primary evaluation using modifications for non-ambulatory children to ascertain triage status. (Please refer to the Modifications for Non-Ambulatory Children* section on the following page). Step 2: a) All remaining non-ambulatory children are assessed for the presence/absence of spontaneous breathing. If spontaneous breathing is present, the rate is assessed and the triage officer moves on to step three. b) If spontaneous breathing is not present and is not triggered by conventional positional techniques to open the airway, palpate for a pulse (peripheral preferred). If no pulse is present, patient is tagged BLACK and the triage officer moves on. c) If there is a palpable pulse, the rescuer gives five breaths (approximately 15 sec.) using mouth to mask barrier technique. If the ventilator trial fails to trigger spontaneous respirations, the patient is tagged BLACK and the triage officer moves on. If respirations resume, the patient is tagged RED and the triage officer moves on without providing any further ventilations. Step 3: If the respiratory rate is 15-45/minute, proceed to check perfusion. If the respiratory rate is less than 15 (less than 1/every 4 seconds) or faster than 45/minute or irregular, tag as RED and move on. Step 4: Assess perfusion by palpating pulses on a (seemingly) uninjured limb. If pulses are palpable, proceed to Step 5. If there are no palpable pulses, the patient is tagged RED and the triage officer moves on. Step 5: At this point all patients have adequate ABCs. The triage officer performs a rapid AVPU assessment of mental status. If the patient is; Alert, responds to Voice, or responds appropriately to Pain (withdraws from stimulus or pushes away), the patient is tagged YELLOW and the triage officer moves on. If the patient does not respond to voice and responds inappropriately to pain (moans or moves in a non-localizing fashion) or is Unresponsive, a RED tag is applied and the triage officer moves on to the next patient. NOTE: All patients tagged BLACK, unless clearly suffering from injuries incompatible with life, should be reassessed once critical interventions for RED and YELLOW victims are completed. *Modifications for Non-Ambulatory Children Children in which this modification would be used include: Infants who normally cant walk yet Children with developmental delay Children with acute injuries which prevented them from walking before the incident occurred Children with chronic disabilities Non-ambulatory children who meet the above criteria are evaluated using the JumpSTART algorithm beginning with Step 2. If the child meets any RED criteria, the child is tagged RED. A quick survey is then conducted to determine whether there are any significant external signs of injury (i.e. deep penetrating wounds, severe bleeding, severe burns, amputations, distended tender abdomen or multiple bruises). If any significant external signs of injury are present, the child is tagged YELLOW. Non-ambulatory children without any significant external injury, with all other aspects of the JumpSTART algorithm normal, are tagged GREEN. MODEL HOSPITAL TRIAGE PROTOCOL  SHAPE \* MERGEFORMAT  PEDITARIC MEDICATIONS Introduction Due to anatomical and physiological differences, pediatric medication dosages are weight-based and use the length-based emergency tape which is a color-coded tool to estimate a childs weight and appropriate medication dosages. HOSPITAL keeps a 72 hour stockpile on hand of emergency Pediatric medications. This list is only a guide and is not intended to be an all-inclusive list of drugs kept in pediatric emergencies. Moreover, indications and adverse effects are not detailed in the table below. Medications may need to be compounded or made into a solution for administration to children. HOSPITAL ensures that sufficient pediatric pharmacy resources and safeguards are available. Pharmacists are on duty 24/7 to make sure the right medication and dosage are used with each patient. Note that the Poison Control Center number is 1-800-222-1222. Please refer to the recently published document, Preparing for Pediatric Emergencies: Drugs to Consider, by Mary Hegenbarth, MD and the Committee on Drugs, in Pediatrics 2008; Vol. 121; No.2, for a more comprehensive description. DrugRoute of AdministrationComments/NotesAcetaminophen PO, PRAnti-pyretic and analgesic Activated Charcoal POIf accidental ingestion or intentional terrorist poisoning; note that non-sorbitol containing products should be used in infants < 1 year of age. Also note that iron, lithium, alcohols, ethylene glycol, alkalis, fluoride, mineral acids, and potassium are not bound by charcoal.Adenosine IVSupraventricular tachycardiaAlbuterol inhalation solution NebulizedBronchospasm due to asthma or may also be useful if disaster involves fumes, fires, inhalation injury, etc. Albuterol metered dose inhaler InhaledAmiodarone IVArrhythmia treatment: ventricular fibrillation, tachycardia. Amoxicillin POUseful for multiple types of bacterial infections Atropine IV, IO, ETCode situations for symptomatic vagally mediated bradycardia or AV block and nerve agent (anticholinesterase) antidote Azithromycin PO, IVGood, broad spectrum, oral antibiotic Calcium Chloride 10% IV, IO Code situations for hypocalcemia, hyperkalemia, hypermagnesiumia Cephazolin IVFor pre-operative prophylaxis, skin infections, etc. Ceftriaxone IVUseful for meningitis, pneumonia, UTI, etc. Chloramphenicol IVFor PlagueCiprofloxacin IV, POAnthrax or Plague Clindamycin IV, POFor PCN allergic patients and for anerobic infections Cyanide antidote kit IVHydroxycobalamin instead? Dexamethasone IV, PO, IMIV, IM, POEmergency treatment of elevated intracranial pressure, laryngotracheobronchitis (croup), asthma exacerbationDextrose 10% in water IVHypoglycemia in neonateDextrose 25% in water IVHypoglycemia in infant or childDextrose 50% in water IVHypoglycemia in older child or adolescent Digoxin injection IVFor congenital heart disease kidsDiphenhydramine injection IVAllergic reaction treatment Diazepam nerve agent antidote IMRegenerates acetylcholinesteraseDiazepam IV, IM, POStatus epilepticus Dobutamine injection 200mg vial IVCardiogenic shock treatment Dopamine injection 200 mg vial IVTreatment for septic and cardiogenic shock Doxycycline IV, POUseful for multiple bioterrorist agents (anthrax, plague, etc.) Epinephrine injection IV, IM, ETFor code situations, cardiopulmonary resuscitationEpinephrine racemic NebulizedErythromycin eye ointmentApplied to the eyes as an ointmentUse for corneal abrasions after traumatic exposures Etomidate IVFor rapid sequence intubation and sedation Fentanyl IVAnalgesia Flumazenil IVAntidote to benzodiazepine overdose Fosphenytoin IV, IMStatus epilepticusFurosemide IVFor the congenital heart disease patients with congestive heart failure Glucagon IV, IMUse for when unable to obtain iv access in hypoglycemic patientsHeparin solution IVHydrocortisone injectionIVAdrenal insufficiency Ibuprofen POAnti-pyretic and analgesic Insulin multiple preparations will be necessary IVFor the insulin dependent diabetics Ipratropium inhalation solution NebulizedSynergistic effect for asthmatics Kayexelate PO, PRHyperkalemia treatment Ketamine IV, IMFor sedation, contraindicated in infants <3 months of ageKetorolac tromethamine injection IV, IMNon-narcotic analgesia Lidocaine injection ET, subcutaneous, IV, IOVentricular arrhythmias, anesthesia Magnesium sulfate IVLorazepam IV, IM, POStatus epilepticusMagnesium sulfate IV, POTreat hypomagnesiumia and hypokalemia, as well as Torsades de pointes VT Mannitol injection IVFor treating increased intracranial pressure Methylprednisolone IV, IMAsthma, allergic reactionsMidazolam IV, IMFor sedation, seizures Milrinone IV, IOMyocardial dysfunctionMorphine IV, IM, POAnalgesia Naloxone IV, IMNarcotic overdoseNitroprusside IVHypertensive crisisPeds Mark1 Nerve agent antidote kits IMNerve agent antidote Penicillin G Benzathine IVPhenobarbital IV, POSeizures Phenytoin injection IVSeizures Polymixin Bacitracin ointment 0.9gm pack Topical For superficial wounds and burnsPotassium Chloride IVPotassium Iodide PORadioactive iodine exposurePralidoxime injection IMNerve agent antidote Prednisone and Prednisolone POAsthma care Procainamide IV, IO Arrhythmia Prostaglandin E IV, IOSuspected or proven ductal-dependent cardiac malformation in the neonatal periodRocuronium IVNeuromuscular blocking agent; paralysis to facilitate mechanical ventilation Silver sulfadizine cream TopicalFor burn care Sodium bicarbonate IV, IOCode situations, hyperkalemia, metabolic acidosis, sodium channel (e.g., tricyclic antidepressant) overdoseSodium chloride injection IVSuccinylcholine IVNeuromuscular blocking agent for emergency intubation Tetanus Immnoglobulin (TIG) IMFor at-risk wounds and those without any vaccination history Tetanus vaccinations IMWound care Tetracaine ophthalmic solution Applied topically to the eyeTo facilitate painful eye examinations Vecuronium IVNeuromuscular blocking agent; paralysis to facilitate mechanical ventilation  EQUIPMENT Introduction Children require size-specific equipment. Thus, we recommend the use of a tool, similar to the length-based (e.g., Broselow) emergency tape. Redundant communication equipment is available (such as Hand held radios, HAM radio operators, cell phones, Vocera, disaster phone system, intercom, satellite computer, mass notification web based software and pagers etc.). In addition to the listed medical and surgical equipment and supplies, we keep stockpiles of diapers, diaper wipes, formula, computers, games, distraction devices, such as toys, bubbles, books, games, and art supplies. FLUID MANAGEMENT Introduction Pediatric patients are vulnerable to dehydration, because 8-10% of their body water is turned over on a daily basis, whereas adults turn over less than 5% of body water daily. Thus, decreased intake through fasting (food and water may be less accessible), vomiting, and diarrhea, or increased insensible losses secondary to fever or respiratory distress may rapidly result in dehydration. The diagnosis of dehydration is based on clinical criteria, where the degree of dehydration is expressed as a percentage of pre-illness weight: mild dehydration approximates 5-8% loss moderate is 9-12% loss severe is >12% loss Less than 5% dehydration is usually clinically inapparent, An infant that is more than 15% dehydrated will have tenting of the skin, sunken fontanels and eyes, a weak and rapid pulse, and may be anuric. To calculate maintenance fluids: Free water needs are 100ml/kg/day for the first 10 kg of body weight or 4ml/kg/hr; 50ml/kg or the second 10 kg or 2ml/kg/hr; and 20ml/kg for more than 20kg of body weight, or 1ml/kg/hr. Note that sodium requirements are 2 to 3 meq/kg/day, and potassium requirements are 1 to 2 meq/kg/day. The following chart categorizes the recommended treatment modalities for dehydration. This underscores the importance for hospitals to have stockpiles of formula, age-appropriate foods, and saline. Treatment for Mild, Moderate, Severe Dehydration MildModerateSeverePrimary Phase*PO*POIVSecondary Phase (If Primary Phase fails)NG IVNG IVCentral line Intraosseous (IO)Tertiary Phase (Optional)POPO+ PO after initialLab StudiesNone**NoneElectrolytes, BUN, Cr, calcium, glucose, urineFluid Amounts< 50 ml/kg50-100 ml/kg> 100 ml/kgTreatment Length< 4 hours1-4 hours> 4 hoursDischarge CriteriaBaseline or near baseline vital signs Urine output during hydrating period Moist oral mucosa Streaming tears No or minimal ongoing losses Able to tolerate POs (optional)Not ApplicableTreatment Failure Admit or Observation UnitAdmit*PO 5cc (1 teaspoon) every 1-2 minutes. ( based on patient tolerance NG 20 ml/kg/hr over 1- 4 hours (ORS) IV (Moderate dehydration) 50-100 ml/kg over 1- 4 hours (NS or LR) IV (Severe Dehydration) 20 ml/kg over 5-30 minutes (NS or LR) Aim for 60 - 100 ml/kg within the first hour. Contraindications include some forms of cardiac disease, e.g. cardiomyopathy, or neurologic disease. ** May need to obtain labs based on dietary history or disease state A safe alternative to the above methods of rehydration that may be useful in a mass casualty scenario in which it is impractical to attempt intravenous insertion or there are many patients unable to maintain adequate oral hydration is Hypodermoclysis, which is a method of infusing fluid into subcutaneous tissue. While the preferred solution is normal saline, other solutions such as glucose with saline, can also be used. The most common infusion sites are the chest, abdomen, thighs, and upper arms. Hyaluronidase can also be added to enhance fluid absorption, and there are commercial products, such as hylenex recombinant (hyaluronidase human injection) that are specifically marketed for this purpose. The most frequent adverse effect of hypodermoclysis is mild subcutaneous edema, which is easily treated with local massage or systemic diuretics. There are few absolute contraindications to hypodermoclysis, but relative contraindications include shock, congestive heart failure, and coagulopathy. MENTAL HEALTH Introduction Children will respond to trauma and disasters differently than adults, and there will be large range in responses, depending upon the childs age, socio-cultural background, and personality. Some may have overt reactions in the acute phase, while others may not manifest symptoms for many weeks or months. It is helpful to know age-specific reactions, however, and to know what interventions may be beneficial. Preschool age (1-5 years of age) and school age (6-12 years) Children may regress to an earlier behavioral stage: they may revert to thumb sucking and bedwetting, become afraid of strangers, and cling to parents. Children may become disobedient, hyperactive, aggressive, or they may withdraw. Changes in eating and sleeping habits are expected, and they may complain of multiple body aches and pains. Interventions: If possible, attempt to avoid separation. Encourage expression through play, drawing, puppet shows, and storytelling. Limit media exposure. Set gentle but firm limits on acting out behavior. Provide structured activities and chores. Preadolescents and adolescents (12-17 years) Preadolescents and adolescents may develop vague physical complaints and may abandon chores, schoolwork, and other responsibilities. They may also withdraw, resist authority, become disruptive in the classroom, and begin to experiment with high-risk behaviors, such as alcohol or drug abuse. Interventions: Encourage discussion of experiences among peers, but do not force them to talk about their feelings. Listening to them is critical Providing structured activities and involvement in community recovery work may be beneficial. Psychological First Aid Psychological First Aid is an evidence-based approach to help victims cope in the aftermath of a disaster. The primary objective of Psychological First Aid is to create and sustain and environment of 1) safety, 2) calm, 3) connectedness to others, 4) self-efficacy or empowerment, and 5) hope. In speaking to children and adolescents, the following steps are evaluated for use with each patient. Contact and engagement My name is _______ and I am here to try to help you and your family. I am a _______ worker here, and I am checking with people to see how they are feeling. May I ask your name? Safety and comfort Do you need anything to drink or eat? Is your family here with you? Do you have a place to stay? We are working hard to make you and your family safe. Do you have any questions about what were doing to keep you safe? Stabilization (if needed) After bad things happen, your body may have strong feelings that come and go like waves in the ocean. Even grown-ups need help at times like this. Is there anyone who can help you feel better when you talk to them? Can I help you get in touch with them? Information gathering May I ask some questions about what you have been through? Can you tell me where you were during the disaster? Did you get hurt? Is your family safe? How scared were you? Is there anything else that you are worried about? Practical Assistance It seems like what you are most worried about right now is _____________. Can I help you figure out how to deal with this? Connection with Social Support You are doing a great job letting grown-ups know what you need. It is important to keep letting people know how they can help you. That way, you can make things better. Information on Coping Its normal for kids to feel scared after bad things happen. You will probably start to feel better soon. If you like, I can tell you some ways to help you feel better. You can also call 800-854-7771(hotline staffed by mental health professionals trained in disaster response) any time to talk to people who can help you. Other support - Provide direct referrals to a) county mental health services or those through private insurance, b) Red Cross and FEMA, as appropriate. Continuity in Helping Relationships Facilitate referrals: May I help make some calls to people who can help you? and if feasible, Id like to check in with you again to see how you are doing. How may I contact your parents later? HOSPITAL Pediatric Emergency Department will evaluate all psychiatric patients and determine what level of care and facility is required for each patient. The age of the patient is considered in all evaluations and referrals for care. SPECIAL NEEDS POPULATION Introduction Children with special needs are those with chronic physical, developmental, behavioral, or emotional conditions. Such conditions may include those with physical problems, such as those who are immunosuppressed because of an underlying malignancy, diabetes mellitus, or end-stage renal disease on hemodialysis. Other pediatric special needs populations include children with mental retardation cerebral palsy (MRCP) who may be wheelchair-bound, have indwelling tracheostomy tubes and enteral feeding tubes, ventilator-dependent children, as well as those with autism, learning disabilities, cognitive disabilities, and limitations in vision or hearing. An emergency care plan has been advocated by the Pediatric Emergency Department. Essential components of a program include the following: 1, 2 A method for identifying at-risk children Education of families and other caregivers 3. Use of a standardized Emergency Information Form for children with special needs (completion of a data set by the childs caregivers and/or physicians) - records of each childs special needs should be maintained in an accessible and usable format. This standard form is easily accessed through the American Academy of Pediatrics and is available in both Spanish and English:  HYPERLINK "http://www.aap.org/advocacy/emergprep.htm" http://www.aap.org/advocacy/emergprep.htm. Vital information to be gathered on such a form includes: Demographics name of child, nickname, birth date, home address and phone, parent/guardian, emergency contacts, and primary language. Physician Contact information primary physicians name and contact information, as well as specialty physicians names and contact information. Anticipated primary ED, pharmacy, and tertiary care center. A list of diagnoses, past procedures, and physical exam, including baseline physical findings, vital signs, and baseline neurologic status. Medications and allergies, including dose and route of administration. Significant baseline ancillary findings (labs, x-ray, EKG). Medications, foods, and procedures to be avoided. Immunization status, including dates of last immunization. Common presenting problems with management strategies. DRILLS AND EXERCISES Introduction Education and training of hospital personnel in coping with pediatric patients in disasters is essential. The children under 18 years of age in Arizona, comprise approximately 25% of the state population. Thus, children will be well represented in any major disaster. The needs of children and their response to disasters may be very different from that of adults. HOSPITAL uses several ways to train personnel, including interactive presentations, lectures, table-top drills, and full-scale drills and exercises. Training include pediatric patients, and involve pediatric triage, treatment and transport. Field decisions regarding pediatric patients are always somewhat more difficult due to differences in cognitive function and size. HOSPITAL included one example scenario here that can be included in a drill or exercise. Disaster Scenario This scenario can be used as part of a larger drill, or as a stand-alone drill. Note that: The scenario can be adapted for any size of hospital configuration, using more or fewer victims. Special consideration should be given to assessing local resources, and then considering regional resources when needed. With parental permission, volunteers can serve as simulated patients, and mannequins can also be used when volunteers are not available. Pediatric patients can either be moulaged, or given a label describing their condition. Scenario #1: School Explosion Scenario 1 At 9:30 a.m., a call to 911 is received. There has been an explosion in a local school. The cause of the explosion is unknown. The school has 200 students, elementary and middle school level. Law enforcement has been dispatched, and is on scene. As you arrive on scene, another explosion occurs. The school is being evacuated by school officials and law enforcement, and it is obvious that there are multiple casualties, including teachers, assistants and children. Both children and adults are exiting from the building coughing, eyes tearing, and collapsing onto the ground. The school Principal tells Law Enforcement that the school has had problems with seepage of methane gas in the past, and although they thought the problem was eliminated, this is a possible source of the explosion. She tells you, however, that the explosion occurred near the science room, and there were some potentially dangerous chemicals such as formaldehyde in a closet in the room. Neighbors and parents who can hear the sirens are showing up at the school and trying to find their loved ones. There are nine hospitals available within the community. Hospital A is a level III trauma center 2 miles away from the disaster; Hospital B has a Pediatric Emergency Department with 24 hour service 2 miles away, and Hospital C is a small hospital with a Emergency Department 2 miles away. Hospital B has a pediatric ward and a Pediatric ICU. Hospital C has no pediatric ward or ICU. Scenario #1: School Explosion Hospital Response Hospital Response to this disaster would include the following (this list is not necessarily complete, or in the appropriate order) Communication from the prehospital setting. Safety of the hospital. Control of ingress and egress to your hospital. Hospital Incident Command concerns. Identification of possible chemical agents. Additional personnel needed for this response. Triage of patients. Identification of patients. Assessment of bed, staff, and system capability to care for patients. Decontamination. Transfer of pediatric patients to local/regional facilities, including destination plan. Available resources, locally and regionally. Family reunification. Scenario #1: School Explosion - Casualty List VICTIMRESPIRATORY RATEPERFUSIONMENTAL STATUSOTHER8 y.o. FRR 32 Palpable pulse Alert, crying hystericallyMultiple small lacerations with embedded wood and glass entire dorsal area of body, head to toe9 y.o. M RR 12Weak, thready pulseDisoriented to place and timeHematoma forehead, facial lacerationsAdult M RR 48 Capillary refill >2 Moaning, unable to follow commandsLarge glass chard protruding from abdomen, wheezing9 y.o. F RR 8 Pulse absentUnresponsiveImpaled onto shelving brackets on wall6 y.o. M RR 36 Pulse present Won't speak but makes eye contact with touchBleeding from ears, bruise on neck7 y.o. F RR 0Weak radial pulseUnresponsive Trapped under rubble; apneic after 5 rescue breaths12 y.o. M RR 34Rapid pulse Keeps asking same questionsTearing, runny nose, complains of headache10 y.o. F RR 52 Thready pulseConfused Coughing, brisk bleeding from facial and hand lacerations11 y.o. M RR 40 Pulse present Disoriented to place and timeScalp lacerations, bleeding from multiple small wounds on upper extremities, coughing.9 y.o. M RR 10 Weak rapid pulseUnresponsiveGlass cuts to leg, heavy bleeding12 y.o. MRR 44Pulse weak, left armHysterical, cryingPartial amputation, right forearm6 y.o. M RR 40 Pulse present Responds to pain Open femur fracture, lacerations to hands and face7 y.o. F RR 32 Pulse present Crying but oriented x 3 Open fracture lower leg; contusions to arms and chest8 y.o. M RR 36 Bounding pulse Alert but won't speakBurns to neck and torso, lacerations to armsAdult F R 28 Capillary refill <2 Crying for help, able to recall eventsLeg caught under lab desk and chairs - open fracture9 y.o. MRR 30Rapid, thready pulseConfusedLarge contusion on forehead, diaphoretic12 y.o. F RR 0 Absent pulse Unresponsive Trapped under rubble11 y.o. M RR 32 Rapid pulse Alert and anxious Coughing, vomiting, blackened hairs in nostrils6 y.o. F RR28 Rapid pulse Alert Crying, no obvious injuries10 y.o. F RR 44 Radial pulse weakResponds to verbal stimuli, disorientedLarge bruise forming on abdomen, contusions on legs FAMILY INFORMATION CENTER Introduction The purpose of a Family Information Center (FIC) at HOSPITAL is to have a comfortable place to assist families who are seeking information about the location of their missing family member(s) following a mass-casualty event, terrorist attack, or large natural disaster. While this Planning Guide is designed for the hospital, its principles can be applied to other settings such as an alternative care site setting where children may need to be held following disasters pending reunification with parents. Planning for a hospital-based FIC involves the following considerations: Location and Layout Staffing Supplies and Equipment Planning and Activation Pediatric Safe Area Planning and Procedures; consider Just in Time training in a disaster response. Pediatric Safe Area Safety and Security Communications and Information Management Appendix A HOSPITAL PEDIATRIC DISASTER PREPAREDNESS General Disaster Preparedness Checklist ItemYesNoIn ProcessPOLICIESDestination policies are in place for numerous children in a multi-casualty incident, including transport to higher levels of care for more seriously ill or injured children in a large-scale disaster.XAgreements have been made with pediatric tertiary care centers and other facilities outside HOSPITAL for pediatric patients requiring higher levels of care or specialized care.XPlans for disasters include means of obtaining additional pediatric equipment, supplies and medications.XDisaster planning includes attention to children with special health care needs and pediatric mental health issues.XPROTOCOLSMethod for triage of pediatric patients such as incorporating the Pediatric Assessment Triangle into the SALT framework, JumpSTART or other means of determining severity of injury or illness of pediatric patients exists.XTriage plan includes method of identifying pediatric patients and their family members to aid in reuniting them. XRapid method of determining dosages for children, e.g. length based tape, computerized decision support tool. XEnsure decontamination of children, including medically stable or unstable children and children with special needs are included in disaster plans. X EDUCATION1. Hospital regularly provides support or recommends special education in pediatrics for personnel, such as PALS, APLS, or pediatric education consistent with pediatric national standards for emergency care. X2. Interventions for biological, chemical, and radiologic disasters, with instructions specific to pediatric patients are included in training of hospital providers.X3. Children are routinely included in disaster drills and exercises. X4. Pediatric expertise (pediatricians, pediatric intensivists, etc.) is included in planning drills/exercises, other disaster-related activitiesX5. Other local hospitals, as well as local/statewide agencies/organizations interested in pediatric care, such as public health agencies, schools, daycare facilities, health clinics, and the American Red Cross are included in planning for disasters, and in disaster exercises...X6. Pediatric expertise is routinely included in debriefings/evaluations for disasters or disaster exercises.X7. Evacuation plan should include supplies, equipment and strategies to safely evacuate children. X There are many resources to use in accomplishing these objectives. The following are a few selected items that give an overview and some additional information: Resources  HYPERLINK "http://www.aap.org/terrorism/index.html" http://www.aap.org/terrorism/index.html  HYPERLINK "http://pediatrics.aappublications.org/cgi/content/full/120/4/e756" http://pediatrics.aappublications.org/cgi/content/full/aap120/4/e756  HYPERLINK "http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf" http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf  HYPERLINK "http://www.ncdp.mailman.columbia.edu/program_pediatric.htm" http://www.ncdp.mailman.columbia.edu/program_pediatric.htm Appendix B Hospital Surge Capacity Checklist ItemYesNoIn ProcessSTAFF1.A list is maintained on a regular basis of pediatric specialists: critical care, anesthesiologists, otolaryngologists, surgeons, RN, RT, etc.). A training log is kept of staff that have been trained in the care of pediatric patients in emergencies. Annual training in pediatric disaster preparedness is provided.Training for pediatric disaster management for staff is provided.Staff is trained in methods of familial reunification. Pediatric hospital staff participate as part of the incident command system during training drills. The number of available pediatric Unit beds, Pediatric critical care beds, neonatal care bed capacity, pediatric operating room capacity, etc. is updated on a daily basis. The adult beds/rooms that may be converted to pediatric beds has been determined. There is a mechanism in place to cancel pediatric surgeries or appointments. There is a method to implement early discharge of pediatric patients to facilitate admissions of disaster victims.  A discharge holding area and appropriate supervision for children has been identified, where they may have access to toys, books, and other distractions.SUPPLIES1. A pediatric medications and equipment stockpile is maintained, as discussed in the section on medications/equipment. 2. There are other non-medical supplies on-hand, such as toys, books, art supplies, and other distractions for children. 3. Have formula, bottles, cribs, and sleep mats in stockpile.SYSTEMS Mutual aid agreements have been made with other healthcare facilities, such as pediatric long-term care and rehabilitation centers.  Schools, faith-based facilities, and pediatric clinics for potential use as alternate treatment areas have been identified and included in local disaster plans. Relationships have been established with pediatric tertiary care centers for assistance in disasters.  References  HYPERLINK "http://www.cdc.gov/ncidod/sars/guidance/core/app2.htm" http://www.cdc.gov/ncidod/sars/guidance/core/app2.htm. Accessed May 22, 2006.  HYPERLINK "http://www.ahrq.gov" www.ahrq.gov. Accessed May 21, 2006  HYPERLINK "http://www.emsa.ca.gov/tba" www.emsa.ca.gov/tba Appendix C Safety and Security Checklist Safety and Security Checklist ItemYesNoIn ProcessStaff trained in supervising uninjured pediatric victims have been identified. A pediatric tracking system that addresses both the accompanied and unaccompanied child has been developed. A protocol to identify displaced, unaccompanied children is included in disaster plan. A document to identify (ID) children, which may help reunify them when their family is available. A Pediatric Safe Area for displaced, unaccompanied, and released children awaiting their caregivers has been identified. Pediatric Safe Area Checklist ItemYesNoIn ProgressThe Pediatric Safe Area has secure windows and doorsChildren can be contained in your Pediatric Safe Area The need for barriers, barricades, baby gates, etc. has been considered and planned for.The Pediatric Safe Area is free or secure from hazardous materials, needle boxes, choking hazards, electrical cords, supply carts, electrical outlets, etc.There is a process to start a sign-in and sign-out sheet to help with tracking, which includes times, the name of the adult picking up the child, and his/her contact information. Fans and heaters in use in your Pediatric Safe Area have been identified and made safe.The Pediatric Safe Area has space for children to safely nap without risk of falling. Cribs, cots, or mattresses on the floor are available.The Pediatric Safe Area has age and gender appropriate books, videos, games, toys, etc. available for children.The Pediatric Safe Area has age appropriate and nutritious snacks available for children.The Pediatric Safe Area has high chairs available for infants.The Pediatric Safe Area has Mental Health Liaisons and Support Services for children with disabilities.  References American Academy of Pediatrics. Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians. Foltin GL, Schonfeld DJ, Shannon MW, editors. AHRQ Publication No. 06(07)0056. Rockville, MD: Agency for Healthcare Research and Quality. October, 2006. Centers for Bioterrorism Preparedness Program Pediatric Task Force, NYC DOHMH Pediatric Disaster Advisory Group, NYC DOHMH Bioterrorism Hospital Preparedness Program. Hospital Guidelines for Pediatrics in Disasters, 2d Edition. NYC Department of Health and Mental Hygiene. December 2006. Illinois EMSC Project. Pediatric Disaster Preparedness Guidelines. Illinois Department of Public Health. August, 2005. Centers for Disease Control and Prevention. Public Healths Role in Terrorism Preparedness and Response for Children. Centers for Disease Control and Prevention. August, 2003. Los Angeles County Local EMS Agency Information Center document Appendix D Decontamination Planning Checklist (Note: This table follows decontamination procedures for adults, dividing decontamination into the standard Hot, Warm, and Cold Zones. Shown here are the added considerations for infants and children during the decontamination process.) ItemYesNoIn ProcessHOT ZONE (Outer area where initial decontamination triage occurs)A system exists for triage of children and families that includes waterproof identification tags or markers.Signage or means of making signage exists to identify areas and explain process to parents and children.Plans exist for parents to accompany children under 8 years of age during the decontamination process.WARM ZONE (Area where active decontamination occurs)Supplies exist to aid in decontamination of children (soft brushes, soft cloths, mild soap, etc.).Warmed water for decontamination is available.High volume, low pressure spray is available. Elevated surface available for decontamination of infants is available. Additional attendant(s) to assist children are available. If no caregiver available, infants and toddlers may be placed on a stretcher. COLD ZONE (Post decontamination)Supplies exist to prevent hypothermia, such as towels and warming blankets.Diapers, gowns and hats for infants and children are available.Decontamination Personnel Roles and SuppliesYesNoIn ProcessHot Zone Personnel Roles and SuppliesHospital has a decontamination protocol that addresses childrenPediatric decontamination signage should be available to explain the decontamination process to parents and children in multiple languages. An instructional recording in multiple languages should be available and provided to reassure the patients.Decontamination Job Action Sheets delineating roles and responsibilities of personnel should be available. Pre-Decon Reception Area Coordinator* Role is to receive adults and children and to triage and organize the patients for rapid decontamination. Role is to communicate with parents and children and to direct them to predesignated waiting areas Decon Reception Area Attendant*(3) Role is to assist in undressing and collecting contaminated children. Children accompanied by parents should be kept together in a designated area and parents should be asked to assist the attendant. Unaccompanied children should be separated into children over 8 years and those under 8 years. Older unaccompanied children should be used to assist attendants in undressing infants when possible and segregated by gender, if possible.  Decontamination system with minimum of 3 shower heads with estimated decontamination time of 5 minutes per patientPre-decontamination supplies including: Clothing bags for contaminated clothing Labels for bags and secure ties Waterproof ink pen Booties Patient tracking system or I.D. bracelets Changing table for infants Warm Zone Personnel and SuppliesDecontamination Job Action Sheets delineating roles and responsibilities for personnel Decontamination attendants*(3) Role is to decontaminate children less than 8 years of age. Two attendants will accompany each child less than 2 years of age. One will hold the child while the other will remove contaminants. The third attendant will assist children between the ages of 2 and 8 years of age. It is anticipated that parents will be able to assist in decontamination of their own children over 2 years of age, and children over 8 years will be able to decontaminate themselves Decontamination supplies including: Scrub brushes Shower heads with hand held devices 4. Designated waiting area exists for children unaccompanied by parents.5. Staffing to assist children and assure reunification of children with their caregivers is available.  Cold Zone Personnel and SuppliesDecontamination Job Action Sheets delineating roles and responsibilities of personnel Post Decon staff - Role is to receive patients following decontamination and before ED triage. Unaccompanied children will be designated to a separate area once warmed and dressed. Accompanied children will be designated to a separate area with their parents/guardians, who can assist their children in getting warmed and dressed. Unaccompanied children regardless of age will likely need adult supervision or sitter.  X XPediatric post decontamination supplies including: Diapers Towels and warming blankets Gowns (paper or cloth) Infant warmers Changing table or gurney for infants. X HOT ZONEChildren are present among the victims. Intake by Pre-Decon Coordinator Victims arrive at the hospital requiring decontamination and are evaluated by the Pre-Decon Reception Area Coordinator Jump Start Triage protocols will dictate who gets decontaminated first. Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority.Non Ambulatory and Special Needs PatientsAmbulatory Patients Estimate childs age by visual inspection by the Decon Reception Area AttendantAny Age disrobe by childs caregiver and hot zone decon reception area attendant place on a stretcher or restraining deviceSchool Age (8 to 18 yrs old) disrobe w/o assistance respect privacy Preschool (2 to 8 yrs old) assist disrobing (childs caregiver or decon reception area attendant )Infants and Toddlers (less than 2 yrs old) disrobe by childs caregiver and/or hot zone decon reception area attendant WARM ZONEescort through the decon shower by decontamination attendant and caregiver direct supervision of decon (of caregiver, too) monitor airway child decons him/herself, but goes through decon shower in succession with caregiver or parent if present respect modesty have screens to provide for gender separation direct supervision of decon monitor airway escort through the shower by either caregiver or warm zone decontamination attendant escort through the decon shower by warm zone decontamination attendants and caregiver direct supervision of decon (of caregiver, too) monitor airway (Caregiver should not carry the child due to the risk of accidental trauma resulting from a fall or from dropping the child while in the shower.) COLD ZONETreat or prevent hypothermia (towels, gowns, warming blankets) Immediately provide patient tracking device/system of identification (photos, etc.) Triage to an appropriate area for further medical evaluation Please note: Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority References CBPP Pediatric Task Force & NYC DOHMH Pediatric Disaster Advisory Group. Hospital Guidelines for Pediatrics in Disasters (2006) 1st Edition. Illinois Emergency Medical Services for Children (2005). Pediatric Disaster Preparedness Guidelines HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kenar%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1"Kenar L, HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Karayilanoglu%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1"Karayilanoglu T. Prehospital management and medical intervention after a chemical attack. HYPERLINK "javascript:AL_get(this,%20'jour',%20'Emerg%20Med%20J.');"Emerg Med J. 2004 Jan; 21(1):84-8. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/17894219?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum"Okumura T, Kondo H, Nagayama H, Makino T, Yoshioka T, Yamamoto Y. Simple triage and rapid decontamination of mass casualties with colored clothes pegs (STARDOM-CCP) system against chemical releases. Prehosp Disaster Med. 2007 May-Jun; 22(3):233-6. Sternberg, P. The Management of Pediatric Victims During Hazmat Decontamination: Practical Considerations for Communication (2005) The Center for Biopreparedness at Childrens Hospital Boston has developed an educational video titled The decontamination of children. The video addresses best practices in decontaminating children. Information is available on the AHRQ Web site. HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tokuda%20Y%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1"Tokuda Y, HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kikuchi%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1"Kikuchi M, HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Takahashi%20O%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1"Takahashi O, HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Stein%20GH%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1"Stein GH. Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. HYPERLINK "javascript:AL_get(this,%20'jour',%20'Resuscitation.');"Resuscitation. 2006 Feb; 68(2):193-202. U.S. Army Soldier and Biological Chemical Command (SUBCOM), Guidelines for Mass Casualty Decontamination During a Terrorist Chemical Agent Incident Appendix E Multi-Casualty Triage Checklist ItemYesNoIn ProgressThere is a multi-casualty triage plan that addresses children at HOSPITAL.A pediatric triage protocol has been developed and is in use in disasters at HOSPITAL.There is a pediatric hospital categorization system in your area.Hospital personnel have had mass casualty training.Pediatric triage tool is included in hospital triage assessment.Training is provided for hospital personnel in use of triage tool for pediatric patients.There is a standard method of tagging pediatric patients to assist in reunification with parents.The hospital has a plan for contacting and activating pediatric disaster team members, including mental health professionals and/or social workers.A patient tracking system that has been operational in all disasters since 2007 that addresses pediatric patientsThere is a readily available community cache of pediatric supplies that is updated regularly. A community wide CISM program has been developed for post-disaster assistance and practiced in 2011. References Comprehensive Emergency Medical Services Systems Act of 1973. Washington, DC: United States Congress, Senate Labor and Public Welfare Committee; 1973. Department of Homeland Security. National Incident Management System. March 2004. Available at:  HYPERLINK "http://www.dhs.gov/xlibrary/assets/NIMS-90-web.pdf" http://www.dhs.gov/xlibrary/assets/NIMS-90-web.pdf ( HYPERLINK "http://www.ahrq.gov/research/pdfhelp.htm" PDF Help). Accessed July 10, 2006. Dieckmann RA. Brownstein D, Gausche-Hill M: Prehospital Education for Prehospital Professionals. Second Edition 2006. American Academy of Pediatrics. Jones & Bartlett, Sudbury Mass. JumpSTART. Combined JumpSTART algorithm. Available at: http://www.jumpstarttriage.com/. Accessed August 17, 2006. National Health Professionals Preparedness Consortium: Healthcare leadership and administrative decision-making in response to WMD incidents. Nobel Exercise Scenario Information, v.2.0. December 31, 2002. President's Disaster Management Egov Initiative. Available at:  HYPERLINK "http://www.whitehouse.gov/omb/egov/c-2-2-disaster.html" http://www.whitehouse.gov/omb/egov/c-2-2-disaster.html. Accessed August 17, 2006. San Mateo County Emergency Services. Hospital Emergency Incident Command System (HEICS) Update Project. January 1998. Available at:  HYPERLINK "http://www.emsa.cahwnet.gov/dms2/heics3.htm" http://www.emsa.cahwnet.gov/dms2/heics3.htm. Accessed July 10, 2006. U. S. Department of Justice, Office for Domestic Preparedness. Hospital Emergency ManagementConcepts and Implications of WMD Terrorist Incidents. Washington, DC: U.S. Department of Justice; April 2002. Illinois Emergency Medical Services for Children (2005). Pediatric Disaster Preparedness Guidelines CBPP Pediatric Task Force & NYC DOHMH Pediatric Disaster Advisory Group. Hospital Guidelines for Pediatrics in Disasters (2006) 1st Edition. Appendix F Medications Checklist ItemYesNoIn ProcessAdequate supply on hand or readily available medications for pediatric patients in disasters.Education/review provided for hospital providers in medications for use for pediatric patients in disasters.Length-based tape available for use in estimating weight of pediatric patients.Pediatric patients included in disaster drills/exercises.  Appendix G Equipment Checklist ItemYesNoIn ProcessCapabilities to maintain emergency medications and equipment recommended by the American College of Emergency Physicians and the American Academy of Pediatrics have been assessed. A method of weight-based medication dosing and equipment use, such as the length-based (e.g., Broselow) emergency tape is available for disaster use.  References Hegenbarth MA and the Committee on Drugs. Preparing for Pediatric Emergencies: Drugs to Consider. Pediatrics 2008; 121:2:433-443. Administration, Personnel, and Policy Guidelines for the Care of Pediatric Patients in the Emergency Department (EMSA #182), March 26, 2008 Broselow Tape:  HYPERLINK "http://www.ebroselow.com" www.ebroselow.com Appendix H Mental Health Checklist ItemYesNoIn ProcessPediatric local mental health practitioners have been identified, and a relationship has been established with them. Resources, hotlines, etc. for use in disasters have been identified, and the list is readily available.Training has been provided to hospital staff in Psychological First Aid.  Appendix I Special Needs Population Checklist Hospitals ItemYesNoIn processAn assessment has been made of the number of children with special needs that frequent your facility. For example, you know how many children undergo hemodialysis, have tracheostomy tubes, g-tubes, etc.There is a means of accessing a database/file (Emergency Information Form) of the names, baseline physical and mental status, etc. of children with special needs who frequent your facility. There has been an assessment, in conjunction with the local MMRS and Pima County Health, of what the resource needs will be to care for the uninjured, unaccompanied population of children with special needs in the aftermath of a disaster. There is regular training in handling the child with special needs (e.g., the importance of maintaining familiarity for autistic children, how to explain events to children with learning disabilities, how to manage children with visual, hearing, or physical limitations, and those with emotional disorders). Staff personnel to care for uninjured, unaccompanied special needs children in a disaster have been identified. There is a stockpile of appropriate equipment and supplies (tracheostomy tubes, feeding tubes, pediatric formulas, wheelchairs, etc.) to care for the child with special needs after a disaster. There is a computerized means to update the Emergency Information Form (medication doses, formula changes, etc.) of children with special needs after every encounter.  Personnel at your facility with proficiency in dealing with children with special needs (mental health, social workers, etc.) have been identified.A point-of-contact list with the pediatric tertiary care center in your region in a disaster has been established.There is a memorandum of understanding with the pediatric tertiary care center in your region to accept transfers of injured children with special needs. Disaster drills, in which mock victims with special needs are included in the scenario, are scheduled on a regular basis. There is a protocol to evacuate children with special needs (wheelchair-bound, ventilated, etc.).  Hospitals ItemYesNoIn processAn assessment has been made of the number of children with special needs that frequent your facility. For example, you know how many children undergo hemodialysis, have tracheostomy tubes, feeding tubes, etc.There is a means of accessing a database/file (Emergency Information Form) of the names, baseline physical and mental status, etc. of children with special needs who frequent your facility.In conjunction with the local EMS Agency and area schools, the resource needs for care for the uninjured, unaccompanied population of children with special needs in the aftermath of a disaster have been identified. Regular training is provided regarding handling the child with special needs (e.g., the importance of maintaining familiarity for autistic children, how to explain events to children with learning disabilities, how to manage children with visual, hearing, or physical limitations, and those with emotional disorders). Staff personnel have been identified to care for uninjured, unaccompanied special needs children in a disaster. There is a stockpile of the appropriate equipment and supplies (tracheostomy tubes, g-tubes, pediatric formulas, wheelchairs, etc.) to care for the child with special needs after a disaster. There is a computerized means to update the Emergency Information Form (medication doses, formula changes, etc.) of children with special needs after every encounter. There are identified personnel at your facility and other regional facilities with special proficiency in dealing with children with special needs (pediatric surgery, pediatric gastroenterologists, pediatric intensivists, mental health, social workers, etc.).As one of the pediatric critical care specialty hospitals in your region, there are regularly scheduled regional meetings with other basic hospitals to brainstorm how to manage children with special needs in the aftermath of a disaster.As one of the pediatric critical care specialty hospitals of your region, you maintain a database of all children with special needs in your region (how many children on hemodialysis, how many children with tracheostomy tubes and g-tubes), and make this available to all hospitals in the region.There is a memorandum of understanding with basic hospitals in your region to accept transfers of uninjured children with special needs who are unaccompanied by adults. There is a memorandum of understanding with the schools, the American Red Cross, and other volunteer organizations to help care for the uninjured, unaccompanied child with special needs. There is a memorandum of understanding with suppliers of tracheostomy tubes, feeding tubes, pediatric formulas, wheelchairs, etc. for re-stockpiling during the aftermath of a disaster.  Disaster drills, in which mock victims with special needs are included in the scenario, are conducted on a regular basis. There is a protocol to evacuate children with special needs (wheelchair-bound, ventilated, etc.).  References Committee on Pediatric Emergency Medicine. Emergency Preparedness for Children with Special Health Care Needs. Pediatrics 1999;104;53-DOI:10.1542/peds.104.4e53 ACEP Policy Statement: Emergency Information Form for Children with Special Health Care Needs Other Resources American Red Cross at  HYPERLINK "http://www.redcross.org" www.redcross.org designed a booklet for anyone who has a disability or who works with, lives with, or assists a person with a disability. The booklet has information on possible disaster effects, assessing personal needs and abilities, and suggestions about forming a personal support group. Children with Special Health Care Needs: An EMS Challenge (CD-ROM)  HYPERLINK "http://www.ems-c.org" www.ems-c.org. This CD-ROM introduces health care providers to general respiratory, cardiovascular, and neuromuscular challenges of children with special health care needs. It reviews the normal differences between adult and pediatric anatomy and physiology, as well as case scenarios. The appendix contains helpful printable files on 13 different medical conditions that the provider may encounter. Florida Institute for Family Involvement at  HYPERLINK "http://www.fifionline.org/disaster_planning.htm" http://www.fifionline.org/disaster_planning.htm has the following disaster links on their website: Disaster Preparedness for Families with Special Needs Disaster Information Form for Children with Special Needs National Association of School Psychologists (NASP) at HYPERLINK "http://www.nasponline.org/NEAT/specpop_general.html"http://www.nasponline.org/NEAT/specpop_general.html provides information and resources on helping children with disabilities and special needs cope with a crisis. Appendix J Drills and Exercises Checklist ItemYesNoIn ProcessHospital personnel have had training in triaging pediatric patients during a disaster.Children have been included in disaster drills or exercises at least once a year.Planning of disaster drills and exercises includes pediatric expertise such as pediatricians, pediatric nurse practitioners, pediatric intensivists, etc.Drills or exercises have included the need to access resources for pediatric patients if the local area is overwhelmed. Drills or exercises include children with special health care needs (CSHCN)Planning for drills includes representatives from community organizations concerned with children in disasters such as the American Red Cross and mental health associations, schools, day care facilities, etc. Drills or exercises include a variety of disasters, such as biological, chemical, radiological terrorism as well as natural disasters. Resources Agency for Healthcare Research and Qualitys Bioterrorism and Public Health Emergency Response Tools.  HYPERLINK "http://www.ahrq.gov/path/biotrspn.htm" http://www.ahrq.gov/path/biotrspn.htm American Academy of Pediatrics, Children Children and Disasters.  HYPERLINK "http://www.aap.org/terrorism/index.html" http://www.aap.org/terrorism/index.html American College of Preventive Medicine.  HYPERLINK "http://www.acpm.org/education/EHCMEOpportunities.htm" http://www.acpm.org/education/EHCMEOpportunities.htm American Red Cross (Children and Disasters).  HYPERLINK "http://www.redcross.org/services/disaster/0,1082,0_602_,00.html" http://www.redcross.org/services/disaster/0,1082,0_602_,00.html Center for Trauma Response, Recovery and Preparedness for Health Care Communities.  HYPERLINK "http://www.ctrp.org/resources_healthcare.htm" http://www.ctrp.org/resources_healthcare.htm Fairfax County Public SchoolsEmergency Preparedness and Support.  HYPERLINK "http://www.fcps.edu/emergencyplan/index.htm#mci" http://www.fcps.edu/emergencyplan/index.htm#mci JumpSTART Pediatric Mass Casualty Incident (MCI) Triage Tool.  HYPERLINK "http://www.jumpstarttriage.com/JumpSTART_and_MCI_Triage.php" http://www.jumpstarttriage.com/JumpSTART_and_MCI_Triage.php National Advisory Committee on Children and Terrorism (NACCT): Recommendations to the Secretary, 2003.  HYPERLINK "http://www.bt.cdc.gov/children/recommend.asp" http://www.bt.cdc.gov/children/recommend.asp National Association of School Nurses (NASN) Disaster and Preparedness: School Nurse Role.  HYPERLINK "http://www.nasn.org/Portals/0/positions/2006psdisaster.pdf" http://www.nasn.org/Portals/0/positions/2006psdisaster.pdf National Center for Disaster Preparedness Pediatric Preparedness for Disasters and Terrorism A National Consensus Conference Executive Summary, 2003.  HYPERLINK "http://www.ncdp.mailman.columbia.edu/files/pediatric_preparedness.pdf" http://www.ncdp.mailman.columbia.edu/files/pediatric_preparedness.pdf Los Angeles County Department of Health Services; Emergency Medical Services Agency Family Information Center Planning Guide; Draft: ____  HYPERLINK "http://ems.dhs.lacounty.gov" http://ems.dhs.lacounty.gov Appendix K Family Information Center Checklists Planning ConsiderationsYesNoIn ProgressThe planned area for the FIC is located far enough from the emergency department to discourage congregation of family members, but close enough for treating physicians to access families for updates and information gathering.The FIC has controlled or limited access by unauthorized visitors and news media personnel.The FIC is accessible to elderly or disabled family members.The FIC has a place for children to play.The FIC has a place for television viewing.The FIC has a briefing area for medical representative or PIO to talk to families.The FIC has one or two side rooms or partitions that can be used by medical, mental health, and spiritual care to interview or counsel families in private.The FIC has work and break areas for staff.The FIC has easy access to restrooms.The FIC has comfortable furniture and area for people to wait for news regarding loved ones.The FIC has a reception area for greeting arriving family members.The FIC has a designated area where arriving family members can be registered and receive hospital/clinic identification.There is a plan that defines the location of the FIC and includes a graphic representation of its floor plan.The Family Information Center has a Consultation and Photograph/Identification area.  StaffingYesNoIn ProgressThe FIC has a designated FIC Unit LeaderThe FIC includes security staff.The FIC includes mental health/spiritual care personnel who may include: social workers, other licensed mental health professionals, or chaplains.The FIC includes medical staff including: nurses, infection control staff, and subject matter experts who can give regular situational updates to families and answer difficult questions about chemical/biological agents, infectious diseases, contamination risks, morbidity rates, etc.)The FIC includes child care workers.The FIC includes clerical staff.The FIC includes a psychiatrist (onsite or on-call).If required, the FIC includes a Public Information Officer/Spokesperson to work with media when they are present.If required, the FIC includes information technology staff.The FIC has a staffing ratio of 1 Mental Health and 1 Spiritual Care staff for every 20 families.The FIC has a regular shift schedule (recommended: 2 12-hour shifts to ensure 24-hour coverage). Supplies and EquipmentYesNoIn ProgressThe area designated for the FIC has a printer, fax machine, copier and related supplies (paper, toner, ink cartridges, etc.)The FIC has an identification or badging systemThe FIC has tables and chairs.The FIC has comfortable seating.The FIC has tissues.The FIC has books and magazines.The FIC has toys and play supplies (paper, crayons, markers, etc.).The FIC has refreshments (snacks, water, etc.)The FIC has a first aid kit.The FIC has mental health information (brochures and fact sheets) for children and adults.There is an identified a storage site for required supplies and equipment.The FIC plan includes a list of required supplies and equipment, their location, and procedures for their access, deployment or procurement. FIC Planning and ActivationYesNoIn ProgressThe plan for the FIC has procedures for its activation and set-up. Recommend Just in Time training in a disaster response.There are FIC Fact Sheets for staff and families describing its basic purpose, available resources, information sharing restrictions, security, and contact information.The plan for the FIC has procedures for the following tasks: Registration Casework What to do if patient cannot be located What to do if hospital/clinic knows the sought family member is deceasedThe plan for the FIC includes Job Action Sheets for the following positions: FIC Unit Leader FIC Registration FIC Medical/Nursing FIC Mental Health and Spiritual Care FIC Security Director/Coordinator Red Cross Liaison Patient Information Center Translators/InterpretersThe FIC Plan is tested annually in a tabletop exercise.The FIC staff receive initial training and annual refresher training on FIC set-up and operations. Communications and Information ManagementYesNoIn ProgressThe FIC has internet access (for ReddiNet or other hospital/EMS systems)The FIC has a minimum of two telephones for incoming and outgoing calls.The FIC has a connection for a large television.The FIC staff has access to handheld radios or an intercom system for rapid communication with security. ACRONYMS AAP American Academy of Pediatrics AAR After Action Report ACEP American College of Emergency Physicians ACF Alternate Care Facility ALS Advanced Life Support ARC American Red Cross BLS Basic Life Support CAHAN California Health Alert Network CDC Centers for Disease Control and Prevention CDPH California Department of Public Health CISD Critical Incident Stress Debriefing CISM Critical Incident Stress Management CSHCN Children with Special Health Care Needs DHHS Department of Health and Human Services DHS Department of Health Services DMAT(s) Disaster Medical Assistance Team(s) DMH Department of Mental Health DOC Department Operations Center ED Emergency Department EMS Emergency Medical Services EMSA California Emergency Medical Services Authority EMSC Emergency Medical Services for Children EOC Emergency Operations Center EPA Environmental Protection Agency EPI-INTEL Epidemiological Intelligence ET Endotracheal EWS Early Warning System FBI Federal Bureau of Investigations FDA Food and Drug Administration FEMA Federal Emergency Management Agency FIC Family Information Center GIS Geographic Information System HICS Hospital Incident Command System HRSA Health Resources Services Administration HVA Hazard Vulnerability Analysis ICS Incident Command System IM Intramuscular IO Intraosseous IV Intravenous JIC Joint Information Center KI Potassium Iodide LEMSA Local Emergency Medical Services Agency MCHB Maternal and Child Health Bureau MCI Mass Casualty Incident MFI Mass Fatality Incident MMRS Metropolitan Medical Response System MOU Memorandum of Understanding MSDS Material Safety Data Sheet NDMS National Disaster Medical System NG Nasogastric NGO Non-governmental Organization NIMS National Incident Management System NIH National Institutes of Health NPS National Pharmaceutical Stockpile OA Operational Area OEM Office of Emergency Management OPS Operations OSHA Occupational Safety and Health Administration PHO Public Health Officer PIO Public Information Officer PO Per Oral PPE Personal Protective Equipment PTSD Post-Traumatic Stress Disorder RFA Request for Assistance SALT Sort Assess - Life Saving Interventions - Treatment and/or Transport SAMHSA Substance Abuse and Mental Health Services Administration SEMS Standardized Emergency Management System SNS Strategic National Stockpile SOP Standard Operating Procedure START Simple Treatment and Rapid Triage US&R Urban Search and Rescue WHO World Health Organization WMD Weapons of Mass Destruction     PAGE   PAGE ii HOSPITAL LOGO   PAGE v  HOSPITAL Pediatric Disaster Plan Page  PAGE 8  HOSPITAL Pediatric Disaster Preparedness Guidelines HOSPITAL Pediatric Disaster Preparedness Guidelines Page  PAGE 16 HOSPITAL Decontamination and the Pediatric Patient Model Algorithm ALGORITHM CLEAN TREATMENT AREA RAPID TREATMENT COLD ZONE WARM ZONE DECONTAMINATION AREA AMBULATORY NON AMBULATORY disrobe by childs caregiver and hot zone decon reception area attendant place on a stretcher or restraining device or escort if ambulatory but disabled escort through the decon shower by decontamination attendant and caregiver direct supervision of decon (of caregiver, too) monitor airway School Age (8 to 18 yrs old) Pre School (2 to 8 yrs old) Infant and Toddler (less than 2 yrs old) PRE DECONTAMINATION RECEPTION AREA Treat or prevent hypothermia (towels, gowns, warming blankets) Immediately provide patient tracking device/system of identification (photos, etc.) Triage to an appropriate area for further medical evaluation Please note: Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority disrobe w/o assistance respect privacy child decons him/herself, but goes through decon shower in succession with caregiver or parent if present respect modesty have screens to provide for gender separation assist disrobing (childs caregiver or decon reception area attendant ) direct supervision of decon monitor airway escort through the shower by either caregiver or warm zone decontamination attendant disrobe by childs caregiver and/or hot zone decon reception area attendant escort through the decon shower by warm zone decontamination attendants and caregiver direct supervision of decon (of caregiver, too) monitor airway Victims arrive at the hospital requiring decontamination and are evaluated by the Pre-Decon Reception Area Coordinator Children are present among the victims. Jump Start protocols determine who will be decontaminated first. Children and their families (parents or caregivers) should not be separated unless HOT ZONE Children with Special Healthcare Needs The JumpSTART Field Pediatric Multicasualty Triage System (Patients aged 1- 8 years) Black = Deceased/expectant Red = Immediate Yellow = Delayed Green = Minor/Ambulatory Identify and direct all ambulatory patients to designated Green area for secondary triage and treatment. Begin assessment of nonambulatory patients as you come to them. Proceed as below: Spontaneous respirations? NO Open airway Spontaneous respirations? YES IMMEDIATE NO DECEASED YES Peripheral pulse? YES Perform 15 sec. Mouth to Mask Ventilations Spontaneous respirations? YESS IMMEDIATE NO DECEASED NO Check resp. rate < 15/min or > 45/min or irregular IMMEDIATE 15 - 45/ min, regular Peripheral pulse? NO IMMEDIATE YES Check mental status (AVPU) A V P (appropriate) DELAYED P (inappropriate) U IMMEDIATE MINOR Lou Romig MD, FAAP, FACEP, 1995 TRIAGE AREA AMBULATORY NON AMBULATORY PRE TRIAGE RECEPTION AREA Please note: Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority Victims arrive at the hospital requiring decontamination and are evaluated by Pre-triage Area Coordinator Children are present among the victims. Critical injuries are triaged first. Every effort should be made to keep children and their families (parents or caregivers) together Children with Special Health-care Needs Some patients may require Decon-tamination TRIAGE Patients 8 years or less of age without accompanying caretaker or those with special needs and all patients 5 years or less of age in the presence of a caretaker should all go through this Triage assessment and should not be considered stable by visual inspection alone. 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