Challenges to an Effective Response to Patient Surges

To respond effectively to bioterrorism or other infectious outbreaks, both pediatric and nonpediatric health care facilities must:

1. Recognize the incident in its early stages.
2. Activate existing surge capacity plans.
3. Adequately prepare for consequence management after such incidents.
4. Provide adequate logistical support for increased patient volume.

Difficulties in Recognizing an Outbreak

Diseases spread by the airborne route have great epidemic potential in those without immunity to the organism, and the ability to recognize such an epidemic is inhibited by the delay between exposure to a bioweapon and the development of clinical symptoms. The ability to identify a bioweapon remains critical to the planning for and management of an outbreak; the same holds true for recognizing a natural outbreak. Experience with the outbreak of the Severe Acute Respiratory Syndrome (SARS) demonstrated that epidemiologic history and tracing patients' travels were critically important in understanding the patterns of disease spread. Unfortunately, many clinicians who work in an emergency setting receive minimal training in traditional epidemiologic methods, or they do not have the time to apply them.

Access to surveillance systems capable of informing clinicians about terrorist attacks can quicken response to a sudden surge of patients.  For example, poison control centers are linked to a single nationwide database that is updated within minutes; the goal of this database is to rapidly identify and disseminate information about sentinel events back to poison control centers and then to local clinicians. Physicians who access this important information source will receive timely notification of developing outbreaks of various types. 

Reluctance to Activate the Surge Capacity Plan

Activation of the surge capacity plan signals the absolute need for transition from normal hospital operations to a disaster footing. Because of the unknown extent and expense of the response, however, clinicians may hesitate to activate the plan. Alternatively, emergency physicians who have become inured to severely crowded conditions may be unaware that activation of the surge capacity plan is warranted when there is a large influx of pediatric patients.

Logistics: Deployment of Hospital Personnel

Effective surge capacity plans require brisk responses at institutional and departmental levels that are supervised by a designated team of individuals following a defined command structure. An organized and well-communicated response can support well-designed surge capacity plans, heighten the benefit of disaster drills, improve the efficiency of hospital operations, and foster the delivery of good quality patient care.

The Emergency Department (ED)

As with any disaster, the ED bears the brunt of the patient inflow into a health care facility. ED operations, the efficiency of which are severely compromised by overcrowding, are further hampered by intentional capacity-to-demand mismatch promoted by hospital administrations to ensure that inpatient bed spaces are never wasted.³ Hospital administrations, credentialing organizations, and Federal, State, and local agencies need to eliminate or minimize ED overcrowding to ensure good quality patient care in the event of a terrorist attack.   

Critical Care

A dramatic number of patients exposed to a bioweapon may become critically ill. An excessive volume of high-acuity children will place extreme pressures on the clinicians staffing intensive care units, particularly if critically ill patients have significant respiratory illness or involvement of multiple organ systems. Critical care staff may be required to assist in patient resuscitation in the ED as well as the traditional intensive care setting. 

Respiratory Care and Radiology

Patient surges may overwhelm the ability of respiratory therapists to provide adequate care to critically ill children. Excess patient load, especially patients with significant respiratory demands, may prevent the adherence to hospital standards for ventilator management, respiratory care, and pulmonary toilet. Hospitals may lack an adequate number of positive-pressure ventilators to effect the degree of activation of a pediatric surge capacity plan. Moreover, respiratory therapists may be at increased risk for infection during procedures such as orotracheal intubation and administration of nebulized therapy. This risks attrition of the available workforce.

Nursing

The numbers of patients who can be admitted to hospital floors is typically determined by the ratio of nurses to patients. In the event of a surge of high-acuity children, nursing staff may need to provide care for greater numbers of sicker patients, at least until additional staff can be mobilized through the surge capacity plan. 

Ancillary Staff (Security, Engineering and Environmental Services, and Public Affairs)

Controlling the flow of patients, families, and visitors into a health care facility is vitally important after a disaster. A breach of hospital security can lead to unnecessary exposure of staff to infected victims, spread of disease, and contamination of "clean" hospital areas. Engineering services may be needed to construct ventilation barriers that can isolate entire floors from the remainder of the facility. Adequate disposal of contaminated materials by environmental services personnel is necessary to avoid contamination of hospital areas. Lastly, centrally controlling communication messages sent to staff, patients, and the public is an important role for Public Affairs, as it improves the response by providing clear, consistent communication while decreasing rumors.

Logistics: Insufficient Resources for Communicable Disease Control

Both pediatric and general hospitals may have insufficient resources to control the spread of communicable diseases. Surges of patients may overwhelm the number of respiratory isolation rooms and permit the spread of airborne pathogens into "clean" hospital areas, a problem that would be exacerbated by inadequate air exchange ensured by antiquated heating-ventilation-air conditioning (HVAC) units.⁴ If multiple patients are cohorted in multi-bed rooms, the distance between beds may be insufficient to prevent the spread of airborne pathogens.⁴ In locations such as the ED, there are many challenges to preventing the spread of infectious agents. Many patient bed spaces are separated only by a curtain; patients may share a common bathroom. Moreover, most EDs have washbasins for which water flow is activated by turning a faucet handle rather than using a motion or body heat sensor; the latter feature avoids direct contact with bathroom hardware and prevents the spread of foodborne pathogens transmitted in the stool. 

Logistics: Maintaining an Adequate Supply of Hospital Stocks

An increased volume of critically ill patients may completely deplete available supplies of ventilators, respiratory isolation gowns, N95 respirators, sheets, medications, intravenous supplies, and other material. For example, to prevent the spread of disease from patients requiring respiratory support after infection with an airborne pathogen, clean gowns, N95 respirators, and bag-valve-mask devices ("ambubags") must be used for each patient. Furthermore, clinicians should change gowns, gloves, and N95 respirators when entering each patient room to avoid the spread of disease. 

Unique Challenges Posed by Pediatric Mass Casualty Incidents

The release of a biological weapon would disproportionately affect children through several mechanisms.^1,2 With aerosolized agents (e.g., anthrax), increased respiratory minute ventilation in children (500 ml/Kg/min) compared with adults (140 ml/Kg/min) results in the child's exposure to a relatively greater inoculum.¹ The high vapor density of bioaerosols, such as those potentially used to disseminate airborne pathogens, places their highest concentration close to the ground in the lower breathing zone of children.¹ The more permeable skin of newborns and children in conjunction with a larger surface-to-mass ratio results in greater exposure to transdermally absorbed toxicants.¹ Children, because of their relatively larger body surface area, lose heat quickly when showered.¹ Consequently, skin decontamination with water may result in hypothermia unless heating lamps and other warming equipment are used.¹ Having less fluid reserve increases the child's risk of rapid dehydration or frank shock after vomiting and diarrhea.¹ Finally, children have significant developmental vulnerabilities.¹ Infants, toddlers, and young children do not have the motor skills to escape from the site of a biological incident.¹ Even if they are able to walk, they may not have the cognitive insight to decide in which direction to flee.¹ All children are at risk of psychological injury, such as posttraumatic stress disorder, from experiencing or witnessing an act of terrorism.^1,5 In a mass casualty incident, children witness injuries and deaths, possibly of their parents, which would produce both short- and long-term psychological trauma that requires intervention.¹

Children are difficult to care for by health care personnel wearing protective equipment, which is essential in the management of chemical, biological, and radiological events. Protective clothing is bulky and cumbersome; it impedes the ability of health care providers to perform procedures such as venipuncture or endotracheal intubation on small children.

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