Integrating Terrorism and Disaster Preparedness Into Your Pediatric Practice
Emergency preparedness should be exercised at all organizational levels, and office-based physicians (either in a hospital or free-standing practice) should understand their specific role in the general system response to disasters. Ideally, office-based policies and procedures should be specific to the location of the practice and its characteristics and be consistent with the policies of affiliate institutions and public and governmental agencies.
Preparedness for disaster by office-based physicians can be subdivided into two broad categories:
- Internal operations of the practice.
- External operations related to communication and coordination with other agencies, institutions, and the community.
Office Readiness
A comprehensive, child-oriented emergency care system aligns with the concept of systematic intervention in response to disasters while viewing the needs of the child in the context of family and community. This framework is particularly suited to the office-based physician who attends to the whole child. Pediatric health care professionals possess knowledge about responses and needs of children involved in disasters, and they should work across public systems to deliver effective medical, educational, and community interventions. The objective is to ensure that the biological and psychological needs of children are addressed before, during, and after trauma.
Office-based physicians should be aware of the particular vulnerabilities of free-standing practice buildings based on geographic location, and their practices should comply with strict building code regulations and be equipped with back-ups for emergency systems. In the event of structural damage to the practice, there should be a plan for its relocation (e.g., by planning to share facilities with another practice).
Offices should have pre-assembled emergency kits that contain water, a substantial first-aid kit (including thermometer, blood pressure cuff, and stethoscope), radios, flashlights, batteries, heavy-duty gloves, food, sanitation supplies, and medical reference books and cards. Emergency supplies should be located both on- and off-site. Lack of refrigeration for medications and vaccines is a likely scenario in a disaster. Back-up generators are important in case of outages. Back-up communication systems—such as cellular phones, direct telephone lines that are not part of the regular telephone system, two-way radios, beepers, and ham radios—should be considered.
Records
The Health Insurance Portability and Accountability Act (HIPAA) mandates that copies of records be stored off-site (some experts recommend at least 50 miles away) in case of catastrophe. This includes copies of patient charts and other vital records, even if most records are stored electronically. In addition to patient charts, other records—such as copies of licenses, insurance policies, and real estate leases—also should be stored off-site
Contact List
A confidential contact list of all physicians, nurses, and other staff that includes home, cell, and emergency contact phone numbers should be kept by designated individuals. The contact list should also include back-up providers. This confidential list should be kept in multiple places (e.g., the practice, an outside location, and/or with the designated individuals). Practices should consider keeping a list of technologically dependent children who, during a disaster or emergency situation, may need specific planning (e.g., availability of back-up generators) and where these children and families should go in case their equipment fails.
Staff Responsibilities
Staff should be made aware that they have a professional responsibility to discuss their availability in case of disasters. This would include calling in to check where their services are needed and the feasibility of responding based on previously discussed office-readiness plans. Discussion with staff of their multiple responsibilities for their own families, work, and the community will help to alleviate concerns and anticipate problem areas. Staff should prepare a Family Emergency Plan so that they will be assured that the needs of their own families will be addressed while they are performing critical health care duties.
The roles of the physician, nurse, and support staff should be agreed upon and documented. For example, everyone should know who will contact the police or fire department, who will aid in evacuation, who will reschedule patients, and so on. Staff members need to know where to go to access credible and up-to-date information during a crisis. Often, such information can be found online, and Web addresses for pertinent sites should be identified and posted in advance for easy access.
The office-based physician may be the first contact for an individual who is the victim of a biological agent and may be called on to treat or answer questions with regard to chemical and radiation exposure. Pediatricians should understand the following:
- The classification and qualities of possible biological agents.
- The natural history and management of biological, chemical, and radiological injuries and exposures.
- Chemical agents that may be used and their properties.
- Types of radiological terrorism.
- Decontamination procedures, especially those specific to children.
- Availability of antidotes and other therapeutics.
The procedure and numbers for alerting the proper authorities (e.g., the Department of Health, CDC, etc.) should be part of the office's preparedness plan.
Office-based physicians may be unsure of their role or feel that they do not have a role in disaster planning or management, yet emergency pediatricians may need to draw on community pediatricians to provide the best possible management of children. The office-based physician may be asked to help hospital-based pediatricians determine which pediatric patients can be discharged or transferred to another hospital. They also will need to triage their own patients who show up at the practice to determine whether they need to go to the hospital or can be safely managed without emergency care. In addition, office-based pediatricians play a critical role in screening children and their family members for medical and psychological distress.
Communication and Coordination with Other Agencies
The office-based physician should determine how the practice will link and coordinate efforts with affiliate hospitals, schools, daycare centers, local response teams, the local department of health, and other entities at the city, State, regional, and Federal levels. Electronic communication, when circumstances permit, is a useful tool for communicating with multiple entities. The chain of command established by the practice should include the points(s) of contact within the organizational structure for communication with the various larger agencies. Ideally, a list of all the relevant agencies should be developed in advance with contact numbers listed (e.g., local and regional hospitals, city fire department, utilities, pharmacies, shelters, and so on).
Communicating with Children and Families
During a disaster or terrorist event, children and families will receive good and bad information from a multitude of sources, including friends, media, and public officials. A well-educated and available pediatrician who can appropriately respond to numerous and varied questions can be of great service. Families view pediatricians as their expert resource, and most expect pediatricians to be knowledgeable in areas of concern. Providing expert guidance entails both educating families in anticipation of events and responding to questions during and after actual events.
Pediatricians can play a central role in helping families develop a disaster and terrorism preparedness plan. Family preparedness may include training in cardiopulmonary resuscitation, rendezvous points, lists of emergency telephone numbers, and an out-of-state friend or relative whom all family members can contact after an event to report their whereabouts and conditions. Family members should know the safest place in the home, make special provisions, know community resources, and have a plan to reunite.
Medications for chronic illness and resources for children who depend on technological means for survival should be included in the family preparedness plan. Pediatricians can advise parents on the need for a power of attorney, living will, advance directive, and other important legal documents. In addition, pediatricians should advise parents and other family members to:
- Notify utility companies to provide emergency support for technologically dependent family members during a disaster.
- Maintain a supply of medications and equipment in case availability is disrupted during a disaster.
- Know how to obtain additional medications and equipment during times of a disaster.
- Learn how they can assume the role of in-home health care providers who may not be available during a disaster.
- Keep an up-to-date emergency information form to provide health care workers with the child's medical information in case the regular care provider is unavailable.
- Know back-up hospitals/providers in the region in case primary hospital/specialists/providers cannot be used.
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Terrorism and Disaster Preparedness for Hospital-Based Pediatricians
In mass casualty incidents, including those involving chemical and biological agents, casualties among children and adults could be significant. Because children are likely to become victims in most disaster events, pediatricians should assist in preparedness planning to ensure coordinated responses of local hospitals that in some cases may have limited pediatric resources.
It is important to remember that health care facilities could themselves be primary or secondary targets. Also, facilities may be overwhelmed by massive numbers of anxious individuals and families. Pediatricians working in or supporting hospitals can play a vital role in ensuring the enhanced care of the pediatric disaster victim by participating in all levels of disaster preparedness planning.
Emergency Department Readiness
Pediatricians working in or supporting hospitals should interact with the planning committee to ensure adequate training and preparation of supplies and treatment areas in the emergency department. Pediatricians working in hospitals can be key facilitators between emergency department services, critical care services, and regular inpatient services. Coordination with the local community should involve primary/prehospital/infrastructure response (e.g., EMS, fire, police, regional poison centers, and so on) with liaison planning to State and Federal agencies and community/citizen response (e.g., schools, daycare centers, service groups, and so on). Planners should take into consideration the fact that usual referral patterns may not typically include accepting pediatric patients.
Inpatient Service Readiness
Anticipating surge capacity for inpatient care is vital in preparedness planning and perhaps represents the greatest contribution of pediatricians working in hospitals. Issues that should be considered include the following:
- Increasing the number of inpatient beds within a community (e.g., by converting cafeterias and meeting spaces into ward capacity or making arrangements with other community hospitals). Local hotels, school gymnasiums, etc., may be converted into low- or mid-acuity medical facilities with some planning. Parallel pediatric services have been documented to improve quality and efficiency in the care of children.
- Making contingency plans for acquiring or maintaining essential services (e.g., water, electricity, portable oxygen, garbage disposal, etc.).
- Planning for stockpiling or readily acquiring medical supplies such as vaccines, antitoxins, and antibiotics (in dosages, formulations, etc., appropriate for pediatric patients). In addition, pediatric-specific supplies and equipment in a full range of sizes to accommodate children of various ages should be available.
- Networking community resources to organize volunteers who can become proxy caretakers for orphaned children.
Hospital Infrastructure Needs
Essential components of hospital preparedness include crisis drills, infection control plans, quarantine procedures, and staff training. For example:
Crisis Drills
Hospital and community-wide drills need to be done on both a wide scale and with a narrow focus. Drills should include not only the initial triage and decontamination stages, but also the 48-72 hours after impact to measure readiness with all provider and support services that will be needed. Specific drills should be planned and practiced for evacuation in response to fire or other disasters.
Infection Control Plans
These plans closely parallel quarantine procedures in the community and on a public health basis. In-hospital infection control plans involve quarantine or isolation and control measures to limit spread of infection to staff and other patients.
Quarantine Procedures
Children who become ill following a disaster or terrorist event may require isolation to prevent spread of disease to other patients and health care providers. The exact nature and severity of quarantine will depend on the specific hazard involved. Close coordination with the public health service, CDC, and local poison control centers is essential in both the planning and execution of quarantine procedures.
Staff Training
Staff training should include the following:
- Use of protective gear.
- Orientation to all aspects of the plan from the disaster site to the emergency department to hospital floors, as well as to rehabilitation and rebuilding in the community.
- Staff preparedness for notification, transportation to treatment sites, self-preparedness (e.g., emergency packages of personal items), strategies for coping with family demands, psychological demands, and plans for personal health and hygiene.
- Support for families of health care workers so that they are available to provide services.
- Mechanism for tracking resources.
- Media/public communication issues.
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Working With Government Agencies
The challenge of dealing with the threat of terrorism in the United States is daunting not only for disaster planners, but also for our medical system and health professionals of all types, including pediatricians. All possible forms of terrorism must be considered, including chemical, biological, explosive, radiological, and nuclear events. Pediatricians must be able to respond to concerns of patients and families, recognize signs of possible exposure to a weapon of terror, understand first-line response to such attacks, and sufficiently participate in disaster planning to ensure that the unique needs of children are satisfactorily addressed in the overall process.
The Federal government provides significant funding for disaster preparedness and response and to a large extent establishes the framework that is then followed by States, regions, and communities. Volunteer organizations, such as the Red Cross and Salvation Army, also have key roles in disaster response. A successful response to a disaster requires the interaction of personnel and resources from multiple agencies in an organized and coordinated manner according to a well-formulated plan. While overall planning has increased significantly in recent times, attention to the unique needs of children and the inclusion of pediatric expertise in the planning phases continue to be insufficient.
Local governments are the first line of defense in emergencies and are primarily responsible for managing the immediate response to most disasters. When a local government receives a warning that an emergency could be imminent, its first priorities are to warn citizens and to take whatever actions are needed to minimize damage and protect life and property. The emergency operations plan is at the center of comprehensive emergency planning. This plan spells out the scope of activities required for community response. Historically, these documents have not focused much attention on pediatric considerations, and only rarely have pediatricians been part of the planning process.
All States have laws that describe the responsibilities of the State government in emergencies and disasters. The State emergency management office follows procedures specified in the State emergency operations plan to respond to virtually all serious emergencies, including disasters and terrorist events. These plans rarely include child-specific guidelines. To remedy this, pediatricians need to be involved in State emergency planning committees to ensure that pediatric considerations are included in State plans and the plans of individual agencies, as well as a component of funding for disaster and terrorism preparedness.
At the Federal level, planning and preparedness for disasters and terrorist events are coordinated by the Federal Emergency Management Agency (FEMA). FEMA uses the interagency Federal response system, also called the Federal Response Plan (FRP), to oversee and coordinate the response and activities of other Federal departments and agencies. The FRP describes the basic mechanisms and structures by which the Federal Government mobilizes resources and conducts activities to augment State and local response efforts. It is important to understand the Federal role and the provisions of the FRP, in that most States use it as a basis for the structure and some content of their own emergency operations plans. In turn, local emergency operations plans are based to some extent on State plans.
On a larger scale, we also should recognize the need for public health preparedness. This requires the existence of a strong public health system. To allow for rapid and efficient response, both a central organization, as specified by Federal planning and State implementation, and the decentralization of some resources, such as diagnostic capabilities, are necessary. Pediatricians should understand the importance of public health and their relationship to departments of health at various organizational levels. This includes their role in public health, reporting requirements and mechanisms, and mechanisms for receiving and soliciting information from departments of health.
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Advocating for Children and Families in Preparedness Planning
Properly informed and motivated pediatricians are essential advocates for children to ensure they receive appropriate attention in preparedness planning at the local, State, and Federal levels. The role of pediatricians can take several forms. Grass roots advocacy can include efforts to ensure legislation and funding to support an emphasis on children in disaster planning at every level. Pediatricians can serve as expert advisors to local, State, and Federal agencies and committees. They also can serve as strong advocates for children through their involvement in boards, community groups, and professional associations, including national organizations.
As experts in the care of children, pediatricians should be prepared to:
- Advocate for inclusion of the needs of children in all Federal, State, and local disaster planning.
- Advocate for research on the pediatric aspects of biological, chemical, and radiological terrorism, including mechanisms, pathophysiology, and treatment, as well as the availability of appropriate medications and antidotes.
- Work with disaster medical assistance teams to ensure that they are equipped and trained for the care of children.
- Assist in developing hospital disaster plans that ensure the proper care of children.
- Provide on-site emergency and primary health care at emergency shelters.
- Be involved in emergency medical services (e.g., develop proficiency in cardiopulmonary resuscitation and first aid, train first responders in pediatric assessment, assist in development of prehospital pediatric protocols, help establish protocols for consent to treat and identification of minors, and ensure the availability of pediatric resources).
At the local and community levels, pediatricians should:
- Work with local police, fire, and EMS departments to ensure their plans and equipment are prepared for children.
- Be involved with local and community emergency preparedness task forces and committees.
- Work with schools, child care centers, and other facilities where children spend their time to ensure that they have adequate emergency plans.
Similarly, at the State level, pediatricians should:
- Ensure that State emergency management, department of health, and EMS advisory committees have pediatric expertise as part of their membership.
- Advocate to ensure that all State disaster and terrorism education and funding require incorporation of children's needs.
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Conclusion
This summary focuses on the very important role of pediatricians in disaster planning. This includes advocating for the needs of children during the development of preparedness plans, the provision of care during and after a disaster or terrorist event, and the mitigation of suffering in the aftermath of a disaster.
Lessons Learned
As a Nation, we have learned some painful lessons about the need for preparedness from recent disasters, in particular Hurricane Katrina. For example:
- The initial response to mitigate the impact of Katrina on New Orleans and surrounding areas was inadequate at many levels. A large part of the problem was insufficient coordination and planning for the magnitude of the destruction, the need to evacuate large numbers of people, and the long-term displacement of people from their homes and schools.
- In disasters, State and Federal aid is always going to take some time to arrive.
- Local and regional authorities, as well as individual families, should have an effective plan in place that includes immediate efforts to be undertaken before distant assistance can arrive.
- Communities need a realistic evacuation plan that provides for quickly setting up emergency shelters, providing food, managing water sanitation, and providing medical and mental health care services for large numbers of people.
Following Katrina, parallel services spontaneously evolved and were found to be readily accepted by providers, decisionmakers, and patients. For example:
- When a pediatrician is invited to command center meetings, children's issues are resolved more appropriately, efficiently, and effectively.
- Well-meaning volunteers will appear, and some organization of their efforts is essential. Some will be untrained; they have proven to be helpful when appropriately managed. For professionals, emergency credentialing and licensing processes aided in more appropriate use of volunteer skills.
- Payment issues for meaningful and necessary services need to be resolved.
Here are some issues for pediatricians and other planners to consider as they develop and refine emergency response plans for their communities. These are issues that directly affect children and families, and they deserve attention.
Vulnerable Populations
In a disaster, the most vulnerable are going to suffer the most. Clearly, vulnerable populations include the poor, the infirm, individuals with mental illness, the elderly, and children. In addition, these situations highlight the need for including large numbers of technologically dependent patients, many of whom require highly specialized regionalized care, in planning efforts to mitigate the impact of a disaster.
Separation of Children from Families
In the event of a disaster or terrorist event, it is likely that numerous children will be separated from their parents or other caregivers. Several national organizations—including the National Center for Missing and Exploited Children and the Red Cross—work to help separated family members find each other.
This issue deserves more attention in preparedness and mitigation planning. For example, pre-disaster identification of children (e.g., name tags, other forms of ID, etc.)—especially for those who are not verbal or cannot give their own name, a parent's name, or other critical information—should be considered. Neonates and their mothers are purposefully given matching ID bracelets in hospitals immediately after delivery so the identity of the maternal-child pair is never in doubt. Similar identification of parent-child pairs at the time of separation (e.g., during rescue or evacuation) could greatly aid in the identification of the child and more accurately track and reunite children separated from their parents.
Sheltering Families
The immediate first responses to a disaster may be the need to mobilize and evacuate a community or large region. Subsequently, those displaced from their homes, schools, and neighborhoods will require basic necessities (e.g., food, clean water, medical care). The unique needs of children in shelter situations include special food needs (e.g., formula), clothing and sanitation needs (e.g., diapers), and sleeping accommodations (e.g., cribs). Planning for special medical needs and for mental health care that focuses on a child's unique developmental stages is also critical.
The frustration to staff and evacuees caused by a crying infant or an obstreperous 2-year-old is predictable and needs to be anticipated. In addition, some shelters will not accept a pregnant female. This also should be anticipated, and alternate arrangements should be in place in advance of a disaster.
Providing Urgent Care to Large Numbers of Displaced Children
There is a need for pediatric specialists in disasters, and it may be necessary to set up a temporary pediatric clinic to care for large numbers of injured and/or displaced children. Some lessons learned that should be taken into consideration in future planning include:
- Physicians and nurses who are trained and experienced in the emergency care of children should always be included, even at the most basic level, when planning for and responding to a disaster.
- Access to local tertiary pediatric care resources should be arranged for in advance, and tertiary care providers should be involved in planning, including pharmaceutical, central supply, and respiratory personnel.
- While volunteerism is essential in the event of a mass casualty, guaranteed staffing of medical facilities, including temporary clinics, should be a priority.
- The appropriate allocation of physician and nursing resources is vitally important to patient flow.
- Cooperation with regional disaster command is essential.
- Choosing an appropriate venue for the staging of disaster response is critical.
- Mental health care and social services should be made available to the evacuated population as early as possible.
- A centrally located, functional phone, cell phone, and/or radio are crucial.
- A command center should be designated.
- There should always be a planned exit strategy.
A Final Word
Timely response and appropriate medical management are essential to minimizing injuries and maximizing survival when a disaster occurs. Being prepared ahead of time is the key to timely and appropriate medical care. Children and other vulnerable populations have special needs that must be considered in the course of planning for a mass casualty event.
Pediatricians can play a very important and unique role in advocating for the needs of children and families who seldom receive enough attention in disaster planning. Response resources dedicated to pediatric populations remain unavailable or extremely limited for most emergency medical response activities related to disasters, even though victims often include children. To address this shortcoming, it is vitally important that pediatricians and other representatives of special populations take part in local, State, regional, and Federal disaster planning to ensure appropriate care for the most vulnerable populations.
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Additional Resources
The following telephone and online resources are provided to assist you in locating additional information on the topics discussed in this summary.
Department of Health and Human Services
For materials to educate families about bioterrorism, go to http://www.os.dhhs.gov/emergency/index.shtml.
Agency for Healthcare Research and Quality
For a variety of resources on bioterrorism and emergency preparedness and response, go to http://www.ahrq.gov/prep/.
Centers for Disease Control and Prevention (CDC)
For the CDC home page, which includes links to information for families, go to: http://www.cdc.gov/.
Emergency consultation and assistance to clinicians and to State and local health agencies is available 24/7; call 770-488-7100 to reach the Director's Emergency Operations Center.
The Clinician Information Line at 877-554-4625 operates 24/7 to provide guidance on management of patients suspected of having bioterrorism-related illnesses.
Physicians can go to http://www.bt.cdc.gov/clinregistry/index.asp to register to receive real-time CDC updates about preparing for and responding to terrorism and other emergency events.
For public health bioterrorism planning documents, go to http://www.bt.cdc.gov/
Go to http://www.bt.cdc.gov/stockpile/index.asp for information on the Strategic National Stockpile.
For a listing of State health department Web sites, go to http://www.cdc.gov/other.htm#states
For a listing of State epidemiologists, go to http://www.cste.org/members/state_and_territorial_epi.asp 
For information about infection control, go to http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
For a video on the history of terrorism, go to http://www.bt.cdc.gov/training/historyofbt/index.asp
Health Resources and Services Administration
Go to http://www.hrsa.gov/healthconcerns/default.htm and the section headed "Emergency Preparedness" for materials related to bioterrorism and disaster preparedness, including materials specific to children and adolescents.
Substance Abuse and Mental Health Services Administration
Go to http://www.nctsnet.org to access resources developed by SAMHSA's National Child Traumatic Stress Network. Resources include materials on disaster and terrorism preparedness for parents and caregivers, educators, professionals, and the media.
American Academy of Pediatrics
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Acknowledgments and Disclaimers
AHRQ gratefully acknowledges the work of Mary L. Grady in developing this summary.
This summary presents highlights from a report that was prepared by the American Academy of Pediatrics (AAP) for the Agency for Healthcare Research and Quality. The American Academy of Pediatrics and AHRQ have made a good faith effort to take all reasonable measures to ensure that this product is accurate, up-to-date, and free of error in accord with clinical standards accepted at the time of publication. Any practice described in this product must be applied by health care practitioners in accordance with professional judgment and standards of care in regard to the unique circumstances that may apply in each situation they encounter.
The American Academy of Pediatrics and AHRQ are not responsible for any adverse consequences arising from independent application by individual professionals of the content of this product to particular patient circumstances encountered in their practices.
The information and recommendations presented in this summary do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.
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Copyright
This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders.
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AHRQ's Bioterrorism Research Portfolio
The Agency for Healthcare Research and Quality (AHRQ) is a component of the U.S. Department of Health and Human Services. The Agency's mission is to improve the quality, safety, efficiency, and effectiveness of health care by:
- Using evidence to improve health care.
- Improving health care outcomes through research.
- Transforming research into practice.
AHRQ's investment in bioterrorism research recognizes that community clinicians, hospitals, and health care systems have essential roles in the public health infrastructure. To inform and assist these groups in meeting the health care needs of the U.S. population in the face of bioterrorist threats, AHRQ-supported research focuses on the following:
- Emergency preparedness of hospitals and health care systems for bioterrorism and other rare public health events.
- Technologies and methods to improve the linkages between the personal health care system, emergency response networks, and public health agencies.
- Training and information needed to prepare community clinicians to recognize the manifestations of bioterrorist agents and manage patients appropriately.
Visit Bioterrorism Planning and Response to find
out more about AHRQ-supported research, tools, and activities related to
bioterrorism and public health preparedness.
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Current as of September 2006
AHRQ Publication No. 06(07)-0056-1
Internet Citation:
Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians. Summary. September 2006. AHRQ Publication No. 06(07)-0056-1. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/pedprep/pedtersum.htm
540 Gaither Road Rockville, MD 20850