Bridget Berg, MPH, FACHE Manager, Disaster Resource Center

Children’s Hospital Los Angeles

Preparing for children’s needs in LA County Forging the way ahead

I have no relevant financial relationships with the manufacturer(s) or any commercial product(s) and/or provider of commercial products or services discussed in this CME activity. I do not intend to discuss unapproved/investigative use of commercial product(s)/device(s) in my presentation.

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Preparing for children’s needs in Los Angeles County – Forging the way ahead

Bridget Berg, MPH, FACHE

Objectives

By the end of this presentation, attendees should be able to:

– Describe common reactions of children following a disaster

– Explain the main functions of a Family Information Center

– Describe the purpose and concept of operations for the LA County Pediatric Surge Plan

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How children are different?

• Physical Differences • Developmental Differences

– Pre-verbal – Reality vs fiction (~ 4 years of age) – Causality

• Psychological Differences • Dosages of medications and volumes of fluid

significantly difference than adults

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MENTAL HEALTH - CHILDREN

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Elements impacting child’s mental health response

Effect of disaster depends on numerous factors:

• Nature of event – amount of death, destruction and disruption

• Degree of personal involvement • Duration of time before return to “normalcy” • 1-time vs chronic event • Coping capability of caregiver • Preexisting mental health, developmental level, and

baseline resiliency and coping skills • Nature of secondary stressors and losses following the

event

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Source: Schonfeld D. et. al,.Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crisis. Pediatrics Vol 136, Number 4. October 2015. DOI: 10.1542/peds.2015-2861

Children’s Mental Health and Development of Concept of Operations

• Children have differential risk for disaster-engendered mental health consequences

• Examples: – Hurricane Katrina, 4 years post event

• 40% of Louisiana parents and 50% of Mississippi parents indicated children still had mental health disorders as a result of the hurricane

• National Children’s Disaster Mental Health Concept of Operations – Efforts for each phase of disaster – Use of PsyStart triage, “Listen, Protect, and Connect” and

services if needed

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Source: Schreiber, M. (2011). National Children’s Disaster Mental Health Concept of Operations. Oklahoma City, OK: Terrorism and Disaster Center at the University of Oklahoma Health Sciences Center.

Psychological Impact

• Reactions may appear immediately or later

• Reactions range – New disorders with complex

comorbidities to short-term distress with improved resilience and possible growth

• Impact may be greater for children

who: – Have previously been abused – Have mental health problems – Lack family support

Managing Pediatric Patients: Mental Health

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Possible Reactions

• Children 5 years and younger – Fear of being separated from parent – Crying, whimpering, screaming – Immobility or aimless motion – Frightened facial expressions – Excessive clinging – Regressive behaviors

Managing Pediatric Patients: Mental Health

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Possible Reactions • Children 6 to 11 years old

– Extreme withdrawal – Disruptive behavior – Regressive behaviors – Inability to pay attention – Outbursts of anger – Bodily symptoms not

medically based

Managing Pediatric Patients: Mental Health

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Possible Reactions

• Adolescents 12 to 18 years – Flashbacks or Nightmares – Emotional numbing – Avoidance of reminders – Depression – Withdrawal – Isolation – Suicidal thoughts

Managing Pediatric Patients: Mental Health

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5,192 children separated

411,000 people evacuated 40 states

7 months later

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Source: http://www.nbcnews.com/id/11909504/ns/us_news-katrina_the_long_road_back/t/final-hurricane-displaced-child-family-reunited/#.VR69AtLF-SU

Cortez Stuart , 4 years old Cortez Stewart

FAMILY REUNIFICATION – FROM CONCEPT TO IMPLEMENTATION

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Family Reunification – What is this?

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Family Registration and Communication

Unaccompanied Minor

Registration and

Identification

Caring for unaccompanied

minors (clinical and possible safe

area)

• Physical description • Any info provided by minor • Description of clothing, jewelry • Distinguishing characteristics • Arrival date / time, location found, brought by • Triage tag number (if available)

CHLA – Family Information Center Plan TTX High Level Results

Plan Development • Inclusive planning

– Social Work, Child Life, Emergency Department

Plan Tabletop Exercise • Tabletop – 4 groups • Activation, Operations, Demobilization

High Level Findings • Separate registration and family call in line • Identify / develop day care documentation for children in safe

area awaiting reunification

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LA COUNTY CONTINUING TO LEAD THE WAY

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LOS ANGELES COUNTY PEDIATRIC SURGE PLAN

Pediatric Surge Plan – Process and Approach

Phase 2 2012-2013

Phase 3 2013-2015

Phase 4 2015

Assessment and Plan Development

Plan Implementation and Training

Plan Exercise and Evaluation

Plan Revision

Phase 1 2011 - 2012

Existing Systems and Resources

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• 100 Acute Care Hospitals • 82 HPP Partners • 14 Trauma Centers • 13 Disaster Resource Centers

(DRC’s) • LAC EMS Agency - Medical Alert

Center (MAC) LAC EMS Agency – Medical Alert Center and Hub and spoke concept

LAC Peds Surge Plan Hospital Tier (# of hospitals)

Tier Description

Tier 1 (13) Full Pediatric Services

Tier 2 (6) Adult Trauma Centers

Tier 3 (11) Peds Acute Beds

Tier 4 (18) Emergency Department Approved for Pediatrics (EDAP)

Tier 5 (21) No Pediatric Services

Tier 6 (8) No Emergency Services / Specialty

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Phase 3 – Plan Evaluation - Exercises April 20, 2015 and June 11, 2015

Children’s Hospital Los Angeles –Susan Goldman

Exercise Highlights – Major Strengths

• Pediatric Surge Plan and Targets – The hospitals were able to meet the surge expectations for

their tier, as described in the LAC Pediatric Surge Plan.

• Pediatric specific concerns – Participating hospitals were able to work through and resolve

pediatric specific concerns.

• Transfers – The Medical Alert Center was able to find destinations for all

patients, from the field and accommodated secondary transfers.

Exercise Highlights Primary Areas for Improvement

• Pediatric Surge Plan Modification

– Separate Tier 1 hospitals into medical and trauma • Important for pre-hospital providers • Provides support for hospitals re: what patients are likely to

treated

• ReddiNet – Concerns re: time process of entering patients – New staff

• Training – Need for advanced and just-in-time training resources regarding

pediatric specific concerns, particularly for lower tiered hospitals

• Plan coordination – Consideration for geographic locations and regional planning outside

of LA County

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Additional Learnings

• Family reunification – Continued development, guidance and exercise needed

• Multi-site MCIs – Highlighted need to work through issues related to simultaneous MCIs

at multiple locations – Knowledge and use of the Fire Operational Area Coordinator (FOAC)

and Medical and Health Operational Area Coordinator (MHOAC) for additional resources

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LAC Peds Surge Plan – UPDATED 6/15 Hospital Tier (# of hospitals)

Tier Description

Tier 1 (13)

Tier 2 (6) Adult Trauma Centers

Tier 3 (11) Peds Acute Beds

Tier 4 (18) Emergency Department Approved for Pediatrics (EDAP)

Tier 5 (21) No Pediatric Services

Tier 6 (8) No Emergency Services / Specialty

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Tier 1 Medical

Tier 1 Trauma

HOSPITAL TIER TIER DESCRIPTION

Tier 1 Pediatric Centers (PTC/PMC)

Tier 2* Pediatric Medical Centers (PMC)

Tier 3 Adult Trauma Centers

Tier 4 Pediatric Acute Beds

Tier 5 Emergency Departments Approved for Pediatrics (EDAP)

Tier 6 No Pediatric Services

Tier 7 No Emergency Services / Specialty Centers

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Pediatric Surge Plan - 2016

* * Note: In a pediatric trauma surge event, patients would go to Tier 3 before Tier 2

SUPPORTING HOSPITALS AND PROVIDERS - TOOLS

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Pediatric Surge Quad Fold

Includes: • Pediatric risks during disasters • Pediatric Assessment Triangle • Pediatric signs of respiratory distress

and respiratory failure • JumpSTART triage • Daily maintenance fluid and electrolyte

requirements • Nutrition • Dehydration • Normal development • Equipment sizes • Shock • Fluid Resuscitation • Burn Treatment – fluid resuscitation

SURGE TRAIN

http://SurgeWorld.lachildrenshospital.net

Why register? • Allows collection of feedback • Ability to see play by hospital

IMPROVING PREPAREDNESS FOR CHILDREN WITH ACCESS AND FUNCTIONAL NEEDS

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Defining At-Risk Individuals

• Before, during, and after an incident, members of at-risk populations may have additional needs in one or more of the following functional areas: – maintaining independence – communication – transportation – supervision – medical care

• Examples: children, senior citizens, pregnant women,… individuals

who have disabilities; live in institutionalized settings; are from diverse cultures; have limited English proficiency or are non-English speaking; are transportation disadvantaged; have chronic medical disorders; and have pharmacological dependency.

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Source: Pandemic and All-Hazards Preparedness Act (PAHPA), Progress report Aug 2008

Project Definition Type of Special Healthcare Need

• Chronic Medical Conditions

Special Education Eligibility or Accommodations

• Other Health Impairments, Orthopedic Impairments

Risks during Disaster/Emergency

• Medications, medical procedures for survival (oxygen, g-tube feedings, ventilators, ostomies); mobility

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Project Deliverables

1. Los Angeles County Hospital System Plan for CSHCN – Annex to the Pediatric Surge Plan – Specific focus on CSHCN and utilizes existing hospital

resources within the county 2. Develop web-based platform

– Provide families with special healthcare needs via two functions: (1) A resource sharing site (2) Opportunity to complete an online emergency information form

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HEALTHCARE PREPAREDNESS FOR CHILDREN

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Elements of Pediatric Preparedness for healthcare facilities

• Awareness and acknowledgement • Leadership

– Identify a pediatric champion (MD and non-MD)

• Plan – Understand your risks – Family Reunification

• Decontamination Nuances – Keep parents / babies together,

baby baths, Warmers, • Pharmaceuticals

– A method for dosing

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• Safety & Security • Staff

– Pre-identified

• Supplies – Basic supplies (diapers,

nutrition, activities & distraction)

– Medical supplies (e.g., smaller items – ETT, Ivs)

• Transportation • Triage

– JumpSTART reference tools

• Training – Advanced training – Just-in-time training

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CHILDREN IN DISASTERS WORKING GROUP

Co-Chairs Rita Burke, PhD, MPH USC and Children’s Hospital Los Angeles

Bob Spears Former LAUSD Emergency Manager

LAC OEM – Access and Functional Needs Meets Monthly

www.CHLA.org/DisasterCenter

Jeffrey S. Upperman, MD FACS FAAP Director, Trauma and PDRTC

Nancy Blake, PhD, RN, CCRN, NEA-BC, FAAN VP, Critical Care Services

Bridget M. Berg, MPH, FACHE Manager

Rita V. Burke, PhD, MPH Assistant Professor of Research

Katie Meyer, RN, BSN House Supervisor

Brenna Carlson, MPH Emergency Management and Trauma Surge Coordinator

QUESTIONS?

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Resources – Hospitals and Healthcare

• American Academy of Pediatrics – Children & Disasters

• Children’s Hospital Los Angeles Pediatric Disaster Resource and Training Center – www.CHLA.org/DisasterCenter

• DHHS – Technical Resources, Assistance Center, and Information Exchange – https://asprtracie.hhs.gov/

• Mental Health – Resource link for Listen Protect Connect and PFA

• http://www.cdms.uci.edu/disaster_mental_health.asp – Schonfeld Article

• http://pediatrics.aappublications.org/content/136/4/e1120

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Resources – Child Preparedness (Schools and Families)

• LA County Children in Disasters Working Group – http://www.childrenindisaster.com/

• Save the Children – Get Ready Get Safe – http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.8777055/k.18AB/Get

_Ready_Get_Safe_Plan_Ahead.htm – Training (must register)

• http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.9111279/k.8B62/Get_Ready_Get_Safe_Training.htm

• American Red Cross – Pillowcase project for schools – http://www.redcross.org/get-help/prepare-for-emergencies/resources-for-

schools • RAND

– school-based group intervention for elementary students exposed to stressful and traumatic events.

– http://bouncebackprogram.org/

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