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Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons

Children In Disasters: Disposition Hospital Tiering System To Match Pediatric Patients With Suitable Pediatric Resources. Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons Director of Trauma & Pediatric Surgical Services Harlem Hospital Center

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Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons

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  1. Children In Disasters: DispositionHospital Tiering System To Match Pediatric Patients With Suitable Pediatric Resources Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons Director of Trauma & Pediatric Surgical Services Harlem Hospital Center Children in Disasters Conference New York City Department of Health and Mental Hygiene New York, New York, March 16, 2011 Contact: ac38@columbia.edu

  2. Planning for Pediatric Blast Trauma Pediatric injuries are to be expected following blast trauma, with most children injured in closed or confined, rather than open, spaces, greatly increasing the magnitude of forces of injury

  3. Planning for Pediatric Blast Trauma • As with adult blast terror injuries, most patients will either die at the scene, or sustain minor injuries, leaving only a small number in the “penumbra” of the blast wave who will sustain major injuries and survive to require hospital care, but who typically will not begin to arrive at the trauma center until some 30-60 minutes after the terror event • Most survivors with major injuries will require early operation and subsequent care in a pediatric critical care unit, followed by lengthy hospitalization and rehabilitation, both physical and psychological

  4. Mitigation of Pediatric Blast Trauma The approximate number and likely destination of casualties can be predicted • Half arrive during the first 60 min • Half go to the closest 3 hospitals • Half go to other hospitals…but are they the right hospitals?

  5. Mitigation of Pediatric Blast Trauma Surge capability depends upon the rate limiting step for maximum victim throughput • Numbers of ORs & RNs, and ICU beds & RNs, determine hospital capability to care for critically ill patients • Numbers of x-ray machines & x-ray technologists determine hospital capability to care for all other patients • Regional hospital capacity for blast trauma is likely adequate in most areas unless a regional resource trauma center is a primary or secondary target

  6. Chain Of Events-Planning Triage Tiering Transport Surge

  7. PDC Recommends When possible and appropriate: Implement expedited procedures for rapid evacuation and primary transport of pediatric patients in MCEs Facilitate primary transport of pediatric patients to pediatric disaster receiving hospitals (PDRHs) according to level of pediatric care required

  8. Tiering Triage Tiering

  9. Pediatric Disaster Trauma Care:Planning AssumptionsAugust 2004 • Pediatric surge capacity ≠ pediatric surge capability • Federal target: 500 patients/1,000,000 people • New York also a model for qualitative analysis • New York State: 700 beds/1,000,000 children • New York State: 3,000 beds/1,000,000 adults • New York City: 248 PICU beds, 1,019 pediatric beds • Israeli blast terror experience: mean age 12 yr • Israeli blast terror experience: 33% need PICU

  10. Pediatric Disaster Trauma Care:Fuzzy Math? • Needed pediatric surge capability in NYC: 1,000 beds • Half the patients are over 12 yrs; could be treated in adult TCs • Surge PICU beds needed in NYC: 500 x 0.33 = 167 • Average PICU occupancy in NYC: 248* x 0.80 = 200 • Staffed PICU beds typically open daily in NYC: 47* • NYC must therefore find about 120 more PICU beds • 23 PICU hospitals could open 4 pediatric PACU beds • There are 4 other PICUs and PACUs in adjacent counties *Source: NYSDOH HERDS Critical Asset Survey August 2004, excluding KCHC NICU beds

  11. Pediatric Disaster Trauma Care:Fuzzy Math? • Together they could accept about 116 additional patients; so, • For blast terror, there may be just enough PICU beds, but . . . • The calculations are only as good as our assumptions, so . . . • How do we find the beds? And who will be staffing them? *Source: NYSDOH HERDS Critical Asset Survey August 2004, excluding KCHC NICU beds

  12. Where Will Children Go? • FDNY will preferentially transport infants and children from the scene of any disaster involving five (5) or more pediatric patients to the closest appropriate PDRH • Pediatric patients are defined in disasters not by age, but by their visual appearance (non-adolescent children who appear to be of primary school age or younger)

  13. Which Patients Go Where? • Tier 1 PDRHs • Mechanical ventilation • Volume resuscitation • Multiple transfusions • Multiple medications • Complex wound care • Artificial airway care • Extensive lab testing • TPN, TEN • Tier 2 PDRHs • Oxygen administration • Intravenous hydration • Scheduled medications

  14. Tier 1 – Pediatric Hospital (+ PICU) Intended to receive red, orange, yellow patients Committed to subspecialty pediatric care Pediatric surgical service Pediatric intensive care unit Pediatric emergency service Comprehensive pediatric subspecialty support Anesthesiology, neurosurgery, orthopaedic surgery with experience in management of children

  15. Intended to receive green patients Committed to general pediatric care Pediatric surgical consultants Pediatric resuscitation capable ED Pediatric transfer agreement Tier 2 – Pediatric Hospital (- PICU)

  16. The following categories of care providers should be encouraged to take the course under PFCCS instructors: • Non-Critical Care MD’s • ED fellows • Chief residents • CNS • PA’s • The hospital should sponsor the training of Pediatric Critical Care faculty to become certified instructors in a course of Pediatric Fundamental Critical Care Support (PFCCS).

  17. How We Found Them • A detailed list of hospital requirements was created for Tier 1 and Tier 2 PDRHs by the Triage Committee in Year 1 and vetted at the 2009 Children In Disasters Conference • A telephone survey of all 63 911 Receiving Hospitals in New York City was conducted by the Triage Committee in Year 2 and was confirmed in writing by their CEOs in Year 3

  18. Resources • Introduction • Security • Dietary Needs • Surge Considerations/Bed Assignments • Equipment • Training • Staffing • Transportation • Decontamination • Pharmacy Needs • Psychosocial Needs • Infection Control • Hospital Triage • Family information and Support Center • New York City Resources http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds-childrenindisasters-010709.pdf

  19. Resources Pediatric Disaster Tabletop ExerciseWritten by: Marsha Treiber, MPS Moderated by: George Foltin, MD Facilitated by: Michael Tunik, MD Bonnie Arquilla, DO http://www.nyc.gov/html/doh/downloads/word/bhpp/hepp-peds-tabletoptoolkit-010709.doc

  20. Resources Pediatric Terrorism and Disaster Preparedness: A Resource for Physicians http://www.ahrq.gov/research/pedprep/pedresource.pdf NYC Hospital Pediatric Resource Directory http://www.nyc.gov/html/doh/downloads/pdf/bhpp/hepp-peds-resdir-apr09.pdf

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