Pediatric Surge Project

California Department of Public Health (CDPH)

California EMS Authority (EMSA)

Richard O. Johnson, M.D., MPH, FAAP, Facilitator

Barbara Taylor, Deputy Director of Public Health Emergency Preparedness, CDPH

Craig Johnson, Chief, Disaster Medical Services Division, EMSA

Raaz Fares, Staff Services Manager, EPO, CDPH

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Introductions and History• EMSA – Craig Johnson

• CDPH – Barbara Taylor, Raaz Fares

• Facilitator – Rick Johnson

• Acknowledging previous work

• Gap leading to the current Project – statewide/Western Region pediatric patient distribution plan

• disclaimer

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GoalIn an incident (slowly progressing or sudden), this annex (to the Patient

Movement Plan) is a resource and tool to be used by healthcare partners (facilities, EMS, MHOAC, RDMHS, etc.) in coordinating the efficient provision of an appropriate and available level of care to

pediatric patients (neonatal, infants, children, adolescents, and OB) from geographic areas affected by a disaster.

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GoalRight Patient, Right EMS Resource, Right

Destination• Ensure the highest and best utilization of and access

to our region’s pediatric resources

• Leverage and maximize every asset at all levels of capabilities at every hospital (large or small, rural or urban, pediatric or adult), EMS, and outpatient

• Recognize that a coordinated and integrated response requires the active participation of private and public resources and systems at every level.

• Strive to equitably maximize the # of children receiving the appropriate level of care for their needs during a disaster

• Recognize and acknowledge that in a major event, demand for pediatric care will likely exceed resources and capacity. Op areas, regions, and CA will move from individual-based care to population-based care with the focus on saving the maximum # of lives possible.

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Context

• Under the best of circumstances, any large disaster is characterized by initial chaos.

• Kids may not be the only ones affected – multiple requests will be made for the same resources.

• Children have rarely received the priority they deserve in planning for disasters.

• Although predictions are that we will have a severe pandemic or catastrophic earthquake, we live in the cocoon of denial, with real life agendas and priorities pushing planning and exercising into the background. (Alan Nager, M.D.: “A catastrophic disaster will occur; we just don’t know when”)

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Definition

A DISASTER is a type of emergency that, due to its complexity, scope, or duration, threatens the organizations capabilities and requires OUTSIDE ASSISTANCE to sustain patient care, safety, or security

functions (from the Stanford TRAIN Tool)

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Triggers for Activation

• whenever facilities/systems providing healthcare to pediatric patients and/or local EMS systems require local, regional, state, or federal assistance to manage the movement of neonatal, pediatric, and/or OB patients created by the incident, including triage, treatment, stabilization and transportation of patients to definitive care, in addition to the evacuation of existing healthcare facilities, as needed.

• A local, state, or federal declaration of emergency is not necessary.

• Depending on the availability of resources in an affected area, this annex may be activated during a Level 1, 2, or 3, incident.

• Activation may be triggered by the MHOAC, or RDMHS, or CDPH or EMSA.

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Pediatric Hazard Vulnerability Assessment• Where are the kids?

• Where are the beds?

• Where are the disasters likely to occur?

• Will we lose some of our response capacity/capability?

• The peds population is unique, includes neonates and OB patients, may be 1/3 to ½ to 100% of victims

• What is the risk (probability, vulnerability)?o Earthquake, wildfires. floodso Pandemic (flu or emerging infectious disease)o CBRNEo Shootero Transportationo Haz mat

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Geographic Linkages: Pediatric population and resources

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California Patient Movement Plan

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Healthcare System – What we have

• Inpatient facilities – excellent specialty centers – private, systems, MOU’s• Professional associations • Joint Commission, CMS, HPP grant surge requirements• EMS – public and private, air/ground, LEMSAs and EMSA• EMSC, Pediatric Readiness Project• Electronic systems – Reddinet, EMResource, CalEOC, etc.• HAvBED, EOM, MHOAC Program Manual, Patient Movement Plan, SEP• Healthcare Coalitions• MHOAC Programs• RDMHS Programs• Outpatient facilities and providers• Perinatal Transport System

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California Patient Movement Plan

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Sub-committees

• Hospital

• EMS

• Outpatient

• The Bridge:

o MHOAC

o RDMHS

o MHCC

o Regional/State/Western Region Patient Movement/Distribution Coordinators

o Clinical Pediatric Subject Matter Experts (SMEs)

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Hospital Sub-committee

Co-facilitated with:Anna Lin, MD

Pediatric Hospitalist, Lucile Packard Children's Hospital Stanford

Clinical Assistant Professor, Division of Pediatric Hospital Medicine, Stanford University

Assistant Medical Director, Office of Emergency Management, Stanford Children's Health and Stanford Healthcare

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TRANSPORT DESCRIPTIONSTransport Type Staffed By Capabilities/Considerations

BLS (Basic Life Support)

Ambulance

2 licensed

emergency

medical

technicians

(EMTs)

Designed for inter-facility transfer and pre-hospital response to ill or injured

patients. EMTs can use AEDs, perform basic and intermediate airway

procedures and complete basic monitoring of patients (i.e. vitals, oxygen

levels). Care is non-invasive by nature.

ALS (Advanced Life Support)

Ambulance

Minimum of

1 paramedic

and 1 EMT

Provide advanced life support and interventional care. Capabilities of

paramedics include the administration of authorized medications, use of

advanced airway equipment, cardiac monitors and blood glucose testing

equipment. Paramedics can start IVs and push authorized medications.

Critical Care Transport (CCT) At least one

provider is a

RN, PA, NP

or physician

along with

an EMT or

paramedic

and others

as needed

(i.e. RT)

The provision of medical care by a critical care transport team to a patient

requiring transport such that the failure to initiate on an urgent basis or

maintain acute medical, pharmacological interventions or technologies would

result in sudden, clinically significant or life threatening deterioration in the

patient’s condition. A patient requiring critical care transport has a critical

illness or injury that acutely impairs one or more vital organ systems such that

there is a high probability of imminent or life threatening deterioration in the

patient’s condition.

Specialized Transport Dependent

on patient

need

Patient’s condition requires ongoing care that must be provided by one or

more health professionals in an appropriate specialty area. Specialty

areas can include nursing, medicine, respiratory care, cardiovascular care or

a paramedic with additional training. Consideration of this type of transport

will include immediate placement needs that may be related to surgical

interventions, autoimmune disorders as well as consideration of physical

requirements and equipment needed for transport (i.e. a bariatric patient).

EMS Transport Types

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NICU TRAIN TOOL

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PEDIATRIC TRAIN TOOLTransport Car (non-

ambulance)

BLS (2 EMT Team) ALS (1 EMT, 1

Paramedic)

CCT (EMTs/

Paramedics & RN)

Specialized (Staffed

depending on need)

Life Support Stable Minimal Minimal/Moderate Moderate Maximal

Mobility Car seat/ Home

Wheelchair

Wheelchair/Stretcher Wheelchair/Stretcher Stretcher Incubator Transport/

Stretcher

Nutrition All PO Intermittent Enteral Continuous Enteral or

Partial Parenteral

TPN Dependent TPN Dependent

Monitoring Level/

Stability

Routine Vitals Routine Vitals + O2

sat;

Moderately stable

Frequent Vitals + Cardiac

Monitoring; Interventions

possible

Continuous;

Changing status;

Interventions

probable

Specialized OR requirements;

Equipment or limited

resources; High complexity

Pharmacy PO Meds IV Lock IV Fluids – IV Drip

without titration

Titrated IV Drip;

TPN Dependent

IV Drip ≥2, type and

monitoring requirement

Life

Support

Minimal = O2; Peripheral IV; Trach (non-vent and not requiring deep suction during transport)

Moderate = CPAP/BiPAP/Hi-Flow; Chest tube; Continuous Nebulizer; Stable home/long-term vent (requires transport with

RT or RN to maintain ventilator support)

Maximal = Ventilator; ECMO; External Pacemaker; Highly Specialized Equipment

Pharmacy IV Drip = Pharmacological agents that cannot be discontinued for transport, agents that require active monitoring. IV

drips that can be maintained safely at current rate versus those that need dose monitoring and possible

titration en route to destination (i.e. vasopressors, insulin, etc.)

Mobility Car (non-

ambulance) =

Able to get in and out of non-ambulance car, van or bus; sit up; follow commands

Wheelchair = Some impairment related to mobility; unable to ambulate long distances

Stretcher = Unable to ambulate or contraindicated to current medical status/condition

Immobile = Unsafe to move without specialized equipment. Non-ambulatory bariatric patient; unstable cervical fracture

(includes incubator) 18

OBSTETRICS TRAIN TOOLTransport Car (Non-

Ambulance)BLS (2 EMT Team) ALS (1 EMT, 1

Paramedic Team)Specialized (Staffed depending on need)

Labor Status None/Early Early Active Active/High Risk

Mobility Car/Stretcher Wheelchair/Stretcher Stretcher/Immobile Stretcher/Immobile

Epidural Status None Placement > 1 Hour Placement < 1 Hour N/A

Maternal Risk Low Low/Moderate Moderate/High High

Labor Status Early= Onset of labor until cervix is dilated to 3 cm; mild to moderate contractions; greater than 5

minutes apart

Active= Continuous contractions (lasting > 40 sec) with contractions < 5 min apart; includes

Transition Phase (<3 min apart) until delivery; normal delivery expected

High Risk= Multi-fetal pregnancy; low birth weight; abnormal fetal presentation; fetal distress;

known congenital defects; complications; premature labor; trauma; imminent threat

Life Support Minimal = O2, peripheral IV

Moderate = CPAP/BiPAP/Hi-Flow; Chest tubes, Continuous Nebulizer

Maximal = Ventilator; ECMO; External Pacemaker; Highly specialized equipment

Pharmacy IV Drip = Pharmacologic agents, not TPN, that cannot be discontinued for transport; agents that

require active monitoring

Mobility Car (non-

ambulance) =

Able to get in and out of non-ambulance car, van, or bus; sit up; follow commands

Wheelchair = Some impairment related to mobility; unable to ambulate for long distances

Stretcher = Unable to ambulate or contraindicated to current medical status/condition

Immobile= Unsafe to move without specialized equipment, e.g. non-ambulatory bariatric patient;

unstable cervical fracture 19

BEHAVIORAL HEALTH TRAIN TOOL

Additional symptoms you may consider in determination of transport type

Car (non-ambulance): Euthymic, mildly depressed and/or anxious. Mood congruent. Normal, blunted or constricted affect. Fair insight and judgment. Alert and oriented, able and willing to ambulate safely.

BLS Ambulance: Manic, hyperactive, dysphoric and/or highly anxious. Some mood incongruence. Exaggerated, heightened affect. Rapid speech, flight of ideas. Mildly delusional. Impaired insight and judgment. Confused and/or lethargic individuals who are unable to ambulate or those

whose willingness to transfer safely is in question.

ALS Ambulance: Psychomotor agitation, angry, gravely disabled and/or signs of active psychosis. Mood incongruence with current situation. Loud, pressured speech. Active delusions and/or hallucinations. Signs of response to internal stimuli. Severely impaired insight and judgment.

Obtunded, stuporous and/or catatonic individuals who are unable to ambulate or those who display a complete lack of cooperation and a high lethality risk.

Transport Car (Non-ambulance) BLS (2 EMT Team) ALS (1 Paramedic, 1 EMT Team)

Lethality Risk

(see definitions

below)

Low Moderate High

AWOL Risk Low Moderate High

Level of Lability Low Moderate High

Pharmacy Infrequent PO PRN Administration Frequent PO PRN Administration Frequent IM PRN Administration

Lethality Risk

Definitions

Low = Passive or no current suicidality and/or homicidality. No current plan or intent to harm self and/or others.

No current signs of psychomotor agitation/physical risk to self and/or others. No restraints required.

Moderate = Active suicidality and/or homicidality with current plan but no intent or means to act out plan. Some signs

of psychomotor agitation/potential threat to self and/or others. May require 2P or 4P restraints.

High = Active suicidality/homicidality with current plan and intent to harm self and/or others. High level of

psychomotor agitation/risk of causing harm to self and/or others. Does require 2P or 4P restraints and IM

medication administration.

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HOSPITAL STATUS (ESSENTIAL ELEMENTS) FORM

UTILIZED TO REPORT TRAIN NUMBERS TO EMS

• When reporting transport needs/TRAIN numbers for the facility to the EMS DOC/MOC, a Hospital Status

(Essential Elements) Form will be submitted by the facility’s Command Center to EMS via WebEOC. This

illustration highlights the “evacuation” section of the required form.

EVACUATION

EVACUATION (“TRAIN” Categories) TOTAL

COUNT

Ambulatory to Evacuate

BLS to Evacuate

ALS to Evacuate

CCT

SPECIALIZED

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Hospital Tiers - HIGH

• Name – Pediatric Tertiary Center

• Definition – a referral/receiving hospital providing comprehensive specialized pediatric medical and surgical care to the most critically ill or injured children

• CriteriaoMust have:

▪ Regional NICU

▪ PICU

▪ Licensed pediatric beds

oMay have▪ Designation as a Trauma Center, ideally pediatric

▪ Will be divided into 2 tiers – those with/without Trauma designation

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Hospital Tiers - MEDIUM

• Name – Pediatric Community Hospital

• Definition – a community-based hospital with licensed pediatric beds, able to provide some pediatric services – relationship to a HIGH Tier facility, may be asked to keep/receive children who would normally be transferred.

• CriteriaoMust have:

▪ NICU (Regional, Community, or Intermediate)▪ Licensed pediatric beds

oMay have▪ PICU▪ Designation as a Trauma Center (Pediatric or Adult)▪ Will be sub-divided into 2 tiers – those with/without Trauma designation

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Presence of PICU and Trauma Center Designation*

• There are no hospitals with a Pediatric Trauma Center designation without a PICU

• There are 14 hospitals with a PICU without a Trauma Center designation (UCLA Santa Monica, KP LA, Huntington, Encino-Tarzana, Fountain Valley, Los Robles, KP Oakland, CPMC, UCSF, KP San Jose, Sutter Sac, KP Roseville, Bakersfield Memorial, KP Fontana)

• There are 6 hospitals with an Adult Trauma Center designation without a PICU (Pomona Valley, Cottage, Sutter Roseville, Mercy San Juan, San Joaquin General, Memorial (Stanislaus),

*all need to be confirmed

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Hospital Tiers - LOW• Name – General Community Hospital

• Definition – a usually small community hospital (includes Critical Access Hospitals), with general medical/surgical beds, able to provide some basic inpatient pediatric services– relationship to a HIGH Tier facility, may be asked to keep/receive children who would normally be transferred.

• CriteriaoMust have:

▪ General acute care beds▪ 911 receiving center

oMay have▪ Adult ICU▪ Newborn nursery

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Hospital Tiers – SPECIALTY CARE

• Name – Specialty care services or facilities

• Definition – a facility ,or specialty service within a facility, that is not a 911 receiving center, including:o Burn centerso Long-term care facilitieso Adolescent psychiatric facilitieso Dialysiso ECLS (ECMO)o transplant

• Criteriao Must have:

▪ Physician staffing or availability 24/7

▪ Licensed specialty beds appropriate for the provided services▪ Surge plan to handle extra patients within the specialty type

▪ An evacuation plan including destination to like facility in coordination with the MHOAC and RDMHS.

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Hospital Data Set –(using CCS, CDPH L and C, EMSA, OSHPD,CA Perinatal Transport System data)

paper and electronic mapping tool

• Region and county and LEMSA

• Name and system (e.g., Kaiser), physical address, phone #, GIS coordinates

• Category (H, M, L, S)

• Trauma Designation (Adult 1 through 4, Pediatric 1 or 2)

• Total Beds

• PICU beds

• Licensed pediatric beds

• Licensed medical/surge beds

• NICU (Regional, Community, or Intermediate)

• OB perinatal beds (and level)

• Well baby nursery beds (probably will not include

• Specialty beds (B, D, E, P, R, T)

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Day-to-day pediatric patient movement

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Pediatric patient movement with emergency system activation – ICS, SEMS, NIMS

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Pediatric patient movement with emergency system activation

• facility, OA, regional, or state resources are insufficient to meet the need (Levels 1, 2, or 3)

• may involve the evacuation of a facility at any level (H, M, L, S)

• may involve a surge of patients from the field to facilities or from a facility needing to evacuate or decompress due to a surge to other facilities

• pediatric, neonatal, and/or OB SME’s may be at an HCC and at an activated government response center

• decision to evacuate or request assistance with transfer is the responsibility of the IC or designee (HCC, FTS) according to internal disaster plans and local policy and procedures

• Obtaining the requested resource is the responsibility of the activated government response center personnel

• Potential transporting EMS provider or receiving facility has the right to accept/reject a request

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Pediatric patient movement with emergency system activation

• A request for assistance (available bed and/or EMS resource) goes from the sending facility/agency to the OA EOC and MHOAC.

• The role of the personnel in the activated government response center is one of support and coordination of resources and resource requests from facilities and EMS providers. However, In order to maximize the efficient utilization of all available and appropriate resources, requests for patient movement will be regulated by the DOC/EOC/MOC and the MHOAC. Normal patient referral networks and transport team protocols will be suspended. Control of EMS assets will under the control of the DOC/EOC/MOC and the MHOAC, including the allocation of scarce resources when the demand/need exceeds the available resources. If the DOC/EOC/MOC and MHOAC in the affected OA is unable to function, then the REOC and RDMHS will carry out these functions.

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Areas needing further development• Mobile pediatric specialty teams – taking a team to the patient rather

than the patient to the team

• Behavioral health – victims, families, professionals

• Telemedicine- linking MEDIUM and LOW capability facilities with a higher level of care (UC Davis)

• Outpatient facilities/providers (Urgent Care, AAP, mid-levels, FQHC, CPCA – probably will use organizations as hubs to reach providers)

• Emergency credentialing – use of DHV, MRC, CAL-MAT, DMAT, SUVs (Joint Comm protocols)

• Patient tracking and family reunification

• Special needs children34

Areas needing further development

• Levels of perinatal care – working with Dr. Kay Daniels at Stanford, and the CPCQC (California Perinatal Care Quality Collaborative)

• Integration with the Patient Movement Plan

• Further refinement of the pediatric capability of CNG and NDMS and DOD resources

• Including guidance regarding HIPAA and new EMTALA requirements

• Multi-state partnerships (Arizona, Nevada, Oregon, Washington, Utah, Colorado, Texas, et al)

• Crisis standards, allocation of scarce resources

• CEO level engagement

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Outline

• California Public Health and Medical Emergency Operations Manual (EOM)

• MHOAC Program Manual (Guide)

• California State Emergency Plan (SEP) (2017)

• Patient Movement Plan (Pediatric Surge Annex)

• The Required Additional Pieces• Healthcare Coalition• Med/Health Multi-Agency Coordination (MAC) Group• TRAIN• M/H Incident Management Team (MHOAC/RDMHS)• Functioning at the Edge of Chaos

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The Evolution of an Incident

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Event Incident Chronological Timeline Representation

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Assumes:- IC to manage the ad hoc responding organizations- Operations Section Chief to carry out the mission

- Planned by the Planning Section Chief- Supported by the Logistics Section Chief

- Paid for through the Finance Section Chief

All in a state-of-the-art EOC with flat screen TVs, radios, computers, with ICS forms on the computers, ready to be filled out for federal compliance and possible later reimbursement.

The Reality – Initial Chaos

• Screaming injured people, bodies

• Crowds, media, elected officials

• Law, fire, EMS, healthcare workers overwhelmed, may not hurt or not able to function

• Fires, mud, water, wind, cold/hot, snow/rain

• Environmental destruction

• Conflicting information, rumors

• Lack of communication and transportation

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The Questions – Situation Awareness

• What has happened?

• What have I never seen before – is foreign to me?

• What have I seen before – is familiar to me?

• What do I know?

• What do I need to know?

• What do I want to do?

• What do I have to do?

• What can I do?

• What am I trying to accomplish here?

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Tenets of Working in Chaos - 1• The party already started – you are late – you need to

catch up

• Find the right MHOAC ahead of time – effective in chaos, experienced, trained, educated

• Not every incident has a playbook – sometimes you just need to think – “sensemaking” in chaos

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Tenets of Working in Chaos - 2

• Manipulation and improvisation are not dirty words – leadership is defined as “giving purpose, direction and motivation to people when there is eminent physical dangers and where followers believe that leader behavior will influence their well-being or survival”. Be calm, focused, positive, relentless, apply experience, set aside ego, overcome obstacles, anticipate/manage change, determine objectives, define expectations, establish priorities, trust subordinates, constantly evaluate and adjust.

BE DECISIVE

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Tenets of Working in Chaos - 3• The starting point for insightful problem solving is

leverage points – specific things, events, PEOPLE –pre-existing relationships, social capital.

• Social Capital is “the stock of active connections among people; the trust, mutual understanding, and shared values and behaviors that bind the members of human networks and communities and make cooperative action possible”.

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“If we don’t hang together –we will all hang separately”- Ben Franklin

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Thank you!!

Contact information:

Richard O. Johnson, M.D., MPH, FAAP

drrickjohn@gmail.com

Cell: 760-914-0496

Raaz Fares

raaz.fares@cdph.ca.gov

Office: 916-445-9195

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