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Pediatric Emergency Readiness and Pandemic Influenza

Pediatric Emergency Readiness and Pandemic Influenza. Steven E. Krug, MD Head, Division of Emergency Medicine Children’s Memorial Hospital Chicago, IL AAP 2009 NCE Washington, DC. Disclosures.

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Pediatric Emergency Readiness and Pandemic Influenza

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  1. Pediatric Emergency Readiness and Pandemic Influenza Steven E. Krug, MD Head, Division of Emergency Medicine Children’s Memorial Hospital Chicago, IL AAP 2009 NCE Washington, DC

  2. Disclosures • I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity • I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation

  3. Objectives • Describe the fundamental link between day-to-day emergency preparedness and disaster (aka pandemic) readiness for children • Define the role for pediatricians as advocates for pediatric emergency and disaster readiness and as participants in disaster mitigation, response and recovery • Discuss lessons learned from the Spring 2009 H1N1 patient surge and strategies for improved pediatric readiness for an influenza pandemic

  4. Pediatric Disaster Preparedness: 101 • Preparation for a pandemic, or any type of disaster, begins with basic preparation for pediatric emergencies • This should occur at alllevels of care • Home/community • Office • Hospital • This should anticipate children with special healthcare needs

  5. A ‘Blueprint’ for Disaster Readiness }- All-hazard mass casualty event readiness }- Day-to-day emergency readiness “The Elevated Hurricane Zone Housing Solution”

  6. So, How’s The Foundation of Our Nation’s Emergency Care System? • Existing public safety systems (EMS, fire, etc) are frequently over-taxed by demand • EMS and trauma systems are woefully under-funded • Hospital-based emergency departments are increasingly and dangerously overcrowded • Pediatric capabilities of our emergency (and disaster) care systems is uncertain

  7. Emergency Care: At the Breaking Point • ED visits grew by 26% between 1993 and 2003 (90  114 million) • Number of ED’s declined by 425 • Critical shortages of healthcare providers (MDs, RNs, etc) • Substantial ED overcrowding • Ambulances are frequently diverted from overcrowded EDs • ~ 500,000 diversions in 2003 • In addition to ED access concerns, overcrowding is associated with poor care quality & medical error Institute of Medicine. Future of Emergency Care in the US Healthcare System, 2006.

  8. Pediatric Readiness: “Growing Pains” • Although children make up at least 1/4 of all ED visits nationwide • Most general EDs and EMS agencies do not require specialized pediatric training for their clinical staff • Only 6% of all EDs have the full scope of pediatric equipment, medications, supplies • Paucity of research on best practices, clinical outcomes, & patient safety in pediatric emergency care “If there is one word to describe the current state of pediatric emergency care in 2006, it is UNEVEN” --- IOM Panel, 2006

  9. Pediatric Emergency Care: The Experience Gap • Children account for 5 to 10% of all EMS patients • Only 0.5 -1% are critically ill/injured • Limited experience for paramedics with sick kids • Children make 25-30 million ED visits per year • Less than 5% of require 30care • Nearly 90% of children are cared for in general hospital ED’s • Many of these EDs see few children • 50% of EDs care for < 10 kids/day • Limited experience with sick kids

  10. Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers Frush K, and the Committee on Pediatric Emergency Medicine POLICY STATEMENT Pediatrics 2007; 120(1): 200-12 • Perform a self-assessment of office readiness for emergencies • Develop an organizational plan for emergency response in the office • Maintain recommended office equipment, medications, supplies and tools to guide resuscitation interventions (e.g. protocols, pre-calculated drug doses) • Develop a plan to provide education and training for all office staff • Practice mock codes in the office on a regular basis • Educate families about what to do in an emergency • Partner with EMS and hospital-based emergency care providers to ensure optimal emergency care and disaster readiness for children – or a pandemic!

  11. Guidelines for Care of Children in the ED Gausche-Hill M, Krug S, and the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association Pediatrics - October 2009; 124(4):1233-43. • Recommendations regarding personnel, training, equipment, supplies, medications, support services, quality and process improvement, policies, protocols, and other resources necessary for optimal pediatric emergency care • Updated version of 2001 AAP/ACEP joint policy statement • The presence of MD & RN pediatric coordinators may be the most important factor associated with readiness* • This ADVOCATE could be a community or hospital based pediatrician • Offers recommendations for patient safety & disaster readiness *Gausche-Hill M, et al. Pediatrics 2007; 120(6): 1229-37

  12. The Pediatrician and Disaster Preparedness Committee on Pediatric Emergency Medicineand the Task Force on Terrorism POLICY STATEMENT Pediatrics 2006; 117(2): 560-65 • Advocate for children and families in disaster planning at all levels • Become knowledgeable about issues related to pediatric disaster mgmt • Participate in disaster planning: • Office emergency readiness and an office disaster plan – develop & practice • Take part in local community and hospital disaster planning, exercises, drills • Work with local schools and child care facilities in developing their plans • Provide anticipatory guidance to families on preparedness – esp. CSHCN • Participate in disease surveillance and reporting activities • Participate/provide guidance to local volunteer disaster response groups

  13. School Readiness Concerns

  14. Children’s Memorial Hospital, Chicago, IL

  15. Children’s Memorial Hospital ED Visits

  16. Spring 2009 – Lessons Learned • Disconnect between federal and local pandemic planning and management recommendations • Variable screening and treatment practices across facilities/practices within local communities • Demand for clinical services by ill and ‘worried well’ patients exceeded capacity • Availability of key medications and supplies limited service delivery and placed patients & staff at risk • Impact of the pandemic on healthcare staff further reduced service capacity at all levels of care • Impact on key safety net services threatened patient care quality and safety

  17. H1N1 Preparedness: 10 Steps You Can Take 1. Develop a business/practice continuity plan • Cross-training of staff to support key functions • Develop alternate plans for critical supplies • Plan to support core business functions for several weeks 2. Inform staff about pandemic surge coping plan • Clear and frequent communication – assure understanding • Promote resiliency through personal/family plan development 3. Plan to operate in the face of absenteeism • Anticipate 20 to 50% 4. Protect the workplace, ill personnel remain home • Staff should engage in self monitoring behaviors • Align FMLA policies with infection control expectations Source: CDC – “Ten Steps” Available at: http://cdc.gov/h1n1flu/10steps.htm

  18. H1N1 Preparedness:10 Steps You Can Take 5. Plan for a patient surge and an increased demand for services • Consider telephone as a tool to deliver messaging on when & where to seek care, or where to seek additional information • Consider extending hours of operation • Telephone triage • Office hours • Develop a plan to manage patients who do not require emergency care 6. Plan to care for H1N1 patients in your facility • Plan to screen patients at entry for signs of ILI • If feasible, employ a separate waiting and exam rooms • Provide face masks where appropriate • Support use of hand hygiene products

  19. H1N1 Preparedness: 10 Steps You Can Take 7. Take steps to protect your workforce • Promote use of PPE, and hand hygiene by staff • Stockpile necessary equipment and supplies 8. Provide seasonal flu immunization for staff 9. Be aware of the pandemic planning and response activities within your community • State/local health department; hospitals and clinics; schools 10. Keep abreast of reliable & updated information on epidemiology, planning and treatment • CDC and AAP websites, Dept of Health, local hospitals CDC: Medical Offices And Clinics Pandemic Influenza Planning Checklist Available at: http://pandemicflu.gov/professional/pdf/medofficesclinics.pdf

  20. Being Aware Being Prepared • Local epidemiology/prevalence of H1N1 • Viral screening/testing • Anti-viral therapy • Treatment and prophylaxis • At-risk populations • Dosing & medication safety concerns • Vaccination • Infection control • N95/PPE use, isolation, furloughs http://aap.org/new/swineflu.htm http://www.cdc.gov/h1n1flu/

  21. http://www.cdc.gov/h1n1flu/update.htm

  22. Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season September 22, 2009 2:00 PM ET Updated to include complications and treatment considerations for infants and young children, clarity on underlying conditions that contribute to increased risk for influenza-related complications, and information on anti-viral medication dosing and safety concerns with oral suspensions

  23. Antiviral Therapy Recommendations Patients at risk for H1N1 related complications People with more severe illness, such as those hospitalized with suspected or confirmed influenza Children younger than 2 years old Children less than 5 years ? Adults 65 years and older Pregnant women People with certain chronic medical or immunosuppressive conditions People younger than 19 years of age who are receiving long-term aspirin therapy

  24. Which Children Are at High Risk? Neurological disorders Epilepsy or cerebral palsy especially accompanied by neuro-developmental disabilities Neuromuscular disorders (muscular dystrophy) Chronic respiratory diseases associated with impair pulmonary function and difficulty with secretions Moderate to severe asthma Technology dependent children (e.g. tracheostomy)

  25. Which Children Are at High Risk? Moderate to profound intellectual disability or developmental delay when associated with specific neurological and respiratory condition Immune deficiencies (congenital or acquired) Congenital heart disease, significant metabolic (mitochondrial), or endocrine disorders

  26. Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel October 14, 2009, 2:00 PM ET Updated interim guidance on infection control measures to prevent transmission in healthcare facilities. Emphasizes the ‘hierarchy of controls’ (Elimination of potential exposures, Engineering controls, Administrative controls, Personal protective equipment) as a strategy to protect both staff and patients.

  27. October 16, 2009 http://www.cdc.gov/h1n1flu/clinicians/pdf/childalgorithm.pdf

  28. http://www.aap.org/disasters • Disaster Planning Resources for Pediatricians • Needle: A Disaster Preparedness Plan for Pediatricians • Information on Biological, Chemical, Nuclear & Thermo/Mechanical Agents • Psychosocial and mental health considerations • Influenza • Resources for clinicians • Practice guidance, patient resources, management recommendations • Resources for patient and families • Numerous links • CDC, HHS, NCCD, others

  29. http://www.aap.org/disasters/pdf/DisasterPrepPlanforPeds.pdf

  30. Policy Statement—Recommendations for the Prevention and Treatment of Influenza in Children, 2009–2010 Committee on Infectious Diseases Pediatrics - October 2009; 124(4):1216-26. • Updated recommendations for the routine use of trivalent seasonal influenza vaccine and anti-viral medications for the prevention and treatment of seasonal influenza in children

  31. AAP DPACDisaster Preparedness Advisory Council • Steven Krug, MD, FAAP - Chairperson • Sarita Chung, MD, FAAP • Daniel Fagbuyi, MD, FAAP • Margaret Fisher, MD, FAAP • Scott Needle, MD, FAAP • David Schonfeld, MD, FAAP • Liaison Members: • DHS/OHA, HHS/ASPR, CDC, NICHD • Laura Aird – AAP Staff

  32. New doll available at the American Girl Store: ‘Suzy Swine Flu’….

  33. Pediatric Preparedness of US Emergency Departments: A 2003 Survey Marianne Gausche-Hill, Charles Schmitz, and Roger J. Lewis Pediatrics 2007; 120(6): 1229-37 • Closed response survey of 5100 US emergency departments assessing their awareness & compliance with published AAP/ACEP pediatric readiness guidelines • Nearly 90% of pediatric ED visits occur in a non-children’s hospital ED • 26% of these visits occur in remote or rural facilities < 1000 kids/yr • 50% of emergency departments see less than 10 kids per day • Only 6% had all recommended equipment per AAP/ACEP 2001 guidelines • Common shortfalls were neonatal & infant sized equipment (e.g. airways) • Readiness scores were higher in larger volume EDs, and particularly in those with a physician and/or nurse leader for pediatric care • This ADVOCATE could be a hospital or community-based pediatrician

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