Pediatric Preparedness and Response in Public Health Emergencies and Disasters Workshop US Department of Health and Huma

1. Developing Pediatric Emergency Preparedness Performance MeasuresSteven Krug, MDChair, AAP Disaster Preparedness Advisory CouncilHead, Division of Emergency MedicineChildren’s Memorial Hospital, Chicago, IL Pediatric Preparedness and Response in Public Health Emergencies and Disasters Workshop US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Nashville, TN – October 2009

2. Objectives • Describe the fundamental link between day-to-day emergency preparedness and disaster readiness and identify existing gaps in our nation’s emergency preparedness for children • Describe the purpose of performance measures in defining healthcare quality and how these tools can be leveraged to accurately assess the current status of emergency and disaster preparedness in all domains and as a resource to establish objective targets for performance improvement.

3. Disaster Medicine 101One Plan for All Hazards & All Victims • Can we manage acutely ill or injured children like they are small adults ? • No, neither singly nor in multiples • Why not…. • Unique vulnerabilities • Assessment/triage • Specialized care resource needs • Development & mental health • Family issues • Do current disaster plans contain sufficient pediatric components ? • If not, how can we improve ?

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. ‘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. 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

8. Pediatric Emergencies:The BIG Picture • Children account for 5-10% of EMS runs, ~ 0.5% require true critical care • Limited experience for paramedics with ill and injured children • Children compose 25-30% of ED visits, 5% of which require 30care • Nearly 25 million visits/yr to US EDs • > 90% of children are initially cared for in general hospital ED’s • 50% of EDs see < 10 kids/day • Limited experience with ill and injured kids for RNs and MDs in most EDs

9. 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

10. Pediatric Emergency and Disaster Preparedness: Are We There Yet? • Perhaps the most obvious deficiency in the current evaluation of disaster response is the lack of objective, quantifiable measures of performance [PM] • We can neither assess nor improve what we are unable to measure!

11. From the National Commission on Children and Disasters Recommendation 1.1 – Distinguish and comprehensively integrate the needs of children across all inter- and intra-governmental disaster planning activities and operations. • Incorporate meeting the needs of children as a distinct priority throughout base disaster planning documents and relevant grant programs • Include children in relevant target capabilities, preparedness training and exercises, with specific target outcomes and performance measures

12. The Pandemic and All-Hazards Preparedness Act - 2006 • Requires localities to create preparedness initiatives consistent with: • “measureable, evidence-based benchmarks and objective standards” • Unfortunately, without clear, standardized performance measures, benchmarking across institutions, communities, states and regions is not possible

13. Hazard Vulnerability Analysis • Many organizations are starting to conduct hazard vulnerability analyses [HVAs] that help to identify to identify risks and areas for focused efforts to improve preparedness • In the absence of quantifiable standards and PMs for emergency readiness, HVAs are likely to subjectively assess current readiness and performance levels, and may not accurately define ‘the gap’ • In the absence of PMs, organizations may poorly identify opportunities for improvement and may be vulnerable in the face of a large-scale event

14. So, Are We Ready ??

15. Performance Measures • We need to develop objective, quantifiable (and evidence based?) performance measures [PMs] to which we can accurately and consistently gauge the current state of emergency preparedness - and - as a target for systematic efforts to improve • As a comprehensive scope of objective emergency management PMs does not yet exist, one typically must extrapolate from more routine health care quality principles and PMs and modify these to apply to mass casualty events

16. Pediatric Measures • In addition to the development of ‘generic’ performance measures for emergency preparedness, we must also consider (prioritize?) the needs of special populations • Children may be more vulnerable or may be affected differently than adults • Children may be disproportionately impacted • Children have unique resource needs • Equipment, meds/MCMs, nutrition, providers, facilities • Tracking and reunification • Must also consider children with special care issues - their needs are particularly unique MCMs - Medical Countermeasures

17. Standards for Alternate Care • PMs must also account for changes in performance across all domains when due to a surge in pediatric victims we are forced to care for children in alternate settings • In adult oriented facilities with adult-trained providers and adult designed equipment • Or in pediatric facilities now with limited resources available to patients and altered/lower levels of care* • This scenario would likely affect performance and perhaps patient outcomes • Therefore, the expectations for performance and outcome need to be different *Kanter RK, Andrake JS, et al. Disaster Med Public Health Prepar 2009; 3:27.

18. Metric Types & Development • Volume • Structure • Process • Outcome • Data elements • Clear, standardized definitions • Objective, scalable • Inclusion & exclusion criteria • Availability across all domains • Support benchmarking • Evidence based ? Bummer of a birthmark, Hal..

19. Volume Measures • Assumption I - increased frequency of a task will improve efficiency and quality • Examples: transplant, coronary bypass • Assumption II - larger volume providers of pediatric care are more likely to perform better in a MCE • However, volume cannot be the sole measure, as high volumes do not equate to high quality • Unfortunately, MCEs are low frequency events, therefore cannot use volumes of disaster events • Surrogate or proxy metrics may prove to be useful • The current H1N1 event offers a unique opportunity to evaluate pediatric readiness at most levels of care

20. Surrogate Volume Measures • Examples of surrogate metrics [day-to-day] • Pediatric ED visits • Pediatric inpatient beds, ICU beds • Trauma center volumes • Related volume metrics • Number of staff trained in emergency mgmt • Hours of staff training in pediatric care • Frequency of disaster drills • Doses of key medications, # of ventilators • Pediatric staff

21. Structural Measures • Binary metrics relating to the presence or absence of specific items -- yes/no • Facilities, plans, procedures • Examples • Presence of an emergency management plan • Presence of an emergency mgmt coordinator • Presence of a decontamination facility • Are disaster drills conducted • Most easily addressed, yet may have little evidence-based rationale for improved performance • Not scalable and may not address pediatric needs

22. Pediatric Structural Measures • Presence of pediatric elements in the emergency management plan • Presence of pediatric experts in plan development • Presence of coordinator for pediatric emergency care • Compliance with AAP/ACEP/ENA ED readiness guidelines? • Pediatric considerations in decontamination • Ability to decon intact families & unaccompanied kids • Water temperature and pressure regulation • Disaster drills involving children • Do all drills include children as victims • Presence of drills with numbers of pediatric victims out of proportion to normal numbers seen • Assess pediatric capabilities and surge capacity

23. Process Measures • A means of assessing component care processes towards a desired outcome • There is typically some evidence that these processes or activities improve outcomes • Steroids and acute asthma; ASA and acute MI • Examples • Time to triage or provider in the ED • Time to OR for trauma victims • Time from arrival to decontamination or prophylaxis • Need to assure the measure also reflects unique aspects of pediatric care delivery

24. Outcome Measures • The ‘gold standard’ healthcare quality PM • Morbidity and mortality • Interval measures (eg. return of circulation) • Functional outcomes, quality of life • Evaluation of patient outcomes during disasters is quite challenging • Low frequency of actual events • Different disaster type and scales • Variables in care delivery • Lack of longitudinal data and benchmarking • Data may not support analysis of pediatric care

25. How Do We Know That We’re Ready? It is difficult to plan, let alone improve, what one does not measure and for which there are no specific goals or targets to be achieved

26. Availability of medications, vaccines, equipment and appropriately trained providers for children in disasters • Pediatric surge capacity for both injured and non-injured children • Decontamination, isolation and quarantine of families and children of all ages • Plan that minimizes parent-child separation and includes system tracking of pediatric patients allowing for the timely reunification of separated children and their families

27. Access to specific medical and mental health therapies, as well as social services, for children and families • Disaster drills, which should include a pediatric mass casualty incident at least every two years • Care of children with special health care needs • A plan that includes evacuation of pediatric units and pediatric specialty care units

28. EMSC Performance Measures • PMs for EMSC State grantees • On- and off-line pediatric medical direction for EMS • Pediatric equipment standards for EMS units • Pediatric training for ALS/BLS units • Categorization and regionalized system of hospitals for pediatric medical emergencies and trauma • Inter-facility transfer agreements for children • Permanence of EMSC within state • EMSC Advisory committee • Pediatric input into EMS/disaster http://www.childrensnational.org/EMSC/ForGrantees/Performance_Measures.aspx

29. Accountability: Notable Quote • “the lack of well-accepted, standardized measures and metrics makes it difficult to satisfy the demands for accountability, or gauge the level of preparedness” • Lurie N, Wasserman J, Nelson CD. Public health emergency preparedness: evolution or revolution? Health Affairs 2006; 25:935. • In the spirit of accountability and as an incentive to drive performance improvement, should federal public health funding and disaster/terrorism grants to states and hospitals have pediatric performance measures and targets for performance improvement?

30. What Do We Really Need ? • We need a better emergency and disaster readiness scorecard • With clear, quantifiable, & objective performance measures specific to children of all ages and their unique needs • Meeting the needs of our nation’s children must become a singular health policy priority