Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Challenges to an Effective Response to Patient Surges
To respond effectively to
bioterrorism or other infectious outbreaks, both pediatric and nonpediatric health
care facilities must:
- Recognize the incident in its early stages.
- Activate existing surge capacity plans.
- Adequately prepare for consequence management after such incidents.
- Provide adequate logistical support for increased patient volume.
Difficulties in Recognizing an Outbreak
Diseases spread by the
airborne route have great epidemic potential in those without immunity to the
organism, and the ability to recognize such an epidemic is inhibited by the
delay between exposure to a bioweapon and the development of clinical symptoms.
The ability to identify a bioweapon remains critical to the planning for and
management of an outbreak; the same holds true for recognizing a natural
outbreak. Experience with the outbreak of the Severe Acute Respiratory Syndrome
(SARS) demonstrated that epidemiologic history and tracing patients' travels
were critically important in understanding the patterns of disease spread.
Unfortunately, many clinicians who work in an emergency setting receive minimal
training in traditional epidemiologic methods, or they do not have the time to
Access to surveillance
systems capable of informing clinicians about terrorist attacks can quicken
response to a sudden surge of patients. For example, poison control centers
are linked to a single nationwide database that is updated within minutes; the
goal of this database is to rapidly identify and disseminate information about
sentinel events back to poison control centers and then to local clinicians.
Physicians who access this important information source will receive timely
notification of developing outbreaks of various types.
Reluctance to Activate the Surge Capacity
Activation of the surge
capacity plan signals the absolute need for transition from normal hospital
operations to a disaster footing. Because of the unknown extent and expense of
the response, however, clinicians may hesitate to activate the plan.
Alternatively, emergency physicians who have become inured to severely crowded
conditions may be unaware that activation of the surge capacity plan is
warranted when there is a large influx of pediatric patients.
Logistics: Deployment of Hospital Personnel
Effective surge capacity plans
require brisk responses at institutional and departmental levels that are
supervised by a designated team of individuals following a defined command
structure. An organized and well-communicated response can support well-designed
surge capacity plans, heighten the benefit of disaster drills, improve the
efficiency of hospital operations, and foster the delivery of good quality patient
Emergency Department (ED)
As with any disaster, the ED
bears the brunt of the patient inflow into a health care facility. ED
operations, the efficiency of which are severely compromised by overcrowding,
are further hampered by intentional capacity-to-demand mismatch promoted by
hospital administrations to ensure that inpatient bed spaces are never wasted.3 Hospital
administrations, credentialing organizations, and Federal, State, and local
agencies need to eliminate or minimize ED overcrowding to ensure good quality patient
care in the event of a terrorist attack.
A dramatic number of patients
exposed to a bioweapon may become critically ill. An excessive volume of high-acuity
children will place extreme pressures on the clinicians staffing intensive care
units, particularly if critically ill patients have significant respiratory
illness or involvement of multiple organ systems. Critical care staff may be
required to assist in patient resuscitation in the ED as well as the
traditional intensive care setting.
Care and Radiology
Patient surges may overwhelm
the ability of respiratory therapists to provide adequate care to critically
ill children. Excess patient load, especially patients with significant
respiratory demands, may prevent the adherence to hospital standards for
ventilator management, respiratory care, and pulmonary toilet. Hospitals may
lack an adequate number of positive-pressure ventilators to effect the degree
of activation of a pediatric surge capacity plan. Moreover, respiratory
therapists may be at increased risk for infection during procedures such as
orotracheal intubation and administration of nebulized therapy. This risks
attrition of the available workforce.
The numbers of patients who
can be admitted to hospital floors is typically determined by the ratio of
nurses to patients. In the event of a surge of high-acuity children, nursing
staff may need to provide care for greater numbers of sicker patients, at least
until additional staff can be mobilized through the surge capacity plan.
Staff (Security, Engineering and Environmental Services, and Public Affairs)
Controlling the flow of
patients, families, and visitors into a health care facility is vitally
important after a disaster. A breach of hospital security can lead to
unnecessary exposure of staff to infected victims, spread of disease, and
contamination of "clean" hospital areas. Engineering services may be needed to
construct ventilation barriers that can isolate entire floors from the
remainder of the facility. Adequate disposal of contaminated materials by
environmental services personnel is necessary to avoid contamination of
hospital areas. Lastly, centrally controlling communication messages sent to
staff, patients, and the public is an important role for Public Affairs, as it
improves the response by providing clear, consistent communication while
Logistics: Insufficient Resources
for Communicable Disease Control
Both pediatric and general
hospitals may have insufficient resources to control the spread of communicable
diseases. Surges of patients may overwhelm the number of respiratory isolation
rooms and permit the spread of airborne pathogens into "clean" hospital areas,
a problem that would be exacerbated by inadequate air exchange ensured by
antiquated heating-ventilation-air conditioning (HVAC) units.4 If
multiple patients are cohorted in multi-bed rooms, the distance between beds
may be insufficient to prevent the spread of airborne pathogens.4 In
locations such as the ED, there are many challenges to preventing the spread of
infectious agents. Many patient bed spaces are separated only by a curtain;
patients may share a common bathroom. Moreover, most EDs have washbasins for
which water flow is activated by turning a faucet handle rather than using a
motion or body heat sensor; the latter feature avoids direct contact with
bathroom hardware and prevents the spread of foodborne pathogens transmitted in
Maintaining an Adequate Supply of Hospital Stocks
An increased volume of
critically ill patients may completely deplete available supplies of
ventilators, respiratory isolation gowns, N95 respirators, sheets, medications,
intravenous supplies, and other material. For example, to prevent the spread of
disease from patients requiring respiratory support after infection with an
airborne pathogen, clean gowns, N95 respirators, and bag-valve-mask devices
("ambubags") must be used for each patient. Furthermore, clinicians should
change gowns, gloves, and N95 respirators when entering each patient room to
avoid the spread of disease.
Challenges Posed by Pediatric Mass Casualty Incidents
release of a biological weapon would disproportionately affect children through
several mechanisms.1,2 With aerosolized agents (e.g.,
anthrax), increased respiratory minute ventilation in children (500 ml/Kg/min)
compared with adults (140 ml/Kg/min) results in the child's exposure to a
relatively greater inoculum.1 The high vapor density of
bioaerosols, such as those potentially used to disseminate airborne pathogens,
places their highest concentration close to the ground in the lower breathing
zone of children.1 The more permeable skin of
newborns and children in conjunction with a larger surface-to-mass ratio
results in greater exposure to transdermally absorbed toxicants.1 Children, because of their
relatively larger body surface area, lose heat quickly when showered.1 Consequently, skin decontamination
with water may result in hypothermia unless heating lamps and other warming
equipment are used.1 Having less fluid reserve
increases the child's risk of rapid dehydration or frank shock after vomiting
and diarrhea.1 Finally, children have significant
developmental vulnerabilities.1 Infants, toddlers, and young
children do not have the motor skills to escape from the site of a biological
incident.1 Even if they are able to walk,
they may not have the cognitive insight to decide in which direction to flee.1 All children are at risk of
psychological injury, such as posttraumatic stress disorder, from experiencing
or witnessing an act of terrorism.1,5 In a mass casualty incident,
children witness injuries and deaths, possibly of their parents, which would
produce both short- and long-term psychological trauma that requires
are difficult to care for by health care personnel wearing protective
equipment, which is essential in the management of chemical, biological, and
radiological events. Protective clothing is bulky and cumbersome; it impedes
the ability of health care providers to perform procedures such as venipuncture
or endotracheal intubation on small children.
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