Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds.

OBJECTIVES: To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented. DESIGN: Retrospective observational study using secondary data. PATIENTS: Children admitted to VPS-participating PICUs between 2009-2012. INTERVENTIONS: A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient's probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources. MEASUREMENTS AND MAIN RESULTS: Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p < 0.001). CONCLUSIONS: Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children's data demonstrated superior population survival during a simulated overwhelming pandemic.

Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event.

OBJECTIVE: ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. DESIGN: A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels ("high risk"), or if they have a low likelihood of requiring ICU support ("low risk"). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. SETTING: One hundred ten American PICUs SUBJECTS: : One hundred fifty thousand records from the Virtual PICU database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. CONCLUSION: An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions.

The Medical Home and Care Coordination in Disaster Recovery: Hypothesis for Interventions and Research.

In postdisaster settings, health care providers encounter secondary surges of unmet primary care and mental health needs that evolve throughout disaster recovery phases. Whatever a community's predisaster adequacy of health care, postdisaster gaps are similar to those of any underserved region. We hypothesize that existing practice and evidence supporting medical homes and care coordination in primary care for the underserved provide a favorable model for improving health in disrupted communities. Elements of medical home services can be offered by local or temporary providers from outside the region, working out of mobile clinics early in disaster recovery. As repairs and reconstruction proceed, local services are restored over weeks or years. Throughout recovery, major tasks include identifying high-risk patients relative to the disaster and underlying health conditions, assisting displaced families as they transition through housing locations, and tracking their evolving access to health care and community services as they are restored. Postdisaster sources of financial assistance for the disaster-exposed population are often temporary and evolving, requiring up-to-date information to cover costs of care until stable services and insurance coverage are restored. Evidence to support disaster recovery health care improvement will require research funding and metrics on structures, processes, and outcomes of the disaster recovery medical home and care coordination, based on adaptation of standard validated methods to crisis environments.

Care of the child with Ebola virus disease.

OBJECTIVES: To provide clinicians with practical considerations for care of children with Ebola virus disease in resource-rich settings. DATA SOURCES: Review of the published medical literature, World Health Organization and government documents, and expert opinion. DATA SYNTHESIS: There are limited data regarding Ebola virus disease in children; however, reported case-fatality proportions in children are high. Ebola virus may affect immune regulation and endothelial function differently in children than adults. Considerations for care of children with Ebola virus disease are presented. CONCLUSIONS: Ebola virus disease is a severe multisystem disease with high mortality in children and adults. Hospitals and clinicians must prepare to provide care for patients with Ebola virus disease before such patients present for care, with particular attention to rigorous infection control to limit secondary cases. Although there is no proven specific treatment for Ebola virus disease, meticulous supportive care offers patients the best chance of survival.

Would triage predictors perform better than first-come, first-served in pandemic ventilator allocation?

BACKGROUND: In a pandemic, needs for ventilators might overwhelm the limited supply. Outcome predictors have been proposed to guide ventilator triage allocation decisions. However, pandemic triage predictors have not been validated. This quantitative simulation study evaluated outcomes resulting from allocation strategies varying in their performance for selecting short-stay survivors as favorable candidates for ventilators. METHODS: A quantitative simulation modeled a pandemic surge. Postulated numbers of potential daily admissions presented randomly from a specified population, with a limited number of available ventilators. Patients were triaged to ventilator care vs palliation or turned away to palliation if no ventilator was available. Simulated triage was conducted according to a set of hypothetical triage tools varying in sensitivity and specificity to select favorable ventilator candidates vs first-come, first-served allocation. Death was assumed for palliation. Survival or death was counted for patients who were ventilated according to the specified characteristic of each randomly selected patient. RESULTS: Triage predictors with intermediate-quality performance resulted in a median daily mortality of 80%, similar to first-come, first-served allocation. A poor-quality predictor resulted in a worse mortality of 90%. Only a high-quality predictor (sensitivity 90%, specificity 90%) resulted in a substantially lower 60% mortality. CONCLUSIONS: Performance of unvalidated pandemic ventilator triage predictors is unknown and possibly inferior to first-come, first-served allocation. Poor performance of unvalidated predictors proposed for triage would represent an inadequate plan for stewarding scarce resources and would deprive some patients of fair access to a ventilator, thus falling short of sound ethical foundations.

Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics-those elements that provide the capability to deliver mass critical care. METHODS: The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process. RESULTS: This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response. CONCLUSIONS: Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

BACKGROUND: System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning. CONCLUSIONS: System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

School interventions after the Joplin tornado.

BACKGROUND/OBJECTIVE: To qualitatively describe interventions by schools to meet children's needs after the May 2011 Joplin, Missouri tornado. METHODS: Qualitative exploratory study conducted six months after the tornado. Key informant interviews with school staff (teachers, psychologists, guidance counselor, nurse, principal), public health official, and physicians. REPORT: After the tornado, school staff immediately worked to contact every enrolled child to provide assistance and coordinate recovery services. Despite severe damage to half of the city's schools, the decision was made to reopen schools at the earliest possible time to provide a safe, reassuring environment and additional services. An expanded summer school session emphasized child safety and emotional wellbeing. The 2011-2012 school year began on time, less than three months after the disaster, using temporary facilities. Displaced children were bused to their usual schools regardless of their new temporary residence locations. In just-in-time training sessions, teachers developed strategies to support students and staff experiencing anxiety or depression. Certified counselors conducted school-based, small-group counseling for students. Selective referrals were made to community mental health providers for children with greatest needs. CONCLUSIONS: Evidence from Joplin adds to a small body of empirical experience demonstrating the important contribution of schools to postdisaster community recovery. Despite timely and proactive services, many families and children struggled after the tornado. Improvements in the effectiveness of postdisaster interventions at schools will follow from future scientific evidence on optimal approaches.

Disaster-related environmental health hazards: former lead smelting plants in the United States.

OBJECTIVE: Natural disasters exacerbate risks of hazardous environmental exposures and adverse health consequences. The present study determined the proportion of previously identified lead industrial sites in urban locations that are at high risk for dispersal of toxic chemicals by natural disasters. METHODS: Geographic analysis from publicly available data identified former lead smelting plants that coincide with populated urban areas and with high-risk locations for natural disasters. RESULTS: From a total of 229 urban smelting sites, 66 (29%) were in relatively high-risk areas for natural disasters: flood (39), earthquake (29), tornado (3), and hurricane (2). States with urban sites at relatively high risk for natural disaster included California (15); Pennsylvania (14); New York (7); Missouri (6); Illinois (5); New Jersey (4); Kentucky (3); Florida, Oregon, and Ohio (2 each); and Indiana, Massachusetts, Rhode Island, Texas, Utah, and Washington (1 each). Incomplete historical records showed at least 10 smelting site locations were affected by natural disaster. CONCLUSIONS: Forgotten environmental hazards may remain hazardous in any community. Uncertainty about risks in disasters causes disruptive public anxiety that increases difficulties in community responses and recovery. Our professional and public responsibility is to seek a better understanding of the risks of latent environmental hazards.

Regional variation in critical care evacuation needs for children after a mass casualty incident.

OBJECTIVES: To determine the ability of five New York statewide regions to accommodate 30 children needing critical care after a hypothetical mass casualty incident (MCI) and the duration to complete an evacuation to facilities in other regions if the surge exceeded local capacity. METHODS: A quantitative model evaluated pediatric intensive care unit (PICU) vacancies for MCI patients, based on data on existing resources, historical average occupancy, and evidence on early discharges and transfers in a public health emergency. Evacuation of patients exceeding local capacity to the nearest PICU center with vacancies was modeled in discrete event chronological simulations for three scenarios in each region: pediatric critical care transport teams were considered to originate from other PICU hospitals statewide, using (1) ground ambulances or (2) helicopters, and (3) noncritical care teams were considered to originate from the local MCI region using ground ambulances. Chronology of key events was modeled. RESULTS: Across five regions, the number of children needing evacuation would vary from 0 to 23. The New York City (NYC) metropolitan area could accommodate all patients. The region closest to NYC could evacuate all excess patients to PICU hospitals in NYC within 12 hours using statewide critical care teams traveling by ground ambulance. Helicopters and local noncritical care teams would not shorten the evacuation. For other statewide regions, evacuation of excess patients by statewide critical care teams traveling by ground ambulance would require up to nearly 26 hours. Helicopter transport would reduce evacuation time by 40%-44%, while local noncritical care teams traveling by ground would reduce evacuation time by 16%-34%. CONCLUSIONS: The present study provides a quantitative, evidence-based approach to estimate regional pediatric critical care evacuation needs after an MCI. Large metropolitan areas with many PICU beds would be better able to accommodate patients in a local MCI, and would serve as a crucial resource if an MCI occurred in a smaller community. Regions near a metropolitan area could be rapidly served by critical care transport teams traveling by ground ambulance. Regions distant from a metropolitan area might benefit from helicopter transport. Using local noncritical care transport teams would involve shorter delays and less expert care during evacuation.

The 2011 Tuscaloosa tornado: integration of pediatric disaster services into regional systems of care.

OBJECTIVE: To empirically describe the integration of pediatric disaster services into regional systems of care after the April 27, 2011, tornado in Tuscaloosa, Alabama, a community with no pediatric emergency department or pediatric intensive care unit and few pediatric subspecialists. STUDY DESIGN: Data were obtained in interviews with key informants including professional staff and managers from public health and emergency management agencies, prehospital emergency medical services, fire departments, hospital nurses, physicians, and the trauma program coordinator. RESULTS: A single hospital in Tuscaloosa served 800 patients on the night of the tornado. More than 100 of these patients were children, including more than 20 with critical injuries. Many children were unaccompanied and unidentified on arrival. Resuscitation and stabilization were performed by nonpediatric prehospital and emergency department staff. More than 20 children were secondarily transported to the nearest children's hospital an hour's drive away under the care of nonpediatric local emergency medical services providers. No preventable adverse events were identified in the resuscitation and secondary transport phases of care. Stockpiled supplies and equipment were adequate to serve the needs of the disaster victims, including the children. CONCLUSION: Essential aspects of preparation include pediatric-specific clinical skills, supplies and equipment, operational disaster plans, and interagency practice embedded in everyday work. Opportunities for improvement identified include more timely response to warnings, improved practices for identifying unaccompanied children, and enhanced child safety in shelters. Successful responses depended on integration of pediatric services into regional systems of care.

Pediatric mass critical care in a pandemic.

OBJECTIVES: Previous simulation studies suggest that temporary pediatric mass critical care approaches would accommodate plausible hypothetical sudden-impact public health emergencies. However, the utility of sustained pediatric mass critical care responses in prolonged pandemics has not been evaluated. The objective of this study was to compare the ability of a typical region to serve pediatric intensive care unit needs in hypothetical pandemics, with and without mass critical care responses sufficient to triple usual pediatric intensive care unit capacity. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: The Monte Carlo simulation method was used to model responses to hypothetical pandemics on the basis of national historical evidence regarding pediatric intensive care unit admission and length of stay in pandemic and nonpandemic circumstances. Assuming all ages are affected equally, federal guidelines call for plans to serve moderate and severe pandemics requiring pediatric intensive care unit care for 457 and 5,277 infants and children per million of the population, respectively. MEASUREMENTS AND MAIN RESULTS: A moderate pandemic would exceed ordinary surge capacity on 13% of pandemic season days but would always be accommodated by mass critical care approaches. In a severe pandemic, ordinary surge methods would accommodate all the patients on only 32% of pandemic season days and would accommodate 39% of needed patient days. Mass critical care approaches would accommodate all the patients on 82% of the days and would accommodate 64% of all patient days. CONCLUSION: Mass critical care approaches would be essential to extend care to the majority of infants and children in a severe pandemic. However, some patients needing critical care still could not be accommodated, requiring consideration of rationing.

Treatment and triage recommendations for pediatric emergency mass critical care.

INTRODUCTION: This paper will outline the Task Force recommendations regarding treatment during pediatric emergency mass critical care, issues related to the allocation of scarce resources, and current challenges in the development of pediatric triage guidelines. METHODS: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS: Recommendations are divided into three operational sections. The first section provides pediatric emergency mass critical care recommendations for hospitals that normally provide care to pediatric patients. The second section provides recommendations for pediatric emergency mass critical care at hospitals that do not routinely provide care to pediatric patients. The final section provides a discussion of issues related to developing triage algorithms and protocols and the allocation of scarce resources during pediatric emergency mass critical care.

Supplies and equipment for pediatric emergency mass critical care.

INTRODUCTION: Epidemics of acute respiratory disease, such as severe acute respiratory syndrome in 2003, and natural disasters, such as Hurricane Katrina in 2005, have prompted planning in hospitals that offer adult critical care to increase their capacity and equipment inventory for responding to a major demand surge. However, planning at a national, state, or local level to address the particular medical resource needs of children for mass critical care has yet to occur in any coordinated way. This paper presents the consensus opinion of the Task Force regarding supplies and equipment that would be required during a pediatric mass critical care crisis. METHODS: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS: The Task Force endorsed the view that supplies and equipment must be available for a tripling of capacity above the usual peak pediatric intensive care unit capacity for at least 10 days. The recommended size-specific pediatric mass critical care equipment stockpile for two types of patients is presented in terms of equipment needs per ten mass critical care beds, which would serve 26 patients over a 10-day period. Specific recommendations are made regarding ventilator capacity, including the potential use of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. Other recommendations include inventories for disposable medical equipment, medications, and staffing levels.

Neonatal and pediatric regionalized systems in pediatric emergency mass critical care.

INTRODUCTION: Improved health outcomes are associated with neonatal and pediatric critical care in well-organized, cohesive, regionalized systems that are prepared to support and rehabilitate critically ill victims of a mass casualty event. However, present systems lack adequate surge capacity for neonatal and pediatric mass critical care. In this document, we outline the present reality and suggest alternative approaches. METHODS: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS: States and regions (facilitated by federal partners) should review current emergency operations and devise appropriate plans to address the population-based needs of infants and children in large-scale disasters. Action at the state, regional, and federal levels should address legal, operational, and information systems to provide effective pediatric mass critical care through: 1) predisaster/mass casualty planning, management, and assessment with input from child health professionals; 2) close cooperation, agreements, public-private partnerships, and unique delivery systems; and 3) use of existing public health data to assess pediatric populations at risk and to model graded response plans based on increasing patient volume and acuity.

Child mortality after Hurricane Katrina.

BACKGROUND: Age-specific pediatric health consequences of community disruption after Hurricane Katrina have not been analyzed. Post-Katrina vital statistics are unavailable. The objectives of this study were to validate an alternative method to estimate child mortality rates in the greater New Orleans area and compare pre-Katrina and post-Katrina mortality rates. METHODS: Pre-Katrina 2004 child mortality was estimated from death reports in the local daily newspaper and validated by comparison with pre-Katrina data from the Louisiana Department of Health. Post-Katrina child mortality rates were analyzed as a measure of health consequences. RESULTS: Newspaper-derived estimates of mortality rates appear to be valid except for possible underreporting of neonatal rates. Pre-Katrina and post-Katrina mortality rates were similar for all age groups except infants. Post-Katrina, a 92% decline in mortality rate occurred for neonates (<28 days), and a 57% decline in mortality rate occurred for postneonatal infants (28 days-1 year). The post-Katrina decline in infant mortality rate exceeds the pre-Katrina discrepancy between newspaper-derived and Department of Health-reported rates. CONCLUSIONS: A declining infant mortality rate raises questions about persistent displacement of high-risk infants out of the region. Otherwise, there is no evidence of long-lasting post-Katrina excess child mortality. Further investigation of demographic changes would be of interest to local decision makers and planners for recovery after public health emergencies in other regions.

Mass critical care: pediatric considerations in extending and rationing care in public health emergencies.

This article applies developing concepts of mass critical care (MCC) to children. In public health emergencies (PHEs), MCC would improve population outcomes by providing lifesaving interventions while delaying less urgent care. If needs exceed resources despite MCC, then rationing would allocate interventions to those most likely to survive with care. Gaps between estimated needs and actual hospital resources are worse for children than adults. Clear identification of pediatric hospitals would facilitate distribution of children according to PHE needs, but all hospitals must prepare to treat some children. Keeping children with a family member and identifying unaccompanied children complicate PHE regional triage. Pediatric critical care experts would teach and supervise supplemental providers. Adapting nearly equivalent equipment compensates for shortages, but there is no substitute for age-appropriate resuscitation masks, IV/suction catheters, endotracheal/gastric/chest tubes. Limitations will be encountered using adult ventilators for infants. Temporary manual bag valve ventilation and development of shared ventilators may prolong survival until the arrival of ventilator stockpiles. To ration MCC to children most likely to survive, the Pediatric Index of Mortality 2 score meets the criteria for validated pediatric mortality predictions. Policymakers must define population outcome goals in regard to lives saved versus life-years saved.

Developing consensus on appropriate standards of disaster care for children.

BACKGROUND: Neither professional consensus nor evidence exists to guide the choice of essential hospital disaster interventions. The objective of our study was to demonstrate a method for developing consensus on hospital disaster interventions that should be regarded as essential, quantitatively balancing needs and resources. METHODS: A panel of pediatric acute care practitioners developed consensus using a modified Delphi process. Interventions were chosen such that workload per staff member would not exceed the previously validated maximum according to the Therapeutic Intervention Scoring System. Based on published models, it was assumed that the usual numbers of staff would care for a disaster surge of 4 times the usual number of intensive care and non-intensive care hospital patients. RESULTS: Using a single set of assumptions on constrained resources and overwhelming needs, the panel ranked and agreed on essential interventions. A number of standard interventions would exceed crisis workload constraints, including detailed recording of vital signs and fluid balance, administration of vasoactive agents, invasive monitoring of pressures (central venous, intraarterial, intracranial), dialysis, and tube feedings. CONCLUSIONS: The quantitative methodology and consensus development process described in the present report may have utility in future planning. Groups with appropriate expertise must develop action plans according to authority within each jurisdiction, addressing likely disaster scenarios, according to the needs in each medical service region, using available regional resources, and accounting for the capabilities of each institution.

Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs.

OBJECTIVE: To estimate the potential for disaster mortality reduction with two surge response strategies: 1) control distribution of disaster victims to avoid hospital overcrowding near the scene, and 2) expand capacity by altering standards of care to only "essential" interventions. DESIGN: Quantitative model of hospital mortality. SETTING: New York City pediatric intensive care unit and non-intensive care unit pediatric hospital capacity and population. MEASUREMENTS AND MAIN RESULTS: Mortality was calculated for a hypothetical sudden disaster, of unspecified mechanism, assuming 500 children per million population need hospitalization, including 30% severely ill/injured warranting pediatric intensive care unit care, with high (76%) predisaster hospital occupancy. Triage rules accommodated patients at lower levels of care if capacity was exhausted. Specified higher relative mortality risks were assumed with reduced levels of care. In a pessimistic baseline scenario, hospitals near the disaster scene, considered to have 20% of regional capacity, were overcrowded with 80% of the surge patients. Exhausted capacity at overcrowded hospitals near the scene would account for most of the 45 deaths. Unused capacity would remain at remote facilities. If regional surge distribution were controlled to avoid overcrowding near the scene, then mortality would be reduced by 11%. However, limited pediatric intensive care unit capacity would still require triage of many severe patients to non-intensive care unit care. Instead, if altered standards of care quadrupled pediatric intensive care unit and non-intensive care unit capacity, then mortality would fall 24% below baseline. Strategies 1 and 2 in combination would improve mortality 47% below baseline. If standards of care were altered prematurely, preventable deaths would occur. However, additional simulations varying surge size, patient severity, and predisaster occupancy numbers found that mortality tradeoffs would generally favor altering care for individuals to improve population outcomes within the range of federal planning targets (500 new patients/million population). CONCLUSION: Quantitative simulations suggest that response strategies controlling patient distribution and expanding capacity by altering standards of care may lower mortality rates in large disasters.