There has been a significant increase in the number and severity of disasters throughout the world. Factors contributing to the increase in disasters include population growth, urbanization, increasingly complex technologies, a rise in world-wide terrorism, social unrest, global economic and social interdependence, an increase in infectious diseases (i.e., SARS, monkey pox, and antimicrobial-resistant infections), and environmental degradation [1].

Since the September 11, 2001 attacks on the World Trade Center and Pentagon, there has been a new emphasis on disaster preparedness. This emphasis has been directed primarily toward adults and little attention has been specifically given to the needs of children. Additionally, while there are a number of efforts to integrate the preparedness and response efforts of public health and health care delivery systems, the uniqueness of pediatric needs has not been addressed fully [2, 3].

The expectation during emergencies is that the care provided for adults is appropriate for children. This thinking and the lack of children's ability to be fully responsible for their own actions and decisions may be at the root of the lack of focus on pediatric needs in disaster planning. Additionally, it is important to consider that although federal, state, and local agencies have programs specifically directed at children, most of the current initiatives and programs focus on a sub-population of children (those with specific chronic conditions, etc.) or are client-centered [4]. Likewise, the number of hospitals that provide pediatric-specific care or units in adult hospitals that provide specialty care for children are limited in number due in part to the general good health and resiliency of children. In some regions of the country, there are limited numbers of pediatric facilities, thus severely limiting the surge capacity for children during disasters and other emergencies.

The purpose of this paper is to examine the increase in disasters and to discuss the importance of specifically addressing the special needs of children in disaster planning. Further, the paper argues for a regional network approach to emergency pediatric care that would identify and respond to the institutional issues surrounding the creation of a regional pediatric medical response network and increase surge capacity for children during disasters and other emergencies.

Prevalence of disasters

The number of natural disasters in the last 100 years in the US and world has grown dramatically. Ninety-four of all worldwide reported natural disasters, occurred in the last 54 years. Similarly, 91 % of all natural disasters in the US occurred in the past 54 years. In addition, human-initiated disasters have increased. The number of reported chemical spills, explosions, collapses, poisonings, fires, and transportation accidents worldwide has increased from 266 in the decade of the 1970s to 2051 in the decade of the 1990s. In the same period, the number of reported human-initiated disasters in the United States doubled from 42 to 86.

Perhaps the most visible increase in disasters in this decade has been attributed to an increase in terrorism. In the last four years there have been 2,687 terrorist events around the world killing or directly injuring 0,605 people [5]. The cost of these disasters is not measured in just the number of lives lost, but also in the adverse psychological effects and negative economic impacts that follow. For example, following the September 11th attacks, US employers cut more than 248,000 jobs attributable to the attacks. The attacks also derailed consumer confidence and spending, affecting the tourism, hotel and restaurant, transportation, and other industries. Further, Porter Goss, Director of the Central Intelligence Agency (CIA), testifying before a senate committee commented; “It may be only a matter of time before al-Qa’ida or another group attempts to use chemical, biological, radiological, and nuclear weapons (CBRN) [6].”

Targets for terrorists have not been limited to adults. For example, in March 1995, sarin gas was released in the Tokyo subway system causing 5,000 casualties including 16 children and five pregnant women. In April 1995, 168 people were killed at the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma; 19 of the victims were children, most of whom were in the building's day care center. More recently, on September 1, 2004, several militants seized a school in Beslan, Russia. The event ended several days later with 330 people killed, mostly children.

The imperative for a pediatric preparedness emphasis

Pediatric care is typically designated as care for those from birth to age 18. In 2004, more than 25 % (roughly 73.3 million) of the total U.S. population was under age 18. Of that substantial population, 20.1 million were under the age of 5 (7 % of total population) [7]. Although a significant proportion of children under age 18 may have a physiologic composition similar to that of adults, younger children have special requirements related to physical needs. Moreover, all children have unique mental health and psychosocial needs that should be considered during emergency response. Given the large proportion of the US population that requires pediatric-specific care, the limited pediatric resources (equipment, hospitals, etc.) compared to adult care, and the unique needs of children, it is imperative that preparedness planning and response specifically consider the needs of children and the capacity needed to serve these children.

Emergencies and other events that affect children require special care. Israeli researchers reported that “terrorism-related injuries in children are severe and increase the demand for acute care” [8]. The demands of a disaster event either natural or human initiated on children are unique in their physiology, psychology, and behavior affects. Children are particularly vulnerable to illness and trauma during disaster or emergency situations and should be protected.

There are efforts related to pediatric preparedness, such as school preparedness, care for children with special health care needs, and several initiatives of the HRSA/MCHB/US Department of Transportation's Emergency Services for Children. Although these initiatives address certain aspects of emergency preparedness and response, lacking is a comprehensive, population-based initiative for pediatric care following a disaster or emergency.

Differences and unique needs of children

Key factors contributing to the uniqueness of children and adolescents in emergency preparedness include those related to developmental, physiological and behavioral attributes, social norms, medical care systems, and preparedness capabilities. Basic anatomic and physiologic differences in children compared to adults, cause children to become ill more quickly when exposed to hazards due to their smaller size and higher breathing rate; they respond more rapidly to certain interventions but require different dosages or different antibiotics and antidotes to many agents [3, 9]; small children also require pediatric-sized emergency equipment

In addition to physiologic differences, there are other unique characteristics of children, making them more vulnerable during emergencies. Children seldom carry personal identification, making it difficult to establish the identity of a child. Likewise, children of certain ages are non-communicative; some may be unable to provide identification and children who are anxious may not be willing to share information. Developmentally, children have non-self-preservation skills, that is, they do not know when or how to flee from danger [10]. Because of the prevalence of children with special health care needs in the general population a higher proportion of children may be affected overall in a disaster [3, 9].

Children are also unique in their capability to handle stress. Potentially devastating to their long-term well-being, consistent long periods of confusion, anxiety or fright are possible results of a disaster event. The way in which children respond to an event varies by age and must be considered for both preparedness and care. Children, unlike adults, cannot seek help and must rely on the adults around them to recognize signs related to stress and anxiety. However, children have great potential and a tendency towards resiliency. Helping children work through feelings and emotions regarding an event or a potential event is a necessity that can easily be overlooked in the adult-focused preparedness world [2].

Institutional constraints

Health care providers need pediatric-specific education and training as well as resources to address culture and language barriers that may delay or compromise care. Currently there are no widely-accepted pediatric protocols for decontamination, drug administration, vaccines, and other necessary standards of care. In addition to the lack of standardized protocols, decontamination procedures differ for children and adults. Most hospitals have decontamination units for both children and adults, but decontamination of children still requires unique skills. Because personal protective equipment is cumbersome and does not allow for free movement, safely managing a young child is challenging. Additional concerns include separation anxiety for both parent and child during the decontamination and treatment process. Although the separation is temporary for decontamination, hospital admittance creates a shared anxiety for both parents and children. Capacity for treating adults in pediatric hospitals may be warranted and should be considered further.

Specific pediatric healthcare facilities are few and are diffused across the nation. The National Association of Children's Hospitals and Related Institutions (NACHRI) estimates that there are 250 to 275 children's hospitals in the U.S., representing about 5 % of the almost 5,000 hospitals. Of the children's hospitals, 50 to 55 (20 %) are freestanding general acute care children's hospitals; 110 to 125 (44 %) are non-freestanding children's hospitals housed in larger hospitals; and 90 to 100 (36 %) are orthopedic, rehabilitative, psychiatric, and other specialty hospitals [11]. At most of these facilities, surge capacity is small and limited for seriously ill or injured children. It is likely that for many of these pediatric-specific institutions one major school bus accident, major fire, tornado, respiratory illness epidemic, or classroom requiring ventilation for a bioterrorism attack would cause the institution to reach maximum capacity [12]. Developing relationships between multiple institutions is critical to meet these needs.

The imperative for a regional preparedness network approach

Attempting to prepare for an emergency on a local or hospital-by-hospital basis is wasteful of resources because of the need to amass resources (specialists, beds, facilities, etc.) well beyond the normal demand for a single locality. For adult-oriented care, it is reasonable to maintain a community and local level response, as resources are relatively plentiful. However, given the limited local pediatric-specific resources, that is, only 5 % of the nation's hospitals are equipped to care for roughly 20 % of the population, the need for a regional response to amass sufficient resources is evident.

In the response to a disaster (human or natural) there is little opportunity for communities, counties, or states to share pediatric-specific resources in a rapid manner. “A successful response to a disaster requires the interaction of personnel and resources from multiple agencies in an organized and coordinated manner according to a well-formulated plan” [3]. A regional approach overcomes problems of both reach and range.

Protecting and ensuring the health and well-being of the pediatric population is the foremost goal of creating a pediatric preparedness network. There are, however, indirect consequences that are equally as valuable. First, the relationship and communication between partner institutions is invaluable. The development of formal and informal communication and collaboration networks will undoubtedly serve as a means to provide mutual support for pre-event planning, process design, knowledge resource support, and human resource and non-human resources support.

In addition to the improved institutional relationships, the inclusion of additional stakeholders, such as Medicaid, HMOs, public health, emergency medical services (EMS), and emergency management agencies (EMA) will provide opportunities for increased collaboration related to pediatric preparedness. In the event of a local, state, or federally declared disaster, the pediatric network must work in the context of the larger emergency response system. Relationships with public health and emergency management agencies are critical to ensure a seamless system of care for children. Communication between the partner institutions and external partners will allow for increased understanding of the roles that each has in areas of preparedness, including pre-event, event, and recovery.

Issues in developing a pediatric preparedness regional network

There are critical pre-event planning tasks that must be undertaken in the development of a regional pediatric disaster response network—network organization planning, financial agreement planning, and operational/medical staff protocol planning. The critical planning tasks identified by a working group of hospital and public health representatives are shown in Table 1.

Table 1 Pediatric disaster preparedness network issues
Full size table

There is considerable upfront work to be accomplished in the creation of a regional pediatric disaster response network. Perhaps the most difficult and essential is the emergence or designation of the network leader who recognizes the need for a pediatric disaster response network and is willing to champion its creation. Early in the process, network leadership must determine the appropriate size and geography of the region and identify the principal institutions (children's hospitals) and other key stakeholders, such as the health department, EMS, and other regional resources.

Once the principal institutions and stakeholders have been identified they must be convened to work through many complex organizational issues such as determining when to activate the network response plan, adoption of common terminology and standardized code language, and determining type of hazard vulnerability and risks. Another significant organizational issue concerns professional licensing and credentialing for performing medical services across state and national borders.

Disaster response plans will have to be formulated to address issues such as communication protocols; data sharing; alternatives for patients with special needs; procedures for adult hospital overflow; staff and victim transportation; and availability of emergency medical supplies and equipment. Perhaps most importantly plans will have to be developed outlining incident command. Finally, drills and exercises must be planned and carried out to test and refine the disaster plan and implementation procedures.

Financial issues are typically not the primary focus during the actual disaster because institutions and medical staff are usually willing “to do what is necessary” to address critical situations. However, the reality is that disasters are profoundly expensive and solving the financial issues in the planning stages will facilitate long-term cooperation. Issues that must be addressed include reimbursement for patients, physicians and hospitals and medical malpractice liability and insurance. Therefore, insurance companies, HMOs, PPOs, and so on will have to be included in the financial issue discussions.

Plans must be in place in advance of a disaster that concerns the medical staff and their roles in the disaster response. This planning will require the designation of facility leaders, standardization of triage, and adoption of best practices. Joint institutional training will be required to acquaint staff that will work together with best practice protocols.

Definitions of success

Ultimately success in the development of the pediatric medical preparedness network only can be measured by the response of the components of the network during an event. However, there are means by which the process of the network development and the success related to communication between the regional partners can be assessed. The indication that partner institutions are working well in the context of the network as well as maintaining an internal standard of excellence are evaluative measures of success. These internal and external aspects of partner institutions work in tandem to improve the response to a medical disaster and further the network capacity. Only then will the network be able to respond to patient needs, monitor resource availability, and increase breadth of operations.

The initial consideration for the successful development of the network is the advantage gained through a regional approach compared to an individual approach to the pediatric needs given an event. The poly-institutional strategies enable the network to have multiple locations of modest surge capabilities and capacities across multiple institutions. This model is much more likely to meet the large scale pediatric-specific needs of a large region related to sporadic, epidemic or disaster events rather than relying on a single institution's heroic strategies. In an area where needed pediatric-specific capability does not exist or where there has been a local loss of resources, a regional network would be critical. Although the development of the network does require planning, coordination, and on-going communication, the risks and costs for individual institutions may be lower. On the contrary, the initiation of the network response can be quick, but not instantaneous and issues outside of the clinical process must be considered, including transportation and lodging for families given patient transfer.

After the development of the network, periodic updates are necessary to maintain the current statistics concerning to capabilities and capacity of each institution. Given that systems are constantly changing and improving, it is necessary to ensure that the most current information, such as contact information for key personnel, is available through a quarterly report or survey. In the case of an event and the utilization of the network, it would be imperative to have an after-disaster debriefing to discuss components of the network that needed improvement or further collaboration.

Conclusions

Nature-initiated and human-initiated disasters are increasing because of population growth, urbanization, increasingly complex technologies, a rise in world-wide terrorism, social unrest, global economic and social interdependence, an increase in infectious diseases, and environmental degradation. These events have impacted both adults and children alike. Because of the unique needs of children, the diffuse nature of pediatric care regionally and nationally, and the limited surge capacity of these institutions, it is necessary to consider the development of a pediatric response network, consisting of pediatric acute care facilities that work in conjunction with the broader emergency response system. The current emergency response system does have some pediatric-specific initiatives and care provisions in place; however, the network focuses on the hospital component of the entire emergency response system. A regional system is needed to increase the surge capacity of a particular area when specific events overwhelm the pediatric and adult care system in one locale.