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Pediatric Issues in Disaster Preparedness: Meeting the Educational Needs of Nurses—Are We There Yet?
CLINICAL PRACTICE COLUMN Column Editor: Maura MacPhee, PhD, RN
Pediatric Issues in Disaster Preparedness: Meeting the Educational Needs of Nurses—Are We There Yet? Lori Fox, RN, MSN, APRN, BC Nathan Timm, MD
Children have unique physical, emotional, and developmental needs making them particularly vulnerable during disasters. Most existing disaster preparedness courses lack a pediatric perspective. This article describes a pediatric disaster preparedness program presented to pediatric nurses in an urban, Level 1 trauma center. Survey results from the participants prior to the program revealed a lack of awareness of pediatric issues. Although the program resulted in an immediate improvement in awareness, retention fell back to precourse levels 2 years later. We conclude that pediatric disaster preparedness training should be integrated into hospital nursing curriculum on a regular basis. © 2008 Elsevier Inc. All rights reserved. Key words: Pediatric disaster preparedness program; Pediatric nurses; Level 1 trauma center
T
HE IMPACT OF September 11, 2001, and Hurricane Katrina in the fall of 2005 resulted in a significant focus placed on disaster preparedness and response, particularly within health care institutions. Technological, human-initiated, and natural disasters demand that health care organizations be in a constant state of readiness. In response to these catastrophic events, organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised and updates its hospital emergency management elements of performance for hospitals (JCAHO, 2006) and the National Incident Management System was developed to provide consistency in the response among all groups involved in disaster preparedness, response, and recovery (Federal Emergency Management System, 2007) including hospitals and health care organizations. Furthermore, greater attention has been paid to the development of educational content for health care and first responders. Programs such as Basic Disaster Life Support, Advanced Disaster Life Support, Core Disaster Life Support-Decontamination (National Disaster Life Support Foundation [NDLSF], 2007), and Pediatric Disaster Life Support (Aghababian, 1999) are available to educate staff about how to respond to a mass
Journal of Pediatric Nursing, Vol 23, No 3 (April), 2008
casualty situation (NDLSF, 2007). Although these educational programs are extremely effective in providing basic education and training for health care workers responding to a disaster, few programs address the needs of special populations in disaster, particularly children. Pediatric nurses must be knowledgeable about the special needs of children in the time of a disaster. Care for the pediatric patient in a disaster continues well beyond the initial triage and stabilization that is provided by first responders. Pediatric nurses are integral members of the health care team and, thus, it is crucial that they are educated about the special considerations for children affected by a human or natural disaster. Despite this need, few disaster readiness programs have been developed for pediatric nurses delivering care beyond the front line. This article provides an From the MetroHealth Medical Center, Cleveland, OH, and Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Corresponding author. Lori Fox, RN, MSN, APRN, BC, MetroHealth Medical Center, Cleveland, OH. E-mail: [email protected]. 0882-5963/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.12.008
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overview of the development and implementation of a pediatric disaster preparedness program to acute care pediatric nurses at an urban Level I trauma center. BACKGROUND
Special Considerations for Children in Disaster Children possess unique vulnerabilities to disaster events due to developmental, psychological, anatomical, and physiological differences (Markenson & Redlener, 2004; Redlener & Markenson, 2004; Seideman et al., 1998). The developmental stage of the child influences both their physical and psychological response to disaster. For example, developmentally, young children may not understand the need to flee from a dangerous situation and may respond by running toward the disaster, rather than fleeing to find a safe location. Children internalize and process stressful events differently than adults. Because children rely on adults to ensure their safety, if a significant adult, such as a parent, is injured or dies as a result of a disaster event, the child is left feeling vulnerable and alone. The stress experienced in the aftermath of a disaster can have lasting psychological effects on a child. Anatomical and physiological differences among children create additional vulnerabilities in the event of a disaster. Increased respiratory rates of children place them at risk for inhalation of large dose of aerosolized agents with rapid effects. The thin skin of children and the large surface area of the skin in relation to body mass place them at significant risk for hypothermia. This becomes particularly important if children endure prolonged exposure to environmental elements or decontamination procedures. When considering these differences between children and adults, it is apparent that simply adapting adult protocols for disaster may be ineffective or inappropriate when caring for the pediatric patient.
National Efforts Toward Pediatric Disaster Education On a national level, several groups have begun to address the special considerations for children in the event of a disaster. One of the initial consensus conferences to address pediatric specific issues in disaster preparedness and planning identified nine areas of special consideration for children in
terrorism and disaster preparedness (Markenson & Redlener, 2003, 2004). These areas centered on the anatomical and physiological differences that place children at risk with regard to absorption, inhalation, and exposure to toxic substances; decontamination issues affected by developmental and physiologic differences; treatment and dosing considerations with antibiotics and antidotes; and exposure to nuclear agents. The committee identified 25 specific recommendations needing immediate priority. These recommendations centered on meeting the minimum needs in disaster and terrorism preparedness for children and addressed a variety of issues, including governmental involvement, integration of various groups to address pediatric needs, and securing pediatric equipment and pharmaceuticals. As a result of this and other consensus conferences, including those that included members of the Society of Pediatric Nurses (Agency for Healthcare Research and Quality [AHRQ], 2006; Nicholson, 2003; Trossman, 2001), educational materials about pediatric disaster preparedness were developed for pediatric providers (AHRQ, 2006; Markenson & Redlener, 2004; Redlener & Markenson, 2004). Education has focused on specific agents (i.e., chemical, biological, and radiological) used in terrorist attacks and pediatric considerations for each of these agents. In addition, terrorist and nonterrorist exposure of these agents and preliminary antidote and treatment guidelines for pediatricians have been identified. Additional education about equipment, community, and environmental efforts has also been provided (AHRQ, 2006). Despite these efforts on a national level to educate pediatric care providers about disaster preparedness, it is apparent that gaps still exist (Dolan & Krug, 2006; Lynch & Thomas, 2004; Redlener & Markenson, 2004). In outlining pediatric considerations specific for chemical exposures, Lynch and Thomas (2004) highlight that frontline responders have been educated about how to respond in the case of a chemical exposure but are not educated about how to care for children exposed to chemical agents. This fact is particularly important because chemical agents are typically deployed in the general population and thus impact individuals of all ages. Another gap exists in regard to pediatric recommendations for medications and antidotes used in a disaster situation (Redlener & Markenson, 2004). Many of these treatments have not been tested or are
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not recommended for use in children. In the event of a disaster, clear dosing guidelines for children may not be available, which will make care for pediatric patients even more difficult. Additional gaps in pediatric disaster readiness became apparent after Hurricane Katrina (Dolan & Krug, 2006). Specifically, the absence of required pediatric disaster drills and pediatric disaster life support training for first responders can result in unorganized or inappropriate care delivery to children affected by the disaster. Educational efforts in regard to the specialized needs of children in a disaster situation are not required and frequently do not include additional considerations about nutritional needs, infectious disease risks, or mental health issues (Dolan & Krug, 2006). A key recommendation to begin addressing these gaps is to incorporate pediatric disaster readiness training into hospital staff curricula and orientation programs.
Disaster Education for Nurses National nursing organizations and colleges of nursing have made significant progress toward educating nurses about disaster preparedness (Egyes, 2004; O'Neal, 2001; Trossman, 2001). Groups such as the American Nurses Association (ANA) and the International Nursing Coalition for Mass Casualty Education have partnered with federal and state agencies to educate nurses about the priorities of care in nuclear, biological, and chemical disasters (O'Neal, 2001; Trossman, 2001). This information has been incorporated into nursing school curricula, publications in the literature, and in programs for nurses who may be frontline responders in a disaster, such as emergency room nurses (Billings & Kowalski, 2006; Coleman, 2001; Egyes, 2004; Ferguson, 2002; Rebmann, 2005; Rose & Larrimore, 2002; Trossman, 2001; Veenema, 2002). In addition to these educational efforts, the ANA noted that education of nurses other than frontline responders is crucial, as these nurses may be called upon to assist emergency room personnel in a mass causality situation, and would be involved in ongoing care for victims of disasters. Despite this need, few programs have been developed and administered for acute care nurses beyond frontline responders. Furthermore, there is a scarcity of educational programs about the special needs of children in a disaster that are administered to acute care nurses (Bernardo & Kapsar, 2003; Davidhizar & Shearer, 2002). This information is
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crucial for acute care pediatric nurses, as many may not have been educated about general disaster terminology, weapons of mass destruction (WMDs), treatment standards, or special considerations for pediatric victims. The program described in this article was delivered to acute care pediatric nurses and is a necessary step toward meeting the educational needs of our nurses about pediatric disaster preparedness. DEVELOPMENT OF A STATE-BASED PROGRAM The State of Ohio Pediatric Disaster Planning Committee was formed in the spring of 2004. The mission of the group was to serve as a panel of experts that could assist in making recommendations regarding the needs and care of children in disaster to pediatric health care providers within the state. These providers included pediatric nurses working in areas other than the front line (first-line responders/emergency room). The committee had representation from a variety of health care organizations and agencies including pediatricians, pediatric emergency medicine physicians (NT), nurses, including advanced practice nurses (LF), pharmacists, emergency medical services (EMS), the Ohio Hospital Association, and the Ohio Department of Health. The committee met regularly and developed a program directed toward health care providers working in primary and acute care settings. The focus of the program was on the key pediatric issues involved in mass casualty and disaster incidents. METHODS The program was developed using best available information surrounding pediatric issues in disaster preparedness. Particular attention was paid to the recommendations set forth by national consensus statements (Markenson & Redlener, 2003). An outline of the content for the Pediatric Issues in Disaster Preparedness Program is provided in Table 1. The program provided definitions commonly used in disaster literature to clearly differentiate between basic disaster terms and concepts that are often mistakenly used interchangeably. A review of the different types of WMDs (i.e., chemical, biological, nuclear, and explosive) was then presented, with specific examples of the different types of weapons that may be used in each category.
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FOX AND TIMM Table 1. Outline of Content for the Pediatric Issues in Disaster Preparedness Program
Definitions
Weapons
Pediatric-specific considerations
Pediatric-specific considerations
Disaster • Any community emergency that disrupts normal community function causing concern for the safety of the citizens • Something that disrupts the environment of care; disrupts care and treatment; changes or increases demand The needs outweigh resources. Mass casualty event • Any event that causes a large number of individuals to become ill or injured • Any incident that exceeds the hospital's capability to transport or treat casualties The health care needs outweigh resources. Chemical agents • Nerve agents: Sarin, VX, and insecticides • Skin agents: Sulfur, mustard, and lewisite • Blood agents: Cyanide • Lung agents: Chlorine and phosgene Biological agents • Bacterial: Anthrax, plague, and tularemia • Viral: Smallpox and viral hemorrhagic fevers • Toxins: Botulinum and ricin Radiological/Nuclear • Nuclear power plant emergencies • Radiological accidents: Highways, railroads, industries, and hospitals • Dirty bombs: Conventional explosive with radioactive material; Blast is primary danger, but radiation impact is unknown. Explosives • Explosive devices account for 70% of all terrorist attacks. • Blast injuries: Primary blast wave affects tympanic membranes, gastrointestinal tracks; secondary injuries caused by flying debris; Tertiary injuries occur when individuals are thrown from the site; Quaternary injuries include burns and crushing injuries Toxic exposure • Exposure affected by characteristics of children: Thin skin, greater surface area, closer to ground, faster respiratory rates, may be unable to escape, and found in large groups • Pediatric effects of specific weapons –Infectious diarrhea: Great risk of dehydration –Smallpox: Greater risk of vaccine complications –Blister agents: Greater risk of skin loss –Nerve agents: Seizures and pulmonary edema –Radiation: Greater penetration Triage • Triage obstacles with children: No adult triage system effective with children, inappropriate triage of children, inappropriate transport, difficulty identifying children, separation from parents, and developmental issues • JumpSTART: Triage system specifically designed for children; however, requires additional training and equipment; must await increased use to support its effectiveness Diagnosis • Children can be diagnostic dilemmas: Fever and rash are common occurrences • Diagnoses guided by education and high index of suspicion of providers • Public health disease-tracking systems may assist with diagnosis. Drug delivery • Strategic National Stockpile: Can reach specific areas in 72 hours; few packs contain pediatric doses • Possible limited availability of needed drugs: Liquid potassium iodide and ciprofloxacin • Mark I kits: Contain medications for treatment of exposure to nerve agents; Issues regarding pediatric dosing and administration still remain Decontamination • Children are at increased risk for hypothermia and may not withstand prolonged decontamination periods • Children in decontamination chambers: May need to be carried/held, increased level of fear, considerations for children with special health care needs, and ability of children to follow directions Mental health concerns • Reactions to unfamiliar events vary greatly: Television images likely to be misunderstood; Care requires familiarity with age-appropriate interventions.
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• Highly influenced by emotional state of caregivers: Parental response will affect child. • Posttraumatic stress disorder: Most common response to disasters in children; affects 40% of children, usually within first 3 months; wide range of symptoms (intense grief, restlessness, sleep disorders, and decline in school performance) Agencies and organizations involved with Government agencies pediatric disaster preparedness • Department of Homeland Security • Federal Emergency Management Agency • Department of Health and Human Services • Centers for Disease Control and Prevention • State and Local Emergency Planning Committees Schools and childcare systems • Need to perform risk assessment • Should identify: Evacuation plans, reunification plans, guardianship, how to protect children with special health care needs, and provision of mental health support for children/staff • Integrate disaster plan with: EMS, public safety departments, public health departments, and local hospitals Physicians' offices • Staff education crucial: Should be able to identify, report, and refer cases of exposure to toxic substances or weapons • Educate families • Identify patients with special needs • Know the resources: Public health departments, Red Cross, and Children's Hospitals • Integrate offices into community plans Families • Family disaster plans: Escape plans and rally points and out-of-state contact person • Education: Proper use of 911 emergency services and first aid • Disaster supply kits: Available through the American Academy of Pediatrics, Red Cross, and Federal Emergency Management Agency Emergency responders • Disaster training: Basic Disaster Life Support and Advanced Disaster Life Support • Pediatric specific equipment, drugs, and protocols • Disaster documentation • Integration with schools, hospitals, and federal agencies • Education regarding: Pediatric medical/legal issues (i.e., guardianship), care for children with special health care needs, and local family reunification schemes Hospitals • Childrens' Hospitals serve as leaders in care for pediatric patients in disaster • Hospitals supplied with appropriate medications, skills, equipment, and education • Disaster plans for all hospitals must address: Children as victims and impact of disaster on staff with children
Pediatric considerations for multiple aspects of a disaster situation were identified and discussed extensively. Finally, a review of different agencies and organizations involved with disaster preparedness, along with ways that specific organizations can better prepare for care of children in a disaster was presented. Participants in the program included all nurses in the pediatric inpatient areas of a tertiary care, Level I trauma center during the 12 months of 2005. The program was provided as part of the regularly scheduled annual nursing education days in our health care organization. Nursing education days are scheduled once a month, and pediatric acute care registered nurses are prescheduled to attend one session. As a result, all pediatric inpatient nurses had attended this program by the end of 2005.
A pretest completed prior to the program assessed baseline knowledge of the participants. The pretest consisted of 10 true-or-false questions and one question that asked the nurse to list three things that place children at increased risk for injury in a disaster situation. Following the 80-minute presentation and discussion, participants were asked to complete the posttest to assess immediate effectiveness of the instruction. The pretests and posttests used were identical and are provided in Table 2. A 2-year follow-up survey was conducted of the program participants using the same posttest to assess long-term retention of information. RESULTS The aggregate mean pretest and posttest scores of the inpatient pediatric nurses were consistent
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FOX AND TIMM Table 2. Pretest and Posttest
Pediatric Issues in Disaster Preparedness Pretest/Posttest _____Pretest _____Posttest
Please circle.
1. JCAHO defines disaster as an event that creates a large number of casualties. 2. Prior to September 11th 2001, planning for children involved in a disaster was a top priority. 3. The most commonly used WMD is a biological agent. 4. Children exposed to a chemical or biologic agent have specific signs and symptoms and are easily diagnosed. 5. A primary goal of disaster triage is to provide definitive care to injured persons. 6. Children comprise 5% of the total population of Ohio. 7. Children are difficult targets for a WMD attack because they are safe in schools or day cares. 8. Nerve agents affect lung secretions. 9. Posttraumatic stress disorder is the most common response to disasters in children. Please fill in: 10. Name three reasons children are more vulnerable to a WMD attack. Pretest: A. _________ B._________ C._________ Posttest: A. _________ B. _________ C. _________
with reports in the literature about the state of disaster preparedness of health care providers (Rose & Larrimore, 2002). At the time of the educational offering, 45 nurses completed the pretest and immediate posttest. The 2-year follow up yielded 35 returned posttests. The aggregate mean pretest score was 71%; the mean posttest score was 91%, and 2-year posttest score was 67%. Thus, most of the nurses had some baseline knowledge about pediatric disaster management. This knowledge level increased for the group immediately after the Pediatric Issues in Disaster Preparedness Program presentation. However, 2 years after the presentation, overall knowledge about pediatric disaster had decreased among the group. The reduction in retention of information is consistent with other educational models (O'Steen, Kee, & Minick, 1996; Wolfram, Doyle, Kerns, & Frye, 2003). DISCUSSION Although information from these pretests and posttests only reflect the aggregate or group mean scores, it does lend support to the recommendation that pediatric nurses, including those beyond firstline providers, should be regularly inserviced on pediatric disaster preparedness. The Pediatric Issues in Disaster Preparedness Program described here is an important step toward meeting the needs of pediatric providers as it pertains to disaster preparedness. It has been identified that the needs of children in a disaster situation are different from adults; thus, the care provided to these children should incorporate what
True True True True
False False False False
True True True True True
False False False False False
we know about these differences. Pediatric nurses beyond frontline providers must have education about these needs, as many may be called upon to assist frontline responders in the event of a disaster and will be involved in the ongoing care for children. Knowledge about pediatric disaster issues will assist the acute care pediatric nurse in delivering appropriate and quality care for patients and will supply them with information to serve as powerful advocates for their patients should a disaster occur. The results of the pretests and posttests administered in this program are consistent with other reports in the literature. Rose and Larrimore (2002) administered a survey to assess knowledge and awareness of health care providers regarding chemical and biological terrorism. The survey was completed by 219 nurses, nursing students, physicians, and medical students prior to a workshop on domestic terrorism preparedness. Survey results indicate that knowledge scores were low; respondents answered less than a quarter of the questions correctly. Furthermore, less than 23% of respondents reported having the confidence to adequately provide care to patients in the event of a terrorism situation. Thus, continued education about disaster preparedness is still needed for our health care providers. Although the gap is narrowing, a significant need still exists with regard to pediatric disaster education targeted for health care providers. Acute care pediatric nurses expressed this need anecdotally during the Pediatric Issues in Disaster Preparedness Program, and the aggregate pretest and posttest scores provide support for the
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recommendation that nurses receive regularly scheduled educational inservices or training on disaster preparedness. Because disaster planning and management is not typically incorporated as part of the daily practice of pediatric nurses, retention of this information may be difficult. However, annual or biannual educational offerings on this topic may help nurses retain key aspects of their role and the type of care required for pediatric patients in the time of a disaster. Given the realities of our environment and that natural or human-initiated disaster will strike again, it is essential that health care organizations including pediatrician offices and clinics incorporate educational programs about disaster preparedness into training programs. Due to the special needs of children and the lack of information about pediatric disaster, it is even more crucial that hospital pediatric providers receive information about the special considerations for children in a disaster situation. The Pediatric Issues in Disaster Preparedness Program described in this article aimed to meet this need among pediatric providers in our state, particularly among acute care pediatric nurses. In our continued efforts to educate providers about
pediatric disaster preparedness, our committee has made the content from this program available through the Web site of the Ohio Hospital Association 2007). It is hoped that the dissemination of this information will aid providers in delivering the highest quality care to children affected by future disasters. The American children are counting on us to provide appropriate, comprehensive, and specialized care in the event they need our help. Without ongoing education and an understanding of their needs, we will not be prepared to face the challenge. Katrina, as devastating as it was, gave us a window into the needs which still exist in relation to children and disasters. It is our great responsibility and challenge as pediatric providers to rise to the occasion and advocate for their needs. Education is a powerful tool, which we need to use wisely. ACKNOWLEDGMENTS The authors wish to acknowledge Dr. William Cotton, MD, and the State of Ohio Pediatric Disaster Planning Committee members for their support in the development of this educational program.
REFERENCES Aghababian, R. (1999). Pediatric disaster life support course. Worcester, MA: University of Massachusetts Medical School. Agency for Healthcare Research and Quality. (2006). Pediatric terrorism and disaster preparedness: A resource for clinicians— Summary. Retrieved April 10, 2007, from http://www.ahrq.gov/ research/pedprep/pedterrorism.pdf. Bernardo, L., & Kapsar, P. (2003). Pediatric implications in bioterrorism: Education for healthcare providers. Disaster Management & Response, 1, 52−53. Billings, D., & Kowalski, K. (2006). Preparing for natural and man-made disasters. The Journal of Continuing Education in Nursing, 37, 56−57. Coleman, E. (2001). Anthrax: Know the guidelines for management. American Journal of Nursing, 101, 48−52. Davidhizar, R., & Shearer, R. (2002). Helping children cope with public disasters. American Journal of Nursing, 102, 26−33. Dolan, M. A., & Krug, S. E. (2006). Pediatric disaster preparedness in the wake of Katrina: Lessons to be learned. Clinical Pediatric Emergency Medicine, 7, 59−66. Egyes, J. K. (2004). Columbia and Vanderbilt University nurses plan emergency response. Education Update, 9, 15. Federal Emergency Management System. (2007). Get disaster information. Retrieved July 13, 2007, from http://www.fema.gov/. Ferguson, S. (2002). Preparing for disasters: Enhancing the role of pediatric nurses in wartime. Journal of Pediatric Nursing, 17, 307−308. Joint Commission on Accreditation for Healthcare Organizations. (2006). Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: Joint Commission Resources. Lynch, E. L., & Thomas, T. L. (2004). Pediatric considerations in chemical exposures: Are we prepared? Pediatric Emergency Care, 20, 198−208.
Markenson, D., & Redlener, I. (2003). Pediatric preparedness for disasters and terrorism: A national consensus conference. Retrieved April 24, 2007, from http://www.bt.cdc.gov/children/ pdf/working/execsumm03.pdf. Markenson, D., & Redlener, I. (2004). Pediatric terrorism preparedness national guidelines and recommendations: Findings of an evidence-based consensus process. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 2, 301−316. National Disaster Life Support Foundation (2007). NDLS courses. Retrieved July 11, 2007, from http://www.bdls.com/. Nicholson, D. (2003). Terrorism and/or natural disasters: Are we prepared to care for America's children? Journal of Pediatric Nursing, 18, 154−155. O'Neal, B. J. (2001). International Nursing Coalition focuses on mass casualty education. On the Edge, 7, 13. Ohio Hospital Association. (2007). Pediatric issues in disaster preparedness. Retrieved July 12, 2007, from http:// www.ohanet.org/. O'Steen, D. S., Kee, C., & Minick, M. (1996). The retention of advanced cardiac life support knowledge among registered nurses. Journal of Nursing Staff Development, 12, 66−72. Rebmann, T. (2005). Bioterrorism preparedness for nurses: A new training and reference program. The Missouri Nurse, 2, 8–9, 13. Redlener, I., & Markenson, D. (2004). Disaster and terrorism preparedness: What pediatricians need to know. Disease-AMonth, 50, 1. Rose, M., & Larrimore, K. (2002). Knowledge and awareness concerning chemical and biological terrorism: Continuing education implications. The Journal of Continuing Education in Nursing, 33, 253−258.
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Seideman, R., et al. (1998). The response of children to disaster: Do children have a greater depth of response to tragedy than we realize? The American Journal of Maternal Child Nursing, 23, 37−44. Trossman, S. (2001). Nurses share accounts of 9–11 aftermath. American Nurse, 33, 15.
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Veenema, T. G. (2002). Chemical and biological terrorism: Current updates. Nursing Education Perspectives, 23, 62−71. Wolfram, R., Warren, C., Doyle, C., Kerns, R., & Frye, S. (2003). Retention of pediatric advanced life support (PALS) course concepts. Journal of Emergency Medicine, 25, 475−479.
Pediatric Issues in Disaster Preparedness: Meeting the Educational Needs of Nurses—Are We There Yet? Lori Fox, RN, MSN, APRN, BC Nathan Timm, MD
Children have unique physical, emotional, and developmental needs making them particularly vulnerable during disasters. Most existing disaster preparedness courses lack a pediatric perspective. This article describes a pediatric disaster preparedness program presented to pediatric nurses in an urban, Level 1 trauma center. Survey results from the participants prior to the program revealed a lack of awareness of pediatric issues. Although the program resulted in an immediate improvement in awareness, retention fell back to precourse levels 2 years later. We conclude that pediatric disaster preparedness training should be integrated into hospital nursing curriculum on a regular basis. © 2008 Elsevier Inc. All rights reserved. Key words: Pediatric disaster preparedness program; Pediatric nurses; Level 1 trauma center
T
HE IMPACT OF September 11, 2001, and Hurricane Katrina in the fall of 2005 resulted in a significant focus placed on disaster preparedness and response, particularly within health care institutions. Technological, human-initiated, and natural disasters demand that health care organizations be in a constant state of readiness. In response to these catastrophic events, organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised and updates its hospital emergency management elements of performance for hospitals (JCAHO, 2006) and the National Incident Management System was developed to provide consistency in the response among all groups involved in disaster preparedness, response, and recovery (Federal Emergency Management System, 2007) including hospitals and health care organizations. Furthermore, greater attention has been paid to the development of educational content for health care and first responders. Programs such as Basic Disaster Life Support, Advanced Disaster Life Support, Core Disaster Life Support-Decontamination (National Disaster Life Support Foundation [NDLSF], 2007), and Pediatric Disaster Life Support (Aghababian, 1999) are available to educate staff about how to respond to a mass
Journal of Pediatric Nursing, Vol 23, No 3 (April), 2008
casualty situation (NDLSF, 2007). Although these educational programs are extremely effective in providing basic education and training for health care workers responding to a disaster, few programs address the needs of special populations in disaster, particularly children. Pediatric nurses must be knowledgeable about the special needs of children in the time of a disaster. Care for the pediatric patient in a disaster continues well beyond the initial triage and stabilization that is provided by first responders. Pediatric nurses are integral members of the health care team and, thus, it is crucial that they are educated about the special considerations for children affected by a human or natural disaster. Despite this need, few disaster readiness programs have been developed for pediatric nurses delivering care beyond the front line. This article provides an From the MetroHealth Medical Center, Cleveland, OH, and Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Corresponding author. Lori Fox, RN, MSN, APRN, BC, MetroHealth Medical Center, Cleveland, OH. E-mail: [email protected]. 0882-5963/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.12.008
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overview of the development and implementation of a pediatric disaster preparedness program to acute care pediatric nurses at an urban Level I trauma center. BACKGROUND
Special Considerations for Children in Disaster Children possess unique vulnerabilities to disaster events due to developmental, psychological, anatomical, and physiological differences (Markenson & Redlener, 2004; Redlener & Markenson, 2004; Seideman et al., 1998). The developmental stage of the child influences both their physical and psychological response to disaster. For example, developmentally, young children may not understand the need to flee from a dangerous situation and may respond by running toward the disaster, rather than fleeing to find a safe location. Children internalize and process stressful events differently than adults. Because children rely on adults to ensure their safety, if a significant adult, such as a parent, is injured or dies as a result of a disaster event, the child is left feeling vulnerable and alone. The stress experienced in the aftermath of a disaster can have lasting psychological effects on a child. Anatomical and physiological differences among children create additional vulnerabilities in the event of a disaster. Increased respiratory rates of children place them at risk for inhalation of large dose of aerosolized agents with rapid effects. The thin skin of children and the large surface area of the skin in relation to body mass place them at significant risk for hypothermia. This becomes particularly important if children endure prolonged exposure to environmental elements or decontamination procedures. When considering these differences between children and adults, it is apparent that simply adapting adult protocols for disaster may be ineffective or inappropriate when caring for the pediatric patient.
National Efforts Toward Pediatric Disaster Education On a national level, several groups have begun to address the special considerations for children in the event of a disaster. One of the initial consensus conferences to address pediatric specific issues in disaster preparedness and planning identified nine areas of special consideration for children in
terrorism and disaster preparedness (Markenson & Redlener, 2003, 2004). These areas centered on the anatomical and physiological differences that place children at risk with regard to absorption, inhalation, and exposure to toxic substances; decontamination issues affected by developmental and physiologic differences; treatment and dosing considerations with antibiotics and antidotes; and exposure to nuclear agents. The committee identified 25 specific recommendations needing immediate priority. These recommendations centered on meeting the minimum needs in disaster and terrorism preparedness for children and addressed a variety of issues, including governmental involvement, integration of various groups to address pediatric needs, and securing pediatric equipment and pharmaceuticals. As a result of this and other consensus conferences, including those that included members of the Society of Pediatric Nurses (Agency for Healthcare Research and Quality [AHRQ], 2006; Nicholson, 2003; Trossman, 2001), educational materials about pediatric disaster preparedness were developed for pediatric providers (AHRQ, 2006; Markenson & Redlener, 2004; Redlener & Markenson, 2004). Education has focused on specific agents (i.e., chemical, biological, and radiological) used in terrorist attacks and pediatric considerations for each of these agents. In addition, terrorist and nonterrorist exposure of these agents and preliminary antidote and treatment guidelines for pediatricians have been identified. Additional education about equipment, community, and environmental efforts has also been provided (AHRQ, 2006). Despite these efforts on a national level to educate pediatric care providers about disaster preparedness, it is apparent that gaps still exist (Dolan & Krug, 2006; Lynch & Thomas, 2004; Redlener & Markenson, 2004). In outlining pediatric considerations specific for chemical exposures, Lynch and Thomas (2004) highlight that frontline responders have been educated about how to respond in the case of a chemical exposure but are not educated about how to care for children exposed to chemical agents. This fact is particularly important because chemical agents are typically deployed in the general population and thus impact individuals of all ages. Another gap exists in regard to pediatric recommendations for medications and antidotes used in a disaster situation (Redlener & Markenson, 2004). Many of these treatments have not been tested or are
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not recommended for use in children. In the event of a disaster, clear dosing guidelines for children may not be available, which will make care for pediatric patients even more difficult. Additional gaps in pediatric disaster readiness became apparent after Hurricane Katrina (Dolan & Krug, 2006). Specifically, the absence of required pediatric disaster drills and pediatric disaster life support training for first responders can result in unorganized or inappropriate care delivery to children affected by the disaster. Educational efforts in regard to the specialized needs of children in a disaster situation are not required and frequently do not include additional considerations about nutritional needs, infectious disease risks, or mental health issues (Dolan & Krug, 2006). A key recommendation to begin addressing these gaps is to incorporate pediatric disaster readiness training into hospital staff curricula and orientation programs.
Disaster Education for Nurses National nursing organizations and colleges of nursing have made significant progress toward educating nurses about disaster preparedness (Egyes, 2004; O'Neal, 2001; Trossman, 2001). Groups such as the American Nurses Association (ANA) and the International Nursing Coalition for Mass Casualty Education have partnered with federal and state agencies to educate nurses about the priorities of care in nuclear, biological, and chemical disasters (O'Neal, 2001; Trossman, 2001). This information has been incorporated into nursing school curricula, publications in the literature, and in programs for nurses who may be frontline responders in a disaster, such as emergency room nurses (Billings & Kowalski, 2006; Coleman, 2001; Egyes, 2004; Ferguson, 2002; Rebmann, 2005; Rose & Larrimore, 2002; Trossman, 2001; Veenema, 2002). In addition to these educational efforts, the ANA noted that education of nurses other than frontline responders is crucial, as these nurses may be called upon to assist emergency room personnel in a mass causality situation, and would be involved in ongoing care for victims of disasters. Despite this need, few programs have been developed and administered for acute care nurses beyond frontline responders. Furthermore, there is a scarcity of educational programs about the special needs of children in a disaster that are administered to acute care nurses (Bernardo & Kapsar, 2003; Davidhizar & Shearer, 2002). This information is
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crucial for acute care pediatric nurses, as many may not have been educated about general disaster terminology, weapons of mass destruction (WMDs), treatment standards, or special considerations for pediatric victims. The program described in this article was delivered to acute care pediatric nurses and is a necessary step toward meeting the educational needs of our nurses about pediatric disaster preparedness. DEVELOPMENT OF A STATE-BASED PROGRAM The State of Ohio Pediatric Disaster Planning Committee was formed in the spring of 2004. The mission of the group was to serve as a panel of experts that could assist in making recommendations regarding the needs and care of children in disaster to pediatric health care providers within the state. These providers included pediatric nurses working in areas other than the front line (first-line responders/emergency room). The committee had representation from a variety of health care organizations and agencies including pediatricians, pediatric emergency medicine physicians (NT), nurses, including advanced practice nurses (LF), pharmacists, emergency medical services (EMS), the Ohio Hospital Association, and the Ohio Department of Health. The committee met regularly and developed a program directed toward health care providers working in primary and acute care settings. The focus of the program was on the key pediatric issues involved in mass casualty and disaster incidents. METHODS The program was developed using best available information surrounding pediatric issues in disaster preparedness. Particular attention was paid to the recommendations set forth by national consensus statements (Markenson & Redlener, 2003). An outline of the content for the Pediatric Issues in Disaster Preparedness Program is provided in Table 1. The program provided definitions commonly used in disaster literature to clearly differentiate between basic disaster terms and concepts that are often mistakenly used interchangeably. A review of the different types of WMDs (i.e., chemical, biological, nuclear, and explosive) was then presented, with specific examples of the different types of weapons that may be used in each category.
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FOX AND TIMM Table 1. Outline of Content for the Pediatric Issues in Disaster Preparedness Program
Definitions
Weapons
Pediatric-specific considerations
Pediatric-specific considerations
Disaster • Any community emergency that disrupts normal community function causing concern for the safety of the citizens • Something that disrupts the environment of care; disrupts care and treatment; changes or increases demand The needs outweigh resources. Mass casualty event • Any event that causes a large number of individuals to become ill or injured • Any incident that exceeds the hospital's capability to transport or treat casualties The health care needs outweigh resources. Chemical agents • Nerve agents: Sarin, VX, and insecticides • Skin agents: Sulfur, mustard, and lewisite • Blood agents: Cyanide • Lung agents: Chlorine and phosgene Biological agents • Bacterial: Anthrax, plague, and tularemia • Viral: Smallpox and viral hemorrhagic fevers • Toxins: Botulinum and ricin Radiological/Nuclear • Nuclear power plant emergencies • Radiological accidents: Highways, railroads, industries, and hospitals • Dirty bombs: Conventional explosive with radioactive material; Blast is primary danger, but radiation impact is unknown. Explosives • Explosive devices account for 70% of all terrorist attacks. • Blast injuries: Primary blast wave affects tympanic membranes, gastrointestinal tracks; secondary injuries caused by flying debris; Tertiary injuries occur when individuals are thrown from the site; Quaternary injuries include burns and crushing injuries Toxic exposure • Exposure affected by characteristics of children: Thin skin, greater surface area, closer to ground, faster respiratory rates, may be unable to escape, and found in large groups • Pediatric effects of specific weapons –Infectious diarrhea: Great risk of dehydration –Smallpox: Greater risk of vaccine complications –Blister agents: Greater risk of skin loss –Nerve agents: Seizures and pulmonary edema –Radiation: Greater penetration Triage • Triage obstacles with children: No adult triage system effective with children, inappropriate triage of children, inappropriate transport, difficulty identifying children, separation from parents, and developmental issues • JumpSTART: Triage system specifically designed for children; however, requires additional training and equipment; must await increased use to support its effectiveness Diagnosis • Children can be diagnostic dilemmas: Fever and rash are common occurrences • Diagnoses guided by education and high index of suspicion of providers • Public health disease-tracking systems may assist with diagnosis. Drug delivery • Strategic National Stockpile: Can reach specific areas in 72 hours; few packs contain pediatric doses • Possible limited availability of needed drugs: Liquid potassium iodide and ciprofloxacin • Mark I kits: Contain medications for treatment of exposure to nerve agents; Issues regarding pediatric dosing and administration still remain Decontamination • Children are at increased risk for hypothermia and may not withstand prolonged decontamination periods • Children in decontamination chambers: May need to be carried/held, increased level of fear, considerations for children with special health care needs, and ability of children to follow directions Mental health concerns • Reactions to unfamiliar events vary greatly: Television images likely to be misunderstood; Care requires familiarity with age-appropriate interventions.
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• Highly influenced by emotional state of caregivers: Parental response will affect child. • Posttraumatic stress disorder: Most common response to disasters in children; affects 40% of children, usually within first 3 months; wide range of symptoms (intense grief, restlessness, sleep disorders, and decline in school performance) Agencies and organizations involved with Government agencies pediatric disaster preparedness • Department of Homeland Security • Federal Emergency Management Agency • Department of Health and Human Services • Centers for Disease Control and Prevention • State and Local Emergency Planning Committees Schools and childcare systems • Need to perform risk assessment • Should identify: Evacuation plans, reunification plans, guardianship, how to protect children with special health care needs, and provision of mental health support for children/staff • Integrate disaster plan with: EMS, public safety departments, public health departments, and local hospitals Physicians' offices • Staff education crucial: Should be able to identify, report, and refer cases of exposure to toxic substances or weapons • Educate families • Identify patients with special needs • Know the resources: Public health departments, Red Cross, and Children's Hospitals • Integrate offices into community plans Families • Family disaster plans: Escape plans and rally points and out-of-state contact person • Education: Proper use of 911 emergency services and first aid • Disaster supply kits: Available through the American Academy of Pediatrics, Red Cross, and Federal Emergency Management Agency Emergency responders • Disaster training: Basic Disaster Life Support and Advanced Disaster Life Support • Pediatric specific equipment, drugs, and protocols • Disaster documentation • Integration with schools, hospitals, and federal agencies • Education regarding: Pediatric medical/legal issues (i.e., guardianship), care for children with special health care needs, and local family reunification schemes Hospitals • Childrens' Hospitals serve as leaders in care for pediatric patients in disaster • Hospitals supplied with appropriate medications, skills, equipment, and education • Disaster plans for all hospitals must address: Children as victims and impact of disaster on staff with children
Pediatric considerations for multiple aspects of a disaster situation were identified and discussed extensively. Finally, a review of different agencies and organizations involved with disaster preparedness, along with ways that specific organizations can better prepare for care of children in a disaster was presented. Participants in the program included all nurses in the pediatric inpatient areas of a tertiary care, Level I trauma center during the 12 months of 2005. The program was provided as part of the regularly scheduled annual nursing education days in our health care organization. Nursing education days are scheduled once a month, and pediatric acute care registered nurses are prescheduled to attend one session. As a result, all pediatric inpatient nurses had attended this program by the end of 2005.
A pretest completed prior to the program assessed baseline knowledge of the participants. The pretest consisted of 10 true-or-false questions and one question that asked the nurse to list three things that place children at increased risk for injury in a disaster situation. Following the 80-minute presentation and discussion, participants were asked to complete the posttest to assess immediate effectiveness of the instruction. The pretests and posttests used were identical and are provided in Table 2. A 2-year follow-up survey was conducted of the program participants using the same posttest to assess long-term retention of information. RESULTS The aggregate mean pretest and posttest scores of the inpatient pediatric nurses were consistent
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FOX AND TIMM Table 2. Pretest and Posttest
Pediatric Issues in Disaster Preparedness Pretest/Posttest _____Pretest _____Posttest
Please circle.
1. JCAHO defines disaster as an event that creates a large number of casualties. 2. Prior to September 11th 2001, planning for children involved in a disaster was a top priority. 3. The most commonly used WMD is a biological agent. 4. Children exposed to a chemical or biologic agent have specific signs and symptoms and are easily diagnosed. 5. A primary goal of disaster triage is to provide definitive care to injured persons. 6. Children comprise 5% of the total population of Ohio. 7. Children are difficult targets for a WMD attack because they are safe in schools or day cares. 8. Nerve agents affect lung secretions. 9. Posttraumatic stress disorder is the most common response to disasters in children. Please fill in: 10. Name three reasons children are more vulnerable to a WMD attack. Pretest: A. _________ B._________ C._________ Posttest: A. _________ B. _________ C. _________
with reports in the literature about the state of disaster preparedness of health care providers (Rose & Larrimore, 2002). At the time of the educational offering, 45 nurses completed the pretest and immediate posttest. The 2-year follow up yielded 35 returned posttests. The aggregate mean pretest score was 71%; the mean posttest score was 91%, and 2-year posttest score was 67%. Thus, most of the nurses had some baseline knowledge about pediatric disaster management. This knowledge level increased for the group immediately after the Pediatric Issues in Disaster Preparedness Program presentation. However, 2 years after the presentation, overall knowledge about pediatric disaster had decreased among the group. The reduction in retention of information is consistent with other educational models (O'Steen, Kee, & Minick, 1996; Wolfram, Doyle, Kerns, & Frye, 2003). DISCUSSION Although information from these pretests and posttests only reflect the aggregate or group mean scores, it does lend support to the recommendation that pediatric nurses, including those beyond firstline providers, should be regularly inserviced on pediatric disaster preparedness. The Pediatric Issues in Disaster Preparedness Program described here is an important step toward meeting the needs of pediatric providers as it pertains to disaster preparedness. It has been identified that the needs of children in a disaster situation are different from adults; thus, the care provided to these children should incorporate what
True True True True
False False False False
True True True True True
False False False False False
we know about these differences. Pediatric nurses beyond frontline providers must have education about these needs, as many may be called upon to assist frontline responders in the event of a disaster and will be involved in the ongoing care for children. Knowledge about pediatric disaster issues will assist the acute care pediatric nurse in delivering appropriate and quality care for patients and will supply them with information to serve as powerful advocates for their patients should a disaster occur. The results of the pretests and posttests administered in this program are consistent with other reports in the literature. Rose and Larrimore (2002) administered a survey to assess knowledge and awareness of health care providers regarding chemical and biological terrorism. The survey was completed by 219 nurses, nursing students, physicians, and medical students prior to a workshop on domestic terrorism preparedness. Survey results indicate that knowledge scores were low; respondents answered less than a quarter of the questions correctly. Furthermore, less than 23% of respondents reported having the confidence to adequately provide care to patients in the event of a terrorism situation. Thus, continued education about disaster preparedness is still needed for our health care providers. Although the gap is narrowing, a significant need still exists with regard to pediatric disaster education targeted for health care providers. Acute care pediatric nurses expressed this need anecdotally during the Pediatric Issues in Disaster Preparedness Program, and the aggregate pretest and posttest scores provide support for the
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recommendation that nurses receive regularly scheduled educational inservices or training on disaster preparedness. Because disaster planning and management is not typically incorporated as part of the daily practice of pediatric nurses, retention of this information may be difficult. However, annual or biannual educational offerings on this topic may help nurses retain key aspects of their role and the type of care required for pediatric patients in the time of a disaster. Given the realities of our environment and that natural or human-initiated disaster will strike again, it is essential that health care organizations including pediatrician offices and clinics incorporate educational programs about disaster preparedness into training programs. Due to the special needs of children and the lack of information about pediatric disaster, it is even more crucial that hospital pediatric providers receive information about the special considerations for children in a disaster situation. The Pediatric Issues in Disaster Preparedness Program described in this article aimed to meet this need among pediatric providers in our state, particularly among acute care pediatric nurses. In our continued efforts to educate providers about
pediatric disaster preparedness, our committee has made the content from this program available through the Web site of the Ohio Hospital Association 2007). It is hoped that the dissemination of this information will aid providers in delivering the highest quality care to children affected by future disasters. The American children are counting on us to provide appropriate, comprehensive, and specialized care in the event they need our help. Without ongoing education and an understanding of their needs, we will not be prepared to face the challenge. Katrina, as devastating as it was, gave us a window into the needs which still exist in relation to children and disasters. It is our great responsibility and challenge as pediatric providers to rise to the occasion and advocate for their needs. Education is a powerful tool, which we need to use wisely. ACKNOWLEDGMENTS The authors wish to acknowledge Dr. William Cotton, MD, and the State of Ohio Pediatric Disaster Planning Committee members for their support in the development of this educational program.
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Markenson, D., & Redlener, I. (2003). Pediatric preparedness for disasters and terrorism: A national consensus conference. Retrieved April 24, 2007, from http://www.bt.cdc.gov/children/ pdf/working/execsumm03.pdf. Markenson, D., & Redlener, I. (2004). Pediatric terrorism preparedness national guidelines and recommendations: Findings of an evidence-based consensus process. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 2, 301−316. National Disaster Life Support Foundation (2007). NDLS courses. Retrieved July 11, 2007, from http://www.bdls.com/. Nicholson, D. (2003). Terrorism and/or natural disasters: Are we prepared to care for America's children? Journal of Pediatric Nursing, 18, 154−155. O'Neal, B. J. (2001). International Nursing Coalition focuses on mass casualty education. On the Edge, 7, 13. Ohio Hospital Association. (2007). Pediatric issues in disaster preparedness. Retrieved July 12, 2007, from http:// www.ohanet.org/. O'Steen, D. S., Kee, C., & Minick, M. (1996). The retention of advanced cardiac life support knowledge among registered nurses. Journal of Nursing Staff Development, 12, 66−72. Rebmann, T. (2005). Bioterrorism preparedness for nurses: A new training and reference program. The Missouri Nurse, 2, 8–9, 13. Redlener, I., & Markenson, D. (2004). Disaster and terrorism preparedness: What pediatricians need to know. Disease-AMonth, 50, 1. Rose, M., & Larrimore, K. (2002). Knowledge and awareness concerning chemical and biological terrorism: Continuing education implications. The Journal of Continuing Education in Nursing, 33, 253−258.
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Veenema, T. G. (2002). Chemical and biological terrorism: Current updates. Nursing Education Perspectives, 23, 62−71. Wolfram, R., Warren, C., Doyle, C., Kerns, R., & Frye, S. (2003). Retention of pediatric advanced life support (PALS) course concepts. Journal of Emergency Medicine, 25, 475−479.