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Pediatric Disaster Updates: Family Reunification and Regional Planning

Sarita Chung MD, FAAP

Assistant Professor of Pediatrics, Harvard Medical School

Member of Council on Disaster Preparedness and Recovery

American Academy of Pediatrics

Course Name

Conflict of Interest Disclosure

• Co-Director, Disaster Domain, Emergency Medical Services for Children, Innovation and Improvement Center.

• Images used in this presentation were obtained from the public domain of the internet.

Objectives• Family Reunification

– Discuss key concepts of family reunification planning including current systems

– Describe results from family reunification research and next steps

• Regional Planning

– Present activities from MA/Region 1 partnership for Regional Disaster Health Response

– Introduce Pediatric Disaster Centers of Excellence

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Children in Disasters

Reunification is Needed• “Improved methods for reunifying

separated children with their families”• Develop a standardized interoperable

national evacuee tracking and family reunification system that ensure the safety and well-being of children”

Need for Reunification after Disasters

Hurricane Katrina, 2005 Border Crisis, 2018

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Healthcare = Part of the Solution

Family ExpectationsAssumptions

• Families will obey evacuation instructions

• Families expect all hospitals have a plan to reunite families

• Families expect immediate identification and reunification of all survivors

Reality• 63% Families would

disregard evacuation instructions

• Peds Ready Data:– Only 47% EDs report having a

disaster plan that address children

• Hospitals will not have that information

– Identity of deceased victims may take days, weeks

https://academiccommons.columbia.edu/doi/10.7916/D8NG50CKGausche – Hill , JAMA Pediatr. 2015;169(6):527-534

Hospital ExpectationsAssumptions:

• My hospital will not be affected- we are not a trauma center

• My community has a family reunification plan

• My hospital already has a plan

Reality

• Scope and Run

– “Siri”

• Families will head to hospitals first– Community family assistance

centers take time to set up

• That’s great - but make your spaces bigger. Drill to failure.

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Community Reunification Partners

• Goal is to prevent duplication of effort

Challenges of Children regarding reunification• Developmental

– May not self-identify

– Immature Cognitive Skills

• Mental Health

– Increase risk of mental health disorders

• Safety

– Child safety and protection

– Escalation of staffing

– More space

Current Systems and Resources Available

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National Level- Federal Resource• Support overall

reunification processes and procedures– Identifying roles of lead and

supporting agencies

– Enhance/develop reunification elements in emergency preparedness plans

– General approach for schools, shelter and hospitals

National Level –Federal Resources

• Federal Emergency Management Agency

– National Emergency Family Registry And Locator System

– National Mass Evacuation Tracking System (radio frequency identification)

• Department of Health and Human Services

– Joint Patient Assessment and Tracking System

Rapid DNA

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•

https://www.dhs.gov/publication/rapid-dna

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National Level- NGO

• Unaccompanied Minors Registry

• Team Adam

– Deployment of retired law enforcement officials

National Level- NGO• Safe and Well website

• Communicate with law enforcement and child welfare agencies

• Track movement through Unaccompanied Minors Report Form

• Designates 2 people to supervise an unaccompanied minor

Social MediaWhat’s currently available?

• Facebook, Twitter, etc, Apps

• Local News (Google, CNN, etc)

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State Level• New York State Operation Safe Child

• Louisiana – Phoenix Tracking System

• Coded arm bands

Local Level• No standardized approach

– Consider photographs

• Need for the whole community involvement for planning

• For the deceased

– Local dental records

– Local Police Department

DNA/finger printing programs

Shortcomings

• FEMA national systems are not in use unless a Federal disaster is declared

• Social Media require that you are alive, have internet access, and are literate

• Local system may not be scalable or remotely accessible

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Does not address

People who can not access the system:• Young Children (pre-verbal)

• Children with Special Healthcare Needs

• Severely Injured

• Deceased

Family Reunification Research

Funded by HRSA (EMS-C Targeted Issues) Grant #H34MC10575-01-01

REUNITE

DisasterMissing Children

REUNITE: Image Based System

Chung et al. Am J Disaster Med 2007 May-Jun;2:113-117

Chung et al. Acad Emerg Med 2012:19:1227-34

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Where Can this System be Accessed? Hospitals

Healthcare Centers

Relocation Shelters

more

Emergency Responder Survey(n= 129)

37 States

Represented

Minimum Number of ReunificationsEmergency Responders

In a large scale disaster, If a system could reunify 10% of families, over half of Emergency Responders would adopt it as a primary system.

Chung et al. Disaster Med Public Health Prep. 2012 Jun;6(2):156-62A

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Development of the REUNITE Prototype

REUNITE Facial Feature ExtractionSkin

• Divided in 2 categories

• Grouping of Light/Dark

Eyes

– Divided in 2 categories

– Grouping of

– Blue/Green/Grey &

– Hazel/Lt & Dk. BrownAge•0-12 month

•13-23 months

•2-4 years

•Over 5 years

GENDER• Male• Female

Similarity (Browsing) Function

• Parents can choose photos that look their child

• Database is reordered to display photos that have similar features (facial shape, hairstyle)

• Advantages

– Large scale disaster

– Homogenous populations

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Missing Child

Browsing with Similarity Feature

Estimation of Age

Novel Algorithm Predicts Age +/- 2.5 years

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Boston Children’s Large-Scale Disaster Drill

Drill Scenario• Scenario: Category 4 Tornado in MA

impacting several schools. About 1,200 children affected and are being transported to different area hospitals.

• Drill Assumptions: Children were brought to the hospital without their parents; were medically evaluated and discharged to the Pediatric Safe Area. Children participating were unable to provide any personal information

Gaps Identified

• Needed dedicated pediatric “quiet space”

• Further training needed

Large Scale Drill:Boston Children’s Reunification Protocol

Pediatric Safe Area- converted conference room

Success

• Multidisciplinary roles in creation of protocol- emergency management, social work, child life, pyschiatry, emergency department

• Age appropriate “pediatric safe area”

• Established parent/child verification process

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Family Vetting Forms

Participant Characteristics

• 22 Families

• Parents

– 28 Parents/Guardians

– 97% 4 year college degree

or more

• Children

– 49 children participated

– 41% searches for children <5 years of age

Performance

Parents missed identifying their child 9.5%of the searches!

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What about Parents?

What information are parents/caregivers willing to share and with who during an disaster in order to facilitate family reunification?

• Convenience sample of adults presenting to 2 pediatric EDs

• N = 363 (52% Boston)

• Electronic survey

Charney RL et al.Disaster Med Public Health Prep. 2019 Dec;13(5-6):974-981.

Information Sharing

Parental Trust

0 20 40 60 80 100

Out-of-state gov't

United Way

State gov't

Local gov't

NCMEC

Parental Trust in Agencies and Organizations (%)

You are it!

Hospitals

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Next Steps

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Family Preparedness• Communication plan

– Memorizing phone numbers• Out of area emergency contact

person• Text

– Evacuation plan local and out of state

• Young, nonverbal– Events

• Picture, Written Info – ID Card/info

• Bracelet, Necklace

https://www.aap.org/en-us/Documents/disasters_family_readiness_kit.pdf

Hospital Family Reunification Tool 2018

• Sponsored by a CDC-AAP State Preparedness Grant

• Vetted by 2 stakeholder groups in Missouri and Massachusetts

• Pilot tested in community hospitals in MA and MO

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Let’s test: Family Reunification Plans

• Use children in drills

• Understand and mitigate barriers

• Drill the entire process from separation to reunification in the whole community

• Don’t be afraid if your assumptions were wrong

Future Research

• Leveraging social media for child identification

• Better image based family reunification system using voice and video recognition

• Other biometrics systems

• …………..

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Regional Planning

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MA/REGION 1 PARTNERSHIP forRegional Disaster Health ResponsePI: Paul Biddinger MDMGH Center for Disaster Medicine

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Catastrophic Tertiary Access Center (CTAC)

• Created to leverage hospital operational expertise to effectively coordinate and support patient placement during catastrophic events

• Staffing included:• Access Center Nurses• Emergency Managers• Clinical SMEs• Admitting Staff

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Pediatric Advisory Group

• Underlying Principles• >80% of children are seen in community hospitals and 1/3 of those

are remote or rural hospitals

• Attention to children’s needs (weight based medication dosing; imaging and radiation exposure; equipment sizes by age or weight)

• Caring for a critically ill child is rare for most providers

• Improve day to day readiness to care for children:➢Makes it that much easier to respond in a disaster involving

children➢Appropriate child diagnoses can stay in the community (less

travel for families)

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Existing Pediatric Disaster Resources

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Pediatric Advisory Group

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Gap Identified Improvement Strategy

Limited Understanding of pediatric capabilities and capacity of healthcare system

Conduct an inventory of currently available ED, inpatient and ICU care resources in the state

Work with EMS-C to create tiered listing of care capabilities to guide patient distribution and care

Limited pediatric capacity and expertise Work with American Academy of Pediatrics to expand pool of available telemedicine experts

Limited pediatric capacity, likely requiring alteration of existing capabilities

Develop tiered strategies for how to expand pediatric care capabilities (i.e. NICU caring for patients < 1 year, adult ICU/floor care for patients 14+, etc.)

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1. Pediatric Capacity and Capability Inventory• What do you have?

–Pediatric Beds (DPH), Specialty Services, Policies

• What can you take?

–Timeframe: Immediately, 4 hours, 8 hours

• How would you be willing to stretch?

–Peds Trauma in the OR, Peds in the ICU; Trauma in non-Trauma Hospitals 55

2. Extending Pediatric Reach

• Pediatric Disaster Focus since 2005

• Federal and National partners

• Exploring Telemedicine

• NEW Council on Disaster Preparedness and Recovery

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3. Expanding Framework for Flexing

• Develop tiered strategies for expansion of pediatric care capabilities

– (e.g. NICU caring for patients < 1 year, adult ICU/floor care for patients 14+)

– Identify barriers when “stretching” becomes “breaking”

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Pediatric Disaster Center of Excellence

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PI: Deanna Dahl Grove MDCharles Macias MD

PI: Chris Newton MDMichael Anderson MD

Michigan and Ohio Region serving nearly 7 million children and their families

Workgroups:

• Pediatric Assets Map

o Regional Coalition Surveys

o Children’s Hospital Survey

o EMS Survey

o Facility Recognition

o Supply Chain Survey

•

• Telemedicine

• Legal and Policy Review

• Behavioral Health

• Hazard/Vulnerability Analysis

● Education collaboration with the other

COE

● Quality collaboration with the other

COE

● Pediatric Strike Teams

● Exercise Development

● Information Technology Integration 59

Eastern Great Lakes Pediatric Consortium for Disaster Response - Helping coalitions prepare to care for Children in

Disasters

Facility Recognition for the Region

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Pediatric Disaster Preparedness Quality Collaborative (PDPQC)

Aim

By September 30, 2020, 100% of participating hospitals will have a hospital disaster plan that includes pediatric-specific needs.

Target Hospitals

Rural, Critical Access, Community, Suburban, Non-Pediatric Urban

Time Commitment

Nine, 2-week modules including participation in the ASPR COE Regional Exercise (July 30th)

1-2 hrs./week for ~20 weeks (40 hours total)

Links:

Intent to Participate Link (RedCap): https://tch-redcap.texaschildrens.org/REDCap/surveys/?s=TYHJTNWPPE

For more information visit: https://emscimprovement.center/collaboratives/pediatric-disaster-preparedness-quality-collaborative/

Application

• Site Recruitment (Jan 1 - Apr 1)

• Intent to Participate (Jan 1 - Apr 1)

• Formal Application (March 1 - Apr 1)

• Environmental Scan (Apr 1 - May 15)

Internal Coordination

• Module 1: Establish a Pediatric Champion (May 18 - 31)

• Module 2: Review Current Policies and Previous Drills (Jun 1 – 14)

• Module 3: Tabletop Exercise (provided) (Jun 15 – 28))

Regional Coalition Building

• Module 4: Regional Coalition Building (Jun 29 – Jul 12)

• Module 5: Regional Coalition Exercise History (Jul 13 – 26)

• Module 6: Participate in ASPR COE Regional Exercise (Jul 30)

Tracking & Reunification

• Module 7: Patient Tracking & Reunification (Aug 10 – 23)

• Module 8: Create/Update a Tracking & Reunification Plan (Aug 24 – Sept 6)

• Module 9: Lessons Learned and Sustainability Planning (Sept 7 – 20)

Learning Session 1 (Jun 26)

Learning Session 2 (Aug 7)

Final Learning Session (Sept 25)

Official Launch (May 15)

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Universities / FacilitiesSeattle Children’s (UW) University of Oregon (OHSU)UC DavisUCSFStanfordValley Children’s Hospital (Fresno)Loma Linda UniversityCHLA (USC)Lindquist Institute (Harbor-UCLA)Cedars SinaiRady Children’s (UCSD) University Medical Center (UNLV)Phoenix Children’s (ASU)

Agency / Consortium / CorporateState Departments of HealthState EMS and EM Health care Coalitions (HCC’s) Western Peds Preparedness Partnership (WPPP) Poison Control CentersBurn Centers ConsortiumEbola Biocontainment centers (NETEC)AMR AmbulanceReach / Calstar Air Medical AmbulanceKaiser PermanenteProvidence Healthcare

13 Million Children~150 Active participants 6

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ASPR

WRAP-EM Board of Directors

(Representation from each state)

State Agency Liason Committee

(Each State: HPP / EMS / Emergency

Management or PH Representative)

PI’s:

Medical Director:

James BettsRegional Operations Director:

Coordination

center

Sub Group

“EEI’s”

Gap Analysis

Group

Sub Group

“Supply

Chain”

Patient Movement /

Tracking

Sub-Group “Surge Plans”

Sub-Group “Evacuations”

Sub-Group “NICU / PICU /

Special Needs”

Sub Group “tracking and

Reunification”

CBRN

Mental Health

Infections

Burns

Telehealth

MCI / Trauma

EMSC /

Readiness

Deployable

Assets

Education /

IT

Clinical / SME

Operational Support staff

6 Area Coordinators

Sub Group

“Center

Integration”

Sub Group

“Drills”

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Summary

• Family Reunification will be needed after major disasters.

• Intensive work is currently being done in the ASPR Pediatric Disaster Center of Excellence

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Acknowledgements

• Paul Biddinger MD, Massachusetts

• Deanna Dahl Grove MD, Ohio

• Chris Newton MD, California

• AAP Council on Disaster Preparedness and Recovery

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Michael Shannon MD 1953-2009