Sarita Chung

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

Objective:We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background:Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods:A collaborative effort among Bostons trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results:A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions:Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

Test characteristics of commercial influenza assays for detecting pandemic influenza A (H1N1) in children.

We assessed the test characteristics of 2 influenza antigen tests, a rapid immunoassay and a direct fluorescence antibody (DFA) assay, in detecting pandemic influenza A (H1N1) in children up to 18 years of age, using polymerase chain reaction as the standard. The sensitivities of BinaxNOW (59.6%) and direct fluorescence antibody (57.3%) were similar. The specificity of each test was >99%.

A Novel Image-based Tool to Reunite Children With Their Families After Disasters

OBJECTIVES Reuniting children with their families after a disaster poses unique challenges. The objective was to pilot test the ability of a novel image-based tool to assist a parent in identifying a picture of his or her children. METHODS A previously developed image-based indexing and retrieval tool that employs two advanced vision search algorithms was used. One algorithm, Feature-Attribute-Matching, extracts facial features (skin color, eye color, and age) of a photograph and then matches according to parental input. The other algorithm, User-Feedback, allows parents to choose children on the screen that appear similar to theirs and then reprioritizes the images in the database. This was piloted in a convenience sample of parent-child pairs in a pediatric tertiary care hospital. A photograph of each participating child was added to a preexisting image database. A double-blind randomized crossover trial was performed to measure the percentage of database reviewed and time using the Feature-Attribute-Matching-plus-User-Feedback strategy or User-Feedback strategy only. Search results were compared to a theoretical random search. Afterward, parents completed a survey evaluating satisfaction. RESULTS Fifty-one parent-child pairs completed the study. The Feature-Attribute-Matching-plus-User-Feedback strategy was superior to the User-Feedback strategy in decreasing the percentage of database reviewed (mean ± SD = 24.1 ± 20.1% vs. 35.6 ± 27.2%; mean difference = -11.5%; 95% confidence interval [CI] = -21.5% to -1.4%; p = 0.03). Both were superior to the random search (p < 0.001). Time for both searches was similar despite fewer images reviewed in the Feature-Attribute-Matching-plus-User-Feedback strategy. Sixty-eight percent of parents were satisfied with the search and 87% felt that this tool would be very or extremely helpful in a disaster. CONCLUSIONS This novel image-based reunification system reduced the number of images reviewed before parents identified their children. This technology could be further developed to assist future family reunifications in a disaster.

Creation and Delphi-method Refinement of Pediatric Disaster Triage Simulations

Abstract Objective. There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. Methods. We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. Results. After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. Conclusions. The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Medical countermeasures for children in public health emergencies, disasters, or terrorism

Significant strides have been made over the past 10 to 15 years to develop medical countermeasures (MCMs) to address potential disaster hazards, including chemical, biological, radiologic, and nuclear threats. Significant and effective collaboration between the pediatric health community, including the American Academy of Pediatrics, and federal partners, such as the Office of the Assistant Secretary for Preparedness and Response, Centers for Disease Control and Prevention, Federal Emergency Management Agency, National Institutes of Health, Food and Drug Administration, and other federal agencies, over the past 5 years has resulted in substantial gains in addressing the needs of children related to disaster preparedness in general and MCMs in particular. Yet, major gaps still remain related to MCMs for children, a population highly vulnerable to the effects of exposure to such threats, because many vaccines and pharmaceuticals approved for use by adults as MCMs do not yet have pediatric formulations, dosing information, or safety information. As a result, the nation’s stockpiles and other caches (designated supply of MCMs) where pharmacotherapeutic and other MCMs are stored are less prepared to address the needs of children compared with those of adults in the event of a disaster. This policy statement provides recommendations to close the remaining gaps for the development and use of MCMs in children during public health emergencies or disasters. The progress made by federal agencies to date to address the needs of children and the shared commitment of collaboration that characterizes the current relationship between the pediatric health community and the federal agencies responsible for MCMs should encourage all child advocates to invest the necessary energy and resources now to complete the process of remedying the remaining significant gaps in preparedness.

Leadership During the Boston Marathon Bombings: A Qualitative After-Action Review.

OBJECTIVE On April 15, 2013, two improvised explosive devices (IEDs) exploded at the Boston Marathon and 264 patients were treated at 26 hospitals in the aftermath. Despite the extent of injuries sustained by victims, there was no subsequent mortality for those treated in hospitals. Leadership decisions and actions in major trauma centers were a critical factor in this response. METHODS The objective of this investigation was to describe and characterize organizational dynamics and leadership themes immediately after the bombings by utilizing a novel structured sequential qualitative approach consisting of a focus group followed by subsequent detailed interviews and combined expert analysis. RESULTS Across physician leaders representing 7 hospitals, several leadership and management themes emerged from our analysis: communications and volunteer surges, flexibility, the challenge of technology, and command versus collaboration. CONCLUSIONS Disasters provide a distinctive context in which to study the robustness and resilience of response systems. Therefore, in the aftermath of a large-scale crisis, every effort should be invested in forming a coalition and collecting critical lessons so they can be shared and incorporated into best practices and preparations. Novel communication strategies, flexible leadership structures, and improved information systems will be necessary to reduce morbidity and mortality during future events.

Pediatric alternate site of care during the 2009 H1N1 pandemic.

Objectives: This study aimed to describe the design and implementation of an alternate site of care (ASC) for nonurgent pediatric patients with influenza-like illnesses during the 2009 H1N1 pandemic and to evaluate its performance. Methods: We describe the design and physical implementation of an ASC. Evaluation of the utilization, patient demographics, throughput, safety, family satisfaction, and cost are presented. Results: The process of project development, site selection, clinical algorithms, staffing supplies, and cost are detailed. The ASC was used for 7.5 days, and 137 patients were treated. The median age was 6.5 years. Forty-five percent were male, and English was the primary language. Median length of stay for patients evaluated was 65 minutes. Of patients, 5.8% were transferred from the ASC to the ED for further care. Also, 2.3% of patients returned to the ED within 72 hours; however, none required admission. There were no adverse events associated with the ASC and 92% of families rated overall care as very good or excellent. Conclusions: Selected nonurgent patients with influenza-like illness during a pandemic can be treated in a safe and timely manner with high levels of family satisfaction in a novel setting.

Going viral: adapting to pediatric surge during the H1N1 pandemic.

Objectives The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. Methods Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant’s hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. Results The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. Conclusions Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.