Public Health Emergency Preparedness

Emergency Department Response: Surge of Children With a Communicable Respiratory Illness

All disaster patients should be triaged immediately on arrival according to the protocol described below. 

Reverse Triage

Before patients can be handled safely in any emergency department (ED), the medical facility that supports ED operations must have adequate bed space into which ED patients may be admitted. As Kelen has described, in a surge environment, reverse triage—the process of determining risk for discharge of inpatients—assumes a critical role. Stratifying risk into minimal (a limit of risk of adverse medical events in the next 72 hours of 3.8 percent); moderate (a limit of risk for consequential events in the next 72 hours of 33 percent); high (limit of risk of 61 percent); and very high (92 percent limit of risk) categories, patient disposition can be identified. Minimal and low risk patients may be sent home; moderate risk patients may deserve immediate transfer to another facility since they may be too sick for simple discharge home. High risk patients require highly skilled care during transport to major acute-care facilities, while very high risk patients may tolerate only ICU-capable transport—if they are stable for transport at all.⁷

Triage

Health care facilities should use a pediatric-specific triage system known by all hospital personnel.^8-10 The use of standardized triage algorithms will provide guidance for triage personnel making potential life and death decisions that otherwise might be influenced by emotional issues.^8,9 Depending on the volume of children arriving at a health care facility, clinicians may elect to use one of two assessment tools. In the event of very large numbers of patients arriving at an ED simultaneously, the Pediatric Assessment Triangle (PAT) suggests the urgency with which treatment should be initiated.⁹ This assessment tool relies on appearance of the patient to determine the severity of illness, the need for treatment, and the response to therapy.⁹ By using only visual and auditory assessments to develop an initial impression of a pediatric victim, PAT allows clinicians to rapidly identify patients with physiologic instability without using sophisticated monitoring techniques.⁹ The components include appearance, peripheral perfusion, and respiratory effort.⁹ The PAT is a simple tool that may be applied during any patient encounter; clinicians should practice applying PAT during routine emergency care to increase familiarity with the method.⁹ 

Slower patient arrival and intake may permit the use of another assessment tool, the JumpSTART Pediatric Multiple Casualty Incident Triage system (Figure 2 and 3).^8,9 This triage protocol is based on an assessment of respiration, perfusion, and mental status (RPM).^8,9 The JumpSTART system is modified from a triage system developed for adults; the modification to pediatric triage is based on known differences between adults and children in terms of risks and patterns of respiratory failure/arrest.^8,9 Unless there is a clear external airway obstruction or compression, or internal obstruction from a foreign body, respiratory failure in adults usually follows massive head injury or circulatory failure.^8,9 In this context, an apneic adult has likely suffered sufficient cardiac insult to preclude successful resuscitation in a mass casualty setting.^8,9 In children, however, circulatory collapse often follows respiratory failure.⁸ Children may develop apnea relatively rapidly for mechanical reasons (e.g., weak respiratory musculature or inhibition of diaphragmatic excursion), rather than after a prolonged period of hypoxia. For this reason, a trial of intubation during a period of brief salvageability is a "jumpstart" for the child.⁹ It also means that increased pressure to respond quickly and effectively will be placed on respiratory personnel during a surge.⁹ 

Step 1: All children who can walk should be directed toward an area designated for minor injuries, where secondary triage will occur.⁹ Secondary triage should, at a minimum, employ the RPM components of the JumpSTART algorithm.⁹ Infants who are developmentally unable to walk should be screened at the initial site using the JumpSTART algorithm; an infant who satisfies all of the "delayed" criteria may be triaged to the minor category (Figure 3).⁹

Special consideration should be given to children with medical conditions that prevent ambulation (e.g., mental retardation-cerebral palsy). These individuals can be triaged in a manner similar to infants.⁹ Clinicians should be aware, however, that patients with chronic respiratory problems may have an elevated respiratory rate at baseline. Moreover, an assessment of the neurological examination may prove difficult without an understanding of baseline function. Emergency personnel should, therefore, attempt to retrieve information from any available source.^8,9 

Step 2A:  Nonambulatory patients should be assessed for the presence of spontaneous breathing. Any patient with spontaneous respiratory effort should then have respiratory rate determined.⁹ Any patient with duration of apnea of greater than 10 seconds must have the airway assessed; any obvious foreign bodies should be removed by finger sweep.⁹ Otherwise, the airway should be opened by maneuvers such as chin lift/jaw thrust. If the patient regains spontaneous respiratory effort, the triage officer or his designee classifies the patient as immediate (red tag) and moves on.⁹ 

Step 2B: If spontaneous respirations do not return upper airway opening, the triage officer or his designee should palpate for peripheral pulses in the radial, brachial, and dorsalis pedis arteries. The absence of peripheral pulses warrants a triage category of deceased.⁹ 

Step 2C: If there is a palpable peripheral pulse, the triage officer or his designee will administer five rescue breaths using a bag-valve-mask device. The use of a mouth-to-mask device, as suggested by some protocols, is contraindicated in patients suffering exposure from airborne bioterror agents. If ventilatory trial fails to trigger spontaneous respiration, the child is classified as deceased.⁹ 

Step 3: At this point in the triage protocol, all patients have spontaneous respirations.  Patients with a respiratory rate of 15-45 breaths per minute move to Step 4. Patients with respiratory rates less than 15, greater than 45, or with irregular breathing are classified as immediate (red tag), and the triage officer or his designee moves on.⁹ 

Step 4: At this point in the triage protocol, all patients have been determined to have adequate respiratory effort and rate. The triage officer or his designee should now assess perfusion by palpation of peripheral pulses.⁹ Because a terrorist attack may occur during winter months, and decontamination will be performed out-of-doors in a potentially cold environment, capillary refill should not be used to assess perfusion. The palpation of pulses is a tactile method that adapts well to poor environmental conditions. If there are palpable peripheral pulses, the triage officer or his designee assesses mental status (Step 5). If there are no palpable pulses, the patient is classified as immediate (red tag), and the triage officer or his designee moves on.⁹ 

Step 5:  For all patients at this point, the triage officer performs a developmentally-tailored "AVPU" assessment. If the child is alert, responds to voice, or responds appropriately to pain (e.g., localizes the painful stimulus or pushes it away), the patient is classified as delayed (yellow tag). If the child does not respond to voice and responds inappropriately to pain (e.g., makes noise or moves in a nonlocalizing fashion), has decorticate posturing, or is truly unresponsive, the patient is classified as immediate (red tag).⁹ 

Personal Protective Equipment and the Triage Location

Triage areas in medical care facilities should be considered "hot zones"—areas in which the greatest risk for contamination occurs. This designation is distinct from field MCI operations, where the triage location is considered to be a "warm zone"—an area defined by a perimeter inside which no or an acceptable level of contamination exists. Based on this definition, an entire health care facility could be considered a "warm zone," which poses a risk of exposure to contaminated victims and equipment.

In general, early recognition of the type of exposure is based on the signs and symptoms demonstrated by patients. The type of exposure, in turn, determines the level of protective gear used by individuals in triage and patient decontamination. ED personnel handling victims contaminated with bioweapons in liquid or powder form require respiratory protection. Skin protection is largely unnecessary because bioterror agents are not absorbed through unbroken skin.^1,9 Personnel handling victims exposed to aerosols do not require protective equipment since secondary aerosolization of residual agent from clothing, skin, hair, or exhaled air is usually insignificant.¹ In all cases, standard hygiene (e.g., hand washing) should be employed. 

The location at which triage occurs will be determined in part by the number of patients presenting to the health care facility. For example, triage may occur in the ambulance bay of the emergency department, in the lobby of the hospital, or in driveways, traffic circles, or other areas normally used by vehicular traffic. Triage teams should report to the triage location determined by the Incident Commander. The exact composition of triage teams may vary with the time of day and week depending on staffing levels. The composition and number of triage teams should be codified prior to a disaster.⁹ 

Example: Smallpox Scenario Smallpox is transmitted by respiratory droplets and airborne particles.11 For victims of smallpox, triage should be performed outdoors in a well-ventilated area.12 Triage teams should employ airborne, contact, and droplet precautions.12,13 This level of protection requires either a fitted N95 respirator with goggles and face shield; alternatively, a powered air purifying respirator (PAPR) hood may be used. In addition, personnel must use hair cover, shoe cover, gloves, and disposable yellow gowns or Tyvek overalls. Triage should be performed outdoors in a well-ventilated area such as the ambulance bay or hospital driveway. Patients may need to be held in the triage area until the ED is prepared for intake of victims. Because victims may be exposed to cold in the outdoor environment, warming lights, disposable blankets, or other devices should be available for patient warming. Specific preparations that the ED may have to make in anticipation of victim intake include moving existing nonvictim patients from negative pressure rooms or the discharge or transport of all patients from the ED.

Patient Recordkeeping

Disaster patients should be assigned a prepared medical record number (Disaster Patient 1, Disaster Patient 2, etc.). Hospitals should have 500 such numbers prepared. As time permits, registration staff will work to establish patient identity. Transport of patients will be via wheelchair or stretcher, but portable isolation units are available to facilitate safe transport. As a patient moves into a new location, the Incident Command Center receives telephone notification of the change. 

Patient Care in the ED

On notification of a surge of patients, the ED staff should prepare to access hospital-generated, pre-positioned stocks of vascular access supplies (e.g., interosseous needles), respiratory materials ("ambu bags"), Broselow tapes (if routinely used), and antidotes. Supplies should be stored in the ED or in a convenient location such as a storage locker in the hospital ambulance bay. 

Depending on the size of the disaster, various State and regional medical supplies may be requested, as well as the U.S. Centers for Disease Control and Prevention-sponsored Strategic National Stockpile (SNS).^14,15 The SNS is a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, airway maintenance supplies, and medical/surgical items.^14,15 The SNS is intended to supplement and resupply State and local public health agencies in the event of a national emergency.¹⁴ The SNS involves a flexible response.^14,15 The first line of support lies within the immediate response in "Push Packages"; these are caches of pharmaceuticals and medical supplies. Although these Federal assets are designed for delivery within 12 hours of the Federal decision to deploy SNS assets, local planners should first use available State and local resouces.^14,15  Clinicians wishing to access the SNS should contact their State's department of public health who will in turn call for the governor's office to request the release of the SNS.¹⁵[*] 

A surge of patients carrying a communicable respiratory illness will require significant modifications of standard ED disaster practice. Typically, patients from a disaster are managed in a single geographical location in the ED, while non-disaster patients ("non-disaster patient flow" or "worried well") are treated in separate areas.⁶ The arrival of patients with infections that may be spread by airborne route may compel striking changes in the management of patient surges. For example, patient volumes that outstrip the number of isolation beds place the entire ED—including its patients and staff—at risk for exposure.¹² The influx of patients infected with an airborne agent may require that all non-disaster patients be discharged or diverted from the receiving facility to avoid exposure and spread. These locations for diversion include the hospital auditorium, schools, or health care facilities not physically attached to the hospital (e.g., a neighborhood health center). 

Scrupulous attention must therefore be paid to ensuring that patients remain isolated.¹² Multiple patients with proven infection may require placement in a single respiratory isolation room, or it may even be necessary to devote the entire ED to bioterrorism treatment, with all nondisaster patients being diverted elsewhere.

Effective patient isolation includes observing biohazard precautions. All staff should wear respiratory isolation garb suitable for droplet precautions.^12,13 Clinicians should employ airborne, droplet, and, if necessary, contact precautions. This level of protection requires either a fitted N95 respirator with goggles and face shield; alternatively, a powered air purifying respirator (PAPR) hood may be used.^12,13 In addition, personnel must use hair cover, shoe cover, gloves, and disposable yellow gowns or Tyvek overalls.¹² When exiting a patient care area, clinicians should observe the following steps.

At the door just prior to exit from the patient care area:

1. Remove gloves by peeling them off inside out. Dispose of gloves in red bag trash.
2. Remove isolation gowns by unfastening the back and with inside outward motion pull from top downward. Dispose of gown in red bag waste.
3. Perform personal hygiene maneuvers, particularly hand washing.

Exit room.^12,13 

At the door just outside of room or in the anteroom:

1. Remove hood respirator if used. Hood and battery pack must be cleaned before next re-use. Place the contents in a clean plastic bag.
2. Remove face shield and discard.
3. Remove goggles and discard.
4. Remove N-95 respirator and discard.
5. Perform personal hygiene.^12,13

The ED air handling system should be isolated from the remainder of the hospital. Ventilation systems that recycle mixed air from the ED and the facility may disseminate airborne pathogens to the remainder of the structure and force isolation of the entire facility. In preparation for the receipt of patients exposed to airborne bioterror agents, engineering services should review ED heating/ventilation/air conditioning systems, the age of air handling filters, and the dispersal of air withdrawn from the ED. Engineering services may be required to construct barriers to limit airflow in the ED and ensure that ventilation of the ED is maximized.

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[*] Information about the Strategic National Stockpile is available from the Centers for Disease Control and Prevention at http://www.bt.cdc.gov/stockpile/.

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