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Little Patients, Big Problems

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Bryan K Breland
June 30, 2015

In his June 5 column, Don’t Waste a Disaster, Anthony Buller discusses the reality of those in the public sector having no option to withdraw during widespread disasters. Many private-sector organizations – wholesale or retail, sales or service, personal or commercial – would often be best advised to “close up shop” and send employees, associates and customers to the safety and security of their homes and families. While some public employees can well do the same, those with disaster-related responsibilities are called upon not only to maintain their routine operations, but often dramatically expand their services under demanding conditions.

As I look forward to Buller’s next installment, in which he promises to examine gaps between what we can do and what we are expected to do, I reflect upon one particularly troubling facet of health care system preparedness: our collective capability to rapidly expand medical services for pediatric patients following a large-scale event.

breland june 2Of the nation’s nearly 6,000 hospitals, only 4 percent are children’s hospitals with an additional 6 percent having a Pediatric Intensive Care Unit (PICU). This alone is disproportionate, considering that approximately 20 percent of the nation’s population is younger than 14 years old. Moreover, because children lack critical decision-making capacity during disasters, the proportion of pediatric to adult disaster victims is likely to be higher than in the general population.

While the perception that pediatric patients are small adults is common, there are number of ways in which children are unique in their need for specialized treatment and care. These include physical and physiologic characteristics, differences in maturation, emotional and behavioral attributes and the ability to communicate. Further, there are ancillary services that are necessary when dealing with younger patients including custodial care and reunification with parents.

The American Academy of Pediatrics (AAP) provides comprehensive guidelines on the treatment of children in hospital emergency departments, which includes minimum inventories of pediatric supplies. But the most recent national health statistics report on the availability of pediatric services and equipment in emergency departments show that relatively few hospitals – including that 10 percent which have PICU services – are able to fully implement those recommendations.

Fewer than 40 percent of pediatric hospitals and only 7 percent of non-pediatric hospitals have 24-hour observation units. Pediatric trauma services are available in only 76 percent of pediatric and 12 percent of non-pediatric hospitals. Less than half of pediatric hospitals have the AAP-recommended inventories of emergency room equipment intended to manage the airway of pediatric patients or perform advanced techniques to deliver and maintain intravenous fluids (IV). That number drops to 14 percent in non-pediatric hospitals.

As public-sector leaders charged with the important work of preparing for and responding to emergencies and disasters in the community, this should be of great concern. Directly following any crisis event, the priority is the life safety of those impacted. The priority in providing medical services to those victims is triage and transportation to a hospital capable of providing appropriate care.

In a previous column, I discussed the challenges of managing a diversity of organizational and personal interests in building and maintaining health care coalitions. Despite the challenges, collaborative efforts to manage surges in the volume of patients following a disaster are necessary to the readiness and resilience of a community. This is particularly true in circumstances where resources are scarce even under normal operations, which is the case in medical services for pediatric patients.

Pediatric preparedness health care coalitions will necessarily include a number of individuals, organizations and public resources that are likely to be needed in the event of a disaster event involving pediatric patients. These go well beyond children’s hospitals in a particular region having agreements to provide assistance or take patients from hospitals in impacted areas. Rather, they will require the involvement of public administrators from a wide range of local and state agencies, including transportation, education, social services and others. Also, public officials must engage and create partnerships with private-sector businesses and industries.

It is important to note that the need for resources is not in question. Though our work to prevent disaster and to mitigate its impact on the population has resulted in dramatic improvements to our safety and security, natural and man-made catastrophes will all too frequently devastate our communities. The question is, rather, what goodwill come from the effort of working together to ensure the efficient and effective use of those resources. The work cannot be deferred until after the damage has been done, but must start immediately in planning and organizing our eventual collective response.


Author: Bryan K Breland, DrPH, JD, MPA, is an assistant professor in the Department of Health Service Administration at the University of Alabama at Birmingham. His current research focuses on emergency preparedness in health care organizations and systems. You can reach Dr. Breland at [email protected].

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