7

Planning for Children and Families During Disaster Response

Highlights of Points Made by Individual Speakers

  • Most people with disabilities do not have acute medical needs. Planning to meet the access and functional needs of disaster survivors in general population shelters can help to preserve limited acute care resources for those with a true medical need.
  • In the aftermath of a disaster, primary care providers are likely to be the first, and possibly the only, responders to provide mental health services to children.
  • Professional staff may be impacted directly themselves and may have some of the same behavioral and mental health needs as those they serve.
  • A single disaster event is really part of a cascade of other events in a child’s life and results in cumulative impact and stress.
  • Stigma related to mental health is a still barrier, even in times of national crisis.
  • Temporary child care in shelters and service centers allows parents to attend to business, such as applying for aid and other recovery activities.
  • Include older children with disabilities in the process when planning for their evacuation and transportation during an emergency. They know what works for them and what does not.

Planning for the specific needs of children and families in response to disasters, including functional needs, nutritional needs, family reunification, and temporary child care, is extremely important when thinking about community plans. These specific needs are discussed



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7 Planning for Children and Families During Disaster Response Highlights of Points Made by Individual Speakers  Most people with disabilities do not have acute medical needs. Planning to meet the access and functional needs of disaster survivors in general population shelters can help to preserve limited acute care resources for those with a true medical need.  In the aftermath of a disaster, primary care providers are likely to be the first, and possibly the only, responders to provide mental health services to children.  Professional staff may be impacted directly themselves and may have some of the same behavioral and mental health needs as those they serve.  A single disaster event is really part of a cascade of other events in a child’s life and results in cumulative impact and stress.  Stigma related to mental health is a still barrier, even in times of national crisis.  Temporary child care in shelters and service centers allows parents to attend to business, such as applying for aid and other recovery activities.  Include older children with disabilities in the process when planning for their evacuation and transportation during an emergency. They know what works for them and what does not. Planning for the specific needs of children and families in response to disasters, including functional needs, nutritional needs, family reunification, and temporary child care, is extremely important when thinking about community plans. These specific needs are discussed 67

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68 CONSIDERATIONS FOR CHILDREN AND FAMILIES throughout this chapter in addition to real-world experiences that support these needs. Participants also share best practices and potential strategies for response. Examples include regional preparedness, infection pre- vention, sheltering, tracking, evacuation and transportation of children with disabilities, and novel training techniques. CHILD AND FAMILY NEEDS DURING MASS CARE AND SHELTERING OPERATIONS Session chair Kari Tatro, executive vice president of Emergency Management Operations for BCFS Health and Human Services,1 said that meeting the needs of children in disasters presents a unique set of planning considerations. She gave an overview of logistical requirements and cultural considerations regarding children with medical needs, shelter placement, unaccompanied children, children in state or federal custody, the impact of stress and trauma on children, and neonatal transport and services. When facility plans cannot be implemented, there need to be alternative plans for evacuation, alternate care sites, and field triage sites. To meet the logistical needs of children, planners need to consider the availability of items in shelters such as cribs and crib linens, clothing, food, eating utensils, diapers, pediatric durable medical equipment, and pediatric consumable medical supplies. There are also cultural considerations when sheltering children, especially as they relate to food service. Change in diet (e.g., providing cow’s milk to children who have only ever consumed almond milk) can lead to gastrointestinal disorders, vomiting, and diarrhea. From a medical perspective, there must be access to pediatric medical equipment and medication dosages. Planning considerations also need to include a process for making medical decisions for unaccompanied children. Children will have medical needs that must be addressed with or without their parents present, Tatro said. Similarly, there must be provisions for maintaining a chain of custody for children in state or federal custody for medical decisions. There are special shelter placement considerations for children with disabilities. Historically, individuals with disabilities have been sent to medical shelters or to medical facilities. Tatro said that children with disabilities should instead be sheltered with their families in general 1 BCFS is an international health and human services agency that provides all-hazards emergency management, planning, preparedness, and response.

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PLANNING DURING DISASTER RESPONSE 69 population shelters whenever possible. As such, it is important to ensure adequate planning for children with disabilities in general shelters. If a child has a medical need that requires professional licensed staff oversight, then placement in a medical shelter may be appropriate, but planning should include considerations for keeping the family unit together (instead of splitting the child and one parent away from the rest of the family). Thinking about mental health, Tatro explained the trauma and stress of disaster and the sheltering experience can impact children differently than adults. New and stressful experiences can include, for example, disease isolation and quarantine, being in a group living situation with thousands of strangers, standing in line to get meals, or trying to find clothing. Educational opportunities, games and recreation, and coun- seling opportunities, including psychological first aid, can help to alleviate some of the stress and trauma for these children. It is important to draw on partnerships to meet some of those needs, Tatro said. Further mental health considerations for children in emergencies are explored in Chapter 8. Functional Needs Support Services The Federal Emergency Management Agency (FEMA) Office of Disability Integration and Coordination was established to provide guidance, tools, methods, and strategies to integrate and coordinate emergency management that is inclusive of children and adults with access and functional needs, in accordance with federal civil rights laws and regulations. Marcie Roth, director of the Office of Disability Integration and Coordination at FEMA, quoted FEMA administrator Craig Fugate, who has stated that “if we wait and plan for people with disabilities after we write the basic plan we fail.” In this spirit, FEMA tools and resources are now inclusive of the whole community (rather than addressing some subpopulations in the back of a manual or in a separate annex). Several federal laws prohibit discrimination in emergency programs on the basis of disability (see Box 7-1). These laws apply to preparation, exercises, notification, evacuation and transportation, sheltering, first aid and medical services, temporary lodging and housing, transition back to the community, clean-up, and other emergency- and disaster-related programs, services, and activities.

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70 CONSIDERATIONS FOR CHILDREN AND FAMILIES BOX 7-1 Federal Laws Prohibiting Discrimination in Emergency Programs on the Basis of Disability  Rehabilitation Act of 1973  Americans with Disabilities Act of 1990  Stafford Act of 1988  Post Katrina Emergency Management Reform Act of 2006  Fair Housing Act Amendments of 1988  Architectural Barriers Act of 1968  Individuals with Disabilities Education Act of 1975  Telecommunications Act of 1996  Twenty-First Century Communications and Video Accessibility Act of 2010 SOURCE: Roth presentation, June 11, 2013. Roth noted that the term “access and functional needs” is now preferred to the term “special needs,” as the latter tends to relegate these issues to annexes, separate documents, and separate plans, she explained, which is the antithesis of inclusion. In addition to adults and children with physical, mobility, sensory, intellectual, developmental, cognitive, or mental health disabilities, others who may have access and functional needs include older adults, people with chronic or temporary health conditions, women in late stages of pregnancy, as well as those with limited English proficiency or low literacy, no access to transportation, very low income, or who are experiencing homelessness. It is important to recognize that most people with disabilities do not have acute medical needs and maintain their health, safety and independence in their home and community on a daily basis. Planning to meet the access and functional needs of disaster survivors with and without disabilities in general population shelters can help to keep people out of the acute care setting and preserve limited acute care resources for those who have a true medical need. If given the proper support, people with disabilities can be successfully accommodated in shelters with their family. But providing this support and meeting their access and functional needs requires planning and coordination, and involvement of the whole community. To help guide local governments and commun- ities, Roth referred participants to the FEMA functional needs support

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PLANNING DURING DISASTER RESPONSE 71 services guidance.2 This tool includes information about planning, finding subject-matter experts, selecting shelter sites, accessible toilets and bathing facilities, personal assistance needs, medical care and equipment, legal obligations, and service animals. Another useful tool Roth highlighted is the FEMA personal assistance services contract.3 If a disaster situation exceeds a state’s ability to meet the needs of people with access and functional needs in general population shelters, FEMA can bring in up to 2,500 personal assistance service providers to assist with both basic and higher-level care. When communities integrate the access and functional needs of children and adults with and without disabilities in all phases of community-wide emergency management, they strengthen their ability to prepare for, protect against, respond to, recover from, and mitigate all hazards, Roth concluded. During the discussion, the need for research was discussed and it was noted that there are grant opportunities with the National Institute on Disability and Rehabilitation Research (part of the U.S. Department of Education) focused disability inclusive emergency management practices. Family Reunification One of the primary needs of children in the shelter environment is family reunification. Mary Casey-Lockyer, manager of disaster health services at the American Red Cross, discussed several Red Cross programs that help to facilitate family reunification in times of disaster, including the Safe and Well Online Registry, and Patient Connection. Safe and Well is a free, Web-based tool that people can use to let their loved ones, friends, and colleagues know they are safe.4 Those affected by disasters self-register on the site, and anyone can search the list for friends and family and view the registrants’ posted messages. Clients can also update their status on Facebook or Twitter, simply by clicking an 2 The FEMA Guidance on Planning for Integration of Functional Needs Support Services in General Population Shelters is available at http://www.fema.gov/pdf/about/ odic/fnss_guidance.pdf (accessed September 9, 2013). 3 Further information on the personal assistance services contract is available at http://www.pascenter.org/publications/item.php?id=1324&focus= (accessed September 9, 2103). 4 The Red Cross Safe and Well website address is http://www.redcross.org/safeandwell (accessed September 9, 2013).

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72 CONSIDERATIONS FOR CHILDREN AND FAMILIES icon in the Safe and Well registration page. Everyone in their “friends list” will be notified that they registered on the American Red Cross Safe and Well website. This is an integrated response, Casey-Lockyer explained, and Red Cross volunteers also physically locate vulnerable people and conduct welfare checks when a request is initiated by a concerned family member. Safe and Well is available 24 hours per day, every day of the year. In addition to the website, Red Cross also uses paper forms in shelters and at evacuation transition points, and has computer spreadsheets for when Internet connectivity is not available. Roth noted that there are many current initiatives to help with family reunification and patient tracking (e.g., FEMA initiatives, individual state systems, Google Missing Persons, Facebook, Crisis Commons, and others) and the question is how these systems will integrate. Another Red Cross tool is Patient Connection. The system is currently being used in Chicago and will be implemented statewide in Illinois in the future. The system is triggered if 10 or more people affected by a particular disaster are sent to area hospitals, or by mass- casualty events such as transportation accidents (e.g., mass transit, aviation, traffic emergencies) or building fires and collapses. Patient Connection has also been activated as a precaution before large events such as the Chicago Marathon and the North Atlantic Treaty Organization summit. In these types of situations, disaster victims are frequently transported without notice to their loved ones. Red Cross activates a single hotline for families to call to locate relatives, reducing calls and walk-in traffic to emergency departments. Hospitals send names and descriptions of affected patients to Red Cross, and call agents work to make matches. Hospitals and emergency management can then refer families that call to the Red Cross hotline to locate their loved one. Casey-Lockyer clarified that the Red Cross is exempt from Health Insurance Portability and Accountability Act (HIPAA) privacy rules, and in times of disasters, HIPAA provisions allow hospitals to share information with a recognized response agency such as the Red Cross for reunification purposes. Casey-Lockyer added that American Red Cross now has a digital disaster operation center, called DigiDOC. The Red Cross can monitor publicly available social media and can push current information back to the public via national communication channels such as Twitter, Facebook, email, and the Red Cross website.

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PLANNING DURING DISASTER RESPONSE 73 Nutritional Needs Another primary need of all children in a shelter is nutrition. Casey- Lockyer said that the Red Cross shelter guidance advises shelter managers to prepare for infants by having cribs and diapers available, as well as baby food, formula, and a quiet area for breastfeeding. An advocate from the U.S. Breastfeeding Committee concurred and referred participants to a physician statement on safe infant and young child feeding in disasters5 and noted that an operational guidance document would soon be available. Breastfeeding is a resource that protects infants from gastrointestinal and respiratory diseases that are prevalent in a disaster, and lowers the infant’s and mother’s stress levels. In addition, it reduces the cost of managing disasters and increases community resilience. The participant also alerted shelter managers to the fact that women may want to bring their breast pumps and frozen milk supply to the shelter. For older children, Casey-Lockyer continued, the rise in peanut allergies is a concern. The Red Cross is evaluating options such as peanut-free snack zones, placing snacks out of reach of children so they cannot help themselves, and possibly having EpiPens available in the shelters (in accordance with laws and policies). It is important to note that shelf-stable meals were designed for the dietary needs of adults in the military, and they are extremely high in sodium and calories. These meals are not suitable for a 2-year-old, Casey-Lockyer noted, or for an 82-year-old who may have the beginnings of congestive heart failure. Some companies are coming out with lower-calorie, lower-sodium meals, but sodium is a key component in the long-term preservation of the meals. Shelter managers also have the ability to purchase fresh food. Some children, especially infants, may also require tube feedings, and shelters need to be prepared. Casey-Lockyer cautioned that although we have done well with the types of disasters we have had in the United States, we have not really had a catastrophic event in a large urban city that results in many thousands of unaccompanied minors in the suburbs. This scenario has not been addressed by school systems or shelters. How will we sustain children for extended periods, and how are we going to reunite parents who were in the city during the event with their children in the suburbs? 5 Available at http://www.usbreastfeeding.org/Portals/0/Position-Statements/Emergen- cies-Statement-2011-USBC.pdf (accessed September 9, 2013).

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74 CONSIDERATIONS FOR CHILDREN AND FAMILIES Providing Child Care in Shelters After a disaster, children suffer from a kind of benign neglect, said Judy Bezon, former associate director of Children’s Disaster Services (CDS), which is part of Church of the Brethren Disaster Ministries. Children are confused and do not understand what is going on around them, Bezon said. They may see their parents crying, worry about who will take care of them, where their pet is, and why they cannot go home. They have very little control over their environment, have few coping skills, and are completely dependent on others for recovery. Young children also have limited language, and limited conceptual skills. They do not think to ask questions to get the reassurance that they might need from parents, and parents are often so totally consumed with their own worries that they do not have the emotional ability to reach out to their children and find out what is going on with them. Bezon reiterated that the mistaken perception is that if they are playing, they must be doing fine. Children have concerns, she said, and these are often expressed and worked out through play. Adults may see children playing, and play is normal, so they assume the children are carefree and not impacted by the disaster. As an example, she described how a young girl in a FEMA facility after Hurricane Katrina had been playing with a doll and when she left the staff noticed that she had carefully raised the doll bed up on toy blocks, presumable to protect the doll from the flooding that she had experienced. She also described a brother and sister at a facility in Joplin who used empty boxes to build a “tornado-proof house.” Children’s drawing can also be quite telling. Following the tornadoes in Oklahoma, center volunteers reported using up the dark colors of tempera paint as the children were painting tornadoes and storms. Children’s Disaster Services Because children use play to express themselves and to understand their experiences, CDS volunteers use a comfort kit full of toys that promote imaginative play. This is a very safe medium, Bezon explained. Children process the disaster experience at their own pace and in a safe environment using their own language and the natural language of play. If the children are too worried or not ready to deal with the disaster on their own or through the play, they will play about stereotypical things. CDS has about 600 volunteers nationwide, and they are trained to follow

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PLANNING DURING DISASTER RESPONSE 75 the child’s lead in play. Volunteers participate in a 27-hour experiential workshop, staying overnight in a simulated staff shelter to give them a sense of what families are going through, as well as what they will go through if they need to stay in a staff shelter during a disaster. The training emphasizes the social and emotional phases of a disaster, rather than the impact, response, recovery, and long-term recovery. They learn to interact with children after a disaster and how to communicate through play, and they undergo a very rigorous screening process to be certified to work with children. CDS’s work in shelters and service centers allows parents to attend to business, such as applying for aid and other recovery activities, without having their children with them. This is an important resource for parents because life is disrupted for many families and their former child care arrangements, including babysitters and family members, may no longer be options. Parents can also leave children with the volunteers at CDS simply to get a break from the “hyper vigilance” needed in a crowded shelter environment to take a much needed shower or nap. Volunteers are also trained to talk with the parents about their concerns regarding their children. Partner agencies (e.g., FEMA, Red Cross, local groups) report that CDS creates an environment that makes it easier to give aid to those in need, Bezon said. “By offering child center care, emotional support and a sense of normalcy, the CDS program helps to meet the immediate needs of children, assists family members who may be overwhelmed as they attempt to deal with the effects of the disaster, and plays an important role in fostering resiliency among children” (Peek et al., 2008, p. 408). BEST PRACTICES AND POTENTIAL STRATEGIES DURING RESPONSE Moving from high-level conversation from involved organizations on different operational needs, this section shifts focus to tactics and practices already being used on the ground in different sectors. Because children make up such a large percentage of vulnerable populations, it is important to continue to integrate their needs across planning areas and situational scenarios. Speakers describe examples of patient tracking, accessible evacuation planning, and hospital-level pediatric competency exercises in the next section.

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76 CONSIDERATIONS FOR CHILDREN AND FAMILIES Best Practice Examples from the Texas Department of State Services Bruce Clements, director of the community preparedness section of the Texas Department of State Services, said that Texas has the largest number of federally declared disasters of any state in the nation. Events the Department has responded to since 2007 include hurricanes, wildfires, disease outbreaks (West Nile virus, tuberculosis, measles, mumps, H1N1 influenza), foodborne illness outbreaks, the plant explosion in West, Texas, and the raid on the Yearning for Zion Ranch. The Department also activated in response to a spike in hospitalizations of young women with mercury poisoning, which turned out to be from mercury-tainted skin cream from across the border. A growing issue for Texas is the need to shelter unaccompanied minors. The thousands of unaccompanied children who cross the border from Mexico are returned home according to a reciprocity agreement with the Mexican government, which can be as simple as filling out the forms and walking them across the bridge. However, there has been a recent surge of undocumented Central American minors who travel north to Mexico and then cross into the United States. It takes longer to arrange to return them home, and they need to be sheltered in the interim. Clements noted that Texas contracts with BCFS for most of its shelters across the state. Texas is continually threatened by hurricanes and tropical storms, and Clements pointed out that the capacity the state has built to respond to hurricanes is very flexible and scalable, and has enabled the response to other events. Texas has had “a lot of practice with a lot of diverse types of threats,” Clements said, and he shared several of the state’s best practices and initiatives in four key areas: regional preparedness, infection prevention, sheltering, and tracking. Local and Regional Pediatric Preparedness Initiative Clements highlighted the Houston Regional Healthcare Pediatric Preparedness initiative as one of the best in the state, in part because of the lessons learned from a long history of flooding and from the city’s role as a central location for evacuees from Hurricane Katrina. Houston’s pediatric disaster planning includes, for example, a prophylaxis dispensing form that has weight conversion charts; pre- identified pediatric response teams to assist at National Disaster Medical

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PLANNING DURING DISASTER RESPONSE 77 System reception sites; pediatrics patient inclusion in exercises; and preparedness guides for families from the children’s hospitals in the area. Another resource from the Houston initiative is the “Together Against the Weather” website with videos and information on how to prepare for a hurricane, whether evacuating or sheltering in place. There is information for people with access and functional needs (e.g., the elderly, individuals with disabilities, developmentally disabled children), and public service materials for emergency management personnel, social services, and the media. Houston has also expanded pediatric preparedness training to all the health care providers in the area, and provides quick reference materials, such as the Broselow Pediatric Emergency Tape, for pediatric medications, doses, equipment, etc. Infection Prevention The concurrent threats posed by the first cases of H1N1 pandemic influenza in late April 2009, and the start of hurricane season that June, raised serious concerns about infection prevention during evacuation and sheltering. In preparation, two different infection control kits were developed, one for buses and one for shelters (see Box 7-2). Although designed to address the double threat of H1N1 and hurricane season, Clements said these kits are now in regular use. BOX 7-2 Contents of Infection Control Kits Bus Kit Shelter Kit  Surgical masks  N95 respirators  Hand sanitizer  Surgical masks  Trash bags  Exam gowns  Nonlatex gloves  Nonlatex gloves  Disinfectant wipes  Disinfectant wipes  Disinfectant spray  Disinfectant spray  Alcohol wipes  Alcohol wipes  Tissues  Tissues SOURCE: Clements presentation, June 11, 2013.

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78 CONSIDERATIONS FOR CHILDREN AND FAMILIES Pediatric Sheltering Sheltering planning for children in Texas is focused in the full range of pediatric vulnerability, Clements said, medical, behavioral health, and social (also referred to as biopsychosocial). The biggest challenge is variability across the state with the integration of the three elements. The quality of the preparedness plans that are already in place is also a concern. Although there are requirements for schools, child care facilities, and foster families to have disaster plans, there is no quality check on those plans, or criteria to define quality, Clements said. This is an important gap to be addressed, and an opportunity for very-high-risk populations to get fundamental support. Clements pointed out that state laws and definitions differ regarding the “age of childhood” (NLCHP, 2012). The majority of jurisdictions define childhood as under the age of 18; however, for several it is under 17 or 16 years of age. Some laws also bifurcate youth and children (e.g., someone up to the age of 12 is a child, and someone aged 13 to 18 is a youth), and in some jurisdictions childhood or youth may encompass persons older than 18. These laws impact both general population and medical sheltering. In most cases a person needs to be 18 years or older to consent to medical care, but in Rhode Island, South Carolina, or Texas the age is 16; in Alabama, Hawaii, and Indiana it is 14; and in Guam and Puerto Rico anyone below the age of 18 can consent if he or she is married. If a child is separated from his or her family, short of surgery, the child can generally make decisions on whether care is received. Multidisciplinary teams are involved in pediatric sheltering planning in Texas. Among those included are child life specialists who assist with coping, normalization, and play therapy; and Child Protective Services, especially those who are conservatorship specialists and can assist with emergency orders for medical consent. Clements added that all members of the multidisciplinary team need to have at least basic incident command training. Texas also promotes crisis counseling skills for responders, and uses the psychological first aid field guide from the National Child Traumatic Stress Network.6 6 The Psychological First Aid Field Operations Guide is available at http://www.nctsu. org/content/psychological-first-aid (accessed September 9, 2103).

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PLANNING DURING DISASTER RESPONSE 79 Pediatric Tracking There were more than 1,000 children missing in Louisiana after Hurricane Katrina, Clements said. This motivated responders from Texas who were involved in the response to Katrina to champion a banding tracking program for Texas. Using computers, a Web-based program, and barcode scanners, evacuees are given a yellow wristband with a barcode on it and a radio-frequency identification (RFID) chip inside. Personal information is entered into the system, which can be as simple as swiping a driver’s license if available. Pets and medical assets are also tagged with the same RFID chip so they can be associated with the person. Portals with RFID chip readers, or staff with handheld readers, can be set up at shelter entrances, the front of a bus, or anywhere else. Evacuees can then be tracked as they board and exit a bus, or enter and leave a triage site, shelter, or medical facility. In addition to tracking individuals, manifests can be printed listing all of the people on a particular bus or in a particular facility at any given time. Clements added that they work to build trust with the undocumented population along the U.S.-Mexico border so that they are not hesitant to participate in the program. Trust is fostered through medical outreach such as an annual exercise where clinics are set up in the Rio Grande Valley offering free health care to these individuals. The banding system is a simple program that can be used across different platforms to share information during a disaster, and Clements said it has been a very successful system for Texas. During the discussion, a participant said that after Hurricane Sandy, he was made aware that some people who were in the shelters were feeling stigmatized because when they were out of the shelter during the day they were known as being shelter residents by their wristbands. Clements responded that he had not encountered significant pushback from shelter residents thus far, and he felt that the benefits of the wristband tracking outweigh the potential for stigma. Tatro added that in Texas, no one is required to be banded, and that education and outreach have helped foster acceptance. Evacuation and Transportation of Children with Disabilities Richard Devylder, senior advisor for accessible transportation at the U.S. Department of Transportation, shared his perspective on best

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80 CONSIDERATIONS FOR CHILDREN AND FAMILIES practices for addressing the needs of children with disabilities in evacuation planning. Identifying needs is the first essential step, he said, and administrators and parents often have different views on what those needs are. Next, it is important to define what resources are available, and what resources need to be brought in to help a specific child. Other key considerations in planning are the accessibility of vehicles and facilities, and ensuring access to any adaptive equipment the child may use (e.g., moving it with the child, moving it separately and tracking it, providing it onsite). If a child has a custom wheelchair designed for his or her needs, for example, simply providing another wheelchair is not suitable, and could be detrimental. Many children with disabilities will have an individual education plan (IEP) with their school, and Devylder stressed that the child’s evacuation plan should be part of his or her IEP. He also emphasized the importance of including the child in the planning process when old enough to provide input. It is the child who knows what works and does not work for him or her during drills or other events at school. There also may be certain adults that children do not trust to help them, he added, and planners need to respect that. Evacuation plans need to include student medical information, including diagnosis, medication allergies, hazardous conditions (e.g., impact of smoke on the child and mitigating measures to take), cardiopulmonary resuscitation and defibrillator steps to take, and climate control needs. Other necessary information includes contact information for parents and guardians, doctors, and hospitals familiar with the child, so that first responders know which hospitals are best to take the child to. Devylder recommended that someone from the local fire department and law enforcement participate in the planning so that they are aware of the child’s situation and how to assist him or her through the evacuation process. Information on communication with the student during the emergency is also an essential component of the plan. Not just primary language, but how to communicate with a child with autism, a deaf child, or how to guide someone who is blind or has impaired vision. Devylder explained that someone who is blind or has low vision cannot simply be put into a wheelchair or evacuation chair as this can be extremely frightening for them. Adhering to the normal ways of communicating with that child on campus is best. An evacuation plan should also include primary, secondary, and tertiary options for exiting the building, determined by accessibility and class location. The plan should also

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PLANNING DURING DISASTER RESPONSE 81 describe under what circumstances elevators and/or evacuation chairs can be utilized. He noted that evacuation chairs vary; some can go both up and down stairs, others can only descend stairs. He also stressed that a plan must include what to do with the child after using an evacuation chair as they are extremely uncomfortable and the child cannot be left in the chair for more than 10 or 15 minutes, or risk injury. Once evacuated, how is the student transported off campus in both medical and non- medical emergency situations? The plan can include transport memor- anda of understanding that define the potential use of school transport- ation and public transport, as well as private entities (e.g., community partners, shuttles, taxis). Children with disabilities need support teams, including an evacuation team, a primary education team, and a substitute team, each with at least three people assigned, Devylder said. If the child had an aide assigned, the aide should also have a defined role in evacuation. The evacuation team should include someone who is very familiar with the child, usually a school nurse, counselor, or teacher who will be available to be with the child and to make decisions during the evacuation of the child (i.e., the lead should not be a teacher who is also responsible for other children in a classroom). With the plan in place, training and drills are essential. “To know it is to do it,” Devylder concluded. Competency in Pediatric Disaster Training and Education Jeff Upperman, program director for the Pediatric Disaster Resource Training Center (PDRTC) at the Children’s Hospital Los Angeles, described novel teaching techniques implemented with the support of Hospital Preparedness Program (HPP) funding. Los Angeles is about 4,000 square miles, with a population of about 11 million, including 2.5 million children below the age of 18. Children’s Hospital Los Angeles has about 300 beds, and there are approximately 400 pediatric beds total in the County of Los Angeles. The PDRTC is part of a disaster network that includes multiple hospitals; however, as the only hospital dedicated to pediatric needs in Los Angeles County, the center is the county resource on pediatric disaster preparedness. It is the hub supporting many spokes, Upperman said. Upperman defined competence, or competency, as the ability of an individual to do a job properly, whether it is care, leadership, or management. But in developing competencies, we often train people for

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82 CONSIDERATIONS FOR CHILDREN AND FAMILIES a certain period of time, give them a paper test, and send them off. When conducting drills and exercises, especially hospital-based, are we really seeing if care providers can intubate in austere conditions? Can they recognize posttraumatic stress disorder and other mental health issues? It is important to train and practice, but there also needs to be some level of competency, he said. A leader in the community helps to make the community resilient and is a role model. Leaders at work (i.e., on commissions, committees, etc.) agitate the system, providing leadership for those who cannot provide it for themselves, such as children. Managers implement the plans through drills and exercises. What competencies are necessary to make these things happen? Upperman highlighted several tools that PDRTC developed with the support of HPP to help foster competency in disaster response. The first is a prototype disaster preparedness logistics tool for pediatric emergency decision support (Neches et al., 2009). The software was designed for hospitals in Los Angeles County to use to begin thinking about their specific plans based on their specific needs. They could, for example, enter a zip code in Los Angeles County into the system and learn, based on available census data, how many children live in that zone and what might be the expected impact to the neighborhood during an earthquake. A novel approach to education is games which allow people to practice what they have learned. Working with the University of Southern California Games Institute, PDRTC developed an online game, Surge World, to give health care workers practice in triage, resource management, and preparedness planning.7 Another example described by Upperman was the “Disaster Olympix,” an interactive drill to foster communication, collaboration, and leadership (Goodhue et al., 2010).8 Fire teams, engineers, pediatricians, nurses, and others at Children’s Hospital Los Angeles participated in competitive events testing their knowledge, skills, and abilities to respond to disaster situations. Finally, Upperman described a tri-hospital drill using technology, including robots and telemedicine, to facilitate triage and treatment consultation by offsite pediatric specialists (Burke et al., 2012).9 In closing, Upperman 7 Surge World is available to play online at http://lachildrenshospital.net/SurgeWorld (accessed September 9, 2013). 8 Upperman played a brief video of the Disaster Olympix, which is available at http://www.youtube.com/watch?v=sZVgdRj-bCc (accessed September 9, 2013). 9 Upperman played a brief video showing the use of telemedicine robots during the drill which is available at http://www.youtube.com/watch?v=sqfZI7Vqsh8 (accessed Sep- tember 9, 2013).

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PLANNING DURING DISASTER RESPONSE 83 urged participants to lead, innovate, and evaluate. Thinking about the specific needs of children and families in shelter situations prior to an emergency, and utilizing and encouraging best practices from other cities, can continually improve both the mass care operations and surge capacity at area hospitals that may not typically care for children.

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