Triage and Transfer

For routine traumas, community hospitals must transfer pediatric trauma patients to our facility through a standardized process. The standardized process involves our transport call center taking a history and vital information on the patient to be transferred from the referring facility and then initiating a trauma team conference call, which includes pediatric surgery, pediatric critical care team, and pediatric emergency department (ED) attendings. Once the patient is accepted, transport to our facility is arranged. This process takes at least 10 minutes depending on patient acuity at the referring and accepting facility. Facilities that received children directly from the MCI scene had well-established relationships with our institution and were familiar with this process. However, during the MCI, this tedious process proved inefficient and a direct phone line from the referring hospitals to the children’s hospital emergency department (ED) liaison was provided to expedite the process. Following the initial resuscitation, patient transfer was mobilized. The direct communication between facilities was highlighted as a positive influence on patient outcomes in our post-MCI debriefs.

In the event of an MCI in the community, hospitals with Pediatric Intensive Care Units (PICUs) should be prepared to provide emergency medical care including mechanical ventilation, fluid resuscitation, vasopressor administration, sedation, and analgesia.Reference Christian, Toltzis and Kanter⁷ A total of 18 pediatric MCI patients received such care at our institution. Of these, 14 were first triaged at regional hospitals and 4 arrived directly from the scene. The first patient arrived in our facility’s ED approximately 35 minutes following the MCI. To assist in the triage and treatment of MCI patients, the on-site PICU attending physician and fellows were stationed in the ED. The PICU attending in the ED directly communicated with the PICU-based incident command system (ICS), which was vital in prioritizing the transfer of patients from the ED to the PICU. Over the next 2 hours, 10 patients from the MCI and another 5 critically ill patients were admitted to the PICU with a pre-MCI census of 28 patients. All 10 patients admitted from the MCI suffered neurological injuries, 6 sustained orthopedic injuries, and 2 had blunt thoracoabdominal injuries. Eight of the PICU patients required surgical intervention and 4 patients had PICU length of stays greater than 7 days (Table 1).

Table 1.

Patient information and injuries

* PICU, pediatric intensive care unit; LOS, length of stay.

Personnel and Patient Management

It is recommended that pediatric hospitals prepare for at least triple their capabilities, specifically in clinical staffing and supplies, in the aftermath of an MCI.Reference Christian, Toltzis and Kanter⁷ On a Sunday evening, 2 attendings, 2 fellows, and 2 advanced practice providers (APPs) staff our 48-bed general PICU and 24-bed cardiac PICU. Upon activation of the hospital MCI, the general PICU attending and fellows mobilized to help in the ED, while the APPs on-site managed the current PICU patients and transferred or discharged patients to prepare for the rapid patient influx. An additional 16 attendings, 8 fellows, and 17 APPs were mobilized through text messages from leadership to station in the PICU.

In our PICU, a centrally located PICU-based ICS was established, separate from a hospital-wide ICS. Hospital leadership had not mandated the formation of the PICU-based ICS, rather this was a construct by PICU leadership, responsible solely for operations within our unit. Although the PICU-based ICS had direct communication with the hospital-wide ICS structure via phone and our electronic medical record system, the 2 operated as separate entities following the MCI. In our PICU policy, there is a physician and nursing leader who are assigned to make patient placement and team assignments. Our PICU-based ICS utilized the responding personnel to create dedicated provider teams for each patient. Each team consisted of an attending, an APP or fellow, and a bedside nurse. Team assignments with pertinent patient information were located on a large whiteboard near the PICU-based ICS. Teams were able to focus on the resuscitation and coordination of their single patient’s care. Considering the similar injury patterns, individualized teams ensured that each patient received meticulous management. Once the PICU-based ICS deemed resuscitation efforts stabilized, there was an organized transfer of care from each patient’s team to the pre-MCI, on-site team.

Supply Chain Considerations and System Stressors

In disaster management, there is the need to work with limited resources. In events involving children, appropriately trained personnel and supplies become more limited given the wide range of age and size-specific supplies.Reference Kanter and Moran^8, Reference Burkle, Argent and Kissoon⁹ For instance, a 10-kilogram toddler and a 75-kilogram teenager will require different sized endotracheal tubes, central lines, catheters, and other supplies. It is also impossible to predict what age distribution of pediatric patients may present during an MCI. Past reports recommend preparing equipment for a patient surge of an ordinary PICU census.Reference Bohn, Kanter and Burns¹⁰ This event, however, included an overrepresentation of school-aged children not following normal distribution. In our event, most patients were intubated prior to transfer, eliminating institutional stressors for airway equipment. The activation of the hospital-wide ICS allowed for mobilization of resources for our surgical services and other supplies needed for resuscitation in the PICU, but we did face challenges in the process.

In public health emergencies, normal supply chain practices may not be dependable.Reference Bohn, Kanter and Burns¹⁰ Our institution’s off-site supply chain warehouse, located 15 minutes from the hospital, was not staffed given the day of the week. In normal instances, it takes approximately 1 hour to receive the supplies requested by our PICU from the warehouse. Following the MCI, the hospital-wide ICS activated necessary procedures to open the warehouse, which allowed for replenishment of supplies. However, once the MCI stabilized in the ED, the hospital-wide ICS closed, which included closure of the warehouse. The downstream effect of this premature closure was the inability to replenish neurosurgical and orthopedic surgical supplies in the PICU where resuscitation continued for over 4 hours after the last patient departed the ED. When it was recognized that the warehouse had closed, the PICU-based ICS communicated with the hospital leadership the on-going stressors in the PICU. The hospital-wide ICS reopened, and the warehouse was once again accessible to replenish the depleted supplies. During the hour-long delay in replenishing supplies, our surgical colleagues accessed resources from the neighboring adult hospital. Had the MCI patient burden been higher on our adult facility, this lack of communication may have caused competition for supplies and delays in care to our PICU patients. Although the ED was no longer stressed, the system stress shifted to the PICU, demonstrating the ongoing need for hospital-wide ICS operations beyond the initial triage site.

Other recommendations were to utilize supplemental providers if needed; however, the impressive response in provider coverage allowed for care with solely PICU providers.Reference Bohn, Kanter and Burns¹⁰ Had external factors been an issue, our team may have needed to utilize pediatric emergency medicine and hospitalist providers or the adult critical care services for support. The PICU nursing response also provided appropriate resources for critical care competencies to all patients.

Family Centered Care

Family centered care (FCC) focuses on the importance of the psychosocial needs of children, emphasizing the role of families in their children’s well-being.Reference Pettoello-Mantovani, Campanozzi and Maiuri¹¹ Collaboration on a child’s care honors the rich diversity of families.Reference Kuo, Houtrow and Arango¹² Providing FCC can be challenging during an MCI, given sudden system stressors. While our medical team resuscitated patients, social workers and chaplains activated by the surge response were instrumental in providing support and assisting families with their immediate needs.

Task forces recommend that EDs have intake tools specific to identifying patients and reuniting families.Reference Mason, Urbansky and Crocker¹³ After trauma bay triage, children are rapidly transferred to the PICU, sometimes before their identity can be confirmed. During this MCI, some children arrived at the ED accompanied by a parent; however, some did not. Social workers in the ED and PICU worked with families to identify patients per our institutions’ policy. During an MCI, the reunification process may begin in the ED, but it’s necessary to have PICU staff dedicated to patient identification.

It is important to respect patient privacy during an MCI, in both resuscitative efforts and family communication.Reference Kuo, Houtrow and Arango¹² In this MCI, most patients participated in the same community activities and multiple members of the family may have been injured, making privacy during medical updates challenging.

Although recommended by task forces to be available on the scene, it was not until the day following the event that mental health professionals addressed patient, family, and staff psychosocial needs.Reference Kissoon⁵ Given the presence of social workers and chaplains the evening of the event, it seemed reasonable to have mental health professionals the next morning to provide enhanced resources for families and staff. Mental health professionals remained involved for several days following the event. A hotline was available for the community and supported over 90 callers.

During an MCI, language barriers may be encountered, and it is recommended to have resources available to communicate with children in their primary languages.Reference Mason, Urbansky and Crocker¹³ In this MCI, most parents or caregivers spoke Spanish as their primary language and the immediate availability of in-person interpreters eliminated inequities in communication. The need to use phone interpreter services may have been a barrier to equitable and timely care. When available, activation of in-person interpreter services should be considered in preparedness planning.

Lessons Learned and Limitations

In the US, firearm injuries, a type of penetrating trauma, are the leading cause of death for children and children account for 25% of mass shooting victims.Reference Lee, Fleegler and Goyal^14, Reference Reeping, Gobaud and Branas¹⁵ This event was unique, as these patients suffered blunt force trauma causing higher neurosurgical and orthopedic burdens. Vehicle usage as weapons, known as “ramming attacks,” have become more frequent, making these lessons applicable to disaster planning.Reference Hess and Mandhan¹⁶

As hospitals differ in resources and location, these lessons learned may not be applicable to all facilities. Recommendations for planning a critical care response following an MCI exist; however, this experience revealed additional insights which may serve other organizations.Reference Kissoon^5, Reference Christian, Toltzis and Kanter^7, Reference Bohn, Kanter and Burns^10, Reference Mason, Urbansky and Crocker¹³ First, foregoing normal interfacility transfer processes may relieve the burden on referring facilities and accelerate the transfer of pediatric patients to tertiary care and definitive treatment.

As many of the children treated at our facility following the MCI received care at a non-pediatric trauma center prior to our institution, the ability of a non-pediatric trauma center to initially stabilize and resuscitate children should also be highlighted. Only 57% of children live within 30 miles of a pediatric trauma center in the US and most children will present to a non-pediatric trauma center for their initial care.¹⁷ There is growing evidence that critically injured children have improved survivability if taken to a hospital with higher pediatric readiness initiatives.Reference Newgard, Lin and Goldhaber-Fiebert¹⁸ This event emphasizes the worth of the Pediatric Readiness program in advancing the emergency care of children and the value to hospitals to invest in this initiative.

Additionally, once the patients arrived at our institution for definitive treatment, we found that the presence of a PICU provider in the ED facilitated efficient patient triage and transfer. In the PICU, the implementation of a PICU-based ICS and the activation of additional personnel ensured meticulous treatment of patients with dedicated provider teams. Although the response was robust, it is important to recognize the need for formalized surge communication beyond text messaging. In addition, a hospital-wide ICS should remain open until the MCI is clear at all levels to support ongoing resuscitative efforts. Prioritizing the psychosocial needs of children and families during any pediatric MCI and providing access to interpreter services ensures equitable care. Finally, even the best prepared and resource-rich facilities may need to adapt during an MCI and debriefs are crucial.