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July 2021
ALAMEDA COUNTY
D ISASTER P REPAREDNESS H EALTH C OALITION
ALAMEDA COUNTY
DISASTER PREPAREDNESS HEALTH
COALITION (DPHC)
- -
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PEDIATRIC MEDICAL SURGE ANNEX
NOT FOR DISTRIBUTION - WORKING DRAFT – OCTOBER 19, ,2021
2
APPROVAL AND IMPLEMENTATION
The Pediatric Surge Annex to the DPHC Response Plan has been approved and implemented in concurrence with
County agencies and departments.
The following members concur with the content of the Annex. As needed, revisions will be submitted to the Alameda
County EMSC Coordinator. Signed:
___________________________________________________ ____________
Lauri McFadden, EMS Director Date Signed
___________________________________________________ ____________
Will McClurg, Deputy EMS Director Date Signed
__________________________________________________ ____________
Colleen Chawla, Director, Health Care Services Agency Date Signed
____________________________________________________ ____________
Nick Moss, MD, Health Officer Date Signed
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DOCUMENT UPDATE RECORD
Version
Date
Description of Change, Reviewers
Published By
DISCLAIMERS
This plan is intended to support, not replace, any existing facility or agency policy or plan by providing uniform
response actions in the case of an emergency that involves (or could involve) significant numbers of children.
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\ CONTENTS
SECTION 1 – PEDIATRIC SURGE PREPAREDNESS ..........................................................................
INRODUCTION / EXECUTIVE SUMMARY .......................................................................... 7
1.1 PURPOSE ................................................................................................................................ 9
1.2 SCOPE .................................................................................................................................. 10
1.2.1 Timeframe .................................................................................................................. 11
1.2.2 Definitions / Age Groups ......................................................................................... 11
1.2.3 Overview Background of Health Care Coalition and Situation ................................ 12
1.3 SITUATION OVERVIEW ........................................................................................................ 13
1.3.1 BACKGROUND / RISK ................................................................................................. 13
Children Demographics ............................................................................................. 13
1.3.2 HEALTH CARE SYSTEM AND PEDIATRIC CAPACITY / CAPABILITIES ...................... 15
Hospitals .................................................................................................................... 15
Regional Facility Designations ................................................................................... 16
Definitions NICU / PICU Levels ................................................................................... 18
1.4 ACCESS AND FUNCTIONAL NEEDS ..................................................................................... 21
SECTION 2 – CONCEPT OF OPERATIONS - RESPONSE ............................................................... 22
2.1 Command and Mutual Aid Organizations ............................................................................ 23
2.2 Activation and Notifications ................................................................................................ 24
2.2.1 Activation / Levels of Activation ............................................................................. 25
- SME Integration .................................................................................................... 27
2.2.2 Notifications ............................................................................................................... 29
EMS Activation and Notifications – Operational Response Tool ____________________30
2.3 Roles & Responsibilities – Coalition (Situation Awareness) .............................................. 30
2.4 LOGISTICS .......................................................................................................................... 31
2.4.1 Surge Definitions 4Ss / 3Cs......................................................................................... 31
- Space ........................................................................................................................ 33
- Staff (PECCs; SMEs-p.5; Pediatric Clinicians) .......................................................... 33
- Supplies (Caches) / Resources (Telehealth) ............................................................ 33
2.4.2 Pediatric Critical Care Expansion Plan .................................................................... 35
Pediatric Critical Care Expansion Options – Operational Response Tool____________35
2.5 SPECIAL CONSIDERATIONS – EVENT SPECIFIC .................................................................. 38
2.5.1 Behavioral Health ........................................................................................................ 40
2.5.2 Decontamination .......................................................................................................... 40
2.5.3 Evacuation ................................................................................................................... 42
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CONTENTS
2.5.4 Specialty Pathogens / Infection Control / COVID-19 / MIS-C ...................................... 44
2.5.5 Security ....................................................................................................................... 45
2.5.6 Special Needs ............................................................................................................. 47
2.6 OPERATIONS – MEDICAL CARE & PATIENT MOVEMENT .................................................... 48
2.6.1 Triage ........................................................................................................................... 48
2.6.2 Treatment / Medical Care ............................................................................................ 54
2.7 TRANSPORTATION ............................................................................................................... 54
SECONDARY TRANSFER ACTIONS – USING PIRT AND EEIs_____________________________58
2.8 TRACKING ............................................................................................................................. 59
2.9 REUNIFICATION .................................................................................................................... 59
2.10 DEACTIVATION AND RECOVERY .......................................................................................... 64
SECTION 3 - APPENDICES ............................................................................................................ 67
3.1 Risk / Demographics ............................................................................................................ 65
3.2 Surge Strategies - 4S/3C Planning / Crisis Standards of Care ............................................. 67
3.3 Triage, Medical Care, Treatment Guidelines ....................................................................... 75
3.4 Inter-Facility Transfer / TRAIN / Evacuation Forms ............................................................. 77
3.5 Decompression – Transfer Centers and EEIs ....................................................................... 83
3.6 SMEs – Pediatric Intensivisits (PIRT)/ MRCs / DHV ............................................................. 84
3.7 Pediatric Readiness Project / EMSC .................................................................................... 85
3.8 PsyStart / Behavioral Health ................................................................................................. 99
3.9 Planning / Training / Exercises ........................................................................................... 104
3.10 Local Referral Resources ................................................................................................... 105
3.11 National Resources / Legal ................................................................................................. 108
3.12 COVID-19 MISC and Resources .......................................................................................... 112
3.13 WRAP-EM ............................................................................................................................. 115
3.14 Acronyms / Definitions ........................................................................................................ 116
3.15 Essential Elements of information EEI Planning Templates ............................................. 118
3.16 Telehealth ........................................................................................................................... 120
SECTION 4 – EMS and Hospital Supplemental References / Toolkits (Separate Documents) ............
4.1 Hospital in-Patient Surge Plan Templates ................................................................................
4.2 Pathogens/Infection: ALCO EMS Field Manual ..........................................................................
4.3 EMS MCI Field Triage / Trauma / Burn ....................................................................................
4.4 Treatment: Color Coded Drug Stickers .....................................................................................
4.5 Security, Patient Tracking Form and Child identification Form ...............................................
4.6 FACs / Reunification ...................................................................................................................
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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ANNEX APPROVAL AND REVIEW
Given the COVID-19 Pandemic, this preliminary draft is pending comprehensive review & approval.
This annex was developed in collaboration with the Alameda County EMSC & Pediatric Surge Advisory Group, Disaster
Preparedness Health care Coalition (DPHC), subject matter experts (SMEs), and other collective health care partners. Health care
Coalition pediatric SMEs with the HPP LEMSA Coordinator will approve, update annually, and maintain the Pediatric Surge
Annex. The review will include identifying gaps in the preparedness plan and working with pediatric SMEs to define strategies to
address the gaps. All DPHC members have the opportunity to provide input and receive a copy of the revised response plan.
PLAN DEVELOPMENT TEAM &/OR SUBJECT MATTER EXPERT ADVISORS *** RESPONSE SMEs
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SECTION 1: PREPAREDNESS PLAN
1. Introduction
‘Children are not little adults’ and separate consideration of their needs during an emergency is critical. The need for a
strong collaborative approach to integrate newborns, infants and children into disaster planning is vital to effective
response. Neonatal and pediatric all-hazard preparedness relies on a strong network of committed emergency
management, public health agencies, emergency medical services, hospitals, and community partners.
Disaster events with unprecedented challenges across the country and around the world over the last decade (including
the COVID-19 pandemic) have forever changed the entire medical and health response landscape. Whether natural
or human-caused, emergencies (often occurring simultaneously) are an expected reality affecting our children in all
communities, hospitals, first responders, and those who live and work in Alameda County. Hospitals and health care
coalitions are faced with significant challenges in pediatric response to natural or human-caused events or disasters.
Critical surge planning and response preparedness must accommodate both large volumes of patients and the needs
of specific vulnerable patient groups including pediatric patients.
With pre-identified collective partnerships, the pediatric surge annex will contribute to pediatric readiness for a potential
surge of pediatric patients and the consequential impact on the delivery system. This plan is anchored in best practices
from across the country and guided by evidence-based models. The framework and guidance tools will support health
care facilities, EMS transport providers, and county department plans for the potential pediatric surge. This document
addresses essential categories including health care delivery, triage, transport, medical care, and logistics that could
be impacted when resources are limited or insufficient to meet the medical needs of patients. An overview of surge
capacity and crisis care operational considerations are provided for health care facilities with an emphasis on the
Alameda County hospitals. Information supports regional and operational area medical coordination for response.
This annex is designed to provide a guide for the Alameda County Health Care Coalition partners with the core
content below:
• The CONOPs sections are aimed at specific target coalition partner roles, integrated within the existing
infrastructure, and intended for use at all levels of care and throughout the coalition with focus on the
hospitals and the Operational Area Emergency Operations Center (EOC).
• The Annex delineates customized EOC Medical/Health Branch response roles and responsibilities with
special focus on activation, communication pathways, patient movement decisions, and medical care of
children impacted during and in the aftermath of an emergency incident or event.
This document is consistent with the “healthcare surge” definition In the California – “Standards and Guidelines for
Healthcare Surge During Emergencies,” developed by the California Department of Public Health as follows:.
A healthcare surge is proclaimed in a local jurisdiction when an authorized local official, such as a local
health officer or other appropriate designee, using professional judgment determines, subsequent to a
significant emergency or circumstances that the healthcare delivery system has been impacted,
resulting in an excess demand over capacity in hospitals, long-term care facilities, community care
clinics, public health departments, other primary and secondary providers, resources and/or
emergency medical services. The local health official uses the situation assessment information
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SECTION 1: PREPAREDNESS PLAN
provided from the healthcare delivery system partners to determine overall local
jurisdiction/Operational Area medical and health status.
• Essential surge foundation elements and assumptions include:
❖ Ensure integration within existing EOC and ICS infrastructure
❖ Enable safe and expert pediatric transfer decision making
❖ Implement standardized care guidelines as needed
❖ Ensure activation of redundant and interoperable communications processes
❖ Support the tracking of pediatric patients throughout the incident
❖ Identify hospital bed expansion and decompression strategies to manage surge and
limited/scarce resources
❖ Ensure the coordination of transferring acutely ill/injured pediatric patients to pediatric tertiary
care centers/specialty care centers
❖ Support decompression from pediatric tertiary care centers/specialty care centers to make
additional critical care beds available for acutely ill/injured pediatric patients
❖ Access to SMEs across and within state lines
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SECTION 1: PREPAREDNESS PLAN
1.1 Purpose
This annex applies to a catastrophic pandemic event, mass casualty incident or evacuation with a disproportionately
large number of pediatric patients. The focus is maximizing pediatric survival, maximizing resources, and
minimizing morbidity. The purpose of this plan is to establish a process in which the strengths of the medical
resources can be used to mitigate the impacts of a large number of pediatric patients within the Alameda County
Operational Area.
This plan is intended to support, not replace, any existing facility or agency policy or plan by providing uniform
response actions in the case of an emergency that involves (or could involve) significant numbers of ill or injured
children. This plan also supports the Alameda County Emergency Operations Plan and the MHOAC Manual.
The purpose of the plan is to serve as a supporting annex to the Health Care Coalition (HCC) Response Plan (also
referred to as the DPHC Response Plan) and the Alameda County MHOAC Manual by addressing the specific needs
of children and supporting appropriate pediatric medical care and transport during a disaster.
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Goals - “Right Patient, Right EMS Resource, Right Destination”
• To increase and sustain pediatric capacity and capability to meet the demands of a surge of
pediatric patients in an Alameda County catastrophic event
• To describe a seamless process for primary and secondary inter-facility transfer of pediatric
patients
• To provide the Alameda County operational area Medical/Health Branch and coalition partners with
pediatric response strategies using a CONOPs (for communications, triage, medical care,
treatment, patient transport, patient tracking, bed expansion, evacuation, acute care and
contingency or crisis standards of care for pediatric patients during a disaster)
• To map resource assets (personnel, supplies, space, SMEs) for “resource matching” during
response
• To ensure pediatric coalition planning, training, and exercises
• To provide best practice resources and access to SMEs
Patient Movement – Scope and Assumptions
• This plan framework establishes the response system based on capacity and capability.
• Patient age and acuity need to be considered when determining the location where children will be
treated and transported.
• Given the variability in pediatric patient census during normal operations and crisis events, all hospitals are
expected to plan for an event resulting in a surge of pediatric patients.
• This annex is based on caring for more critically ill children in specialty pediatric facilities that are
accustomed to caring for children with provisions for critical care expansion through decompression
of less critically ill children and adults to other facilities.
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SECTION 1: PREPAREDNESS PLAN
Patient Movement – Scope and Assumptions
• A priority focus of the plan is on movement of large numbers of patients:
o Field transport to initial hospital
o Initial hospital to destination hospital
o Evacuating facility to destination facility
• In day-to-day operations, perinatal and pediatric patients are triaged, treated and then transported to a facility
which can provide the level of care needed for the best outcome. However, with a surge of patients during a
disaster, there may be times when patients need to be cared for at a facility that normally would transfer them
to a higher level of care.
EMS-C Overview and Integration
This annex ensures coordination between the Hospital Preparedness Program (HPP) and the EMS for Children
(EMS-C) program. This annex aligns with the California EMS for Children Regulations in effect as of July 1, 2019.
• The mission of the Alameda County EMS for Children (EMS-C) program is to reduce pediatric morbidity
and mortality from injury or illness by development, implementation, and integration of EMSC activities into
the spectrum of EMS systems. Alameda County EMSC is a specialty care program of the EMS Agency.
• The vision is to create a seamless system of care for children throughout the county from injury prevention,
emergency preparedness, prehospital care, and medical care through reintegration into the community.
• The overall goal of theEMS-C program is to ensure that acutely ill and injured children have access to
high quality, coordinated, and comprehensive emergency and critical care services appropriate for children’s
special needs.
The EMS-C Model provides a continuum of care, beginning with the detection of illness or injury to emergency
department care and rehabilitation. Refer to Section 3.7 and the Alameda County EMS website for additional
information: http://ems.acgov.org/ClinicalProcedures/EMS-C.page?
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SECTION 1: PREPAREDNESS PLAN
1.2 SCOPE
This plan is designed to provide a guide for the Alameda County Operational Area Health Care Coalition to:
• Enable safe pediatric transfer decision making
• Implement standardized care guidelines as needed
• Ensure associated communications processes are in place
• Support the tracking of pediatric patients throughout the incident
• Identify strategies to manage surge and scarce resources.
• Assist with the coordination of transferring acutely ill/injured pediatric patients to pediatric tertiary
care centers/specialty care centers
• Assist with the decompression from pediatric tertiary care centers/specialty care centers to make
additional critical care beds available for acutely ill/injured pediatric patients
Timeframe
• The timeframe covered by the plan includes the Immediate, Intermediate, Extended Operational Periods
which may last for days, weeks or months depending on the type of event (e.g. mass casualty or pandemic),
until beginning Demobilization System Recovery.
Pediatric Patient and Age Group Definitions
• Many methods exist for identifying the pediatric population using age criteria to plan for the care of large
numbers of children. An age criterion is due to many considerations regarding pediatric transport, treatment,
supplies, and size of patient. Pediatric patients can be defined as ages 21 and under (American Academy of
Pediatrics). or under 14 years old in the California Pediatric, Neonatal, and OB Surge Annex to the Patient
Movement Plan (draft 2019).
• Per the Alameda County EMS Field Manual 2020, the defined age of a pediatric patient is 14 years old or
less, and unless specified otherwise, pediatric protocols should be used to treat these patients. (Note: An
infant is considered to be < 1 year old. A child is considered to be ≥ 1 year old).
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AGE GROUPS
• For this annex, the following pediatric age groups are utilized to define the pediatric population and
determine special age group related considerations:
❖ Infants/toddlers (0-24 months)
❖ Toddlers/preschoolers (2 -5 years)
❖ School aged children (6 up to age 14 years)
❖ Adolescent children over 14
❖ Children with underlying complex medical conditions. (Note: Some children with special needs
who are over 14 and experience chronic conditions such as cystic fibrosis, cerebral palsy, and
others will likely require specialized attention during a disaster.
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SECTION 1: PREPAREDNESS PLAN
• The plan includes the mother-baby couplet (obstetrics), newborns (NICU and well newborns) and children from
birth through 14 years of age.
Overview/Background of Health Care Coalition & Situation
Coalition and Operational Area Partners
• The Annex is directed to multi-level partners: Alameda County Operational Area (OA) government departments and
agencies; municipal governments (local jurisdictions); health care systems and facilities (HCFs) including tertiary
care/specialty hospitals and non-hospital HCFs; prehospital 911 and inter-facility (IFT) transportation providers,
coordinating agencies from outside the county; nongovernmental organizations (NGOs) and community based
organizations (CBOs) that respond to disaster incidents and events. The health care system includes provider networks,
of hospital, ambulatory care, in-home services, long-term care, behavioral health, and ancillary care services. Provider
networks include Alameda Health System, Kaiser Permanente, Sutter Health, Stanford and others.
Disaster Preparedness Health Coalition and Health Care System
• The Alameda County Disaster Preparedness Health Coalition (DPHC) is integral to the planning and response for
children. DPHC comprises core health care partners including EMS, Public Health, Emergency Management, Hospitals,
Long Term Care Facilities and Clinics with other pediatric health care partners and county agencies and organizations
making up the rest of its membership.
Hospital Pediatric Readiness – PECCs & SMEs.
• Alameda County has a contract with UCSF Benioff Children’s Hospital to conduct pediatric readiness hospital site
visits with pediatric simulation training and customized evaluations. Site visits occur at a minimum every other year.
• Through the Pediatric Readiness Project, Pediatric Emergency Care Coordinators (PECCs) have
been identified within hospitals including emergency departments, pediatric experts and
coordinators, physicians, and nurses. Other pediatric specialists and SMEs have been engaged
including primary care representatives, pediatric behavioral health, inpatient maternity, critical care
(PICU), and post-natal services have been identified. - Refer to Section 3.6 and 3.7 for additional
information. The PECCs participate in annual state medical / health exercises and real events.
Operational Area (OA) Medical Health Mutual Aid Structure
• Alameda County lies within the Medical Health Mutual Aid (MHMA) Region II - which includes the
counties of San Francisco, Santa Clara, San Mateo, Santa Cruz, Monterey, San Benito, Contra Costa, Solano, Lake, Napa,
Humboldt, Del Norte, and Mendocino. This regional approach ensures the RDMHS and MHOAC program, multi-agency
coordination, establishing priorities during a response, and allocating resources.
• The Region II – Regional Disaster Medical Health Specialist (RDMHS) and OA Medical Health Operational Area
Coordinator (MHOAC) coordinate to ensure resources are matched with need. The coalition is central to
leveraging situational awareness and identifying system-wide needs.
NGO and CBO Referral Agencies
• NGOs and private-sector businesses that provide pediatric resources and services in response to a disaster are
encouraged to provide liaisons to the EOC. The Alameda County EOC has designated space to facilitate he support of
select liaisons. – Refer to Section 3.10
Western Regional Alliance for Pediatric Emergency Management (WRAP-EM)
• UCSF Benioff Children’s Hospital was awarded the National ASPR Center of Excellence grant which created a pediatric alliance amongst
specialty children’s hospitals across five states and pediatric expert connections across the country. The goal is to develop pediatric
disaster planning and response capabilities across states and to leverage unprecedented partnerships. The Alameda County LEMSA
Coordinator actively participates on the WRAP-EM project, facilitates the surge focus group, and leverages pediatric SMEs in planning
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SECTION 1: PREPAREDNESS PLAN
and response including during the COVID-19 pandemic. Several Alameda County DPHC Coalition partners are leading or participating in
the WRAP-EM working groups. -Refer to Section 3.13 for additional information.
1.3 SITUATION OVERVIEW
• 1.3.1 Background / Risk
Children Demographics
• Alameda County is approximately 739 square miles of land and 82 of water, located in the center of the San Francisco
Bay Area, with a diverse demographic and socioeconomic population of 1.6 million. The City of Oakland, in the north part
of the County, is the largest city with a population of 412,000+. Other large cities include Fremont in the south
(210,000+), the City of Hayward in the mid-part of the County (146,000+), and the City of Berkeley in the northern sector
of the County (105,000+). Approximately 160,000+ people reside in the cities of Livermore, Dublin and Pleasanton
located in the eastern County. Refer to http://www.acgov.org/government/maps.htm and Section 3.1
````````````````
• The population of Alameda County in 2019 was 1,671,329. The table below shows the child population of
Alameda County by sex and age group. Alameda County residents are almost evenly split by gender—
50.9% are female—but males make up the majority in younger age groups and females in older. Most
Alameda County residents are between 25 and 64 years.
• In 2020, the child population ages 0-17 years old was 354,212. Refer to tables with the specific age groups
for children identified below: https://www.kidsdata.org/region/127/alameda-county/summary#44/physical-health
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SECTION 1: PREPAREDNESS PLAN
• Over 10% of children in Alameda County live in poverty with the highest concentrations in the urban areas of
Berkeley, and Oakland. Poverty will impact a child’s access to transportation and communication in a
disaster and may, therefore, contribute to separation from parents/guardians during an evacuation.
• Approximately 13%, children in Alameda County have special needs. Almost 3% of children have major
disabilities during this time period. In 2018 0.5% of children ages 5-19 were hospitalized for mental health
issues.
Children in Deep Poverty Data Demographics
-
Special Education Enrollment, by Disability
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SECTION 1: PREPAREDNESS PLAN
Local Risks for Pediatric-Specific Mass Casualty Events (e.g., schools, transportation accidents)
• During complex catastrophic pandemics, mass casualty incidents due to terrorism or natural disasters (e.g., earthquakes),
a heightened pediatric surge risk exists. Co-occurring events may occur.
• Civil unrest, and extreme heat emergencies will especially impact the EMS response and medical care of children and
their families.
• Critical care bed capacity for children is limited system-wide.
• Pediatric capability may be compromised with competing needs for resources.
• For specific hazards for Alameda County see the Alameda County Emergency Operations Plan Section 2.4.
• Refer to Section 3.1 for additional hazard vulnerability information.
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• Children have specialized medical issues due to their unique developmental and physiologic characteristics different from adults.
• Children are dependent on adults for care, shelter, transportation, and protection from predators.
• Children are more susceptible to chemical, biological, radiological, and nuclear threats and require different medications, dosages, and
delivery systems than adults.
• A strained over-whelmed system will compromise the medical and psychological needs of children.
1.3.2 Health Care System and Pediatric Capability and Capacity
Hospital Systems
• Within Alameda County, currently thirteen hospitals exist as emergency receiving centers for ambulance transport: 12
adult and 1 pediatric. Thirteen are LEMSA designated Pediatric Receiving Centers (PedRCs).
• The acute care receiving facilities located in Alameda County provide a wide range of services to care for the health needs
of residents/visitors and feature specialized care programs including trauma, stroke, pediatric, psychiatric and cardiac
services. There is one Level I Adult Trauma Center and one Level II Adult Trauma Center. UCSF Benioff Children’s Hospital
in the main pediatric hospital with Level I Trauma designation, while other hospitals have varying pediatric capacity and
capabilities, including adolescent beds, intensive care units for children, specialized equipment and resources for neonatal and
pediatric patients, and ambulance transport providers with capability to transport children including LifeFlight operations.
• In addition to UCSF Benioff Children’s Hospital, Alameda County has neonatal and pediatric beds at hospitals including:
Kaiser Permanente Oakland, Stanford ValleyCare Health System, and Washington Hospital Healthcare System.
• All emergency rooms are expected to have the capability to take care of children.
• Hospital status and bed availability information can be found through the ReddiNet system, which can be
accessed through EMS and the EOC Medical/Health Branch if activated.1
1ReddiNet is a password protected system. For more information regarding access to this system, contact EMS or the OA EOC Medical and Health Branch.
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SECTION 1: PREPAREDNESS PLAN
Regional Facility Designations
Regional Adult Centers Trauma Ctr
Designation
PICU Level
of Care
NICU
Designation
Alameda County Health System - Medical Center (Highland)- Oakland
Level 1
John Muir Medical Center – Walnut Creek Level 2 Yes Level III
Kaiser Permanente – Oakland Yes
Kaiser Permanente Medical Center – Vacaville Level 2
Regional Medical Center San Jose Level 2
Santa Clara Valley Medical Center – San Jose Level 1 Yes Regional
Level IV
Sutter Alta Bates – Berkeley Regional
CCS
Sutter Eden Medical Center – Castro Valley Level 2
Stanford Health Center Lucile Packard Children’s Hospital of Stanford –
Stanford
Level 1
Pediatric &
Adult
Regional
Level IV
UC Davis Medical Center – Sacrament Level 1
Pediatric &
Adult
Yes Regional
Level IV
UCSF Benioff Children’s Hospital – Oakland Level 1
Pediatric Yes Regional
Level IV
Zuckerberg San Francisco General Hospital Level 1 Level III
Pediatric Capability and Asset Mapping
• Pediatric resources and capabilities are represented in the DPHC coalition. Specifically, there are
children’s/pediatric hospitals, hospitals with routine pediatric services [Emergency Department], inpatient
pediatrics, and/or neonatal or pediatric intensive care units):
Hospital Bed Capacity
• The table below represents the daily total of licensed beds by type in Alameda County facilities with 24-hour
emergency care services These numbers represent the normal licensed capacity for inpatient and
emergency care services.
• Once the CA Pediatric Surge Annex to the Patient Movement Plan draft 2019 is approved, Alameda
County will implement the tiered definitions noted in the table above and described below as follows:
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SECTION 1: PREPAREDNESS PLAN
Pediatric Capability and Capacity for Patient Movement – REFORMAT TO SEE #s
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COMPREHENSIVE PedRC
(HIGH TIER)
Kaiser Oakland ** H Y Regional 315 12 37 24 42 32 Kaiser
UCSF Benioff Children’s
Hospital Oakland ** H P1* Y Regional 190 23 104 51 North
ADVANCED PedRC
(MEDIUM TIER)
Stanford Valley Care M 167 4 10 15 22
Washington Hospital M Y Intermediate 341 17 14 22 29
GENERAL PedRC
(LOW TIER)
Alameda Hospital L 135
Alta Bates Summit MC L Y 416 55 116 30
Alta Bates Summit MC-Alta
Bates Campus ** L Community 347 54 75 North
Eden MC L A2 130
Highland Hospital L A1 Y Non CSS
ICNN 249 8 17
Kaiser – Fremont L 106 Kaiser
Kaiser San Leandro L Y Community 216 20 38 30 Kaiser
San Leandro Hospital L 93
St. Rose Hospital L Y Basic 217 17
13 13 1 – P; 2 – A ###
➢ PEDRCs=Pediatric Receiving Centers
➢ Category: H = high, M = medium, L = low
➢ Trauma: A = ADULT TRAUMA - - P = PEDIATRIC TRAUMA -- - MC = Medical Center
➢ PICU: pediatric ICU
➢ NICU Reg: Regional Neonatal ICU (Level IV)
➢ NICU Comm: Community Neonatal ICU (Level III)
➢ NICU Int: Intermediate Neonatal ICU (Level II)
TRANSPORT COORDINATION AND TEAMS
• Critical Care Deployable Teams = Alta Bates Berkeley; UCSF Benioff children’s; and Kaiser Oakland
• Regional Transport Coordination = UCSF Benioff Children’s Hospital Oakland
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HIGH TIER - Pediatric Tertiary Center
• Definition – a referral/receiving hospital providing comprehensive specialized pediatric medical and surgical care to the most critically ill or
injured children; Criteria - Must have regional NICU, PICU, and licensed pediatric beds; may have designation as Trauma Center, ideally
pediatric
MEDIUM TIER – Pediatric Community Hospital
• Definition – GACH community-based hospital with licensed pediatric beds, able to provide some pediatric services – relationship to a
HIGH Tier facility, may be asked to keep/receive children who would normally be transferred.- - Criteria - Must have NICU (Regional,
Community, or Intermediate); licensed pediatric beds; may have PICU; Designation as Trauma Center (Pediatric or Adult)
LOW TIER – General Community Hospital
• Definition –Usually small community hospitals (includes Critical Access Hospitals), with general medical/surgical beds, able to provide
some basic inpatient pediatric services– relationship to a HIGH Tier facility, may be asked to keep/receive children who would normally
be transferred. Criteria - Must have general acute care beds, 911 receiving center; may have adult ICU, newborn nursery
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SECTION 1: PREPAREDNESS PLAN
Definitions -
- NICU Levels from AAP -
Level I (Well Newborn Nursery)
• Level I units are typically referred to as the well baby nursery. These facilities have the capability to provide neonatal
resuscitation at every delivery; evaluate and provide postnatal care to healthy newborn infants; stabilize and provide care
for infants born at 35 to 37 weeks gestation who remain physiologically stable; and stabilize newborn infants who are ill
and those born less than 35 weeks' gestation until transfer to a facility that can provide the appropriate level of neonatal
care. Required provider types for well newborn nurseries include pediatricians, family physicians, nurse practitioners
and other advanced practice registered nurses.
Level II (Special Care Nursery)
• Level II units are also known as special care nurseries and have all of the capabilities of a Level I nursery. These facilities
are required to have pediatric hospitalists, neonatologists and neonatal nurse practitioners, in addition to Level I health
care providers.
• Level II units are able to:
o Provide care for infants born at 32 weeks gestation or older and weighing more than or equal to 1,500 grams who
have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not
anticipated to need subspecialty services on an urgent basis
o Provide care for infants who are feeding and growing stronger or recovering after intensive care
o Provide mechanical ventilation for a brief duration or continuous positive airway pressure
o Stabilize infants born before 32 weeks gestation and weighing less than 1,500 grams until transfer to a neonatal
intensive care facility
Level III (Neonatal Intensive Care Unit)
• Level III units are required to have the same care providers required for Level II facilities (pediatric hospitalists,
neonatologists and neonatal nurse practitioners) and Level I facilities (pediatricians, family physicians, nurse practitioners
and other advanced practice registered nurses).
• In addition, Level III units must provide, either on site or at a closely related institution by prearranged consultative
agreement, the following providers: pediatric surgeons, pediatric medical subspecialists, pediatric anesthesiologists and
pediatric ophthalmologists.
• Level III neonatal intensive-care units are able to:
o Provide sustained life support
o Provide comprehensive care for infants born at all gestational ages and birth weights with critical illness
o Offer prompt access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric
anesthesiologists and pediatric ophthalmologists
o Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and
inhaled nitric oxide -
o Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI and
echocardiography
19
SECTION 1: PREPAREDNESS PLAN
Level IV (Regional NICU)
• The highest level of neonatal care provided occurs at regional NICUs, or Level IV neonatal intensive care units. These
units are required to have pediatric surgical subspecialists on staff in addition to the care providers required for Level III
units.
• Regional NICUs have all of the capabilities of Level I, II and III units. In addition to providing the highest level of care,
• Level IV NICUs:
• Are located within an institution that has the capability to provide surgical repair of complex congenital or acquired
conditions.
• Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists and pediatric anesthesiologists
at the site
• Facilitate transport and provide outreach education
• Provide ECMO (Extracorporeal Membrane Oxygenation)
PICU Levels from AAP
• The 2019 policy establishes three levels of PICUs: community based PICU, tertiary PICU and quaternary or
specialized PICU. Refer to: https://www.aappublications.org/news/2019/09/05/picu090519 and
https://pediatrics.aappublications.org/content/144/4/e20192433
Community based PICUs
• Play an important role in health care systems that provide care to infants and children. In general, these
centers are mostly located in hospitals that offer medical-surgical care and a range of services targeted at
the most fundamental level of pediatric intensive care services.
Tertiary PICUs
• Have enhanced ability to care for critical care pediatric patients compared to community based PICUs.
Tertiary PICUs can provide advanced respiratory support such as high frequency oscillatory ventilation.
However, they would not be expected to provide ECMO support or transplantation services. In tertiary
PICUs, the majority of pediatric medical and surgical services should be available, although in-house
coverage would not be expected.
A Quaternary or Specialized PICU Facility
• Serves as a regional center and possesses a large catchment area likely to encompass tertiary and
community based PICUs. These centers provide comprehensive services to all pediatric critically ill patients,
including cardiovascular surgical services, transplantation services, and neurocritical intensive care services.
This highest level of PICU would be capable of supporting an American College of Surgeons-verified level I
or level II children’s surgical center or Level I or level II pediatric trauma center.
20
SECTION 1: PREPAREDNESS PLAN
COVID-19 Licensed Beds and Available Beds – Sample
Hospital Licensed
Beds
Licensed
ICU Beds
Total
Pediatric
Beds
Inpatient
Pediatric
Total Beds
Surge
Beds
ICU Total
Pediatric
Beds (PICU)
Alameda Hospital 66 0
Alta Bares Summit (Oakland and Berkeley 800 101 1 1 43
Highland Hospital 169 32
Kaiser Permanente Fremont 100 10 0
Kaiser Permanente Oakland 315 66 40 40 21
Kaiser Permanente San Leandro 215 50 8 8
San Leandro Hospital 91 9
Stanford Health Care ValleyCare Pleasanton 202 26 4 4
St Rose 153 9
Eden 130 24 1 1 28
UCSF Benioff Children’s 223 74 246 188 61 23 *
Washington 415 62 4 196
Totals 304 242 1221 44
• The table above represents the number of beds that 24-hour emergency care facilities can expand beyond normal
licensed bed capacity for inpatient and emergency care services. The total number of surge pediatric ICU beds is 44.
21
SECTION 1: PREPAREDNESS PLAN
1.4 Access and Functional Needs
• All support for children will be compliant with the Americans with Disabilities Act (ADA). Support for such
children will be provided to the extent possible and expanded upon as resources become available.
------------------------------------------------------------------------
• Person with Access and Functional Needs (PAFN) - Definition:
o Those in the community who may have additional needs before, during, and after an incident including but
not limited to maintaining independence, communication, transportation supervision, and medical care.
• Children with Special Health Care Needs:
o Children in the community who have significant behavioral, emotional, or physical health care needs.
o They may be cared for at home or in residential treatment centers.
o They may or may not be dependent on equipment and/or medication for their care. Examples of medical
equipment may include feeding devices, ventilators, or wheelchairs.
• Children (0-14 years of age) are a highly vulnerable segment of the population in times of disaster.
o Children in this age category comprise nearly 25 percent of the U.S. population and have significant and
often complex planning and emergency response needs.
o Under normal conditions, there are components at the governmental, private, and non-profit levels that form
the networks on which children depend to support their development and protect them from harm. In addition
to these systems, children fall under the supervision of their parents, guardians, and/or primary caregivers.
o Once a disaster occurs, however, most or all these foundations in a child’s life may collapse.
• The American Academy of Pediatrics has established that children have unique physical and emotional needs when
a disaster strikes.
o In addition to being placed at an increased risk of physical harm, children respond to illness, injury, and treatment
differently than adults do.
o They also rely on stable routines in their daily lives, and when a disaster occurs, the drastic changes to their known world
endanger their safety and greatly frighten them.
o To ensure the physical security and emotional stability of children in disasters, communities must modify their emergency
planning efforts to include children's unique needs during disasters.
• Access and functional needs populations may have additional needs before, during and after an incident in functional
areas, including but not limited to: communication, medical care, maintaining independence, supervision, and/or
transportation.
o Individuals in need of additional response assistance may include: children who live in institutionalized settings and
children from diverse cultures, those who have limited English proficiency or are non-English-speaking, and/or those who
are transportation disadvantaged.
• Historically, in major disasters, children with access and functional needs suffered increased morbidity and
mortality due to a lack of general preparedness and community coordination with EMS and hospitals, such as lack of
necessary equipment, staffing and instructions for community coordination.
o Understanding and accurately estimating medical care requirements of the pediatric population with pre-existing medical
conditions is critically important for preparedness planning and emergency response.
o If this is not done, it is anticipated that patients who were previously stable and cared for at home will suffer medical
crises when their support network is disrupted and significantly add to the surge burden being presented to EDs and
hospitals.
22
SECTION 1: PREPAREDNESS PLAN
• Individuals in need of additional response assistance may include children who live in institutionalized settings and
children from diverse cultures, those with limited access to transportation, and those who have limited English proficiency
or are non-English-speaking.
o Response plans for children in disasters need to include resources and preparations for children with disabilities and
special health care need.
• Because of the limited availability of pediatric resources, such as pediatric ventilators and wheelchairs,
the need for transfer capability of children with special needs out of a disaster area is heightened.
o This may involve the performance of large-scale interstate transfer of children with special health care needs
and shelter resources for residents of all ages with disabilities.
• Alameda County is committed to ensuring that considerations are made for children with access and functional
needs at every stage of the emergency management process.
o Caring for access and functional needs populations in a disaster is part of the responsibilities of each leader in the
emergency management organization.
o The County maintain maintains compliance with the Americans with Disabilities Act.
• Alameda County Functional Assessment Service Team (FAST):
o The Public Health Officer may deploy and coordinate local FAST members to assess the function and access needs of
people in shelters, including children with disabilities and others with access and functional needs.
o The FAST team inspects shelters and ensures that shelter residents with access and functional needs have the
resources they require while staying in the shelter. They coordinate with state / local governments, and NGO’s.
Alameda County Departments and OA EOC Roles to Support children (including Access and Functional Needs)
Social Services
Agency/Operations Section:
Mass Care and Shelter Branch
Health Care Services
Agency (HCSA):
Operations Section:
Medical Health Branch
Probation
Department/
Logistics
Section
General Services
Agency
(GSA)/Logistics
Section
Sheriff’s Office/Operations
Section/Law Enforcement
Branch
• Supports children in mass care
environments
• Provides personal assistance
services to support unaccompanied
minors
• Coordinates custody and reunification
of unaccompanied minors through
Department of Children and Family
Services (DCFS) • Child care liaison (shelter,
community)
• Assesses, oversees and
provides support for:
o Public Health Support
o Medical Support
o Behavioral health
support
o Environmental health
and safety
o Emergency Medical Services
• Manages minors
within the
detention system
• Provides staff to
support security
and/or mass care
operations
• Fulfills requests from
response operational
functions for child-
specific supplies, equipment, and staffing • Provides transportation
to move children to and
from schools, child care
facilities, and
appointments
• Manages OA EOC and
emergency management
• Provides and coordinates security
at mass care sites
• Provides supervision for
unaccompanied minors prior to
their move to the social services
system
• Coordinates missing persons to
support reunification processes
23
• SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.1 GENERAL COMMAND STRUCTURE AND COMMUNICATIONS
• The official County operational area EOP is utilized for the Alameda OA EOC activations and
demonstrates the overall coordination structure for all functions during disaster response
operations.
o The HCSA DOC may be activated concurrently with the OA EOC to address the pediatric surge
response needs.
o The EOP demonstrates the overall coordination structure for all functions during disaster operations.
Refer to the EOC organization and COVID-19 DOC organization below:
Alameda County EOC Organization
24
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
Alameda County HCSA DOC for COVID-19 Response Organization
25
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.1 GENERAL COMMAND STRUCTURE AND COMMUNICATIONS
OA EOC Command and Medical Health Branch- Functions and Responsibility for Children.
• The OA EOC or County Emergency Operations Manager (EOM) will coordinate response agencies and
organizations for overall emergency management activities in support of children.
• The OA EOC or EOM will coordinate information and communication between local jurisdictions (cities),
special districts, Regional, State and Federal response partners; facilitate mutual aid resources and activities
for children.
• The OA EOC will facilitate vertical and horizontal communications and disseminate information with partners
consistent with ICS.
• Within Operational Area EOC Medical/Health Branch (if activated), the MHOAC Program coordinates Health
Care Services Agency functions for children and adults identified in Health and Safety Code §1797.153.
Regional and Operational Area Coordination
• Alameda County ensures an essential regional approach, requiring linkages between the Disaster
Preparedness Health Coalition (DPHC) including government response entities, outpatient providers,
EMS providers and hospitals.
• To effectively achieve a continuum of care, bridges are established between government and private entities,
across health care systems, beyond catchment areas, and in a catastrophic event, across state lines.
• Regionalization especially for pediatrics is needed to organize resources within a geographic area to
ensure access to medical care of a level appropriate to the patient’s needs, while maintaining
efficient use of the available resources– “right care, at the right place, at the right time.” (consistent
with the State Pediatric Surge Annex draft 2019).
• The Region II RDMHS and the OA MHOAC coordinate to ensure resources are matched with need.
The coalition is central to leveraging situation awareness and identifying system-wide needs.
2.2 ACTIVATION AND NOTIFICATION
2.2.1 Activation
• The Alameda County (ALCO) Pediatric Surge Plan may be activated in response to an event that has
a disproportionate number of pediatric patients.
o This plan will be activated in the same way ALCO EMS functions daily using ReddiNet®.
• The primary assumption is that an event has reached an Emergency System Activation Level 2 or 3
as defined in the California Health and Medical Emergency Operations Manual (EOM, outside of
traditional general acute care facility day-to-day operations. Refer to table below
• In accordance with SEMS, this plan may be activated by any of the following ALCO positions or entities:
o The Medical Health Operational Area Coordinator (MHOAC) of his/her designee
o The Public Health Officer, or his/her designee
o The local EMS Agency Director or his/her designee
o The local EMS Agency Medical Director
26
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
Activation Levels of Event Complexity
Level 1 Requires resources or distribution of patients within the affected Operational Area only or as available from
other Operational Areas through existing agreements.
Level 2 Requires resources from Operational Areas within Mutual Aid Region beyond existing agreements and may
include the need for distribution of patients to other Operational Areas.
Level 3 Requires resources or distribution of patients beyond the Mutual Aid Region. May include resources from
other Mutual Aid Regions, State or Federal resources.
Level 1 Public Health and Medical Incident
• A Level 1 Public Health and Medical Incident can be adequately mitigated using available health and/or medical resources
from within the affected Operational Area or by accessing resources from other Operational Areas through existing
agreements (including day-to-day agreements, memoranda of understanding, or other emergency assistance
agreements).
• During Level 1 Incidents, a variety of response partners may be involved depending on the nature of the incident.
• The Medical and Health Operational Area Coordinator (MHOAC) should be notified of Level 1 Public Health and Medical
Incidents, including the need for accessing resources through existing agreements, and assist in accordance with local
policies and procedures. Public Health and Medical Incidents may require emergency system activation, including
activation of Department Operations Center (DOC) or Emergency Operations Center (EOC) within the Operational Area.
Level 2 Public Health and Medical Incident
• A Level 2 Public Health and Medical Incident requires health and/or medical resources from other Operational Areas within
the Mutual Aid Region beyond those available through existing agreements and may include the need for distribution of
patients to other Operational Areas. During a Level 2 Public Health and Medical Incident, resource requests should be
coordinated by the MHOAC program of the affected Operational Area. Public Health and Medical Incident will typically
require assistance from the Regional Disaster Medical and Health Coordinator (RDMHC) within the Mutual Aid Region and
may require emergency system activation, including activation of Department Operations Center (DOC) or Emergency
Operations Center (EOC) within the Operational Area.
Level 3 Public Health and Medical Incident
• During a Level 3 Public Health and Medical Incident, the need for health and/or medical resources exceeds the response
capabilities of the affected Operational Area and associated Mutual Aid Region. This determination is made from an
assessment of health and medical resources relative to current and expected demands.
• As with Level 2 Public Health and Medical Incidents, requests for health and medical resources are coordinated
by the MHOAC Program within the affected Operational Area(s), working in conjunction with the RDMHC Program.
• A Level 3 Public Health and Medical Incident will lead to activation of DOCs/EOCs within the Operational Area, Mutual Aid
Region, and State. If there is a clear need for significant out-of-region resources, or if communication with the affected
area(s) is not available, State and/or federal government response agencies may begin mobilizing and pre-positioning
resources while awaiting local requests
Unusual Event
• It should be noted an event does not have to reach an Emergency System Activation Level 2 or 3 event prior to using these
guidelines. Once an event has become as Unusual Event, as described below, the incident should be evaluated, and
determination made if the use of the framework is appropriate to the event. The California EOM defines and “Unusual
Event”, as an incident that significantly impacts or threatens public health, environmental health or emergency medical
services.
27
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
• An unusual event may be self-limiting or a precursor to emergency system activation. The specific criteria for an unusual
event many include any of the following:
• The incident significantly impacts or is anticipated to impact public health or safety;
• The incident disrupts or is anticipated to disrupt the Public Health and Medical System;
• Resources are needed or anticipated to be needed beyond the capabilities of the Operational Area, including those
resources available through existing agreements;
• The incident produces media attention or is politically sensitive;
• The incident leads to a Regional or State request for information; and/or
• Whenever increased information flow from the Operational Area to the State will assist in the management or mitigation of
the incident’s impact.
Resource Request Needs based on Levels
• The requesting of resources during a disaster will follow processes as outlined in the California State Emergency
Plan (SEP), the California Public Health and Medical Emergency Operations Plan (EOM), the California Patient
Movement Plan (PMP) and the Alameda County OAl MHOAC Program Manual.
Pediatric SMEs Integrated in Levels - Refer to Section 3.6 for SME definitions.
• At all levels of response, pediatric SMEs are utilized at the OA EOC Med/Health Branch to inform decisions
and patient movement. SME’s facilitate communication and links between sending facilities, EMS resources
and receiving facilities, and assess and monitor gap between assessed need and hospital bed availability for
OB, neonatal / pediatrics.
Level 1 Incident (OA)
Local resources sufficient
Level 2 Incident (region)
Local resources insufficient
Level 3 Incident (state and beyond)
regional or state resources insufficient Definition Requires resources or
distribution of pediatric
patients within affected
operational area only, or
as available from other
operational areas
through existing
agreements
Requires resources from
operational areas within the
mutual aid region beyond
existing agreements, and may
include the need for distribution
of patients to other operational
areas
Requires resources or distribution
of patients beyond the mutual aid
region. May include resources
from other mutual aid regions,
state, other states, or federal
resources
Emergency
System
Activation
HCC – incorporation of
clinical neonatal,
pediatric, and/or OB
SME’s at both sending
and receiving facilities,
live or remotely
Health/Medical
DOC/EOC/MOC –
MHOAC
HCC - Pediatric SME’s*
EMS DOC/OA EOC – MHOAC*
REOC – RDMHS*
Regional Patient Movement
Coordination Center **
*Pediatric SME’s may be
inserted at any location as
available and indicated
HCC - Pediatric SME’s*
DOC/EOC – MHOAC*
REOC – RDMHS*
Regional Patient Movement
Coordination Center **
MHCC* – state level patient movement
group**
FCC/JFO
*Pediatric SME’s may be inserted at
any location as available and
indicated ** Tools Internal facility/system
disaster plans (e.g.,
decompression, surge)
MOA/MOU/transfer
agreements (catchment
areas)
OA MHOAC Program
Manual OA Emergency
Operations Plan EOM
(for situational
reporting only) Other
existing local plans
TRAIN
HavBED or other
EOM (for resource requesting)
WRAP-EM
PMP
Other existing regional plans
SEP
WRAP-EM
National EMS Contract
Regional (Western States)
Partnerships
Applicable federal plans
28
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
Activation Considerations
• While this plan may be activated in response to any incident in Alameda County with a disproportionate
number of pediatric casualties, the plan may also be activated prior to a declared or proclaimed
emergency.
o In those cases, the gathering of information, assessment of the situation, and notification of health care
facilities and providers will be emphasized to provide a basis for full implementation of the plan should an
emergency be declared, and surge be required.
• The declaration of an emergency along with other actions taken by the governor’s office has significant
impact on the ability to meet the demands created by a surge incident.
o Specifically, health care regulations may be relaxed or waived during a declared emergency. This allows
the health care system to meet these demands in ways that it cannot when regulations are in effect.
• It is assumed that the systems, structures, and guidance recommended within this plan will always be
used after the hospital’s emergency operations plan has been activated.
o Therefore, it is also assumed that the Hospital Incident Command System (HICS) will be used throughout
the duration of the hospital’s emergency response.
o This plan does not replace or alter an institution’s fundamental HICS structure but rather proposes to add
additional specific functional components that may be utilized during emergency response.
• The ALCO EMS Duty Officers and the MHOAC will monitor hospital bed availability using ReddiNet®,
in collaboration with local hospitals and the Operational Area.
o The Medical / Health Branch at the OA EOC will work closely with the Hospital Incident Command
System (HICS).
o Hospitals will report situational status and resource needs up through the OA EOC M/HB. The
MHOAC will notify the state immediately upon activation.
Levels of OA EOC activation include:
OPERATIONAL
STATUS DESCRIPTION
Surveillance
The incident or event can be effectively managed at the field level. The Duty Officer
monitors information sources regarding the incident or event in collaboration with the
Health Officer on call.
Partial Activation
Incident management complexity is increased, and it is determined that partial staffing
of the OA EOC and/or HCSA DOC is warranted to provide adequate support for field
operations, local health care provider operations, local/OA EOC operations, or
RDMHC/S resource requests.
Full Activation
Incidents are of such magnitude that coordination of the response(s) at the scene or
another location is not possible; full staffing of the OA EOC and/or HCSA DOC is
necessary to provide the support for health and medical operations.
29
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
This ConOPs section supports the County EOP. Direction and guidance from the OA EOP are applicable to this
Pediatric Surge Annex. The Annex county tasks and requirements are coordinated and managed in the OA EOC.
The goals specific to children will include:
• Shared situational awareness and a common operating picture.
• Coordination with and integration of Local jurisdictions, OA (County), Region, State, and Federal agencies and
organizations.
• Shared resource and operational status information including coordination to avoid duplication of requests for
common resources.
• Information management and dissemination with OA supporting partners and stakeholder agencies and
organizations.
2.2.2 Notification
• Upon activation of the OA Pediatric Surge Plan, the hospitals in the coalition will be responsible for activation
of their HCCs,notifying the EMS Duty officer and initiating their internal EOPs, Multi-Casualty Incident (MCI)
alert, and/or Pediatric Surge Plans as needed, and expand hospital capacity.
o Each individual hospital will determine specific strategies to meet their surge target.
• The EMS Duty Officer will notify the MHOAC, EMS ICS group, local hospitals, Health Officer, County Health
Care Services Agency Director, and OA Office of Emergency Services.
o The MHOAC will notify appropriate stakeholders and coordinate a threat assessment conference call, as
needed.
• Notifications shall occur via pre-identified advanced and conventional communications systems includingbut
not limited to, the following:
o ReddiNet EMS Notification (Initiated by LEMSA) – Message Flash Report
o Telephone
o Email
o Radio Communications (MHOAC can broadcast a general alert message to connected health care
facilities within the OA)
o ReddiNet Notification (Regional or Local notification placed by RDMHS – Regional or MHOAC – Local)
o Everbridge DHV system (Initiated by local DHV Administrator via the MHOAC and or State DHV if
additional staff is needed to manage surge)
o Everbridge AC Alert notification
• Notifications should include a general statement of the nature of the Pediatric Surge. Number of patients
and MCI triage acuity (if available). (Do not include specific patient information.)
30
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
EMS Activation and Notifications – Operational Response Tool
PEDIATRIC EMS ACTIVATION CHECKLIST *** Module 1
2.3 Roles and Responsibilities
Organization and Assignment of Responsibilities
• During an incident with significant pediatric casualties, resources at health care facilities with pediatric critical
care capabilities will quickly become exhausted. Therefore, developing a system that outlines how all health
care facilities and supporting entities can assist in providing care to children is crucial to the response.
• The table below lists the responsibilities of the local coalition health care facilities and supporting entities.
PARTNER ROLES AND RESPONSIBILITIES
EMS DUTY OFFICER • Initial notifications
LEMSA • MHOAC Functions • Activate EMS DOC or OA EOC M/HB
• Coordinate Situation Status & Resource Requests
ACRECC • Initial notifications patient dispersal
• Tracking patient destinations
MHOAC • Notification of pediatric stakeholders
• Conduct conference call (if needed)
• Coordinate medical health resources • Process medical health mutual aid requests
HOSPITALS – Pediatric Specialty
Centers
• HICS • Triage & treatment
• Decontamination (if needed)
• Tracking • Secondary facility transfers • Critical Care Expansion
• Decompression
• TRAIN • Provide victim/casualty information to FAC POC
• Reporting SitStat tRequest Resources
• SMEs
• Activate HCCs
HOSPITALS – Non-pediatric
specialty hospitals
• HICs
• Triage/stabilization • Provide bed space for older children
• Additional health care workers
• Critical Care expansion for older children
Clinics / Primary Care / Community
Health Centers
• Additional health care workers;
• SMEs
Other HCFS • Additional health care workers; SMEs
911 • Triage patients; Field decontamination (if needed)
• Transport to health care facility • Patient dispersal
• Tracking patient destinations; Communications
IFT • Transportation of patients between facilities
• Secondary Transfer
Field Level EMS/First Response • Triage patients; Field decontamination (if needed) • Transport to health care facility
Office of Emergency Services • Assist coordinating pediatric requests for Mutual Aid resources • Initiate Family Assistance Centers Notifications to families of victims/casualties
Public Health • Public Health Officer Local Health Emergency Declaration (if needed)
Law Enforcement • Coordinate with Child Protective Services to ensure the safety of all
unaccompanied children • Aid in the identification and reunification of children in disaster
• Conduct investigations (if needed)
Skilled Nursing Facilities • Provide bed capacity
Behavioral Health Acute Care • Adolescent psychiatric care
Specialty Clinics (Pediatric) • Provide pediatric consultation services to hospitals
31
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.4 Logistics – 4Ss – 3Cs
2.4.1 Definitions
The underlying annex foundation is based on the surge definitions and concepts provided below:
Surge Capacity
Defined as ability to manage a sudden influx of patients and to expand care capabilities to meet sudden and/or more prolonged
demand for patient triage and treatment.
• Therefore, patient age and acuity need to be considered when determining where children will be treated.
Surge Capacity – Hospital Expansion Plan
• Surge capacity is the health care system’s ability to expand quickly beyond normal services to meet an increased demand for medical
care in the event of a disaster or large-scale public health emergency.
• The plan is guided by the following surge capacity principles:
o Would be activated in response to an event that has a disproportionate number of pediatric patients.
o Expand hospital’s existing capability – each hospital will determine what specific strategies to implement to meet their surge capacity
target.
o Hospitals that currently care for pediatric intensive care, pediatric acute care, and neonatal intensive care patients would be
requested to take care of the most critically injured children.
Surge Capacity Goal
• The goal during a medical surge event is to maximize surge capacity strategies that mitigate the crisis while minimizing the risks
associated with deviations from conventional care.
• Choosing the strategies that are most appropriate to the situation and pose the least risk to the patient and provider first, and then
proceeding to riskier strategies as demand increases and options decrease, is the preferred path.
Surge Capability - The ability to manage patients requiring very specialized medical care.
Pediatric Specialty Surge Event
o An event in which the number of specialty pediatric patients exceeds capability of the local pediatric specialty center.
Resource Matching
o Addresses issues of availability of surge resource assets: space, personnel, medications, supplies and equipment specific to the
pediatric patient population.
Medical Surge Determinants
• In a disaster, the number of patients presenting for care may cause a surge.
• Surge is determined by the number of patients a hospital can receive while maintaining usual standards of
care.
Surge Measurements 4Ss
• For each of the critical system components needed to respond to a medical surge incident, space,
staff, and supplies (3Ss), these three surge measurements of assessment guide overall surge
capacity at each of the tiered levels.
o Alameda County surge capacity/capability determinations include Systems (Command
Management) with the 3Ss which is known as the 4Ss
• An incident does not have to overwhelm assets in all of the categories to impact health care. Refer to
definitions below:
32
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
Surge Capacity Levels -3Cs
Alameda County hospital surge capacity and the 3Cs levels of care can be provided in catastrophic scenarios:
• Conventional care
o During conventional care, customary routine services are provided through standard operating procedures. Usual
resources and level of care provided. For example, during a surge in patients, maximizing bed occupancy and
calling in additional staff to assist.
o Space, staff and supplies are consistent with daily practice within the institution used during a multi-casualty
incident (MCI) that triggers activation of the facility emergency operations plan. In this case, expectations would be
for expansion of critical care by as much as 20% above baseline ICU maximum capacity using facility resources.
• Contingency Care
o Provision of functionally equivalent care that may incur a small risk to patients. Care provided is adapted from usual
practices. (e.g., boarding critical care patients in post-anesthesia care areas using less traditional, but appropriate
resources.
o During contingency care, care provided is functionally equivalent to routine care but equipment, medications, and
even staff may be used for a different purpose or in a different manner than typical daily use (e.g., substituting one
antibiotic for another that covers the same classification). The demands of most incidents can be met with
conventional and contingency care.
o Space, staff and supplies are not consistent with daily practice but maintain or have minimal impact on usual
patient care practices. These spaces or practices may be used temporarily during an MCI or on a more sustained
basis during a disaster. In this case, expectations would be for expansion of critical care by at least 100% above
baseline ICU maximum capacity to meet patient demand using local and regional resources.
• Crisis Care
o Disaster strategies are used when demand forces choices that pose a significant risk to patients but is the best that
can be offered under the circumstances. For example, cot- based care, severe staffing restrictions, or restrictions on
use of certain medications or other resources. State ratio waivers should be considered. Crisis care falls at the far
end of the spectrum when resources are scarce and the focus changes from delivering individual patient care to
delivering the best care for the patient population.
o Adaptive spaces, staff and supplies are not consistent with the usual standards of care but provide sufficiency of
care in the setting of a catastrophic disaster, providing the best possible care to patients given the circumstances
and resources available. In this case, expectations would be for expansion of critical care by at least 200% above
baseline ICU maximum capacity to meet patient demand using local, regional, state, interstate and national
resources.
Crisis Options – Children’s Tertiary Care/Specialty Centers
• Concentrate care for children at pediatric centers to preserve necessary pediatric systems, including accepting any
pediatric transfers, even ones for whom they may not typically care
• Increasing pediatric age thresholds to 21, 25, or 30 years iteratively as surge requires (as long as no adult comorbidities
exist that are not consistent with pediatric critical care practice)
• Pediatric centers should regionally activate pediatric triage when shared pediatric resources (accounting for
transportation capacity) are exhausted, with mortality predictions subject to expert opinion, which should be agreed on
and documented by members of treating team. Prior to movement to higher triage levels, especially considering such
steps being unlikely to mobilize resources, discussions should be held regarding movement of ventilators to pediatric
centers from adult sites if there is a difference in resource demand.
33
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
Contingency and Crisis Standards of Care Options and Considerations
Crisis Pediatric Intensive Care Unit Restructuring
Capacity:
• Increase ICU bed capacity by incorporating ~20 beds from step-down unit
Staffing:
• Increase ICU faculty/fellow coverage
• Deploy nursing and respiratory teams to adult care
• Designate triage roles to facilitate system-wide coordination
Bedside Care:
• Position IV pumps and ventilator consoles outside of rooms
• Coordinate bedside care with ICU nurses, respiratory therapists, PT/OT
• Balance optimal patient care and safety of health care workers
Potential Medical Surge Response Strategies *** Module 2 TTX
`
E T S E E S O MO E S
34
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.4.2 PEDIATRIC CRITICAL CARE EXPANSION PLAN
PEDIATRIC CRITICAL CARE EXPANSION OPTIONS *** Module 2 TTX
Principles and Assumptions
• Plan would be activated in response to an event that has a disproportionate number of pediatric patients.
• In a medical surge disaster event, many patients may require a high level of acute care as normally provided
in an ICU. Increased hospital ICU/PICU/NICU capacity will be a priority.
• In a declared disaster – pandemic or large MCI event, Alameda County EMS may need to expand the system-
wide hospital pediatric staffed bed capability.
• Priority is to transfer the most critical and then youngest patients (<8 years old) as early as possible to an
appropriate referral center.
• Hospitals that currently care for pediatric intensive care, pediatric acute care, and neonatal intensive care
patients would be requested to take care of the most critically injured children.
Goal
• Increase pediatric medical surge capacity and capability using hospital capability tiered approach and
expansion for critical care during an MCI/disaster event
• Expand hospital’s existing capability – each individual hospital will determine what specific strategies to
implement to meet their surge capacity target.
Pediatric Medical Surge Plan - CONOPS
• This plan is founded on a tiered system based on capacity and capability. Therefore, patient age and acuity
need to be considered when determining the location where children will be treated.
• Given the variability in pediatric care on a daily basis, all hospitals are requested to plan for an event
resulting in a surge of pediatric patients. Although hospital capabilities and capacity vary, all hospitals will
need to participate to meet the medical surge needs of children.
• This plan is based on caring for more critically ill children in facilities that are accustomed to caring for
children and allowing them to decompress less critically ill children to other facilities.
Hospital Capability Tiered Approach
• Patients should be distributed to an appropriate level of care given the specific circumstances of the situation. The tiered
options provide general guidelines that may be used in a surge that disproportionately affects children as a method for
supporting distribution of patients throughout the County.
• A pediatric medical subject matter experts should be consulted in the triage and distribution of patients when
operationalizing this plan (including at the OA EOC if activated)
• Pediatric acute patients would be cared for in facilities that may or may not typically care for children. Goal would be to
triage older (over age 8), more stable patients to facilities not accustomed to caring for children.
• The plan includes using existing PICU capacity and expanding that PICU capacity as much as possible during a surge
situation. All facilities with existing PICUs would need to meet the surge for additional PICU patients. The adult trauma
centers and their ICUs would also need to expand capacity and their capability to meet the PICU need. This plan calls
upon hospitals with PICU capability to accommodate the surge of PICU patients. This may require a shifting of non-
critical patients from these facilities so that the most critically ill children are cared for at hospitals that are accustomed to
caring for and treating critically ill children. The remainder of the hospitals will be called upon to meet the pediatric acute
35
• SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
care surge need. This means that as an event unfolds, there may be a need for secondary transfers of patients to move
more stable patients to alternate locations.
Hospital Capacity Expansion Strategies – for Critical Care ICU/PICU/NICU *** Module 2 TTX
HOSPITAL PEDIATRIC TIERED EXPANSION OPTIONS
– FOR CRITICAL CARE ICU/PICU/NICU
The following hospital bed expansion options for critical care will be considered.
UNDECLARED DISASTER
1. OPTION 1A :
• All hospitals use 5% flex to increase their inpatient PEDIATRIC critical care capacity by 5% in PICU and ICU
(not to exceed total allowed licensed beds).
DECLARED DISASTER
1. OPTION 1B:
• All hospitals increase their PEDIATRIC beds over their licensed bed capacity by 5% in PICU & ICU
(above total licensed capacity).
2. OPTION 2
• All hospitals in Alameda County with ICU or PICU beds, double their number of staffed ICU and PICU beds.
3. OPTION 3
• All hospitals take 5 additional PEDIATRIC patients in their ICU and PICU.
4. OPTION 4
• All hospitals increase their PEDIATRIC beds over their total licensed bed capacity by 10% in ICU and PICU.
HOSPITAL CAPABILITY (BASED ON LICENSED BEDS) DESCRIPTION
CRITICAL CARE FOR PEDIATRICS
- PICU (UCSF Benioff Children’s Hospital; Kaiser Permanente Oakland) PEDIATRIC PICU
- NICU NICU
- ICU ICU
- TRAUMA CENTERS ADULT & PEDIATRIC TRAUMA
CENTERS
GENERAL MEDICAL/SURGE CARE FOR PEDIATRICS
- GENERAL PEDIATRIC BEDS PEDIATRIC ACUTE BEDS
- GENERAL MED/SURGE BEDS; NO LICENSED PEDIATRIC BEDS
NO INPATIENT PEDIATRIC BEDS
- NO PEDIATRIC CRITICAL CARE; NO PEDIATRIC BEDS - - - -
- EMERGENCY ROOM ONLY
36
• SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
HOSPITAL CAPACITY EXPANSION STRATEGIES – FOR CRITICAL CARE ICU/PICU/NICU
To accommodate the initial stabilization and treatment the EMS system must have a triage system in place that will
maximize the potential for pediatric patients being taken to a hospital that has the resources for adequate care.
Surge plans must be adaptable to meet the needs of any event and corresponding surge response. The diagram below
illustrates how a surge response may change with increasing needs:
Hospital Surge Measures
Community
Hospitals with No Pediatric
Capacity
Community
Hospitals with Pediatric Capacity
Pediatric Specialty
Centers
Referral Pathway
Referral Pathway
Pediatric Center Bed Decompression
Referral Pathway
PICU/Complex
Pedi Cases Bed Expansion0-12 yearsPedi General Care
Bed Expansion0-12 years
Pedi General Care
Bed Expansion> 12-14 years
Joint CoCo-ALCO Emergency Medical Services
Recommended Pediatric Surge Bed Preservation Model
Maintaining Daily Operations
•Discharge and transfer patients, including adults when applicable, to increase the number of available pediatric beds
•No significant modifications in daily pediatric operations required
Modifying Pediatric Operations
•Increase the number of pediatric beds within the pediatric department
•Access department dimensions to ensure that additional beds can be accomodated in a given space
Modifying Facility Operations
•Utilize non-pediatric space within the facility for pediatric patients
•Use monitored beds first
Extrinsic Operations
•Order extrinsic pediatric mobile facilities
•Evacuate to facilities in unaffected areas
37
• SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
MODULE 2 TTX
Pediatric Surge Capability – Assessment (Conducted During the COVID-19 Pandemic Response 2020 - Sample) – Check Data
differs from CHA
COVID-19 Pediatric Surge Data
• During the COVID-19 pandemic, the pediatric available resources were identified and available (i.e., pediatric
referral centers, sub-specialists, telemedicine capabilities, etc.).
• The EMSC and HPP LEMSA Coordinator leads the WRAP-EM Surge Group to access COID-19 data and
resources. Refer to Section 3.12 Appendix.
• CDPH/CHA sends daily reports with the Alameda County Surge capability with pediatric surge data.
• SMEs for telemedicine and pediatric critical care are significant assets for pediatric surge.
System Name Hospital Name Licensed
Beds
Licensed
ICU Beds
State 40% Surge
Objective
Ability to Meet Capacity –
Adult & Pediatric
Alameda Health
System
Alameda Hospital 66 0 26 Yes
Highland Hospital 169 32 68 Yes
San Leandro Hospital 91 9 36 Yes
Alecto Health
care Services
St. Rose Hospital
153 9 61
Kaiser
Permanente
Northern
KP Oakland Medical
Center
315 66 126 Yes- Pediatric Capability Vent procurement almost
tripled
KP Fremont Medical
Center
100 10 40 Yes
Vent procurement almost
tripled in 2020
KP San Leandro
Medical Center
216 50 86 Yes - includes surging from
20 ICU beds to 70
Stanford Health
cCare
Stanford Health Care –
ValleyCare
202 26 81
Sutter Health
Eden Medical Center 130 24 52 Yes
can double up pts in room
and can surge up to 54 ICU
beds using all vents
Alta Bates Summit
Medical Center
800 101 320 Yes
UC Health
UCSF Benioff
Children’s Hospital
Oakland
223 74 89 Plan is to take all pediatric
patients in the county.
Unclassified
Washington Hospital
Healthcare System
415 62 166 Yes
Offering 21 spaces in
decommissioned area of
hospital.
8 Systems 14 Facilities 2979 473 1308 4287
Sources: CDPH Reports, Medical Health Branch interviews with hospitals
38
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.5 Special Considerations – Event Specific
2.5.1 Behavioral Health *** Module 3 TTX
Behavioral Health support will be managed through the OA EOC Medical /Health Branch and HCSA DOC if
activated.
• Alameda County Behavioral Health Care Services (BHCS) will
o Assess NGO/CBO mental health resources.
o Assess and implement support for the mental health needs of children within the disaster response
operation and/or affected area.
o Provide Mental Health Counseler to support children in shelters including those who have been identified
with pre-existing mental health issues.
• The OA Behavioral Health Care Services will ensure the continuation of care, treatment, and housing for
persons who were existing clients residing within the County mental health system before the incident/event.
• If a child requires greater mental health support than is available at a shelter, mental health providers will
consult with the Behavioral Health Care Services Agency and/or the OA EOC Medical/Health Branch for
additional assistance or transfer of the child to a health care facility. If a child is transferred, the child’s
parents/guardians will remain with the child through admittance and be provided support, if needed, for
visitation.
• BHCS may coordinate with the Red Cross to activate the Red Cross Disaster Mental Health staff if feasible to
provide appropriately credentialed mental health volunteers at shelters.
• BHCS will coordinate continued support from community counseling resources and/or mental health referrals
with specific expertise in counseling children if possible.
--------------------------------------
HOSPITALIZATION CONSIDERATIONS - Children
• Children may respond to disaster and hospitalization in similar ways to adults, but will also experience,
mediate, and communicate trauma in unique ways characteristic of their developmental levels. Hospital staff
should consider this when helping children cope with their hospital stay after a disaster.
• Staff can help children feel safer in the unfamiliar environment of a hospital by including familiar people,
things, and routines. Hospitals should also prepare staff for the different ways culture impacts a child’s
response to trauma
Refer to links below and Section 3.8 for additional information
• Developmental Level-Specific Guidelines for Treating Children in the Hospital
• PsySTART Rapid Pediatric Mental Health Triage System - https://www.acep.org/how-we-serve/sections/disaster-
medicine/news/june-2017/the-psystart-rapid-mental-health-triage-system/
• NCTSN (The National Child Traumatic Stress Network) Resources Related to Understanding Child Traumatic Stress
Alameda County EMS Website links:
MENTAL/BEHAVIORAL HEALTH RESOURCES
o Meeting the Challenges of Pediatric Behavioral Emergencies: Article written by Cynthia Frankel, RN, MN; Brian Blaisch,
MD; and Bruce Hagen, EMT-P for Fire Engineering Online magazine.
o Management of Behavioral Emergencies for EMS Providers (Presentation)
o Mental Health History Form for 5150 (AB 1424)
39
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
HOSPITALIZATION – TRAUMA CONSIDERATIONS - Children
• Children may display signs of trauma through their behavior, mood, and interactions with others. Key factors:
o Behavior may manifest as those of younger children.
o Watch for withdrawal as this may signal a symptom of PTSD that will distance children from adults who could provide support.
o Typically, girls are more likely to express anxiety and sadness; boys tend to display more behavior problems.
• Short and long-term impacts of trauma that may delay children’s developmental growth:
o Infants: may display sleep and feeding problems, irritability, and failure to achieve developmental milestones.
o Preschool children: may exhibit separation anxiety, dependence, clinginess, irritability, misbehavior, sleep disturbance,
withdrawal.
o School-aged children and adolescents: may include those listed above as seen in younger children as well as somatic
complaints, anxiety, change in academic performance, guilt, anger and hate, and preoccupation with death.
o Traumatic events have profound sensory impacts on young children. Their sense of safety may be diminished due to
frightening visual images, loud noises, violent movements, and other sensations associated with memories of the event. This
overwhelming stress may limit children’s ability to effectively communicate what they feel or need.
• Stepped Care Approach
o Early Interventions - Early in the post-impact phase, supportive interventions should include:
• Ensuring the child’s safety and protection from additional harm.
• Address immediate physical needs.
o Provide reassurance with age appropriate, accurate and measured information. Along with avoiding unnecessary or graphic
details.
o Take care to minimize exposure to traumatic aspects of the event.
o Validate experiences and feelings.
o Move to restore routine or schedule when possible.
o If possible, pediatric mental health professionals can help other health professionals, such as Hospice counselors, and family
members with the process of death notification.
o Reuniting family members should be a priority.
• Factors that suggest need for immediate mental health services for children:
o Dissociative symptoms such as detachment, extreme confusion, or daydreaming.
o Inability to concentrate or make simple decisions.
o Evidence of extreme cognitive impairment or intrusive thoughts.
o Intense fear, anxiety, panic, helplessness, or horror.
o Uncontrollable and intense grief, suicidal ideation or intent.
• Assessment and Screening - Assessment should include:
o A history of the child’s exposure and reactions.
o The extent of assessment should be based on level of exposure.
• When children or close family members have been directly exposed, the children may require more comprehensive
assessment
• Children with less direct exposure may also need attention.
o Education to children and their parents about trauma reactions and coping.
o Encouragement of questions to correct misperceptions.
o Ask children directly about their experiences. They may not spontaneously describe their feelings without prompting.
o Screening to identify children at risk and those needing referral can be conducted with symptom rating scales.
o Rating scales can include measuring type and degree of exposure, subjective reactions, personal consequences, PTSD
symptoms.
o Identify accommodations for children with disabilities or other functional needs which might not be readily apparent.
• (Ped Disaster Preparedness Topical Collection: Ch.4, p.6-8)
• School-Based and Community Interventions
40
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
o Schools are an optimal setting to deliver mental health services to children and families after a disaster. They provide access to
children, encourage normalcy, and minimize stigma. PTSD and associated symptoms are likely to emerge in the school setting.
o The use of play and art may aid in assessment while also being useful in treatment. This can be delivered through the schools,
community centers, faith-based facilities, and organizations that specialize in youth services.- -
AAP- (Ped Disaster Preparedness Topical Collection: Ch.4, p.8-9)
2.5.2 Decontamination
Decontamination of children requires skills and equipment to prevent effects such as hypothermia and
psychological trauma to youngest kids. The following recommendations are intended to facilitate
decontamination of all children presenting to any hospital during a disaster in a timely manner. Both prehospital
and ED personnel must be prepared to switch to “disaster” triage that incorporates pediatric physiologic
differences. Children require special considerations that may not be addressed in a general Hospital
Decontamination Plan.
Decontamination General Guidelines
Infants and children have unique needs that require special consideration during the process of hospital-
based decontamination, such as:
• Avoiding separation of families during the decontamination process.
• Older children may resist or be difficult to handle due to fear, peer pressure and modesty issues.
• Since parents or caregivers may not be able to decontaminate both themselves and their children at the
same time, decontamination personnel may need to assist them.
• Incorporating high-volume, low pressure water delivery systems that are child-friendly into the hospital
decontamination showers.
• Risk of hypothermia increases proportionally in smaller, younger children when the water temperature in
the decontamination shower is below 98°F.
• Attention to airway management, a priority in decontamination showers.
• The smaller the child, the bigger the problem regarding any of the above considerations.
• Infants, children, and adolescents have anatomical, physiological, psychological, and developmental
characteristics that are different than the adult population.
• First responders and hospital providers should be prepared to deliver age-appropriate care, including
decontamination.
• Infants and children can have limitations in communication skills, self-care, independence, supervision, and
transportation.
• Infants and children may not be able to answer triage questions about their symptoms, or to follow instructions
given to them.
• Children and adolescents could be encouraged to do self-decontamination such as clothing removal and
showering.
• Ideally, decontamination of infants, children, and adolescents will maintain family units to maximize efficiency,
minimize psychological trauma, (from disrobing in front of others), and possibly improve physical outcome.
41
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
Decontamination
Victims arrive at the hospital requiring decontamination.
Children are present among the victims.
Patients with critical injuries are decontaminated first.
Children and their families (parents or caregivers) should not be
separated unless critical medical issues take priority
Estimate child’s age by visual
inspection
Non-ambulatory Ambulatory
▪assist
disrobing
(child’s
caregiver or
“hot zone”
personnel)
▪direct
supervision of
decon
▪monitor
airway
▪escort
through the
shower by
either
caregiver or
“hot zone”
personnel
Infants and
Toddlers
▪disrobe by child’s
caregiver and “hot
zone” personnel
▪place on a
stretcher or
restraining device
▪escort through the
decon shower by
“hot zone”
personnel and
caregiver
▪direct supervision
of decon (of
caregiver, too)
▪monitor airway
(Caregiver should not
carry the child due to
the risk of accidental
trauma from a fall or
dropping the child
while in the shower.)
▪disrobe by
child’s
caregiver and
“hot zone”
personnel
▪place on a
stretcher or
restraining
device
▪escort
through the
decon shower
by “hot zone”
personnel and
caregiver
▪direct
supervision of
decon (of
caregiver,
too)
▪monitor
airway
▪Treat or prevent hypothermia (towels, gowns, warming blankets)
▪Immediately give a unique identification number on a wristband (or equivalent)
▪Triage to an appropriate area for further medical evaluation
Please note: Children and their families (parents or caregivers) should not be separated unless critical medical issues
take priority
▪disrobe w/o
assistance
▪respect
modesty
▪respect
privacy
▪child decons
him/herself,
but goes
through
decon
shower in
succession
with
caregiver,
parent, or
classmates
Preschool (2
to 8 yrs old)
School Age (8
to 18 yrs old)
42
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.5.3 Evacuation
• Protective actions such as evacuation and shelter-in-place have become more important to emergency
management operations in previous years, requiring a more comprehensive look at concepts and principles that
plans should be built around and considerations that are critical to ensuring effective implementation.
• Over eight million people across the nation were affected by evacuation orders in 2017, including:
• Flooding in February near the Oroville Dam in California caused an evacuation of over
180,000 people ;•
• Hurricane Harvey struck Texas in August and resulted in the evacuation of over 780,000
people ;
• Hurricane Irma struck Florida in September and resulted in evacuation orders covering
a record 6.8 million residents;
• In October, wildfires in California forced the evacuation of over 100,000 residents.
• These disasters illustrate that the use of evacuation and shelter-in-place as protective actions are commonplace
regardless of the threat or hazard. The challenge is to tailor the protective actions to best address a variety of
factors, including a community’s demographics, location, infrastructure, resources, authorities, and decision-
making processes as found in the following document.
https://www.fema.gov/sites/default/files/2020-07/planning-considerations-evacuation-and-shelter-in-place.pdf
Evacuations of children
• In some emergency situations—fire, explosion, and some weather and geological events—it will not be safe
to stay in or around your facility.
• Areas where large numbers of children may be vulnerable and require evacuation include:
o Schools
o Residents in Group Facilities (e.g., childcare programs, residential care facilities)
o Children at Public Sites Evacuation (e.g., movie theaters, cultural centers, malls)
o Children on a Group Trip (e.g., school field trip)
o Children from Medical Facilities
o Minors in Detention Facilities
• Evacuation of neonatal infants will require specialized modes of transport.
Hospital Evacuation
• Transfer of patients from a hospital would use the internal Surge Transfer Process for identifying bed
availability.
• Evacuation requires coordination with the Alameda County OA EOC Medical/Health Branch if activated or
the MHOAC if the EOC is not activated.
• Alameda County recommends the TRAIN Model for internal hospital evacuation.
• Refer to table below and Section 3.5.
43
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
TRAIN™ (Triage by Resource Allocation for Inpatients)
• A patient typing and ambulance asset triage tool, designed to maximize efficient use of paratransit, BLS, ALS,
CCT and Specialized Ambulance services during a large disaster.
• It categorizes inpatients according to their resource transportation needs during an evacuation or mass casualty event
requiring increased surge capacity.
• It accurately assesses patients quickly and easily to determine transportation needs, which allows facilities to
request and receive resources required for evacuating patients to other facilities in a disaster. However, T ™
does not type inpatient beds.
• The tool is used to determine the number of each level of transportation required for evacuation. Appropriate levels of
transportation are based on local EMS transport guidelines and protocols.
• The tool does not determine the level of care or acuity of the patient or identify the receiving institution for an
evacuated patient. It is most powerful when all institutions in a region use it to facilitate collaboration and
communication.
• It allows:
o Rapid determination of resource requirements for pediatric transport
o Augmentation of surge capacity by identifying candidates for rapid discharge or transfer to lower level of care
o Communication with receiving institutions and supporting agencies
o More accurate resource requesting
o Streamlined communication with common code.
o Implementation of standardized and automated inpatient hospital evacuation triage system with minimal impact to
workflow
o Increased awareness and disaster preparedness across a facility
o Greater understanding of gaps between transport needs and available resources at local and regional level which will
need to be allocated across the county, state, and nation, depending on magnitude of disaster
(Resourced from Perinatal, Neonatal, and Pediatric Surge Annex to the California Patient Movement Plan stays - DRAFT
January 2020. Additional resources in References)
Refer to Section 3.4 for additional information.
44
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.5.4 Specialty Pathogens / Infection Control / COVID-19 / MIS-C
• As the COVID-19 pandemic has illustrated, infectious disease outbreaks can create a surge in patients and
overwhelm local hospital systems.
o It is possible that a novel infectious disease could impact children exclusively or to a much great degree
than adults.
o Because pediatric resources are limited in both scope and location, a surge of exclusively pediatric
patients would have devastating effects on the pediatric health care infrastructure.
o The same components of surge response would apply to infectious disease, focusing on space, staff,
and supplies.
• Alameda County Infectious Disease Emergency Response (IDER) Plan was adopted as the coalitions’
response plan for infectious disease emergencies.
o Activation of the Infectious Disease Emergency Response Plan will be coordinated with and through the
Alameda County Health Services Agency’s Department Operations Center (DOC) (if activated).
o Hospital Command Centers may also be activated in response to an infectious disease emergency and
will coordinate response activities with the OA EOC Med/Health Branch and HCSA DOC.
INFECTION CONTROL Resources
• 2020 Alameda County Field Manual -
http://ems.acgov.org/ClinicalProcedures/FieldTreatmtProtocols.page?
• CDC Information MIS-C: Case Definition; Clinical Presentation - https://www.cdc.gov/mis-c/hcp/
• COVID-19 Alameda County School, Childcare, and Camp Guidance
o https://covid-19.acgov.org/schools
o COVID-19 School Guidance: Alameda County School Reopening Plans
o Guidance for Camps and Education/Recreational Programs (ACPHD)
o Guidance and FAQ for Out-of-School-Time Camps and Youth Extracurricular Programs: English | Arabic | Chinese
(Simplified) | Chinese (Traditional) | Khmer | Korean | Spanish | Tagalog | Vietnamese (ACPHD, 9/30/2020)
• Infection prevention and control in pediatric ambulatory settings
• Infection Control: Standard Precautions for All Patient Care
45
SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.5.5 Security
Security will play an integral role in any event requiring activation of a plan due to a disaster. Many of these events
could involve increased security risks, such as in the case of an active shooter scenario or terrorist activities. In addition,
as families attempt to find their loved ones, crowds will form requiring an increased need for security personnel.
OA EOC Security Responsibility
• The OA EOC Public Safety Branch and on-site security/law enforcement will oversee safe environments for children.
• Safety activities will focus on the safe operation and functions of facilities and sites including mitigation and correction of
physical hazards to children. Security activities will include site security, childcare area security, control of unaccompanied
minors, traffic management, and perimeter/access control.
OA EOC Public Safety Branch shall:
• Coordinate with Environmental Health officials for assessment of shelter facility/site sanitation and health risks to
children (e.g., chipping paint, extreme heat).
• Coordinate with appropriate OA EOC Branches or agencies (e.g., Construction/Engineering, Fire) to implement safety plans
including safe operation of and, if necessary, evacuation from, children’s play areas, sleeping areas, common areas (e.g.,
bathroom/showers, recreation areas), and unused areas.
OA EOC Logistics Branch
• Assessment and, if necessary, addition of lighting inside and outside the facility for safe movement of families and children.
• Review and correction of child-risk hazards (e.g., trailing cords, open power outlets, stairs, non-alarmed exit doors).
Site Security and Evacuations - HCFs and Shelters
• Local jurisdiction law enforcement will provide security to facilities and sites. If local resources are exceeded, Logistics
at the OA EOC will request support from adjacent jurisdictions or the State.
o State may request EMAC and/or Federal support if applicable. Private security companies may provide security.
• The Public Safety Branch will advise on-site security (e.g., local law enforcement) and site management of any known security
risks to children at the facility or in the surrounding community.
• For large HCFs and shelters, if resources are available, management will implement a roving volunteer patrol to
provide greater visibility to staff of activities and, to shelter residents, increase the comfort level regarding the safety
of their children in the facility.
• A percentage of the evacuee population will be subject to judicial and/or legislative orders restricting their freedom of movement
geographically or in proximity to specific individuals (e.g., sex offenders, people under court orders/on probation). Applicable
codes, regulations, statues will be referenced and implemented for required response.
• If a person required to report by law and seeks government provided transportation or arrives at a HCF or shelter
and self-reports, then reception or staff will advise the HCC or designated site manager, who will consult with on-site
security and/or law enforcement for required follow-up action. Merge with bottom 4 rows
• If an evacuating person does not self-report and is identified, site management will notify on-site security or law enforcement
and the OA EOC Care and Shelter Branch to request further information, direction, or action.
• Law enforcement will determine whether the person required to report will remain on general evacuation
transportation and/or in the shelter or will be provided alternate transportation and/or a separate shelter.
• If person required to report remains in the general population environment, law enforcement will coordinate with reception
center or management and with on-site security as to security plan to be implemented and procedures to follow.
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• If reception center, transportation, or shelter site also holds the person or people from which the person required must remain
at a distance, alternate arrangements will be made.
Perimeter and Building Access Control
• On-site security will identify perimeter and access control for all areas including parking areas, loading/unloading access,
ingress and egress routes, and all entrances/exits.
• On-site security will monitor children’s inside play areas and outside green spaces for access points, secure entrances
and exits, hazards, and visibility.
Traffic Management
• Public Safety will create and implement a traffic management plan in and around mass care sites, including appropriate
safety barriers and personnel in areas where children may be moving or playing.
• At publicly accessed mass care sites (e.g., shelters, bulk distribution sites, mass feeding sites) law enforcement will:
• Disseminate information to the affected public regarding traffic management and appropriate movement of people while
at the site (e.g., control of children).
• Address ingress and egress traffic management issues with consideration for safety of children.
HOSPITALS AND SECURITY
• Hospitals and other HCFs should include the institution’s security leadership early in the planning process. At a minimum,
the hospital family reunification plan should include the creation of a security leader within its command structure.
• Hospital security personnel can also assist with the coordination of interface between the facility and outside law
enforcement. Ideally, an individual with preexisting relationships with law enforcement on local and regional levels, including
relevant entities (e.g., Federal Bureau of Investigation; Bureau of Alcohol, Tobacco, Firearms and Explosives), may fill this
position. There will need to be a security presence in the Hospital Family Reunification Center (HFRC) and the Pediatric
Safe Area (PSA).
Refer to Section 4.5 and the Alameda County EMS Website Link below for additional information.
RESOURCES FOR PARENTS/GUARDIANS/CARETAKERS OF AT RISK/VULNERABLE CHILDREN
• Emergency Medical Information Brochure- Information on the Emergency Medical Information Form and developing an
Emergency Care Plan for your child.
• Emergency Medical Information Form (from American Academy of Pediatrics ) a detailed medical form that includes all
aspects of your child's care.
• Emergency Medical Information Card a shorter version of the form that can be carried by your child.
• Fact Sheet for developing an Emergency Care Plan for the Special Needs .
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2.5.6 Special Needs
Given children in disasters have special needs including supervision, medical, food, and transportation, this Annex
assumes specialized planning and response will occur in a disaster event as listed below.
FUNCTIONAL NEEDS
• A percentage of the population impacted by an emergency incident or event will be people with disabilities or
others with access and functional needs (PAFN) including children who have medical conditions; who require
assistance with activities of daily living; who have limited English proficiency or are non-English speaking; who have
limited mobility, sensory impairment, or intellectual disabilities; or who are unaccompanied minors.
• PAFN will include children from congregate settings (e.g., licensed community care or health facilities) and who
receive in-home care.
Children with Special Needs – Group Homes
• There are several pediatric group homes within the coalition service area that care for high risk vulnerable pediatric
populations.
• These patients require 24/7 care, are primarily non-mobile and non-verbal.
• They depend on durable medical equipment and are vulnerable to infrastructure damage (i.e. loss of power,
transportation, etc.).
• It is of utmost importance that these institutions maintain and exercise their internal disaster plans and remain connected
with regional response planning.
Cultural/Religious/Non-English Speaking Considerations
• It is important to consider language barriers and varying cultural traditions that may affect how patients and their families
respond in a disaster situation. This is especially true with children as their cognitive ability at certain ages may lead them
to misinterpret what is happening to them and their families.
• Refer to Section 3.10 and 3.12 for local resources.
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2.6 OPERATIONS – MEDICAL CARE & PATIENT MOVEMENT 2.6.1 Triage
• Triage is the process of determining the priority of patients' treatments by the severity of their
condition or likelihood of recovery with and without treatment.
o This prioritizes patient treatment efficiently when resources are insufficient for all to be treated
immediately, influencing the order and priority of emergency treatment, emergency transport, or transport
destination for the patient.
• Primary triage is done at the scene by first responders (i.e. Field/EMS triage).
o Triage category is assigned rapidly and is based on physiologic parameters and survivability.
• Secondary triage occurs typically at the facility where the patient is transported.
o The initial triage assignments may change and evolve as the patient’s condition changes so
reassessment is crucial.
o It is essential that medical personnel prioritize transport and treatment based on level of injury and
available resources. Ideally, this would be facilitated by Pediatric Subject Medical Experts.
• Patient reassessment occurs continuously throughout the medical care of the victims.
o For example, patients in the ED are triaged by their needs such as operating room access, radiologic
imaging, admission, etc.
• Patients are also re-triaged if secondary transport/transfer to another facility is needed (e.g. higher
level of care, decompression, evacuation, etc.)
• To accommodate the initial stabilization and treatment the EMS system must have a triage system in
place that will maximize the potential for pediatric patients being taken to a hospital that has the
resources for adequate care.
o For example, children (≤ 14 Years of age) should be triaged preferentially to a pediatric-capable trauma
center (e.g.- Children's). Refer to recommended policies/plans below
▪ MCI EMS Response Update from new 2020 Alameda County EMS Field Manual
▪ New York’s Triage Algorithm https://www.nycremsco.org/wp-content/uploads/2018/02/2018-01-
REMAC-Advisory-Modified-START-Triage.pdf
▪ Rady Children’s Hospital, San Diego; Pediatric Surge Plan 2019
▪ Washington Peds Surge Annex Triage Algorithms
▪ Interim Guidance: SARS-CoV-2 (COVID-19) and Field Trauma Triage Principles
• Disaster triage is a method of quickly identifying victims who have life-threatening injuries and who
also have the best chance of survival.
o Identification of such victims serves to direct other rescuers and health care providers to these
patients first when they arrive on the scene.
o The use of disaster triage involves a change of thinking from everyday care to:
o Doing the greatest good for the greatest number.
o Identify victims with the best chance of survival for immediate intervention, focusing care on those with
serious and critical injuries but who are most likely to survive.
o Identify victims at extremes of care by sorting those who are minimally injured and those who are so
severely injured that they will not survive.
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o Immediate treatment is given only those victims that the procedure or intervention may make a difference in
survival.
ALAMEDA COUNTY EMS TRIAGE POLICY
• Refer to the EMS Triage Policy pediatric sections below:
o http://ems.acgov.org/ems-
assets/docs/Clinical/Field%20Protocols/2020%20FM%20Updates/3%20ACEMS_FM_2020_MainBook.p
df
EMS MCI POLICY
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COVID-19 Considerations
• The SARS-CoV-2 virus (the virus that causes COVID-19) has spread widely throughout the globe and is still continuing
to spread. Emergency Medical Services (EMS) systems may experience a trauma-based mass casualty event
-that necessitates triage while COVID-19 remains a significant threat to public health.
• Several factors related to SARS-CoV-2 infection should be considered when planning for, or responding to, trauma
and mass casualty events in which field triage principles or schema are applied.
• Appropriate use of Personal Protective Equipment (PPE), universal precautions, and other scene safety
considerations must be in place at all times.
2.6.1 Triage
• Alameda County is considering the New York Field Triage algorithm
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2.6.2 Treatment/Medical Care
Pediatric Medical Care
• Caring for children requires continued didactic and skills training especially for those who do not routinely
care for children. Planning for children can be a daunting task.
• The Pediatric Readiness Program is promoted with all acute care receiving hospitals participating.
o Refer to Section 3.7
• Alameda County EMS has pediatric policies and procedures identified in the EMS Field Manual 2020.
o Refer to the Alameda County EMS Field Manual http://ems.acgov.org/ems-
assets/docs/Clinical/Field%20Protocols/2020%20FM%20Updates/3%20ACEMS_FM_2020_MainBook.pdf
• The Alameda County EMS Field Manual and the Hospital Surge Templates provides a step-by-step
instructions on how to prepare hospitals and care for children during a disaster.
o These resources provide information on pediatric triage, treatment, pharmacy, equipment,
decontamination, security, behavioral health, infection control and neonatal preparedness and
resuscitation, along with links to Just-In-Time training for basic pediatric skills.
o Refer to Sections 3.7 Alameda County Pediatric Readiness Resources and 4.1 for the Planning
and Caring for Pediatric and Neonatal Patients in Disasters: Inpatient and Outpatient Guidelines,
2020
2.7 Transportation
• Pediatric transport at times requires specific equipment and always requires appropriately trained staff.
• Facilities will have in place proper procedures to transport pediatric patients safely to the appropriate facility.
• Evacuation of neonatal infants will require specialized modes of transport.
• In a large event when a regional and/or state JEOC has been activated, transport control will follow
established procedures as outlined in the CA Patient Movement Plan and Alameda County EMS Plans.
----------------------------------------------------
OA EMS and OA EOC Coordination
• In a catastrophic surge event, the Alameda County EOP, EMS field policies, and MHOAC Manual are
activated as applicable and scalable to the event.
• The Incident Command on scene and/or Hospital Hospital Command Center (HCC) will communicate with
the appropriate OA EOC Med/Health Branch to coordinate vehicle transport and patient destination.
• Regarding a hospital evacuation, OA EOC Med/Health Branch may consider sending an ambulance
strike team to triage patients and determine patient destinations at the impacted hospital.
• In a hospital evacuation event, patients should be prioritized by the hospital Medical Triage Officer on scene
who will be in communication with Incident Command and appropriate Hospital HCC and OA EOC
Med/Health Branch.
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Transport Options for Limited Transport Vehicles
• It is understood that there are limited EMS vehicles with pediatric capabilities, primarily due to lack of
appropriately trained staff.
Therefore, it may be necessary to transport pediatric patients with staff from the referral institution in order
to provide safe transport.
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• Alternate means of transportation such as transit buses, facility shuttles and vans, ambulances, private
vehicles etc. should also be considered and equipped with appropriate safety measures and staff when
transporting children.
MCI and Triage Considerations
• In an out-of-hospital event, pediatric patients should be triaged and prioritized by established pediatric MCI
triage algorithms to include JumpSTART or SALT.
o Refer to Section 3.3 for the Alameda County EMS Policies including the MCI policy.
Patient Destination and Movement Decision Considerations
“Moving the Right Child, at the Right Time, to the Right Place”
• Once the CA Pediatric Surge Annex to patient Movement Plan 2020 is approved. Alameda County
with adopt the transportation and patient movement essential components.
o Refer to the Diagrams below.
• Hospital HCC will make any requests for resources through MHOAC Program - OA EOC Med/Health
Branch
o Resource requests can include durable and non-durable medical goods, pharmaceuticals, bed
availability and transport resources.
o The MHOAC Program will attempt to fill the request using standard policy and procedures as outlined in
the EOM and MHOAC Program Manuals.
1. Day-to-day movement of pediatric patients:Refer to CA Pediatric, Neonatal, and OB Surge Annex
• Facility resources are adequate to meet the need.
• Usually a transfer is from a M, L, or S facility to a higher level of care.
• The appropriate SME is either pediatric, neonatal or OB (including PICU and NICU)
• The authority to request a move rests with the SME at a sending facility.
• The authority to accept a patient belongs to the SME at the receiving facility.
• The responsibility to arrange an appropriate level of EMS transport belongs to the SMEs.
• Existing agreements may be used including catchment areas, transfer agreements, MOU, MOA, etc.
• A MHOAC may or may not be used as a resource or informed.
2. Pediatric patient movement with emergency system activation:
Sending facility (M, L, S) SME EMS receiving facility (H, M,) SME
communication
Activated Government response center ------------------ position
DOC/EOC/MOC MHOAC
REOC (patient movement coord center) RDMHS
State MHCC patient movement group
FCC/JFO FCO/JPMT
Sending facility (H, M, L, S)
HCC with peds, neo and/or SME
Receiving facility (H, M, L)
HCC with peds, neo and/or OB SME
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Key Elements
• Aims to prioritize pediatric patients for transport to the most appropriate facility from the scene of an MCI
o Minimizes need for inter-facility transfer for seriously injured children
o Addresses inter-facility (secondary) transport - Secondary transport assessed AFTER completion of primary
transport - SMEs would support prioritizing patients for movement
Ambulance Transport 911 Pediatric Capability
• Alameda County is separated into five exclusive operating areas (EOAs) for the provision of 9-1-1 ambulance transport
services. Within each EOA there is a contracted provider for 9-1-1 ambulance transport services.
Inter-facility transport (IFT)
• There are several facilities within te coalition that contract with their own hospital pediatric transport vehicles.
• The Alameda County permitted Inter-facility transport (IFT) providers are listed below with their capabilities:
PROVIDER - IFT
BLS-CCT
Capability
Pediatric Critical
Care / NICU CCT
Capability
Pediatric BLS
EMS Providers
(BLS/CCT)
Contracts directly with
ALCO hospitals
Sutter-AMR YES YES . NICU contract with Alta
Bates
ROYAL AMBULANCE YES YES NO
NORCAL AMBULANCE YES YES NO
UNITED AMBULANCE NO YES NO
FALCK AMBULANCE BLS NO YES NO
FALCON CCT YES YES NO
PROTRANSPORT-1 NO YES NO
ARCADIA AMBULANCE NO NO NO
BAYMEDIC AMBULANCE NO YES NO
WESTMED AMBULANCE YES YES UCSF CHO-BENIOFF
SACRAMENTO VALLEY
AMBULANCE YES YES NO
LIFEwest NO YES Kaiser
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Patient Movement – Transfer Assumptions
• General suggested criteria for transfer from a higher-level facility to a medium or low-level facility, when necessary, are as
follows, in order of first to transfer priority:
o Patient >14 years of age and developmentally age appropriate, medically stable condition, no special equipment
needs.
o Patient >12 years of age and developmentally age appropriate, medically stable condition, no special equipment
needs.
o Patient >10 years of age and developmentally age appropriate, medically stable condition, no special equipment
needs.
o Patient >8 years of age and developmentally age appropriate, medically stable condition, no special equipment
needs.
o Community level NICU patient to Intermediate NICU.
o Regional NICU patient to Community level NICU.
o Patients with multiple medical issues or chronic medical conditions (e.g., cardiac, pulmonary, oncology, endocrine)
will stay at a High-level facility.
o Patients requiring specialized pediatric equipment or procedures or are medically unstable will stay at a High-
level facility.
-----------------------------------------------------------------------------------
Any pediatric patient that requires a level of care outside the EMT/AEMT/paramedic scope-of-practice will be required to
remain at the sending hospital (and under the care of the attending physician) until one of the following can be arranged:
• An R.N. staffed air ambulance can be arranged to transport the patient.
• An R.N. staffed ground Critical Care Transport (CCT) ambulance can be arranged to transport the patient.
• A transferring hospital R.N. can be assigned to assist the EMT/AEMT/paramedic in providing care for the patient in the
ambulance during transport.
During a pediatric surge event, the clinical determination of which patients are suited for transfer, and the prioritization for those
transfers to specialty centers, will be made by the sending physician(s) in consultation with the receiving physician(s). The
LEMSAs and MHOAC Programs will provide operational support/assistance in obtaining transportation resources (including
ambulance strike teams and alternate modes of transportation).
The general practice in Region II for any large-scale surge event that involves pediatric patients will be as follows:
• According to current LEMSA policies/protocols, pediatric patients (between the ages of 0-14 years, including
unaccompanied minors), will be evaluated/ treated on-scene and initially transported to the nearest acute care hospital
emergency department for further evaluation/treatment.
• If a pediatric patient requires medical care that cannot be provided at the original receiving hospital,
arrangements will be made, by the sending hospital, to transfer the patient to the most appropriate higher-level
facility.
• Pediatric patient interfacility transports will be accomplished by either ground ambulance or EMS aircraft, as available
and appropriate.
• Individual Operational Areas (OAs) will maintain current contact lists of local agencies that may be able to provide
alternate modes of transportation, such as non-emergency medical transportation, bus companies, para-transit
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*** Module 2 – Surge TTX **
A Pediatric Intensivist Response Team and Essential Elements of Information (EEIs) are required for secondary transport
SECONDARY TRANSFER ACTIONS – USING Pediatric Intensivist Response Team (PIRT) AND EEI
• During secondary transport the transferring facility is responsible for collecting the patient related EEI data
and transmitting is to the transfer center and the receiving facility.
o The receiving facility is responsible for the facility related EEI data and reporting it to the transfer center and
sending facility.
o The sending facility physician should share the patient related EEI with the accepting facility physician who will
share the facility EEIs.
o Transfer will take place if the patient care needs are matched by the facility available capabilities.
• The transfer center will arrange for secondary transport of all patients based on the patient EEIs including
ambulatory status and equipment needs.
o The facility EEI data will be shared with the transfer center and sending facility to match resources to needs. The
transfer center will decide on the type of transport need based on the transmitted EEIs.
o The transfer center will request permission for transfer to the appropriate level of care facility designated in the
EEIs. Refer to Section 3.4 and 3.15
o The transfer center will submit the patent EEIs to the receiving facility who will review the information and then
provide answers and availability based on the facility EEIs.
o If the receiving facility resources meets the needs of the patient, the sending physician will speak to the receiving
physician, confirm the information and update transfer patient status and notify the transfer center to proceed.
Once completed the transfer center will proceed with transport.
• If there are limited transport capabilities due to magnitude of the disaster the transfer center will contact the
Pediatric Intensivist Response Team (PIRT) physician on call via the OA EOC M/HB to prioritize the patients
based on their EEIs (clinical severity, subspecialty and equipment needs). – Pending Further Planning Discussions
o Alameda County is considering using the Pediatric Intensivist Team PIRT which is currently in the planning
stages Refer to Section 3.6
• The OA EOC M/HB in coordination with transfer center will decide on the type of transport need based on the
transmitted EEI and PIRT recommendations.
o The transfer center will submit the patent EEIs to the receiving hospital who will review the information and then
provide answers and availability based on the facility EEIs.
o If receiving hospital resources meets the needs of the patient, the sending physician will speak to the receiving
physician, confirm the information and update transfer patient status and notify the transfer center to proceed.
o Once completed the contracted Transfer Center with coordination with Alameda County EMS will proceed with
the transport.
• The collection of information should be done electronically preferably by email or web-based platform that is
accessible to both facilities and the transfer center.
o Incorporating the EEIs into the platform in the future would be optimal.
o For large scale events overall facility surge capacity based on the EEI facility information would allow for overall
utilization of resources, however the challenge is to maintain current up to date situational awareness.
o In the event of a power or computer system failure a paper back up system should be utilized.
o If possible the patient’s complete medical record should accompany them to the receiving facility.
2.8 TRACKIN
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2.8 TRACKING
• The focus of this annex is to establish a standard process to identify, track, and reunify children and
families and outline the roles and responsibilities of agencies involved in tracking and reunification
activities. ReddiNet may be used for data gathering for Patient Tracking (using the MCI and messaging
Modules) and Family Reunification.
CA Tracking Plan Consideration - CUPTS
This plan will consider using the patient tracking system that is a part of the CA Patient Movement Plan:
• The California Unified Patient Tracking System (CUPTS), while still an untested concept and
must be practiced, will provide a standard method of tracking patients in a large-scale surge event.
• This system will provide a uniform method of tracking both adult and pediatric patients.
The CUPTS consists of three (3) components:
• The County of Origin: Using the FIRESCOPE OA Code
• The Sex of the Patient: M, F, U
• The last four digits of the Triage Tag (or last four of the SSN if no tag)
2.9 Reunification
Reunification - HCFS
• Every health care facility will maintain internal procedures for family reunification.
• Planning for a Pediatric Safe Area (PSA) is key to pediatric security and pediatric tracking during
response. If the event requires resources beyond what individual health care facilities can provide, then
local, operational area, regional and/or federal Family Assistance Center plans will be activated and family
reunification will follow designated procedures below.
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ALAMEDA COUNTY AGENCIES AND DEPARTMENT REUNIFICATION ROLES
Alameda County Social Services Agency (SSA)
• Lead agency supporting children affected by a disaster incident/event.
• Care and Shelter Branch Coordinator for the County’s unincorporated areas of Ashland, Castro Valley, Cherryland,
Fairview, San Lorenzo, and Sunol
• OA EOC Care and Shelter Branch Coordinator for mass care.
Support children who become unaccompanied minors as a result of being separated from or lack a
parent/guardian as a result of a disaster.
• Coordinates care of unaccompanied minors in sheltering system which includes mobile teams with resources if shelter in
place is needed for groups of unattended children in congregate care facilities (e.g., schools or child care programs)..
• Coordinates trained staff to support and is responsible for the following in mass care:
• Coordinates mass care activities with local Red Cross chapter or Red Cross Disaster Relief Operation (DRO) if activated.
• Coordinates with Voluntary Agencies Active in Disaster (VOAD), local governmental agencies supporting mass
care, NGO/CBOs supporting mass care, State agencies, and Federal personnel, when applicable.
• Manages registration of evacuees or tracks children in shelter in place settings.
• Responds to inquiries from people outside affected area who are seeking information regarding missing persons.
• Provides funds or purchase orders for food, clothing, shelter, medical care, transportation, and other essential needs to
support children, based on casework with individual persons.
• Manages the CalFresh and Disaster CalFresh (D-CalFresh) programs (i.e., formerly “food stamps” and Federal
regular and disaster Supplemental Nutrition Assistance Program [SNAP/D-SNAP]).
• Manages, or provide assistance with, programs that support families with children including child care, Medi-Cal, housing
assistance, and Supplemental Security Income.
• Develops memorandums or statements of understanding and collaborative planning efforts with support agencies and
organizations such as the Red Cross, Voluntary Organizations Active in Disaster (VOAD), the Salvation Army, local
community-based organizations, national response organizations, and child care providers.
Department of Children and Family Services (DCFS)
• Manages custody issues of unaccompanied minors.
• Coordinates physical reunification of unaccompanied minors with parents/guardians or other family separated as a result
of the disaster.
• Manages follow-up on the welfare of children within the foster care system who have evacuated and/or whose foster
homes have been affected by disaster.
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Procedures for Care of Unaccompanied Minors will include the following:
REUNIFICATION AND MISSING CHILDREN
OA EOC Reunification Processes
Reunification Methods and Services
• OA SSA shall assist in the reunification process by taking some or all of the following actions:
o Activate or request activation of all systems used for disaster welfare information and reunification (e.g., Red Cross
Disaster Welfare and Reunification Systems - Safe and Well).
o Coordinate through the OA EOC Care and Shelter Branch to request information from other OA Branches, Units, or
agencies (e.g., coroner’s office, Family Assistance Center (FAC), Search and Rescue, law enforcement) to support
parents/guardians seeking missing children, people who have information about missing persons, or unaccompanied
minors seeking missing parents/guardians.
o Parents or guardians seeking custody of a child will have their identities and rights to the child verified prior to release
of the child to their care.
o If multiple persons seek custody of the child (e.g., divorced parents, relatives), verification of legal and physical
custody will be sought prior to release of the child to either parent/guardian. If verification cannot be acquired from the
affected area or the person seeking custody, the decision-making will be moved to a judicial process.
o Transportation or access to a mode of transport will be provided for reunification of unaccompanied minors with
parents or guardians via the OA EOC or local jurisdiction.
Procedures for Reunification of Unaccompanied Minors will include the following:
• If a verified parent, guardian, or extended family has not been located within a timeframe determined by SSA, DCFS will
implement its standard operating procedures for placing the child into foster care.
• If a group of unaccompanied minors is under shelter care when a shelter is closing, the group will be moved to another
shelter or a shelter supported by DCFS will be opened and staffed for their longer-term care until appropriate foster care
can be located.
• Child care support groups, nonprofit organizations, and faith-based groups will be requested to provide care assistance
until parents, guardians, or caregivers can be located or long-term arrangements can be made. Resources from these
groups will be vetted through regular processes.
Support Unaccompanied Minors
• During or following a disaster, some minors may become separated from their families or guardians. Reunification of these minors is a
priority.
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Support for Unaccompanied Minors in Shelters
Information Regarding Missing Victims and Safe Locations
• Staff will obtain as much information as possible about the minor and his or her parents/guardian (e.g., names, phone number, and last known
• Unaccompanied minors will be tracked in official shelters for the purpose of family reunification. Independent shelters are encouraged to track
unaccompanied minors as well.
• The child will be placed in a secure area, supervised, until DCFS, law enforcement, or a verified parent/guardian takes physical charge of the
minor.
• Red Cross procedures for unaccompanied minors will be used until the minor is turned over to DCFS or their designate.
Parents/Guardians Seeking Missing Children
• Parents/Guardians seeking children who are identified as deceased will be informed in the presence of a mental health or behavioral
health staff person, shelter management, and a representative from the coroner’s office or law enforcement, as appropriate and available.
• Parents/Guardians will be assisted in claiming the remains and possessions, if any, of the victim using law enforcement, coroner’s office, or
other agency standard procedures, as appropriate.
Children Whose Parents/Guardians are Missing
• If parents/guardians of unaccompanied minors are identified as deceased, a mental health or behavioral health staff person, shelter
management, and a representative from the coroner’s office or law enforcement , as appropriate and available, will be present when the child
is advised.
• DCFS will be advised as soon as possible.
• Reunification processes will proceed to identify an alternate guardian and/or extended family.
Confidentiality requirements
• Brief response personnel in requirements, protocols, procedures, and importance of confidentiality in managing information about children.
• Medical information will be managed based on HIPAA requirements, as needed.
Coordination of disaster welfare information from investigative and disaster support services sources will be managed by the Care and
Shelter Branch with information from the following sources:
• Missing-persons records – law enforcement
• Coroner records – coroner’s office
• Evacuee tracking systems – NGO/CBOs, governmental, private.
Welfare Information Services
The following resources can be used by the public to assist in obtaining information during and after a disaster.
Red Cross Safe and Well Website
• The Red Cross Safe and Well website provides a tool with which to exchange welfare information with loved ones and friends in the immediate
aftermath of a disaster. The Red Cross also actively seeks out and coordinates welfare inquiries as they are received.
National Emergency Child Locator Center
• The National Emergency Child Locator Center is operated by the National Center for Missing and Exploited Children. During a disaster
declared by the President, this system is used to assist in the reunification of families and locating children.
National Resource Center for Child Welfare Data and Technology
• The National Resource Center for Child Welfare Data and Technology created a web application called Reconnect Families designed to aid
child welfare organizations, both public and private in locating and reconnecting the families they serve.
National Emergency Family Registry and Locator System
• The National Emergency Family Registry and Locator System is a web-based system that assists families separated by a disaster reunite.
Family Assistance Centers (FACs)
• FACs are used during mass casualty events as safe and secure locations for families of missing victims to wait for or receive information
regarding their family member(s) (e.g., victim is deceased, has been admitted to a hospital, or is still missing). They are also places at which
families may provide information to authorities in order to assist in identifying victims, receive updates regarding incident recovery, and receive
emotional support, spiritual care, and health and social services as resources are available.
Family Reunification Requests
• Family Reunification Requests, which are requests to reunite family members who have been separated within the disaster area, are handled
in the same way as Emergency Welfare Inquiries.
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Tracking & Reunification
HOSPITALS – Displaced Children
• Hospitals have historically served as safe havens for displaced persons during a disaster. Abandoned children are also
often brought first to a hospital emergency department for evaluation.
• During a disaster, hospitals may again serve as safe havens and may find themselves host to displaced and
unaccompanied children. As an example, Hurricane Katrina and the ensuing floods and chaos caused over 3,000
children to be displaced throughout the United States.
• These displaced children, if unaccompanied, are at increased risk for maltreatment, neglect, exploitation, and
subsequent psychological trauma. Hospitals and medical clinics will need to be especially alert to the safety and mental
health issues of these children.
----------------------------------------------------------------------------------------------------------------------------------
• Hospitals, especially those that do not routinely take care of the pediatric population, need to pay special attention to the
specific security needs of this group and take the necessary precautions to ensure proper care of these individuals while
they are in the hospital.
There are two populations of accompanied children during a disaster that should be addressed:
1. The pediatric patient who is a patient of the hospital because of the disaster and who may become separated from the
responsible adult; for example, if the responsible adult is also a patient.
2. The pediatric visitor who is not a patient of the hospital but who may be accompanying an adult person who is a patient;
for example, a critical adult patient who was caring for a minor at the time of the disaster or event.
• A possible solution to tracking these persons is to use a system of identification bands for the minors and corresponding
responsible adults that are distributed as soon as these individuals contact the Emergency Department (ED) area.
• Care must be taken to quickly and correctly place bands or other identification devices on both parties. Create a safe
area that will serve as a holding area for uninjured, displaced or released children awaiting adult caregivers.
Hospital Considerations for Displaced Children
Rapid identification and protection of displaced children (less than 18 years) is imperative to reduce the potential for
maltreatment, neglect, exploitation, and emotional injury.
▪ A critical aspect of pediatric disaster response is effectively addressing the needs of children who have been displaced
from their families and legal guardians.
o The separation of children from significant others is a recognized factor influencing the psychological responses of
children after a disaster.
▪ All hospitals, medical clinics, and shelters providing care to child survivors of disasters should immediately implement
appropriate child-safety measures in direct response to this crisis.
o Initiatives such as “Operation Child-ID” implemented in Camp Gruber Oklahoma after Hurricane Katrina in 2005
o Find out where they are sleeping/being held and the name and age of person(s) who is/are supervising them.
• Parents/Caregivers have a key role in a child’s sense of safety and security. Helping them reconnect quickly is a high
priority. Essential considerations are:
o Gather all available identifying information to provide to the appropriate authorities. This should include:
o Name - - Parent(s)’s name - - Caregiver’s name - - Sibling name(s)
o Address - - School - - For younger children, and those unable to respond, notate other differentiating characteristics (birthmarks, hair
color, eye color, etc….)
➢ If an unaccompanied child is encountered, gather the above information and contact the appropriate authorities.
➢ Provide children with accurate, easy to understand information about who will be supervising them and what to expect
next.
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SECTION 2 – RESPONSE CONCEPT OF OPERATIONS
2.10 Deactivation And Recovery
Demobilization Indicators
• Throughout the Annex activation, the OA EOC Med/Health Branch, in consultation with applicable coalition
partners, will determine the appropriate conditions to partially or fully demobilize and deactivate the Annex.
• Demobilization indicators may include:
o The pediatric health care impact from the incident is at a low level sufficient for ending response
coordination.
o DPHC Partner agencies have deactivated any EOC/HCCs and/or emergency response plans.
o The threat of a reoccurrence of the pediatric incident or similar events is sufficiently low to not require
response coordination.
Demobilization Communications
• The OA EOC Med/Health Branch, in consultation with any applicable partners, will communicate deactivation
of the Annex to the same partners that received the activation notice. Annex deactivation will likely be
communicated by, at a minimum, email or ReddiNet messaging.
• Depending on the severity or scope of the incident, the NWHRN will lead and/or participate in an after-action
process. If the OA EOC leads an after-action process, results will be communicated and distributed to
partners following completion of the after-action report.
Recovery
• After demobilization and during recovery the following activities should be completed:
o Return of any borrowed assets (e.g. equipment, staff).
o Debrief participating local, regional, and/or state partners with after action reports, discuss improvement
plans, and create a coordinated approach to incorporating recommendations into future planning.
o Communications concerning payment and reimbursement for the response.
o Communication of any operational activities that need to be revised or continued
65
SECTION 3 – APPENDICES
3.1 RISK AND DEMOGRAPHICS
66
SECTION 3 – APPENDICES
3.1 RISK AND DEMOGRAPHICS
“The Haves and the Have Nots”: A comparison of Pediatric Mass Casualty/Multiple-Casualty Policy
in San Francisco and Alameda Counties
The World Health Organization (WHO) defines a mass casualty incident as an “event which generates more patients at one time
than locally available resources can manage using routine procedures” or “any event resulting in a number of victims large enough
to disrupt the normal course of emergency and health care services.”1 These events can arise from the hands of men or nature.
Regardless of the culprit, both have risen since the 1970s, with natural disasters having increased. The WHO reported that in the
“1970s, man-made events accounted for 16.5% of disasters and 4.3% of related deaths; in the 1990s, they had risen to 42% and
9.5% respectively (these figures do not include “complex emergencies” involving armed conflict and a total breakdown of
authority).”1 If we were to look at gun violence’s role in mass fatalities, just in the last six years, we have seen a 55% increase in
mass shootings, and though the year has not yet ended, the United States has already exceeded the number of mass killings in
2019 at 491 incidents.2
In light of these increases, it is more vital than ever for every local government and municipality to create a Mass Casualty Incident
plan to prepare for these catastrophes. California is unique because it has been a victim of MCIs from gun violence (7 of 31
mass murders were committed in California in 2019, the most of any other state), and massive wildfires that have
ravaged its forests.
Two of its counties, San Francisco and Alameda, are only 13 miles apart, but the counties could not be more different. San
Francisco is home to the most billionaires per capita in the world.3 While 15% of Oakland (of Alameda County) residents live
below the poverty line, beyond the California and national averages.4 However, this is not the biggest difference between the two
cities. When we consider the pediatric population of both areas, there is a stark difference. San Francisco has the lowest
percentage of children among any of the largest 100 cities in America, while Oakland’s (as well as its county, lameda)
percentage of children exceeds ew York ity’s percentage of children.5
The disparity in these two counties’ populations is reflected in its EMS policies when it comes to Mass Casualty/Multi-Casualty
Incidents (MCI). Alameda County EMS has a stand-alone, robust pediatric surge protocol (as an adjunct to the MCI policy), while
San Francisco County EMS has only incorporated minimum pediatric protocols into its larger MCI policy.
We know from the merican cademy of ediatrics’ ( ) numerous publications, that children are one of the most
vulnerable populations in MCI/Disaster events. Pediatric populations have unique physiology that varies with age and are
oftentimes taken care of by those who are not familiar with pediatric care is only part of what worsens their care in these events. In
Shirm et al, 72.9% of agencies report having written plan responses for MCI, while only 13% of agencies report having pediatric
specific plans.6 Though San Francisco County has approximately 120,000 children (the same number of dogs), its minority
pediatric population has another layer of vulnerability.
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SECTION 3 – APPENDICES
3.2 SURGE STRATEGIES - 4S/3C PLANNING & CRISIS STANDARDS OF CARE
Hospital Pediatric Surge Readiness Requirements
Adapted from Kaiser Permanente
The most important aspects of plans are as follows:
1. Assurance that every medical center has a local disaster plan and leaders who know how to access that plan. This
plan includes a means of communication with the local counties and regional support teams. This should include triage
systems including SALT, transfer systems including TRAIN and evacuation systems like EVAC 1,2,3.
2. Baseline capacity: A general idea of pediatric capacity and ability to take care of different complexity of care at baseline,
on a non-disaster day, for medical centers. This will never be perfect but knowing who has PICUs, NICUs (and the level),
Pedi Surge, ECMO capability, Pedi Burn, Pedi trauma and mixed Adult/Pedi capability is very important. The county EMS
leaders generally has an idea of the capacity at the different medical centers in their county.
3. A plan for communication, coordination, transfer/transport—one that looks at many different possibilities for who is
open, impacted, not open, etc. The most important thing here is knowing how these entities will communicate, and who
will coordinate and facilitate that communication, with as much specificity of the need as possible. It’s impossible to plan
for every possible set of circumstances—but it is possible to plan general strategies, and then really drill down on the
decision making and communication processes that work the best, with the appropriate agencies planning the role they
should be playing. The plan ensures local command center to reach out to regional command centers who then help
move patients from areas under surge to facilities with capacity for those patients. Any transport between states for
PICUs or NICUs will involve direct communication between involved physicians. If we are moving multiple patients
between facilities due to a disaster, our regional and state disaster leaders will be involved to help monitor capacity,
remove barriers and assure our tracking tools are being used.
4. Tracking and Reunification- Having basic details which stay with the patient and also available on an Electronic Medical
record is important. It is important to be able to track patients through transitions to other facilities or locations.
5. Strategies to increase surge capacity
1. Rapid discharge of patients
2. Transport of complicated and vulnerable patients early
3. Age guidelines to allow non-pediatric facilities/floors to care for older kids
4. Green zones
6. Early identification of resource needs:
1. Personnel
2. Supplies
3. Equipment
4. Medications
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SECTION 3 – APPENDICES
3.2 SURGE STRATEGIES - 3S/3C PLANNING & CRISIS STANDARDS OF CARE
3.2.1 Logistics
Medical Surge and Medical Surge Triggers
In a disaster, the number of patients presenting for care may cause a surge. Surge is determined by the number of patients a
hospital can receive while maintaining usual standards of care. For each of the critical system components needed to respond to a
medical surge incident, space, staff, and supplies, three measurements guide overall surge capacity at each of the tiered levels.
An incident does not have to overwhelm assets in all of the categories to impact health care.
• Conventional capacity is the ability for hospitals to manage a surge while operating daily practices with little or no
impact on the patients or facility.
• Contingency capacity affects hospital daily practices' ability to be consistent but has minimal impact on usual patient
care. At this point, the demand for resources has not exceeded community resources.
Crisis Capacity may require adjustments in care not consistent with daily practices, but the standard of care is coherent within
the setting of an emergency.
• The best possible care is provided to patients under these circumstances.
• Once contingency or crisis capacity is reached during a surge of pediatric patients, hospitals without pediatric resources
will require greater assistance from regional, state, and federal partners.
o In a mass casualty incident, the resources to assist children will likely be scarce, and staff inexperience
with pediatric critical injury and illness will result in an inadequate surge capacity.
• Each Regional Health Care Coalition should maintain knowledge of the total capacity for pediatric casualties and
have a plan in place to be able to support an increase in pediatric surge capacity during an incident.
• Strategies to increase surge capacity within the hospital should be consistent with and integrated within Regional Health
Care Coalition operational guidelines.
• All appropriate available space should be utilized.
• Some areas to consider include the following:
o Discharging inpatients and emergency department patients as soon as feasible and safe.
o Converting outpatient procedure beds into inpatient beds.
o Establishing a discharge holding area.
o Using hallways or creating alternate treatment areas (e.g., ambulatory clinics, on-site fitness center, etc.)
o Strategies to create pediatric emergency treatment capacity outside the hospital.
o Initiate mutual agreements with other health care facilities, such as long-term pediatric care and rehabilitation
facilities.
o Utilize mobile clinics, hospital-based ambulances, faith-based facilities, fitness centers, and/or schools as alternate
treatment areas.
o Establish relationships with pediatric tertiary care centers.
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SECTION 3 – APPENDICES
3.2.2 Potential Medical Surge Response Strategies
Table-1 Potential Medical Surge Response Strategies
Table 1 below demonstrates how each stage of surge capacity could be managed as the number of pediatric patients
increases.
Essentials Resources – Space, Staff, Supplies
- Every hospital in Alameda County must be prepared to provide supportive care services to all patients regardless of
age.
- This section of the plan aims to provide guidelines for health care providers to continue to provide treatment
ethically to pediatric patients, when there may be a significant imbalance between the needs of the patients and the
resources available to the health care provider.
Supplies
• Stockpiled supplies used
• Medical Supply Chain
able to resupply on
request
• •
• •
•
Hospital MOUs
Regional Equipment,
Supply, and Pharmaceutical
Caches
• •
•
State Caches
Strategic National Stockpile
(SNS)
Allocation of Scarce Medical
Resources
Space
• Cancel elective
procedures
• Use in-place bed
additions
• Begin surge discharge
•
•
Clear patients from preinduction
and procedure areas
Fill all available beds
Bed availability reporting
(ReddiNet)
•
•
Place patients in hallways or
lobby areas
Activate Alternate Care
Sites
Staffing
• Use all staff trained to
care for pediatrics to
provide care
•
Request pediatric trained staff
from
• regional hospitals
• Medical Reserve Corps
(MRC)
- Mobile Medical Field Teams
- Ambulance Strike Teams
• Nurse Registries
- DHV
- National Disaster Medical
System (NDMS) Disaster
Response
- Utilize staff not trained for
pediatric care
Conventional Capacity Contingency Capacity Crisis Capacity
Medical Surge
Capacity
Capability
Tiers
Tier 1 Tier 2
Tier 3
Tier 4
Tier 5
Tier 6
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SECTION 3 – APPENDICES
POTENTIAL MEDICAL SURGE RESPONSE STRATEGIES
Space Surge Strategy
Primary Goal: To maintain operations and increase the capacity to preserve life and patient safety and ensure appropriate health
care delivery to the community.
SPACE2
Strategies Regulatory Considerations
•
Utilize licensed space for other types of
patients
- Use outpatient beds for
inpatient care
- Use internal skilled beds as acute
patient areas
- Convert adult space into pediatric
space
- 22 CCR 70811(c): Patient rooms which are approved for ambulatory patients
only shall not accommodate non-ambulatory patients
- 22 CCR 70805: Spaces approved for specific uses at the time of licensure
shall not be converted to other uses without the written approval of CDPH
- 22 CCR 70809(a): No hospital shall have more patients or beds set up for
overnight use by patients than the approved licensed bed capacity except in
the case of justified emergency when temporary permission may be granted
by the CDPH Director or designee
• Increase capacity inpatient rooms or
hallways in patient care areas
• Two (2) patients in a single room
• Three (3) patients in a double room
• 22 CCR 70811(a): Patients shall be accommodated in rooms with a
minimum floor area (as detailed in 22 CCR 70811 (a) (1) and (a) (2)
• CCR 70805: Spaces approved for specific uses at the time of licensure shall
not be converted to other uses without the written approval of CDPH
• 22 CCR 70809(a): No hospital shall have more patients or beds set up for
overnight use by patients than the approved licensed bed capacity except in
the case of justified emergency when temporary permission may be granted
by the CDPH Director or designee
•
•
Open hospital floors that are vacant
Use areas of the hospital for inpatients
• 22 CCR 70805: Spaces approved for specific uses at the time of licensure
shall not be converted to other uses without the written approval of CDPH
•
• G.I. Lab
• Recovery Room Outpatient Surgery or
Physical Therapy
• Other
o Use non-traditional areas of the
hospital for inpatients
o Cafeterias
o Conference Rooms
o Parking Structures
• 22 CCR 70809(c): Patients shall not be housed in areas which have not
been approved by CDPH for patient housing and have not been granted a
fire clearance by the State Fire Marshal
• Use tents to create additional patient care
areas
• 22 CCR 70809(c): Patients shall not be housed in areas which have not
been approved by CDPH for patient housing and have not been granted a
fire clearance by the State Fire Marshal
• Request relaxation of nurse/patient ratios to
allow occupancy of all licensed beds
• 22 CCR 70217: Nurse ratios
• Union Regulations
• AB 294: California R.N. Staffing Ratio Law, requires Governor's standby order
for statutory suspension
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SECTION 3 – APPENDICES
POTENTIAL MEDICAL SURGE RESPONSE STRATEGIES
Staff Surge Strategy
Primary Goal: Increase the ability to maintain staffing levels and/or expand the workforce.
STAFF5
• Paramedics
• Retired health
professionals with
an active license
o EMRs
o EMTs
o Medical
Assistants
o LVNs
o CNAs
o Liability/licensing regulations
o State laws regarding malpractice coverage for granted a fire
clearance by the State Fire Marshal volunteers
• Utilize families to render care under the direction of
a health care provider
• Title 22 – Certified nursing assistant to render care
• Implement and/or develop just-in-time training for
clinical staff commonly assigned to nondirect
patient care positions
• None
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POTENTIAL MEDICAL SURGE RESPONSE STRATEGIES
Supplies Surge Strategy
Primary Goal: Ensure adequate levels of supplies and equipment are available.
Region III Pediatric Surge Work Group identified the following three (3) areas to prioritize when developing strategies for the
allocation of scarce supply and equipment resources:
• Airway
• Breathing
Circulation
The workgroup has identified the following categories of supplies and equipment that should be available for use in the
emergency room during a pediatric surge event:
SUPPLIES
Airway Oral Pediatric Airway
Nasopharyngeal Airway
Laryngeal Masks
Endotracheal Intubation Tubes
Laryngoscope Blades
Breathing Face Masks
Non-rebreather Masks
Ambu bags
Chest Tubes
Nasogastric Tubes
Circulation Intravenous Supplies
Invasive Mechanical Vents
HFO Ventilators
OR Invasive Mechanical Ventilators
Portable Invasive Mechanical
Non-invasive Ventilators
Pediatric Specific Broselow Bags
Broselow Carts
73
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3.2.2 Crisis Standards of Care
74
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75
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3.3 Triage, Medical Care, Treatment Guidelines, and Decontamination
3.3.1 Decontamination Based on Child’s Age (_____
The following recommendations are based on the child’s estimated age of appearance, since asking may be impractical due to
the limitations of personal protective equipment (PPE) and/or due to a large influx of patients. These recommendations are
divided into three groups by ages:
• infants and toddlers (0-2 years)
• preschool children (2-8 years)
• school aged children and adolescents (8-18 years)
Infants and Toddlers (0-2 years)
Infants and toddlers are the most challenging group to treat; special needs considerations are of the utmost importance in this group.
Follow the guidelines below during treatment.
• ll infants and toddlers should be placed on a stretcher and undressed by either the child’s caregiver or hospital
decontamination personnel.
o All clothes and items should be placed in appropriate containers or bags provided by the hospital and labeled.
• Each child should then be accompanied through the decontamination shower by either the child’s caregiver or
hospital decontamination personnel to ensure that the patient is properly and thoroughly decontaminated. It is
not recommended that the child be separated from family members or adult caregivers.
o Caregivers should not carry the child because of the possibility of injury from a fall, or from dropping a slippery and
squirming child. Special attention must be given to the child’s airway while in the shower.
• Non-ambulatory children should be placed on a stretcher by hospital decontamination personnel and undressed
(using trauma shears if necessary).
o All clothes and items that cannot be decontaminated (glasses, hearing aids, or other devices) should be placed in
appropriate containers or bags as provided by the hospital and labeled.
• All non-ambulatory children should then be escorted through the decontamination shower by either the child’s
caregiver or decontamination personnel to ensure the patient is properly and thoroughly decontaminated.
o Special attention must be paid to the child’s airway while in the shower.
• Once through the shower, the child’s caregiver or post-decontamination personnel will be given a towel and
sheets to dry off the child, and a hospital gown.
o The child should immediately be given a unique identification number on a wristband and then triaged to an
appropriate area for medical evaluation.
• Children and their parents or caregivers should not be separated unless critical medical issues take priority.
Preschool-Aged Children (2-8 years)
Children ages two to eight years can walk and speak, yet (with considerable variations in physical characteristics), are
clearly children.
• mbulatory children should be assisted in undressing with help from either the child’s caregiver or
hospital decontamination personnel.
o All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as
provided by the hospital and labeled.
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SECTION 3 – APPENDICES
3.3 Triage, Medical Care, Treatment Guidelines, and Decontamination
3.3.1 Decontamination Based on Child’s Age (cont’d)(_____
• Each child should be directly accompanied through the shower by either the child’s caregiver or hospital
decontamination personnel to ensure the entire patient is properly and thoroughly decontaminated.
o The child should not be separated from family members or the adult caregiver.
• Non-ambulatory children should be placed in a stretcher by hospital decontamination personnel and
undressed (using trauma shears if necessary).
o All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as
provided by the hospital and labeled.
• Each non-ambulatory child on a stretcher should be escorted through the decontamination shower and
assisted with decontamination to ensure the patient is thoroughly and properly decontaminated.
• Once through the shower, each child should be given a towel and sheets to dry themselves, and a hospital
gown.
o The child should be immediately be given a unique identification number on a wristband and then triaged to
an appropriate area for medical evaluation.
• Children and their parents or caregivers should not be separated unless critical medical issues take
priority.
School-Aged Children and Adolescents (8-18 years)
At the age of eight years and older, children’s airway anatomy approximates that of an adult. Although it is tempting to regard this
age group as “small adults” there are special needs unique to this age group.
• Ambulatory children should undress as instructed by hospital decontamination personnel.
o All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as provided
by the hospital and labeled.
• Each child should then walk through the decontamination shower, preferably in succession with their parent or
caregiver, and essentially decontaminate him or herself.
• Non-ambulatory children should be placed on a stretcher by hospital decontamination personnel and undressed (using
trauma shears if necessary).
o All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as provided
by the hospital and labeled.
• Each non-ambulatory child should be escorted through the decontamination shower and assisted with
decontamination to ensure the entire patient is properly and thoroughly decontaminated.
• Once through the shower, each child should be given a towel and sheets to dry themselves, and a hospital gown. The
child should then immediately be given a unique identification number on a wristband and triaged to an appropriate area
for medical evaluation.
• Children and their parents or caregivers should not be separated unless critical medical issues take priority.
77
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3.4.1 Inter-Facility Transfer - EVACUATION FORMS
Patient Evacuation Transfer Form
78
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Loma Linda PICU Form
79
SECTION 3 – APPENDICES
3.3.1 Inter-Facility Transfer - EVACUATION FORM HICS 260e - Sutter
80
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3.4.2 TRAIN - EVACUATION MODEL
• Alameda County is adapting the TRAIN Model.
NICU TRAIN TOOL
81
SECTION 3 – APPENDICES
3.4.2 TRAIN - EVACUATION MODEL
PEDIATRIC TRAIN TOOL
82
SECTION 3 – APPENDICES
3.4.2 TRAIN - EVACUATION MODEL
83
SECTION 3 – APPENDICES
3.5 DECOMPRESSION - TRANSFER COORDINATION Centers and EEIs
- Inter-Facility Transfer Options with EEIs
84
SECTION 3 – APPENDICES
3.6 SMEs- Pediatric Intensivist PIRT/MPERT/DHV/MRC
Pediatric SUBJECT MATTER EXPERTS (SME) Definitions
There are three types of Pediatric Care Medical Specialists. and SMEs
• Group 1 Specialists:
o Includes pediatric intensivists, pediatric emergency physicians and/or pediatric physicians with transport expertise
who will be called upon during all events in which the Annex is activated to assist with patient triage, coordination of
transfers and system decompression.
• Group 2 Specialists:
o Includes pediatric specialty physicians, primary care physicians and neonatal subspecialists who will be activated to
serve in a medical consultation role based on the specific needs of the event and the affected population.
• Group 3 Specialists:
o Includes pediatric specialty advanced practice providers (e.g., nurse practitioners) and support resources (e.g., child
life specialists, pediatric pharmacists) that will be activated to serve in a consultation role based on the specific
needs of the event and the affected population.
OA EOC Subject Matter Experts
• Children’s Annex Coordination, Technical Specialists, Liaisons, and Subject Matter Experts (SMEs)
• A Children’s Focused Liaison and/or SME designated by the Operations Chief may work with SSA under the Mass Care
Operations Branch or if needed and feasible, the Children’s Liaison and/or SME may function within the EOC Medical /
Health Branch. The SME may also be appointed as a liaison to the Director of Emergency Services at the EOC.
• To facilitate coordination within the OA EOC and the local jurisdiction operations in support of the emergency response
for children, Shelter, Plans, Medical, and Logistics branches may designate children’s technical specialists and subject
matter experts.
• The Children’s liaison, children’s technical specialists and specific subject matter experts will conform to the ICS
reporting structure assigned at the OA EOC as directed.
• These specialists may be convened by the Operations Chief serving as liaison or working within the Shelter or Medical
branch to contribute to the OA Incident Action Plan.
• The Children’s Liaison and SME may act as County liaison with NGO/CBOs supporting children.
• Within the ICS planning intelligence section, a designee may be responsible for collecting, evaluating, and
disseminating operational information related to children.
MPIRT/MPERT/MRC/DHV TEAMS
• Alameda County is utilizing clinical pediatric intensivists and physicians identified in the Alameda County Unit
DHV and MRC in the COVID-19 response.
• Given the HPP LEMSA and EMSC Coordinator is also the DHV Administrator, clinicians with pediatric
capability can be accessed when needed for subject matter expertise remotely and for deployments.
• The concept of a Mobile Pediatric Emergency Response Team (MPERT) will be activated if needed.
• The Mobile Pediatric Intensivist Response Team (MPIRT) will be activated for secondary transport decisions
if needed. Refer to p; 60 – “SECONDARY TRANSFER ACTIONS – USING PIRT AND EEIs”
85
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3.7 Pediatric Readiness Project / EMSC
86
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3.7 Pediatric Readiness Project / EMSC
Pediatric Readiness Checklist
87
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3.7 Pediatric Readiness Project / EMSC
Pediatric Readiness Checklist
88
SECTION 3 – APPENDICES
3.7 Pediatric Readiness Project / EMSC
Pediatric Readiness Checklist
89
SECTION 3 – APPENDICES
3.7 Pediatric Readiness Project / EMSC
Pediatric Readiness Checklist
90
SECTION 3 – APPENDICES
3.7 Pediatric Readiness Project / EMSC
Pediatric Readiness Checklist
91
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Pediatric Readiness Checklist
92
SECTION 3 – APPENDICES
Pediatric Readiness Checklist
93
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Pediatric Readiness Checklist
94
SECTION 3 – APPENDICES
Pediatric Readiness Checklist
95
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Pediatric Readiness Checklist
96
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97
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CA EMSC Regulations
CALIFORNIA EMSC REGULATIONS
- APPROVED – EFFECTIVE 7/1/19
GOAL / PURPOSE
To ensure children receive adequate & appropriate EMS to prevent loss of life & human potential,
creating EMSC program.
• To protect welfare, health, & safety of pediatric patients.
• To provide consistent, equitable, & standardized criteria statewide
• Provide direction/requirements to local EMS for implementation of EMSC programs
• Clarify REQUIREMENTS FOR LEMSA to develop & implement EMSC programs
• Create quality improvement for PEDIATRIC FACILITY DESIGNATIONS
• Facilitate RESOURCES & TRAINING for prehospital providers & hospital EDs
➢ Ensure preparedness for providing medical care to pediatric patients, from neonates to adolescents.
EMSC REGULATIONS - PedRCs
COMPREHENSIVE
▪ Inpatient resources - NICU & PICU
▪ California Children’s Services (CCS) tertiary hospital
▪ Transfer agreements & regional referral center for specialized care pediatric patients.
▪ Can provide comprehensive care to any pediatric medical & surgical care child
ADVANCED
▪ Community neonatal intensive care unit (NICU) or as an intermediate NICU
▪ ED able to stabilize critically ill or injured infant, children, & adolescents prior to admission to PICU or
transfer to Comprehensive PedRC facility.
▪ Establish formal agreements with minimum one Comprehensive PedRC for education/consult
▪ Participate with Comprehensive PedRC for pediatric education
▪ Establish transfer agreements with Comprehensive PedRC
▪ Establish transfer agreements for pediatric patients needing specialized care
▪ Specialties on-call & available for consult to ED within 30 minutes: Radiologist – with pediatric experience;
neonatologist; general surgeon with pediatric experience; otolaryngologist with pediatric experience.
GENERAL
• Participate with Comprehensive &/or Advanced PedRC for pediatric emergency education
• Establish agreements with Comprehensive PedRC &/or Advanced PedRCs as approved by local EMS
Establish transfer agreements for pediatric patients needing specialized care
• Have physician &/or nurse PECC which may be shared with other PedRCs.
BASIC
• Establish agreements with at least one Comprehensive PedRC; Establish agreements with Advanced or
General PedRCs; Establish transfer agreements for pediatric patients needing specialized care
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Alameda County Pediatric Readiness Training Plan 2021-22
- UCSF Benioff Children’s Hospital Partnership
EMERGENCY DEPARTMENT PEDIATRIC READINESS/SITE VISIT EDUCATION PROJECT
The Alameda County EMS Agency strives to assist the various medical facilities in our County to be better prepared to handle
pediatric patients during both day-to-day operations and during disaster/surge situations. Below are resources and Alameda
County EMS links related to those efforts:
o 2020 ED Pediatric Site Visit Participation Form
o Alameda County's Pediatric Medical Surge Plan
o Pediatric Disaster Plan Template for Hospitals
o Pediatric (Non-PICU) Hospital Surge Plan Guidelines
o Pediatric Surge Plan Template
o Pediatric Surge Readiness Checklist
o Pediatric Readiness Fact Sheet
o Pediatric Readiness Assessment
o Inter Facility Transfer Tool Kit
o AAP Pediatric Preparedness Disaster Resource Kit
o National Pediatric Readiness Project and Toolkit
o Joint Policy Statement - Guidelines for Care of Children in the Emergency Department
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3.8 PsyStart / Behavioral Health
Children Response to Trauma and Interventions
- Children may respond to disaster and hospitalization in similar ways to adults, but will also experience, mediate, and
communicate trauma in unique ways characteristic of their developmental levels.
- Hospital staff should consider this when helping children cope with their hospital stay after a disaster. Staff can help children
feel safer in the unfamiliar environment of a hospital by including familiar people, things, and routines.
- Hospitals should also prepare staff for the different ways culture impacts a child’s response to trauma.
Neonates (< 1 month) and Infants (0-1 year)
• Let a parent or caregiver stay with and, when possible, hold the infant during medical procedures.
• Use familiar objects from the baby’s home such as stuffed animals, blankets, music, boxes, or toys for comfort before,
during and/or after a procedure.
Toddlers (1-3 years) and Preschool-aged (3-5 years) Children
• Avoid discussing toddler or preschoolers’ care in their presence unless you include them in the conversation. Children
overhear much more than adults realize and, without any explanation, information may seem terribly frightening.
• Let a parent or caregiver stay overnight with the child if possible and let other family members, including brothers and sisters,
visit when appropriate.
• Reassure the child that the hospitalization is not a punishment. Avoid applying good or bad labels to the child, particularly
during a procedure. For example, instead of saying “See, you were so good, the doctor only had to do this once,” you can
say “You did such a good job of sitting still, I know that was hard.”
• Allow children to handle medical equipment such as stethoscopes, blood pressure cuffs, etc. and to practice procedures
on a doll. Children learn best through play— “medical play” can be particularly useful.
• Allow the child to make choices whenever possible, but don’t offer a choice when none exist. For example, do not say,
“Would you like to come into the treatment room now, so the doctor can look at you?” Instead say, “Do you want to bring
your bear or blanket with you to the treatment room?”
Middle Childhood (6-11 years)
• You can give school-aged children more specific information about what they will experience; however, many medical
terms can be confusing. For example, the term "I.V." could be confused with the word “ivy,” or “dye” with “die.” Give
simple, specific explanations for procedures and use non-technical language.
• This is a great age for medical play (communicating understanding, fears, etc. through play with medical equipment).
Let the child reenact events through play with different kinds of toys or art materials. This will help school-aged
children express their feelings and gain a sense of control over what is happening to them.
• Children this age may regress or revert to behaviors that they had outgrown (thumb sucking, bed wetting, etc.) during
stressful situations such as hospitalization. Do not berate (e.g., say, “Come on, you’re a big girl now…”) or punish
children for such behavior; instead, encourage them to express their feelings and discharge emotions through play.
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3.8 PsyStart / Behavioral Health
Adolescents (12-18 years)
• Avoid discussing teenagers’ care in their presence unless they are included in the conversation. Adolescents can
understand much more about their bodies and what is happening to them than younger children and may resent being
excluded from discussions.
• Do not assume that teens manage their emotions the same way as adults. Give teens opportunities to talk to staff
about what is happening and to ask questions, both with and without parents or caregivers present.
• Encourage all staff to respect teens’ privacy by knocking before entering exam rooms and by being sensitive to who
is around during examinations.
• Adolescents are particularly concerned about body image and do not want to be perceived as “different” than peers
because of an illness or injury. Be especially sensitive to the physical changes adolescents may experience when
explaining any procedures, injuries, or treatments.
How to Help Children During and After a Disaster
Children Younger than Five Years of Age
• Maintain their normal routines and favorite rituals as much as possible.
• Limit exposure to TV programs and adult conversations about the events.
• Ask what makes them feel better.
• Give plenty of hugs and physical reassurance.
• Provide opportunities for them to be creative and find other ways to express themselves.
Children Older than Five Years of Age
• Don’t be afraid to ask them directly what is on their minds and answer their questions honestly.
• Talk to them about the news and any adult conversations they have heard.
• Make sure they have opportunities to talk with peers, if possible.
• Set gentle but firm limits for “acting out” behavior.
• Encourage expression, verbally and through play, of thoughts and feelings.
• Listen to their repeated retellings of the event.
When to Consult a Mental Health Professional
• Seek psychiatric consultation if children exhibit any of the following behaviors:
o Worry about unfamiliar people, places, or activities
o Fear of not being able to escape if something goes wrong
o Suicidal thoughts or the desire to hurt others
o Feelings of being helpless, hopeless, or worthless
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3.8 PsyStart / Behavioral Health
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3.8 PsyStart / Behavioral Health
MENTAL HEALTH TRIAGE (PsySTART) MANAGER
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3.9 Planning / Training / Exercises
Given the HPP requirements, pediatric surge training and exercises are a priority in the Alameda County
EMSC workplan. The details are provided in the annual HPP project summaries and workplans.
Alameda County integrates pediatrics in all medical/health functional and state-wide exercises.
Alameda County actively promotes the annual state EMSC educational forums and other pediatric surge training
events. Alameda County is considering integration of the Washington recommended training modules below:
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3.9 Planning / Training / Exercises
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3.10.1 Local Referral Resources for Children
Community and Non-Government Organizations (NGO)
• Alameda County NGO/CBOs provide some or all of the following disaster response and recovery support for
children in Alameda County: Refer to list below:
Emergency Sheltering
• American Red Cross; faith-based-organizations
Feeding and Bulk Distribution
• Red Cross; Food Bank, Salvation Army, Private Sector Supplier
Childcare Services
• Select Childcare programs have contracts and MOUs with Alameda County for care and supervision of
children (including unattended if needed) in shelters and childcare for emergency responders.(e.g., Church of
the Brethren, Southern Baptist Children and Family Services, Head Start, other licensed child care programs,
local faith-based organizations)
Reunification of Unaccompanied Minors
• National Center for Missing and Exploited Children, Red Cross Safe and Well) with DCFS and enforcement
Mental Health Support
• Red Cross Mental Health Services, local community-based mental health organizations, private practitioners
Child Care Resource and Referral programs
• Alameda County has critical roles to support individual child care providers and/or the response and recovery
operation, when possible and as needed will include: Assistance with unmet needs (e.g., local Kiwanis Club,
Lions Club, Rotary Club, private sector businesses, local NGOs with various mission statements).
Alameda County Child Care Resource and Referral Agencies:
❖ BANANAS, Inc., (North County): 510-658-7353,
❖ Hively (Formerly Child Care Links) (East County): 925-417-8733,
❖ Community Child Care Council of Alameda County (also known as, 4Cs of Alameda County), (South
County): 510-582-2182.
American Red Cross
• Manages mass care operations at American Red Cross (Red Cross) shelters, feeding sites, and other Red
Cross sites in coordination with SSA and other agencies and/or organizations supporting mass care.
• “Under the joint operating agreement between the Bay Area Chapter of the American Red Cross and the
County of Alameda, organizing, mobilizing and directing the mass care and registration tasks of the
Emergency Care and Shelter Operation of the Unincorporated Areas will be provided in a non-wartime
emergency by the [Red Cross].”
Department of Developmental Services
• Provides support to County through Regional Center NGO/CBOs to support children’s unmet needs.
• State Department of Social Services serves - lead State Mass Care & Shelter agency; coordinates CalFresh.
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3.10.2 COVID-19 Referral Resources for Children and Families
Manage Stress for HealthWe might find comfort when we ... PDF (221k)
7 Aug 2020: We can also help our children find small things to be thankful for every day. ... In addition, these simple steps from
Donna Jackson Nakazawa, author of Childhood Disrupted and The Angel and The Assasin, can help us support children during
this time.
COVID-19 Alameda County Rapid Response Resources From the desk ... PDF (770k)
26 Aug 2020: http://www.alameda.courts.ca.gov/Resources/Documents/COVID-19% 20May% 2020% 20Press% 20Release.pdf
http://www.alameda.courts.ca.gov/Pages.aspx/COVID-19. 10 Women, Infant &Children (WIC). ... HRC Drop-In Update
https://www.abodeservices.org/alameda-county.
COVID-19 Considerations for Extreme Heat & Unhealthy Air Quality PDF (401k)
107
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3.10.2 COVID-19 Referral Resources for Children and Families
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3.11 National Resources for Pediatric, Children and Families Planning
Pediatric COVID JIT Resources, Webinars, Data, Listservs and Collaboratives
• AAP Critical Updates on COVID-19 https://bit.ly/3cCKvbh
• CDC COVID-19 Caring for Children https://bit.ly/2WAdxms
• EIIC COVID Resources: https://bit.ly/2EDUEJ4
• COVID-19 Data: North American PICUs https://covid19.myvps.org/
• OPENPediatrics (COVID) Public Group https://bit.ly/2LA4uvi
• ACOG COVID-19 Obstetric Preparedness https://bit.ly/2Tb1zO1
• Pediatric COVID Tracking Data https://bit.ly/36bWMDm
• Pediatric COVID webinars and collaboratives https://bit.ly/3l0uiRj
• REMS COVID Resources for Schools:https://rems.ed.gov/coronavirus
• National Association of School Nurses: https://bit.ly/346RFl9
• COVKID Project: https://www.covkidproject.org/
• Paediatric International Patient Safety and Quality Community (PIPSQC) https://www.pipsqc.org/
Pediatric Disaster Care Centers of Excellence
• Eastern Great Lakes Pediatric Consortium for Disaster Response (EGLPCDR) https://bit.ly/2Z0DmxF
• Western Regional Alliance for Pediatric Emergency Management WRAP-EM https://wrap-em.org/
Emergency Medical Services for Children Initiatives
• EMSC Innovation and Improvement Center https://emscimprovement.center/
• EMSC Toolkits https://emscimprovement.center/education-and-resources/toolkits/
• National Pediatric Readiness Project https://bit.ly/2LqkyQj
• Pediatric Readiness Quality Collaborative https://emscimprovement.center/collaboratives/prqc/
• Pediatric Disaster Preparedness https://emscimprovement.center/domains/preparedness/
• National Emergency Medical Services for Children Data Analysis Resource Center (NEDARC) https://www.nedarc.org/
• Pediatric Emergency Care Applied Research Network http://pecarn.org/
Pediatric Surge Annex Resources
• Illinois State Pediatric and Neonatal Surge Annex https://bit.ly/368z9K1
• Alameda County California Pediatric Surge Plan Template https://bit.ly/2Wykncl
• Los Angeles County http://file.lacounty.gov/SDSInter/dhs/206938_cms1_206938.pdf
• NYC Pediatric Disaster Healthcare Preparedness Toolkit http://www.programinfosite.com/pdc/resources/
• Rady Childrens Surge Planning Train the Trainer https://bit.ly/2WtW6nt
• California Department of Public Health Pediatric Surge https://bit.ly/2T0P5Z6
• ASPR TRACIE Pediatric Surge Annex Webinar https://bit.ly/2T2DfxP
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3.11 National Resources for Pediatric, Children and Families Planning
Pediatric Disaster Reunification Resources
• Children Separated by Disaster: Reunification Challenges and Resources Webinar https://youtu.be/8mjPYn8cnFQ
• Family Reunification Following Disasters: https://www.aap.org/en-us/Documents/AAP-Reunification-Toolkit.pdf
• National Center for Missing & Exploited Children https://www.missingkids.org/HOME
• Red Cross Safe and Well https://safeandwell.communityos.org/cms/index.php
• Unaccompanied Minor Reunification Checklist https://bit.ly/2Z6ekNw
• Post-Disaster Reunification of Children: A Nationwide Approach https://bit.ly/3dNpWJw
Pediatric Disaster Mental Health
• National Center for School Crisis and Bereavement -- https://www.schoolcrisiscenter.org/
• National Child Traumatic Stress Networkhttps://www.nctsn.org/
• Listen, protect, connect (LPC) Psychological First Aid System https://www.fema.gov/media
library/assets/documents/132712
• Child Mind Institute https://childmind.org/
• Foltin GL, Schonfeld DJ, Shannon, MW (editors). Pediatric Terrorism and Disaster Preparedness: A Resource for
pediatricians. AHRQ Publication No. 06-0056-EF. Rockville, MD: Agency for Healthcare Research and Quality. October
2006. -- http://archive.ahrq.gov/research/pedprep/pedresource.pdf
Children with Special Needs (CFAN) Disaster Resources
• CDC Children with Special Healthcare Needs https://bit.ly/3bvpz4MHHS Public Health Emergency: Hurricane Response
• Resources for Children with Special Health Care Needs https://bit.ly/2T7C54f
• Complex Child (monthly online magazine for families) https://complexchild.org/
• AAP Children and Youth with Special Needs https://bit.ly/2zCYYpl\
• The Center for Children with Special Needs https://bit.ly/3dGIXxg
• Autism Speaks Disaster Resources https://www.autismspeaks.org/autism-speaks-natural-disaster-resources
• Cerebral Palsy Guidance https://bit.ly/3dGIXxg
• Emergency Preparedness for Families of Children with Special Needs (Virginia) https://bit.ly/2T8YuOGDisaster Survival
• Resources Simplifying Survival: Disaster Preparedness Special Needs https://bit.ly/360myIH
Disaster Planning for OB/GYN & NICU
• Stanford OB Disaster Planning Toolkit: https://obgyn.stanford.edu/divisions/mfm/disaster-planning.html
• American College of OB/GYN (ACOG) Hospital Disaster Preparedness for Maternity Care https://bit.ly/2Z4SxWz
• Disaster Planning for Obstetric Units: OB TRAIN
• https://bit.ly/2zzKTccPregnant Women in Disasters and Emergencies: https://disasterinfo.nlm.nih.gov/pregnant-women
• Neonatal Disaster Preparedness
• https://www.cpqcc.org/content/can-neonatal-disaster-preparedness-toolkit
• CDC Disaster Safety for Expecting and New Parentshttps://bit.ly/2WZFcwi
• Loma Linda Pediatric Neonatal Disaster Reference Guidehttps://bit.ly/2WMp4xK
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3.11 National Resources for Pediatric, Children and Families Planning
Children and Disasters Research and Reports
• 2020 National Academies From Hurricane Katrina to Paradise Wildfires, Exploring Themes in Disaster Human Services:
Workshop 1 - Children and Youth in Disasters https://bit.ly/2S2ZSkS\
• 2020 Department of Homeland Security "Enhancing School Safety Using a Threat Assessment Model: An Operational
Guide For Preventing Targeted School Violence: https://bit.ly/345cPAe
• 2019 Natural Hazards Center Children and Disaster Special Collection: https://bit.ly/3cDG6oL
• National Advisory Committee on Children and Disasters (NACCD):https://bit.ly/3cvNaDP
• Institute of Medicine Preparedness, Response & Recovery Considerations for Children and Families https://bit.ly/2LqkyQj
• 2010 National Commission on Children and Disasters: https://bit.ly/2y7Fqcf
Pediatric Disaster Triage Systems
• JumpSTART Pediatric Triage Algorithm https://chemm.nlm.nih.gov/startpediatric.htm
• SALT (Sort,Assess, Lifesaving Interventions, Treatment/Transport) https://www.remm.nlm.gov/salttriage.htm
• TRAIN: Triage by Resource Allocation for INpatients: Matching medical transport to patient
need https://www.stanfordchildrens.org/en/research-innovation/train?
• PsySTART: Psychological Simple Treatment and RapidTriage https://www.oregon.gov/oha/HSD/Pages/PSYSTART.aspx
Pediatric CBRNE Resources
• Radiation Emergency Medical Management (REMM) - https://www.remm.nlm.gov
• INFANTS AND CHILDREN - https://www.remm.nlm.gov/radiation_children.htm
• PREGNANT WOMAN AND FETUS - https://www.remm.nlm.gov/specialpops.htm#children
• National Emerging Special Pathogens Training and Education Center (NETEC) https://netec.org/
• Pediatric Medical Countermeasures Resources for Public Health Preparedness (FDA) https://bit.ly/2WyoJjH
• Chemical Hazards Emergency Medical Management (CHEMM) https://chemm.nlm.nih.gov/
Child Care Disaster Resources
• Child Care Aware of America: http://usa.childcareaware.org/families-programs/resources/crisis-and-disaster-resources/
• The Child Care Resource Center (CCRC): https://www.ccrcca.org/providers/emergency-preparedness
• Childcare Disaster Preparedness (UCSF): https://cchp.ucsf.edu/content/disaster-preparedness
• Institute for Childhood Preparedness: https://www.childhoodpreparedness.org/
American Academy of Pediatrics (AAP) Disaster Resources
• Children's & Disasters https://bit.ly/2T2DwAR
• Healthychldren.org Building Resilience https://bit.ly/3czTOsE
• Children & Disaster Educational Tools https://bit.ly/3cw9X2k
Federal Disaster Resources for Children and Families
• ASPR TRACIE Pediatric Technical Resource https://asprtracie.hhs.gov/technical-resources/31/pediatric-children/0
• CDC Caring for Children https://www.cdc.gov/childrenindisasters/
• FEMA Ready Kids: https://www.ready.gov/kids
• NHTSA Hospital Discharge Recommendation for Safe Transport of Children https://bit.ly/35Z5Idi
• Health and Human Services/ASPR Webinar Pediatric Issues in Disasters https://bit.ly/2WrVChH
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•
3.11 National Resources for Pediatric, Children and Families Planning
American Red Cross Pediatric Disaster Resources
• Make a Plan https://rdcrss.org/2WTiJAH
• Pillow Case Project https://bit.ly/2LnskKZ
• Child Safety-Before During & After A Disaster https://rdcrss.org/2xZ2GJe
• School Disaster Preparedness https://rdcrss.org/2YZgUF1
Save the Children Disaster Resources
• Family Emergency Preparedness Get Ready. Get Safe kits and Lesson Books https://bit.ly/2Z7hfpv
• Disaster Report Cards https://bit.ly/2AlpG60
-------------------------------------
WRAP-EM Recommended Resources
• Texas A&M Engineering Extension Services Course titled "Medical Countermeasures: Point of
Dispensing (POD), Planning and Response": https://teex.org/class/mgt319/
• The National Academies' Framework for Equitable Allocation of COVID-19 Vaccine report:
http://ow.ly/TTZG50BGUPh
• The Pediatric Overflow Planning Contingency Response Network (POPCORN) resources:
o Home page: https://www.popcornetwork.org/ - - Webpage on health system operations:
https://www.popcornetwork.org/health-systems-operational-protocols
• A Journal of Hospital Medicine article titled " hildren’s Hospitals aring for dults uring a andemic:
Pragmatic Considerations and Approaches":
https://www.journalofhospitalmedicine.com/jhospmed/article/220705/hospital-medicine/childrens-
hospitals-caring-adults-during-pandemic
• The webpage for the ational cademies Security of merica’s Medical Product Supply Chain -
Committee Meeting 2 and Public Workshop: https://www.nationalacademies.org/event/12-01-
2020/security-of-americas-medical-product-supply-chain-committee-meeting-2-and-public-workshop#sl-
three-columns-fa1c5f25-4c59-4ecb-861d-49368ac74b85
• Children's Hospital Association resources:
o Webpage for a policy discussion coordinating pediatric hospital care to increase capacity for adults
with COVID-19: https://www.childrenshospitals.org/Quality-and-
Performance/COVID19/Resources/Consolidating-Pediatric-Hospital-Care-Increase-Capacity-Adults-
COVID19
• Coordinating Hospital Care for Children to Increase Capacity for the Surge in COVID-19 Patients report:
o https://www.childrenshospitals.org/-
/media/Files/CHA/Main/Quality_and_Performance/covid19/covid_cha_pediatric_consolidation_guidance.pdf
• The Accreditation Council for Graduate Medical Education guidance on pandemic emergency status:
https://www.acgme.org/Stage-3-Pandemic-Emergency-Status-Guidance
• CDC's webpage for the V-Safe App: https://www.cdc.gov/coronavirus/2019-
ncov/vaccines/safety/vsafe.html
• Virtual Pediatric Systems (VPS) website: https://www.myvps.org/
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3.12 COVID-19 Resources and Considerations
- Multi-System Inflammatory Syndrome in Children (MIS-C)
• Health Department-Reported Cases of MIS-C in the United States
CDC Information MIS-C: Case Definition; Clinical Presentation
o As of October 1, the number of cases meeting the case definition for multisystem inflammatory syndrome in
children (MIS-C) in the United States surpassed 1,000.
o Since mid-May 2020, CDC has been tracking reports of multisystem inflammatory syndrome in children (MIS-
C), a rare but serious condition associated with COVID-19. MIS-C is a new syndrome, and many questions
remain about why some children and adolescents develop it after a COVID-19 illness or contact with someone
with COVID-19, while others do not.
- Last updated December 4, 2020 - - https://www.cdc.gov/mis-c/cases/index.html
MIS-C Clinical Presentation
• Patients with MIS-C usually present with persistent fever, abdominal pain, vomiting, diarrhea, skin rash, mucocutaneous
lesions and, in severe cases, with hypotension and shock. They have elevated laboratory markers of inflammation (e.g.,
CRP, ferritin), and in a majority of patients laboratory markers of damage to the heart (e.g., troponin; B-type natriuretic
peptide (BNP) or proBNP).
• Some patients develop myocarditis, cardiac dysfunction, and acute kidney injury. Not all children will have the same
signs and symptoms, and some children may have symptoms not listed here. MIS-C may begin weeks after a child is
infected with SARS-CoV-2. The child may have been infected from an asymptomatic contact and, in some cases, the
child and their caregivers may not even know they had been infected. - - https://www.cdc.gov/mis-c/hcp/
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3.12 COVID-19 Resources and Considerations
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3.12 COVID-19 Resources and Considerations - for Pediatric, Children and Families Planning
115
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3.13 WRAP-EM - Resources for Pediatric, Children and Families Planning
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3.14.1 Acronyms
Acronym/ Abbreviation Description
ACRECC Alameda County Regional Emergency Communications Center
ADA Americans with Disability Act
BHCS Behavioral Health Care Services
BLS Basic Life Support
CAGOES California Governor’s Office of Emergency Services
CAL-MAT California Medical Assistance Team
CalFRESH California name for Federal Supplemental Nutrition Assistance Program
CBO Community-Based Organization
CCRC Child Care Resource Center
CFR Code of Federal Regulations
CHA California Hospital Association
ConOps Concept of Operations
CRCG Children’s Response Coordination Group
DCFS Department of Children and Family Services
DHV Disaster Health Volunteers
DMAT Disaster Medical Assistance Team
DOC Department Operations Center
DPHC Disaster Preparedness Healthcare Coalition
EMS Emergency Medical Services
EMSA Emergency Medical Services Authority
EMS-C Emergency Medical Services for Children
EOC Emergency Operations Center
EOM Emergency Operations Manual
EOP Emergency Operations Plan
FAC Family Assistance Center
FAST Functional Assessment and Service Team
FCC Federal Coordinating Center
FEMA Federal Emergency Management Agency
GOES Governor’s Office of Emergency Services
GSA Alameda County General Services Agency
HCC Health Care Coalition
HCF Health Care Facility
HCSA Alameda County Health Care Services Agency
HICS Hospital Incident Command System
HPP Hospital Preparedness Plan
IC Incident Commander
ICS Incident Command System
IFT Interfacility Transportation
ICU Intensive Care Unit
JFO Joint Field Office
JPMT Joint Patient Movement Team
LEMSA Local Emergency Medical Services Authority
M/HB Medical Health Branch
MCI Mass Casualty Incident
MERS Mobile Emergency Response System
MHCC Medical Health Coordinating Center
MHOAC Medical Health Operational Area Coordination/Coordinator
MOU Memorandum of Understanding
MPERT Mobile Pediatric Emergency Response Team
MPIRT Mobile Pediatric Intensivist Response Team
MRC Medical Reserve Corps
MTS Medical Tech Specialist
NICU Neonatal Intensive Care Unit
NGO Nongovernmental Organization
NIMS National Incident Management System
OA EOC Operational Area Emergency Operations Center
OEM Office of Emergency Management
OES Office of Emergency Services
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3.14 Acronyms
OEM Office of Emergency Manager
OHSES Alameda County Sheriff’s Office of Emergency Services
PAFN People with Disabilities and Others with Access and Functional Needs
PECC Pediatric Emergency Care Coordinators
PICU Pediatric Intensive Care Unit
PIO Public Information Officer
PMP Patient Movement Plan
POC Point of Contact
POD Point of Dispensing
Red Cross American Red Cross
RDMHC Regional Disaster Medical and Health Coordination/Coordinator
REOC Regional Emergency Operations Center
SEMS Standardized Emergency Management System
SEP State Emergency Plan
SME Subject Matter Expert
SOC State Operational Center
SSA Alameda County Social Services Agency
TRAIN Triage by Resource Allocation for INpatients
UCSFBCH UCSF Benioff Children’s Hospital
WIC Women, Infants, and Children
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3.15 Essential Elements of Information (EEIs) – Planning
- Alameda County conducts pediatric surge planning assessments as needed. The following EEI data tool is adapted from
Washington State Pediatric Coalition
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3.15 Essential Elements of Information (EEIs) – Planning
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3.16 Telehealth
Telemedicine Resources: *** Module 3 TTX
• Understanding Virtual Care (Telemedicine) Overview - What Is Virtual Care?
o https://alameda.networkofcare.org/mh/library/article.aspx?hwid=acl2140
• Telehealth Connections for Children and Youth
o http://www.healthyalamedacounty.org/promisepractice/index/view?pid=777
• FAQs: COVID-19 Telehealth and HIPAA Privacy & Security
o https://www.acbhcs.org/Providers/News/2020/Telehealth%20&%20HIPAA%20FAQs%20for
%20HCSAStaff%20FINAL.pdf
• Community Based Organization Clinic Care & Urgent Care Clinics in Alameda County
o Community Based Organization (CBO) Care:
https://covid-19.acgov.org/covid19-assets/docs/community-resources/cbo-clinic-care-
urgent-care-in-alameda-county-2021.08.04.pdf
• Starting Out Strong Telehealth Practice and Guidelines
o https://www.calwic.org/wp-content/uploads/2020/04/Alameda-County-WIC_Telehealth-
Guidelines.pdf
• Telehealth Frequently Asked Questions
o https://www.dhcs.ca.gov/provgovpart/Pages/TelehealthFAQ.aspx
• Setting Interfacility CCP transports - Telemedcine
o 2020 Alameda County EMS - Critical Care Paramedic (CCP) Field Manual
o http://ems.acgov.org/ems-
assets/docs/Clinical/Field%20Protocols/2020%20ALCO%20EMS%20CCP%20Policy%20Guid
elines.pdf