The 2008 Task Force for Mass Critical Care guidelines (1), combined with recent experience from the 2009 Influenza A/H1N1 Pandemic, demonstrate the potential for an event that may overwhelm our ability to provide contemporary critical care services to all pediatric patients. Preparation of alternative care sites and utilization of caregivers unaccustomed to taking care of children for pediatric emergency mass critical care (PEMCC) is necessary to optimize outcomes. Numerous studies published in the last several years have outlined the shortcomings of emergency preparedness and disaster competency of various healthcare professionals (2).
Pediatric intensivists in many regions may know the availability of intensive care unit (ICU) beds in their own institution and in ICUs within a reasonable distance through formal and informal networks (3). In some instances, this “reasonable” distance may constitute several hundred miles or more and/or may no longer be a “reasonable distance” in the circumstance of disrupted transportation infrastructure (4). During PEMCC, these networks are useful but will clearly exceed usual capacity if called upon to triple the occupancy. Although a reasonable response to this crisis may be a more distant patient referral outside of the normal referral pattern or overflow capacity, the fallback units may be facing similar surge stresses. PEMCC would require that medical teams unaccustomed to managing ill children will be pressed into service to care for pediatric patients. Furthermore, the crisis may be a novel pediatric mass critical care event that overwhelms even the most experienced pediatric teams. In both cases, education and training will be crucial to the success and outcomes of treatment provided to children affected by such an event.
In this article, we outline education approaches and tools as well as resources that should be developed to meet educational needs.
There are two basic approaches to education for a PEMCC event. The first is to provide advance training in anticipation of a potential threat or event, and the second is to provide “just-in-time” training to those who are thrust into service during PEMCC. Each has advantages and disadvantages, which are summarized in Table 1 and elucidated in the following sections.
Training in advance has numerous advantages over just-in-time training. The biggest advantage is the luxury of time. More time is available for addressing details, asking questions, and pursuing questions that might arise during training. In addition, a wider range of topics and scenarios can be covered. Emergency planners and disaster managers can bring in experts to assist with teaching a course, providing insight from experience to complement the coursework and offering personal accounts of disaster experience. In addition, planners can identify networks and solidify connections and plans for use in support of PEMCC if the need arises. Any existing networks could be activated and new ones created to provide support during such an event.
Just-in-time training is a less-than-ideal solution to disaster preparedness education. By definition, it cannot be as thorough, reflective, or comprehensive as training done in advance of a need. It also does not allow for anticipatory preparation or identification of systemic needs or weaknesses. However, just-in-time training provides specific, target-driven training that meets the specific knowledge deficit, at the time when that knowledge deficit is identified and the learner is presumably most receptive to new information. It has been shown to be beneficial in maintenance of cardiopulmonary resuscitation skills (5).
Just-in-time training must be developed in advance of the need, so even though it is created for rapid deployment at the time of need, development cannot be simultaneous with need. Emergency planners must anticipate critical functions and develop modules in advance to meet the myriad of potential PEMCC situations. Adult critical care specialists would require instruction in ventilation and weaning differences for young children; acceptable blood pressures, respiratory rates, and other vital sign parameters; visual cues for identifying the critically ill child; and dosing guidance for medications. Specific procedural guidance would also be required, and includes catheter size and length, endotracheal tube size and placement parameters (cuffed and uncuffed), and other modifications of procedures for younger patients. Frequent pediatric caregivers need less focus on the basic recognition of sick children, but they will need more education to help differentiate between moderately and critically ill children. General pediatricians also need training in basic invasive and noninvasive mechanical ventilation and the management of uncomplicated critically ill children.
Training Needs and Strategies.
Training needs and strategies will depend on classification, i.e., tier of hospital based on resources and level of pediatric care they are able to provide. Training should combine advance and just-in-time approaches. We will describe three classifications (tiers) of hospital-based resources and their associated limitations and provide recommendations for types and approach to training.
Tier 1 includes children's hospitals with existing pediatric ICUs that normally receive admissions and referrals for pediatric critical care services. These facilities may be free-standing children's hospitals or larger, multispecialty hospitals with significant pediatric bed allocation for inpatient wards and ICU care (4). Pediatric intensive care multidisciplinary staff and pediatric subspecialists provide clinical services for these units. Tier 2 facilities include regional hospitals that admit children in noncritical settings, and they often refer and transport patients for critical care services to Tier 1 hospitals. Pediatricians and pediatric subspecialists may staff these hospitals but on-site intensive care by pediatric intensive care specialists is not available. Tier 2 hospitals may have critical care resources capable of caring for an adult population that may potentially be utilized to provide care for pediatric patients in the event of a PEMCC. Tier 3 hospitals do not typically provide any inpatient pediatric services. Tier 3 institutions may be free-standing adult hospitals in communities with limited pediatric bed availability, or they may be located in more rural areas that refer and transfer all patients requiring inpatient pediatric care. Typically, they would not have pediatric specialists on staff. They may or may not have some physicians with pediatric expertise. They may or may not have adult ICU facilities but could potentially accommodate less-ill pediatric patients in their general ward or ICU (4).
Tier 1 hospitals are expected to increase their capacity three-fold in response to a PEMCC event. In this response, they may need to recruit nonstandard caregivers into the critical care environment. During the course of this response, providers may manage sicker children outside of the ICU or recruit on-site providers from outside the PICU, such as other pediatric subspecialists (e.g., pediatric emergency medicine, cardiology, or pulmonary attendings or fellows), hospitalists, general pediatricians, and physician extenders (pediatric nurse practitioners, physician assistants, etc), as well as trainees, including pediatric critical care medicine fellows, chief residents, and residents (see the article, “Treatment and triage recommendations for pediatric emergency mass critical care”). Both scenarios may require situational or task-specific training.
The advantage that Tier 1 hospitals have is ready access to specialists who are experts in managing critically ill and injured patients on a routine basis. Additional training in leadership, triage, and disaster management would help critical care providers prepare for and manage an increase in census and demands on services. For instance, critical care nurses, respiratory therapists, and physicians can act as team leaders and mentors for providers limited in their knowledge and experience with the recognition and management of critically ill children to enhance the ability of these providers to recognize and care for sicker children. The educational priority for this group would center on improving the non-ICU caregiver's ability to recognize sicker children.
Tier 2 hospitals should prepare to respond to emergency mass critical care events involving large numbers of children because of the potential inability to evacuate sicker children or the inability of Tier 1 hospitals to take additional patients. Tier 2 hospitals with pediatricians, family practitioners, pediatric subspecialists, skilled pediatric nursing, respiratory care, and other ancillary staff will need training for the evaluation and management of sicker children. With pediatric experience, Tier 2 healthcare workers will have an advantage over Tier 3 personnel, but Tier 2 facilities will still face challenges with limited in-house resources for managing sicker children. Hospital emergency management planners should identify what resources are available, and most importantly, recognize educational gaps and address them. Disaster, leadership, or other training in managing critically ill children, potentially from Tier I hospital providers, will be beneficial.
It may fall upon Tier 3 hospitals to provide support and assistance to pediatric hospitals in the setting of an emergency mass critical care event. Adult hospitals may need to manage older children (i.e., children >12 yrs old) so that Tier 1 and Tier 2 hospitals can focus their attention on younger or more critically ill children. This is commonly done today in some trauma systems where adult trauma centers manage adolescents while the younger children are preferentially transported to pediatric trauma centers. Educational needs for adult providers would include subjects that focus on both the immediate and more long-term recognition and management of sick children. Particular emphasis should be placed on the physiologic differences among infants, children, and adults and their responses to critical illnesses.
Types of Training That Would Be Beneficial
2) Disaster management (hospital incident command system, critical resource management)
3) Recognition of a sick vs. a not-sick child
4) Recognition of a critically ill child
5) Assessment and management of airway and breathing – normal respiratory rates and patterns of respiration in children compared to adults, pediatric ventilator modes and patterns, dosing of respiratory medications
6) Vascular access – venipuncture and intravenous access
7) Pediatric dosing of medications
8) Nonpharmacologic techniques for calming children
Existing resources for pediatric critical care education
Dedicated training resources exist for both disaster management and critical care in pediatrics. Group coursework and educational resources are available, and several teaching aids have been developed for pediatric critical care education. The World Health Organization has a large library of materials under the title “Integrated Management of Childhood Illness” at http://www.who.int/child_adolescent_health/documents/imci/en/index.html. These materials cover a wide variety of topics, are free, and are available in multiple languages.
The Society of Critical Care Medicine has a 2-day Pediatric Fundamentals of Critical Care Support course similar in structure to its adult counterpart, Fundamentals of Critical Care Support. The pediatric course was designed specifically to aid the nonintensivist in identifying and managing the critically ill child in the absence of a pediatric intensivist. The course contains both didactic and hands-on, simulation-based training (both low and high fidelity) in the management of critically ill children for a variety of common critical care scenarios. More scenarios could be easily developed to simulate a PEMCC event.
There are three current certifying courses for advanced life support for pediatric-aged patients. Pediatric Advanced Life Support (PALS), provided by the American Heart Association, is the primary course for the recognition and resuscitation of pediatric-aged patients. PALS is an initial 2-day course, and providers seeking renewal (every 2 yrs) partake in a single-day refresher course. This course is based on the guidelines issued by the International Liaison Committee on Resuscitation and is revised continually as guidelines are updated. New recommendations were just released in 2010 (6). The course has always involved low-fidelity simulation and skills training. There are current versions of PALS that include high-fidelity simulation. In recent years, the course has incorporated videos of actual critically ill children to enhance recognition training. The course is intended for all healthcare providers who are likely to take care of sick children.
Advanced Pediatric Life Support is a joint project between the American College of Emergency Physicians and the American Academy of Pediatrics. This course has significant overlap with PALS but with more disease-specific modules that can be used to tailor the course to specific needs. In the last decade, Advanced Pediatric Life Support organizers have moved away from the scheduled recertification process. This course tends to be more physician focused.
The Neonatal Resuscitation Program is a joint venture of the American Academy of Pediatrics and the American Heart Association. It is a 2-day course that is primarily focused on newborn resuscitation at birth. The Neonatal Resuscitation Program is based on the International Liaison Committee on Resuscitation guidelines.
Pediatric Emergency Assessment, Recognition, and Stabilization is a newer course produced by the American Heart Association and is meant to bridge the gap between Basic Life Support and PALS. It is a video-intense course with the focus being recognition of the sick child and the initial 5 mins of management. The Pediatric Emergency Assessment, Recognition, and Stabilization course is intended for providers who are less commonly responsible for extended management of sick children. It is a 1-day course that does not provide a certificate.
The Emergency Nurses' Association has two certifying courses that were designed to train nurses in emergency triage and trauma care. These courses are Emergency Nursing Pediatric Certification and Trauma Nursing Core Curriculum. Both are 16-hr courses that are given over 2 days. Emergency Nursing Pediatric Certification was designed to educate nurses to care for acutely ill and injured children. This course was developed to teach all aspects of pediatric emergency nursing and focuses on rapid assessment, triage, and identifying significant yet subtle changes in the less acutely ill child. There are sections on pediatric trauma resuscitation, crisis intervention, stabilization, and transport. There is a lecture and a skills assessment for this course. Upon successful completion, the nurses are given a verification that is renewed every 4 yrs.
Trauma Nursing Core Curriculum is a also a 16-hr course given over 2 days and focuses on the process and content of all the different roles nurses have in care of the trauma patient. The course is designed to teach the basic concepts of trauma nursing. There is a section of this curriculum designed to teach the care of the pediatric trauma patient. There is also a section of the curriculum that focuses on disaster management and disaster triage. There are lectures and a skills assessment for this course, and upon successful completion, the nurses are given a verification that is renewed every 4 yrs. Information regarding these courses can be found online at: http://www.ena.org/coursesandeducation/Pages/Default.aspx.
Other specialty-based courses focusing on pediatric emergency care include: Emergency Pediatric Care, from the National Association of Emergency Medical Technicians; the Virtual School Nurse and Emergency Medical Services course by the University of New Mexico (online at http://hsc.unm.edu/emermed/PED/school_RN/course.shtml), which focuses on the school nurse; and the Pediatric Respiratory Care Slide Library at www.pediatricrespiratory.org. Other courses are available online, but many are time limited.
Many online resources are available that could be useful for just-in-time training. Centralized access to these widespread resources will be crucial in the face of emergency mass critical care event to minimize the extra time and effort caregivers must spend to find valuable information.
PedsCCM.org (7) is the premier English-language resource for pediatric critical care information online. Established in 1995, it remains the central reservoir for links to educational material related to pediatric critical care on the Web. It contains numerous links, including an Evidence-Based Journal Club and Filing Cabinet for educational material arranged by topic.
The Society of Critical Care Medicine–pediatric ICU course materials offer an online curriculum of critical care PowerPoint presentations geared for resident and fellow pediatric critical care medicine education (http://www.LearnICU.org). These are readily available and many have audio commentaries. They could prove worthwhile as topic-specific resources for adult critical care practitioners, or pediatric caregivers whose usual practice is outside of the pediatric ICU and may be a lower level of care. This resource requires registration, although registration is free.
“PICU without Walls” (8) from Children's Hospital of Boston is a growing resource of critical care content expertise that has been working with international sites to provide distance critical care education on a variety of topics provided by experts in the field.
None of these resources are specifically focused on PEMCC or disaster management, although all of them cover topics related to pediatric critical care, which would potentially be useful for caregivers in unfamiliar settings where they need additional critical care knowledge.
Numerous organizations produce pocket cards and posters that can provide some crucial pediatric data. The Broselow tape is widely distributed in the United States and provides length-based assistance with dosing for many medications necessary during resuscitation. Many of the proactive resources also have cards, such as PALS from the American Heart Association as well as the American Association of Critical Care Nurses.
Just-in-time training is also a framework for surviving the early phase of a disaster or surge response. Healthcare workers should recognize that they may be the best available resource for their colleagues, and they should rehearse how they share key learning points. Emergency planners should direct leaders to practice communicating brief educational topics to their staff on a regular basis so that staffs are familiar with hearing and reacting to new information in a short time frame. Just-in-time training should also be a regular component of disaster training. This would allow opportunities to validate and improve the just-in-time training modules to optimize their effectiveness for when they are needed (9).
Broadening educational recommendations
In the foregoing sections, we highlighted the important features that characterize local preparations for PEMCC. Our approach is guided by the principle that all disasters are indeed local and the response starts locally. In the following section, we will introduce a broader strategy for addressing PEMCC that not only includes local facilities but expands the strategy to international and national preparations. PEMCC preparation requires local education as described above, but in order for facilities to benchmark their preparations and for regions to assess their readiness, a threshold for educational preparation should be established. Regional planners should be able to identify experts in their region, assess hospital-level readiness, and provide region-specific trainings.
National training and credentialing bodies need to determine criteria for expert status and perhaps expand curricula to include PEMCC. Extramural agencies, such as regional hospital associations and the Joint Commission, should establish benchmarks and guidance for PEMCC. Professional societies and relevant federal agencies should craft a PEMCC training strategy and appropriate resources for PEMCC training. These efforts can also be applied in the international arena and perhaps led by the World Health Organization and others.
Educational tools for what are hopefully rare events are not inexpensive to produce, and because their usefulness may apply only to rare occasions, marketing the materials to generate revenue is unlikely to succeed. The federal government should provide funds to encourage development of a variety of just-in-time training modules for a spectrum of potential PEMCC events.
Finally, these approaches should be assessed through a comprehensive research strategy that examines hypothesis-driven educational research. These investigations should test PEMCC training approaches and provide evidence-based recommendations for training systems. This effort is best served by a public-private partnership between federal agencies, private societies, and educational institutions.
In summary, evidence-based education is the foundation for a robust system for preparing clinicians and other allied health workers for PEMCC. The educational strategy requires active participation from numerous national and international stakeholders. Resources are required on all levels to prepare facilities and surrounding communities that will have critical care needs in the face of a pediatric mass emergency.
Task force recommendations
As part of comprehensive emergency preparation, educational needs should be identified and addressed.
* Practitioners should work to maintain their basic pediatric care levels pertinent to their job and contemplate whether additional training might benefit them in preparation for potential mass critical care events. If they are likely to be involved in a PEMCC response, they should seek out additional proactive training, as described.
* Hospitals should:
- Identify, on the basis of their level of planned response to a PEMCC event, who the team leaders and pediatric care providers would be. They should encourage those individuals to receive additional training and stay current in the management of critically ill children. This applies at all levels of care – not just physician care, but also nursing, respiratory care, child-family life, pastoral care, and others.
- Identify just-in-time resources that could be used in times of need, and contemplate how they could best implement those resources, particularly if infrastructure, such as internet access, is compromised.
- If they do not have pediatric critical care capabilities, establish a relationship with a regional children's hospital and look for potential educational and training collaboration.
* Regional pediatric critical care centers should:
- Maintain an active educational role in both self-education in management of critically ill children and in regional education in their usual referral network.
- Identify potential local hospitals that could help with surge capacity and ensure that those hospitals are receiving necessary training to manage potential surge patients.
- Work to develop just-in-time resources for remote assistance in training, such as telemedicine or telephone consultation.
* State/federal/professional societies should:
- Fund and develop additional training courses for pediatric mass critical care, both proactive courses and just-in-time training modules. Funding should be provided for the development, evaluation, and distribution of these just-in-time modules. The modules should be widely publicized and made readily available and maintained.
- Investigate how best to distribute the material in the case of compromise to the infrastructure, such as power loss or internet unavailability, or even the loss of telephone communication.
The Pediatric Emergency Mass Critical Care Task Force thanks the American Academy of Pediatrics and its Disaster Preparedness Advisory Council for their review and contributions to this issue.