Section 5. Security

Purpose: Previous literature regarding the security of the pediatric population primarily addressed preventing infant abductions. The recent Gulf Coast hurricanes of 2005 highlighted the importance of this critical need in the care of the pediatric population.

The focus of this document is to raise the level of awareness regarding the issue of the pediatric population and security issues during an emergency or incident that would require a child to go to a hospital. 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. Also of concern during a disaster- level event is when a minor accompanies an adult to the hospital and the adult is in need of care. The child could easily be lost during the chaos of such an event.

These recommendations for pediatric security during a disaster are intended to assist planning for the needs of all pediatric patients presenting to any hospital during a disaster. The recommendations included in the section focus primarily on pediatric patient/visitor tracking and creating pediatric safe areas.

Section Contents

General Guidelines:

All hospitals responding to a disaster are advised to:

  1. Develop a protocol to rapidly identify and protect displaced children which includes:
    • Creating a Child ID document to record any key identifying information about the child for use in later tracking or reunion with caregivers. A computerized patient tracking and locator system is being developed by the NYSDOH for use on a statewide basis. The basic elements expected to be captured in the patient tracking and locator system are reflected in the Child ID Survey on page 5 - 6. While this system is under development, each hospital may want to develop a similar and, if possible, compatible system to capture these same data elements.
    • Developing a Pediatric Tracking System that addresses both the accompanied and unaccompanied child.
  2. Create Pediatric Safe Areas that will serve as a holding area for uninjured, displaced or medically cleared children awaiting adult caregivers. A Pediatric Safe Area Checklist has been provided to assist in the establishment of such area.
  3. Identify a Pediatric Safe Area (PSA) Coordinator who will assume the responsibility of setting up and supervising the pediatric safe area in the event of a disaster. Included in this section is a Sample Job Action Sheet, which outlines the PSA Coordinator position.
  4. Create and use a Pediatric Safe Area registry sheet to document child activity such as transfer status, location and final disposition.
  5. Facilities should give careful consideration to how they will credential and clear volunteers pre-event to ensure the safety of children that may be in their care.

Pediatric Patient Tracking:

Hospitals have historically served as safe havens for displaced persons during a disaster. During the August 2003 Blackout, many members of the NYC community came to hospitals as secure places known to have functioning generators and supplying light, safety and nourishment. 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 a recent example, Hurricane Katrina and the ensuing floods and chaos caused over 3,000 children to be displaced throughout the United States (1). These displaced children, if unaccompanied, are at special risk for maltreatment, neglect, exploitation and subsequent psychological trauma. Hospitals and medical clinics will therefore need to be especially alert to the safety and mental health issues of these children.

The issue of pediatric patient tracking has historically been restricted to maternity and pediatric wards. Much of the literature refers to the cases of infant security and the reduction of pediatric patient abductions from various hospital wards. There are specific measures discussed that can be taken to prevent the abduction of pediatric patients, such as the use of identification bands. Examples of systems that might be considered include the tracking devices used to prevent infant abductions or those used to monitor long term care patients at risk of elopement.

Patient Tracking – the Accompanied Child in Disaster:

There are two populations of accompanied children during a disaster that should be addressed:

  1. The pediatric patient - a sick or injured child is hospitalized as a result of the disaster and is separated from the responsible adult. An example of this could be if the responsible adult was also admitted as a patient.
  2. The pediatric visitor - a well child accompanies a sick or injured adult as a result of the disaster. An example of this could be if an adult who was caring for a minor at the time of the disaster or event needed to be hospitalized.

Presently, many hospitals have policies in place for the tracking of minors from pediatric and maternity wards such as using identification bands. A possible solution to tracking minors during a disaster is to use a system of identification bands for the minors and corresponding responsible adults. The bands would be distributed and placed as soon as these individuals make contact with the emergency department. Care must be taken to quickly and correctly place bands or other identification devices on both parties. Special attention needs to be taken to ensure that this measure is completed as soon as possible at the entry point to the hospital to reduce the possibility of human error during the matching and placing of the bands.

The stress of a disaster may be exacerbated by the separation of mothers and neonates, infants and children. Facilities should endeavor to ensure, whenever possible, that mothers and children are evacuated to the same location or a method is developed to ensure that families are located and reunited as soon as is reasonably possible.

The identification bands used should include the following information which will be useful in maintaining a tight link between the pediatric patient or visitor and the accompanying adult:

  • Name of pediatric patient/ visitor and Date of Birth
  • Name of adult and Date of Birth
  • Admission date of adult
  • Admission date of pediatric patient
  • Date of visit of pediatric visitor
  • Relationship between child and adult

In addition, a more sophisticated approach to tracking could be implemented by the use of bar-coded bracelets as identifiers that can be affixed to the pediatric patient or visitor and to the adult at the time of entry to emergency department or other point of entrance to the hospital. In this manner, the same bar code is assigned to the adult and the pediatric patient/visitor(s) with the adult. For further information, hospitals may also review the infant abduction protocols in place at their facility or from another local facility that currently provide obstetrical services, as well as the National Center for Missing and Exploited Children's publication entitled "For Healthcare Professionals: Guidelines on Prevention and Response to Infant Abduction."2

See: http://www.missingkids.com/missingkids/servlet/PublicHomeServlet?LanguageCountry=en_US

Patient Tracking – the Displaced or Unaccompanied Child in a Disaster:

Rapid identification and protection of displaced children (less than 18 years) is imperative in order 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. 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. Initiatives such as "Operation Child ID" implemented in Camp Gruber, Oklahoma, after Hurricane Katrina in 2005, have provided a rapid, systematic protocol for successfully identifying and protecting displaced children. The CDC has reviewed this protocol and considers it to be a useful resource to share with its partners to promote a safer and healthier environment for displaced children in shelters (1). The following protocol has been adapted from CDC Health Advisory, "Instructions for Identifying and Protecting Displaced Children." Sept. 28, 2005, to address displaced children during disasters in New York State.

Protocol to Rapidly Identify and Protect Displaced Children:

  • Survey all children entering the hospital or medical clinic to ensure all children are identified. Children who are not accompanied by an adult have a high probability of being listed as missing by family members. Therefore, it is important to find out where they were sleeping/being held and the name and age of person(s) who is/are supervising them, if available. A sample survey form for identifying a displaced child is attached.
  • Place a hospital-style identification bracelet (or, ideally, a picture identification card) on the child and a matching one on the supervising adult(s), if such an adult is available. Check frequently to make sure that the wrist band matches that of the adult(s) seen with the child in the hospital or medical clinic. If there is no supervising adult, the child should be taken to the hospital's pre-determined Pediatric Safe Area (see following pages) where he/she can be appropriately cared for until a safe disposition or reunification can be made.
  • The names of all children identified through the survey as not being with their legal guardians or who are unaccompanied should be considered at high-risk and immediately reported to the hospital's emergency operations center. Additional reporting should also be made to the National Center for Missing and Exploited Children (NCMEC) at 1-800-THE-LOST (1-800-843-5678). The NCMEC can then crosscheck them with the names of children who have been reported missing. Children may also be reported as missing using the following website:
    http://www.missingkids.com/missingkids/servlet/PublicHomeServlet?LanguageCountry=en_US
  • After the "high risk" children have been reported, a complete list of all children's names in the hospital, clinic or shelter should be sent to the NYS Hospital Emergency Resource Database System (HERDS) if activated and the information is requested. A complete list should also be sent to the NCMEC in case adults and/or children have provided incorrect information about their relationship and status.
  • Unaccompanied children and those who are not with their legal guardians should undergo a social and health screening taking into consideration an assessment of the relationship between the child and accompanying adult, ideally performed by a physician, nurse or social worker with pediatric experience.
  • If NYSDOH, another New York State agency, or NCMEC informs you that the child has been reported as missing, locate the child and facilitate reunification of the child and his/her legal guardian.
  • Again, facilities should do all they can to ensure that children and families are reunited as soon as is reasonably possible.

References

1. CDC Health Advisory, "Instructions for Identifying and Protecting Displaced Children", September 28, 2005.

2. "For Healthcare Professionals: Guidelines on Prevention of and Response to Infant Abductions" - http://www.ncmec.org/en_US/publications/NC05.pdf

3. Association of Maternal and Child Health Programs, "State Emergency Planning and Preparedness: Summary recommendations for MCH populations", October 2007.

Child Identification Survey Form:

The following is a sample form that may be used in the tracking of children in times of emergency. This form can be used at intake to match children with accompanying adults and to identify unaccompanied children. The form can also be used to track the child's discharge to other means of care or to responsible adults. A form such as this should be completed for each child presenting during the emergency event.

Please note the form has space for photographs. It is recommended that intake areas have access to digital or cameras with instantly developing film in order to take photographs as children are taken in.

You may print a copy of the Child Identification Survey Form from here.

Pediatric Safe Areas:

Create supervised areas to cohort all unaccompanied pediatric visitors or unaccompanied medically cleared pediatric patients in one central and safe location. This central location will need to be pre-assigned and secured to ensure that minors can not leave the area without appropriate escorts. Security personnel or other responsible staff will need to be trained to supervise and assist pediatric visitors who may be frightened or who have other mental health issues as a result of being involved in a disaster and separated from family members.

Included in this section are three forms that may be helpful for hospital planning required for a Pediatric Safe Areas. These forms include:

  1. Pediatric Safe Area Checklist. This form was adapted from the Chicago Department of Health, and outlines recommended steps to ensure that the Pediatric Safe Area is appropriately set-up to receive children.
  2. Pediatric Safe Area Coordinator Job Action Sheet (JAS). Created for the staff coordinating these pediatric safe areas. By having a JAS, staff can readily review what steps need to be taken to prepare for the possible influx of pediatric patients. See JAS at the end of this chapter.
  3. Pediatric Safe Area Register. This is a sample of a form that could potentially be used in the Pediatric Safe Area to monitor the arrival and departure of children. A copy of this register should be made available to the hospital Emergency Operations Center (EOC) on a frequent basis.

Pediatric Safe Area Checklist

Area Reviewed:
Date Reviewed: Time Reviewed:
Reviewer:
 
Area of Concern Finding Follow-Up Action Needed
 Yes   No
1. Is access to the area selected as the Pediatric Safe Area able to be controlled?
Can children be contained in this area? (Consider stairwells, elevators, doors.)		      
2. Is there a plan for security of the unit?      
3. Have you conducted drills of the plans for this area with relevant departments?      
4. Do you have a plan to identify the children?      
5. Do you have a plan for identifying the mental health needs of these children?      
6. If there is need, can the various age groups be separated into different areas?
(Consider whether older children pose a safety issue for younger children.)		      
7. Are enough staff available to adequately supervise the children? (Consider that younger children need more staff to supervise.)      
8. Do you have a sign-in, sign-out sheet for all children and adults who enter the area?      
9. Are all children admitted to the area required to have appropriate identification bracelets?      
10. If children need to leave the area to use bathrooms, are there appropriate methods to escort them?      
11. Is there a safe, stable area near a sink but away from eating areas that can be used for diapering?      
12. Are there appropriate facilities for handwashing?      
13. Does the area have fire and smoke alarms?      
14. Is there adequate egress in case of fire?      
15. Do the windows open? (Consider whether the windows would be used for egress in case of fire.)      
16. Are the windows appropriately protected? Do they have window guards?      
17. Is the area free of binds, drapes or cords that could pose a strangulation hazard?      
18. Are electrical outlets child safe/covered?      
19. Is the areas free of any water basins/buckets/sinks that can pose a drowning hazard?      
20. Is the area free of fans and heaters that could pose a safety risk? If fans or heaters are used, are they sectioned off at a safe distance so that they do not pose a risk for burns or amputation?      
21. If radiators or hot pipes run through the area, are they covered to prevent burn hazards?      
22. Are undersink areas and cupboards appropriately locked?      
23. Is the area free of small toys and parts that would pose choking hazards?      
24. Are cabinets and tables free of items that might topple on children? Is the area free of unstable and heavy items or carts that might topple on children?      
25. If medical supplies are in the area, are medication carts and supply carts locked? Is access sufficiently controlled? Are meds and syringes at least 48" off the floor?      
26. Are there safe, adequate sleeping accommodations available (i.e. foam mats on the floor) to avoid co-sleeping?      
27. Are infants placed on their back to sleep to reduce the risk of SIDS?      
28. Are mattress surfaces firm and soft pillows and toys removed from infant sleeping areas?      
29. Is the area smoke-free?      
30. Are there adequate age-appropriate games, videos and toys to occupy the children?      
31. Are there nutritious, age-appropriate snacks available for the children, avoiding foods that comprise a chocking hazard for younger children?      
32. Are there nearby childcare centers or other experts who could be approached to help or advise, should it be necessary?      
33. Have staff/volunteers who will be working in this unit received security clearance? (No known child protection issues, criminal history)      

Sample Job Action Sheet - Pediatric Safe Area (PSA) Coordinator

You report to: _____________________________________________ (Pediatric Services Unit Leader)

Hospital Command Center Location: _________________________ Telephone: __________________

Fax: ______________________ Other Contact Info.: ______________ Radio Title: _______________

Mission: To ensure that the pediatric safe area (PSA) is properly staffed and stocked for implementation during an emergency and to ensure the safety of children requiring the PSA until an appropriate disposition can be made.

Immediate (0 - 2 hours):

  • _____Receive appointment from Pediatric Services Unit Leader (PSUL)
  • _____Read the entire job action sheet
  • _____Obtain briefing from the Pediatric Services Unit Leader
  • _____Ascertain that the predestinated pediatric safe area is available
  • _____If not immediately available, take appropriate measures to make the area available as soon as possible
  • _____Gather information about how many pediatric persons may present to the area
  • _____Make sure that enough security staff is available for the PSA
  • _____Make sure that there is adequate communication in the PSA
  • _____Make sure that there is a sign in/out log for the PSA
  • _____Make sure that all items in the PSA checklist have been met; if there are any deficiencies, address them as soon as possible and report them to the PSUL

Intermediate (2 - 12 hours):

  • _____Ascertain the need for ongoing staff for the PSA
  • _____Maintain a registry of children in the PSA as they arrive or as they are released to an appropriate adult
  • _____Determine estimated length of time for the expected operational period of the PSA
  • _____Maintain communication with the Pediatric Services Unit Leader for planning needs
  • _____Determine if there are any medical or non-medical needs specifically needed by pediatric persons in the PSA
  • _____Prepare an informational session for the pediatrics person in the PSA
  • _____Prepare to make arrangements for sleeping capacities if needed
  • _____Ascertain if there will be any additional needs required for this event (volunteers, staff, security and equipment)
  • _____Make sure that pediatric persons have the appropriate resources such as food, water, medications, age appropriate reading materials and entertainment for their stay
  • _____Report frequently to the PSUL concerning the number of children in the PSA

Extended (Operational period beyond 12 hours):

  • _____Make sure the PSA staff have enough breaks, water and food during their working periods
  • _____Coordinate with Psychological Support for ongoing mental health evaluations of volunteers and pediatric persons in case there is a need for psychosocial resources
  • _____Document all action/decisions with a copy sent to the PSUL
  • _____Other concerns:________________________________________________________


Pediatric Safe Area Registry Sheet
# Name of Child  Age   Arrival Time   Discharge Time   Disposition*   Name of Responsible Adult**
& Relationship to Child 		  Responsible Adult Signature   Contact Phone # 
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
*Disposition: Admit to Hospital (A); Discharged to Parent (D-P); Discharged to Relative (D-R); Discharged to Other (D-O); Social Services Placement (SS); Police (NYPD)
**Responsible Adult: Adult responsible for child at time of discharge. PSA Coordinator should determine if child can be discharged to this adult based on hospital policy.