Respondent Name* must provide value
Respondent Email* must provide value
State* must provide value
Alaska California Connecticut Georgia Illinois Indiana Kansas Missouri New Jersey New York Oregon Rhode Island Texas Tennessee Washington Wisconsin Vermont
Hospital Name* must provide value
Adventist Health Clear Lake Medical Center Adventist Health Lodi Memorial Adventist Medical Center - Portland Advocate Good Shepherd Hospital Anderson Hospital Ascension Franklin Atchison Hospital Aurora Sheboygan Memorial Medical Center Blue Mountain Hospital District Charlotte Hungerford Hospital CHI Mercy Health Children's Hospital of Georgia - Augusta University Children's Mercy Cogdell Memorial Hospital Cohen Children's Medical Center Comer Children's Hospital University of Chicago Connecticut Children's Medical Center Crossing Rivers Health Dell Children's Medical Center of Central Texas Dell Seton Medical Center at the University of Texas Divine Savior Healthcare East Tennessee Children's Hospital Enloe Medical Center Eskenazi Health Fairchild Medical Center Greenwich Hospital Hawkins County Memorial Hospital Hays Medical Center Heartland Regional Medical Center Hospital Authority of Miller County Hospital of Central Connecticut Howard Young Medical Center Huntington Hospital Indiana University Health Arnett Hospital Jerold Phelps Community Hospital Kaiser Sunnyside Medical Center Legacy Salmon Creek Medical Center Legacy Silverton Medical Center LifeBrite Community Hospital of Early Long Island Jewish Valley Stream Maimonides Medical Center Marshfield Medical Center Mayers Memorial Hospital District McPherson Hospital Medical City Alliance Medical City Arlington Medical City Burleson Medical City Dallas Medical City Denton Medical City Flower Mound Medical City Fort Worth Medical City Frisco Medical City Grand Prairie Medical City Las Colinas Medical City Lewisville Medical City McKinney Medical City North Hills Medical City North Plano Medical City Park Cities Medical City Plano Medical City Saginaw Medical City Stonebridge Medical City Weatherford Memorial Hospital Belleville Memorial Medical Center Mercy Health System and Trauma Center - Janesville Mercy Medical Center Redding Mercyhealth Walworth Hospital and Medical Center Mile Bluff Medical Center Mount Sinai Hospital Newport Medical Center Norton County Hospital OHSU Doernbecher Children's Hospital Orchard Hospital Peace Harbor PeaceHealth Southwest Medical Center Piedmont Columbus Regional Providence Alaska Medical Center Providence Health Center Providence Hood River Memorial Hospital Providence Medford Medical Center Providence Milwaukie Hospital Providence Newberg Medical Center Providence Portland Medical Center Providence Seaside Hospital Providence Seward Medical Center Providence St Vincent Medical Center Providence Williamette Falls Medical Center Randall Children's Hospital Ransom Memorial Health Rideout Health Riley Hospital for Children Russell Regional Hospital Saint Elizabeth Medical Center Saint Joseph Hospital - Elgin Saint Mary's Hospital Saint Raphael Campus Salem Hospital Sauk Prairie Hospital Seton Edgar B. Davis Hospital Seton Highland Lakes Hospital Seton Medical Center Austin Hospital Seton Medical Center Hays Seton Medical Center Williamson Seton Northwest Hospital Seton Smithville Hospital Seton Southwest Hospital Shawnee Mission Medical Center Shore Medical Center Sky Lakes Medical Center Smith County Memorial Hospital Southern Regional Medical Center Southwest Health Springfield Hospital SSM Health - DePaul Hospital SSM Health - Saint Louis University Hospital SSM Health - St. Clare Hospital SSM Health - St. Joseph Hospital - Lake St. Louis SSM Health - St. Joseph Hospital - St. Charles SSM Health - St. Joseph Hospital - Wentzville SSM Health - St. Mary's Hospital - St. Louis SSM Health Cardinal Glennon Children's Hospital St. Charles Medical Center - Bend St. Elizabeth O'Fallon St. Mary's Sacred Heart Hospital Stamford Hospital Staten Island University Hospital Swedish American Hospital Sweetwater Hospital Association Trego County Lemke Memorial Hospital Tuality Healthcare UC Davis Medical Center Union Health Inc. UnityPoint Health Meriter University of Connecticut Health Center Via Christi Hospital, Pittsburg Waupun Memorial Hospital Wellstar Cobb Hospital Wellstar Douglas Hospital Wellstar Kennestone Regional Medical Center Wellstar Paulding Hospital Westerly Hospital Wisconsin Children's Health Alliance (Medical College of Wisconsin) Wisconsin Children's Health Alliance (UWHealth University of Wisconsin Hospital and Clinics American Family Children's) Witham Health Yale New Haven Children's Hospital
Does your Emergency Department have a scale that weighs in pounds and kilos? * must provide value
Yes
No
Can your scale be switched to kilograms only? * must provide value
Yes
No
Can your scale be locked in kilograms? * must provide value
Yes
No
How often is the scale checked to confirm the appropriate unit of measure? * must provide value
Each shift change
Daily
Weekly
Monthly
Unknown
Rarely
Other
Do you have a policy that defines frequency for assuring your scale is locked in kilograms? * must provide value
Yes
No
Who triages patients in your ED? * must provide value
Nurse
Technician
Medical Assistant
Other
Other (specify)* must provide value
What triage system has been adopted for children at your institution? * must provide value
Emergency Severity Index (ESI)
Manchester Triage System (MTS)
Pediatric Canadian Triage and Acuity Scale (CTAS)
Australasian Triage Scale (ATS)
Ramathibodi Triage System (RTS)
Color-coded
Other
Specify colors/levels used* must provide value
Other (specify)* must provide value
Which of the following vital signs are documented on every child in triage and/or during the ED stay? (check all that apply)* must provide value
Heart rate
Blood pressure
Respiratory rate
Pulse oximetry
End-tidal CO2
Temperature
Mental status
Where are initial vital signs usually taken?* must provide value
Registration
Triage area
ED room
Other
Other (specify)* must provide value
Is there currently a process in place for notifying physicians of abnormal initial vital signs at triage? * must provide value
Yes
No
Is pain assessed and documented on every child? * must provide value
Yes
No
Is social/behavioral health assessed and documented on every child? * must provide value
Yes
No
Only if Admitted
Is suicide assessment documented in all adolescent children who present to the ED?* must provide value
Yes
No
What age range is mandated for mental health assessment? * must provide value
If the age range is 5 years to 10 years, enter 5-10 in the response field.
What standard is used for normal vital signs? * must provide value
American Heart Association, Pediatric Advanced Life Support (PALS) Advanced Paediatric Life Support (APLS) World Health Organization (WHO) Advanced Trauma Life Support (ATLS) Pediatric Early Warning Signs (PEWS) Pediatric Advanced Warning Score (PAWS) European Pediatric Life Support (EPLS) Unknown No set standard exists at our hospital Other
Other (specify)* must provide value
Do all staff receive regular training on normal pediatric vital signs by age/weight/height? * must provide value
Yes No
How are vital signs recorded? * must provide value
Electronically Manually Both
Is there a written guideline of how staff communicate with physicians or advanced providers regarding abnormal vital signs? * must provide value
Yes No
Is there currently a process in place for notifying physicians of abnormal vital signs during the ED visit (including before discharge)? * must provide value
Verbal Electronic Manual There is no standard process in place
Are there criteria in place that define those patients/diagnoses to be considered for pediatric interfacility transfer? * must provide value
Yes No
Are there criteria in place to guide decisions regarding mode of pediatric interfacility transports? * must provide value
Yes
No
Which of the following patient inpatient capabilities are available at your site? (check all that apply)* must provide value
Newborn Nursery
NICU
Pediatric Ward
PICU
Adult services only, pediatric patients admitted on case-by-case basis only
None
Approximately how many pediatric (as defined by your institution) patients were transferred to another facility in the last year? * must provide value
Which of the following ground transportation services are readily available? (check all that apply)* must provide value
Municipal/Fire-based EMS Basic Life Support
Municipal/Fire-based EMS Advanced Life Support
Private/Franchise ambulance company
Critical Care transport unit
Pediatric transport unit
Other ________________________
Other (specify)* must provide value
Do you have interfacility transfer agreements for pediatric medical patients? * must provide value
Yes
No
Do you have interfacility transfer agreements for pediatric trauma patients? * must provide value
Yes
No
Does your site have a formal all-hazard written disaster plan (in writing)? * must provide value
Yes
No
Who is responsible for maintaining the plan (choose all that apply)?* must provide value
Emergency Management/Preparedness Coordinator
Emergency Management/Preparedness Committee
Hospital Administrator
Clinical Leadership
Other
Other (specify)* must provide value
Which of the following are included in the disaster plan (choose all that apply):* must provide value
Surge capacity
Decontamination
Patient tracking/Family Reunification
Which of the following pediatric-specific needs are included in the plan (check all that apply)? * must provide value
Pediatric essential resources (medications, equipment, nutrition)
Pediatric surge capacity/mass casualty
Pediatric decontamination
Pediatric triage
Pediatric patient tracking and family reunification
How are ED staff educated on the plan details? * must provide value
New Employee Orientation
Web based learning
Table top drills
Department specific meeting updates
CME/CNE (Continuing Education)
Other_______________________
I do not know
Other (specify)* must provide value
Does your site have a disaster/emergency preparedness committee? * must provide value
Yes
No
Is there a pediatric representative on the committee? * must provide value
Yes
No
Specify Primary Title
Does the pediatric representative carry a formal title (in writing) related to pediatric disaster coordination? * must provide value
Yes
No
Specify Formal Title
Does the pediatric representative have any formal training in disaster preparedness?* must provide value
Yes
No
Over the last 2 years, has your emergency department conducted any disaster exercises or drills?* must provide value
Yes
No
How frequently are exercises/drills conducted involving the emergency department?* must provide value
Once every two 2 years
Annually
Two 2 times per year
Three 3 times per year
Four 4 times per year
Greater than 4 times per year
On average, over the last 2 years, what is the percentage of children (live or simulated) represented in the drills?* must provide value
On average over the last 2 years, were actual children used in the drill (i.e. live child actors)?* must provide value
Yes No
Has your site conducted pediatric-only or pediatric-focused disaster exercises or drills? * must provide value
Yes No
Does your site have a tool/process for calculating the emergency department's surge capacity? * must provide value
Yes No
Does your site participate in a regional disaster coalition? * must provide value
Yes No
What is the name of the coalition? * must provide value
Is pediatrics represented on the regional disaster coalition? * must provide value
Yes No
Has the regional coalition determined pediatric surge capacity strategies? Yes No Unknown
What pediatric triage tool or approach has been adopted by your facility/region? * must provide value
START JumpSTART SMART SALT Other Unknown
Other (specify)* must provide value
Does your site have a process in place to decontaminate pediatric patients? * must provide value
Yes No
Does your site have a pediatric tracking tool for use when children might be separated from parents/guardians during disasters? * must provide value
Yes No
If yes, are the following included (check all that apply):* must provide value
Photo tracking ID bands
Based on your site's all-hazards vulnerability analysis, what are the top five (5) hazards for your site?* must provide value
Pandemic Influenza Other infectious pandemic Flooding Fire Radiation Tornado Tsunami Volcano Landslide Hurricane Wildfire Earthquake Extreme Heat Winter Storm Chemical Emergency Bioterrorism Active shooter event Information Technology Cybersecurity Medication shortages Other
Other (specify)* must provide value
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