Prehospital and Disaster Medicine

Brief Report

Waterworks, a Full-Scale Chemical Exposure Exercise: Interrogating Pediatric Critical Care Surge Capacity in an Inner-City Tertiary Care Medical Center

Vikas S. Shaha1a2 c1, Lauren C. Piercea3, Patricia Roblina1, Sarah Walkera1, Marte N. Sergioa4 and Bonnie Arquillaa1a2

a1 SUNY Downstate Medical Center, Brooklyn, New York USA

a2 Kings County Hospital Center, Brooklyn, New York USA

a3 Northwestern University, Chicago, Illinois USA

a4 Stony Brook University School of Medicine, Stony Brook, New York USA


Introduction Pediatric Intensive Care Unit (PICU) resources are overwhelmed in disaster as the need to accommodate influx of critically-ill children is increased. A full-scale chlorine overexposure exercise was conducted by the New York Institute for All Hazard Preparedness (NYIAHP) to assess the appropriateness of response of Kings County Hospital Center's (KCHC's) PICU surge plan to an influx of critically-ill children. The primary endpoint that was assessed was the ability of the institution to follow the PICU surge plan, while secondary endpoints include the ability to provide appropriate medical management.

Methods Thirty-six actors/patients (medical students or emergency medicine residents) were educated on presentations and appropriate medical management of patients after a chlorine overexposure, as well as lectures on drill design and expected PICU surge response. Victims presented to the hospital after simulated accidental chlorine overexposure at a public pool. Twenty-two patients with 14 family members needed evaluation; nine of these patients would require PICU admission. Three of nine PICU patients were low-fidelity mannequins. In addition to the 36 actor/patient evaluators, each area had two to four expert evaluators (disaster preparedness experts) to assess appropriateness of global response. Patients were expected to receive standard of care. Appropriateness of medical decisions and treatment was assessed retrospectively with review of electronic medical record.

Results The initial PICU census was three of seven; two of these patients were transferred to the general ward. Of the nine patients that required Intensive Care Unit (ICU) admission, six actor/patients were admitted to the PICU, one was admitted to the Surgical Intensive Care Unit (SICU), one went to the Operating Room (OR), and one was admitted to a monitored-surge general pediatric bed. The remaining 13 actor/patients were treated and released. Medical, nursing, and respiratory staffing in the PICU and the general ward were increased by two main mechanisms (extension of work hours and in-house recruitment of additional staff). Emergency Department (ED) staffing was artificially increased prior to the drill. With the exception of ocular fluid pH testing in patients with ocular pruritus, all necessary treatments were given; however, an unneeded albuterol treatment was administered to one patient. Chart review showed adequate discharge instructions in four of 13 patients. Nine patients without respiratory complaints in the ED were not instructed to observe for dyspnea. All patients were in the PICU or alternate locations within 90 minutes.

Discussion The staff was well versed in the major details of KCHC's PICU surge plan, which allowed smooth transition of patient care from the ED to the PICU. The plan provided for a roadmap to achieve adequate medical, nursing, and respiratory therapists. Medical therapy was appropriate in the PICU; however, in the ED, patients with ocular complaints did not receive optimal care. In addition, written discharge instruction and educational material regarding chlorine overexposure to all patients were not consistently provided. The PICU surge plan was immediately accessible through the KCHC intranet; however, not all participants were cognizant of this fact; this decreased the efficiency with which the roadmap was followed. An exaggerated ED staff facilitated evaluation and transfer of patients.

Conclusion During disasters, the ability to surge is paramount and each hospital addresses it differently. Hospitals and departments have written surge plans, but there is no literature available which assesses the validity of said plans through a rigorous, structured, simulated disaster drill. This study is the first to assess validity and effectiveness of a hospital's PICU surge plan. Overall, the KCHC PICU surge plan was effective; however, several deficiencies (mainly in communication and patient education in the ED) were identified, and this will improve future response.

VS Shah, LC Pierce, P Roblin, S Walker, MN Sergio, B Arquilla. Waterworks, a full-scale chemical exposure exercise: interrogating pediatric critical care surge capacity in an inner-city tertiary care medical center. Prehosp Disaster Med. 2014;29(1):1-7.

(Received February 06 2012)

(Revised June 04 2012)

(Accepted August 28 2012)

(Online publication December 13 2013)


  • chemical exposure;
  • disaster preparedness;
  • drill design;
  • pediatric critical care medicine;
  • surge capabilities


  • ED:emergency department;
  • EMR:electronic medical record;
  • EOC:Emergency Operations Center;
  • HSEEP:Homeland Security Exercise and Evaluation Program;
  • ICU:intensive care unit;
  • KCHC:Kings County Hospital Center;
  • NYIAHP:New York Institute for All Hazards Preparedness;
  • OR:operating room;
  • PACU:post-anesthesia care unit;
  • PED:pediatric emergency department;
  • PICU:pediatric intensive care unit;
  • SICU:surgical intensive care unit


c1 Correspondence: Vikas S. Shah, MD Downstate Medical Center 440 Lennox Road, Suite 2M Brooklyn, New York 11203 USA E-mail


  Conflicts of Interest/Funding: The authors declare no conflicts of interest. No funding was received for this research.