Post-Disaster Considerations for Pediatricians in Practice

• Make sure mobile phones are fully charged and that you have your phone charger with you.
• Write/type all important contacts from your phone onto paper, in case there is an electrical outage and access to phone recharging is not available. Consider placing the paper-based important contacts in a plastic zip-lock bag to help preserve these in the event of water-related disasters.
• Get gasoline for cars, obtain cash and food/water for at least 3 days.
• Review your own family's disaster plan so that everyone knows who to contact and where to meet.
• Organize the office to store supplies appropriately and minimize risk to equipment.
• Review the office communications plan with staff. Update telephone and web-based or other automatic messaging as appropriate.
• Bookmark or write down URLs for important resources.
• Take pictures or a quick video of the office (inside and out) before the disaster.
• Share with all staff where the nearest disaster relief center is so that they can have access to telephone landlines and other alternative communication devices as needed.

• Focus first on basic needs for you and your family: food, water and shelter.
• Follow instructions given by civil authorities.
• If you or other staff can safely reach your office(s), try to ascertain building conditions.
• Contact key staff to learn where they are, how they are doing and when they might be available to help.
• Post information on your clinic windows, website, recorded telephone message and social media letting people know the current status and plans for your practice as well as hours of service and any referral facilities (with addresses) for them to seek assistance if needed.
• Carry identification and credentials with you any time you leave your house (eg, driver's license, medical license, hospital and/or office badge). You may need these items if there are travel restrictions and/or curfews in place.

• Determine what services you can provide/what you will need to defer (eg, vaccinations, laboratory tests, well-child examinations, chronic care visits, etc). 
• Consider a plan to triage appointments, especially if you are only working part-time. 
• Determine what you will need to provide your usual services and develop a rough timeline for practice recovery. 
   

• When cellular telephone towers are down, texting may still work. Try to use app-based programs as these may work when other communication systems may not (ie, WhatsApp and Facebook messaging worked following hurricane Maria when other modalities did not).
• Publicize office hours, location, services, and availability. Direct patients to where they can receive updated information. Update this information as needed. Consider using:
  • Recorded telephone message
  • Mass texting or email (via Electronic Health Record or similar)
  • Website postings
  • Social media messages
  • Local media (newspaper, radio, television)
  • Fliers at community recovery centers, grocery stores

As you plan your communication mechanisms, remember that not everyone in the community will be affected equally. Power outages may affect some areas but not others, and power will likely be restored at varying times. Not all individuals will have the same access to basic utilities at the same time. Some patients may be in shelters. Vulnerable populations including those who do not speak English will have greater challenges.

• Inspect your office as well as the surrounding areas. Ensure that the building and area are safe and accessible before allowing patients and staff back in.
• If your office is not usable, look for alternative practice space. Options might include:
  • Space owned or leased by a local hospital or another practice
  • Local health department
  • Commercial office space
  • Federally qualified heath centers in the community
  • Open-air visits out of your car in a parking lot
  • Home visits
• If using an alternate practice space, make sure to consider how this affects your billing.

• Check on availability of staff, and if they are safe and have their basic needs met (safety, housing, food/water, utilities).
• If not already decided, determine how you will continue to pay the staff if the practice is closed and/or they cannot report to work. Discuss leave policies in case staff need to attend to personal needs. Inform staff of what to expect.
• If staff who perform critical functions are not available, people may need to cover for each other or take on responsibilities they wouldn't typically manage. This includes you! Just do the best you can and help with whatever needs to be done.

• Take pictures of all damage and losses.
• Contact your insurance adjuster as soon as possible.
• Recognize that your initial insurance claim may be at least partially denied. Be prepared to appeal.
• If business interruption coverage is denied, you may be able to appeal under civil disruption or similar. Mandatory evacuation will help your case.
• Know that insurance can help offset losses but will not "make you whole".
• You may be able to deduct unreimbursed losses on your tax return. Consult with your accountant.

• Save all vials! 
• Contact Vaccines for Children Program (VFC) representatives for instructions on what to do with VFC stock. 
• For private vaccines, submit a loss claim to insurance. Most insurance will cover vaccines losses as "spoilage". 
• If you still have uncovered losses after your insurance claim is settled, contact the vaccine manufacturers (see AAP Resource). These companies should allow replacement of uncovered vaccine losses.

• Call vendors to see if they will offer extended payment terms.
• If shipments of equipment/supplies/vaccines are in process, contact vendors to make sure you are not liable for any shipments disrupted or not received due to the disaster.

• If you cannot use your Electronic Medical Record, determine how you will record patient visits.
• Determine if, and how, you will charge patients for visits if telephone, internet and/or Electronic Medical Record systems are down. Keep in mind that you may not be able to verify patient insurance information, and some patients may lose their insurance if they are no longer employed.

• Consider tapping into a business line of credit.
• Investigate short-term bridge loans.
• Consider a Small Business Administration disaster recovery loan.
• Consider applying for Community Development Block Grant funding.

• Prepare a list of what you need to operate and recover, both for the short-term as well as the long-term. Think in terms of both "stuff" and services (help, manpower, expertise).
• Talk with your local AAP Chapter leaders to see how they might help.
• Reach out to community organizations and leaders (e.g., city or county government, Chamber of Commerce, state or federal elected representatives) to let them know your needs, and your importance to the community and its recovery. Create a "wish list" so that when people ask how they can help, you have ideas on hand.

• Make sure to ask families how they are doing after the disaster. You may want to make a special "disaster history" template or section in each patient chart.
• Be alert for ways that the disaster may be impacting the health of children. While most children will be doing okay, others may be suffering but will not want to share what they are feeling. Children may be anxious if their parents are having trouble coping or are experiencing difficulties. Pre-existing conditions (both physical and behavioral/emotional) may be exacerbated or deteriorate. The Centers for Disease Control and Prevention offers handouts that you may be able to access and share with families. The AAP also offers a resource to help promote adjustment and help children cope.
• Get involved in community recovery efforts. Figure out which groups are directing the recovery. Make sure that the needs of children are being considered.

• Make sure to take time for yourself. Do not feel that you need to attend to your practice 24/7. It is critically important to allow yourself downtime.
• Attend to what needs to be done at home.
• Reach out to peers to ask for and offer emotional support.
• If you feel overwhelmed or hopeless, seek professional help immediately.
• Recognize that there is a limit to how much you can do in a day, and that this is OK.

• When operations are more stable, involve your staff in an after-action review. Share what went well, and what did not work out quite as well. Identify a few concrete steps to take to improve your office preparedness and disaster plan for next time.
• Consider writing up your experiences (and after-action review) to share with your staff, your colleagues (perhaps your AAP Chapter), and to save for posterity.