Pandemic Influenza Response: Ketchikan's Alternate Care Site Exercise

Learner Objectives Discuss the planning process required to supply and staff an Alternate Care Site (ACS). List the staffing challenges of operating an Alternate Care Site. Discuss lessons learned.

Polling Question #1 B. No A. Yes Participants, have you ever participated in setting up an Alternate Care Site, either in a drill or as a real event? A. Yes B. No

Where is Ketchikan Alaska? Ketchikan is the first Alaskan port-of-call for northbound cruise ships, commercial vessels, and Alaska Marine Highway State ferries, hence the name “Alaska's First City.” Ketchikan is 680 air miles north of Seattle (1.75 hour jet flight) and 230 miles south of Juneau (1 hour jet flight). Ketchikan is situated in the nation's largest national forest, The Tongass, which totals 17 million acres. This regional hub of about 14,000 makes its living from the surrounding forests, from abundant salmon runs, and from the nearly 1 million visitors that flock to Ketchikan each year. Ketchikan is on an island in Southeast Alaska

Primary Community Partners in the Exercise Ketchikan Fire Department (KFD) Fire Dept. The Ketchikan Fire Department, with their 19 career staff and 40 volunteer members, boasts some of the most qualified fire and EMS personnel in the state of Alaska. Many of their personnel are state-certified instructors and they travel throughout the state providing instruction in Fire Suppression, Emergency Medical Services, Marine Shipboard Firefighting, Hazardous Materials Response, and Incident Management. All of their career staff are certified Firefighter-II’s. Ketchikan’s volunteer staff members are all Firefighter-I and soon to be Firefighter-II certified. The city of Ketchikan is one of the only municipalities in Alaska “accredited” to provide Firefighter-I and Firefighter-II certified training programs to our personnel. Because of aggressive grant application processes in 2003 and 2004, Ketchikan is now proud to have the first Level-A hazardous materials response team in southeast Alaska. The City of Ketchikan has inter-local agreements with the North Tongass Volunteer Fire Department, the South Tongass Fire Department, and the Ketchikan International Airport. Ketchikan is also a part of the SEREMS “SE Alaska Mass-Casualty Contingency Plan.” Health Care Ketchikan has 1 Critical Access hospital with 25 beds, attached LTCU with 29 beds, Home Health Service, PT/Rehab, CT, MRI, Primary & Specialty Clinics, part of the hospital (7) Family Practice, Internal Med, OB/Gyn, Ortho, Peds, Psychiatry, Surgery Ketchikan Indian Community Tribal Health Clinic, Primary Clinics, stand alone (5) Internal Med, Optometrists, OP Family Practice, Acupressure, Visiting Physician Specialty Clinics, Allergy & Asthma, Cardiology, ENT, Foot & Ankle, Head & Neck Surgery, Plastic & Reconstructive, Ophthalmologists, Rehab Med, Urology, U.S.C.G. Clinic, Dentists Offices (6), Ketchikan Public Health Nursing, Pioneer Home Gateway Human Services; Behavioral Health, Substance Abuse Youth Residential Center, Pharmacies (5), Medevac Services: Airlift Northwest, GuardianFlight,Inc., EMS Services: City (KFD), North Tongass, South Tongass PH Nursing Sandra Woods, RN, MS, Preparedness Training Coordinator Ketchikan General Hospital (KGH) Ketchikan Indian Community (KIC) Ketchikan Public Health Nursing

Additional Community Partners in the Exercise City of Ketchikan Law Enforcement Public Works Ketchikan Public Utilities GuardianFlight, Inc. Ketchikan Gateway Borough Ketchikan Gateway Borough School District Ketchikan Pastoral Association Laidlaw Transit Inc.

Additional Community Partners in the Exercise North Tongass Volunteer Fire Department State of Alaska Behavioral Health South Tongass Volunteer Fire Department Temsco Helicopters, Inc. University of Alaska at Anchorage (UAA), Certified Nursing Assistant (CNA) Program

Community Goal Our goal is to create an “All Hazards” plan—an Emergency Operations Plan (EOP) that will allow our managers to perform their duties with confidence and efficiency. This exercise will help guide our responders and managers and will provide us, the authors of the “New EOP,” a means to create a document that is useful for all types of events and for all departments or agencies involved.

City of Ketchikan Objective To exercise evacuation policies and procedures To test mutual aid agreements To simulate an actual Emergency Operations Center (EOC) activation that will include a training session To exercise large-scale incident management procedures To assist any associated agency for the duration for the exercise This will help us in the completion of the “re-write of the emergency operations plan.”

Ketchikan Indian Community Tribal Health Clinic Objective To exercise and evaluate its ability to set up, staff, supply, and operate an Alternate Care Site for overflow of triaged “walking wounded” patients from the Ketchikan General Hospital ER.

Ketchikan General Hospital Objective To work with community partners to exercise and evaluate the: Establishment and set up of the ACS Supply and transport of resources to the ACS Communication at the ACS Record keeping of care/services rendered at the ACS

Ketchikan Public Health Nursing Objective For Alternative Care Sites, public health officials will take the lead in: Establishment (identifying a site) Set-up Staffing Operations

Funding Funding was provided by The City of Ketchikan through the United States 2005 Homeland Security Grant and the Alaska Division of Homeland Security and Emergency Management. Grant # 2005-GE-T5-0031. Disposable supplies, sleeping bags, and pillows were provided by the Alaska State Hospital and Nursing Home Association grant. KGH financial crisis, originally had HLS grant, money taken back, forced to limit participation to what funding would cover. Occurred approximately 4 weeks prior to event. Core staff: registration, nursing, maintenance for set up/tear down/transportation of equipment, materials management for supplies, photographer to document event, fiscal for payment

6/06 site visit to the proposed site at Fawn Mountain School Planning Timeline 12/05 to 10/06 12/05 Community was approached about exercising the setting up of an Alternate Care Site for Pandemic Influenza. 1/06 Community partners agreed to participate and that the exercise would be incorporated into the “EvacAlt 2006” Exercise Plan 1/06 Monthly meetings and teleconferences started. These increased in frequency as the exercise date approached 2/06 Incident Command System (ICS) for Emergency Medical Services (EMS) class for community partners 3/06 National Incident Management System (NIMS) ICS Workshop for SE Alaska 3/06 and 9/06 Approached Pastoral Association for help with volunteers 6/06 Jana worked with KIC staff set up the KIC Health clinic as an ACS for acute minor injuries as part of the KGH surge capacity plan. 6/06 The planning group made a site visit to the proposed site at Fawn Mountain School. Potential layout for the exercise was discussed. 7/06 “Always Ready” Emergency Preparedness for Ketchikan published & distributed to Community 9/06 EOC/ICS/NIMS workshop was conducted for the Ketchikan-based planners 6/06 site visit to the proposed site at Fawn Mountain School

Scenario Mobile command post The dam Evacuation area (red) Ketchikan Creek Bridges destroyed KGH & KIC are located 3 miles north. South Tongass Hwy: Fawn Mountain School is 4 miles south Ketchikan has been experiencing increased influenza activity over the past week. On 10/6/06, the hospital is full and the decision is made to set up an ACS at Fawn Mountain School, south of town. Influenza patients were transported to the completed site prior to the dam blowing up On the evening of 10/6/06, the dam that holds the local water supply was blown up, flooding areas of downtown Ketchikan, cutting off access to the Fawn Mountain Alternate Care Site. Scenario

Exercise: KPD

Mobile Command Center

Exercise: Set Up Tent & Security

Exercise: Tent & Patients A nurse was assigned to monitor patients awaiting transfer to Fawn Mountain Alternate Care Site (FM ACS). Ten influenza patients are taken to the isolation tent outside of the ER to await transportation to FM ACS.

Exercise: Materials Materials Management readies supplies according to the pre-determined lists. Categories include: CS Disposables, Equipment, Pharmacy-Meds Description Quantity Needed Per Day UOM Order Quantity Dispensed

Set Up Hospital maintenance staff Transfers equipment and supplies to Fawn Mountain school Sets up the beds, privacy curtains

Set Up: Signage

Bus Loading

Bus Leaves KGH

Bus arrives at Fawn Mountain ACS The influenza patients arrive. The cots are ready!

FM ACS Care: Registration Charts

FM ACS Care: Triage

FM ACS Care: Bed Board

FM ACS Care

Discharge Station

Pastoral Care

The Group Photo

KGH Command Center

KGH: Patients Arrive

KIC ACS

KIC ACS: Pharmacy

Helicopter: Fawn Mountain to KGH Depart FM ACS Arrive KGH

Road blocks Funding sources through KGH were not available; Home Land Security Grant money withdrawn Volunteer patients: age, family, rules Timing of the exercise was shorter than planned Other community events: Health Fair, Mass Immunization Clinic, Auction

Lessons Learned

Lessons Learned Staffing Supplies Registration Process Equipment List Hospital Community Supplies Transport Trial Registration Process Equipment List KIC Activate, communicate, transport Medical Reserve Corp

Lessons Learned: Nutrition/Hydration For the volunteer patients and staff KGH, DEC, sack lunches

Lessons Learned: Participant Responses Actors in Fawn Mountain ACS Exercise (10 responses) It's nice to know that we are preparing for a disaster before one appears. Thank you. You did a great job practicing your job and taking care of us and fulfilling our needs, and I would enjoy doing this again. They took really good care of me and made me feel comfortable. I felt like I was well cared for and would definitely go to this hospital if I really did get sick. Everyone was nice. You did a great job taking care of your patients.

Lessons Learned: Participant Responses Actors in Hospital Exercise: KGH & KIC (7 responses) KIC staff were more thorough than KGH staff. Great staff.

Lessons Learned: Dolls Blow up dolls before buying them outfits!

Lessons Learned Emergency Operations Plan Completed Approved locally Currently pending State of Alaska “OK”

Ketchikan Healthcare Community Comes Together Public Health Primary Care Providers Clinics EMS Ketchikan General Hospital