Application of Incident Action Plan & Forms: Chemical Attack Hospital Incident Command System Application of Incident Action Plan & Forms: Chemical Attack This material has been developed for training purposes; do not share, distribute, transmit or reproduce without prior written consent of California Hospital Association This course was developed by the CHA Hospital Preparedness Program with grant funds provided by the U.S. Department of Health & Human Services Assistant Secretary for Preparedness & Response Hospital Preparedness Program and awarded by the California Department of Public Health. No part of this course or its materials shall be copied or utilized for monetary gain.

Objectives Demonstrate the Incident Action Planning Process Demonstrate the use of HICS Forms Implement the use of the Incident Response Guides

Scenario Based Implementation Discuss and rehearse practical implementation of the Incident Action Planning process utilizing HICS forms and the Incident Response Guides Utilize a “Table Top” learning process

Incident Action Planning Assess the Situation Set the Operational Period Determine Safety Priorities & Establish Control Objectives Determine Operational Period Objectives Determine Strategies & Tactics Determine Needed Resources Issue Assignments Implement Actions Reassess & Adjust Plans We will be using the Incident Action Planning Process to walk through our scenario Usually multiple things are being done at once but we are going to be linear and go through one thing at a time Reference the CHA IAP Checklist

Scenario The Universal Adversary terrorist group releases Sarin into the ventilation systems of three large commercial office buildings. Within minutes, people develop runny nose, watery eyes, coughing, chest tightness, blurred vision, drooling and sweating. Some develop severe muscle twitching, confusion, nausea and vomiting. Many have died. People are self evacuating the building and there are numerous fall/crush injuries. EMS has initiated triage and performing decontamination outside of the buildings.

Scenario Based on the symptoms, EMS requests large quantities of nerve agent antidotes to be brought to the scene. Hazmat confirms Sarin is the causative agent. Your hospital is the closest hospital about 2 miles from the scene. Many victims self evacuate and drive to your hospital. EMS also begins transporting the most critical victims to your facility with a short ETA. It is unknown if the victims have been fully decontaminated.

Scenario Time: 0830 Weather: Clear, 68º F, no winds

First Actions Within 15 minutes large numbers of contaminated and worried well are presenting to the hospital for care. Number of victims expected to arrive: Unknown Is this an incident? What are your first actions? Who is in charge? Start with 201 Is this an incident? Yes First Actions – Appropriate person takes role as Incident Commander Activates EOP, HICS, HCC Conduct situational assessment Direct victims to decontamination area, do not allow into facility Assure protection of first receivers Activate Decontamination team and/or request Fire Dept. assistance depending on level of capability Set up decontamination Prioritize victims for decontamination Monitor decontamination staff (Decontamination Safety Officer & Medical Monitoring) Assure all staff engaged in receiving and caring for patients have appropriate PPE Determine where triage and initial treatment will take place Obtain Nerve Agent antidote supply

Incident Action Planning Step 1: Assess the Situation Use HICS form 214: Operational Log Complete HICS form 201: Incident Briefing Event History and Current Actions Summary Begin form 202: Incident Objectives Weather/environmental implications for period Refer to forms in handouts Have the Incident Commander give you the summary to put on the 201 Put the weather on the 202

Which Positions to Activate? Based on this situation, what needs to be activated? Use the Chemical Attack – Nerve Agent Incident Response Guide Command Staff Section Chiefs (consider finance) Infrastructure Branch Director Medical Care Branch Director Hazmat Branch Director Security Branch Director Situation Unit Leader Support Branch Director How long did that take us to figure out? (go to next slide)

Immediate Time Period Look at the IRG for Chemical Attack (towards the back of the handout) This is a great cheat sheet, use the IRG to figure out what positions to activate

Naming the Incident The Incident Commander names the incident If the incident is a community-based incident, the appropriate jurisdiction will name the incident (e.g., county, city, EMS) The incident name should be documented on all forms Have the incident commander name the incident

Incident Action Planning Step 2: Set the Operational Period HICS form 202: Incident Objectives Operational Period Date/Time Incident Commander sets the Operational Period Based on number of simultaneous activities How quickly the situation is changing An Operational Period breaks the incident down into manageable timeframes Incident Commander should state the Operational Period In a situation that is not stable, still changing – it should be 2 hours. Usually the 1st Op Period is 2 hours.

Incident Action Planning Step 3: Determine Safety Priorities & Control Objectives Identify Command & Control Objectives (these are the overarching objectives that will last throughout the whole response) HICS form 202: Incident Objectives Control objectives – Identify, decontaminate, triage, and treat contaminated/exposed patients Assure safety and security of staff, patients and visitors. Accurately track patients through the healthcare system Communicate to community response partners (EMS, PHD, local fire and law enforcement) Maintain security and safety of facility After they come up with some ideas then you can show them objectives on the IRG – next slide Safety Officer addresses safety priorities on the HICS form 261 IAP Safety Analysis

Control Objectives Utilize the Incident Response Guide Chemical Attack: Identify, triage, isolate and treat contaminated/ exposed patients Safely admit a large number of contaminated/exposed patients while protecting your staff and facility Accurately track patients through the healthcare system Assure safety and security of the facility Fill in what they decide on the 202

Scenario Update #1 It has been 30 minutes since the event: Approximately 40 ambulatory self-transported victims have arrived at the hospital claiming to be in the vicinity of the release. Hospital decontamination set up is complete and decontamination has been started. EMS reports they have approximately 50 victims in moderate to severe distress. Field decontamination is in process. There are unknown numbers minor exposed/contaminated. EMS is ready to transport 4 critical victims.

Side Note: Safety Officer Tasks Assess the Safety issues What hazards exist and what precautions need to be taken Potential contamination of the facility, activate limited access Ensure safety of staff receiving victims, appropriate PPE Potential of hospital to be overwhelmed by incoming victims, insure security response Complete form 261 – Incident Action Plan Safety Analysis Safety Officer to work on the 261

Side Note: Public Information Officer Tasks Prepare a statement for the media Prepare a statement for the staff, patients and visitors (e.g., situation, status, safety precautions, next update time) The statements need approval from the Incident Commander Coordinate consistent messaging with the Joint Information Center (JIC)

Side Note: Liaison Officer Who or what entity operates as the county contact/MHOAC, and how do you make contact? Who else should be notified of the situation? Who should be notified of hospital status? Bed status? Decontamination capability? How? Who is the source of government resources in your local plan? (e.g., Fire department, local EMS Department Operations Center (DOC), PHD DOC, County/City Emergency Operations Center) Key contacts should be determined prior to the incident If there are immediate needs for decontamination, security, or pharmaceutical resources, where and how will these be obtained? Is there a need for EMS diversion and who needs to be notified? What other resources could be requested? Note: “Situation” refers to the event summery. Hospital “status” refers to functioning, partial functioning, non-functioning or could relate to diversion status.

Side Note: Documenting your Actions Utilize HICS forms Form 214 - Operational Log

Incident Action Planning Step 4: Determine Operational Period Objectives Document on HICS 204 – Branch Assignment List They are based on the Control Objectives These are based on what is desired to be achieved by the Section in that operational period Objectives need to be SMART (Simple, Measurable, Achievable, Realistic, Time Sensitive & Task Oriented) 5 – 10 min for students (Section Chiefs) to develop 3-4 objectives. PIO does PIO report. Liaison officer making calls. Safety Officer – form 261 People get confused about Sections/Branches use. A separate 204 for each Branch, if more than one branch is activated. Have them work on this in their sections. Actually write on a 204

Operational Period Objectives A common problem during exercises is that Sections/Branches don’t develop their objectives promptly Report top 3 objectives Have the groups share their top 3 objectives Some examples: Operations Implement decontamination procedures Administer antidotes as indicated Provide triage and care to exposed/injured patients Protect environment/facility from contamination Ensure medical monitoring of personnel participating in decontamination Secure the facility Planning Track patients Develop the Incident action plan in collaboration with the Command and General Staff Initiate materiel and personnel tracking procedures Logistics Obtain and deliver antidotes to decontamination area and emergency department Determine medication, equipment, supply and personnel needs Prepare for receipt, distribution and tracking of external pharmaceutical resources Provide mental health support for patients/family/staff/command personnel Assure communications are in place between decontamination unit, emergency department and HCC Finance Track costs

Incident Action Planning Step 5: Determine Strategies & Tactics Strategies & tactics are how your Section/Branch is going to achieve the objectives What actions do you need to take? Use your facility response plans and Incident Response Guides Record strategies & tactics on form 204 – Branch Assignment List Assure decontamination, chemical agent guides, security, surge related policies, plans, procedures are available from the EOP in the Hospital Command Center

Incident Action Planning Step 6: Determine Needed Resources Does additional space need to be activated? What personnel resources do you need? What equipment and/or supplies/ pharmaceuticals do you need? What resources do you need in the patient collection/decontamination area? What communication devices do you need? Document resource activities: Resources assigned (form 204) Resource requests (form 213) Actions taken to utilize & obtain resources (form 214) Space for holding minor/mild victims Security, decontamination, medical monitoring personnel Antidotes/Valium Doffing/donning kits Blankets Communication devices (Radios) Hydration for decontamination staff

Incident Action Planning Step 7: Issue Assignments Who will be assigned to the units? Fill in the assignments on form 204 – Branch Assignment List Are there other branches that need activated? Have them work in groups on their strategies, tactics and assignments for their branches

Incident Action Planning For the first Operational Period the Incident Action Plan should be done within 30-45 minutes What makes up the Incident Action Plan? Form 201 - Incident Briefing Form 202 - Incident Objectives Form 203 - Incident Assignments Form 204 - Branch Assignments Form 261 - Incident Action Plan Safety Analysis The Planning Section compiles the forms to create the Incident Action Plans As we did this process, completed the forms – THIS made up our IAP Put a cover on it with the date, time of the Operational Period – process it, share with others

Incident Action Planning Step 8: Implement Actions Put your activities / plans into action What are some of these activities? Remind students about monitoring and evaluating activities being implemented

Scenario Update #2 It is now 1000 – 1.5 hrs into the incident The hospital has received 60 additional ambulatory self-transported victims, 4 in severe distress and 10 in moderate distress Decontamination of victims continues EMS has transported 2 critical victims to your hospital What are your major concerns? Major Concerns: Continued medical care Security Hospital contamination Continued ability to provide decontamination services Staff contamination/injury Media management Disruption of services PIO messaging to patients, staff, media Communication to governmental agencies (Liaison)

Incident Action Planning Step 9: Reassess & Adjust Plans Towards the end of the operational period, you will need to evaluate status Repeat steps 1-8 Update the forms Evaluate and/or update your Operational Period Objectives This creates your Incident Action Plan (game plan) for the next operational period

Scenario Update #3 It is now 4 hours into the incident All victims have been transported Hospital decontamination is completed and there is a large volume of victim belongings and grey water collection Universal Adversary has claimed responsibility and states a secondary device is in place What issues should be considered? Security considerations Evidence collection/Law enforcement communication Handling of victim belongings Grey water handling and decontamination zone clean up/recovery Assessment of decontamination staff Family reunification Communication with local DOC/EOC to determine what resources can be provided to the hospital Staff Communication Public Information

How are we doing? What are things we need to remember to do? Share information Recovery / Restoration After Action Report Corrective Actions Plan

Questions? Clean-up, part of any event is recovery-put the vests back as they belong Post test Evaluation

Incident Action Plan & Forms: Application of Incident Action Plan & Forms: Chemical Attack developed by the California Hospital Association’s Hospital Preparedness Program www.calhospitalprepare.org This material has been developed for training purposes; do not share, distribute, transmit or reproduce without prior written consent of California Hospital Association This course was developed by the CHA Hospital Preparedness Program with grant funds provided by the U.S. Department of Health & Human Services Assistant Secretary for Preparedness & Response Hospital Preparedness Program and awarded by the California Department of Public Health. No part of this course or its materials shall be copied or utilized for monetary gain.