1 [Hospital Name] [Local Health Department Logo] [Hospital Logo] Moderated by: and Facilitated by: Bioevent Tabletop Exercise

2 Increase bioevent awareness Assess level of hospital preparedness and ability to respond during a public health emergency Explore surge capacity issues for increasing staffed beds, isolation rooms and hospital personnel Identify triggers for activating the incident command system Evaluate effectiveness of incident command system policies, procedures and staff roles Discuss the psychosocial implications of a bioevent and the role of mental health assets Update and revise the emergency management plan from lessons learned during the tabletop exercise Exercise Objectives

3 Exercise Format This is an interactive facilitated tabletop exercise with three modules. There are breakout group sessions after the first two modules, which are both followed by a moderator facilitated discussion with each breakout group reporting back on the actions taken. After the third and final module there is a facilitated plenary discussion with all participants. A Hot Wash is the final component of the exercise followed by an exercise evaluation.

4 Breakout Groups There are three (four) groups for the breakout sessions: Administration  EOC/Incident Command Clinical services  Operations Ancillary services  Logistics Infection Control/Epidemiology Each participant has been assigned to a group Interaction between groups is strongly encouraged

5 Rules of The Exercise Relax - this is a no-fault, low stress environment Respond based on your facility's current capability Interact with other breakout groups as needed Play the exercise as if it is presently occurring Allow for artificialities of the scenario – it’s a tool and not the primary focus

6 Hospital [Your institution] Certified beds – Staffed beds – Staff – FTEs ED visits – Airborne Infection Isolation Rooms (AIIRs)– [Graphic of your facility]

7 Module One Recognition

8 [Season] in [Local area] Current weather (hot/cold) Used to set the scene – time of year etc. Graphics depicting local area e.g. Manhattan, Bronx, etc.

9 [Day One] at 3:30 pm The emergency department is busy as usual Exam rooms are filled, staff are busy, tensions are high Wait times for non-emergent patients is exceeding [six] hours. Getting patients admitted to a room seems to be taking longer than usual Ambulance traffic is steady – the midday backup of vehicles is taking its toll

10 [Day One] at 3:30 pm A 36 year-old man arrives at the ED by ambulance from [local outpatient clinic] to be admitted for pneumonia. He’s complaining of fever, chills, nausea, and general malaise. On exam his vital signs are temp o F, HR 108, BP 96/50, O 2 saturation 93% on room air, and RR 24 with crackles at the right base.

11 [Day One] at 6:30 pm His chest X-ray shows possible bilateral pleural effusion and he is placed on oxygen & started on IV Ceftriaxone and Azithromycin. The admitting team diagnosis is community-acquired pneumonia. The patient’s inpatient bed does not become available until almost 4:00 am.

12 [Day Two] at 6:30 am During morning rounds the medical team finds that throughout the previous night, the patient had continuous fever of 102 o F and several episodes of vomiting. On exam he has worsening respiratory function, increasing lethargy, and there is a question of nuchal rigidity.

13 [Day Two] at 6:30 am The patient’s sister states that her brother has been previously well with no history of medical problems. He’s traveled both domestically and internationally on political advocacy business. He arrived in [Name of your city] to visit his sister four days ago from Denver.

14 [Day Two] at 7:30 am The case is presented during rounds and the attending requests that a lumbar puncture be done immediately When the resident goes into the patient’s room to prep him, he finds the patient extremely short of breath with an O 2 sat of 82% on 5 liters of oxygen He’s emergently intubated and moved to the ICU He later becomes hypotensive, codes and dies The patient’s family agrees to a post-mortem

15 [Day Two] at 8:30 am Admissions from the ED are lining the hallway; wait time for inpatient beds is averaging [12 hours]. [Fifteen] patients are awaiting admission: [10] with pneumonia, two of whom are six year-old twins, whose parents are extremely anxious; [3] with chest pain; and [2] trauma patients requiring surgical beds. [Four] ED nurses scheduled for the morning shift call in sick.

16 [Day Two] at 2:00 pm The ICU attending is watching the local news on Channel [4] in a patient’s room while waiting for him to return from X-ray. She hears [local reporter’s name] reporting on the death of a city official from an acute respiratory illness. The aide to this official is in the ICU at [other local hospital] with a respiratory illness and is listed in serious condition.

17 [Day Two] at 2:15 pm A few minutes later the ICU attending is paged by the ED resident. [Six] of the [ten] pneumonia patients in the ED, including 6 y.o. twins, require ICU admission. All are hypotensive with fever and shortness of breath; intubation anticipated or underway for all [six]. Nurses are starting to talk amongst themselves about the cases and speculation is rife.

18 Total suspect: [10] patients admitted [4] to ICU [2] to Pediatric ICU Total worried well in ED: [~50] Fatalities: [1] Total available beds by Department [5] Adult Medical/Surgery [3] Pediatric Med/Surgery [1] ICU [12] Other Situation Report #1 [Specify dates for Day One and Two]

19 Module One Breakout Group Discussion Are you experiencing an outbreak ? Would your emergency response plan/EOC be activated? Describe specific communication needs and how to address them. How will your hospital meet the current demand for beds and staffing? What are your infection control, supply, and environmental needs at this point?

First Breakout Group Report Back

21 Module Two Response

22 [Day Three] at 8:30 am The hospital ICP notified the [Local DOH] yesterday afternoon regarding: The unusual number of severe respiratory cases presenting to the ED. A lab report indicating gram negative rods w/ bipolar staining from the blood cultures of the index case admitted on [Day One] [Local DOH] initiated an onsite epidemiological investigation, in coordination with FBI and [Local Police Department]. Specimens were sent to the [Bio-Threat Laboratory at the Local Public Health Lab]; a presumptive diagnosis was made for Yersinia pestis by PCR and DFA testing. The [Local DOH] contacted the Colorado Dept. of Health who were not able to identify any risk exposures for plague near the index case’s residence.

23 Local Health Department [Year] ALERT #38: Presumptive case of Pneumonic Plague in [Your City]. Please Distribute to All Medical, Pediatric, Family Practice, Laboratory, Critical Care, Pulmonary, Dermatology, Employee Health, and Pharmacy Staff in Your Hospital Dear Colleagues: The [your city] Public Health Laboratory has presumptively diagnosed a case of pneumonic plague in a previously healthy 36 year-old male resident of Colorado. To date no other cases of plague have been described in humans or Yersinia pestis in rats in Colorado. A blood culture tested positive for Yersinia pestis last night by both polymerase chain reaction and direct fluorescent antibody testing. Further confirmatory tests will be performed by the Centers for Disease Control (CDC). [Local DOH], CDC and law enforcement authorities are actively conducting epidemiologic and environmental investigations; the exact location and source of plague exposure is not yet known. [Local DOH] requests immediate reporting of any suspected case of plague… [Day Three] 9:00 am Health Alert

24 Summary of Public Health and Other Governmental Agency Responses Citywide Emergency Operations Center activated Press briefing with Mayor, Commissioner of Health and law enforcement agencies is held [Local DOH] initiates citywide active surveillance and epidemiologic investigation to determine common source and site of exposure. Daily citywide hospital conference calls provide clinical and epidemiological investigation updates

25 [Day Three] at 9:30 am The [five] critical patients admitted to the ICU remain on vents, all have acute respiratory distress syndrome and sepsis. [One] of the pediatric ICU patients has expired All [five] patients are isolated and given IV antibiotics, fluids, and pressors. Several other pneumonia patients in ED awaiting admission are deteriorating and intubation is being contemplated for [four]. Many hospital employees are requesting antibiotic prophylaxis.

26 Total suspect: [25] patients admitted [10] in ICU [15] in ED Total worried well in ED: [~65] Fatalities: [2] Total available beds by Department [5] Adult Medical/Surgery [2] Pediatric Med/Surgery [1] ICU [12] Other Situation Report #2 [Day 1-3]

27 [Day Three] at 4:30 pm The Director of Nursing reports that [20%] of nursing personnel have called out sick for the night shift as have numerous house staff and physicians. Other [your city] hospitals are reporting similar staff shortages. House officer reports to work with fever and cough.

28 Module Two Breakout Group Discussion How will you handle the increasing number of ill and worried well? Where and how will you set up triage for screening and isolation? Where will you admit all the patients needing Droplet Precautions? How will you identify and handle exposed employees who are ill? Who are asymptomatic? What supply and materials management issues will be critical to address?

Second Breakout Group Report Back

30 Break

Module Three

32 [150] patients with non-specific complaints and without fever are seeking medical attention. Wait time in the ED for non-emergent patients is still exceeding [12] hours. The hospital is operating at capacity. EMS is also extremely busy. [Day Four] at 10:30 am

33 [Day Four] at 2:00 pm Major local and national news channels are running continuous coverage of the events. The networks are speculating about the source of the outbreak and the risk for additional terrorism events in the city. Reporters are lined up outside the hospital asking staff and visitors for on-camera interviews.

34 [Day Five] at 12:00 pm [Your hospital’s] emergency department and outpatient treatment areas continue to be swamped with persons seeking care and attention. Security measures have been initiated as waiting patients become more and more unruly. Patients are being told about the long wait times and that efforts are being made to seek alternative sites for their evaluation and treatment.

35 [Day Five] at 12:00 pm Attention is focused on planning for the management of fatalities, given limited capacity in the hospital morgue

36 Situation Report #3 [Day 1-5] Total suspect: [#] patients admitted [#] in ED [#] in ICU Total worried well in ED: [~#] Fatalities: [#] Total available beds by Department [#] Adult Medical/Surgery [#] Pediatric Med/Surgery [#] ICU [#] Other

37 Government Agency Responses The governor has requested resources from the Federal Government and the National Disaster Medical System has been activated [Local DOH] and [Office of Emergency Management] have set up points of distribution for dispensing antibiotics Based on the latest epidemiologic findings, [Local DOH], [Local Police Dept.] and FBI are conducting an environmental and forensic investigation at the presumed site of the attack [Local DOH] is maintaining a provider and public hotline, and continuing its active surveillance, regular health alerts and daily hospital conference calls [Local DOH] and [OEM] are working together with hospitals to address regional surge capacity needs There are frequent mayoral press briefings to address public concerns and minimize impact of the worried well on hospitals.

38 Module Three Group Discussion How well does your Emergency Management Plan address surge capacity? How will you set up screening at entrances to your facility? How are you handling exposed asymptomatic staff? How are you communicating with staff, patients, families, outside agencies? What type of support are you providing for staff? How are you dealing with staff fatigue? Mental health issues? What are the current policies to assure staff safety? Based on your earlier decisions, what might you have done differently (hindsight)?

39 [Fourth of July] at [South Street Seaport] Some additional history…

40 Hot Wash What have you learned during this tabletop exercise? What are the hospital’s Emergency Preparedness strengths? What are the weaknesses / gaps in the Emergency Preparedness Plan? What should the hospital’s next steps in preparedness be? List and prioritize five short and long-term actions for follow-up

41 Thank you!