1 [Name of Center] Bioevent Tabletop Exercise

2 Exercise Goals To increase your staff’s awareness of issues surrounding a bioevent. To assess the Center’s level of preparedness and ability to respond during a public health emergency. To validate the center’s emergency management plan concepts.

3 Exercise Format This is an interactive facilitated tabletop exercise with three modules: Module 1:Recognition Module 2: Response Module 3: Escalation and Recovery A Hot Wash is the final component of the exercise followed by an exercise evaluation.

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

5 Module One Recognition

2005 ALERT #38: Clusters of severe H5N1 influenza outbreaks with community transmission in Vietnam Dear Colleagues: Clusters of severe H5N1 influenza outbreaks have been identified in southeast Asia. There are currently no cases in the United States. The NYC DOHMH and the Centers for Disease Control and Prevention (CDC) have instituted screening of travelers to and from affected countries. A vaccine is in development and will be available in 3-4 months. The NYC DOHMH is requesting heightened surveillance for persons presenting with the following illness: 1. High fever (>38o C or 101.4o F) AND 2. Respiratory signs or symptoms, including cough, shortness of breath or difficulty breathing AND/OR 3. Anyone with these symptoms who has traveled to SE Asia or had contact with someone who has been to SE Asia.

7 Public Health Response NYC DOHMH enhances surveillance and outreach efforts: Hospitals, Community Health Centers Laboratories Vietnamese and Asian communities Daily teleconferences scheduled for hospitals and community health centers for updates NYC DOHMH press office generates a public health message

8 Discussion Points Describe how your Center would respond to this Health Alert. Who is responsible for distributing this Health Alert to the rest of the staff? If you have satellite clinics, how does this information get to them? How do you coordinate your response with the satellite clinics? Does your center activate its IMS at this time? If Yes, is it partial or full activation? What are your criteria for activating your IMS?

9 Day One at 11:00 am A 55-year-old man and his 31-year-old daughter walk into center. At the registration desk they are coughing, appear flushed and somewhat short of breath. They ask to see a doctor because they have been having fevers and coughing badly for the last 3-4 days.

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11 How do you manage these two patients? Discuss how your center would manage these two patients with regards to: Infection control Notification of medical staff Remember: This is in light of the Health Alert asking for increased vigilance.

12 Day One at 11:00 am The two patients are given surgical masks by the registration clerk and are taken to a separate examination room. Other patients in the waiting area have seen this interaction and want to know what is going on. QUESTION: What is your Center message going to be to the patient’s in the waiting area who want to know what is going on? Remember the need to protect patient privacy.

13 Meanwhile in the examination room… The two patients are now sitting in exam rooms. They are anxious and want to know what is happening. The nurse enters to take their vital signs. Both of them have temperatures greater than 101.4ºF. Questions: Medical personnel: Describe the type of personal protective equipment that the nurse and provider will wear when seeing the patents. What signage would you place outside the room?

14 Patient Histories The two patients had recently traveled to Vietnam with their families and had returned 4 days ago.

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16 Questions Medical provider: You have just seen and examined the patients. What do you say to the patients? What notification do you do? All players: At this time, what issues do you think will come up because of these two patients?

17 Day One at 1.00 pm You alert the DOHMH as per the Health Alert. Recommendations are to transfer the two patients to [affiliated hospital] for further evaluation.

18 Let’s Review

19 So far… Your center has received the Health Alert. You had two patients walk in to your center that fit the criteria for reporting. You notified the New York City Department of Health and Mental Hygiene. You have successfully transported them to the hospital for evaluation.

20 Discussion Points Senior staff: What follow up steps would be taken at this time? Housekeeping? Follow up of the two patients? Response to concerned staff and center patients? Return to “normal” center activities? Public Information Officer (PIO)/Public Relations: What message or information would you have in place should these two patients be true cases?

21 Day One at 5:00 pm Evening news headline story running on all networks: Report of first case of H5N1 in Boston and possible cases in San Francisco and New York City Index case: 24 year old man who was in Vietnam and became symptomatic five days ago. Arrived in States 4 days ago, prior to institution of airport screening. Traveled from Vietnam to San Francisco then to NYC and to Boston.

22 Day One at 5:30 pm Breaking local news: CBS reports that at least 95 of the 150 passengers on the plane, are from NYC DOHMH is currently investigating 5 cases that traveled on same plane as index case and are hospitalized with severe illness. Three of the cases are in [location of center] and two are in [other location].

23 Day One at 5:30pm The Medical Director gets a call from the New York City Department of Health and Mental Hygiene. Two medical epidemiologist would like to come to your center now to review charts and speak to staff who cared for the two patients.

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25 Discussion Points Is there any change in the activation level of your EMP? It is highly likely that your staff will be aware of the situation on the news: How do you notify staff that are not present or at home (e.g., day off) about what is going on? PIO/Public Relations: What message are you going to develop at this time for staff,patients and the media?

26 Discussion Points In the time that it takes the DOHMH staff to come to your center, how do you respond to the concerns of the staff who had contact with the two patients? How will you utilize your Mental Health staff? Senior Staff: Anticipating that there will be more in the media of the influenza outbreaks, when do you start discussion of closing the center? What would be your criteria? What are your steps?

27 Module Two Response

28 Day 2 A novel strain of influenza A (H5N1) is identified in Southeast Asia Vaccine will not be available for 3-4 months. Prioritization of vaccine Two shots needed for efficacy Oseltamivir (tamiflu) is recommended for treatment. Not recommended to give for prophylaxis. Needs to be given within 48 hours of symptoms

29 CDC Guidelines: Pandemic Influenza Recommended protective measures: Standard Precautions Droplet Precautions Gloves/gowns Dedicated equipment Eye Protection Masks Hand hygiene

30 Day Two The World Health Organization makes a formal declaration of an Influenza Pandemic. Your center has made the decision to stay open and see patients.

31 Day Two at 8:15 am There are 25 people waiting for the center doors to open. 10 of them have scheduled appointments 15 of them are walk-ins. You notice that some of them are coughing. Patients are asking for more information on the “flu” and how to protect themselves. Patients and staff are asking/demanding Tamiflu.

32 Day Two at 11:00 am There are 15 symptomatic individuals in your waiting room needing evaluation Outside 8 individuals visibly ill try and push their way into the facility One doctor and one nurse are asking to leave. They are nervous about the situation and want to go to their families.

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34 Questions Clinical Staff: How would your center handle the asymptomatic and symptomatic patients in your waiting area? Infection Control Housekeeping Cohorting? Health Educators/Human Resource: What materials do you prepare for: Patients Staff

35 Discussion Points Describe how you would handle crowd control outside your facility. How do you handle staff that want to leave for home?

36 Module Three Escalation and Recovery

37 In the City All major local and national news networks are broadcasting flu updates around-the-clock. Public mass gatherings are cancelled. Hospitals and Community Health Centers are overwhelmed with patients. Surgical masks are sold out in all stores.

38 For the next four weeks, some issues for your center to grapple with: Staff absenteeism (sickness, fear, family) Supplies of mask and hand hygiene products running low Trying to work with the local hospital in Triaging patients for their ED Providing staff to manage PODs Mental Health support Decisions to close/reopen your center “Normal” center functions Keeping track of finances

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40 Discussion Points What can you do now to work with staff on being able to come in to work during an emergency?

41 Hot Wash What have you learned during this tabletop exercise? What are the primary care center’s strengths? What are the weaknesses / gaps? What should your next steps in preparedness be? List and prioritize five short and long term actions for follow-up.

42 Thank you!