1. 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.

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

3. 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

4. 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

5. 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.

6. 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.

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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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.

17. 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

18. 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)

19. 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.

20. Side Note: Documenting your Actions
Utilize HICS forms
Form Operational Log

21. 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

22. 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

23. 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

24. 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

25. 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

26. Incident Action Planning
For the first Operational Period the Incident Action Plan should be done within minutes
What makes up the Incident Action Plan?
Form Incident Briefing
Form Incident Objectives
Form Incident Assignments
Form Branch Assignments
Form 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

27. 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

28. 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)

29. 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

30. 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

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

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

33. Incident Action Plan & Forms:
Application of
Incident Action Plan & Forms:
Chemical Attack
developed by the
California Hospital Association’s
Hospital Preparedness Program
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.