[Hospital Logo] [Hospital Name] Bioevent Tabletop Exercise Moderated by: and Facilitated by: Suggested Moderator Speaking Points: Introduce yourself.

[Hospital Logo] [Hospital Name] Bioevent Tabletop Exercise Moderated by: and Facilitated by: Suggested Moderator Speaking Points: Introduce yourself – give a thumbnail sketch of your credentials Briefly explain the rationale for conducting this exercise and define a tabletop Define the term bioevent – emerging infectious disease either naturally occurring or intentional in nature. [Local Health Department Logo]

Exercise Objectives 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 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 Instructions to Moderator: The objectives may be adjusted to meet the needs of your exercise and facility (e.g., you may be testing the capability of a specific department, a specific shift or you may be focusing on surge capacity, triage, disease recognition, laboratory diagnosis, screening and isolation of patients coming to the emergency department, case-finding within the hospital and/or mental health aspects).

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 (debriefing) is the final component of the exercise followed by an exercise evaluation. Instructions to Moderator: There are 2 options for conducting the exercise (See Chapter 2 for details), including: 1. Breakout Group Format: Participants assemble into breakout groups after Modules 1 and 2 to discuss probable actions based on their facilities’ and specific departments’ plans, policies, and procedures. The breakout groups reconvene to share key points/actions taken with the entire group. After the third module, there is a facilitated plenary discussion with all participants. (Slide 3 reflects this option). 2. Single Group Format: After each module, the Moderator facilitates the discussion session in a large group format, without breaking into smaller groups. The moderator can use questions from Appendix 5 - “Generic Questions for Moderator and/or Facilitators” - to lead the discussion sessions. If you use this option, Slide 3 should be edited to reflect this format. EOC Option (Can be used with either of the above formats): Before the breakout or single group discussion, convene the members of the EOC/Incident Command group at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. Suggested Moderator Speaking Points: Describe format chosen for the tabletop exercise If using breakout groups, Introduce facilitators for each group. Define “Hot Wash” - A “Hot Wash” is an open discussion at the end of the exercise allowing participants to provide instant feedback about immediate lessons learned and to identify barriers/gaps in current emergency management plans and procedures.

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 Instructions to Moderator: This slide should be deleted if the Single Group format is chosen If the Breakout Group format is chosen, the “Infection Control, Epidemiology and Laboratory Services” group may be added as a fourth breakout group or included within operations (Clinical Services). Please refer to Appendix (1a and 1b), “Breakout Groups” for suggested groups of player participation.

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 Instructions to Moderator: Delete 3rd bullet if Single Group format is used.

Hospital [Your institution]
Certified beds – Staffed beds – Staff – FTEs ED visits – Airborne Infection Isolation Rooms – [Graphic of your facility] Instructions to Moderator: Insert your hospital name and the number of available certified beds, staffed beds, FTEs (you may want to divide this between clinical and non-clinical if the information is available from your finance department), annual or monthly ED visits, and number of Airborne Infection Isolation Rooms available in your facility. You may also add the number of ICU beds, OR Rooms, etc.

Module One Recognition
Suggested Moderator Speaking Points: The first module focuses on disease recognition and the steps that the hospital must take in the earliest phase of a suspected outbreak.

[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. Instructions to Moderator: This slide should be customized for your area. You may want to use a season when influenza is not expected (e.g., summer).

[Day One] at 7:30 pm The emergency department has been busier than usual. Last week [Local DOH] announced an early start to the flu season and urged high-risk individuals to get flu shots. The ED has seen several cases of flu-like illness over the past two weeks. Instructions to Moderator: Optional: replace “Day One” with date and day of week on this slide and continue to do so on subsequent slides. Would suggest using a date that occurs in early to mid Fall, given that the scenario suggests an early influenza season.

[Day One] at 7:30 pm A 28 year old female reservist presents to the ED with complaints of fever, cough, mild shortness of breath and chest pain for the past 12 hours. She works as an ICU nurse on the day shift at [your hospital] and is pursuing her MPH at night at [NYU]. She shares an apartment with three other students. Her exam is unremarkable with normal chest and cardiac exam and she has no prior medical conditions.

[Day One] at 7:30 pm Her chest X-ray shows no pulmonary infiltrates.
A blood culture is drawn to rule out other conditions. The physician recommends bed rest and fluids and tells the young woman to seek medical care if her symptoms worsen. Instructions to Moderator: The 2nd and 3rd bullets can be phrased as questions and asked directly to the Emergency Medicine staff: What tests would you order? If and if so, what antibiotics would you order for this patient? Would you discharge or admit this patient? If, and if so, what infection control and isolation precautions would you take?

[Day Two] at 6:30 am The young reservist seen yesterday evening returns to the ED with a higher temperature and shortness of breath. Her vitals are: Today Yesterday Temp 103 oF Temp 101 oF BP 85/50 BP 105/65 HR HR 102 RR 30 RR 24 O2 sat. 90% She has paroxysmal tachycardia and a heart murmur. A repeat Chest X-Ray is performed.

[Day Two] at 6:30 am The patient reports no history of heart murmur, thyroid problems, and is not using medications, drugs or alcohol. She’s a serious student and most of her time is either spent working or studying. She is an ardent baseball fan and occasionally attends a [Local baseball team] game when she has time or can get a ticket. Instructions to Moderator: Change logo for baseball team to represent a sports arena or other appropriate location for your jurisdiction.

[Day Two] at 8:00 am The ED attending asks the unit secretary to pull the patient’s labs from last night. A repeat chest X-ray shows a new pleural effusion. A chest CT is ordered. He pages the ID attending for a consult and he gives orders for IV antibiotics and admits the patient. Instructions to Moderator: The 3rd bullet can be phrased as questions directed to the Emergency Medicine staff: What antibiotics would you order for this patient? Would you consult infectious diseases? (If so, could have them role play the discussion briefly) What infection control and isolation precautions would you take now?

[Day Two] at 10:00 am The young woman suddenly develops respiratory distress and is emergently intubated and transferred to the ICU where she rapidly becomes septic. Although she is given fluids and pressors, at 11:00 am she arrests and cannot be resuscitated. A post mortem is scheduled. Instructions to Moderator: Consider asking the following question after the last bullet: Would the hospital consider calling the local health department about this unusual and fulminant death in a previously healthy woman? Who would be responsible for reporting to the local health department?

[Day Two] at 11:00 am The triage nurse notices a larger volume than normal for a [Day of Week] morning in the ED with many complaining of flu-like symptoms, especially upper respiratory ailments. Since yesterday evening [20] patients, all from different parts of the city, have presented with similar symptoms. The triage nurse, ED resident and ED attending discuss the current situation and attribute the unusually high numbers to the early flu season. Instructions to Moderator: Consider asking the following questions after the last bullet and direct them to the Emergency Medicine and Infectious Disease staff: Would this set off the hospital’s emergency response plans or prompt mobilization of any kind? Would the infection control program be involved? What kind of isolation precautions should have been instituted at this stage? What kind of PPE should healthcare workers be wearing? Are airborne precautions or droplet precautions appropriate while disease is still non-specific? Moderator should warn the participants to work with the information that has been given and not to get ahead of the scenario.

[Day Two] at 1:00 pm Isolation rooms are already full and many more patients with similar symptoms continue to present to the ED. There are now [thirty] people with fever and respiratory complaints, including cough and difficulty breathing. [Ten] of these patients are being processed for admission. There are an additional [two] patients with chest pain and [two] trauma patients awaiting admission. Patients on gurneys are lining the hallway. [Three] ED nurses scheduled for evening shift call in sick. Speculation is rife among the hospital staff particularly with the death of a previously healthy staff member. Instructions to Moderator: For fifth bullet, consider having 10-15% more than usual absenteeism among the ED nursing staff. Consider asking the following question: Is it unusual that three ED nurses from one shift call in sick? Would anyone question whether their illnesses might be related to the other nurse’s illness?

Situation Report #1 [Specify dates for Day One and Two]
Total suspect: [25] Patients admitted [30] In ED Fatalities: [1] Total available beds by department: [5] Adult Medical/Surgery [10] Pediatric Medical/Surgery [1] ICU [12] Other Instructions to Moderator: The numbers in this report should be a 10-15% surge in patient admissions and ED visits over normal baseline capacity by the end of Module 1. The number of available beds should reflect what is usual for your facility.

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. Who and when do you notify partners (internal and external)? What are your staffing, infection control, supply, and environmental needs at this point? Instructions to Moderator: Ideally this session will run approximately minutes. If using the EOC option: Ask the EOC/Incident Command members to convene at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. If using the breakout group format: Remind groups to assign a recorder and/or reporter. Explain roles of each. You should circulate between the groups and, you can distribute injects as a tool to encourage the group if conversation lags or to provide extra pressure for more sophisticated groups. Injects for each scenario are included in Chapter 5 of the exercise planning toolkit and are listed according to module and different breakout group categories. Give the facilitators a five minute warning so they can have the participants wrap up and have information ready to report back. If using the Single Group format: You should chose questions from Appendix 5 and direct these to the appropriate members of the audience to highlight key issues for the group discussion.

First Breakout Group Report Back
Instructions to Moderator: If using the Breakout Group format: Ask each breakout group to report back on key issues/decisions made. Use the questions in Appendix 5 to highlight other key issues that might not otherwise be discussed. If using the Single Group format: Delete this slide.

Module Two Response Suggested Moderator Speaking Points:
The second module is designed to simulate an escalating outbreak. Players should focus on the issues as they are presented and not “play ahead of the scenario”. Issues of patient triage, appropriate isolation, and prophylaxis should be addressed.

[Day Two] at 4:00 pm After discussing with the patient’s attending [Your hospital] ICP notifies the [Local DOH] regarding: The blood cultures drawn on [Day One] from the young woman (the index case) who died have grown large gram positive bacilli. An increased number of patients with similar complaints are continuing to present to the ED. [Local DOH] states there are similar reports being received from other local hospitals.

[Day Two] at 10:00 pm [Local DOH] initiates epidemiological investigations in conjunction with the FBI and [local law enforcement] by sending a team on-site to [Your hospital] and four other hospitals where similar cases have been reported. Preliminary diagnosis of “Bacillus anthracis” is received from the Public Health Laboratory based on a positive direct fluorescent antibody (DFA) and PCR result. Instructions to Moderator: Note that once testing starts in the lab any initial PCR rest results on clinical specimens require at least six hours. Confirmatory testing will take an additional hours.

[Day Two] at 10:30 pm Local Health Department
[Year] ALERT #38: Presumptive case of Inhalational Anthrax in [New York City]. Please Distribute to All Medical, Pediatric, Family Practice, Laboratory, Critical Care, and Pharmacy Staff in Your Hospital Dear Colleagues: The [your city] Public Health Laboratory has presumptively diagnosed a case of inhalational anthrax in a previously healthy 28 year-old female based on PCR and DFA testing. Further confirmatory tests will be performed by the Centers for Disease Control (CDC). Due to concern of bioterrorism, the [Local DOH], CDC and law enforcement authorities are actively conducting epidemiologic and environmental investigations; the exact location and source of the inhalational anthrax exposure is not yet known. [Local DOH] requests immediate reporting of any suspected case of anthrax…

Summary of Public Health and Other Governmental Agency Responses
The City’s Emergency Operations Center is activated. Press briefing with the 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.

[Day Two] at 11:00 pm Patients are being referred to the ED by ambulatory care centers and community based outpatient clinics. Patient flow through the ED is hampered by lack of space and patients are also being evaluated in the waiting area and the ED conference room. Wait times in the ED for non-emergency patients are now abnormally high. Family members of several patients not yet admitted are beginning to panic and are starting to vent their mounting fears and frustration at the staff. This leads to increased anxiety amongst the staff and they request additional security in the ED.

[Day Three] at 7:00 am The Director of Nursing reports that [40%] of nursing personnel have called out sick for the morning shift as have numerous house staff and physicians. Other [Your City] hospitals are reporting similar staff shortages. A House officer reports to work with fever and cough Instructions to Moderator: Adjust the % of staff calling in sick in first bullet to place a moderate- severe level of stress on your facility.

[Day Three] at 9:00 am All major local and national news networks are broadcasting round-the-clock information. Subject matter experts are speculating on the type of anthrax and are wondering if this is connected to the 2001 incidents at post offices, Capitol Hill, TV stations, etc. Instructions to Moderator: Consider asking the following questions: How will the hospital coordinate communicating to the media with the local Department of Health and other city agencies? How will you handle the press outside of your hospital? What information will you give the hospital staff about speaking with the press?

Situation Report #2 [Day 1-3, Enter Days of week]
Total suspect: [65] patients admitted [86] in ED Total worried well in ED: [~65] Fatalities: [2] Total available beds by Department [1] Adult Medical/Surgery [1] Pediatric Med/Surgery [0] ICU [2] Other Instructions to Moderator: The number of available beds should decline markedly. Suggest at least a 20-30% surge in demand for each area of the hospital. Consider asking the following questions: How many ventilators would [your hospital] be able to access right away? Many hospitals rent ventilators from the same distributors. How difficult will it be to obtain additional vents under these circumstances? Would you be able to request additional ventilators from nearby hospitals?

[Day Three] at 11:30 am Several baseball players from both playoff teams as well as coaches and umpires have been admitted to hospitals with anthrax symptoms. A preliminary investigation by [Local DOH] in conjunction with law enforcement shows all confirmed cases of anthrax to date were people who attended the local [Your City] playoff game on [Day One minus four] or who live or work downwind of the stadium. A decision is made to prophylax all persons who were at the ballpark that night as well as those living/working in zip codes within a given perimeter.

[Day Three] at 12:00 Noon A second alert is put out by [local DOH] updating the information on the outbreak: Bacillus anthracis had been confirmed by the Public Health Laboratory and the CDC. [Local DOH] has recommended the use of IV quinolone plus one other antibiotic for initial treatment. Preliminary epi data implicates the [Local baseball team’s playoff game] as the likely site of the anthrax release. Persons potentially exposed at the [playoff game] and in the general area require prophylaxis with oral ciprofloxacin or doxycycline. The City is setting up antibiotic clinics targeting those at risk.

DOH Health Alert (Continued)
As inhalational anthrax is not transmissible person-to-person, standard precautions are adequate. Antibiotic prophylaxis of healthcare workers is not indicated. Hospitals should continue to admit and treat patients who are symptomatic. All suspect cases should continue to be reported to the DOH, regardless of exposure history.

Module Two Breakout Group Discussion
How will you handle the increasing number of ill? Worried well? Where and how will you set up triage? What supply and materials management issues will be critical to address? What are your communication needs? How will you handle communication with the media? Who will you coordinate with? Instructions to Moderator: Ideally this session will run approximately minutes. If using the EOC option: Ask the EOC/Incident Command members to convene at the front of the room and have them openly deliberate for 5-10 minutes about the current status of the outbreak and prioritize the issues for the participants to address during the breakout group or single group discussion, much as an actual EOC would function. If using the breakout group format: Remind groups to assign a recorder and/or reporter. Explain roles of each. You should circulate between the groups and, you can distribute injects as a tool to encourage the group if conversation lags or to provide extra pressure for more sophisticated groups. Injects for each scenario are included in Chapter 5 of the exercise planning toolkit and are listed according to module and different breakout group categories. Give the facilitators a five minute warning so they can have the participants wrap up and have information ready to report back. If using the Single Group format: You should chose questions from Appendix 5 and direct these to the appropriate members of the audience to highlight key issues for the group discussion.

Second Breakout Group Report Back
Instructions to Moderator: If using the Breakout Group format: Ask each breakout group to report back on key issues/decisions made. Use the questions in Appendix 5 to highlight other key issues that might not otherwise be discussed. If using the Single Group format: Delete this slide.

Fifteen Minutes Please
Break Fifteen Minutes Please Instructions to Moderator: Break can be adjusted to fit time available and can also be placed elsewhere in the slide set.

Module Three Surge Capacity
Instructions to Moderator: For the third module, the entire audience will assemble as a large group. There will no be no breakout groups. Depending on the size and composition of your audience, you may wish to ask some probing questions following selected individual slides in Module Three.

[Day Three] at 12:00 pm The emergency department is swamped with patients with non-specific complaints and without fever seeking medical attention. Wait time for non-emergent patients is exceeding [twelve] hours. The number of patients waiting to be seen exceeds hospital capacity. EMS is overwhelmed. Instructions to Moderator: Consider asking the following questions: How will these ambulatory non-event related patients be triaged? What kind of mental health services may be provided?

[Day Three] at 4:00 pm The Local Office of Emergency Management (OEM)] and [Local DOH] have set up points of distribution (PODS) to dispense antibiotics starting at 5:00 pm today. Each individual will initially receive a ten-day supply. Additional distribution will occur once additional antibiotic supplies arrive from the Strategic National Stockpile (SNS). Instructions to Moderator: Consider asking the following questions: How will you determine which patients may be at risk for exposure so that you can provide or refer them for prophylaxis? How will information about where to obtain antibiotic prophylaxis be distributed to patients, staff and worried well?

[Day Three] at 4:00 pm Reports of potential shortages of antibiotics have resulted in hordes of people seeking out their primary care physicians, clinics and emergency departments throughout [Your City]. There are long lines outside many facilities. News crews are camped outside all major healthcare facilities. Instructions to Moderator: Consider asking the following question: How do you direct persons coming to the ED for antibiotic prophylaxis to their neighborhood point of distribution (POD) clinic established by [DOH]?

[Day Three] at 4:00 pm [Your hospital’s] emergency department and outpatient treatment areas continue to be inundated 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. Instructions to Moderator: Consider asking the following question: What strategies will security use to manage the crowd around the emergency department and to secure entrances/exits?

Situation Report #3 [Day 1-3, Enter Days of Week]
Total suspect: [At capacity] patients admitted [250] in ED [60] in secondary triage area Total worried well in ED: [~50] Fatalities: [3] Total available beds by Department [0] Adult Medical/Surgery [0] Pediatric Med/Surgery [0] ICU [0] Other Instructions to Moderator: Final numbers for the outbreak should be provided here. Numbers should reflect tallies provided on previous slides. The total cases and fatalities are only those at your facility, not citywide numbers. Suggest using numbers that represent a > 40-50% surge for your hospital. Most hospitals would be expected to have minimal to no available beds by this point in the outbreak. Consider asking the following questions: Would another area of the hospital (e.g., Cafeteria of Physical Therapy Exercise Room) be used to handle overflow? Would you use an outdoor triage for those assessed not to be acutely ill?

Government Agency Responses
The Governor has requested resources from the Federal Government and the National Disaster Medical System has been activated. Points of Distribution Clinics are providing antibiotics to those determined to be exposed at [Local Baseball Stadium] [DOH] is maintaining a provider and public hotline, and continuing its active case surveillance, regular health alerts and daily hospital conference calls. [DOH] and [Office of Emergency Management] are working together with hospitals to address regional surge capacity needs. There are frequent mayoral press briefings to address public concerns, provide safety recommendations and minimize impact of the worried well on hospitals.

Module Three Group Discussion
How well does your Emergency Management Plan address surge capacity? How will you direct persons coming to the ED for antibiotic prophylaxis to the nearest antibiotic clinic? 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)? Instructions to Moderator: This is the opportunity to draw out groups/individuals who have maintained a low profile such as housekeeping, nutrition, social services, security, etc. Other important topics that may be discussed, if not already well-addressed during earlier modules, include: How will you provide mass care? How do you triage ambulatory, non-event related patients, and the “worried well” away from the ED? Where will you get the staff? Do you have enough supplies to do this? How will you direct persons coming to the ED for antibiotic prophylaxis to their neighborhood mass antibiotic distribution clinic? How will you coordinate your efforts with the city, state and Federal response? Who do you call first? What steps should be taken to plan for the recovery phase?

BT Attack at [Local Baseball] stadium Some additional history …
Instructions to Moderator: Provide a brief background for what happened during the bioterrorist event. One example that could be used is as follows: On the evening of [Day One minus four], the first playoff game between the Local Baseball Team and their main rival is being played in the local Stadium before a crowd of 56,000. The evening sky is overcast, the temperature is unseasonably mild, and the wind blows from north to south. During the first inning of the game, a private helicopter flies one mile north of the stadium. When it is half a mile from the stadium, it releases an aerosol of powdered anthrax over 45 seconds, creating an invisible, odorless anthrax cloud more than a third of a mile in breadth. The wind blows the cloud across the stadium parking lots, into and around the stadium, and onward for several miles over the neighboring residential and business districts. After the anthrax release, the helicopter flies away from the stadium and lands in the next state. No one detects the anthrax release. Approximately 12,000 of the 56,000 baseball fans are infected by the anthrax cloud. Another 6,000 in the business and residential districts downwind of the stadium also are infected. After the game, the fans disperse to their homes in the greater metropolitan area and the city of the rival team. Those individuals closest to the dissemination site inhale the most spores of anthrax bacteria and will tend to have the first clinical presentation. There are no medical symptoms or other indications that a covert biological attack has taken place at this time.

Hot Wash What have you learned during this tabletop exercise?
What are the hospital’s emergency management preparedness strengths? What are the weaknesses / gaps in the Emergency Management Plan? What should the hospital’s next steps in preparedness be? List and prioritize five short and long-term actions for follow-up. Instructions to Moderator: This is an open discussion that occurs immediately after the tabletop exercise and is conducted by the moderator. The objective of the “hot wash” is to review events or key decisions that took place during the exercise and to provide an opportunity for participants to describe any immediate lessons learned and to identify barriers/gaps in mounting an effective response. All participants are free to contribute and are encouraged to do so. Do not forget to distribute the post exercise evaluation survey at the end of the hot wash.

Thank you!

[Hospital Logo] [Hospital Name] Bioevent Tabletop Exercise Moderated by: and Facilitated by: Suggested Moderator Speaking Points: Introduce yourself.

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[Hospital Logo] [Hospital Name] Bioevent Tabletop Exercise Moderated by: and Facilitated by: Suggested Moderator Speaking Points: Introduce yourself.

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Presentation on theme: "[Hospital Logo] [Hospital Name] Bioevent Tabletop Exercise Moderated by: and Facilitated by: Suggested Moderator Speaking Points: Introduce yourself."— Presentation transcript:

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